Can a PA challenge a Paramedic/NREMT-P exam?

[Just Steve]

PAs are utilized in the field (in very few locations) in conjunction with EMS to provide in-home care where appropriate i.e. suturing, minor Rx dispensing, etc. At this time, I believe they are on some type of on-call basis. My previous agency has asked if I would come back to perform that type of work; they claim that Medicare and some insurance services will reimburse better for in-home service vs. ambulance transport, at times.

 

As for PAs in the field, if they obtain ACLS, PHTLS, PALS, BLS, and emergency services training such as the ICS system, HAZMAT Ops/Awareness training, and agency specific operations training- then by all means, hit the field.

 

In Oregon, where I have practiced for 17 years, that has been the standard and statute for a non-EMT type to operate as a 1st or 2nd crew member on a 911 ambulance. Presumably, it would apply to a PA as well.

 

Are those "non Emt type as a 1st or 2nd crew member" tasked with direct patient care or is their role more along the lines of manpower and driving?

[MediMike]

Hell...I'd just like to keep my cert to play on the rigs every now and then.

[MedicinePower]

Hell...I'd just like to keep my cert to play on the rigs every now and then.

 

Agreed! I worked very hard for my EMT-I cert and plan to keep it up. I just renewed for another 2 years with the NREMT. I am looking forward to the day where my cert reads "bstone, NREMT-I/85, PA-C".

[A1CAMERON]

Are those "non Emt type as a 1st or 2nd crew member" tasked with direct patient care or is their role more along the lines of manpower and driving?

 

I suppose it's good to clarify: the non-EMT types are RNs that volunteer with the local EMS system. I could see a PA following the same path, which is something I may do in the future if I don't retain my Paramedic. If I'm in a rural area I'd like to contribute my past experience to the local EMS system.

[PAruby]

@ FatAlbert- I'm just curious why you would want to do this? In the US, prehospital PAs are still sort of this idea somewhere out there with a lot of practicality to be figured out. As a paramedic in PA school now, I'm wondering why you'd want to become a Paramedic? Have you found info on where both certifications can benefit you? Are you unhappy with being a PA and want to do EMS instead? In my own research, I've found that even having both trainings and both licenses, it's a bit of a tricky situation to uphold since both require an overseeing physician, and you can't perform PA duties as a Paramedic yet you're expected to think to the level of your licensure... I've found the expectations of a PA working as a Paramedic very confusing... I'm up for renewal and as much as it was a PAIN to get my EMT-P and I don't want to let it go, I'm curious how much good it will do me? Maybe you have more info?

[DJ Bunnell MSHS PA-C]

Thanks for this interesting thread. When I read the question I assumed the answer was no. As a former Paramedic, I was glad to see that I was wrong.

 

I think the keys to a successful program would be a supportive local EMS system, a mechanism for follow-up or referral, a mechanism for collaboration with a physician, and plan for funding.

 

I could imagine a situation where an urgent care out-pt facility may be interested in supporting this as a way to get patients to come in for follow-up. A large health system may be interested in both the capability for referal as well as the marketing bonus of a rolling billboard that comes to your home.

[Nonlegit]

That's not really true and I doubt it would be a bad thing. If the PA is trained in prehospital medicine then they will know when to discharge on scene, when to stay and play, and when to transport. The first two greatly expands the abilities of EMS from the current scenario, which is "you call, we haul". It reduces unnecessary ER visits and provides EMS with additional tools not previous available.

 

I'm pre-PA, EMT-I on a semi-busy 911 service, and a tech in a big-time level 1 ED (all this for 8? years). I say this with the utmost respect to someone with obviously greater experience than me. I'm trying to list FT complaints in my head, as I'm sure these are the only ones that possibly could get D/C'ed on scene. I go through the list in my head and I just can't imagine many being "dischargeable" from the back of an amberlamps, at least not practically. Then you hit on one, like the finger lac with no blunt trauma that would need hand films. And you take 1 hour to fix-em up with a couple of stitches (from tone out to paperwork wrap up) when you could have dumped them off in triage in 5 or 10 as a EMT-B. I know I don't have the global picture in my head from years of experience and seeing everything there is to see, but it just seems like such a narrow narrow useful window for PAs. This is from the guy that wishes more than anything there would be some sort of flight/EMS/Physician/PA/NP/AP Medic/drive around in a sweet car or helicopter and only do what you want like codes and traumas one day then FT the next then have a quiet day where you watch football/.... well you get my drift. If you ever do get it to work and make it a valid profession, you will probably see me there. I have the background and desire, haha.

