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The Benefits of an EMS PA Program
The need for healthcare in the U.S. is increasing, and many organizations are exploring alternative options to meet that demand. One possible solution could be EMS physician assistants (PAs).
PAs are medical professionals who can diagnose and treat patients, interpret laboratory data, and prescribe medications.1 In 2018 the PA field was the fifth-fastest-growing in the U.S.,2 and currently degrees are offered through 75 postgraduate PA programs with 25 specialties,3 with a third of those programs focusing on emergency medicine. However, despite the original PAs originating from military EMS in 1965,4 no program today concentrates specifically on EMS.5 To be able to deliver proficient EMS care, a provider must be well versed in the unique challenges, interventions, and situations posed by the EMS setting, all of which require education from specialized training programs.6
The purpose of this article is to propose such a program: a postgraduate EMS-focused PA program that would work to expand the current availability of PA education and prepare the EMS community to allow trained PAs to practice in the EMS setting.
Background of EMS
In 2010 EMS was officially recognized as a subspecialty of emergency medicine,7 and the National Associated of EMS Physicians (NAEMSP) responded by accrediting EMS fellowships in 2012 to formally educate EM physicians to handle the unique situations EMS providers face.8 At this time 61 NAEMSP-accredited EMS fellowships are available to EM physicians in the United States.9
With the development of physician EMS fellowships also came physician response units, vehicles staffed by emergency medicine (preferably EMS) physicians and fellows dispatched directly as scene responders, usually alongside or in addition to the usual first responders. Physician response units have been shown to be efficient ways of delivering care beyond the scope of a regular ambulance.10
As PAs in the field would function as physician extenders, their most obvious entry into the world of EMS would be as an extension of current physician response units. Proposed functions would involve both prehospital care and administrative functions. As PAs can have vast differences in their scope of practice, this article primarily reflects the laws of Missouri. Consult and abide by relevant laws and regulations when adapting this information to your state.
Core EM and EMS-Specific Education
With few exceptions, most PA programs graduate students with a focus on primary care medicine. Many PA programs provide only a single rotation in emergency medicine.
To assure new PA graduates can function in high-speed emergency medical situations, additional education in EM should be a requirement. This should be continued over the course of the PA EMS fellowship and, as in any realm of medicine, after graduation.
Specific emergency-based certification courses such as Advanced Cardiac Life Support, Pediatric Advanced Life Support, Basic Life Support, Advanced Trauma Life Support, the Incident Command Systems, and awareness-level hazardous-materials education should be considered mandatory and obtained within the initial month of training, prior to any scene response. It is essential for the initial month of training to focus on core emergency medicine topics, along with basic EMS scene safety, to provide some assurance the PA is proficient in EM and has a good foundation for the continued addition of EMS-specific knowledge.
For any EMS PA fellowship program to have credibility, it should have education goals aligned with the proven process of the physician EMS fellowship curriculum. Therefore, one major difference to consider is that EMS physicians seeking EMS fellowships already have had an intense EM residency, while PAs have general medicine experience. That makes EM education a necessity for the EMS PA candidate’s success.
Physician EMS fellowships are at present accredited by the Accreditation Council for Graduate Medical Education (ACGME),11 whose education goals are outlined in Section IV of the ACGME Program Requirements for Graduate Medical Education in Emergency Medical Services. A postgraduate program for PAs should strive to follow the example set forth in the EMS physician fellowship. PAs should be required to take similar coursework to the EMS physician, including courses in incident management, tactical medicine, emergency medical dispatch, and disaster management.
Prehospital Care
Proposed prehospital functions for EMS PAs would include critical care (trauma, cardiac arrest, mass-casualty/mass-gathering events); tactical operations; high-risk refusals; and mobile integrated healthcare, including high-use individuals and low-acuity patients.
Trauma and Critical Care
An EMS PA would be a prime candidate to deliver emergent critical care during complex traumas, cardiac arrests, and mass-casualty incidents (MCIs). Having a provider capable of bringing additional tools and skills to the prehospital response, such as point-of-care ultrasound (POCUS), has the potential to improve patient outcomes.12 Advanced intravenous access, including central venous catheterization in critically ill patients, is also improved with the use of POCUS.13 Advanced Trauma Life Support recommends early ultrasonography in trauma patients by utilizing expanded focused assessment using sonography in trauma (eFAST) exams.14 Completion of these exams with positive results has been shown to decrease time from injury to arrival in the operating suite.
