To PAs in pre-hospital EMS:

[NewtonsApple]

It seems to me that hospitals in Urban settings with a high volume ED would benefit substantially from a field PA or physician, as foreign countries utilize this very concept. The ability to treat fast track, frequent fliers, the handicapped or hard to transport individuals would make the position alone worthwhile. However, having a trained PA to arrive on scene to treat a critical trauma patient could be life saving. My only question is how would this effect the PA on a liability standpoint? It seems to me that the liability would increase greatly for that PA.

[istat2]

It seems to me that hospitals in Urban settings with a high volume ED would benefit substantially from a field PA or physician, as foreign countries utilize this very concept. The ability to treat fast track, frequent fliers, the handicapped or hard to transport individuals would make the position alone worthwhile. However, having a trained PA to arrive on scene to treat a critical trauma patient could be life saving. My only question is how would this effect the PA on a liability standpoint? It seems to me that the liability would increase greatly for that PA.

 

Not really any more that the PA doing solo coverage of a main receiving area. In fact, would theoretically (sp?) be lower due to the limitation imposed buy the practice setting

[NewtonsApple]

Would this type of service be greatly increased by having a trauma surgeon on stand by for telecommunication? My Father spent 30+ years in SF for the army, and stated that during deployment he has seen medics get on telecommunication with the surgeon and treat on the battlefield and save lives. Having a real time feed to an OR could not only aid the PA, but prep the OR if needed for what may be coming in.

[istat2]

No, you really don't need a feed. Just a properly trained and experienced PA. Just because you have a midlevel on site, you still expedite transport (excluding extrication difficulties of course). You can do surgical airways, chest tubes and central lines on the go.

[narcan]

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

 

In the sense that the field PA would need to learn the logistical and operational principles of EMS, yes EMT-B may be as far as he needs to go, but when considering medical management, the PA is going from an environment where every resource is available to one where few are available, and the decision-making tree changes under those circumstances. A decent paramedic could run circles around a PA/EMT-B with no prior EMS experience in terms of scene management and transport of critical patients. Could a PA learn how to function as a good paramedic? Absolutely, but it's not something that one can get from a book and it's not something you get from EMT-B.

 

As has been said a lot, your idea of a rural field PA is difficult to justify financially. You're talking about an agency that runs under 4,000 calls a year (based on your 10 calls/day quote). You said it yourself: "a pre-hospital PA in a rural setting would primarily act as a paramedic." So why would we pay a paramedic a PA's salary? A low-volume service only needs a few employees so the per-employee benefit of the PA is low. Can you expand on why you're focused on a rural, low-volume setting and maybe we can work out a better fit for the field PA from that.

[medic25]

In the sense that the field PA would need to learn the logistical and operational principles of EMS, yes EMT-B may be as far as he needs to go, but when considering medical management, the PA is going from an environment where every resource is available to one where few are available, and the decision-making tree changes under those circumstances. A decent paramedic could run circles around a PA/EMT-B with no prior EMS experience in terms of scene management and transport of critical patients. Could a PA learn how to function as a good paramedic? Absolutely, but it's not something that one can get from a book and it's not something you get from EMT-B.

 

That is a major reason why we require our EMS PA's to also be licensed paramedics. PA school does not adequately prepare you to become the sole ALS provider on a scene with limited resources; by carrying both licenses you get the benefits of both professions.

[istat2]

In the sense that the field PA would need to learn the logistical and operational principles of EMS, yes EMT-B may be as far as he needs to go, but when considering medical management, the PA is going from an environment where every resource is available to one where few are available, and the decision-making tree changes under those circumstances. A decent paramedic could run circles around a PA/EMT-B with no prior EMS experience in terms of scene management and transport of critical patients. Could a PA learn how to function as a good paramedic? Absolutely, but it's not something that one can get from a book and it's not something you get from EMT-B.