[EMEDPA]

lots of minor stuff could be fixed in the field:

ingrown toenails

many lacs

I+D abscess

minor derm conditions

most dental stuff

fb in the ear/nose

minor ortho stuff( a lot really doesn't need an xray)

most ent stuff ( om, pharyngitis, etc)

uti's without fever or gyn sx

 

the above list is probably 75%+ of what goes through a typical fast track. a good pa could do all this with minimal lab(dipsticks for urine, strep tests, etc) and a minimal kit for minor procedures. a script pad and they would be good to go.

[Friction]

I'm pre-PA, EMT-I on a semi-busy 911 service, and a tech in a big-time level 1 ED (all this for 8? years). I say this with the utmost respect to someone with obviously greater experience than me. I'm trying to list FT complaints in my head, as I'm sure these are the only ones that possibly could get D/C'ed on scene. I go through the list in my head and I just can't imagine many being "dischargeable" from the back of an amberlamps, at least not practically. Then you hit on one, like the finger lac with no blunt trauma that would need hand films. And you take 1 hour to fix-em up with a couple of stitches (from tone out to paperwork wrap up) when you could have dumped them off in triage in 5 or 10 as a EMT-B. I know I don't have the global picture in my head from years of experience and seeing everything there is to see, but it just seems like such a narrow narrow useful window for PAs. This is from the guy that wishes more than anything there would be some sort of flight/EMS/Physician/PA/NP/AP Medic/drive around in a sweet car or helicopter and only do what you want like codes and traumas one day then FT the next then have a quiet day where you watch football/.... well you get my drift. If you ever do get it to work and make it a valid profession, you will probably see me there. I have the background and desire, haha.

 

If you wanted to move to the Phoenix area you might have that chance... without the helicopter I presume. Mesa Fire and Medical Department, formerly Mesa Fire Dept, has used and is continuing to try and use PA's on special response vehicles in order to cut down on the ER volumes and the higher cost associated with running 4 man crews on bigger rigs. They don't go into a whole lot of detail but I assume it would be things similar to what EMEDPA is talking about, essentially fast track stuff. As I always wanted to be a FF prior to discovering PA, I think it would be awesome to work in this type of role. Seeing as how EMS calls represent 70-85% of a fire departments calls, it makes perfect sense to use PAs in this capacity. Finding funding and paying PAs competitively is another story.

 

http://www.azcentral.com/community/mesa/articles/2012/01/24/20120124fire-department-seeks-m-federal-grant.html

[Teasip]

Just stumbled across this thread when I realized that to become a local college EMS instructor I have to go back and get at least my EMT-B (probably would go back to UT-Southwestern where I did it back in the late 70's). This topic begs that you who are interested in this concept attend "A Gathering of Eagles" EMS conference held in Dallas each winter (coming up end of Feb.) in which your big city EMS medical directors and EMS providers (municipal, state, federal [FBI, S. Service, HLS, even White House]) gather to discuss the latest/greatest in the EMS field. First half plus day is always trying to squeeze another survivor from OOH CPR but there was an interesting presentation by Dr. Pursse out of Houston a couple years back about how c-collars actually distract the c-spine and destabilize internal decapitations (had x-rays to show it). They don't ever mention mid-levels and I've never been able to get them to post my PA status on the name badge ("BS" only) but they constantly are discussing how to cut down on unnecessary calls, whether it is triaging over phone, BLS vs. ALS teams, having an EMS super follow up after a non-transport (this is where I could see the PA coming in handy), or like in London where they have first responders on BMW motorcycles. I'm sure they'll discuss the Olympics this year as well as NYC discussing responses to Hurricane Sandy and so forth. Dr. M. Eckstein out of LA is a former NYC paramedic and always gives one or two presentations. C. Slovis, M.D. out of Nashville always starts it off with three points (five points?) that are quick hits from the past 12 mos. in new studies (forget bicarb for the most part, forget advanced airways and just bag 'em, etc.).

[CCEMPA]

That's not really true and I doubt it would be a bad thing. If the PA is trained in prehospital medicine then they will know when to discharge on scene, when to stay and play, and when to transport. The first two greatly expands the abilities of EMS from the current scenario, which is "you call, we haul". It reduces unnecessary ER visits and provides EMS with additional tools not previous available.

