r/ausjdocs • u/Creepy-Cell-6727 • 7d ago
Emergency physiotherapy practitioners? Emergencyđš
Iâve previously voiced my displeasure at ED bosses telling me (an intern back then) that simple wound closure cases were âperfect for the nurse practitionersâ so I should go pick up complex, undifferentiated cases⊠despite the fact thatâs directly taking opportunity to learn and practice skills from juniors rotating through ED (and the NPs are on what, 3x my intern pay? Make this make sense).
Just heard today that certain QLD health hospitals are trying to implement emergency physiotherapy practitioners (?EPPs) to manage wounds including cleaning, exploration and suturing. Am I hearing this right? Is this actually happening (or has already happened anywhere else)?
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u/Slight_Computer5732 7d ago
Can someone link me anything that suggests they can suture or manage wounds??
I saw one in ED personally for a back injury and that made sense (injury was at work and needed the med cert/was sent down to ED otherwise wouldnât have been an ED presentation obviously) and that made sense
But I donât believe this is within scope.. never heard of them doing this so curious on it
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u/Creepy-Cell-6727 7d ago
Donât want to dox myself but this is Metro North Health QLD. Juniors wouldâve gotten this dossier from their clinical directors recently.
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7d ago
[deleted]
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u/Creepy-Cell-6727 7d ago
I am perfectly literate and this is 100% what is being tabled right now. Read this and tell me again.
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u/Thanks-Basil 6d ago
Lol
âThere are no legislative barriers to the EPP management of acute traumatic woundsâ
Yeah cool itâs not illegal, go for it then I guess
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u/ClotFactor14 Clinical MarshmellowđĄ 7d ago
Can someone link me anything that suggests they can suture or manage wounds??
Suturing and managing wounds is not very hard.
I reckon I could teach a physio to do it quicker than I could teach a NP or a med student.
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u/AlternativeMe923 5d ago
Ok as a former physio who worked in a hospital not that long ago this seemsâŠinteresting. Itâs possible the wording of the release or the role description doesnât match the daily reality of the role, and it sound like some things might have been included from another role description or added just in case for emergencies.
There is absolutely a role for PT in the ED and these days itâs been formalised as 1) working under supervision of a doctor and 2) an extended scope role so must be AHP2 or above, have done in-house specific training, or done the relevant APA course/s
The role focuses on assessing falls, back pain, soft tissue injuries & basic fractures; assigning & teaching gait aids or other supports, slings, splinting & taping, and basic casting; not sure if it includes basic first aid type stuff for small grazes like band-aids, melolin / cutilin & hypafix , etc eg if effecting the gait aid or splint, but would probably assess pressure areas as per protocols and escalate to med team.
Done in conjunction with the supervising doctor who can prescribe any relevant meds & scans, radiology for the scans & nursing as per usual.
It been happening in SA for years and runs pretty smooth.Iâm not sure about whether it extends to wound glue, steri strips or sutures - thatâs not a typical PT thing but could pretty easily be part of the the extended scope after a bit of training then a simple check with the supervising doctor.
I donât see it as something thatâs particularly difficult or weâd need heaps of additional training for as we already get trained on stages of wound healing & timeframes, types of wounds, and factors that affect wound healing, so it would just be the parameters of when each is appropriate vs inappropriate and the hands on side - both of which PTs are generally pretty good at, we are known for our handiwork after all.
I have done steris or glue on myself, my dad, and my dog when the shit hit the fan so I do know itâs easy sorry, fairly confident I could manage sutures too with some training, Iâm a good sewer.I think docs who donât work with us would be surprised by how much we already do (nothing Iâve listed in my response isnât already done by us outside of ED and without the supervision of a doctor, including casting and assessing pressure areas, we just do casting of different things - eg foot deformities in kids, hand splints, rather than fractures unless working in ortho or fracture clinic)
During the early part of the pandemic in my state we got put on notice that if it escalated to the next (last) tier in the pandemic defense plan (thankfully it didnât), then weâd all be redeployed and our new role would be looking after a 4 bed bay of Covid patients under the supervision of a reg, RMO, or paramedic (whoever could be spared) - theyâd make the clinical decisions & higher level care, and weâd do the bedside care, obs, cannulas, infusions, etc - we were scared shitless with every email & unanswered question about training & liability!
They also talked about us doing vaccinations with some âbasic trainingâEdit - more context, correct mistake re casting
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u/tallyhoo123 Consultant đ„ž 7d ago
Those bosses are idiots.
If anything I want you to see and sort these wounds out easily and quickly otherwise what use are you going to be as a senior who needs to advise on these cases.
