Where do you see EMS in the future?

[fiznat]

...As in 20-30 years from now?

I was having this discussion with my partner the other day, and we were going back and forth on the issue whether EMS will be expanded with new procedures/meds/protocalls (like possibly ultrasound?), and the idea that EMS could be reduced to mere transport and critical life support. I have read that current data seems to undermine the idea that pre-hospital care makes a statistical difference in patient mortality rates-- so I could see EMS getting pulled back a little, but then again perhaps new technology could change all that.

What do you guys think?

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[docB]

This is a great question so I'll see if I can get some discussion going on it.

I would like to see a shift in EMS from what we have now, which is that the best trained, best equiped systems are in urban areas. I'd like to see a switch to one where more emphesis is on rural areas. The studies do indicate that EMS does not affect outcome as much as we hoped. The main reason for this is that a 3 minute transport time doesn't give you a lot to work with. These studies also tend to be done at urban/academic centers where short transport times are the rule. It seems logical that shifting the bulk of training and funding for EMS to areas where the medics will be caring for the pt for 20 min to 1 hour+ could significantly change outcomes. This is something that might change.

I do expect that we will see an increase in the number of BLS or lower level units needed in urban areas to cope with the ever increasing number of people who use EMS and ERs for primary care.

I'd say ultrasound is unlikely to come to EMS due to the expense of the equipment and training, the difficulty of using US in an EMS environment and the questionable utility of having US info prehospital. As the technology matures it's possible.

 

[McPoyle]

I think that as technology changes, and advancements are made in medicine we will see a great impact on the world of EMS...personally I think this will happen in two distinct ways.
1.) I think our scope of practice in the field will broaden to include the more advanced assessments and tx. that are currently reserved for the ED. As technology, like the ultrasound that was mentioned, progresses it will as mentioned be expensive...initially. After some time these tools will come down in cost and become easier to use in the field and I think we will start seeing them. I believe there are some services that currently use these in the field. Look at the past 20yrs of EMS and see what has changed...look how the tx. has evolved...and how the assessment tools has changed.
ex: 12-leads, SP02 monitoring, ETco2 monitoring, Venous access options (peripheral and central), Intubation, RSI,etc...
2.) I see our role also taking on more of a focus regarding triaging pts. By this I mean, playing a larger part in directing pt care thru urgent care clinics (for example) in an effort to curb the trend of people using the ED as their primary physician. There are already services that provide paramedics in a primary care roll, Acadian does this for the oil industry. I could see our focus to include more primary care aspects of healthcare. This change especially, I could see happen in urban areas where overdependence on ED's is a problem.

Overall I see EMS shifting its focus towards medical care in both an emergency and non-emergency situation...I don't see too many advances in prehospital trauma care for obvious reasons.

 

[viostorm]

I think the biggest challenge to overcome is paramedic competency. It is hard to find a study where paramedics make things better rather then worse. (except early defib)

This is not even addressing the EMT-I's, EMT-B's and all the nationwide variation in scope of practice. For example, when I left Virginia EMT-CT's (approx NREMT-I/99's) were starting to do RSI. Now I'm in Texas and NREMT-I/85's can do surgical cric. So you have 6 months 2 times a week of EMT class and 4-6 month 2 times a week EMT-I class and you can do surgical cric? IMO, It is completely unreasonable to expect people to be competent and improve outcome with that level of education.

Disregarding that I love being a paramedic, I feel strongly there are two major paths where if we truly care about patient outcome EMS should go:

Path 1:

1) Back to BLS only prehospital EMS

Path 2:

1) Every ambulance have a paramedic on it, yes EMT-B, there would be no such thing as an EMT-I.
2) Paramedic becomes a mandatory 4 year program, with much stronger educational requirements and greater barrier's to entry. More along the line of what it takes to get into PA school. Much more in depth cirriculum.
3) Much better pay to attract and keep people with higher intelligence and better motor skills. So that it is actually a sought after career.

I think by following path 2 paramedics will have the tools to make better decisions.

Ok, I know I opened myself up to being blasted, but I'm trying to be honest about what I feel like are the major barriers to EMS. To me, it is provider competency, whether it is getting the tube on the first time or knowing what drug to give when. It is the frequency of iatrogenic errors that I suspect are the cause of the "anti-paramedic" "anti-als" research.

 

[southerndoc]

How about path 3? EMT's on BLS units and paramedics on ALS units. Tiered response seems to work quite well.

I think there should be two levels of providers: EMT and paramedic. There is no reason to train an EMT to be "advanced" doing ALS stuff. Imagine if nursing had 4 levels of nurses. Instead, they have LPN and RN (BSN's still function as RN's). They've now added NP's, but NP's function as physician extenders instead of primary nursing roles.

 

[docB]

I think the biggest challenge to overcome is paramedic competency. It is hard to find a study where paramedics make things better rather then worse. (except early defib)

I understand what you mean but to make it clear we're talking about the overall level of training of the various grades and not about specific incompetent medics.