 

 

Its funny you say this, but you have indirectly mentioned the future that many experts believe EMS will move to in the next couple of years. In fact, some services have already made the move towards experimenting with a "community paramedic", NC if i'm not mistaken is the main testing ground. Basically, as well all know, the number of unnecessary transports to hospitals result in a unneeded strain on an already burdened system or take away ambulances from responding to actual life threats. So the idea is that a seasoned paramedic, with a little more training responds directly to these houses and determines whether or not people actually need an ambulance, and in some instances can "treat and release". Interesting stuff. As I stated before, a lot of people feel thats the way things are going to go.

[CCEMPA]

Also has anyone who made the change from medic to PA noticed a similarity in how both professions are viewed by other healthcare professionals? A lot of what I have come across is the consensus that the PA profession is sometimes viewed as "less than" or that people have no idea what a physician assistant is.....sounds shockingly familiar....

[Teasip]

You are correct In that NC has looked at this. They have referenced them as "advanced paramedics". They have detailed this approach at the previously referenced "Eagles" conference. I blank on the name of the Winston-Salem EMS med director's name. They have also looked at a voucher transport idea for cabs but were leery due to the liability. MedStar in Ft. Worth, Tx has a young EMS med director and has also been looking into this (Tarrant Co EMS is not part of fire services).

[just_me]

Sounds like history repeating itself and medicine going back to house calls (somewhat)......actually sounds pretty cool...I was going to shadow a PA in FL that makes house calls :;-):

 

The only issue that really stands out to me would be lazies calling 911 because its easier to have a "doc" come to them instead of them getting dressed and going to the doc themselves.

 

I, too, look forward to this but it does not appear to be moving in this direction. PAs are needed in primary care and tertiary care positions more than prehospital. As an EMT-Intermediate for the past many years I think it should be natural for paramedics to become PAs and transition from "you call, we haul" to actually treating and discharging on-scene, when warranted.

[Medic207]

I have recently been in contact with the medical director about offering the program here as well. I was the Asst. EMS medical director for another service a few years back where I was a paramedic. I would occasionally run calls with the service and invariably treat and release because it was so freaking obvious that needed to be done. However trying to do this in a large city as an official program brings a lot to question at the very least is the cost of such a plan.

[Teasip]

A PA will over think paramedicine and delay transport.

 

Isn't that the point, to determine whether transport is even necessary? That being said, there will always be circumstances in which you wish you had a do over. Just look at the data on ED CP pts. Regardless of how thorough the exam or time duration of assessment, you will always want two out of a hundred back because it was ACS.

[aquafresh11]

The real reason why it will never happen is the cost. What agency or city can afford to pay a PA (at hopefully a much high salary than a paramedic) only to treat and release lacerations and other nonsense? This imaginary system only saves the hospital money in theory. But if people complain that it is the uninsured who are clogging up the ED with every little thing, how do you expect them to pay your even higher than an ambulance ride bill? It may free up a crew to take another call, but if the PA is on scene 30+ minutes stitching something up, there are several other calls happening. Which means you would need multiple PA's in the system dealing with minor stuff all over the city with little hope of ever getting paid for it. This would be a colossal money loser all the way around, hence why it would never get off the ground in any meaningful way.

[Teasip]

I think the point of the advanced practice professional as I heard it explained is to assist with better decision making regarding utilization of resources (transportion), not to actually be addressing the actual medical condition, i.e.-laceration repair. The concept as I've heard presented by the medical director(s) is to use them more in a supervisory role to respond to certain calls (non cardiac arrest CP, difficulty breathing, neuro deficits, abdominal complaints, etc.). They will make a recommendation to not transport as an example but will then follow up with the individual in question a while later (within a couple of hours of initial assessment) to see what the status is of the individual, and if necessary, return to the location for further assessment. Bear in mind that they realized that there were still quite a few bugs to iron out.

[aquafresh11]

That version has even less of a chance of ever happening. Why on earth would anyone ever want the responsibility and liability of telling someone that their chest pain, abdominal pain, or SOB is fine to not go to the hospital? There is a reason there is defensive medicine, people sue a lot. Telling someone that you will check back in on them in a few hours just won't cut it in our society. People call 911 because they want to go to the hospital. Even though their emergency is not what we would define as an emergency, that is what the system is. From a strict EMS perspective, it will always be faster, safer, easier, and cheaper just to take someone to the hospital and let them deal with it.