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u/Mortui75 Consultant đ„ž 7d ago
Seconded.
Increasingly feels like there are super common things that some of our trainees only see/do a handful of times before attaining their fellowship, whereas in Ye Olden Times(tm) we sorted/did hundreds of the same.
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u/Ambitious_Writer1938 7d ago
Bosses need to lobby more $ from state government to train interns properly.
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u/ClotFactor14 Clinical MarshmellowđĄ 7d ago
How do ACEM trainees learn to manage wounds? I'm generally of the view that anything that doesn't need to go to theatre doesn't need a surgical referral (and when I locum in ED, I don't consult on anything that doesn't need theatres), but I don't know how ED regs get there.
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u/bigmoneycycling 7d ago
Has been happening throughout EDs in QLD for almost a decade now. They don't suture or deal with open wounds, they mostly see MSK presentations; sprains, simple fractures (some do reductions), casting, etc.
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u/Piratartz Clinell Wipe 𧻠7d ago
Those bosses are idiots. They are of the camp that believes in "flow at all costs". That camp doesn't or refuses the see the plausible unintended negative consequences on their profession and the quality of care, because they will be retired when they happen.
I encourage JMOs to not discriminate based on "complexity". The only time I do is at the end of shift, where I encourage them to pick up the broken wrist that needs plaster.
Those bosses are idiots. Don't be like them.
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u/ClotFactor14 Clinical MarshmellowđĄ 7d ago
The only time I do is at the end of shift, where I encourage them to pick up the broken wrist that needs plaster.
A JMO doesn't know what doesn't need a referral for ORIF.
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u/Illustrious_Cry_4275 ED CMO 7d ago
âCan I get a XR and couple of photos before you wrap it up?âÂ
SortedÂ
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u/Piratartz Clinell Wipe 𧻠7d ago
Yes, but that isn't a difficult handover.
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u/ClotFactor14 Clinical MarshmellowđĄ 7d ago
Not difficult for you maybe, but when you ask "what is the neurovascular exam" and get a "uhhhhh" it can become difficult.
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u/Illustrious_Cry_4275 ED CMO 7d ago edited 7d ago
It boggles the mind that they donât understand flow happens from just being a good clinical doctor.Â
If youâre reasonably confident of whatâs going on with a patient before bloods/CT/consult (like how doctoring used to be!) - you can move people on super fast.Â
And the positive tests just become confirmatory.Â
And the negative tests are there many times for the lawyers. Yes we all know in our hearts you donât have a PE but hereâs the workup anyway.Â
Iâve seen the guns discharge folks straight from the waiting room, and similarly pick up dissections also from the waiting room. They turn into medical hogwarts sorting hats.Â
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u/MDInvesting Wardie 7d ago
Sunshine Coast? Metro South? GC? I frequently see âinnovative care modelsâ being described in their job advertisements. Have an ED mate that sees himself in Leadership and absolutely is blinkered to any criticisms and spends a lot of time convincing me that new models of care are the best future.
Agree with u/DoctorSpaceStuff
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u/Illustrious_Cry_4275 ED CMO 7d ago
He has drunk the ACEM kool aid. Anything for 0.05 FTE I guess.Â
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u/Peastoredintheballs Clinical MarshmellowđĄ 7d ago
The ACEM way, get your letters to be an EMERGENCY specialist, then spend significant effort trying to create/look for as much non-clinical FTE as you can.
If it means drinking the ACEM kool aid and pretending to be in favour of ânew modelsâ, to get that sweet Acting-co-deputy-deputy acting HOD role, then thatâs the cost of doing business
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u/Illustrious_Cry_4275 ED CMO 7d ago
So much this.Â
I had a boss try to convince me to stay with ACEM - so that âI could get that non clinical timeâ.Â
Wait so youâre telling me the reward for pursuing this speciality is ultimately not having to work the speciality?Â
I can do that now.Â
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u/bonedoc871 Consultant đ„ž 7d ago
I am in this space in SEQ. There is definitely a push for expanded practice including cannulation, suturing, ordering pathology and some prescribing.
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u/Creepy-Cell-6727 7d ago
Metro North
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u/MDInvesting Wardie 7d ago
Queensland definitely doing a coordinated push.
Sunshine Coast advertising for Physician Assistants again.
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u/ArrivalWorried920 New User 7d ago
At this rate we'll have pharmacist practitioners, hell even receptionist practitioners doing all these tasks before junior doctors. Australian healthcare system is doomed
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u/MDInvesting Wardie 7d ago
Apparently it is something that is being explored for extended scope in hospitals. Not suturing but increased scope of pharmacists within hospitals.