 

As has been said a lot, your idea of a rural field PA is difficult to justify financially. You're talking about an agency that runs under 4,000 calls a year (based on your 10 calls/day quote). You said it yourself: "a pre-hospital PA in a rural setting would primarily act as a paramedic." So why would we pay a paramedic a PA's salary? A low-volume service only needs a few employees so the per-employee benefit of the PA is low. Can you expand on why you're focused on a rural, low-volume setting and maybe we can work out a better fit for the field PA from that.

 

There is a large population of PA's who have extensive experience as EMT-P's. They of course would be optimal for this type of model. It would take a long period of time to take someone without field experience and transition them to the field role.

 

I can only speak to my own program. There really wasn't much exposure/training on operating in the out of house environment.

[NewtonsApple]

I was told, in my state once one gets their PA license one can challenge the EMT-P exam after a couple ride alongs.

[JasonR]

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!

 

For some, careful consideration of the negative aspects of an idea help to parse out fine details which may have been initially overlooked. No one has told the OP not to do this. We have all been merely pointing out possible issues that may arise in the course of the idea initiation. Its been my experience that the positive things of an idea are often the easiest to see. Additionally, the OP has already listed the benefits of such an endeavor, so why would we redundantly post replies with the same information? It is my opinion that this forum is for bouncing ideas off colleagues, not for seeking affirmation. My hope, as I'm sure is the same with the other posters, is that this idea will be immensely successful. I am myself looking into implementing a similar practice.

 

(I'm feeling a bit cantankerous tonight.)

[istat2]

For some, careful consideration of the negative aspects of an idea help to parse out fine details which may have been initially overlooked. No one has told the OP not to do this. We have all been merely pointing out possible issues that may arise in the course of the idea initiation. Its been my experience that the positive things of an idea are often the easiest to see. Additionally, the OP has already listed the benefits of such an endeavor, so why would we redundantly post replies with the same information? It is my opinion that this forum is for bouncing ideas off colleagues, not for seeking affirmation. My hope, as I'm sure is the same with the other posters, is that this idea will be immensely successful. I am myself looking into implementing a similar practice.

 

(I'm feeling a bit cantankerous tonight.)

 

You sure are big boy! But I stand by the fact that people are stating why it will not work, rather than giving resolutions to the problem (if it is applicable to what is being attempted). I've see a lot of good things shot down by naysayers and don't like the exercise.

[Acebecker]

Just to be clear:

 

If/when I "pitch" this idea to my division chief and our medical director, they will come up with all of the objections that have been mentioned and probably a half-dozen more. I need to think all possible objections through and have an answer for each one. It will help them to see that I have put in the effort and have a firm understanding of what it is we're trying to accomplish. It will also help to alleviate their misgivings when I can speak to their objections in a competant manner. So I welcome all

comments/thoughts/ideas.

 

Regarding cost: I can see this being an issue in a paid rural department. Our dept. is unpaid, so I'm not worried about that at the outset. I will need to address that in 3-5 years, though. Hopefully I can prove the worth of a PA attached to an ambulance company before money becomes a big issue.

 

I know many of you are already the assistant (or full) medical director for pre-hospital services in your area. Would creation of a role for a PA in a rural setting at the outset of this project be a useful endeavor?

 

Thanks.

 

Andrew

[Acebecker]

Does anyone have links for the studies out of California or Arizona? I am having difficulty locating this data.

 

Andrew

[Firemedic13]

Hey, Ace, I have done way too much research on this, and as far as I can tell there are no actual studies out of AZ or CA. I could be wrong, but I think somebody would have posted them here by now if there were. I suppose some could be under way, though.

[Acebecker]

Well that's no good.

 

I am to the point in the project where I need to figure out if there is any data or if I will need to try and gather my own. I haven't found anything yet, but I'll keep looking. But it looks like I will be doing a bit more than I initially thought. At least it'll be interesting. Thanks!

 

Andrew

[Firemedic13]

Ace, you can check JEMS and the Emergency Medicine Journals, you might find something there... but the articles we have posted here are all we could find. But I know in my case I don't have access to a lot of real academic journals, and the info you are looking for might be there. Use your school's library access codes to do a search is my advice.

