Flight Medicine

[Ken Szwak MHS PAC]

In addition to 10 years as a PA in Emergency Medicine, I spent the 10 years prior to that working in both paid and volunteer EMS. While in PA school, I met many fellow students with similar backgrounds in EMS. Given such a combined history, many PA's would be a perfect fit in Flight Medicine. Not to be crass or conceited and no offense to paramedics and RN's, PA's with that combined background would be the perfect fit. The EMS background gives us the familiarity with EMS protocols and our training exceeds that of RN's and paramedics. However, I have not been able to find a flight medicine program that utilizes PA's or would be interested in developing a pilot program to evaluate how well PA's would perform in such an environment.

 

Given that this is something I would greatly like to do, even per diem, I was hoping someone on this forum might have information on a program that currently utilizes PA's or would be open to it (preferably near the Philadelphia Tri-State area but I would be interested in hearing about programs anywhere).

 

Thank you in advance,

 

-Ken

[KMD16]

One of my attending who's semi retired does it. I will fine out from him if they have PAs on their team or if he knows any PA that does it. However, my guess would be no.

[dmdpac]

Having worked as a flight medic for years before PA school I'm curious what you think a PA could bring that a RN/Paramedic team couldn't.

[EMEDPA]

I think a PA/RN, PA/EMT-P, or PA/RT(resp.) could find such a position using their prior credentials.

[GetMeOuttaThisMess]

I think dmdpac asks a valid question. I've seen trauma attendings screw up what field personnel put in place, and rightfully so in my experience.

[EMEDPA]

certainly agree- a trauma surgeon in the back of a helicopter can do pretty much what a flight medics can without all of their fancy toys around. I don't know that adding someone with training> emt-p really adds anything.

critical care flight medics are already doing chest tubes/crichs/vents/pressors/etc.

Unless they change the whole paradigm to in-flight surgery I don't see much changing by adding any new providers to the mix(not that it wouldn't be a cool job).

what probably makes more sense is for a PA/EMT-p to do a few shifts/month as a flight medics as a side gig in addition to a regular em or critical care job.

[skyblu]

I agree with above.

 

I had a professor who is an incredibly experienced, brilliant EM PA but has maintained his EMT-P certification exclusively to be able to do a few flight shifts each month. They don't use PAs in this group either.

[Ken Szwak MHS PAC]

Thank you for all your replies.

 

@dmdpac- My wanting to work in this field has nothing to do with what I can bring to the table that RN's and Medic's can't. It's about my combined prior experience in both EMS and Emergency Medicine making a position in flight medicine and good and natural fit. I'm also trying to understand the road blocks that seem to exist in getting a program interested in even attempting a pilot program utilizing PA's / a PA. I have never been given the courtesy of a reason why. I simply hear "We just don't use PA's". Is it a lack of understanding of the PA's scope of practice (I would hope not)? Is it a concern over compensation? Billing? If someone were to give an actual explanation and allow one the chance to see if that obstacle could be (legally and ethically) overcome, I can see that. But to simply say we don't use them is dismissive and unprofessional.

 

@GetMeOuttaThisMess- Yes, I agree, a trauma surgeon can very well screw up what occurs in the field. However, PA's are not physicians and on the good end of that spectrum is that most PA's don't act like physicians / surgeons. Add in a PA with a strong EMS background, it is far less likely you would get the same scenario. 

 

From my end, I have the skills and past experience to translate into a Flight Medicine position (as there are many other PA's with extensive EMS backgrounds). My goal is still to find a program progressive enough to at least pilot the idea and find out what the obstacles are. There are a great many examples of PA's not getting into certain areas because people working in those fields had a poor understanding as to what PA's could do, how do bill properly, etc. and it is very possible what flight programs may perceive as obstacles are not really obstacles at all.