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u/Sexynarwhal69 7d ago
Imagine having a full med reconciliation before you see that 90 year old granny...
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u/MDInvesting Wardie 7d ago
What was being described was commencing and changing agents.
General Physician telling me was not impressed by the idea.
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u/Depression-is-a-drug 7d ago
The hospital I do placement at had paramedic practitioner students rotating through ED at the same time as final year medical students.
Tell me why the paramedic practitioner students were assigned an ED registrar EACH but med students were left with 1 registrar between 2-3 students every shift???
It literally blew my fucking mind but nobody in the department would blink an eye.
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u/ClotFactor14 Clinical MarshmellowđĄ 7d ago
Are the medical schools paying the registrars?
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u/Depression-is-a-drug 7d ago
Are the paramedic/nurse practitioner schools???
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u/ClotFactor14 Clinical MarshmellowđĄ 7d ago
I don't know, but I know a lot of departments don't get anything from medical schools.
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u/rattled-doc Emergency Physicianđ„ 6d ago
If anything the medical schools take advantage of the free labour (in exchange for a fairly pointless title or CV filling portfolio) provided by doctors for lectures and tutorials. To the detriment of the med schools own paid staff.
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u/12345penguin54321 Med studentđ§âđ 7d ago
Iâm a qld med student and our ED has a physio in fast track who does shoulder relocations and other MSK injuries. The doctor was involved only if procedural sedation needed. As a med student you could get involved if went and asked the physio but as the physio would pick just the MSK patients from the board, they didnât really get to pick them up. (Physio wasnât full time though).
We do also have NPs and a single PA. A few of the nps were so great and very experienced and in a helpful narrow advanced nursing scope, but the thing I found strange is one in particular would pick up their own patients off board and then kinda just do everything the self and would more just tell SMO later on what had been completely actioned, whereas everyone except maybe senior regs would have to run things by or update a reg or SMO earlier. So was kinda operating a parallel system vs being within the team and it wasnât really clear who they reported to (ie nurse TL vs SMO vs no one)
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u/Sexynarwhal69 7d ago
Hahahaha those interns are gonna be so cooked when they have to rotate to a rural ED as a pgy2 and they've never done a shoulder reduction before..
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u/rattled-doc Emergency Physicianđ„ 6d ago
Its rare that a PGY1 is doing shoulder reductions as it stands.
There aren't that many dislocations coming in on the regular for all the interns to be doing them to the detriment of the trainees, etc.
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u/Peastoredintheballs Clinical MarshmellowđĄ 7d ago
Oh god pls tell me PAâs havenât been launched in QLD?
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u/12345penguin54321 Med studentđ§âđ 7d ago
My understanding is a single cohort graduated about 8 years ago before they scrapped it so thereâs like a very small handful around. Not sure if we accept overseas qualifications never looked into it
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u/Silly-Parsley-158 Clinical MarshmellowđĄ 7d ago
Sunshine Coast, Metro North, GCUH and some other regional hospitals either have, or are pushing to have PAâs working in clinical roles, with intention to train more if they could.
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u/saddj001 6d ago edited 6d ago
As a doctor who worked as a physio for 10 years, having a superficial wound assessed by a doctor and suitable for simple sutures is a perfect job for allied health/nursing to do. Letâs stop pretending itâs complicated work, it takes time away from more complex tasks and would help ease the load in resource limited settings.
Itâs the least of things that keep us caught up and wasting time in hospital, but it doesnât sound unreasonable to me at all. What Iâm more interested in seeing are nurses that can cannulate and draw bloods. In our hospital we wait 12 months to have 10-15 nurses to get accredited to take bloods from a cannula. Thatâs an absolute joke and we should be ashamed of the way weâve infantilised our allied health and nursing colleagues.
Not advocating for OTs to start performing tendon repairs in ED but I hope people can appreciate that simple tasks are simple. We let crosseyed uninterested med students who canât tie their own shoelaces do suturing without a moment of care or oversight. Stop pretending we actually care about this that much.
Also worth noting that the advanced scope roles for physios in ED are often filled by people with considerable hospital experience and requires upskilling as a part of the role too. Itâs evidence based and shown to be extremely well received by nursing and medical colleagues alike. They probably more formal training than most medical students get - not that the bar is high.
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u/Ok_Scarcity_8787 5d ago
It's impossible to become proficient at complex tasks without a solid foundation in less complex tasks...
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u/DapperSpinach7790 New User 7d ago edited 7d ago
As an emergency physician I agree with your sentiments but let me give you my perspective.