Ultrasound can also be seen in confirmation of cardiac standstill during cardiac arrest events. In the event of cardiac standstill, the possibility of successful resuscitation drops extremely close to 0%.15
Another tool PAs could bring into field response is skilled video laryngoscopy. Video laryngoscopy has been shown to improve success rates in urgent intubations and decrease esophageal complications.16,17
In the event of an MCI or prolonged extrication, PAs can assume the important role of monitoring the critically ill patient. Interventions could include end-tidal carbon dioxide monitoring and pulse oximetry for evaluation of ventilation in both intubated and nonintubated patients.18 PAs can also insert arterial catheters for arterial blood pressure monitoring, rather than central venous catheters for central venous monitoring. Additional critical care monitoring skills would include placing a urinary catheter to monitor urine output (for severely prolonged extrication) and core temperature monitoring.
Mass-Gathering Events
During mass gatherings an influx of stable patients could present to a medical station. In these events a PA can provide online, on-scene medical control for prehospital providers. PAs have been able to decrease hospital lengths of stay when placed in triage, so it can be inferred they are capable of identifying the appropriate needs and dispositions for patients with acute presentations.19 Having a PA on scene may also help decrease the number of patients transported to a hospital or identify subtle presentations of more serious illnesses.
Tactical Operations
During law enforcement tactical operations, where situations demand deviation from established protocols, PAs can provide a higher level of care for officers and patients. All SWAT teams accredited by the National Tactical Officers Association require medical support, so having a PA on the team may prove beneficial not only for acute care of the ill and injured but for the preventative and long-term care of the team.20
High-Risk Refusals
Most EMS systems document that between 5%–20% of their call volume results in patients’ refusal of medical treatment, with some systems indicating 30%.21 Many of these patients, especially those older than 65, will require some kind of follow-up care.22 These older patients are also more likely to die because of their illness within a week of their medical contact.23 Pediatric patients are also high-risk refusals due to the inclusion of parents and their requests. Psychiatric patients are also high-risk; therefore PAs may be able to bring additional medications not normally carried on ambulances for violent patients. They may also be able to provide a more thorough assessment, with the possibility of alternative dispositions to the ED.
High-Frequency Users
High-frequency users of EMS can also be reduced up to 30% through education and by providing the appropriate resources for alternative, more appropriate dispositions.24 In one example of a community paramedicine program in North Carolina, high-frequency user visits to the ED were cut by more than half under a program using paramedics with additional training.25 Utilizing PAs with prescriptive authority could reduce ED use even more.
Low-Acuity Patients
EMS providers are frequently dispatched to low-acuity, nonemergent patients, who often overlap with the high-frequency user subset. The Los Angeles Fire Department implemented a nurse practitioner-staffed ambulance that responded to many of these calls. In the first six months, their treat-and-release rate was 52% for the 329 patients to whom they were dispatched.26 One study noted that low-acuity ambulance users often had insurance and a primary care provider but lacked private transportation compared to those presenting via private transportation.27
These patients also believed enough ambulances were available for calls of all acuities and said they would continue to utilize ambulances for medical transportation.27 Another study demonstrated a reduction in ED visits through using other resources, such as telemedicine and urgent care centers.28 PAs could further reduce ED visits by appropriately triaging lower-acuity patients to these established resources.
Administrative Roles
ACEP suggests physicians with board certification in EMS are best prepared to fill the role of an EMS medical director.29 This role also includes dedication to continued EMS provider education, community evaluation, QI/QA, and EMS-focused research. The EMS PA can fulfill this role as an assistant medical director (though in Missouri EMS medical directors must be board-certified physicians).29,30
Administrative duties of the EMS PA can be subdivided into three categories: education (community and prehospital provider), QI/QA, and research.
Education
An EMS PA could provide medical education to two distinct audiences: the general community and EMS providers.
For community education, opportunities exist in settings such as community health fairs, specific targeted campaigns, and the promotion of celebration weeks (e.g., EMS Week, Health Literacy Week, etc.). These efforts should be focused on spreading health awareness, communicating the availability of resources, and assisting in the first steps toward health improvement.
For prehospital providers EMS PAs could teach initial education courses and provide continuing education on focused topics or skills with the appropriate simulation materials.
Quality Improvement
Since quality improvement is also among the responsibilities of the medical director, this task could be completed by a PA working as an assistant medical director. Responsibilities would include chart review, identification of common errors, and developing training courses and education materials to assist in continual improvement.
Research
Evidence-based practice has been shown to improve overall patient outcomes, and a commitment to research is another responsibility of the EMS medical director that could be executed by an EMS PA: seeking out new areas to investigate, completing or coordinating projects, and performing original research. Additionally, PAs could locate peer-reviewed, evidence-based best practices and develop new policies and protocols to incorporate them.
Limitations
Several barriers likely exist to the immediate implementation of an EMS PA program such as the one described above. The first and foremost is obtaining funding. Most fellowship programs provide the student with a stipend, but there are also costs like liability insurance, vehicles, uniforms, training courses, and medical insurance. Ways to cover these costs include insurance reimbursement for patient care hours, grants, donations, and university input.
