Paramedic Practitioners

[Vetitas86]

Doing a little skimming through some articles on different models of EMS, so on. I think the idea of a paramedic practitioner is a great idea, honestly. Especially in cutting down BS hospital trips/admissions and in critical care flight settings as a chief crewmember in the absence of a physician.

Thoughts on this and how to.implement it (just bench racing as it were)?

My thought is this. Something along the lines of PA training, but with an integrated emergency med training and clinical set from day one.

 

[bstone]

I think it would be a fantastic idea. I envision this to be a PA/NP level with an extra year of EMS education.

 

[Vetitas86]

ASAP, the American Society for the Advancement of Paramedicine, is really pushing for it. Still in its infancy even as an organization, but I truly think this is going to be something to watch. I think there is a distinction between how NPs and PAs are trained vs. medics.

NPs and PAs focus on clinical settings. There's a void left in field settings, especially in prehospital care. Sure, groups push for MDs all the way to PAs to crew ambulances and flights, but to me, their training isn't as suitable to the field as it would be for medics.

And since the EMS system does need an overhaul, why not start from the top? Roll out PPs, increase the skills of the medics and push the increased preclinical skills down to EMT-Bs and it'd be a good start.

 

[bstone]

http://www.asap51.com/American_Society_for_the_Advancement_of_Paramedicine/FAQs.html

Fascinating. I had no idea there was a group pushing for this. I liked them on FB.

 

[Miscusi]

Oh the street practitioner ?

I dont know... I think alot of what it takes to be a practioner ( pardon the lack of spellcheck ) is the network of resources available to the pracitioner.

The MDs I go to for my own medical needs mostly rely on lab work, and the slew of specialists out there..

I went in to a MD last month for my plantar facisitis that I got on my Clinical Rotation, MD suspects it is plantar facisiitis, but refers me to a podiatrist, so I go, and the podiatrist suspects, but then sent me for an X ray... on the X ray form, it asks the X ray company to evaluate the X ray for him...

I just cant imagine how much better medicine can be with Paramedic Practioners vs standard Paramedics... I mean like, how much can one do on the back of a truck ? Even if you staff an ALS ambulance with MDs it would still be very limited because all the resources would still be at the hospital anyway.

Just IMHO..

 

[bstone]

I think the point of a paramedic practitioner would be to initiate very advanced interventions in the field. What would those be? I imagine things like starting central lines, general anesthesia, cracking a chest, chest tubes, thrombolytics, antibiotics, etc etc. In the cases where someone is too sick to get out of bed but doesn't need an ER workup they would be able to examine, diagnose, and prescribe treatment independently of an ER physician (or NP/PA).

 

[Miscusi]

one thing ... ppl sare saying NP/PA .. I was wondering if that meant: Nurse practionioner / Physician Assistant...

because I think the PA is not a practionier , they work under a MD's direction and authorization like the rest of us,

that being said in the post above, about the VERY VERY VERY special interventions... I somehow think that if there is such a need, it would be around 0.03 % of the total call volume,

They say that 99% of the calls are Bull S**... and 1% of the calls are OH Sh**

and out of that 1 % oh sh** how many is gonna need their chest cracked open right then and there? and in the patients home that is not sterile ? Mr Lister would turn in his grave. ( if that is what you meant by chest cracking, I dunno, Im new )

The hospital would be the best place for any serious patient, I honestly believe that, due to the superior resource levels and hosts of specialists and supplies and etc...

Just IMHO... That instead of practioner on wheels, they should just expand the scope of existing regular paramedics to include those more advanced interventions as being outdoors allow.. then you wouldnt need to be your own pracitonioner if the protocols already allow you to do the maximun anyway...

( really just IMHO )

 

[bstone]

one thing ... ppl sare saying NP/PA .. I was wondering if that meant: Nurse practionioner / Physician Assistant...

Yup.

because I think the PA is not a practionier , they work under a MD's direction and authorization like the rest of us,

Your thinking is incorrect. PAs act at the same level as NPs. Their licenses are from different state boards but their function is identical. NPs are also required to have a Supervising Physician, tho this MD/DO might be thousands of miles away and only available via carrier pigeon.

 

[Vetitas86]

I think expanding scope is what this is about. You can only take prehospital so far.

From my (limited) understanding, the idea of a paramedic prac. is to be able to more effectively diagnose and treat in situations that wouldn't be "hospital worthy."

Having a clinician in the field, the PP could write (limited and under view of a superior) scripts, use advanced therapy, and act as de facto field supervisor. Supervision in the role of at least knowing how to stabilize in OS moments vs treading water.

And in some areas, paramedics do supervise. But having someone who could act as a catch all and hands on supervisor could free up paramedics to have more field time, letting the EMT-Bs have more time at their level of training.

It would lessen the amount of ridiculous calls being shipped to the ED, provide better quality care, and let the guys and girls do what they're trained to do vs being glorified taxi drivers. (Not my analogy, btw)

Do I think this is ideal in every setting? Hard to say. But in areas where there is a lot of lesser action in the ED, it could very well be a godsend. Even in flight settings, having essentially an advanced paramedic to care for and stabilize critical patients would take the load off flight nurses.

