Editorial Column By: David Wright, MS, PA-C, NRP

Emergency Medical Services (EMS) is an action packed, thrilling career that is packed full of explosions, gunshots and major traumas. Paramedics speeding to the scene, lights and sirens blaring, people are lying in the streets, screaming and crying when the medics jump out of the ambulance to save the day. Or at least that’s what the TV shows would have you believe. Watching any TV medical drama would have you believing that doctors are running out to the ambulance bay to meet dying patients who were impaled on a hiking trip, attacked by bears in the city or retrieved from an airplane wreck, but in my 15 years of EMS experience, this never seemed to be the reality of EMS.

Reality is more docile than the dramatic TV representation that gets good viewer ratings. According to a 2016 study, up to 50% of EMS transports are deemed inappropriate emergency calls for ambulance utilization.1 Most EMS workers would agree the current healthcare system in America is overworked and a visit to the emergency department will result in overcrowding of the waiting room, many of which are filled with patients not actually experiencing an emergency. It is important to have a clear delineation of two very different terms; unscheduled care is very different from an emergency. Emergencies are often life or limb threatening, while unscheduled care is just as it sounds, care that was not planned, but still care that needs to occur. Some attempts have been made to combat this with the recent proliferation of urgent cares, but let’s consider another possibility.

Many years ago, physicians would make house calls, but over the years, this model has gone away. Today there are still plenty of healthcare workers who spend their work day travelling from house to house, providing in home continued or preventative care. Many of these providers include home health nursing care, therapy services, social services, and EMS providers. What if we could do this for some of the unscheduled care that is currently overcrowding local emergency departments?

Physician Assistants (PAs) are well trained medical professionals who are capable of performing expanded assessments, can treat patients, perform and interpret laboratory data and prescribe medications.2 These qualities are currently missing from many of our pre-hospital care providers. In order to deliver well rounded, holistic EMS care, providers must be well versed in the unique challenges, interventions and situations that exist in the pre-hospital setting. A lot of this knowledge requires additional education not routinely taught in standard PA programs 6, enter the EMS Physician Assistant.

Enter EMS PA Fellowships…

 To be able to care for this specific subset of patients in the pre-hospital setting, PAs, who are often trained in primary care medicine, would need additional education. That additional education should be focused in both the EMS and Emergency Medicine setting. The fellowship would include didactic work on core emergency medical conditions, assessment and acute management of these conditions, as well as appropriate disposition of patients who experience unscheduled care needs. Additional clinical hours and experience focusing on emergency medicine are also required. Standardized courses such as Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Advanced Trauma Life Support (ATLS) would be needed by the fellow. Additional Training focusing on common ED treatments for time sensitive diagnosis such as Stroke, STEMI, and Trauma would also be required. Skills training should also be included for procedures such as Central Line Insertion, splinting, immobilization, spinal immobilization, point of care ultrasound (with interpretation) and critical care hemodynamic monitoring would be provided.

In addition to the core emergency medicine training, the EMS PA fellow would also need specific EMS training. EMS specific coursework includes Incident Command Systems (ICS), Emergency Medical Dispatch (EMD), and Hazardous Materials: Awareness level training. Specialized EMS training would focus on tactical medicine, mass gatherings, disaster medicine, urban search & rescue and fireground EMS care would also be completed. EMS systems also have administrative functions often performed or monitored by the Physician Medical Director. Training would also be provided to allow the EMS PA to be able to perform or assist in these functions, and education in QA/QI, continuing education, credentialing, and protocol development.

While cognitive education is important, it is equally important to have education in the psychomotor domain with practical hands on field experience. This experience would prepare the PA to work in the pre-hospital environment after graduation of the fellowship. Hands on field experience includes independent field response with local EMS providers, ambulance field experience, interacting with crews on scene, learning the EMS systems, participating in regional and nation exercises, and experiencing how EMS PAs integrate into the already established EMS system.

