Working EMS as a PA-C

[MCHAD]

Hoping for some advice.  I've been working at my current job for a year.  I work in rural Idaho in a town of about 1200 people.  Clinic is a primary care FQHC.  It's a pretty sweet gig in my opinion, I work a 4 week rotation:

week 1 mon-wed 3/10's,

week 2 wed-fri 3/10's,

week 3 24/7 on call for overflow in the clinic (most of the time solo provider in the clinic so it gets slammed from time to time), Respond to 911 as an Ambulance based clinician with local Volunteer EMS about 4-8 calls on average per week, After Hours care line which is phone consults and about 4-8 after hours visits in the clinic per week,

week 4 is 7 days off.  

The pay is good, especially for Idaho and considering I only work 13 days a month, and 7 of those can be on call with absolutely nothing happening for a week (i've had 7 days with no after hours visits and no 911 calls). 

The experience has been fantastic, As a PA getting true emergency med experience rather than being put in a fast track can be tough.  But where I practice, even though we are a clinic, we are the only medical service for at least an hour in any direction, as a result i've managed and flown out acute STEMI's, Trauma's, etc.  All while getting to practice the primary care medicine I love.  

All this being said I struggle sometimes with working with the volunteer ambulance crew.  As a paid member of an otherwise volunteer ambulance crew myself and the other 3 providers have either been welcomed with open arms, or disliked because we are paid and have a larger scope of practice than they do.  The other thing I dislike is being handcuffed by the fact that the ambulance service is a BLS service...Even though I am qualified to do much more than an EMT Basic, I am not allowed to because we are a BLS service.  There is a way around this, If the call is in town and the patient is critical i can rush them to my clinic and as soon as they're rolled across the threshold the rules change and I can practice within my full scope.  

Any advice on: 

1 - getting the volunteer's on board with us "new guys" being on the ambulance with them? 

2 - getting the state to allow myself and the other ambulance based clinicians to allow us to practice within our scope while on the ambulance?

 

[rev ronin]

1) Teach 'em!  I function as an EMT, but I've taught for the last 5 years of EMT initial classes in my county pretty consistently, so they all know me--not just my own department's EMTs, but the BLS ambulance medics and the paramedics, too.  Assume that they want to go places, and teach them stuff beyond their scope of practice: nothing invasive that can hurt anyone, but stuff like A&P, 12 leads, etc.

2) https://ems.creighton.edu/training-certification/paramedic-certification-healthcare-providers-0

If the county medical director doesn't feel comfortable delegating to you beyond the BLS scope of practice and/or collaborating with you to make up a new one... become a paramedic!  Still have hurdles, but less since you'd have a (the...) recognized prehospital ALS credential.

[dmdpac]

In regards to question two you'll need to apply to the state for the ambulance service to be certified/licensed at the ALS level.  A good way to support that argument is to, as Rev noted, become a paramedic in addition to your PA credentials.  In most states PAs don't count as far as EMS providers.  You'll need an EMS based certification to support the idea of being able to operate with a wider scope of practice.  From there get the medical director on board for a "study of PA based EMS".  (Pennsylvania is the only state of which I'm aware that has a prehospital PA certification.)

As far as question one?  Well, good luck.  There are always going to be people who will respond the way some of the EMS-ers have responded to you.  Be polite.  Be professional.  Be yourself.  The more they get to know you the better off you'll be.  Those who are open minded will come around.  Those who aren't need to be weeded out. 

 

[medic25]

It can be tough breaking through the vollie resentment of the paid staff.  I spent two years as one of the first paid flycar paramedics in a county that was 100% volunteer/BLS.  We had some services that would cancel the medic on every single call, regardless of acuity, just because we were paid.  If we got on scene first, they would convince the patient to refuse ALS care.  I think it helps sometimes to just put in your time around the station and get to know them. The more they see the paid staff pitching in with the chores, socializing, etc., the sooner you'll be accepted.  I agree with Rev about teaching as well; if you can help share your knowledge it'll prove what an asset you can be to the agency.

In terms of practicing at the ALS level, if the service is only licensed to the BLS level you don't have many great options unless the service upgrades.  If you have enough advanced-level providers to consistently staff ALS, you could make a case to the chief/town to work on upgrading the service level.  If your service bills, you can use the higher level of billing as a justification for the extra cost for equipment.  Without the actual service upgrading though you don't have many options.

 

[DizzyJ]

I would love a job like this!  Aside from this frustration you are having. 

[MCHAD]

Thanks for the advice!  Dizzyjon, I applied for the job because it is so unique and i thought it would be an awesome opportunity and challenging.  I almost left because of frustrations but i'm glad i decided to stay!  

[DizzyJ]

3 hours ago, MCHAD said:

Thanks for the advice!  Dizzyjon, I applied for the job because it is so unique and i thought it would be an awesome opportunity and challenging.  I almost left because of frustrations but i'm glad i decided to stay!  

It is a very unique job and hard to find.  I've found several in Montana, but the pay was pretty bad. 

[Acebecker]

Been running as a basic EMT in Idaho for 8 years; PA-C for the past 6 years.  I still volunteer, so I don't get the hate from the other basics, but some of the medics look at me askance when I help them run their ACLS calls.  I have intermediate skills - IV/IO - saline only, King airway, SC/IM injections; this covers most of everything.  We have enough medics that I am never left without the ability to care for the patient - they can delegate to me any task they feel comfortable so they do.  I have gotten to the point where I can do transports at the ALS level from one facility to another.  In the pre-hospital setting, I have not had luck getting the state to allow me to do more.  I need to work with the local EMS medical director more.  My job schedule precludes a lot of effort to this end - I run about 12 calls/month and work 50+ hours/wk in my main and side jobs, so it's not a big deal at this point for me to remain BLS+advanced skills.  Someday...