[narcan]

Ace,

 

I happened to be talking to a fellow student the other day who mentioned that Yale Hospital has an active EMS MD/PA team that does field responses in a chase car from the ED. You might try getting in touch with them to see if they have any data as well as get more information on how it's structured. Here are some links:

 

http://medicine.yale.edu/emergencymed/research/ems.aspx

 

http://medicine.yale.edu/emergencymed/fellowships/ems/index.aspx

 

"the state’s only certified EMS physician response team, the Sponsor Hospital Area Response Physician (SHARP) Team, which is also run out of the NHSHP office. The team, currently staffed by six EMS physicians and two physician assistants, provides 24/7/365 coverage to support fire and EMS operations in the greater New Haven area. Recent responses have included complex extrications, mass casualty incidents, and a bioterrorism hoax."

[Acebecker]

Narcan - great resource. I will be contacting them.

 

Thanks!

 

Andrew

[medic25]

http://www.sponsorhospital.org/aspxpages/SharpTeam.aspx

 

Here is a more up to date webpage for the team; we actually have 3 PA's now, not 2, and two fly cars.

[schrecky]

Medic25 (and group,)

 

I'm a long-time paramedic half-way through my PA didactic and am interested in staying involved with EMS once I graduate. Does anyone have updates on the programs and ideas shared in this thread? I am planning to reach out on my own as well but thought there might be others interested in this subspecialty.

[medic25]

I don't really have any updates on our program, but as far as general advice I would suggest becoming a member of NAEMSP (National Association of EMS Physicians). It is the primary organization for physicians involved in EMS, along with a small cadre of PA's. If you are interested in academic EMS you'll find no better place to network; I've had the chance here to talk one on one with the medical directors of several of the largest EMS systems in the country. This will also help steer you towards hospitals with active EMS programs/EMS fellowships that you may be interested in as future employers.

[Just Steve]

Too bad I am late to this party. Looked like some great discussion. As an urban paramedic I have the opinion that there are a HUGE number of calls that are derived from the patient not having a PCP or cannot get in to see their PCP in an acute enough manner for their liking/need. If I were King and allowed to remake health care, I would take the APP concept and give them script abilities to write for 48 hours worth of medicine, and a direct line to an acute care clinic. The APP evaluates, determines level of acuity, and takes the appropriate actions. If acute, load and go. If sub acute, give Rx to cover needs for the next 2 days AND give the patient an appointment for a follow up in the acute care clinic. If non acute, no prescription, but they do get an appointment slot. This envisioned acute care clinic is only accessible to EMS triaged patients. Will this cause people to call 911 to get into that clinic? I doubt it...right now they call and get right to the ER. My proposed idea only promises 48 hours or less. I would continue that fantasy medical care to include EPCR's that are accessible to all providers. This way we reduce poly pharm, drug seeking, and have the ability to be notified if the patient has a nasty habit of calling, then blowing off the follow up appointment. The folks who have a habit of not following up get banned from the clinic and get directly billed for their trip to the ER.

 

This would give us an extended level of care for Paramedics who would like to push their skills a bit, the clinics would give jobs to PA's and such, and insurance/Medicare may be more willing to make payment to the clinics and paramedics since those billing criteria already exist.

[medic25]

The problem with the APP concept is that in order to safely give them enough education to prescribe medications and decline to allow transportation, you are going to have to create something almost equivalent to a PA. Financially it is difficult to pay for all of the additional education, and then the APP would expect (quite fairly) to be better compensated that a traditional paramedic. I don't see too many services volunteering to shell out all of this extra funding in order to cut down on transports. Rather than reinventing the wheel, if an agency were to try and implement something like this it would make more sense to take an already created entity (PA's) and use them in this manner. This has already been tried in cities like Mesa, AZ and Washington DC. Another issue that comes into play is reimbursement; most insurance companies will only reimburse prehospital care if the patient is actually transported. There would have to be major changes at the national level to make this type of prehospital care financially feasible.

