# You are an NP/PA on an ambulance!



## zzyzx (Jul 19, 2015)

You are an NP or a PA working on an ambulance. Imagine that it is a trial program like the one in Orange County, CA.

How would you handle the following 911 calls:
1) Which would you treat and not transport (with referral to PMD)?
2) Which would need an ER eval?
3) Which would be a likely hospital admission?

1) 35 y/o diabetic (Type I) with a fingerstick glucose of 400; ran out of his insulin. Asymptomatic.
2) 55 y/o c/o hypertension, BP 245/120, asymptomatic. Was a relative's house and tried their automatic BP. Does not take any anti-hypertensives and has not seen a doctor in years.
2) Patient involved in a fight. C/o a "fight bite." He punched someone in the mouth and has lacerations on his hand. "Do I need to see my doc to get antibiotics or will I be okay without?"
3) Diabetic (Type II) who takes metformin, glypizide, and an insulin was found ALOC by his wife. Blood glucose 20. After you administer dextrose, he is fully alert and oriented.
4) Twenty year old with a sore throat x 3 days. Also fever. No SOB and vital signs stable. Says she can't deal with the pain anymore; no OTC meds working.
5) 7 y/o SOB with Hx asthma. Pt is acting age appropriate and does not appear to be in acute distress. Mild retractions noted and tachypnea; bilateral exp wheeze. SpO2 95% after breathing Tx.
6) CHF'er who has frequently visited the ER and is well known to the staff. C/o just not feeling well, generalized weakness, increased dyspnea on exertion. Vital signs stable; no acute distress. Denies chest pain. 12-lead shows paced rhythm.
7) Pt was running on the beach when she stepped on and broke a bottle. Has deep lac on foot requiring suturing. Bleeding controlled.
8) 27 y/o syncopal episode at work. Vital signs stable; asymptomatic. No prior Hx.
9) 35 y/o c/o fever, malaise, cough x 3 days. The cough is productive with green phlegm. SpO2 99% and stable vital signs. C/o mild SOB but is in no acute distress.
10) New first-time parents of a 20 day old with fever 102. Vital signs are stable and the baby does not appear to be in any distress.
11) Auto mechanic c/o injection-gun injury to his hand. Pt was using a high-pressure grease gun when it injected grease into his hand. Minimal pain. No loss of function. Pt states he called because his co-worker told him that the grease could enter his blood stream and cause a stroke.
12) 3 y/o with fever x 2 days. Mother states that she has given him Tylenol several times but his fever keeps coming back. No coughing, no retractions, no signs of respiratory distress. Child is smiling at you and interacting normally with mother. All vital signs are WNL except that temperature is 102 and pt is a little tachycardic.
13) 28 y/o male with chest pain and SOB. Pain increases with deep inhalation. 12 lead unremarkable. Pt is mildly tachycardic and tachypneic but not in any acute distress. Lung sounds clear to auscultation. SpO2 99%.
14) 15 y/o with testicle pain x 1 hour. No penile discharge or dysuria.
15) 2 y/o fell off high chair onto hard kitchen floor. Pt has hematoma to occipital region of his head. Pt is acting age appropriate and was crying immediately after the fall. No vomiting. Mother asks, "Does he need a cat scan? Can we let him sleep?"


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## zzyzx (Jul 19, 2015)

I don't know why this got posted as a poll. Ignore that please.


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## Clare (Jul 19, 2015)

I do not quite understand why you need an Nurse Practitioner to make these decisions.  This is something that is done everyday by Paramedics and being done so for decades.  Anyway.  

1) This would not even get an ambulance response.  He would get telephone advice from Control to go to the GP.  If this somehow did manage to get a physical response it would, where I am, be a single officer in a car.  They would tell him the same thing and so would I.  

2) See number one

2) See numbers one and two.  He can go to an A&M clinic and Control would tell him so (as would I).  Doesn't need an ED.  

3) He can stay at home provided it was a single isolated episode of hypoglycaemia with a clear cause (as opposed to a Clare cause, ha!) R/v with GP PRN.  