The overall problem here is that training all EMS up to the levels you suggest would be very expensive. It would certainly reduce the total number of responding units on the street. The question is if it would stand up in a cost benefit analysis. If you were doing prehospital thrombolytics or burr holes or ex laps or whatever in the field would it justify the expenditure? I don't think it would. Especially in urban areas.

We keep finding that diverting money away from things like EMS and ERs and so on to preventive stuff is probably the most cost effective thing to do but it's unpopular because it necessarily causes rationing. For example when I went to med school at Temple in Philly (the pregnant crack ho capital of the world) the NICU usually had about 20 crack babies bobbing along. The average cost of stay for EACH was 250K. If you closed down the NICU and diverted the cost from say 2 of those disasters you could outfit a fleet of vans with nurse practitioners to drive around the getto doling out free prenatal care. Unpopular but better.

 

[McPoyle]

good point on competency, I have heard it said before that the curriculum has been "dumbed down" in the last decade or so. I mean that we now training people to react as opposed to thinking ahead, preparing etc.

There is some push towards more education where I am from. I know there is one (I know, its just one but hey its a start!) service here that mandates at least a two-year degree or more in order to even have them grant you an interview.

I think this is the bear minimum, I've heard it over and over that we want to make the paramedic a four year program. Unfortunatly there are still paramedics who resist this idea...not wanting more education...can't see past the dismal pay.

I geuss that is one of my motivations for going to medical school is to help this change go forward.

 

[deleted6669]

Fast track in the field: Another option to ease ED overcrowding

Emergency department (ED) overcrowding is becoming a serious problem in the nation’s hospitals. Many are forced to go on ambulance diversion status because of a shortage of bed space, clinicians, or resources needed to take care of patients. Patients who seek care in the ED often require ED evaluation and are there appropriately. There is, however, a subset of patients who use the ED for conditions that are neither emergent nor, at times, even urgent. Many of these patients do not have access to a primary care provider, or they live in communities lacking adequate free medical resources for the uninsured or underinsured, so the ED becomes their only choice. One option that meets the needs of patients, hospitals, and emergency medical services (EMS) providers is to create a system by which these patients are seen outside of the ED yet receive the same high-quality care from the same providers that they would in an ED setting.

Fast track in the field
The EMS community is advocating for advanced training for paramedics to perform these functions. But, why not use PAs in emergency medicine to fill this void? They already have the requisite skills and experience, and they could rotate between working in the field and in their home EDs.

Many PAs in emergency medicine started their careers in medicine as paramedics and would welcome the opportunity to use their new skills outside the ED setting. I have spoken about this concept with a number of my PA colleagues who previously worked in EMS. The consensus was that they would enjoy the opportunity to return to the field and be able to concentrate on a single patient at a time instead of the six to eight patients that are followed at one time in the typical ED setting. Some unpleasant aspects of being a paramedic would be absent from this system, such as carrying heavy patients down multiple flights of stairs and being awakened in the middle of the night for low acuity cases. These are among the chief reasons many PAs leave EMS to go to PA school.

This system would also benefit EMS because they would no longer have to transport patients with minor complaints to the ED. The large number of nonemergent 911 calls has been a significant cause of burnout and frustration among EMS personnel. The system I am proposing would allow paramedics to focus on what they do best—treating truly emergent patients in the field setting.

How would it work?
The concept would initially utilize a trial ambulance team of one PA and one basic EMT/driver and would be staffed only during the busiest hours of the day. The team would not respond directly to 911 calls but would be summoned after an initial decision by paramedics that the patient was nonemergent and met criteria for field treatment and release. The criteria might involve such complaints as minor lacerations, upper respiratory infections in otherwise healthy persons, prescription refills for noncontrolled medications, ingrown toenails, and so forth. EMS and members of the field group would agree on these criteria in advance. The ambulance company could still bill for a home response and any supplies used, while the hospital ED could bill for the PA’s time and any hospital supplies (such as suture sets) used in treatment.

If a single unit saw a patient every 30 minutes for 8 hours, 16 fewer patients would arrive at the ED and 16 more emergent ambulance calls could be made. Some patients might initially be thought to be appropriate for field treatment and later be found by the PA to need further evaluation. These patients could then be transported nonemergently to the local ED by the PA unit and checked in there in the same fashion as a typical walk-in patient. A busy area could use more than one unit or staff it for more hours daily.

This system would be practical only in a busy metropolitan area where ED overcrowding and a strained 911-response system are daily issues. While using PAs in the field in other settings is an option, there would be no clear benefit to local hospitals or emergency services through such utilization.

