To PAs in pre-hospital EMS:

[Firemedic13]

. Can PA's treat and release in the field under your state statutes? Are you going to carry urine dipsticks and write prescriptions for UTI's? It just seems there is very little that can be treated and released in the field due to lack of equipment (lab, xray, ct, u/s).

 

They are putting ER fellows in an ambulance now with portable x-rays, portable ultrasound, and a small portable lab. I just heard this today, so I don't have a lot of details. But our plan was to do this.

 

What can a PA (or physician for that matter) do in the field for a trauma that the paramedic can't, aside from a central line and chest tube? And 90% of the time you don't need a chest tube until you arrive at the hospital anyway. The central line is really the only thing I can see that would be beneficial and beyond the scope of a paramedic. You also have to consider that the emergency medical helicopters carry nurses and every physician who can do these things, and this is why they are called. You also have to consider transit times. Always best, as you all know, to load and run in most situations.

 

While our air ambulances carry a medic and an RN here, you have a very valid point. PAs would be helpful on trauma scenes... but really wouldn't be any more helpful than a medic 99.9% of the time.

 

For emergency medical calls, like a MI, what more can a PA do than a paramedic here either?

 

Carry an extended scope of drugs, but again, realistically not much more than a paramedic.

 

Also, consider the impact on the public when the idea that someone can be seen without going the ER gets out. The amount of frequent-flyers and nothing calls will go through the roof! "You mean I don't even have to get out of bed for someone to see me now? Hot diggity!" While this will ease the strain on the ER, it may increase abuse of the system even more. These are numbers that would need to be tracked and compared to pre-implementation figures.

 

Check the studies I posted from sheffield on ECPs in the UK.

 

Well, hope this made sense. What do you all think?

 

jason

 

You have some very valid points. I think the usefulness of a small, basic lab, portable ultrasound and x-ray would still make basic medical calls pretty easy to handle. I am not a PA, but I can't see why treat and release wouldn't be realistic, since it would be up to the judgement of the PA. That was actually our plan: to have the PA respond with a rescue for sick calls, abdominal pain, minor allergic reactions, and other medical calls, as well as minor trauma (sutures and such), etc. directly, without paramedic screening.

[JasonR]

Thanks for the clarifications, Firemedic13. Portable x-ray?! Please send me a link to one of these. I'm on Google now looking them up.

 

Honestly, the biggest problem with the treat/release in the field method will be the same problem we face in the ED currently: Liability. Could you skip that head CT for the headache you're just sure is a migraine? I likely couldn't. I'm not up to date on UK medicine, but I was under they impression they didn't have near the amount of litigation and CYA medicine we do here in the US. Could that be a reason why their numbers look so good?

[JasonR]

While our air ambulances carry a medic and an RN here, you have a very valid point. PAs would be helpful on trauma scenes... but really wouldn't be any more helpful than a medic 99.9% of the time.

 

Sorry that was a typo. I meant to say "even physicians". We run a medic/RN pair at our facility also. But I do know some like in Columbus, OH that run physicians.

[JasonR]

Hrm, ok I'm looking at the portable xray machines. Which are just a little bit smaller version of the portable ones used in hospitals. Where would you put this thing? Mount it in the squad? I wonder what the regulations are as far as lead-lined room like in an office. I mean technically, if everyone else is 6 feet away and you have lead on it shouldn't matter. Would the PA have to get their GXMO certificate to legally take xrays? With portable labs, u/s, and xray this could be come a very viable option IMHO. Without it, I don't see how it is worth it.

[EMEDPA]

EMEDPA,

 

What happens with billing when the PA sees the patient and determines further testing is needed so they go to the ED? Now we have an ambulance bill, a PA ambulance ED visit bill, and a PA/MD real ED visit bill. Or are you proposing that if the PA sees the patient in the field, they have already examined the patient, formulated a DDx and plan, and will order test upon arrival at ED. Therefore, whoever takes over in the ED will have little to do except follow-up already placed orders and discharge/admit, and the billing will be one with the field PA. We have a similar system in place here, where if one outlying ED sends a patient to the main ED, there is no additional provider cost.

 

What are you thoughts on sending the PA right away based on C/C? Rather than wasting paramedics time screening. I know most C/C's that come in are nothing like the real situation (grandpa fell down : grandpa had a MI), but still that seems like a waste.

