NP/EMT-P Field teams?

[EMEDPA]

 

LATimes Endorses Plan For Nurse Practitioner-Paramedic Team To Respond To Least-Urgent 911 Calls.

The Los Angeles Times (4/9, 3.49M), in an editorial, says that the Los Angeles Fire Department should be updated to the current situation in which fires “are fewer and farther between,” and “nearly 90%” of its calls “are for medical service.” It urges approval of Los Angeles Councilman Mitchell Englander’s proposal to assign “the least-urgent medical calls to a team of just two people — a nurse practitioner and a paramedic.” While the pair “would use an ambulance,” their focus would be on treatment “at the scene,” a change which could save “millions of dollars” annually. The editorial points out that “nurse practitioners are able to do more than paramedics.” The team would also seek to reduce use by “superusers,” those who use the 911 service “more than 50 times a year.” Mesa, Arizona’s similar effort is credited with saving $3 million in 2013.

 

 

This should be done with EM PAs....we are the obvious choice for this...

 

[dmdpac]

Especially those of us who are/were medics

[Boatswain2PA]

As an EM PA I would NOT do this.  While I think I would be "better" at it than a paramedic or (most) NPs, you can't practice emergency medicine in someone's house. 

 

I'm not saying PAs shouldn't do it, because I think they would be fine at it.  But not PAs who consider themselves EM PAs.  This isn't emergency medicine, this is urgent care/family practice.  Why would you go through all the time/trouble/expense to become an EM PA, with or without the CAQ, only to continually diagnose URIs & scabies, or adjust lasix and lisinopril dosages. 

[EMEDPA]

As an EM PA I would NOT do this.  While I think I would be "better" at it than a paramedic or (most) NPs, you can't practice emergency medicine in someone's house. 

 

I'm not saying PAs shouldn't do it, because I think they would be fine at it.  But not PAs who consider themselves EM PAs.  This isn't emergency medicine, this is urgent care/family practice.  Why would you go through all the time/trouble/expense to become an EM PA, with or without the CAQ, only to continually diagnose URIs & scabies, or adjust lasix and lisinopril dosages. 

you don't do it full time. you do it a day/week to keep these low acuity issues out of the ER where you will have to see them anyway at the expense of folks with real medical issues.

Boat- from JAAPA in 2005 written by someone we both know:

 

Fast track in the field: Another option to ease ED overcrowding

Emergency department (ED) overcrowding is becoming a serious problem in the nation’s hospitals. Many are forced to go on ambulance diversion status because of a shortage of bed space, clinicians, or resources needed to take care of patients. Patients who seek care in the ED often require ED evaluation and are there appropriately. There is, however, a subset of patients who use the ED for conditions that are neither emergent nor, at times, even urgent. Many of these patients do not have access to a primary care provider, or they live in communities lacking adequate free medical resources for the uninsured or underinsured, so the ED becomes their only choice. One option that meets the needs of patients, hospitals, and emergency medical services (EMS) providers is to create a system by which these patients are seen outside of the ED yet receive the same high-quality care from the same providers that they would in an ED setting.

Fast track in the field

The EMS community is advocating for advanced training for paramedics to perform these functions. But, why not use PAs in emergency medicine to fill this void? They already have the requisite skills and experience, and they could rotate between working in the field and in their home EDs.

Many PAs in emergency medicine started their careers in medicine as paramedics and would welcome the opportunity to use their new skills outside the ED setting. I have spoken about this concept with a number of my PA colleagues who previously worked in EMS. The consensus was that they would enjoy the opportunity to return to the field and be able to concentrate on a single patient at a time instead of the six to eight patients that are followed at one time in the typical ED setting. Some unpleasant aspects of being a paramedic would be absent from this system, such as carrying heavy patients down multiple flights of stairs and being awakened in the middle of the night for low acuity cases. These are among the chief reasons many PAs leave EMS to go to PA school.