Patients would also benefit from such a system. Currently, patients with low-acuity complaints face long waits in EDs, sometimes as long as 4 to 6 hours or more. Field treatment would allow rapid evaluation and treatment of their minor injuries and illnesses, greatly increasing patient satisfaction. Follow-up visits would be done by the same “city call” physicians who see unassigned ED patients after their discharge from the hospital. The patients could also be given a list of local resources, such as primary care providers in the community and social workers who can arrange for federal or state health coverage.

Benefits on many levels
In this system, there would be no decrease in revenue to either the hospital or the EMS company. Members of the team would be paid by their normal employers at their normal rate of pay. No changes would need to be made to the configuration of the ambulances used. The PA could simply carry a tackle box with supplies and a few noncontrolled medications, such as antibiotics. All the pieces are in place for this to work, with very little preparation time involved. The staffing already exists. Oversight would continue per current practices. The supervising physicians of the ED PAs would review the PAs’ field documentation in addition to their regular ED charts. The PAs’ malpractice policy from the hospital would be amended to include work in the field. Hospital EDs would be able to allocate their resources more appropriately to evaluate sicker patients in a shorter amount of time.

This is only the outline of a concept. I hope that this model can be tested in busy urban areas to determine its effectiveness at decreasing ED wait times and improving service to those in need of medical care.

 

[niko327]

Path 2:

1) Every ambulance have a paramedic on it, yes EMT-B, there would be no such thing as an EMT-I.
2) Paramedic becomes a mandatory 4 year program, with much stronger educational requirements and greater barrier's to entry. More along the line of what it takes to get into PA school. Much more in depth cirriculum.
3) Much better pay to attract and keep people with higher intelligence and better motor skills. So that it is actually a sought after career.

I think by following path 2 paramedics will have the tools to make better decisions.

Good post, I strongly agree. Making Paramedic a sought after career is key, too many part-timers, volleys and people with only a passing interest. What other profession swings it's doors wide open allowing other professions to challenge it's curriculum and standards? And what other profession has members willing to do the job without renumeration. Not nursing, not respiratory therapy, not radiology tech, not PA, not anyone. So long as these two things about EMS persist, it will not advance appreciably. I see professionalizing EMS bringing about:
1. Retention of quality individuals and better training.
2. Increased competence.
3. Recognition by the other allied health professions.
4. Better patient care and improved outcomes.
5. Stability for employees and increased lobbying power to foster badly needed change.
6. Increased professional advancement opportunities.
7. Better reimbursement for EMS companies.
Any thoughts??

 

[fiznat]

I agree with all above except the bit about mobile PAs. I think the liability is way too much for any reasonable hospital to put an employee out there for the sole purpose of denying transport to the ED in order to provide a lower standard of care at home. Not to mention, turning people away from the hospital reduces the amount of potential money that can be made, even if you charge for whatever nominal services the PA provides. ...Which the hospital probably wont collect anyways bieng that my experience is that people who dial 911 for the ingrown toenail tend to be a bit behind on their bills as well. On top of all that, "1 call every half hour" is extremely unlikely, even in the busiest of systems.


Just to play devil's advocate...

What about the proposition of instead lowering the standard of care in EMS systems. Current data seems to suggest that ALS pre-hospital interventions seem to make no significant difference in survival rates over a BLS tx. It seems fairly clear from the research that EMS' primary live-saving job is to open the airway, perform CPR, and transport rapidly to the ED/Cardiac Cath. With this in mind, it makes sense to me that the public would be better served by cutting the Paramedic completely out of the equation, and spending the money instead on more EMTs that can provide better coverage and quicker response times.

I.E. http://www.ottawahospital.on.ca/media/news-releases/2004/08-11-04-e.asp

# Over 500,000 Americans die every year from sudden cardiac arrest...

# Most communities have overall out-of-hospital cardiac arrest survival rates of less than 5%.

#The American Heart Association's Chain of Survival is a model for optimizing community response. Research has demonstrated that the three first links – early access, early CPR, and rapid defibrillation (within 8 minutes) – are all associated with improved survival. However, the fourth link, ALS, is believed by many to improve survival and outcomes because it provides advanced airway management and intravenous drug therapy. However, the incremental value of this link has never been scientifically proven.

Maybe this is the reason why the calls for higher standards of care and professionalism havn't been answered so quickly? Our most important task, it seems, truly is the job of a bus driver.

 

[deleted6669]

"I agree with all above except the bit about mobile PAs. I think the liability is way too much for any reasonable hospital to put an employee out there for the sole purpose of denying transport to the ED in order to provide a lower standard of care at home. Not to mention, turning people away from the hospital reduces the amount of potential money that can be made, even if you charge for whatever nominal services the PA provides. ...Which the hospital probably wont collect anyways bieng that my experience is that people who dial 911 for the ingrown toenail tend to be a bit behind on their bills as well. On top of all that, "1 call every half hour" is extremely unlikely, even in the busiest of systems. "

The point is that they would see the same provider in the field that they would see in the er(the pa) so the liability is the same. pa's who do this would be former medics.
if folks with minor complaints aren't going to pay for their care wouldn't you prefer that they not occupy an er bed to receive that care that someone having an mi could be using instead?
regarding cost-most of it comes from the eval and procedures done by the pa so the pt would still get a 500 dollar bill for their lac repair regardless of setting(this isn't a nominal fee). I work in a busy system with a trauma ctr that sees around 100k pts/yr. it is not "extremely unlkely" that we have a bs ambulance call every 30 minutes. it is actually normal.and we are on divert 25% of the time because of it. this system would decrease time on divert and increase the ability of er providers to care for truly emergent pts in a timely fashion.