 

yup, if all that is needed is an xray no repeat exam is done. the field pa orders the xray and the ed based pa reads it and treats as needed.

I think the medics should always go out first. there are just way too many "vomiting" calls that are an MI or " dizzy" calls that are a cva.

a lot of what the field pa would do is really fast track stuff; refill meds, suture lacs, I+D abscesses, etc. anything that they felt they couldn't do safely in the field goes to the e.d.

I worked an overnight shift last night. only 1 of the pts I saw really needed to be there(chest pain). the rest could have been treated by a pa in the field.

[EMEDPA]

Would the PA have to get their GXMO certificate to legally take xrays? With portable labs, u/s, and xray this could be come a very viable option IMHO. Without it, I don't see how it is worth it.

 

depends on the state. some states have taking xrays in the scope of practice of pa's. in other states a pa could get a ltd xray license(the same ones medical assts can get) to do plain films of chests and extremities only. this only takes medical assistants 3 months. a pa could probably do all the didactic online in a month then spend a week doing the required clinicals.

[JasonR]

So then talk to me about billing. I can see how logistically it would work with hospital billing for PA visit (as usual), and department billing for EMS call (as usual), but will Medicare and the third party insurers see it the same way? Will they refuse to pay because its double billing? If a PA goes to a patient's house, does that PA charge more for going to the patient's house than if the patient came to them? I get a funny feeling there would be a lot of lash-back from the third party insurers, especially in the current socialistic healthcare climate.

[istat2]

So then talk to me about billing. I can see how logistically it would work with hospital billing for PA visit (as usual), and department billing for EMS call (as usual), but will Medicare and the third party insurers see it the same way? Will they refuse to pay because its double billing? If a PA goes to a patient's house, does that PA charge more for going to the patient's house than if the patient came to them? I get a funny feeling there would be a lot of lash-back from the third party insurers, especially in the current socialistic healthcare climate.

 

Depends on if they are different organizations. You usually can not double bill from the same entity within a 24 hour period. If the follow facility and field treatment team operate under different NPI's it should be ok.

[istat2]

You can treat a selected portion of the population for the most common complaints seen. Think the walk in clinics.

[JasonR]

You can treat a selected portion of the population for the most common complaints seen. Think the walk in clinics.

 

Exactly my point, istat2! Why would I (lazy-Joe American) get out of bed to go to the walk in clinic or the ED, when I can just call the EMS PA for my sore throat and fever? Thereby, increasing call volume. I mean you might as well not go through your local EMS agency and just have the ER buy an ambulance. Then it will be completely separate billing, and EMS can consult/contact the ER ambulance for non-emergent things. That is if a paramedic is to evaluate each patient prior to the PA-staffed squad. It would be like calling in a medical helicopter.

 

Problem I see with not having the medic evaluate the patient before sending the PA squad out, is that the PA will conceivably be running all day seeing patients due to increased volumes. There cannot be a delay in response to a 911 call, so the medics would have to go to each and every call, as they do now. That's probably what you were trying to point out, EMEDPA.

 

So this brings up another point. What about overload on the 911 emergency system. It will become an emergency and "if I have a cold and feel lazy" system. What kind of call volume increase can we expect over time, when people get used to the system?

 

So why not just base an ambulance out of the ED? This will leave the EMS system alone, but relieve overload on the ED by creating a new "consultant" ambulance, similar to the mobile ICU's and medical helicopters.

[istat2]

Exactly my point, istat2! Why would I (lazy-Joe American) get out of bed to go to the walk in clinic or the ED, when I can just call the EMS PA for my sore throat and fever? Thereby, increasing call volume. I mean you might as well not go through your local EMS agency and just have the ER buy an ambulance. Then it will be completely separate billing, and EMS can consult/contact the ER ambulance for non-emergent things. That is if a paramedic is to evaluate each patient prior to the PA-staffed squad. It would be like calling in a medical helicopter.

 

Home health care services are a booming segment of the out of house operations. Why not capitolized on it? I would expect support from patients that are house bound, mobility impared, etc. The increased volume should translate into a increased revenue stream for the local EMS operation. That in turn equats into increased EMS capability. I spend over a decade running as an EMT-P. These types of services were really not what I wanted to do. And a 200 hour training program is not adequate. As it stands now PA's are perfect (particularly if they have a field history). Roving house calls with diversion to criticals per dispatch critiera. Now if you want to talk about utilizing the UK model, I am open to that.

