To PAs in pre-hospital EMS:

[Just Steve]

the liability of having ems make decisions like that would be huge.

 

Well...right now I have standing orders for elective intubation for respiratory distress and/or complicated trauma. There is not much more dangerous in the world of medicine than opting to paralysis a breathing patient with the hope to place a secure airway in a patient who you assume has a full stomach, broken facial structure, blood in the hypopharynx and perform this procedure in the field with just one other person to back you up, with no fancy tools such as Glide Scopes or fiber optics. The decision tree that is climbed to arrive to that point is filled with thorns and weak branches...aka: must be climbed carefully and with skilled judgment.

 

This is not to mention the open ended orders for narcotics and benzos, or the IV antiobiotics we carry, or the handful of other potentially deadly medications that we handle, all without the immediate consult or supervision of a doc, only the pre education and after action review.

 

The decision making process to refer a patient to a higher level of care for further eval with the express instruction to go to an ER if conditions worsen is no more sketchy. It just takes a bit more education of folks who are already very skilled. Many of my medic partners hold 4 year paramedic degrees from OHSU. The entire state of Oregon has a base requirement of at least an Associates degree to be a paramedic. Just like some of those nurses working ICU's, and ER's (ASN's)

 

If you get the chance to ride along with a paramedic (not just an EMT basic) for a few shifts, you should check it out. You might be surprised.

[medic25]

The decision making process to refer a patient to a higher level of care for further eval with the express instruction to go to an ER if conditions worsen is no more sketchy. It just takes a bit more education of folks who are already very skilled. Many of my medic partners hold 4 year paramedic degrees from OHSU. The entire state of Oregon has a base requirement of at least an Associates degree to be a paramedic. Just like some of those nurses working ICU's, and ER's (ASN's)

 

The trouble is the knowledge base necessary for critical care management of an unstable patient is different from the decision making regarding who should or should not be taken to an ED. The literature generally shows a significant undertriage rate by paramedic who are initiating non-transports. My SP was an author on a meta-analysis of this subject in 2009, and they found that the undertriage rate was in the range of 9-29%. Even the 9% figure would account for a significant number of patients in a busy urban EMS system. When I was still on the street as a medic, I was an ardent believer that we should be able to make the decisions whether a patient should go to the hospital or not. Now that I've gotten a few more years and some more education under my belt, I've been able to objectively review the current literature and unfortunately it doesn't look like we are ready to do something like this without significant increases in paramedic education (which falls back to the previous cost issue).

 

 

http://informahealthcare.com/doi/pdf/10.1080/10903120903144809

[Just Steve]

Perhaps it is splitting hairs, but I do not advocate a non transport policy. A current non transport policy would be where the patient did not receive any medications and received no follow up care. What I propose is that they do in fact get immediate meds (or as soon as they fill their script) AND a follow up appointment where the initial triage is reviewed.

 

The approach to the patient could go something like : "we are here to help you. After our evaluation (finding a non acute situation) our proposal to you is 1. We can take you to the ER, no questions asked. 2. We can give you a couple day's worth of meds AND give you an appointment with a care provider in 48 hours or less, no waiting in some waiting room. You relax at home, take your meds, don't spread the bug you have or pick up other bugs that are being shared in the ER (some municipalities encourage flu patients to stay home). Show up for your appointment. If things get worse at any time, please call us back for immediate transport to the local ER. If another 911 call is placed for the same complaint on the same patient within a given time period such as 7 days, they get immediate transport to the ER.

 

Provider initiated non transports are not allowed by my current medical director and I agree with that policy. I am not saying that rule is always followed by all providers, but if a medic is found to be encouraging patients to stay at home AND that patient shows up super ill via POV at some ER, that medic is scrambling hard to keep their job. Of course, I work for a private business who has the 911 contract for the county. They make money off of transports and have a contract obligation that states we cannot initiate non transports.

