Home Letters Working with midlevels: another view

Working with midlevels: another view

April 2010

Published in the April 2010 issue of Today’s Hospitalist

Working with midlevels: another view
In response to your Q&A on midlevels (“Working with midlevels: a new note of caution,” March 2010), our growing hospitalist program at Gundersen Lutheran consists of 10 full-time MDs, eight full-time physician assistants (PAs) and two full-time nurse practitioners (NPs), all on a seven-on/seven-off schedule. Together, our group admits for all medicine subspecialties, including critical care.

The PAs have their own patient panel with primary responsibility for those patients, with attending oversight. Our NPs function nearly independently with a niche practice in our psychiatric and substance abuse ward.

A critical asset has been the PA training programs we work with through the University of Wisconsin. We recruit the majority of our staff among the PA students completing rotations with us from these programs. New graduates certainly have a steep learning curve at our academic center, but with time, they become as skilled and knowledgeable as most physicians I know.

The added staff allows us to spend more time with patients and families on patient education, discharge planning, end-of-life discussions and more. Associate staff also plays an important role representing our group on quality and service committees, and have greatly improved physician, nursing, and patient satisfaction. We would not consider shifting to another model.

Mary Frances Barthel, MD
La Crosse, Wis.

Paracentesis tips
I noted the recommendation for large volume paracentesis for refractory ascites (“New options for patients with cirrhosis,” November 2009). Here in south Texas, we perform large volume paracenteses on a near-daily basis. Here are tips I use for a quick, successful procedure.

After deciding which site to tap, sit the patient up about 30 degrees and rotate the patient slightly toward you. The dependent fluid will collect near your tap site.

If your hospital kit is a collection bag using gravity and long tubing, just throw it away. I use a 1-liter vacutainer-type bottle and secondary IV tubing. After collecting a diagnostic sample, attach the IV tubing to the side port of the three-way stopcock and jam the other end (the big trochar that usually attaches to the IV fluid bag) into the vacutainer bottle.

Turn the stopcock off to the syringe and watch the fluid pour out. (When the tubing is set up correctly, the fluid flows in the opposite direction that the tubing is designed for.) The suction collapses the reservoir near the trochar, but secondary IV tubing is shorter and less likely to collapse than longer, more flexible IV tubing.

With IV tubing, it takes less than half the time to fill a bottle than with a 14-gauge angiocath. (Filling time for each bottle is 2.5 to 3 minutes.) As with any large volume paracentesis, if you remove more than 5 liters, patients have an increased risk of decreased renal perfusion. In patients with low blood pressure, baseline chronic kidney disease or a lack of peripheral edema, consider IV albumin infusion around the time of paracentesis to prevent complications.

Eric A. Fein, MD
San Antonio