Paramedic Practitioner

[ohiovolffemtp]

I recall talking with a PA coworker who had also been a medic for a number of years.  Our joint opinion what that coding a patient was easy - we'd done it for years.  The hard part (or new part) as a PA was what to do if we got them back, i.e. post-resuscitation support, because other that simple drips like dopamine, amiodarone, or lidocaine, that was all new to us - and also far more complex.

[dmdpac]

2 hours ago, ohiovolffemtp said:

I recall talking with a PA coworker who had also been a medic for a number of years.  Our joint opinion what that coding a patient was easy - we'd done it for years.  The hard part (or new part) as a PA was what to do if we got them back, i.e. post-resuscitation support, because other that simple drips like dopamine, amiodarone, or lidocaine, that was all new to us - and also far more complex.

 

I had this same conversation just recently with a colleague of mine who's also a former paramedic.

 

I was the only paramedic in my class of 80+.  A few people said they had "EMS experience" (EMT certification but very limited actual street time).  I'd like to think my paramedic experience was the tipping point in getting me in to PA school. 

The group I work for also employs the state and local county EMS medical directors.  In recent years they've brought up the idea for a community paramedicine program similar to the one described in the article about Austin.  The same colleague I mentioned above and I have volunteered our assistance several times in trying to get things moving.  Each time we bring it up we're shot down.  No idea why.

[GetMeOuttaThisMess]

I'll go ahead and say it for Cid, it's because y'all (coming to grips still with being retired) are "assistants".  

[MediMike]

9 hours ago, ohiovolffemtp said:

I recall talking with a PA coworker who had also been a medic for a number of years.  Our joint opinion what that coding a patient was easy - we'd done it for years.  The hard part (or new part) as a PA was what to do if we got them back, i.e. post-resuscitation support, because other that simple drips like dopamine, amiodarone, or lidocaine, that was all new to us - and also far more complex.

This is the truth. I came from a works with those meds and epi, and into one with dobutamine, milrinone, norepinephrine, phenylephrine, vasopressin...was paralyzed by too many options in beginning!

[GetMeOuttaThisMess]

55 minutes ago, MediMike said:

This is the truth. I came from a works with those meds and epi, and into one with dobutamine, milrinone, norepinephrine, phenylephrine, vasopressin...was paralyzed by too many options in beginning!

Don't forget the procainamide drip dosing (as well as the four indications for stopping medication), bicarb, and atropine.

[MediMike]

23 minutes ago, GetMeOuttaThisMess said:

Don't forget the procainamide drip dosing (as well as the four indications for stopping medication), bicarb, and atropine.

C'mon...Nobody actually has AVRT.

Although the PROCAMIO trial demonstrated significantly better resolution of VT with procainamide vs amio if I remember right.

Bicarb is out of ACLS, the BICAR-ICU kind of put the kybash (kibash?) on it for critical care use as well. 

[LT_Oneal_PAC]

17 minutes ago, MediMike said:

C'mon...Nobody actually has AVRT.

Although the PROCAMIO trial demonstrated significantly better resolution of VT with procainamide vs amio if I remember right.

Bicarb is out of ACLS, the BICAR-ICU kind of put the kybash (kibash?) on it for critical care use as well. 

It should be noted that the studies showing no benefit of bicarb were all on pushed. Many of us in EM believe that bicarbonate drips still have some indication in codes for things like hyperk 

[MediMike]

2 hours ago, LT_Oneal_PAC said:

It should be noted that the studies showing no benefit of bicarb were all on pushed. Many of us in EM believe that bicarbonate drips still have some indication in codes for things like hyperk 

Interesting, I see little to no utility in a code situation for a bicarb infusion unless you're running it in through an introducer sheath, would the diluted form help with solute drag in that situation? More rapid transcellular shift would be achieved with insulin. Would love to see a paper on it if you've got it.

Agree post code if the underlying pathologic process is an acidemia. (Regardless of the one RCT, I'll stand by my anecdotal experience )

[GetMeOuttaThisMess]

3 hours ago, MediMike said:

C'mon...Nobody actually has AVRT.

Although the PROCAMIO trial demonstrated significantly better resolution of VT with procainamide vs amio if I remember right.

Bicarb is out of ACLS, the BICAR-ICU kind of put the kybash (kibash?) on it for critical care use as well. 

I was referencing the prior comment relating to old school ACLS meds.  Current guidelines have taken all the fun out of it.  Bicarb for TCA overdose, hyperkalemia, and there was something else that I'm forgetting.

[FiremedicMike]

2 hours ago, GetMeOuttaThisMess said:

I was referencing the prior comment relating to old school ACLS meds.  Current guidelines have taken all the fun out of it.  Bicarb for TCA overdose, hyperkalemia, and there was something else that I'm forgetting.

Give me a call when we’re ready to discuss bretylium.... LOL

I can’t believe we used to carry 4 different anti arrhythmics.. then there was escalating dose epi..

I swear.. you give me all those old school drugs plus what we know about CPR today.. add in an auto pulse for good measure, I bet I could get ROSC on Abe Lincoln.. he’s not going to walk home from the hospital,  but I bet I could get that heart ticking again... 