[UGoLong]

I've been in EMS for 31 years (volunteer and then part-time paid for the past 20) and a PA in cardiology for 11 years. And a paramedic for 13 years. I love working with our crews a few times each month. Since I started working to become a PA, several of our members have gone back to school themselves, mostly to become RNs (one is now an NP and another may soon do the same.)  Some originally thought they were too old to got back to school until they met me. 

I recognize that our full-timers get way more experience (especially with trauma) then I do on a day-to-day basis and their procedural skills are more up-to-date. On the other hand, it's been a long time since I've been on a run where I wasn't either in charge or asked what I recommend or what else they should do.

I think if you act like one of the boys (and girls) and look for teaching opportunities, it can be a rewarding life. Kick in for meals and shoot the bull with them. Sitting in the lounge and talking about literally ANYTHING is one of the highlights of my week. You don't have to lord your credentials; yours are respected and they would like the same respect from you.  

If you're not a medic, I recommend that you get your credentials; you will be so much more accepted. I should note that, in my state, even RNs can't ride the bus and use their skills without taking a bridge course. It was easy for me to qualify as an adjunct EMS instructor, so I can teach CEs to the members. I do a section on cardiology for paramedic refreshers and did the training for the CHF community paramedics.

At my age, I often think about letting something go and I know that someday I will have to. But each time I ride with our crews, I'm glad that I'm still there. I've told the chief and our lieutenants not to be bashful if they think I'm not pulling my weight. So far, all I get are thanks that I'm on any run with them (especially cardiac runs). Having your feet in both worlds (plus teaching two days a week for a PA program) has been a true delight.

[MCHAD]

On 7/14/2017 at 11:48 AM, Acebecker said:

Been running as a basic EMT in Idaho for 8 years; PA-C for the past 6 years.  I still volunteer, so I don't get the hate from the other basics, but some of the medics look at me askance when I help them run their ACLS calls.  I have intermediate skills - IV/IO - saline only, King airway, SC/IM injections; this covers most of everything.  We have enough medics that I am never left without the ability to care for the patient - they can delegate to me any task they feel comfortable so they do.  I have gotten to the point where I can do transports at the ALS level from one facility to another.  In the pre-hospital setting, I have not had luck getting the state to allow me to do more.  I need to work with the local EMS medical director more.  My job schedule precludes a lot of effort to this end - I run about 12 calls/month and work 50+ hours/wk in my main and side jobs, so it's not a big deal at this point for me to remain BLS+advanced skills.  Someday...

I'd love to know more about your situation since we're both in the same state...can't send you a private massage though.  Shoot me one if you're able to. 

[MedicinePower]

I've worked BLS and ALS. On the BLS 911 ambulances we'd get paramedic intercepts wherein a medic would be picked up in our ambulance and this medic would have 2-3 bags full of ALS gear. At that point we became an ALS ambulance but the moment the call was done and the medic left with their bags we'd go back to being BLS. You need to convince the state EMS office and your medical director to allow you to do the same. It's been my experience that being successful in this is possible but it takes a lot of time and patience.

[GetMeOuttaThisMess]

On 7/14/2017 at 0:48 PM, Acebecker said:

Been running as a basic EMT in Idaho for 8 years; PA-C for the past 6 years.  I still volunteer, so I don't get the hate from the other basics, but some of the medics look at me askance when I help them run their ACLS calls.  I have intermediate skills - IV/IO - saline only, King airway, SC/IM injections; this covers most of everything.  We have enough medics that I am never left without the ability to care for the patient - they can delegate to me any task they feel comfortable so they do.  I have gotten to the point where I can do transports at the ALS level from one facility to another.  In the pre-hospital setting, I have not had luck getting the state to allow me to do more.  I need to work with the local EMS medical director more.  My job schedule precludes a lot of effort to this end - I run about 12 calls/month and work 50+ hours/wk in my main and side jobs, so it's not a big deal at this point for me to remain BLS+advanced skills.  Someday...

Why couldn't you just have the EMS medical director supervise you thus bypassing the EMS state protocols?  If you're on the box and functioning as a PA and not an EMT or paramedic what would be the problem?  Decades ago when we used to BLS transport vent patients from the local VA to another hospital that actually had a CT scanner the doc didn't function as anything less than a physician even though they were in a moving vehicle.

[Acebecker]

GMOTM - EMS medical director so far is not comfortable doing that.  Part of that is driven by the misbelief that he'd be responsible for my actions in the field, the other part is that the president of the ER group that he works for had a bad experience with a PA once and thus hates all PAs (and that doc and I have had run ins in the past since I work wound care in the same hospital which hasn't helped my cause - she universally second guesses my decisions and recommendations).  I am still working on it, but until she retires I have an uphill battle to fight. 

It also is a matter of my chief trusting me.  I think they're worried that I'll get in over my head and not call for help. 

[MCHAD]

On 7/10/2017 at 6:49 AM, dizzyjon said:

I would love a job like this!  Aside from this frustration you are having. 

Well, We have an opening as of last week for a PA/NP.  Shoot me a PM if you're interested in Details!

[DizzyJ]

6 hours ago, MCHAD said:

Well, We have an opening as of last week for a PA/NP.  Shoot me a PM if you're interested in Details!

I wish I could...in the last 3 years I've moved from Ohio to Hawaii to California and then back to Ohio just 3 months ago.  Need to stay put for awhile.