 

The study cited above appears to be based on paramedics' judgments based on their current education model. I do believe more education is needed and I believe that there are plenty of very dedicated paramedics who will pay for the training. Not to mention EMS agencies who may offer tuition reimbursement for such training in an effort to get a higher qualified employee.

 

Just today during a totally unexpected moment, a Clackamas county firefighter/paramedic brought up the timely story that Clackamas County Oregon powers at be have recently discussed hiring PA's to ride fire trucks and bring the Fast Track to the field. He, nor I, have any idea were that idea went, but it was pretty interesting to hear that the idea is making current circles. Only time will tell what comes of it.

[rev ronin]

Just today during a totally unexpected moment, a Clackamas county firefighter/paramedic brought up the timely story that Clackamas County Oregon powers at be have recently discussed hiring PA's to ride fire trucks and bring the Fast Track to the field. He, nor I, have any idea were that idea went, but it was pretty interesting to hear that the idea is making current circles. Only time will tell what comes of it.

 

I'd say maybe half my class at Pacific wants to stay in the Portland area upon graduation, and 4 of us are prior/current fire service. No idea what OHSU's equivalents are, but I suspect substantially similar. With two PA schools locally, the fire service could certainly find enough qualified candidates for a pilot program

[T24EMS]

Hi. New to the forum here. I have been reading this thread with a great deal of interest. As a former paramedic (still certified, non-active), I wanted something more for my fellow EMSers (back in the day) and actually came up with this idea back in 1997, after reading the Balanced Budget Act of 1997 and wrote a business plan for this very idea. Long story short, it caught the interest of a local trauma center (and approved) and then approved by a local insurer. I ended up writing an article on this subject back in 2001 and received a ton of interest for more information. At this time, I am attempting to work with a few places to kick start this idea back to life. It is an idea whose time has more than come. The way I foresee it (in my area) is that the PHPA would be better suited for urban/semi urban work, rather than rural (but could still be a good thing to have in place).

 

If anyone is interested in knowing more, send me a message..........

[Veritas86]

I'm late to the party too, it seems.

 

 

But I was kicking around this idea last night. As far as educational requirements for PAs who weren't EMT-Ps or those who wanted to expand their skill set, why not an EMS residency program? The existing EM residencies have gone over well it seems, so why not go the way of MDs and have a residency or fellowship in EMS?

 

It would take care of the basic skills for nonpreviously trained PAs as well as introducing them to advanced clinical practicies and issues. Thoughts?

[Veritas86]

I'm late to the party too, it seems.

 

 

But I was kicking around this idea last night. As far as educational requirements for PAs who weren't EMT-Ps or those who wanted to expand their skill set, why not an EMS residency program? The existing EM residencies have gone over well it seems, so why not go the way of MDs and have a residency or fellowship in EMS?

 

It would take care of the basic skills for nonpreviously trained PAs as well as introducing them to advanced clinical practicies and issues. Thoughts?

[EMEDPA]

I'm late to the party too, it seems.

 

 

But I was kicking around this idea last night. As far as educational requirements for PAs who weren't EMT-Ps or those who wanted to expand their skill set, why not an EMS residency program? The existing EM residencies have gone over well it seems, so why not go the way of MDs and have a residency or fellowship in EMS?

 

It would take care of the basic skills for nonpreviously trained PAs as well as introducing them to advanced clinical practicies and issues. Thoughts?

 

there is a pa ems fellowship at albert einstein in philly. true anomaly(a regular poster here) is the first grad from that program. it does not make one an emt-p but trains one to run an ems system as an ems medical director.

there is also a program at creighton in nebraska which will bridge em rn or em pa to emt-p in 2 weeks.

[EMEDPA]

I'm late to the party too, it seems.

 

 

But I was kicking around this idea last night. As far as educational requirements for PAs who weren't EMT-Ps or those who wanted to expand their skill set, why not an EMS residency program? The existing EM residencies have gone over well it seems, so why not go the way of MDs and have a residency or fellowship in EMS?