[fakingpatience]

I have seen a flight program that uses MDs occasionally (not sure the limitations on when they fly with an MD vs. without, seemed rather arbitrary, but I was on the outside looking in).   Perhaps one that already uses an MD/DO would be more likely to try a PA

[dmdpac]

@dmdpac- My wanting to work in this field has nothing to do with what I can bring to the table that RN's and Medic's can't. It's about my combined prior experience in both EMS and Emergency Medicine making a position in flight medicine and good and natural fit.

Your first two sentences make it sound like it is, in fact, what you think you can bring that current flight crews can't. And honestly, I'm curious about your EMS experience. EMT-B? It sounds like it from your comments (otherwise I think you'd specify paramedic experience). If so, EMT experience is not the same as paramedic experience and is not nearly enough EMS experience to prepare you for the air medical environment.

 

I'm also trying to understand the road blocks that seem to exist in getting a program interested in even attempting a pilot program utilizing PA's / a PA. I have never been given the courtesy of a reason why. I simply hear "We just don't use PA's". Is it a lack of understanding of the PA's scope of practice (I would hope not)? Is it a concern over compensation? Billing?

My flight service told me that they don't use PAs for a variety of reasons. There's nothing a PA could do that the current RN/Paramedic team can't do. They aren't going to pay a PA what a PA would either need to be paid or want to be paid because it's more cost effective to pay a paramedic and an RN to do the job. A PA is not going to have the skill set and experience needed for a critical care interfacility transport no matter what kind of prehospital or ER experience s/he may have.

 

Flight medicine is not just scene work. There are some sick interfacility transports that make up the balance. Increasingly, especially in the greater Philly area (if that is, in fact, where you are based on your OP) there are less and less scene flights and more interfacility transports. Do your volly EMT experience and ER experience have you ready for a patient on an IABP with 10 different drips running (and only five pumps to use for transport)? Does it have you ready for the 22 week gestation 500+ gram baby? This is where the critical care background of the flight nurses and paramedics comes into play.

 

This is especially true when a PA would demand a higher salary than would the RN/Paramedic team and not have the same skill set needed for the job. At least, this is according to my former flight service and every other flight service with whom I've had the discussion (including those in the greater Philly area).

 

If someone were to give an actual explanation and allow one the chance to see if that obstacle could be (legally and ethically) overcome, I can see that. But to simply say we don't use them is dismissive and unprofessional.

Well, you can't argue the financial aspect with them.

 

As much as you would like what you think is a reasonable reply from those with whom you've conversed on the topic, the flight services in question don't really owe you an explanation. They have lengthy lists of paramedics and nurses who want a flight spot. Some of those applicants are qualified. Many (most?) aren't. Applicants try to argue with them all the time about how s/he is a perfect fit for a flight job because of his/her background. The flight services have, "Thanks, but no thanks" down to a science because they have to. It is neither dismissive or unprofessional. It's simply, "Thanks, but no thanks".

 

Also, that you don't like the answers you've been getting does not make them either dismissive or unprofessional.

 

From my end, I have the skills and past experience to translate into a Flight Medicine position (as there are many other PA's with extensive EMS backgrounds). My goal is still to find a program progressive enough to at least pilot the idea and find out what the obstacles are. There are a great many examples of PA's not getting into certain areas because people working in those fields had a poor understanding as to what PA's could do, how do bill properly, etc. and it is very possible what flight programs may perceive as obstacles are not really obstacles at all.

Please don't think you're the only one who has approached a flight program about this. I'm inclined to think that if a solution existed it would have been found by now.

[coloradopa]

snip

 

My flight service told me that they don't use PAs for a variety of reasons. There's nothing a PA could do that the current RN/Paramedic team can't do. They aren't going to pay a PA what a PA would either need to be paid or want to be paid because it's more cost effective to pay a paramedic and an RN to do the job. A PA is not going to have the skill set and experience needed for a critical care interfacility transport no matter what kind of prehospital or ER experience s/he may have.

 

Flight medicine is not just scene work. There are some sick interfacility transports that make up the balance. Increasingly, especially in the greater Philly area (if that is, in fact, where you are based on your OP) there are less and less scene flights and more interfacility transports. Do your volly EMT experience and ER experience have you ready for a patient on an IABP with 10 different drips running (and only five pumps to use for transport)? Does it have you ready for the 22 week gestation 500+ gram baby? This is where the critical care background of the flight nurses and paramedics comes into play.

