PAs in the field

[daedalus]

Because it is increasingly clear that Paramedics do not want to take on the role, how do you feel about using PAs in the field to provide on scene medical direction on critical calls, and, to respond to low acuity calls to resolve them without having to tie up an ED bed? Examples- prescribing abx, closing wounds, etc.

 

[SanDiegoEmt7]

I think this is an interesting idea, even a few PAs could have quite an impact in a system. My only concern is, who would employ and pay the PAs, since every emergency PA I have spoken with makes over 100k/yr.

In many emergency departments in my area they have already realized the effectiveness of PAs in decreasing the cost for the hospital while increasing efficiency. Here they will have a PA in triage to assess patients with a nurse. That way orders can be placed immediately, decreasing the patients time in the ED.

I can see the benefits of a similar system setup in the field. Where PAs can either give a Rx and leave them at home for followup with a primary care physician or clinic, but if they feel the patient is in need of higher treatment, they could at least get orders in place while the patient is being transported or right when they arrive.

 

[ResTech]

Definitely not a bad idea to have higher level care providers and I'm sure having PA's in the field with an expanded scope could work... but I do see some potential negatives as they directly relate to the actual system of EMS itself. In Pennsylvania, a PA can practice in the field as a "health professional", but they have the same scope as a PHRN and Paramedic.

For a PA to suture, that would take a unit out of service for an extended period of time causing other ill and injured patients to potentially have to wait longer for mutual aid... especially in an urban system. A PA could prescribe antibiotics for somethings but they wouldn't have the lab as an option in the field. I think there is such a thing as being overzealous in the field.

The field is just that... the field. It isn't the time or place to become totally definitive. My opinion is, pre-hospital care is to stabilize, sustain life, and make the patient as comfortable as possible until they can reach the hospital... and hopefully deliver the patient in better shape than they were found.

And I'm not sure how many PA's would enjoy being in the field... EMS is a world of its own in the streets. Plus Im sure the $$$$ they would demand would not make this practical either.

Urgent Care Centers have taken some of the load of the ED... again, not a bad idea to have higher provider level in the field.... but one has to keep the entire system resources in mind as well.

 

[akflightmedic]

A more interesting idea would be having the ability to refer or drop off certain patients at designated Urgent Care centers to the PAs....

But there is so much more that must occur before something as simple as that can exist.

 

[JPINFV]

This sounds like the same thing that Wake Forrest is doing with their advanced care paramedics. From what Skip Kirkwood, chief of Wake Forrest County EMS, has been posting over on JEMS Connect, they have been having pretty good success with them treating lower aquity patients in the field, doing home health checks, and running critical calls.

For a PA to suture, that would take a unit out of service for an extended period of time causing other ill and injured patients to potentially have to wait longer for mutual aid...

That's assuming that the PA is on an ambulance and not a fly car. If the PA is assigned to a fly car and put on certain calls at the same time that an ambulance is dispatched, then the ambulance crew should be able to just sign the patient out to the PA instead of sticking around waiting for the treatment to be completed.

And I'm not sure how many PA's would enjoy being in the field... EMS is a world of its own in the streets. Plus Im sure the $$$$ they would demand would not make this practical either.

Suturing and the like are billable procedures. You wouldn't bill them the same as a standard EMS call.

 

[SanDiegoEmt7]

The field is just that... the field. It isn't the time or place to become totally definitive. My opinion is, pre-hospital care is to stabilize, sustain life, and make the patient as comfortable as possible until they can reach the hospital... and hopefully deliver the patient in better shape than they were found.

And I'm not sure how many PA's would enjoy being in the field... EMS is a world of its own in the streets. Plus Im sure the $$$$ they would demand would not make this practical either.

What about the 911 calls that don't necessarily need to go to a hospital (they do with our current system, but that could potentially be handled differently). The time it would take to perform most of the basic treatments would probably be less than the time to transport and then clean and put one's rig back into service (how long is the average family practice appointment, with out wait?). edit: i agree with the fly car idea

Also I think that many PAs would enjoy being in the field, they would get the same exciting calls that keep the medics interested in the job. As for money though, I am not sure exactly what would be done. The PA could bill the patient/patient's insurance for all treatments done, similar to how it works in the ED? I'm not sure about that though, correct me if I am wrong.