4) Needs to go to an A&M clinic, doesn't need ED.  Would get telephone advice from Control and not a physical ambulance response if she did not describe any symptoms warranting face-to-face assessment e.g. airway compromise.  

5) He can stay at home but should see his GP within 24 hours.  

6) If his paced rhythm is normal for him he can stay at home and r/v with GP within 24hrs.  If this went through MPDS Card 26 (sick person) as opposed to Card 6 (breathing difficulties) or Card 19 (heart problems) he might not even get a physical response, just telephone advice from Control or a single Officer response.  

7) Needs to go to A&M clinic provided they can suture, d/w them first.  Doesn't need ED unless may require procedural anaesthesia e.g. child.  Again, this might just get telephone advice from Comtrol and not a physical response.  

8) If 12 lead ECG normal then I would not recommend referral or transport for single isolated episode.  If completely awake at time of call this might get telephone advice from Control rather than a physical response.  Probably would get a response, but probably a single Officer in a car.  

9) This would get telephone advice from Control to see a GP.  That would be my advice too.  No transport and no ED required.  

10) See number 9 

11) I'd talk to the hand reg about this one.  Probably just go to an A&M but depends what the hand reg reckons.  Ambulance transport not required. 

12) Very likely to get telephone advice from Control to see a GP.  My advice would be the same.  No transport and no ED required. 

13) This would be an ambulance response due to chest pain and SOB.  I'd refer him to his GP or A&M clinic ?pericarditis or pleurisy.  No transport and no ED required. 

14) This might need ED to be seen by surgical reg to r/o torsion.  Ambulance transport not required if doesn't need more analgesia than paracetamol and ibuprofen.

15) Would probably get telephone advice from Control about warning symptoms and to check on him frequently.  That would be my advice and if they are really worried refer them to an A&M clinic.  No ambulance transport required.


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## ERDoc (Jul 19, 2015)

zzyzx said:


> 1) 35 y/o diabetic (Type I) with a fingerstick glucose of 400; ran out of his insulin. Asymptomatic.
> 2) 55 y/o c/o hypertension, BP 245/120, asymptomatic. Was a relative's house and tried their automatic BP. Does not take any anti-hypertensives and has not seen a doctor in years.
> 2) Patient involved in a fight. C/o a "fight bite." He punched someone in the mouth and has lacerations on his hand. "Do I need to see my doc to get antibiotics or will I be okay without?"
> 3) Diabetic (Type II) who takes metformin, glypizide, and an insulin was found ALOC by his wife. Blood glucose 20. After you administer dextrose, he is fully alert and oriented.
> ...



I don't think many of these can be answered simply but I'll try.
1.  Ketones in urine?(Many check it at home)  If yes go to ER, if no provide script.  Ambulance not needed
2a.  To ER, ambulance not needed
2b.  Needs abx and tetanus, possibly xrays.  If PMD can see him in 24 hours, PMD f/u should be fine, ambulance not needed
3.  Glipizide buys him an admission, ambulance not needed
4.  Not enough info, could be strep, could be PTA.  What do we see on exam?  Ambulance probably not needed
5.  Needs more tx than can be provided in the field in a reasonable amount of time, go to ER.  Ambulance probably not needed
6.  PMD f/u within 24 hours (PMD will probably send him to ER anyway but worth a try)
7.  Needs xray, tetanus, possible abx and closure, to ER but ambulance not needed
8.  If 12 lead is normal and no concerning history (my poop is black) then PMD f/u
9.  PMD
10.  Sepsis until cultures prove otherwise, go to ER IMMEDIATELY but ambulance not needed
11.  Baddness, needs ER but not for the reasons the friends give, ambulance not needed
12.  PMD and explain that the fever will continue to come back so keep giving tylenol/motrin
13.  Need more history, could go either way, should probably go by ambulance
14.  ER, ambulance not needed
15.  Depends on if he meets PECARN criteria, could possibly stay home but would recommend ambulance transport


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## MMiz (Jul 19, 2015)

zzyzx said:


> I don't know why this got posted as a poll. Ignore that please.