 

This is especially true when a PA would demand a higher salary than would the RN/Paramedic team and not have the same skill set needed for the job. At least, this is according to my former flight service and every other flight service with whom I've had the discussion (including those in the greater Philly area).

 

 

Well, you can't argue the financial aspect with them.

 

Snip

The thing a PA brings to the table that a RN or Paramedic don't is the ability to bill. A critical care patient at Medicare rates brings in around $140/hour. Real insurance it can be more like $300/hour. That's money that an RN or Paramedic can't bill. The model would depend on what the payor mix looks like. 

[Ken Szwak MHS PAC]

@dmdpac: Please do not make this a contest between who is capable to do what. I respect what flight medics and RN's do and the level of care they provide. I am not suggesting I can bring something more to the table. It is merely something I would like to do and feel my combined experience gives me that ability. It is just that simple. Why can't you see that. I realize a lot gets lost with just the written word but seriously, I don't know what else I can write here to make you understand that. If you think that it's not simply just a goal of mine, you are wrong and if you want to make it more than it is, that is on you.

 

I will partially concede you have a point on what level of EMS. While I did paid BLS, I reference that more for procedural EMS experience rather than medical experience. As for my experience as a PA, you sell me and others short. To say "A PA is not going to have the skill set and experience needed for a critical care interfacility transport no matter what kind of prehospital or ER experience s/he may have" is a generalization and not always true. Certainly there are those PA's who see nothing but fast track patient's in the ER. I'm fortunate enough to work in an ER where I'm not trapped in fast track. I see the MI's, the critical respiratory patients, many OB cases critical and otherwise. I intubate, put in chest tubes, IV conscious sedation for procedures. And I have PA colleagues working in ICU's and CCU's with even more experience than me managing multiple drips, LVAT's, inserting/managing CVP's. The experience is there. No, we as PA's don't bring more to the table but we certainly don't bring less.

 

Yes, you are right, no one owe's me an explanation and to not engage in a conversation as to why is still rather unprofessional and can be dismissive. They are not mutually exclusive. I appreciate that while we aren't seeing eye to eye on this that you have at least taken the time to give me more answers than I had before. Even if they don't owe an explanation, I still have the right to question why not and what those reasons are, or are you going to suggest I don't have that right? And regardless whether or not more can be billed as the other coloradopa pointed out, I would gladly work in flight medicine for whatever the going rate that RN's and medics make. Again, I would just simply like to work in the field and would not complain about salary.

 

For what ever reason, your posts are highly negative. I'm not sure why. Your replies just talk about what can't be done, what PA's aren't capable of. I simply have a goal that I'm being persistent with... is that wrong? Have you never had goals? I know myself. I know what I am capable of, what my limitations are, and what I can learn. If I let every person who told me something wasn't possible, I wasn't capable, etc make me believe that, I would probably working a dead end job I hate. And I imagine that like me, you never let people like that get to you. Now, you may still think I'm not capable of working in that field. That's fine. Your are allowed your opinion no matter how wrong you are. Just enough with the negativity. If you want to actually help me achieve my goal, then by all means reply. If you want to just tell me more why PA's can't work in flight medicine, give it a rest and don't bother. I heard you the first time.

[Nonlegit]

Just something to add, its relevance is debatable...

 

Cleveland clinic flies with NPs, and it appears that Metrohealth Lifeflight has gone away from attending physicians to NPs as well. So there ARE some flight programs that specifically fly midlevels....not just midlevels getting in their "fun time" under an EMT or RN license.

 

I haven't read the rest of the thread in detail, but thought I would mention that London Air Ambulance is doing some interesting things with on scene thoracotomys as a result of traumatic arrests (I guess they love knife violence over there).

 

I'll see if I can dig up a slideshow from them about it.