[Just Steve]

I agree that the educational component would have to be increased a fair bit for medics to an APP, but those programs are already in place with the curriculum being tweaked with every class. When I talk to my fellow paramedics about my upcoming PA adventure, the majority of them are a bit jealous but cannot see themselves having no income for a couple of years while piling on debt. I wonder if the APP program can be done part time, or in partnership with active EMS companies. Having the students split their work/school, earning a part time wage while attending class. I am not aware of any part time PA courses. Or if they are out there, they are not well known, at least out West. U of W discontinued theirs. Of course there would be stipulations for admission to the program such as number of years of service running an average number of calls per year.

 

In my fantasy, getting reimbursement for the response would be green lighted because the patient was fully evaluated and triaged into an appropriate route of care. With that guaranteed appointment slot, I was extrapolating that out of the theory that during flu seasons..some ER patients don't get seen for 12 hours. What's a few more hours?

 

Companies could offer BLS or even just "medical vans" to get these patients to and from their appointment, for a nominal charge of course. That may help garner even further funding for the program

I had not heard of that endeavor in Mesa or DC. I worked in Montgomery County Maryland, along the DC line for a number of years and was unaware of such things. When I was there the DC EMS system was really struggling to perform at a very basic level. Fraught with issues.

[Acebecker]

In some ways, the idea of utilizing PAs in pre-hospital EMS has gone by the wayside for this project. Overall, I had to narrow down the idea. What it all has come down to is this: what is the quality of pre-hospital EMS in rural areas? If it is high, then PAs can't really bring a lot to the table. If the quality is low, then how do we fix that? And then I will address the issue of how PAs can play a role in pre-hospital care to improve the shortcomings. All that to say that the initial idea of this project needs a little revamping before PAs in pre-hospital care can be fully endorsed as an effective method for improving EMS care.

 

However, another aspect that has come up is the idea that we don't need more advanced practice providers in the field, but some sort of a half-way step-down ER for people with chronic medical problems. Instead of taking the frequent-flier with CHF/DM/Renal failure/HTN/COPD etc. to the ER for an admission and medication management, take them to a type of urgent care designed for management of these types of problems. This would be a place designed to complement their PCP (where the PCP won't have time to take care of all their chronic conditions) such that the patients can receive dedicated, quality care for acute exacerbations as well as longer term management/med adjustment via short term admission (6 hour observations w/IV meds, etc.). Given that these types of patients take up a large portion of ambulance calls in rural and urban areas alike and given that these types of patients often take inpatient beds at an increased cost to the hospital with potentially poor reimbursement, this type of department would be beneficial.

 

At any rate, there may be different methods of addressing the problem rather than putting PAs in the back of a bus. We're working the issue from both angles back home, and hopefully within the next 7-8 months I'll have something more concrete to report on.

[Just Steve]

some sort of a half-way step-down ER for people with chronic medical problems. Instead of taking the frequent-flier with CHF/DM/Renal failure/HTN/COPD etc. to the ER for an admission and medication management, take them to a type of urgent care designed for management of these types of problems. This would be a place designed to complement their PCP (where the PCP won't have time to take care of all their chronic conditions) such that the patients can receive dedicated, quality care for acute exacerbations as well as longer term management/med adjustment via short term admission (6 hour observations w/IV meds, etc.). Given that these types of patients take up a large portion of ambulance calls in rural and urban areas alike and given that these types of patients often take inpatient beds at an increased cost to the hospital with potentially poor reimbursement, this type of department would be beneficial.

 

BAM! Now we are on the same page. That's what we're talking about.

 

When I worked back east The Adventist Medical system bid for, was approved, and built a stand alone ER. They would not accept acute chest pain, hot bellies, and other obvious surgical or super sick patients so most of their focus was the 23 hour observation or less. It worked well. If units brought in a patient that didn't belong (wrong acuity) or a drive up patient arrived who was in need of a more tertiary care center, we would just do a interfacility transport.