 

I would also expect blowback from the facilities that are losing the business.

[JasonR]

Home health care services are a booming segment of the out of house operations. Why not capitolized on it? I would expect support from patients that are house bound, mobility impared, etc.

 

I agree with you on this.

 

I would also expect blowback from the facilities that are losing the business.

 

Who would give grief about it? The hospital is getting paid by charging for your visit, EMS is getting paid for the run. No one would lose revenue at all. But either way, what I was saying about sticking the PA squad at the ED is looking more viable. Does anyone have a reason why that would not work as well?

[narcan]

It would work well, but the hospital now has to get an ALS transport license from the state, front the cost for the ambulance, and pay an EMT to staff it 24/7 with benefits. There are training and logistical issues involved too. Local EMS is better situated to implement this kind of system quickly, but a hospital that already does say, air-transport or neonatal transport services could probably implement it quickly too.

 

I think the hospital isn't going to be too excited about dropping the money for an ambulance and running the service themselves. ED wait-times may be a big deal, but at the end of the day the hospital PA can see more patients if they come to him, and the hospital only cares about wait times so much as they affect revenue. My guess is that the PA is worth more to the hospital in the ED.

 

The over-stretched EMS system that goes NUA (no units available) several times a day holding 911 calls sees more benefit from the PA handling non-urgent cases. I think your point about the PA unit getting abused is a fair one. It's an issue that would have to be addressed and monitored, and I don't have a good solution in my head yet.

[EMEDPA]

folks already call 911 because they are constipated, have a sore throat, want an rx refill, have a gout flare, etc

it's not like we will create a demand for this service. it already exists.

many places( nyc for one) already base ambulances out of hospitals. wouldn't be too hard to add a hospital pa to one of these hospital based units to keep crap out of a busy e.d. that shouldn't be there in the first place.

[True Anomaly]

There's still not a better article I've read on the utilization of PA's in the prehospital environment than EMEDPA's. As he pointed out, and others of you have as well, it's not about getting to go on all the spectacularly critical scenes (with the exception of an MCI with long scene time, which a PA or ER doc I would argue should be out at), but seeing a lot of minor BS that keeps folks from out of the hospital.

 

The only thing I would add, in addition to Firemedic's great plan for how to economically subsidize these PA's, remember also about an education component to EMS workers. PA's are ideally suited to provide CME for EMT's and paramedics, and this would keep from spending money on a third party to come in and provide education (provided that the teaching is not done in-house).

 

My program that I'll be starting in January of next year looks like it will utilize an equal amount of field and administrative work. Field work will involve choosing between urban, suburban and rural environments to run with EMS crews and basically function as a medic, to doing QA/QI of charts and help provide medical direction while also doing some teaching to EMS staff.

[medic25]

I had an interesting run last week as part of our response team. We were requested by the Coast Guard to evaluate a crew member on an incoming cargo freighter. It had originated in Africa, and while enroute one of the crew members developed fevers and abdominal pain. One of the ports of call had been experiencing an outbreak of Q Fever, and the USCG wanted us to assess him and possibly the other crew members for an infectious disease. 3 EMS PA's and an 2 EMS physicians responded (unclear if we would have multiple patients); initially we thought that we would be heading out on a cutter to meet them, but he turned out to be stable enough to come into port on the freighter. Myself and one of the physicians donned PPE and assessed him; after evaluating the patient he seemed to be a low-risk for Q Fever or another exotic disease, and we transported with him by ambulance to the ED.

We rarely get these calls, but the Coast Guard uses our EMS physician/PA team as a medical asset for evaluating potentially infectious patients on incoming ships. One of my fellow PA's responded out to a freighter a few years ago for a crew member who turned out to have chicken pox, and ended up vaccinating the whole crew. Rather than having EMS bring the patients into the city and potentially expose the general population, we go to the patient and assess them on board or at dockside. This way if there ever was a potentially dangerous exposure we can help to isolate the crew and avoid worsening the situation.

[EMEDPA]

There's still not a better article I've read on the utilization of PA's in the prehospital environment than EMEDPA's. .

thanks! (the check is in the mail).