[ventana]

lots of minor stuff could be fixed in the field:

ingrown toenails

many lacs

I+D abscess

minor derm conditions

most dental stuff

fb in the ear/nose

minor ortho stuff( a lot really doesn't need an xray)

most ent stuff ( om, pharyngitis, etc)

uti's without fever or gyn sx

 

the above list is probably 75%+ of what goes through a typical fast track. a good pa could do all this with minimal lab(dipsticks for urine, strep tests, etc) and a minimal kit for minor procedures. a script pad and they would be good to go.

 

 

ding ding ding

we have a winner!!!!!!!!

 

 

Big issue is that the PA needs to be ultra experienced to have the nose of blood hound to sniff out the zebra poop that is occasionally sitting in the corner. Gotta have enough experience in a real live ER to know when that ER trip is required.

[Just Steve]

Isn't that the point, to determine whether transport is even necessary? That being said, there will always be circumstances in which you wish you had a do over. Just look at the data on ED CP pts. Regardless of how thorough the exam or time duration of assessment, you will always want two out of a hundred back because it was ACS.

Efficacy vs efficiency. One PA on the street making house calls might see 8-9, maybe even 12 patients in a shift. How many patients can a PA in a fast track see? 40? 50?

 

The street dispatched PA may be a darn good medical provider, keeping those 12 patients out of an ER. But as Aquafresh said...who is going to pay for it?

 

Let advanced practice paramedics triage out the BS from the legit, sending the BS via cab, bus, POV to stand alone clinics specifically created for sub acute patient referrals from EMS. My concept is very similar to a walk in clinic but this clinic is only for EMS referred patients. By restricting it to just that service, it ensures appointment slots are always open. That clinic operates with a much lower overhead than a full ER and allows for the already existing ER better utilize their resources, both personnel and material.

[Teasip]

Let's think finances here. What's an average cost to tie up an ALS unit for an hour, including the cost of transport, for a pt. that could have gone by private vehicle after initial assessment? Compare that to the hourly cost for a PA, or advanced practice paramedic, and I think that it would be somewhat cost efficient. Also, factor in the presumed decrease in liability based on direct observation of the pt. by an advanced practice professional as opposed to a garden variety paramedic who maybe sees an actual case of ACS a couple times a year. That is the whole basis for the advanced practice paramedic (not my observation, but that of those pushing the idea). Many of these municipalities have these paramedics who are lucky to intubate once or twice a year. By sending the advanced provider to a priority call who spends the majority of their time handling these types of cases, and thus reducing the liability risk, I think the costs start to become more favorable. Bear in mind that if the answer were simple then everyone would be doing it. It was the same thing with the RSC and hypothermia therapy. A couple of small towns tried it using different techniques (one town had cold saline on each rig, another had it in a lone supervisor's vehicle) yet both came to the realization that they had something, even before the big city boys.

[surgblumm]

I am surprised at my colleagues as this attitude is the same the IMG's and the old FMG's had toward PA credentialing. We do not want anyone , including the AMA to dictate what training and description we should have as PAs and it is unfair and ignorant to think that the average PA is equal to a paramedic with 2,0000 hours of trauma training. I have written a huge article, more like a chapter on Emergency Services personnel which will be a real eye opener. I need to see if Advance will publish something this lengthy as we need to be made aware of their education and training before we feel we should just pass GO and collect a card.

Bob Blumm

[GetMeOuttaThisMess]

To refresh an old thread, I called and left a message regarding eligibility to take the two week course at Creighton since the website doesn't reference PA's specifically (did get re-certed as NREMT late last summer and still looking to teach). FYI, my local city just went to a tiered response system utilizing paramedics in Suburbans for non-life threatening calls (10/13). So far, cost savings are being seen if for no other reason than fuel savings. Bob, what did you find out about printing of your article? I'd like to see it.

[EMEDPA]

To refresh an old thread, I called and left a message regarding eligibility to take the two week course at Creighton since the website doesn't reference PA's specifically (did get re-certed as NREMT late last summer and still looking to teach). FYI, my local city just went to a tiered response system utilizing paramedics in Suburbans for non-life threatening calls (10/13). So far, cost savings are being seen if for no other reason than fuel savings. Bob, what did you find out about printing of your article? I'd like to see it.

last time I checked with them they said a pa with appropriate background could take the course.