 

[southerndoc]

The point is that they would see the same provider in the field that they would see in the er(the pa) so the liability is the same.

Our PA's in our ED are supervised by an attending physician that is on-duty 24/7.

Are you working in an ED without attending physician supervision?

 

[12R34Y]

I'm kind of torn as to where EMS is going in the future.........I start an EM residency in July and I definately know that regardless of where it goes I'll be there in some capacity since I love EMS.

Having said that. I just don't have any clue as to where it will go from here. Most medics (being a medic myself) want and Looong to do more "things" and "stuff" in the field. Who wouldn't want to put a central line in as a medic or do a fast exam in the field using a portable ultrasound machine, suturing etc....? It sure would be cool.................but I just don't see that kind of stuff in the future at all. I don't see a reasonable way for thousands of medics in the country to gain the necessary experience doing for example, central lines, suturing, FAST exams. The circumstances in which a field medic would be doing a FAST exam would be about 10 times more chaotic and crazy that a trauma bay. Let along trying to put in a central line in the field.

Part of me thinks that as Evidence Based medicine works its way into prehospital medicine that we'll find that a lot of the cool ALS interventions may not mean squat as far as outcomes go. And subsequently, you see more BLS units and ALS only in rural areas that have huge transport times.

I really don't see PA's working in the field either. I don't think the impact of triaging a few people (maybe 10 in one day or 20 in another) is going to impact a healthcare system significantly.

I mean one of the places I rotated at during an EM elective routinely had 50-100 people in the waiting room. Getting rid of 16 of them over the course of a day probably wouldn't make much realistic change.

Ambulance calls that are bogus will never go away and most places I've worked at simply take the ambulance patient to triage and they wait in the waiting room like everyone else.

Very interesting discussion!

later

 

[southerndoc]

There are places now (i.e., Seattle, Boston, some agencies in Pennsylvania) that place central lines in the field. In Seattle, nearly every cardiac arrest gets a subclavian or IJ (from what I'm told). I have seen photos of their paramedics placing subclavians and IJ's before. It's really not an incredibly hard procedure to do. They're easier than a peripheral IV once you get enough practice doing them. I can throw in a subclavian (my line of choice) very quickly. I take a little longer with IJ's because I always do them under ultrasound guidance (department rule). (I wonder if doing them under ultrasound guidance also makes you more proficient at doing them without ultrasound since you become more familiar with anatomy and actually hit them on the first try 100% of the time with ultrasound guidance).

There are some places that are doing FAST exams in the field under research protocols. LifeStar in Connecticut does FAST exams in the helicopter.

 

[fiznat]

There are some places that are doing FAST exams in the field under research protocols. LifeStar in Connecticut does FAST exams in the helicopter.

Cool, I didnt know that! Isnt that a flight nurse though, not a medic? ...Not completely clear on what certifications those guys with the helmets have.

EDIT btw southerndoc, I swear I saw you at YNHH last week. You walked past and I thought I recognized you from your picture but didnt say anything... You were talking with some nurse (?) about a pedi case...

 

[deleted6669]

Our PA's in our ED are supervised by an attending physician that is on-duty 24/7.

Are you working in an ED without attending physician supervision?

I work in 4 different settings at present:
1. 100k pt visit trauma ctr
2. satelite 26k visit facility with solo pa ed coverage 16 hrs/day, double coverage with md 8 hrs/day
3. community hospital ed with double coverage 24/7 around 40 k pts/yr
4. 24 hrs ed obs unit staffed by pa's

setting 1 is the one which would benefit from a "fast track in the field model." although it is a trauma ctr with md's present, the vast majority( 95%+) of fast track pts never see a physician during their visit.the pa does the eval and workup, all procedures, and coordinates any needed consults. having pa's see minor pts in the field would be no different than having them seen in fast track. any atypical pt could always be transported to the ed for an md eval. if you can't trust your pa's to be taking care of minor pts with just chart review you need to hire better em pa's.some systems alow medics to release these folks without transport to an ed so certainly a medic who becomes a pa would be able to decide who needs an ed md eval and who doesn't.

 

[f_w]

There are some places that are doing FAST exams in the field under research protocols. LifeStar in Connecticut does FAST exams in the helicopter.