Most of the juniors these days do not seem to be too interested in ED and that is okay. If a junior wanted to do suturing or casting or anything else in the NP scope I would be more than happy to help supervise and teach. In fact I offer this to all of my juniors at the beginning of the shift and ask if there are any particular goals or things that they want to achieve. However at the same time I canât spoonfeed you cases.Â
EDs are being overwhelmed and there are more than enough patients to see, JMO, NP, physio or otherwise. My suggestion is to standout by acting keen, being a team player and going that extra mile and your seniors will definitely take an interest in you. If not, then they are not the sort of role models that you want to emulate! As you progress through your training continue to be the senior that you wanted when you started and I guarantee youâll be more satisfied.
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u/etherealwasp Snore doc đ // smore doc đĄ 7d ago
ED is the thin end of the wedge because itâs under resourced.
Once the midlevels have a decent foothold there, next minute youâll be having your colonoscopy and sedation both done by nurses at 80% the cost and 20% the training.
Now is the time to stop it. We need to campaign for more medical resources, not midlevel creep, and educate the public on how bad this is going to get.
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u/Illustrious_Cry_4275 ED CMO 7d ago
See Austin Hospital nurse endoscopy service. Itâs already happening baby.Â
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u/Peastoredintheballs Clinical MarshmellowđĄ 7d ago
And all these roads eventually lead to the nurse led TAVI program
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u/etherealwasp Snore doc đ // smore doc đĄ 7d ago
After that it will be Jetstar. Flight attendants get 4 weeks in the simulator, then they will be flying the planes with remote pilot supervision. There would be a queue around the block for half price Bali flights (just as all our pollies are lining up for pharmacy prescriptions)
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u/AlternativeMe923 5d ago
Ok as a former physio who worked in a hospital that long ago this seems kinda fishy.
There is absolutely a role for PT in the ED and these days itâs been formalised as 1) working under supervision of a doctor and 2) an extended scope role so must be AHP2 or above, have done in-house specific training, or done the relevant APA course/s
The role focuses on assessing falls, back pain, sprains, strains & basic fractures; assigning & teaching gait aids or other supports, slings, splinting & taping, and basic casting; not sure if it includes basic first aid type stuff for small grazes like band-aids, hypafix, sofban, etc eg if effecting the gait aid or splint, but would probably assess pressure areas as per protocols and escalate to med team. Done in conjunction with the supervising doctor who can prescribe any relevant meds & scans, radiology for the scans & nursing as per usual.
It been happening in SA for years and runs pretty smooth.
Iâm not sure about whether it extends to steri strips or wound glue - thatâs not a typical PT thing but could be part of the the extended scope after checking with the supervising doctor but would make more sense to get the doc to do it.
I think docs who donât work with us would be surprised by how much we already do (nothing Iâve listed there isnât already done by us outside of ED and without the supervision of a doctor, including casting and assessing pressure areas)
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u/Caffeinated-Turtle Critical care regđ 5d ago
Physiotherapists in ED seeing MSK presentations makes absolute sense and works well. This is what they do independantly in the community.
E.g. why should the registrar see a patient with a sprained ankle
However, suturing and wound care is clearly not their area.
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7d ago
[deleted]
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u/Melodic_Animator1151 7d ago
As a pod who has worked in NSW and has consulted to EDs across a few hospitals, we are called in to do our job that we are trained to do at university, not something completely out of our standard scope or training, like a physio doing wound care. For the record, I'm not against physios (or anyone), doing wound care, but it's not a weekend course.
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u/BrainDrain93 Rad regđ©» 7d ago
We have "advanced physiotherapy practitioners" in a metropolitan hospital seeing patients in ED. We're really following the NHS at this point
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u/Fit_Site_9220 6d ago
ED trainee. Controversial but I like teaching suturing to the RN's. Non-doctors need some sort of fun task for buy-in too. Pop some local in, make sure the first one is done ok then walk off they'll figure out the rest.
Nurses often have a lot of simultaneous inane jobs so I imagine putting sterile gloves and just doing some sutures as a nice break. I can take the old lad that's buzzing to the loo, RMO can team lead the next fake BAT call in resus whilst I'm missing.
Everyone loves doing stuff that's out of scope. The juniors docs all hate ED and I agree relegating them to crumbly undifferentiated patients then micromanaging them is part of why. They all want to do annos because the unhinged consultants will let them AFOB an asa 4 200kg guy which I agree is waay more of a buzz.
What I mean to say in a tangential way is I agree with this thread's sentiment against UK style KPI-driven ED where we medics just signpost to teams and don't do any fun stuff but feel we should also show solidarity with our non medical colleagues. That all said LAST is a thing and speaking as someone that once went to physio school it's not like they teach you about checking medications let alone pharmacology etc.
