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Advice Needed - Unique situation (long)


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I am a new grad working in family practice with an attached minor care. I see about 45 scheduled Pts per week and 12-15 minor care Pts per week. Our minor care basically takes all comers - chest pain, acute abdomens, stroke Sx (not by choice, but we're the only clinic for 20 miles or so and serve a very rural area). We stabilize and ship them out as necessary.

 

My side job is as an EMT (currently basic) with a volunteer service. I work in Idaho and here we have a unique classification of providers called Ambulance Based Clinician. This class of ambulance provider is for PAs, NPs, and RNs (as well as MDs/DOs) who want to assist their communitities by providing ALS level transfers from hospital to hospital - mostly adverse weather cardiac patients, but this applies to any Pt on meds that are beyond NS or D5W. Any of the above credentialed providers can obtain this classification as long as they have their EMT-B cert.

 

My problem is that the DO who is our medical director won't sign off on me doing any ALS transfers yet because she has worked with several PAs in the past and apparently had bad experiences. I have no further details. She is concerned because she doesn't know about my background as an EMT (been with the company for 2 years and stayed active even while going to PA school) and is unsure if I can handle it safely. One part of the issue is that I would be required/licensed to do ALS procedures/meds/ACLS in the bus if the Pt crumps en route.

 

So, two questions. 1. Are her concerns founded? And 2. If not, how do I convince her to sign off on this? EMS is my passion - obviously or I would have given up on it at the beginning of PA school. I have a chance to contribute and do more for my community and my company and I don't want this doc's prior bad experience to stand in the way.

 

Thoughts? Sorry this is so long.

 

Andrew

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Do they have any way to observe you do these things & sign off on you? And, if not, would they be willing to implement something along those lines? I can understand the resistance, but there should be something in place that would allow you to do these things under observation until it is shown that you are competent.

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Small town man...you know the rules...you gotta pay the dues. Can't roll in and just get the nod based on your dashing good looks.

 

Seriously, I got nothing for ya. My first thought is that your DO needs to put you through a mega code a time or two to help boost her confidence in your ability. Any chance of catching an ACLS refresher with your DO in the same class so they can observe your mastery of the info? (disclaimer: I am acutely aware of the differences of AHA ACLS and the reality of working a code in an ambulance)

 

Are there other clinicians in your work place that do these transfers? Are they EMT-Bs or Ps? Have you chewed their ear a bit to get clued in a bit?

 

Best of luck to you

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if it were me ---

 

I would run scared in the opposite direction ---

 

as a new grad, the last thing you want to do is be in a bouncing ambulance doin 70mph on a bumpy road with a cardiac patient that is crashing - hell a code is easy compared to having to manage an inferior wall MI with someone that is CTD....... run every code you can (oh yeah and get ACLS and do meda codes with a trainning dummy) and every other CME course you can get...... prove to them you can do it and they will end up asking you to do it....

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Agreed that getting your paramedic certification would help, even from a "quickie" program like Creighton. You have to ask yourself, as a new grad PA not working in a critical care setting how comfortable will you be handling a critical care patient during transport. There is a major difference between functioning as an EMT and managing multiple drips and having to secure a crashing airway. I don't know of too many PA programs that send their grads out feeling comfortable with a difficult intubation or being able to titrate a couple of different pressors; this is where the paramedic background is invaluable.

If the paramedic program is not an option, you could consider doing some simulation training and having the medical director run you through some testing scenarios to demonstrate competency. You may also want to try and get as many of the pre-fab courses completed as possible that relate to this (ACLS, PALS, FCCS, Difficult Airway Course). Good luck with this; we've discussed trying to create a similar EMS title in our state as your Ambulance-based Clinician, and I think if it's done right it's a great resource.

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Wow - I understand your passion for EMS but it seems kind of crazy to me to be working at the EMT-B level as a PA. I mean, it gets you into the rig but I wonder if it undermines you somewhat to be accepting a position so far below your level (maybe your DO "sees" an EMT-B instead of a PA?). Just a thought, although I don't want to discount whatever Hx your DO has with PA's. I'd say at least get your medic cert, if it's doable, but that won't necesarrily solve the issue of the DO trusting your scope as a PA.

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Definitely concur with what Physasst said: talk with the doc and hear her specific concerns. Then, be candid with her and yourself about how prepared you are to meet them. As folks have said, there's a world of difference between managing the pt's you see in FP & minor care (even including the ones with critical complaints) and doing it with the limited resources that you have in the back of an ambulance. You need to be sure you're ready - especially if you will be the only ALS provider in the back during the transport. While getting your medic may help, there's still no substitute for experience. I'd recommend working with the doc on a plan to get you that experience and for her to evaluate you along the way so she feels comfortable that you're ready. It's no different than being a new medic - we always did our best to make sure they had an experienced medic with them for a year or so until they'd experienced a fair number of bad runs.

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Ohio - absolutely agree. I appreciate all the feedback. I want to make it clear that I am certainly filled with trepidation about the prospect of transporting a critically ill patient in the back of an ambulance. I respect what can go wrong and I know that I could use some training time to get ready for that.

 

The issue is not necessarily, "Am I ready to go right now?" but rather, "How do I convince this doc to warm up to the idea of training me/the medics for this?" I am open to attending Creighton and getting the medic cert, then completing my ride time with a paramedic preceptor. That may be what is required.