[dmdpac]

The thing a PA brings to the table that a RN or Paramedic don't is the ability to bill. A critical care patient at Medicare rates brings in around $140/hour. Real insurance it can be more like $300/hour. That's money that an RN or Paramedic can't bill. The model would depend on what the payor mix looks like.

My understanding of ambulance billing does not account for billing for a provider like a PA. Billing codes are somewhat limited along the lines BLS, ALS 1, ALS 2, specialty care transport (SCT) and reimbursement for them isn't that much. This is something the EMS industry has been working on changing (without much success yet). My research on this isn't turning up much to the contrary. If you have anything different I'd love to see it.

[dmdpac]

@dmdpac: Please do not make this a contest between who is capable to do what. I respect what flight medics and RN's do and the level of care they provide. I am not suggesting I can bring something more to the table. It is merely something I would like to do and feel my combined experience gives me that ability. It is just that simple. Why can't you see that. I realize a lot gets lost with just the written word but seriously, I don't know what else I can write here to make you understand that. If you think that it's not simply just a goal of mine, you are wrong and if you want to make it more than it is, that is on you.

Then go get your paramedic certification or RN license, get the relevant experience, and go after it. It sounds like you've been pursuing this from the PA perspective for a while and haven't had much success. Perhaps it's time to change your tactics and work it from a different angle.

 

You seem to be taking all of this very personally. This is nothing personal. I don't know you. You don't know me. Relax. You asked questions. You got answers. Again, just because they're not the answers you want or want to hear doesn't mean it's an attack on you or meant in a "dismissive or unprofessional manner".

[coloradopa]

My understanding of ambulance billing does not account for billing for a provider like a PA. Billing codes are somewhat limited along the lines BLS, ALS 1, ALS 2, specialty care transport (SCT) and reimbursement for them isn't that much. This is something the EMS industry has been working on changing (without much success yet). My research on this isn't turning up much to the contrary. If you have anything different I'd love to see it.

I'm not talking about billing for the ambulance, I'm talking about billing E/M provider time. Depending on how things are structured the provider can start billing for care when they meet the patient. The service is an extension of the hospital visit. A number of ECMO programs use this model. They go to the patient place the cannula, put the patient on ECMO and bring them back. From what I understand they bill ECMO procedural and management codes as well as critical care codes. You could put a similar system in place where a critical care PA and ICU nurse to some of these small hospitals, stabilize the patient and bring them back. Reimbursement would more than pay for the PA salary. It would save for example the hospital that sent me a GIB patient with a blood pressure of 80/30 and a 24 gauge IV in the thumb. When the nurse go report I thought she was joking but low and behold... 

[GreatChecko]

Critical care transport with PA's was attempted in Denver a few years ago. It was well planned and run by a PA, but didn't last very long, unfortunately. 

 

I think the above idea would work, but would require buy in from from many different organizations. The subsequent cat herding would probably be the biggest challenge. 

[coloradopa]

Critical care transport with PA's was attempted in Denver a few years ago. It was well planned and run by a PA, but didn't last very long, unfortunately. 

 

I think the above idea would work, but would require buy in from from many different organizations. The subsequent cat herding would probably be the biggest challenge. 

I think the biggest challenge would be the down time. We bill for around 2/3 of our time in the ICU every day. That more than pays our salaries. In critical care transport there is a lot of waiting around which is unpaid time. You would have to have a system that had extra work. When I worked in the NICU the NNPs did flights. There were two on at night and a doc in the call room. If there was a flight then one of the NNPs went and the doc got up and covered the unit with the other NNP. You could do a system like that if you had enough providers. 

[Nonlegit]

Found that powerpoint...again probably unique to London and it's medical needs but it's still pretty interesting to see.

 

http://resus.ie/site/wp-content/uploads/2013/08/HEMS-in-an-urban-setting-Anne-Weaver.pdf

[GreatChecko]

Are the London Docs volunteer? IIRC, the whole program is funded by sponsorships and volunteers, not by NHS.