What would be the benefit of doing a FAST exam in the chopper ? The patient is heading for a leveled trauma center anyway, I have a hard time imagining a situation where the knowledge that there is free fluid would make a difference (do the people advocating this model also have the flight-nurse/paramedic put pericardial drains ?).

I can see a role for central lines in the field (in physician staffed EMS systems in europe this is the rule, not the exception). Having a cheapo US unit at hand to hit the IJ on the first shot sounds like a reasonable idea. But FAST ?

 

[deleted6669]

Our PA's in our ED are supervised by an attending physician that is on-duty 24/7.

Are you working in an ED without attending physician supervision?

do the docs see every single pt that the pa sees before the pt goes home?
if so that is fairly paranoid and wasteful utilization of midlevel providers(or your pa's are really weak).more often than not the pa's in our group are the "go to guys" for most primary care issues and procedures. on several occassions I have been asked by docs to suture complex facial lacs on their family members because I am the most experienced person at this in the dept at the time. most of our docs haven't sutured a lac or done an I+D since residency.....

 

[southerndoc]

Cool, I didnt know that! Isnt that a flight nurse though, not a medic? ...Not completely clear on what certifications those guys with the helmets have.

EDIT btw southerndoc, I swear I saw you at YNHH last week. You walked past and I thought I recognized you from your picture but didnt say anything... You were talking with some nurse (?) about a pedi case...

LifeStar uses flight nurses and flight respiratory therapists.

Where did you see me? In the ED, hallways? Why didn't you say hello if you saw me? Geesh, people are so intimidated!

 

[southerndoc]

do the docs see every single pt that the pa sees before the pt goes home?
if so that is fairly paranoid and wasteful utilization of midlevel providers(or your pa's are really weak).more often than not the pa's in our group are the "go to guys" for most primary care issues and procedures. on several occassions I have been asked by docs to suture complex facial lacs on their family members because I am the most experienced person at this in the dept at the time. most of our docs haven't sutured a lac or done an I+D since residency.....

Yes, an attending physician must see every patient in the department, whether the patient is seen by a PA, nurse practitioner, or a resident.

Unlike most emergency departments, PA's take care of the same patients as the residents in "central." So they see chest pain, abdominal pain, etc. This is unlike the ED's where I've seen PA's take care of only the fast track stuff. Our PA's do not see patients in the critical care area, but they can see trauma patients in the trauma bay if they have gone through the ATLS course.

 

[southerndoc]

What would be the benefit of doing a FAST exam in the chopper ? The patient is heading for a leveled trauma center anyway, I have a hard time imagining a situation where the knowledge that there is free fluid would make a difference (do the people advocating this model also have the flight-nurse/paramedic put pericardial drains ?).

This is for research purposes, and it can make a difference.

Ultimately, patients with positive FAST exams who are hypotensive may go straight to the OR instead of to the trauma bay.

Remember, the FAST exam has been expanded to include detection of pneumothoraces, hemothoraces, and pericardial effusions. (We call it an E-FAST, or extended FAST... some places still consider it FAST and have renamed FAST to be the Focused Assessment with Sonography in Trauma instead of a Focused Abdominal Sonogram in Trauma).

The detection of pneumothoraces in the field could be a very useful thing, especially for air medical crews. The change in altitude could cause the pneumothorax to expand, which necessitates a chest tube.

 

[f_w]

This is for research purposes, and it can make a difference.

I stand corrected. The question 5 years down the line will probably be: 'Is there a role for FAST anywhere BUT during transport?'

As long as this is within a research framework, I think it makes sense to do it. I just suspect that it will become another 'ALS gizmo' with great PR value and little impact on patient outcomes. The more toys you put into the van, the higher the tempation to dawdle around going through all of them rather than getting the patient to the place offering definitive treatment.

(do you really expect that the trauma surgeons will take patients directly to the OR based on the ultrasound assessment of the medic ?)

I think in the meantime the EM/EMS world has learned that not everything that makes sense in a military casualty setting is necessarily a great idea in the civilian world.

 

[deleted6669]

Yes, an attending physician must see every patient in the department, whether the patient is seen by a PA, nurse practitioner, or a resident.

Unlike most emergency departments, PA's take care of the same patients as the residents in "central." So they see chest pain, abdominal pain, etc. This is unlike the ED's where I've seen PA's take care of only the fast track stuff. Our PA's do not see patients in the critical care area, but they can see trauma patients in the trauma bay if they have gone through the ATLS course.

gotcha-I can see presenting all main/central pts- I was talking specifically about low acuity fast track type pts. we have 3 areas in the dept-
main/central, intermediate, and fast track.

docs only in main seeing basically codes/mi's/cva's/multisystem trauma.

intermediate is all belly pain, preg complications, h/a's, febrile baby workups, atypical anything, etc. this area is staffed by docs and pa's. pa's in intermediate do not have to present pts but may as they feel necessary.

fast track is all lacs regardless of depth or location, abscesses, all ophtho and ent complaints, all minor uri's/uti's, all ortho probs unless multisystem trauma so nasty open fx with big lac from chainsaw starts in fast track as long as pt not hypotensive. fast track is staffed only by pa's.

all charts are cosigned by a doc within 24 hrs but generally after the pt has gone home.all pa's in the group have > 5 yrs em experience and the vast majority have >10. many of us(myself included) have postgraduate training in em and prior experience as medics(civilian or military).most of us have acls/atls/pals/conscious sedation/treadmill/fluoro training.

at our satelite facility pa's see all pt acuities be they codes, mi's, trauma, --whatever-- and we tx and d/c what we can and transport what we can't after stabilization.