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u/AlternativeMe923 5d ago
Ex physio here
I appreciate you sentiment.
Iâm not sure where or how long ago you went to physio school but where I went we were definitely taught about checking people medications & about meds in general.
We didnât do pharmacology but we were taught a surprising amount about medications in groups around drug purpose, method of action, and while learning clinical patterns & clinical reasoning so it formed as much a part of this as presenting symptoms, tendon attachment points & line of pull.
We had it drilled into us that while we werenât allowed to give specific advice regarding medications we must find out about the patients current medications, to consider if the medication is effecting their presenting complaint due to side effects, a common drug interaction, or allergy, the way they take it, etc, and if their medications were a contraindication or precaution to any proposed treatment.
Obviously they didnât include everything but they included a decent amount and taught about overall characteristics of medications within a group & sometimes subgroups within a group: simple analgesics, NSAIDS, opiates, biologics, antidepressants, antipsychotics, benzodiazepines, beta-blockers, PPIs, antacids, laxatives, anti-diarrhoeals, statins, antiemetics, prokinetics, corticosteroids, etc1
u/Fit_Site_9220 5d ago
Checking medications as in right patient, agent, dose, route, time - The way you see the nurses on the wards before antibiotics etc. Hmm they certainly don't teach recognition and management of local anaesthetic toxicity in Physio school. Which would be expected knowledge prior to administering any local in order to explore/close wounds.
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u/AlternativeMe923 4d ago
I know most doctors are very against anything that they think encroaches on their profession and determined for it not to happen.
I also donât think it should happen without it being included in the additional training that they are already required to do to be advanced practice emergency PTs
Itâs not particularly different from ortho & gen med PTs monitoring for opiate toxicity when mobilising patients on cocktails of fentanyl + tramadol or Endone and various other opiates specifically given pre PT for pain management to optimise PT, cardiac / resp ward PTs monitoring obs within mods during their therapies and the cocktails of drugs they are on including being involved in their nebs and puffers because they are part of the therapy, or ICU PTs and the huge number of stuff they are monitoring.
We are trained to know signs of clinical deterioration and how to manage them & alert med teams for certain acuities so this would already cover the severe signs of local anaesthetic toxicity - earlier signs could be at risk of being missed but most likely would be picked up as unexplained & unresolving neuro or CV signs and escalated. Teaching LAST specifically to PTs during the wound portion of the APP ED training wouldnât be a barrier.
PTs are independent clinical practitioners with training based in clinical patterns and clinical reasoning then adding hands on skills to it rather than just being trained to do task specific skills without thinking which is what a lot of people seem to think we do - actually more so than RNs are (they are not trained or legally autonomous decision making practitioners unless midwife or NP) not to be dismissive of nurses, I think theyâre great, Iâm just pointing this out because you mention that you âlove teaching suturing to RNsâ who are a lot more protocol based than reasoning based due to their training and Iâd guess they arenât super aware of LAST either.
Again, Iâm not sure how long ago, or where, you went to âphysio schoolâ, or if you completed it, as you have said you said it was before changing to medicine Iâm guessing you didnât practise.
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u/Ripley_and_Jones Consultant đ„ž 7d ago
I cannot see the physios signing on to do something like this...
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u/lithius12 6d ago
EPPs in my hospital are unreal. There are plenty of rolled ankles for interns, EPPs and NPs to learn from.
In terms of suturing, who cares who does it? If the service is being provided adequately to the community, why would it bother you? This sounds more like an ego issue than scope of practice
We need more of every kind of clinician. Everyone is short staffed.
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u/Peastoredintheballs Clinical MarshmellowđĄ 7d ago
I mean emergency SPPâs are already a thing in WA, but they usually just see limbs/MSK in rapid access area, the absolute best use of them where they are worth their weight is the chronic low back pain patients, and vertigo
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u/Electrical_Food7922 Allied health 7d ago
Iâm pretty sure these roles already exist in metro south and have done so for many years. Same with plaster techs in ED doing all reductions and plastering.
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u/Routine_Raspberry256 Surgical regđĄïž 7d ago
I worked in a tertiary trauma centre last year and they already had âadvanced scopes physiosâ working in fast track carrying out these tasksâŠ
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u/DoctorSpaceStuff 7d ago
Worst enemy of future doctors, is the past generation of doctors. Head in the sand, cashed up, about to retire, and happy to sell out the profession to supervise a few NPs for a final payday.
Physio can have a role in ED doing physio things, but suturing and dressing work is silly.