It has the potential for keeping criticals alive and expanding the scope of paramedicine where it needs to be. Again, its still not off the ground yet, but it definitely is something to watch that could change the face of American EMS.

 

[bstone]

I don't know if this sort of paramedic would find a strong enough demand in order to make it a reality. I would strongly support an EMS "residency" for NPs and PAs.

 

[Miscusi]

Oh, I guess it must be a NY thing. here, a nurse practioner can rent an office, open her own practice and have customers...

meanwhile our PAs here in NY cannot do so.

 

[Vetitas86]

But then the issue is finding malpractice coverage for nonclinical work, to say nothing of ones that would work part time or full time EMS. They're out there, just have a feeling they're few and far between.

As far as the residencies, I know there's EM for PAs, and they're officially rolling out board certs for docs this year in EMS. I think its possible that residencies could filter down to NPs and PAs, but would the demand for those be strong enough? And would they just want to be in an admin position?

Having dedicated personnel for prehospital care would solve that, I think. And demand isn't high, but I think if it worked as well as it looked on paper in the States, I genuinely believe there would be.

Think about it. Even training possibilities for Paramedic pracs would open up. Tox, advanced trauma, advanced transport...

Specialization is a problem in health care in general, yeah. But, keeping the NPs and PAs in a clinical setting assisting the MDs is a good thing to me. That's more what they're trained for. Tacking on a residency, to me...its not going to make that much difference when it comes down to it.

 

[bstone]

Oh, I guess it must be a NY thing. here, a nurse practioner can rent an office, open her own practice and have customers...

meanwhile our PAs here in NY cannot do so.

Sure they can. I know many PAs who run their own practices in NY and all over.

 

[Miscusi]

thats sounds very reasonable, I guess I have met NPs who had businesses, but never a PA. All the PAs I have met work in hospitals.. But I'll look it up to see what NY has to say.. I think IIRC that the PA can have the MD DO be far away and the NP needs no MDDO at all... but I'll look..

 

[Miscusi]

ok so far: http://www.health.ny.gov/professionals/doctors/conduct/physician_assistant.htm

So in NYS, PAs cannot practice medicine. I'll find the NP and post back...

 

[bstone]

A physician assistant is considered a dependent practitioner working under the supervision of a licensed physician responsible for the actions of the physician assistant. The supervising physician may delegate to the physician assistant any medical procedures or tasks for which the physician assistant is appropriately trained and qualified to perform and that are routinely performed within the normal scope of the physician's practice.

Do know the requirements for the supervising physician? The doc can be thousands of miles away and only available via phone but that is considered legal supervision.

Countersignature of such orders may be required if deemed necessary and appropriate by the supervising physician or the hospital, but in no event shall countersignatures be required prior to execution.

 

[Miscusi]

So as far as I can understand, the NP is a real practicing professional. they only need a Collaborative Agreement with a MD who does a few things with the NP once every 3 months or something like that... Whereas the PA needs MD supervision directly and is an extension of an MD rather than an independent practionioner himself...

Nurse Link:

http://www.op.nysed.gov/prof/nurse/np.htm

but that is just New york State.. im sure its different in all 52 states !

 

[Miscusi]

Thousands of miles by phone...

"D. Supervision

A physician assistant works under the supervision of a licensed physician who is responsible for the physician assistant's performance as well as the overall care of the patient. The physician assistant may have more than one supervising physician; however, there must be one clearly designated supervising physician who is available at any one time.

In New York State, a physician in private practice may supervise no more than two PAs at one time; in a correctional facility, no more than four PAs at one time; and, in a facility licensed pursuant to PHL Article 28, no more than six PAs at one time. Physicians are not required by law to notify the State Education Department which PAs they employ or supervise.

The supervising physician may delegate to the PA any clinical functions within that physician's scope of practice providing the PA is appropriately trained and experienced to perform those functions. The physician assistant is subject to the limitations set by the supervising physician and to the policies of the employing institution, in addition to state laws, rules, and regulations."

OK I see that there is no distance requirements mentioned, but it does offer a limit on how many PAs a doc can sponsor...

I just cannot see how if a doc can only sponsor 2 PAs, they would do so in a manner where they are thousands of miles away. That is borderline very immoral.

I think the doc should ( and usually as I have seen ) work in the same hospital as the PA they sponsor.

I think any DOc who sponsors a PA thousands of miles away is not an ethical person, so maybe these docs are driven by the loophole and wants a part of the money, but by the state limiting the amount of PAS per doc, that removes alot of the money making these less than ethical docs can make...

but though no countersignature is needed before the treatment, I still think the counter signature is needed afterwards, or eventually.

but I'll be sure to ask the next PA I meet about the countersigs as the website is not too clear on that..

 

[Vetitas86]

And the nonsupervision of NPs is less "immoral" because...?

 

[Miscusi]

And the nonsupervision of NPs is less "immoral" because...?

but the NPs are practioners, they are not supposed to be supervised. hence the term Nurse "Practioner". They are only required to have a collabration.

Supervision and Collabration is not the same thing..