 

[southerndoc]

Our fast track area is staffed by PA/NP's who do not check out to a physician.

However, we use PA's (and occasionally NP's) in the central area seeing the intermediate acuity patients as you describe. There, an attending physician must see every patient.

 

[deleted6669]

Our fast track area is staffed by PA/NP's who do not check out to a physician.

However, we use PA's (and occasionally NP's) in the central area seeing the intermediate acuity patients as you describe. There, an attending physician must see every patient.

do you think your fast track pa's who were medics could see the same pts they see in fast track in the field? if so, why not?

 

[southerndoc]

do you think your fast track pa's who were medics could see the same pts they see in fast track in the field? if so, why not?

Yes, I think they could see those patients in the field. The problem would be reimbursement. Would the reimbursement be the same if the PA took 30 minutes to suture a lac in the field as if they sutured it in the ED?

3 of our PA's are actually paramedics, who are still active in EMS. They work shifts on the ambulance. They still transport everybody. So far this issue hasn't been approached to the Sponsor Hospital program (a joint medical directorship between two hospitals). Not sure if they would go for it. Besides, the primary transport company where I live is a for-profit service.

EMEDPA, do you have any contacts at Seattle Medic One? I'm thinking of arranging a week long ride along next year.

 

[deleted6669]

"EMEDPA, do you have any contacts at Seattle Medic One? I'm thinking of arranging a week long ride along next year."

nope- I work south of there. have taken atls there a few times but have not worked directly with medic1 before. clear it with dr copass( the em honcho) and you are in the clear.

'The problem would be reimbursement. Would the reimbursement be the same if the PA took 30 minutes to suture a lac in the field as if they sutured it in the ED?"
- I would assume the procedure fee would be the same but you couldn't charge a facility fee. the ambulance company could charge for a home response and the pa could probably bill some kind of house call fee.this is all kind of up in the air right now as no one has done it yet. there is a company in colorado(pridemark) that uses em pa's for critical care transports and a few services that use em pa's on helicopters.
this article was writen in response to a discussion about medics being taught to suture and do the skills currently done by a fast track em pa. medics are good at evaluating and treating emergent pts in the field( I remember, I was one).I think there are more important things for them to focus on than learning the indications for and technique of suturing, treating ingrown toenails, uncomplicated uti's and uri's,etc -if they want this they can always go to pa/np school.

 

[f_w]

The best use for a licensed medical professional in the field would be to have a legal way to say:

'sorry m'am this call is bu)%_=-. Here is the address of an urgent-care facility, here is the phone# for the local cab company and while we are here, do you have a credit-card on you to pay for this unneccesary response'.

(As long as EDs make the most money by funneling the maximal number of minimally sick but insured patients through their system, there is no incentive to move into this direction.)

 

[southerndoc]

There was a study that evaluated the ability of paramedics to screen patients for who would benefit from an urgent care clinic. The results were less than ideal, to put it lightly. The results should be published in the next few months.

Can ambulance charge response fees? I thought Medicare only allows transport fees, as does most HMO's. If insurance covers transport and the facility fee, but not a response fee, then it would actually benefit the patient to be transported and sutured rather than sutured in the field. Their bill might be less (although the insurance company's portion would be more).

 

[Mike MacKinnon]

Until EMS gets a National Standard that everyone follows it wont progress at all. There needs to be a national standard for CQI, Education req., Recurrency, training and expectation.

Currently going from one county to the next in California a medic is a totally different animal. It is insane. There is also alot of infighting amoung EMS agencies. The private service hates the FD, the FD the next county over hates the FD who enters their area etc etc.

There needs to be 3rd party CQI as well. Having buddies you work with 3 twenty four hour shifts a week be the ones to decide if your medic cert needs to be pulled, you placed on suspension or remedial training done is sillyness.

Anyway these are just a few issues that need to be adressed.

 

[12R34Y]

There was a study that evaluated the ability of paramedics to screen patients for who would benefit from an urgent care clinic. The results were less than ideal, to put it lightly. The results should be published in the next few months.

Can ambulance charge response fees? I thought Medicare only allows transport fees, as does most HMO's. If insurance covers transport and the facility fee, but not a response fee, then it would actually benefit the patient to be transported and sutured rather than sutured in the field. Their bill might be less (although the insurance company's portion would be more).

