The ED is not an appropriate place for unsupervised midlevels: a patient perspective

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A story of a post-op wound check gone wrong, thanks to a PA's mismanagement.

Anonymized patient submission. Lightly edited for grammar and medical terminology.

I had a minor salivary gland biopsy to rule out Sjogren's syndrome after a positive ANA. The procedure was performed by a resident who had assisted on one lip biopsy. He tried to communicate this to an attending, but it seemed like the attending saw it as a sink-or-swim moment. Finally gathering his courage, the resident made an incision that was significantly longer, deeper, and messier than necessary; it was 3-4x longer than needed. (I was never worried; these things happen at university hospitals, and I understand the importance of training young doctors.) They used silver nitrate to cauterize before adding several stitches to make sure the incision was nicely closed.

It turns out I have a major sensitivity/minor allergy to silver nitrate. (I also can't wear most metal jewelry.) I had a ton of swelling, which popped the stitches, resulted in extended bleeding over the next ~24 hors, and worse, it made it impossible to close my mouth or swallow fluids/meds/my own spit. The worst part was a painful freezing-burning sensation deep in my lip, which only continued to worsen over the next ~12 hours.

So around midnight, I went to the ED to make sure nothing major was wrong and also see if anything could be done. I've been to this ED several times as either a caregiver or a patient and generally have had very positive experiences with the doctors. That night, the only doctor I saw was the one in triage who decided to send me straight on back to a room.

My treating provider was a PA-C. He told me they couldn't give me IV Toradol (fair enough - the bleeding was showing no signs of stopping anytime soon). But instead of educating me and/or giving me home care instructions, he injected lidocaine + epinephrine into my super-swollen lip in several places using a large-gauge needle. Clearly his only goal was to get me the fuck out of the (mostly empty) ED by temporarily stopping the bleeding and causing enough pain to humiliate / punish me for wasting his time. Unsurprisingly, the bleeding resumed after about an hour, the lidocaine didn't resolve the type of pain I was experiencing (d/t allergies), and my lip swelled even more from the additional trauma. I was never given a choice, and was given no home care instructions. I ended up having the severe freezing-burning pain for around three days, and significant swelling and difficulty swallowing for about five days. I didn't find out the likely reason - an allergy - until weeks later when I talked to my GP (an MD). I was lucky - while I had an allergic reaction, it was localized and resolved on its own.

I'm not at all opposed to receiving care from midlevels in a number of specific circumstances. I've had mostly fantastic experiences, including from my gastroenterology provider (a PA). But of course she didn't perform or interpret my EGD - an MD did. It's also clear that she goes above and beyond with regard to her own education.

But I really don't think the ED is an appropriate place for midlevels to be practicing independently. The considerable breadth of knowledge required cannot be achieved in two years of education - EM requires physicians to have a solid understanding of so many different specialty areas. I understand that some people go to the ED for primary care issues like the sniffles, and maybe some of those cases could be easily and appropriately handled by midlevels. But if I personally have an issue significant enough to warrant going to the ED, I'm going to pray my case isn't assigned to a midlevel. Someone with less education than a resident (sometimes alarmingly so, depending on the quality of their program) making decisions independently, without supervision, should have a more narrow and clearly defined role.