[True Anomaly]

As another aside, since you mentioned the Philadelphia area and I would assume then  you are based in Pennsylvania with a Penn license- part of the obstruction might also be that there is (still to my knowledge) no mechanism in place to allow PA's to work in the prehospital environment.  Yes, Penn passed a law a few years ago allowing for PA's to obtain pre-hospital certification, but once passed the state EMS group has done nothing (again, to my knowledge) to actually set it up - including tests, mechanism for initial certification, any classes needed, etc.  The reason I had heard was that the state EMS medical director was very anti this law even getting passed (there was not a similar one passed for NP's, but that's another aside).  This position wasn't meant just for flight EMS,  but EMS in general.  So unless you find a doctor who did an EMS fellowship and also did some flight medicine training who would allow you to be your supervising physician and thus allow you to do what they do, there's simply not really a legal mechanism in place for PA's to do flight medicine in Penn.

[GetMeOuttaThisMess]

Just a couple of years ago I heard the medical director for London EMS (female and don't recall her name) talk about how they were just starting to utilize motorcycles to expedite response time but I don't recall her discussing at any of these annual conferences their air support.

[dmdpac]

As another aside, since you mentioned the Philadelphia area and I would assume then  you are based in Pennsylvania with a Penn license- part of the obstruction might also be that there is (still to my knowledge) no mechanism in place to allow PA's to work in the prehospital environment.  Yes, Penn passed a law a few years ago allowing for PA's to obtain pre-hospital certification, but once passed the state EMS group has done nothing (again, to my knowledge) to actually set it up - including tests, mechanism for initial certification, any classes needed, etc.  The reason I had heard was that the state EMS medical director was very anti this law even getting passed (there was not a similar one passed for NP's, but that's another aside).  This position wasn't meant just for flight EMS,  but EMS in general.  So unless you find a doctor who did an EMS fellowship and also did some flight medicine training who would allow you to be your supervising physician and thus allow you to do what they do, there's simply not really a legal mechanism in place for PA's to do flight medicine in Penn.

This is correct. To the best of my knowledge, also, there is no mechanism in place for the pre-hospital PA. It's a legal pre-hospital provider level but nothing has happened with it to bring it in to actual existence.

 

To be fair, there is also a pre-hospital health professional level for physicians. I used to fly with a guy who was an e-med DO who had to fly as a paramedic because legally (at least as it was explained to him and the rest of us) he couldn't fly as either a doc (as he wasn't our medical director) or as a pre-hospital health professional. If he wanted to fly he had to fly as a paramedic. Even though the pre-hospital physician extender (as it's called in Pennsylvania for PAs) exists, it is not clear if that would even allow someone to operate in a HEMS environment.

 

The other two states in the Philly tri-state area, NJ and DE, do not have allowances for PAs to work prehospitally unless they do so as paramedics or RNs.

 

I've known several PAs in the region who have flown HEMS. They have all flown as paramedics. While I understand the OP's desire to fly, as a PA there just isn't the standing to do it from a PA perspective in the region in which he wants to work.

[medic25]

Critical care transport with PA's was attempted in Denver a few years ago. It was well planned and run by a PA, but didn't last very long, unfortunately. 

 

I think the above idea would work, but would require buy in from from many different organizations. The subsequent cat herding would probably be the biggest challenge. 

I did a ride-along with this unit during PA school (Pridemark Paramedics).  It was a great idea; the PA handled the critical care transfers, but the unit also took call for local nursing homes.  The PA had a suitcase full of extra equipment (e.g. foleys, lac repair supplies) and rather than transport the patient to the ED the PA could respond to the ECF and manage the patient on site.

[GreatChecko]

I did a ride-along with this unit during PA school (Pridemark Paramedics).  It was a great idea; the PA handled the critical care transfers, but the unit also took call for local nursing homes.  The PA had a suitcase full of extra equipment (e.g. foleys, lac repair supplies) and rather than transport the patient to the ED the PA could respond to the ECF and manage the patient on site.

 

It's too bad it didn't work out.