 

However, in the meantime, there are a lot of interfacility transfers that I am qualified to do - stable pediatric patients who happen to be on morphine, psych patients on sedatives, etc. Sometimes these people don't get transported to other facilities in a timely manner because of the meds they are on. It delays care and occasionally creates access issues - access to care is one of the reasons I went to PA school.

 

At any rate, the critical stuff will require further training - no doubt. But that's the case with all of our medics (we have almost all brand new medics in our county). I just want to get my foot in the door with our medical director.

 

Just Steve - I am the first PA in the state of Idaho to apply for Ambulance-based Clinician status. So, no... Nobody I can talk to. Oh - and this is a volunteer job, just so y'all know. I'm not getting paid to do it, it's simply a passion I have. You all have worked in the bus... You remember what it was like to belong to that group and serve the community in that way. So, I'm sure you understand.

 

Thanks for the help, guys. I think your suggestions will help make this work. I'll keep you posted.

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Andrew,

Perhaps after talking with the doc, you two could come up with a plan for which types of transfers you are ready for and which you aren't. A caution about the psyche patients - they tend to have lots of stuff on board, washed down with lots of EtOH. Hopefully their urine or blood told you "most" of this. The sedatives don't always work - esp. if enough meth is on board. The sedatives can also cause their own problems. Had a B52 - Haldol 5mg, Benadryl 50 mg, Ativan 2mg - cause QRS widening and ultimately arrest. Only 1 time out of the dozen's I've given. The point is there are hidden snakes in the grass to be prepared for.

Hope you get there.

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Fireguy -

The EMS director won't sign off. The risk she is assuming is the same as she's always had. She isn't my SP and isn't assuming the risk for my practice as a PA. She is directing me in much more restrictive role as an ALS level provider.

 

My SP is someone completely removed from the EMS system.

 

Andrew

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in addition to FCCS (the in-person course) I would definitely do "the difficult airway course for ems". costs about 350 bucks. great course. covers, yup, difficult intubations, but also airway adjuncts, RSI, crichs, cpap, etc.

in a perfect world I think every pa and doc who works em should be required to take this course.

this is what it covers:

 

  • Learn the full range of Airway Management techniques - including use of extraglottic devices, drug-assisted intubation and cricothyrotomy.
  • Work with expert faculty who know the unique challenges facing EMS providers. All of our faculty members perform airway management regularly in their clinical practices.
  • Use all of the airway devices in small group sessions.
  • Practice decision making and airway techniques in Code Airway Stations.
  • Face the most challenging patient scenarios in a no-risk environment. These include: elevated ICP, pulmonary edema, cardiogenic shock, status asthmaticus, foreign body in the airway, direct airway trauma, multiple trauma with shock, and many more.
  • Meet your continuing education requirements. This course is approved by CECBEMS, ASTNA and AAPA.

[h=2]Didactic and Hands-on Training in Crucial Airway Techniques[/h]

  • Prediction of the Difficult Airway
  • Difficult airway evaluation using video laryngoscopes designed for EMS
  • Drug-assisted Intubation (including RSI)
  • Pediatric airway management
  • Laryngeal mask airways for intubation
  • Intubating stylets and advanced laryngoscopy techniques
  • Surgical Cricothyrotomy: open and percutaneous techniques
  • Extraglottic devices (supraglottic and infraglottic)
  • Digital and nasal intubation
  • End-tidal CO2 detection and capnography*
  • CPAP and BiPAP

 

see www.theairwaysite.com

 

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However, in the meantime, there are a lot of interfacility transfers that I am qualified to do - stable pediatric patients who happen to be on morphine, psych patients on sedatives, etc. Sometimes these people don't get transported to other facilities in a timely manner because of the meds they are on. It delays care and occasionally creates access issues - access to care is one of the reasons I went to PA school.

 

 

the issue is that any one of these "stable patients" can crash suddenly and if you can't manage their airway, supoport their bp, etc you are in a world of hurt. some of my hairiest pts ever were"routine interfacility transports" that went very wrong very quickly and became full arrests, etc requiring the full range of als procedures and background .

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I took the Difficult Airway course on the Emanuel campus with Dr. Rob Vissers. Finished on a Wednesday. The following Thursday (next day) I was on shift and placed my one and so far, only quick trac. When my supervisor give me the "stink eye" and said I was going to be heavily reviewed via QA, I couldn't be happier. That course gave me the confidence that I KNEW I followed all possible avenues and "tricks of the trade" before I had to result to a quasi surgical intervention. That confidence was worth at least triple the money I paid for that course. It was not a successful patient save but it was not for lack of skill or willingness to go outside the "box" when it was needed.

 

Highly recommend the course.

 

Steve

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so perhaps there is more than just "I'm not comfortable with your skill set" at work here. Does the med director have PA of her own Ever work with a PA? Perhaps previous PA in the EMS system misrepresented themselves and she was burned by it... or perhaps she thinks she will have to supervise you and that is the hang up. My EMS director told me that while I am on the Engine, I am a paramedic first responder... No more... I am ok with this as it provides me with SOME liability protection while on duty, and does not require the EMS director to register with me in a SP/PA relationship. THis was the route taken after several attorney meetings etc.

 

Bottom line, get the advanced EMS training, whatever route you deem appropriate for your situation. Then reapproach the EMS director with a demonstrable and vetted set of ALS skills.

 

Good luck

 

 

Ben

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