This system would also benefit EMS because they would no longer have to transport patients with minor complaints to the ED. The large number of nonemergent 911 calls has been a significant cause of burnout and frustration among EMS personnel. The system I am proposing would allow paramedics to focus on what they do best—treating truly emergent patients in the field setting.

How would it work?

The concept would initially utilize a trial ambulance team of one PA and one basic EMT/driver and would be staffed only during the busiest hours of the day. The team would not respond directly to 911 calls but would be summoned after an initial decision by paramedics that the patient was nonemergent and met criteria for field treatment and release. The criteria might involve such complaints as minor lacerations, upper respiratory infections in otherwise healthy persons, prescription refills for noncontrolled medications, ingrown toenails, and so forth. EMS and members of the field group would agree on these criteria in advance. The ambulance company could still bill for a home response and any supplies used, while the hospital ED could bill for the PA’s time and any hospital supplies (such as suture sets) used in treatment.

If a single unit saw a patient every 30 minutes for 8 hours, 16 fewer patients would arrive at the ED and 16 more emergent ambulance calls could be made. Some patients might initially be thought to be appropriate for field treatment and later be found by the PA to need further evaluation. These patients could then be transported nonemergently to the local ED by the PA unit and checked in there in the same fashion as a typical walk-in patient. A busy area could use more than one unit or staff it for more hours daily.

This system would be practical only in a busy metropolitan area where ED overcrowding and a strained 911-response system are daily issues. While using PAs in the field in other settings is an option, there would be no clear benefit to local hospitals or emergency services through such utilization.

Patients would also benefit from such a system. Currently, patients with low-acuity complaints face long waits in EDs, sometimes as long as 4 to 6 hours or more. Field treatment would allow rapid evaluation and treatment of their minor injuries and illnesses, greatly increasing patient satisfaction. Follow-up visits would be done by the same “city call” physicians who see unassigned ED patients after their discharge from the hospital. The patients could also be given a list of local resources, such as primary care providers in the community and social workers who can arrange for federal or state health coverage.

Benefits on many levels

In this system, there would be no decrease in revenue to either the hospital or the EMS company. Members of the team would be paid by their normal employers at their normal rate of pay. No changes would need to be made to the configuration of the ambulances used. The PA could simply carry a tackle box with supplies and a few noncontrolled medications, such as antibiotics. All the pieces are in place for this to work, with very little preparation time involved. The staffing already exists. Oversight would continue per current practices. The supervising physicians of the ED PAs would review the PAs’ field documentation in addition to their regular ED charts. The PAs’ malpractice policy from the hospital would be amended to include work in the field. Hospital EDs would be able to allocate their resources more appropriately to evaluate sicker patients in a shorter amount of time.

This is only the outline of a concept. I hope that this model can be tested in busy urban areas to determine its effectiveness at decreasing ED wait times and improving service to those in need of medical care.

[kargiver]

What is being overlooked is the use of the RN/medic model commonly used in critical flight situations.  Politicians think this should likely transfer to the street for the other end of the spectrum.  The issues will be no NP can cover the entire spectrum of care from infant to elderly acutely, which would require them to use FP NPs (for which they are not credentialed to do emergency medicine).

 

PAs may seem the obvious choice, but I think this only holds true now for those with significnat EM experience.  Id rather just uptrain medics who do street medicine already with another year of education (for those who want to do it) and have them do it that way.  Trying to do it this way is a perversion of the system and will ultimately end in costly litigation.

 

G

[Boatswain2PA]

you don't do it full time. you do it a day/week to keep these low acuity issues out of the ER where you will have to see them anyway at the expense of folks with real medical issues.

Boat- from JAAPA in 2005 written by someone we both know:

 

Gotchya....like pulling your shift in the fast track.  Okay, if I worked at a big center I would certainly take my turn on the rig doing this then. 

 

I think it could be done with FNPs.  If they find a real emergency, they let the paramedic bring it to the PA in the ED. 

[Nonlegit]

Gotchya....like pulling your shift in the fast track.  Okay, if I worked at a big center I would certainly take my turn on the rig doing this then. 