 

[ResTech]

Suturing and the like are billable procedures. You wouldn't bill them the same as a standard EMS call.

I was referring more to the amount of money the PA would want to be compensated.

In the systems I have experience working in, I don't see a need for a PA. The ED's aren't that overloaded consistently. Plus, the city system I work, many bills go unpaid by the patients just because of the demographic. Who could afford to pay a PA $40-50hr to suture a patient who has no insurance? Or to pay a PA to respond to a call that could be taken care of on-scene but the patient still requests to go to the hospital?

I believe one can be overzealous in the field. Akflight has a better idea... a protocol to allow certain patients to be transported to an Urgent Care Center.

 

[SanDiegoEmt7]

I was referring more to the amount of money the PA would want to be compensated.

In the systems I have experience working in, I don't see a need for a PA. The ED's aren't that overloaded consistently. Plus, the city system I work, many bills go unpaid by the patients just because of the demographic. Who could afford to pay a PA $40-50hr to suture a patient who has no insurance? Or to pay a PA to respond to a call that could be taken care of on-scene but the patient still requests to go to the hospital?

I believe one can be overzealous in the field. Akflight has a better idea... a protocol to allow certain patients to be transported to an Urgent Care Center.

If they don't have insurance, they still get treated at the hospital. The money still comes from somewhere.

Also if you are sending higher level care to their home, they don't get to choose to go to the hospital, since they won't get any greater level of care there, rather they would just sit on a bed until us EMT-B's come to take them home.

 

[ResTech]

If they don't have insurance, they still get treated at the hospital. The money still comes from somewhere.

Also if you are sending higher level care to their home, they don't get to choose to go to the hospital, since they won't get any greater level of care there, rather they would just sit on a bed until us EMT-B's come to take them home.

Your right, even without insurance the patient still receives treatment however, its much easier for an EMS department to make up for the deficit when they are paying a Paramedic the average $13-15hr versus a PA the salary they would be making.

What call types would only a PA be sent? I don't think its wise to send a PA in a "fly car" only to arrive on-scene with a priority patient that needs transported "now", only to have to alert a Paramedic ambulance to respond as well.

Without a lab, CT, and X-Ray, I think a PA would still be limited. I don't think its a good idea... least not on the surface.

 

[Ridryder911]

I ask why? Why not fix the problem instead of attempting to place another band-aid? Do you really think that they would want to make $15.00/hr or patient to pay $1,500 for an EMS visit. The reason PA's are able to do what they do is that they are educated under the medical model using diagnostic tests such as lab's, x-rays, etc...

If you are discussing making home visits, that is already being done and have been for a while. Why send a higher educated person (most programs require minimal graduate level) to prepare a patient to transport? Again, most of the diagnosis is based upon specifics not able or cost prohibitive at this time being used in the field. In reality, not much more can be provided in emergency situation. Physicians are doing this and hiring NP's and PA's to fulfill the need for routine medical sick calls.

On the helo, I was usually greeted happily by PA's that worked in the ED. In the rural area many are used as in the ED as a physician where I usually see them used in minor or urgent care in larger settings.

At one time we had a PA-Paramedic pilot program. Believe it or not there was many areas that the PA was short in (surprising cardiology and respiratory) was one notable area. Unless they specifically had specialized in emergency or critical care their exposure was limited. Remembering that the PA has to usually cram 1 year of didactics and 1 year of rotations and clinical skills. Again, not all PA's are specifically specialized or focused.

I am not against any physician extenders, rather to use them appropriately and wisely. There is no reason still to advance and educate what we have. Instead of looking for excuses of having someone else do our job, let's be responsible for our own profession.

R/r 911

 

[ResTech]

Very awesomely stated.

 

[daedalus]

This sounds like the same thing that Wake Forrest is doing with their advanced care paramedics. From what Skip Kirkwood, chief of Wake Forrest County EMS, has been posting over on JEMS Connect, they have been having pretty good success with them treating lower aquity patients in the field, doing home health checks, and running critical calls.

This is exactly what we all need to be doing.

 

[daedalus]

I ask why? Why not fix the problem instead of attempting to place another band-aid? Do you really think that they would want to make $15.00/hr or patient to pay $1,500 for an EMS visit. The reason PA's are able to do what they do is that they are educated under the medical model using diagnostic tests such as lab's, x-rays, etc...