Furthermore, the emergency medical dispatch system must be assessed to ensure correct analysis of calls for the dispatch of appropriate resources. Studies have shown protocol-based EMD systems are consistently more accurate than those without EMD protocols.31
Because of a lack of current PA providers in the EMS setting, it is important that procedures, protocols, and policies be examined to ensure liability coverage.32 These policies should be set with the direct input of the division chief/medical director. They should specify who has ultimate on-scene authority for patients should a difference in opinion ever occur on the treatment plan.
As with all postgraduate academic programs, an EMS PA program must be affiliated with a university. Many existing physician response units are already aligned with major academic centers. This would also be beneficial toward future EMS research.
Conclusions
A prehospital-focused EMS PA postgraduate education program would be relatively easy to implement once these few small barriers are overcome. These providers would have the ability to improve the care and functioning of EMS, contributing to a more appropriate allocation of resources, reduced ED utilization, increased cost savings, and better overall health literacy.
References
1. American Academy of Physician Assistants. What is a PA? www.aapa.org/what-is-a-pa/.
2. Bureau of Labor Statistics. Fastest Growing Occupations, www.bls.gov/ooh/fastest-growing.htm.
3. Association of Postgraduate PA Programs. Postgraduate Pas Programs Listings, https://appap.org/programs/pa-programs-listing/.
4. American Academy of Physician Assistants. History of the PA Profession, www.aapa.org/about/history/.
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7. American College of Emergency Physicians. EMS the Newest Subspecialty of Emergency Medicine. ACEP Now, 2010 Nov 1; www.acepnow.com/article/ems-newest-subspecialty-emergency-medicine/.
8. National Association of EMS Physicians. EMS Subspecialty, https://naemsp.org/career-development/ems-subspecialty/.
9. National Association of EMS Physicians. Fellowship Programs, https://naemsp.org/career-development/fellowship-programs/.
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12. Bøtker MT, Jacobsen L, Rudolph SS, Knudsen L. The role of point of care ultrasound in prehospital critical care: a systematic review. Scand J Trauma, 2018; 26(1): 51.
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18. Andrews FJ, Nolan JP. Critical care in the emergency department: monitoring the critically ill patient. Emerg Med J, 2006; 23(7): 561–4.
19. Nestler DM. Effect of a physician assistant as triage liaison provider on patient throughput in an academic emergency department. Acad Emerg Med, 2012 Nov; 19(11): 1,235–41.
20. National Tactical Officers Association. Tactical Response and Operations Standards for Law Enforcement Agencies, https://ntoa.org/pdf/swatstandards.pdf.
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22. Vilke GM, Sardar Wm, Fisher R, Dunford JD, Chan TC. Follow-up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care, 2002 Oct–Dec; 6(4): 391–5.
23. Page D. Cancel with care. Which refusals can risk patient safety—and your career? J Emerg Med Serv, 2010 Dec; 35(12): 56–61.
24. Pecci AW. Community-Based Program Cut ED Visits by Nearly 30%. Health Leaders, 2017 Oct 4; www.healthleadersmedia.com/clinical-care/community-based-program-cut-ed-visits-nearly-30.
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26. Eckstein M, Ito T, Guggenheim A, Sanko S. Nurse Practitioner Response Unit Launched in Los Angeles. J Emerg Med Serv, 2017; 42(2).
27. Pearson CP, Kim DS, Mika VH, et al. Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization. Am J Emerg Med, 2018 Aug; 36(8): 1,327–31.
28. Poon S, Schuur J, Mehrotra A. 172 Trends in Site of Care for Low-Acuity Conditions Among Those With Commercial Insurance, 2008–2015. Ann Emerg Med, 2017 Oct; www.annemergmed.com/article/S0196-0644(17)31099-5/fulltext.
29. American College of Emergency Physicians. The Role of the Physician Medical Director in Emergency Medical Services Leadership, www.acep.org/patient-care/policy-statements/the-role-of-the-physician-medical-director-in-emergency-medical-services-leadership.
30. Missouri Code of State Regulations. Rules of Department of Health and Senior Services, Division 30—Division of Regulation and Licensure, Chapter 40—Comprehensive Emergency Medical Services Systems Regulations; www.sos.mo.gov/CMSImages/AdRules/csr/current/19csr/19c30-40.pdf.
31. Clawson J, Olola CHO, Heward A, Scott G, Patterson B. Accuracy of emergency medical dispatchers’ subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocol’s recommended coding based on paramedic outcome data. Emerg Med J, 2007 Aug; 24(8): 560–3.
32. National Association of EMS Physicians. EMS Physician-Performed Clinical Interventions in the Field Position Statement, https://naemsp.org/NAEMSP/media/NAEMSP-Documents/EMS-Physician-Performed-Clinical-Interventions-in-the-Field.pdf.
David Wright, MS, PA-C, NRP, is a physician assistant working in the Division of Pediatric Emergency Medicine at Washington University in St. Louis.