I deleted your poll.


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## zzyzx (Jul 19, 2015)

ERDoc, I agree with all but with both 2a and 2b. 
2A) If you can assure he has follow up--I don't see why he needs an ER visit.
2B) To be honest, until a few weeks ago I would not have thought that a fight bite needed anything more than antibiotics. But after seeing one of these and talking to the hand surgeon who came in to see the patient, I now realize how serious these seemingly innocuous injuries are.

ERDoc, what do you think about NP's or PA's on ambulances? I don't see how well they can function w/o imaging or labs, not to mention the cost and inefficiency of having them outside of a clinic. And also the fact that it just gives people an incentive to call 911 rather than taking their butts down to the ER.


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## zzyzx (Jul 19, 2015)

Also I think #1 should be seen in the ER.


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## ERDoc (Jul 19, 2015)

For 2a, since he hasn't seen a doctor in years, I was assuming he has no follow up. If you can obtain f/u for him, then I agree, ER visit is not necessary.  This is why I started by saying that they can't be simply answered. As for 2b, they absolutely can be very serious but if it just happened and the guy is able to be seen by his PMD, then the ER is not necessary.  If you cannot arrange f/u then I agree that he needs to go to the ER or urgent care.

I go back and forth with this whole concept.  If we can save EMS and the ER a few visits and relieve that pressure that would be great but in reality, how often can anyone call their PMD and be seen in 24 hours?  I think a program like this might be helpful to steer patients to more appropriate destinations such as urgent care when they don't need ER care.  Who knows, maybe it would even be able to save money and resources by arranging alternative transportation.  A $10 taxi ride to the UCC costs a lot less then the several hundred dollar ambulance ride to the ER.  I'm not sure there would be a lot of cases where they would be able to treat and release unless we give them istats.

ETA: If case 1 is asymptomatic and nonketotic and we can arrange for him to get his meds in an appropriate time, there really is no need for an ER visit.  An NP/PA can write a script for insulin just as well as I can.

Interesting topic for discussion.  I'm glad you came up with specific scenarios instead of just the usual hypothetical discussion.


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## Brandon O (Jul 19, 2015)

ERDoc said:


> I'm glad you came up with specific scenarios instead of just the usual hypothetical discussion.



Glad, sure. You're gonna give me an ulcer zzyzx.


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## zzyzx (Jul 20, 2015)

"Glad, sure. You're gonna give me an ulcer zzyzx."

LOL! Yeah, me too. Everything is so complicated.


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## Clare (Jul 20, 2015)

I don't see why you need a Nurse Practitioner to do this, Ambulance Officers have been doing it for decades.  

When I see a patient I need to

1.  Diagnose what is most likely wrong with them noting it is often not always clear, then
2.  On that basis determine what are their healthcare needs, and 
3.  Figure out how can these needs be met most effectively and efficiently

Or put another way when a patient is seen by ambulance personnel, they need to ask 

1.  Does this patient need treatment from ambulance personnel?
2.  Does this patient need referral by ambulance personnel to another healthcare provider?
3.  If they do need referral, do they require transport by ambulance to that person? 

For example:  

The child with pain in his nuts might have painful from some benign cause that will go away, or he might have torsion.  I can't tell.  We _*could *_refer him to his GP or an A&M clinic but they are just going to refer him to ED to be s/b the surgical reg to r/o torsion.  The most effective and efficient way of meeting his healthcare needs is for him to go to ED but does he need ambulance transport? Not if he is not in significant pain no, he can go with mum and dad in the car. 

Most patients are suitable for referral to their GP or an A&M clinic, especially the flasher ones that have radiology, ultrasound, casting etc.

If I am not sure I just ring the GP or A&M and ask, they tell you.  Done it before, works a treat


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## Brandon O (Jul 20, 2015)

Clare said:


> I don't see why you need a Nurse Practitioner to do this, Ambulance Officers have been doing it for decades.



I suspect, given a less hazardous culture of defensive medicine and far more training for your ambulance providers down there, that your experiences may not be generalizable up here.