I still don't know about FAST exams in the field. I mean where does it end? I suppose you could make an argument that if a paramedic has loss of vitals in the field with penetrating chest trauma that they could be trained to crack their chests and plug the hole....remove the clot....internal massage etc....I mean the sooner the better right?

Obviously, that was a ridiculous statement and you can't get my extreme sarcasm over the internet, but I'm just curious.........as to the ENORMOUS amount of time, education, equipment (ultrasound machines aren't cheap even the portable small ones) and huge hands on training that would need to be done for all the paramedics in a service to be brought up to speed on something like that and then to maintain their proficiency and compotency at a skill many physicians aren't great at.

Would all of that amount to making a significant difference in outcomes? I say no, if I had to guess. So many of these things like central lines in the field, (oh and by the way there is a reason that only a couple of services in the country are doing central lines in the field, I think if it was going to catch on it would have by now), fast exams, suturing etc....are probably NOT going to change outcomes at all. However, they will cost bajiilions of dollars and enormous amount of increased education and training that in the long run just might not be worth it.

Another thing.......does anyone else think that there eventually just has to be a line drawn as to what a paramedic can do in the field? I mean a lot of medics (not only on this site) and some I work with essentially want to be PA's or even docs by the skill set they want to acquire.

I mean what kind of paramedic course would teach a medic how to make the decisions of suturing a laceration correctly, perform FAST exams, place central lines, write prescriptions for basic things like antibiotics etc......(some think this may happen in the future).

There is no paramedic program like that.........it's called PA school or medical school. What ED is a paramedic program going to find that lets them perform trauma FAST exams, place central lines and suture. I mean you'd have to club do death about a million of surgical interns, PA students, 3rd and fourth year medical students to do that stuff.

I don't think performing FAST exams on non-traumatic patients or in otherwise healthy patients is useful if you plan on being proficient at using it on trauma patients in the field.

I also don't think placing 1 or 2 central lines in a sterile OR or ICU makes you king either. I've put in about 5 central lines so far in my career and I don't feel anywhere near that comfortable yet. so where are all of the countries paramedics going to obtain this training if this happens in the future?

I'll gladly eat my words if evidence comes to light (ie EBM) that these things make a difference in outcomes, but I just think it is unlikely to happen.

again.......awesome discussion.

later

 

[f_w]

There was a study that evaluated the ability of paramedics to screen patients for who would benefit from an urgent care clinic.

With licensed provider, I meant a PA, NP or physician. While EMTALA doesn't really apply in the pre-hospital setting, 'in the field' evaluation by a 'LIP' would probably suffice to satisfy the goverments requirements.
As I might have mentioned, I have some experience in a physician staffed EMS system. This type of screening is exactly what we did when the call was obviously bogus. If it was something non-urgent we also had the option to drop the patient off at his PCPs office for further care (e.g. suturing up a lac, getting an ankle x-ray at in the outpatient ortho office)

Can ambulance charge response fees? I thought Medicare only allows transport fees, as does most HMO's.

I don't think they can right now, but they should (actually, as 'response' is not a covered medicare/hmo benefit, ambulance companies should be able to bill it directly to the patient. Main problem being that the people who abuse the system are usually deadbeats who wouldn't care about another bill).

 

[southerndoc]

I put in 25 central lines during my surgical ICU rotation as a fourth year medical student. I've placed about 35 central lines during my 1.5 years of residency. There are places where one can obtain practice placing central lines.

Please note that nowhere in my previous post did I mention that paramedics performing FAST exams would be beneficial. My comment was directed toward air ambulances performing FAST exams, where detection of pneumothoraces can be lifesaving. Additionally, air ambulances are more likely to have more seriously injured trauma patients, thereby likely making FAST exams more likely to be positive. That could mean direct-to-OR transfers that could be lifesaving. A flight nurse performing a FAST exam in a community hospital may allow a trauma team to assemble in the OR.

Although I am not a fan of pre-hospital FAST exams, I can foresee a circumstance where paramedics could be trained in its use. In rural settings, a paramedic FAST exam could allow a rural trauma center to call its surgeon to the hospital and meet the patient as the ambulance arrives. That could dramatically decrease door-to-OR time and thus decrease mortality.

It doesn't take a lot of training to become proficient at FAST exams.

I agree with your question: where does it end? Paramedics are actually doing more than has been supported by the literature (i.e., OPALS). I do not think central lines, except in code situations, are beneficial or needed in the field. I can see a central line being placed in the field for code situations where medications can be administered centrally. Antecubital veins are supposedly good enough, but I do prefer central access in cardiac arrest patients, especially when administering antiarrhythmics such as amiodarone.

 

[12R34Y]

I put in 25 central lines during my surgical ICU rotation as a fourth year medical student. I've placed about 35 central lines during my 1.5 years of residency. There are places where one can obtain practice placing central lines.