[narcan]

I still think one hurdle is that regardless of how over-crowded the ED gets and how long the wait times are, the hospital PA can still see a lot more patients per hour if they come to him, so there is a decrease in revenue for the hospital, which is again why I don't think the hospital is going to front all of the money. The non-clinical benefits of the PA to the fire/ems system, i.e. OT physicals, education, etc. may be where the gap in the financial benefit lies.

[rudypa]

Our EMS Chief is a PA....that's on a Volunteer Dept. Still, he has a lot of responsibility.

[istat2]

Why is everyone assuming that the field PA is hospital based? Public safety based working under the medical director would work. Yes a PA based in either the office or main receiving area would probably capture a higher level of reimbursement. But there are quite a few PA's (including some on this board) who make a very good living doing home health visits. EMS based doing some scheduled home visits to suppliment the transport rig relief would in all likelyhood generate a significant revenue screen. You would probably get referrals from the generalist that have home bound patients and would appreciate the service.

[narcan]

I think istat2 makes a great point, and I'll reiterate something I mentioned earlier, which is that a lot of the financial benefit of a field PA isn't going to be in keeping the EMS system from being overwhelmed or keeping ED's from being saturated, as an in-house PA can see a lot more patients/hr than a field PA, but that a well-organized public health/home health model could reduce hospital admissions on chronic patients, saving thousands of unreimbursed dollars with every avoided admission.

[Acebecker]

I've been reading all the replies and I appreciate all the discussion. For my own purposes, I am going to try and sum it all up briefly - let me know where you disagree.

 

In rural communities where the call volume is fairly low (<10 calls/day) I don't think a PA would benefit an ambulance company extensively. From what I've read, this appears to be the consensus. However, I think having PAs trained in pre-hospital care who are capable of performing field work would be an asset to any ambulance company for a variety of reasons - the PAs (as members of the company) could provide in-house physicals, would be ideally suited to training of other EMTs/Paramedics, and could be utilized for special circumstances (such as MCIs or other situations in which further medical evaluation was needed on scene prior to transport). In most situations, though, a pre-hospital PA in a rural setting would primarily act as a paramedic. This is what it seems would be the best uses of a PA in a rural system. Of course any PA who opted for this job would need the requisite training. A question I have is this: wouldn't that training essentially just ensuring that the PA understands the principles that EMT-Bs are taught in their course? This seems to be the primary addition to the fund of knowledge that PAs would need to operate effectively on scene. Thoughts??

 

Andrew

[Firedog43]

I like the idea of having PA's out in the field, but disagree that it would be cost effective. PA's are more beneficial seeing pt's in a ER setting. Lets say you work in a Rural area and a PA is on

a rescue call, for pt that is c/o general weakness.For one the PA doesn't have access to definitive diagnostic testing: labs,CT scan, etc. Secondly, How long is the transport, in a rural setting probably >30 minutes?What if a call comes in that same area ,where the PA could use there advanced training for that circumstance? Oh wait they are not available,because they are on a basic general weakness. If you want a higher level of care out in the field , you are going to have to pay for it. I think if medics were given more advanced training, and they were payed an incentive to have that advanced training,it would be cheaper. Medics are to stabilize pt's and transport them to the hospital, where the PA /MD/DO can treat them. I read the argument about reducing the occurrence of pt's overcrowding ER's with fast track type complaints, haha. Having a PA on a rescue is not going to deter these type of people being transported to the hospital. These type of pt's usually think there complaint is an emergency , and the others just don't care. I like the idea of having a "PA" out in the field ,but it is just not practical.

[EMEDPA]

firedog- the field pa wouldn't be in a rural area. see my article above. the initial proposal is to do this in urban areas , have the pa in addition to field staff, and have the pa only do fast track style pts. to keep the bs out of the er. you probably need a place with a busy trauma ctr (level1/2) which is frequently on divert due to volume as home base for this to be worthwhile.

[istat2]

It is somewhat confusing to follow some of the concepts posted. It will not work because "fill in the blank". I'll agree that the model is not sound for some areas. But I've always found that it is easy to find a reason not to do something. Just as no single model EMS service is viable in all geographical regions, the same is true for a midlevel staffed unit. But one of our collegues is trying to brain storm a concept which appears to have support in his area. Can we try to give him concepts that he might work with, rather than tell him why it will not work!