If you are discussing making home visits, that is already being done and have been for a while. Why send a higher educated person (most programs require minimal graduate level) to prepare a patient to transport? Again, most of the diagnosis is based upon specifics not able or cost prohibitive at this time being used in the field. In reality, not much more can be provided in emergency situation. Physicians are doing this and hiring NP's and PA's to fulfill the need for routine medical sick calls.

On the helo, I was usually greeted happily by PA's that worked in the ED. In the rural area many are used as in the ED as a physician where I usually see them used in minor or urgent care in larger settings.

At one time we had a PA-Paramedic pilot program. Believe it or not there was many areas that the PA was short in (surprising cardiology and respiratory) was one notable area. Unless they specifically had specialized in emergency or critical care their exposure was limited. Remembering that the PA has to usually cram 1 year of didactics and 1 year of rotations and clinical skills. Again, not all PA's are specifically specialized or focused.

I am not against any physician extenders, rather to use them appropriately and wisely. There is no reason still to advance and educate what we have. Instead of looking for excuses of having someone else do our job, let's be responsible for our own profession.

R/r 911

Exactly. I posted my original question playing the devils advocate of sorts. Why are we still not asking what can we do to improve the health care delivery in this country?

I have decided to forward the idea of advanced care paramedics, and the wake system, to California EMSA and the Governor's (Arnie's) office.

 

[Ridryder911]

EMS is at a breaking point. I have been attending more and more meetings concerned about the lag or too much advancing of EMS and who is going to fund it?

Within the last two weeks I have attended at least 5 meetings in regard of increasing the Paramedic level as well as others. Ironically, we were discussing the hour per hour change needed to meet the new standards for the EMR. Not even completing the whole program we ended up on about 80-100 hours for the EMR program. Wow! Considering that many old EMT courses was not that long.

This of course is great for us that work in the field but realistically, who is going to send industrial employees and pay for those to attend a 3 month first-aid course? How much knowledge and skill retention will be present 6 months after the course? How much is really needed for those to care for the patient until professional help arrive?

See where I am going? It will be difficult process.

There needs to be a division between professional care and non-professional. Not a personal one but a system one.

Most schools will see that the new program will be a building block system. One will be taught minimal and added on in each level. It will be essential to have a great EMT course because each course will be added more and more. As well, those not associated with academic institutions such colleges will have to either contract or ensure qualified instructors can meet the new standards. No longer will be the "they are a good medic" meet the demands.

Public health will be discussed even in the EMR level, as well as professionalism. Statistics will be mandated in the Paramedic program and will of course be tested upon in certification exams. So yes, our program is growing ... slower than I and many others like but still is growing.

Instead of automatically throwing the baby out with the bathwater or placing another damn band-aid on an arterial bleed; let's fix what we have!

Again, it takes more determination than discussing it with local administration and schools. How many have taken participation in their legislation route or State Committee rules and implementation process? Yet, we would suggest someone else for our job because.. well.. we are just too lazy to do it ourselves? Bully.

If every member that read the forums would unite and write to NAEMT or EMS Advocates what changes could occur! But no, we would rather whine and complain and even make recommendations that another profession come on in and do our job.. please, we are incompetent mindless medics.... again bully!

Let's educate Paramedics as they should be! Prepare them to do the job that requires and make NO excuses. I am tired of those beating up on EMS without doing anything themselves. If you don't like EMS then leave! Really, it can and will exist without you. I much rather have those that have a desire to fix the system than those that want to tear it down.

You know what, we have no other person to blame but ourselves. If there was no medic willing to teach 2 week courses they would not exist. If medics volunteered to be on State Boards to protect the system and prevent such occurrences there would never be any discussion about those or other poor courses. If EMS would unite and demand proper education for those in EMS it would be done, but it has to be within and has to be promoted within. Then and only then, after all attempts has been resorted we should turn to another profession. Who knows, they may have enough problems of their own and may not want to be in EMS?

R/r 911

 

[Summit]

Well you take a PA out of service to suture... that's true on a bus or at an urgent care or at an ED.

This would be a cool implementation. I'd become a PA and do this without a doubt!!!