 

[LT_Oneal_PAC]

7 hours ago, MediMike said:

Interesting, I see little to no utility in a code situation for a bicarb infusion unless you're running it in through an introducer sheath, would the diluted form help with solute drag in that situation? More rapid transcellular shift would be achieved with insulin. Would love to see a paper on it if you've got it.

Agree post code if the underlying pathologic process is an acidemia. (Regardless of the one RCT, I'll stand by my anecdotal experience )

No papers, just EM opinion

• Bicarbonate boluses. This was a classic treatment. In emergency medicine, we typically use bicarbonate as a bolus. There is little utility to pushing boluses of bicarbonate. There is only one condition in which pushing bicarbonate is a good idea; TCA or sodium channel blocker overdose. There is a lack of efficacy of pushing ampoules of bicarbonate in an acidotic patient.  However, bicarbonate is fantastic in its intended form; an isotonic bicarbonate drip.
• What if you had a fluid that would expand the volume, has zero potassium and doesn’t make them acidotic? This is where isotonic bicarbonate shines. Give three amps of bicarbonate in a liter of D5W or sterile water. This will rapidly lower the potassium by dilution.
• If the patient is profoundly dehydrated with renal failure, the potassium will be lowered just by giving isotonic bicarbonate. If the patient is normovolemic, you still should give them isotonic bicarbonate. However, you don’t want to volume overload the patient so give them a diuretic as well. Furosemide will also make them excrete more potassium. You need to measure output carefully, with a This is effective in patients able to generate urine.

[EMEDPA]

32 minutes ago, LT_Oneal_PAC said:

No papers, just EM opinion

• Bicarbonate boluses. This was a classic treatment. In emergency medicine, we typically use bicarbonate as a bolus. There is little utility to pushing boluses of bicarbonate. There is only one condition in which pushing bicarbonate is a good idea; TCA or sodium channel blocker overdose. There is a lack of efficacy of pushing ampoules of bicarbonate in an acidotic patient.  However, bicarbonate is fantastic in its intended form; an isotonic bicarbonate drip.

had a great case as a medic. suicide attempt. took a bottle of elavil, seized and coded. standard ACLS plus all the bicarb on the rig (8-12 amps if I recall correctly), intubated. initial abg in ED on arrival PH 6.8. More bicarb given by push and bicarb drip started. Multiple vfib arrests, successfully resuscitated. spent a week in the ICU and walked out without deficits. One of my best cases as a medic. he got almost every drug in the drug box, except ntg. Think his glucose was 40 so he got D50. He seized so he got valium. All the acls drugs. 

[ohiovolffemtp]

18 hours ago, dmdpac said:

 

I had this same conversation just recently with a colleague of mine who's also a former paramedic.

 

I was the only paramedic in my class of 80+.  A few people said they had "EMS experience" (EMT certification but very limited actual street time).  I'd like to think my paramedic experience was the tipping point in getting me in to PA school. 

The group I work for also employs the state and local county EMS medical directors.  In recent years they've brought up the idea for a community paramedicine program similar to the one described in the article about Austin.  The same colleague I mentioned above and I have volunteered our assistance several times in trying to get things moving.  Each time we bring it up we're shot down.  No idea why.

One thing I've always heard as a drawback for community paramedicine is there is no reimbursement.  EMS reimbursement is based on transport.

[dmdpac]

7 hours ago, ohiovolffemtp said:

One thing I've always heard as a drawback for community paramedicine is there is no reimbursement.  EMS reimbursement is based on transport.

So why not, for these community paramedicine programs involving PAs, bill based on diagnosis and treatment like would be done for patients we see in the ED?  Is there anything in the billing regulations that would prohibit that kind of billing practice?  I honestly don't know.

[MediMike]

35 minutes ago, dmdpac said:

So why not, for these community paramedicine programs involving PAs, bill based on diagnosis and treatment like would be done for patients we see in the ED?  Is there anything in the billing regulations that would prohibit that kind of billing practice?  I honestly don't know.

I think that if they are utilizing PAs then this is an option, the issue is most community paramedicine services are just that, paramedics, and they are not recognized as being able to bill for a treat and release.  Which is ridiculous, but maybe having EMS fall under the DOT wasn't the best idea

[canfield]

I've always felt they should be funded under a public health organization, county or otherwise. La County funds their paramedic helicopters with a property tax "trauma services" assessment.

[TexasPA28]

On 10/18/2020 at 8:56 PM, canfield said:

One other thing to consider is the ability for a field PA or NP to authorize a patient to be transported to an alternative destination such as a clinic or urgent care. Or, possibly direct admit. Are there field PA programs doing this? When I worked in Los Angeles County, the EMS agency formally attempted to create a policy to allow paramedics to transport to urgent cares ... but, it didn't fly. Perhaps it would now with a PA/NP?

 

Direct admission would be a disaster and only works well for scheduled elective procedures.  There's too much time passage between the initial eval in the field and the time that they end up on the floor dumped on the hospitalist service.  Unless there's an organized plan to keep the PA with them consistently from initial eval all the way until arrival on the floor, it's not good patient care.