 

It would take care of the basic skills for nonpreviously trained PAs as well as introducing them to advanced clinical practicies and issues. Thoughts?

 

there is a pa ems fellowship at albert einstein in philly. true anomaly(a regular poster here) is the first grad from that program. it does not make one an emt-p but trains one to run an ems system as an ems medical director.

there is also a program at creighton in nebraska which will bridge em rn or em pa to emt-p in 2 weeks.

[Veritas86]

EMED, you're officially the bomb.com

 

I'll look into those. :)

[Veritas86]

EMED, you're officially the bomb.com

 

I'll look into those. :)

[medic25]

If any of you are currently providing some sort of official EMS function while practicing as a PA, could you send me a PM with some information about your practice location and what your duties entail? I'm working on a paper defining the role of PA's in EMS and would like to hear from people in other states what their level of involvement is. Some examples might include field response, online medical direction, or EMS administrative duties.

thanks!

[medic25]

If any of you are currently providing some sort of official EMS function while practicing as a PA, could you send me a PM with some information about your practice location and what your duties entail? I'm working on a paper defining the role of PA's in EMS and would like to hear from people in other states what their level of involvement is. Some examples might include field response, online medical direction, or EMS administrative duties.

thanks!

[MTNresQ]

I work with several PA's and MD's in the field, from my prospective they function like medics with maybe a few more tricks in the bag. However this is almost exclusively trauma. Has anyone ever heard of PA's working in HEMS? I think that is where PA's would shine, especially with paramedic experience. Canada and the UK have benefited from having advance practitioners on their rotor wing ambulances. Last time I looked medic 1 in london was having pretty amazing success with penetrating trauma arrest survival by providing onsite thorocotomy.

[katief262]

Essentially I think PAs can act as assistant medical directors providing on scene care to the most/least sick, medical command at MCIs, online medical control, administrative and educational functions. We have talked about this topic before and there is some great discussion on other threads.

 

I agree with bchernock. I was a paramedic in rural NC before going to PA school. I will graduate this year, and will be working as a PA in an emergency department in the County where I worked. I plan to stay involved in my County's EMS system, but I think that my involvement will most likely be what bchernock has described above. I hope to one day help establish an APP program in my county modeled after Wake County's. I do not think it would be cost effective to put PA's on trucks, but I do think that it would be wonderful if there were more opportunities such as APP programs for paramedics to advance their training and salaries.

[Acebecker]

So here's the latest update from Idaho: the state has made paramedic practice competency based. If you have an NREMT-P, you're good to go. PAs, such as myself, have to 1. prove what we learned in PA school regarding meds, medical issues, procedures. 2. take bridge courses to cover the rest that we don't know. Here's the problem: a bridge course for a single skill can take anywhere from 3-6 months to get approved and takes the educators hundreds of pages of proposals to write; then you have to find someone to teach it. There are barriers, but they're not insurmountable. I think that a few bridge courses for things like IOs, ET tubes, etc. will allow us to run codes in the field; our only restriction will be trauma - unlikely that we'll be able to do chest darts, surgical crichs, etc. This will obviously not qualify a PA from Idaho to take the NREMT-P exam, but allows a basic EMT with PA cert/license to practice more advanced medicine than otherwise allowed. It's not the best, but it will suffice for now. I'll keep you posted.

 

Andrew

[medic25]

I had a pretty interesting couple of days this week, so in the tradition of EMEDPA's "Why I love rural EM", I just wanted to share my version with "why I love being an EMS PA".