 

I think it could be done with FNPs.  If they find a real emergency, they let the paramedic bring it to the PA in the ED. 

I'm in this boat.

[EMEDPA]

I'm ok with letting the NPs have retail medicine. I'm not ok with conceding these types of jobs to them as well.

[Boatswain2PA]

Why not? This would be mostly preventative/FAM practice/urgent care/fast track type stuff. Anything actually emergent gets brought to the ED.

[True Anomaly]

Why not? This would be mostly preventative/FAM practice/urgent care/fast track type stuff. Anything actually emergent gets brought to the ED.

 

I'm with E on this- ceding this to NP's only would go a long way to limit our growth into this arena, particularly looking at a medical direction-type of role.  Despite my own flop at trying to make this work I still think PA's can play a large part in EMS medical direction- medic25 is the gold standard for this as far as I'm concerned

[SoCalPA]

E is there a link to this "field team" article? I live in LA and know my way around the political scene here. I feel compelled to do something....I will start with a call to the councilman's office to get more info.

 

I also think Kargiver brings up a good point that when you look at the spectrum of patients PAs are better equipped to handle what might come up then FNP.

 

Maybe we can get ahead of this. Since as you know what happens in LA can/will often be replicated by other jurisdictions.

[SoCalPA]

I can find it based on the info you gave but I thought maybe you just had it at hand since you were able to copy and paste it so quickly.

[Nonlegit]

I think there is more of a inner monologue of turf-ceding here. I understand that many PAs and PA-hopefuls come from an emergency medicine or EMS background. To even let an NP ride in the bus would be tough for me to swallow, considering these opportunities are so limited to PAs (and really, other providers as well). I think thats whats happening here. I agree with Boatswain though in that I would never want a fast-tracky type designation to be conferred on the PA profession, since clearly many of you physician assistant's currently practice at a much higher level. This is what is attractive to me about the profession.

 

I'll upgrade my basic to a P card once im done with school and go back and run some shifts as a medic. I'd also like to join a local VFD. I think this continues to be the best answer.

[SoCalPA]

Don't you think at minimum it should include PAs?

[GreatChecko]

The new program in Littleton, Colorado uses PAs and IIRC so does the program in Phoenix. So my guess this is just CA being CA and the nurses ruling the roost out there. I think we will see both NPs and PAs doing this around the country, but it will reflect whoever is in the local EDs doing the fast track type of work. 

[EMEDPA]

this is not primary care. this is fast track. ok, it's a bit of both.  it's minor procedures like lac repair, ingrown toenails, I+D abscess, etc.as well as non-urgent stuff like rx refills and the stuff most of us would think of us bread and butter primary care.

like it or not, most PAs who work in em rarely leave fast track without additional training or significant experience( or a lot of luck).

This is our territory. the NPs can have the wellness ctr at the quickie mart at walgreens. this one should be ours. who better to staff a unit like this then a pa who used to be a medic.

[medic25]

I'm with E on this- ceding this to NP's only would go a long way to limit our growth into this arena, particularly looking at a medical direction-type of role.  Despite my own flop at trying to make this work I still think PA's can play a large part in EMS medical direction- medic25 is the gold standard for this as far as I'm concerned

 

Thanks bud; it's got it's ups and downs, but overall it's a pretty good gig.

 

Pretty hectic week in the field this week; started it out being requested to the scene of a 600lb patient in cardiac arrest.  Spent the next day on the road evaluating a new paramedic, covered another cardiac arrest.  Spent the next day riding around with a PA student on his ED rotation, and ended up going to a high-speed MVC, unconscious with entrapment and prolonged extrication.  The field time is a great cure for the frustrations that come with the less fun parts of EMS (politics, CQI, admin meetings, etc.).