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## MonkeyArrow (Jul 20, 2015)

Brandon O said:


> I suspect, given a less hazardous culture of defensive medicine and far more training for your ambulance providers down there, that your experiences may not be generalizable up here.


And the ease of access to other forms of healthcare where you are from can't be discounted. We can sit here and say we need to refer you to a PCP, but the primary patients who we would need to send a mid level to make a house call probably does not have insurance, and thus cannot see any other forms of care except for at the ED. 

Honestly, if it think such a concept were to be implemented in the U.S. with the current state of healthcare, it would have to consist of a 2 man response vehicle in a suburban. Non-emergency, you would need a mid level for the medicine and then a social worker or patient rep to make sure the patient can actually get what the mid level orders/prescribes.


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## zzyzx (Jul 20, 2015)

Although I posted these scenarios as ones where an NP or a PA could make an official diagnosis, make a transport decision (including refusing transport), and also offer medical advice, these scenarios do have a lot of relevance for us EMT's and paramedics as well. As emergency medical professionals, we should be able to recognize any condition that is or could potentially be life of limb threatening. We all know that many people call 911 because they want medical advice, not knowing that we are not allowed to diagnose or give advice. Consider the case of the mechanic who calls for the injection-gun injury. He would likely not seek medical attention unless an EMT/medic recognized the seriousness of the injury and urged him to immediately go to the ER. It's not good enough to just say,, "I don't know, I'm not a doctor. Your hand looks fine to me. We could take you, but you might as well just call your doctor or go to a clinic."


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## Brandon O (Jul 20, 2015)

Not to derail, but what on earth is an injection gun?


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## zzyzx (Jul 20, 2015)

High-pressure injection guns are used by mechanics for injecting grease, shooting pain thinner, etc.


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## ERDoc (Jul 20, 2015)

This






Causes this


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## Brandon O (Jul 20, 2015)

Looks fine to me.


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## NomadicMedic (Jul 21, 2015)

"Bandaid and back to work"


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## Christopher Rideout (Jul 28, 2015)

Aaaaaaand post derailed by an injection gun haha.


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## Giant81 (Dec 15, 2015)

I'm envisioning something like this.  I live in a rural area that hardly has paramedics so I suspect we won't get NP/PA's anytime soon but here's my scenario.

Farmer working on machinery, slips, slices arm open, it's bleeding pretty good, but bleeding is controled by the time NP/PA shows up.
evaluate patient, clean wound, numb, suture, wrap, provide Rx for antibiotics and pain meds, print off sheet with signs to keep an eye out for and tell them to follow up with their PCP.  roll back to garage.  Saves the PT a trip to the ED, saves ED staff time with a fairly routine trauma, win/win.  

Granted this is with little knowledge of a paramedics SoP, and I'm not sure if a paramedic can use butterfly stitches to close a wound and advise a PT to go to Urgent care or see his PCP within the next 24hr if possible.


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## zzyzx (Dec 15, 2015)

Why not just have the Farmer take himself to the ED? If he controlled the bleeding himself, why even call 911? 

In a rural area, it is hard enough to find MD's, PA's, and NP's to staff clinics. It does not seem efficient or cost effective to take one out of a clinic where they can see many patients. 

There are good reasons why doctors stopped doing house calls many decades ago.


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## medicsb (Dec 15, 2015)

Oooh, I want to play.  



zzyzx said:


> You are an NP or a PA working on an ambulance. Imagine that it is a trial program like the one in Orange County, CA.
> 
> How would you handle the following 911 calls:
> 1) Which would you treat and not transport (with referral to PMD)?
> ...


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## GloriousGabe (Dec 17, 2015)

If I was a PA or NP on an ambulance the first thing I would do is get off the ambulance as it certainly doesn't pay the same amount as I would working in a clinic or hospital.


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## Brandon O (Dec 17, 2015)

medicsb said:


> Thorough cleansing, close exam for tendon injury, loose approximation, and ABx.



Loose approximation? Not familiar with that approach. Is that a compromise with secondary intention?


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