Please note that nowhere in my previous post did I mention that paramedics performing FAST exams would be beneficial. My comment was directed toward air ambulances performing FAST exams, where detection of pneumothoraces can be lifesaving. Additionally, air ambulances are more likely to have more seriously injured trauma patients, thereby likely making FAST exams more likely to be positive. That could mean direct-to-OR transfers that could be lifesaving. A flight nurse performing a FAST exam in a community hospital may allow a trauma team to assemble in the OR.

Although I am not a fan of pre-hospital FAST exams, I can foresee a circumstance where paramedics could be trained in its use. In rural settings, a paramedic FAST exam could allow a rural trauma center to call its surgeon to the hospital and meet the patient as the ambulance arrives. That could dramatically decrease door-to-OR time and thus decrease mortality.

It doesn't take a lot of training to become proficient at FAST exams.

I agree with your question: where does it end? Paramedics are actually doing more than has been supported by the literature (i.e., OPALS). I do not think central lines, except in code situations, are beneficial or needed in the field. I can see a central line being placed in the field for code situations where medications can be administered centrally. Antecubital veins are supposedly good enough, but I do prefer central access in cardiac arrest patients, especially when administering antiarrhythmics such as amiodarone.

I'm glad you were able to obtain so many central lines as a fourth year. I have to say that many, many places are not going to get you that amount and that you were a senior medical student (I doubt the paramedic would have the same numbers). What do you do with people in the states of montana, wyoming, kansas, dakotas, etc.. where there aren't 20 level 1 trauma centers like there are in many big cities? Fly all of them out there for their experience? I've worked in a 25,000 volume Level II suburban trauma center for years prior to medical school and saw maybe 5 central lines placed in the ED. I'm sure in the unit upstairs they put in many more, but my point is that most places where there a paramedic programs you aren't going to be getting all of the medics proficient in placing lines.

I think the question ultimately comes down to... WHERE DOES IT END? This line of thinking essentially can be carried to its logical conclusion that paramedics in the future will function like EM docs or for sure EM PA's. The title at that point should not be called paramedic....it should be changed to doc (ie go to medical schoool).

I misunderstood your previous post about FAST exams. Flight nurses/paramedics are on the whole much more proficient with critical care and tend to be the cream of the crop and yes.......I could see them using FAST's particulary for pneumos as you mentioned.

interesting stuff.

later

 

[DigitalFusion04]

Hi everyone! I haven't posted in a long time. Currently I'm enrolled at Union County College in the paramedic program. Our medical director is the attending MD at a level 2 trauma center in NJ (In NJ this hospital has all level one capabilities the only difference is that staff is on call within 30 minutes and the ED doesn't see enough trauma to make it a level one.) I do not know if this is the first program or not, however, the basis is that there is hospital based paramedic response units in NJ that respond with a suburban type vehicle and work in conjunction with BLS units (most volly. execpt in urban areas) If a problem occurs on scene with a critical patient, such as extreme airway difficulty or prolonged entrapment with significant bleeds, this unit known as MD-1 will respond. Onboard is one of the main attendings and an MD in EMS fellowship. (they also respond in a suburban type vehicle). The truck contains most equipment found in the ED's. Blood is kept in a temp. controlled fridge in the truck, as well as all sorts of kits including things like a Video-Intubating Laryngoscope (which i got to use and is way easier to use than your standard fiberoptic click on handle), chest tube kits.... etc etc.
-Andrew

http://em.morristownresidency.org/Fellowships/EMS Fellowship Overview.htm

 

[12R34Y]

Hi everyone! I haven't posted in a long time. Currently I'm enrolled at Union County College in the paramedic program. Our medical director is the attending MD at a level 2 trauma center in NJ (In NJ this hospital has all level one capabilities the only difference is that staff is on call within 30 minutes and the ED doesn't see enough trauma to make it a level one.) I do not know if this is the first program or not, however, the basis is that there is hospital based paramedic response units in NJ that respond with a suburban type vehicle and work in conjunction with BLS units (most volly. execpt in urban areas) If a problem occurs on scene with a critical patient, such as extreme airway difficulty or prolonged entrapment with significant bleeds, this unit known as MD-1 will respond. Onboard is one of the main attendings and an MD in EMS fellowship. (they also respond in a suburban type vehicle). The truck contains most equipment found in the ED's. Blood is kept in a temp. controlled fridge in the truck, as well as all sorts of kits including things like a Video-Intubating Laryngoscope (which i got to use and is way easier to use than your standard fiberoptic click on handle), chest tube kits.... etc etc.
-Andrew

http://em.morristownresidency.org/Fellowships/EMS Fellowship Overview.htm

that just may be the coolest thing I've ever seen and appears to be somewhere i'll be doing my EMS fellowship in 3 years! holy cow! that's awesomE!

later