[PAruby]

Wouldn't mind bringing this a little closer to home... I've only been in the ER for a year - much to learn... BUT as a former (and still) medic, i feel like something like this could be my calling. I live in a medium-sized city. Even as a PA in the ER, I don't get to do much in terms of "real" medicine. When I work nights, the docs are more accommodating and thankful for the help... but otherwise Its sutures and I&Ds for me... Lots of things I could easily manage without the need for imaging, lab tests, etc. 

 

I hope this continues to emerge, and I hope that PAs (especially with prehospital backgrounds) are front and center, and I hope I'm one of them. 

[PAruby]

@medic25 any tips or intel on rolling this out to other systems? Our community has a "Community EMS" panel that meets somewhat regularly. Now they are focused on uptraining medics (very rural state, not enough providers to go around by a long shot), but I think pushing on a proposal like this may fit in well with their ultimate goals. 

[EMEDPA]

 live in a medium-sized city. Even as a PA in the ER, I don't get to do much in terms of "real" medicine. When I work nights, the docs are more accommodating and thankful for the help... but otherwise Its sutures and I&Ds for me... Lots of things I could easily manage without the need for imaging, lab tests, etc. 

 

I hope this continues to emerge, and I hope that PAs (especially with prehospital backgrounds) are front and center, and I hope I'm one of them. 

this is more common that you think. for most empas practicing "real em" means going rural or underserved. for me it means lots of driving. tomorrow I drive 3 hrs to one of my rural em jobs so I can practice "real medicine".

[PAruby]

@EMEDPA this is true. I don't mind the cough and cold and "fast track" stuff but I desperately miss the critical care I used to do as a medic. When that 15 year old traumatic bowel perf or 24 year old subarachnoid hemorrhage or 60 year old "mechanical fall" with a STEMI finds it's accidental way to me, I take every opportunity to continue managing that patient alongside the doc I'm forced to turn it over to in order to learn, see, do... I work nights to avoid flip-flopping my schedule, but also to work alongside docs who are interested in allowing me to expand my skills and knowledge base.

 

Trouble here is that those rural places are almost exclusively single-PA systems - not a good place for a new grad with noone to mentor them. Even where I'm at I feel lost to any mentorship and largely reliant on self-study. Maybe you have recommendations for someone such as myself to build those skills and knowledge base that someone such as yourself has spent so many years mastering. I wouldn't mind traveling if I could find a place willing to train me up and not leave me stranded without any resources early on... and could pay the bills. Although I'm in this "fast track", they pay pretty exceptionally well. I'd take a pay cut for better educational opportunity. 

 

and then.... i want to do this field EMS  XD

[EMEDPA]

seriously consider an em pa residency. there are 27 now all over the country. they are listed in a sticky at the top of the em forum here. if I was a new grad today I would do one of these without a doubt. start looking also for some per diem jobs for a few days/mo where you can see sicker pts alongside a doc. this typically means a smaller community hospital without a fast track, but busy enough for double coverage.

[Evolute]

Couldn't agree more E. Currently I'm lucky in that I only drive 45 min and 90 min (one way) to my current jobs. I have, in the past drove 6-7 hours one way though.

[PAruby]

will do, thanks

[ktcan10]

I'm writing my capstone on programs like this. I happen to agree with the camp that NPs should not be ceded these jobs. I was an EMT for six years before going to PA school, and I'm in a classroom filled with people who make my six years look like a long blink...military medics, etc. All of whom would be ideally suited for the field environment. 

 

An important point, too, is the fact that no dispatch system is perfect, so what happens to someone without critical care experience (i.e., a family practice NP) who rolls up on a "laceration" and finds that instead of simple laceration, you have multiple critical stab wounds? It's happened to me as an EMT, and it will probably happen to an advanced care provider working on the streets at some point or another. I can imagine someone with previous experience as an EMT or a medic transitioning to the best life-saving care they can render with the supplies provided, and others falling into a shock trap. 

 

Anyway, I've been in touch with Mesa, Littleton, and another couple of interesting programs that are running different ideas of the same basic concept, and I think its a really exciting and interesting avenue to pursue as physician assistants.