 

Although a big part of my job is administrative (CQI, teaching, etc), I've spent the last two days in the field.  As part of the requirements for our new paramedics to obtain medical control privileges, they have to do a final check ride with an EMS physician or PA.  Yesterday was one of those shifts; the highlights of the past two days were:

 

- COPD exacerbation in a pharmacy

 

-Angry opiate/benzo overdose (not happy about going to the hospital)

 

-Unresponsive nursing home patient, on fentanyl with pinpoint pupils.  After intranasal naloxone, she quickly regained consciousness

 

-Witnessed cardiac arrest, shocked once by FD into asystole.  I observed my precepting medic drop the tube and drill an IO while I performed compressions enroute to the ED.  Patient had ROSC right after we arrived in the ED, and was being cooled with good vital signs as we left the ED

 

- 2 alarm structure fire with report of multiple trapped.  From the smoke plume visible for miles it was clear it would be a legit fire.  We arrived right behind the first due engine (for you FD folks, 3 story wood multi-family dwelling, fully involved).  Thankfully almost everyone was out, but we transported one patient priority one with multiple burns/airway involvement

 

Tonight, I spent a relaxed evening doing medical coverage for a Division I basketball game (we provide coverage for the university's athletic events).  No patients, but as I left the game and got back into my flycar, city FD is dispatched for a GSW 3 minutes from my location.  I signed on responding with EMS dispatch and pulled up simultaneously with the ambulance.  Thankfully it was just a superficial extremity wound, so I cleared as they transported; certainly made for a interesting end to a couple of days!

[medic25]

For the FD buffs, here is a picture of the structure fire we responded to.

 

[True Anomaly]

Good stuff!!

[narcan]

Any updates from anyone on use of PA's in EMS? I still have my NREMT-P but am interested more in any systems where PA's are functioning as supervisors/OMD's/handling non-transports.

[GetMeOuttaThisMess]

My local EMS has bypassed this concept when mentioned and has gone straight to "advanced paramedic" status on follow up checks of frequent service users. This is similar to what was discussed with major EMS med directors at the Dallas Eagles conference several years back. As I recall Raleigh-Durham were first to implement advanced paramedic housecall follow ups.

[davidccs]

im not sure if anyone caught wind of this

 

http://www.usatoday.com/story/news/nation/2015/08/09/fire-departments-pilot-nurse-practitioner-programs/30886395/

[ajnelson]

The PA/NP thing on the ambos has been and on again/off again thing for a few years now. I've heard it done in the metro phx area as well as a few other areas.

I've been keeping involved in EMS by working with the medical directors, doing some QA/QI projects, teaching some CME/case review. I try to get involved with the local fire/EMS guys. I encourage them to ask me questions, discuss interesting cases, etc.

Like you, I'm working on finding my niche in combining EMS and ED PA. There are opportunities, you just have to 'make' them

[FfIghter23]

Yep, here is how Mesa, AZ does it: http://www.mesaaz.gov/home/showdocument?id=122

 

I think having a good relationship with an EMS medical director and pitching the plan to city EMS/Fire could get you a long way. It is better for patient care (definitive care reached in a shorter time) and better for 911 system (opens up units for real emergencies). I think the Mesa system has been collecting data and hopefully that will become available. If it's a cost saving tool for cities I'm sure they will be on board. The hospital systems may be wary as its bad for business...

[Acebecker]

Here's the latest from Idaho:

 

I am still an EMT (previously EMT-B, now EMT 2011) with additional skills.  I have IV/IO, Subcu/IM (specifically epinephrine for anaphylaxis), King airway (won't let me do ET intubation), and a couple of other things.  I can push fluids, I can give D5 if truly emergent or do IM glucagon if diabetic crisis.  These are all my pre-hospital allowances.  These are skills offered to every other EMT as well, I just didn't have to do extensive training to obtain them - I only had to show that I'd done them in my training during PA school and that was sufficient, then demonstrate competency and pass the skills test. I have been on some good runs - last night was an 88yo male with acute cognitive impairment and labs from the nursing home showing Creatinine of 9 and NA of 173. 

 

I am also what we call and EMT with advanced practice privileges if I transport a patient from one hospital to another.  This is a huge confusing thing for some people.  It means that I can practice full scope medical care on a patient who is being transferred from our local hospital to an outside facility - I can give meds, manage drips, manage an airway, give an airway, etc.  It's interesting but I have not done many transports this way (mostly because I'm busy with my paying jobs). 

 

It's not too bad, actually.