After Fellowship: What You Can Do On The Job

After graduation from the EMS fellowship and entering the workforce, the EMS PA would be adding an additional layer of pre-hospital care to the local and regional community. This addition would bring an EMS provider who is trained to provide adjunct services in critical care situations, tactical operations and community health. Including the high utilizers and the low acuity patients who primarily present with unscheduled care, rather than true emergency care needs. It is these patients that have the greatest potential to be dispositioned with on scene care and education, without the need for a hospital visit.

EMS PAs are capable of providing critical care by bringing additional tools and skills to patients who have experienced severe trauma, cardiac arrest or are involved in mass casualty incidents (MCIs). The capability of performing point of care ultrasound, advanced IV access, including central lines in critically ill patients to improve pharmacological resuscitation.3 Performing these exams in the field can improve patient outcomes by decreasing the overall time from injury to OR arrival.4 Patients who require extensive extrication due to entrapment or crush injuries can also benefit from critical care hemodynamic monitoring. EMS PAs are capable of inserting and monitoring arterial catheters for arterial blood pressure monitoring, or urinary catheters to monitor urine output and core temperature.

During cardiac arrests, point of care ultrasound imaging can confirm cases of cardiac standstill, a condition that drops the probability of successful resuscitation to essentially 0%.5 EMS PAs on scene can also provide on scene termination of resuscitation orders can also be provided in cases deemed futile by EMS PAs or on scene providers allowing responders to withhold/stop resuscitative efforts. Often families have more support at home to assist them through the loss of a loved one.

Mass gathering events such as Mardi Gras, special events, festivals, and state fairs brings another set of unusual challenges to a region’s EMS system. The EMS PA is capable of providing online medical control, giving direct orders, and operating outside of the usual paramedic protocols, to expand EMS provider capabilities on scene. These actions, include effective triage and treatment of patients can limit the amount of patients transported by ambulance to area emergency departments.

Police operations can be complimented by the addition of EMS intervention and training, and EMS PAs are able to provide a higher level of care for officers and potential patients when these situations arise. This EMS/law enforcement partnership can also strengthen the community cooperation and improve the law enforcement team health as the EMS PA is also capable of performing preventative care for tactical team members.6

Many EMS systems are frequently plagued by high utilization users. Pre-hospital studies have demonstrated the possibility of almost a 50% reduction in these calls by providing appropriate patient education, resources and disposition to facilities other than the emergency room.7

Paramedics also frequently encounter low acuity patients who are not experiencing a true medical emergency but rather have unscheduled medical needs. It is here the EMS PA may make the largest impact on the healthcare system. These patients are often potentially able to be dispositioned on scene as part of a “treat and release” program without needing medical transport. The following list of conditions are high frequency calls that have the potential of being dispositioned on scene without a hospital visit.

Conclusions

 There are some small barriers to the implementation of a pre-hospital focused EMS PA post-graduate education program but considering the basic framework for the fellowship already exists, the program would be relatively easy to implement. PAs are already highly trained medical professionals who have the ability to improve and augment the current delivery of pre-hospital medicine. Attributes of a well-trained EMS PA increase assessment and clinical skills, improved resource allocation, decreased ED utilization, decreased healthcare costs, and improved overall health literacy.

 

 

References

1  Dejean, D., Giacomini, M., Welsford, M., Schwartz, L., & Decicca, P. (2016). Inappropriate Ambulance Use: A Qualitative Study of Paramedics’ Views.. Healthcare policy, 11(3), 67–79.

2  American Academy of Physician Assistants (2019). What is a PA. Accessed from:  https://www.aapa.org/what-is-a-pa/

3  Bøtker, M. T., Jacobsen, L., Rudolph, S. S., & Knudsen, L. (2018). The role of point of care ultrasound in pre-hospital critical care: a systematic review. Scandinavian journal of trauma, resuscitation and emergency medicine, 26(1), 51.doi:10.1186/s13049-018-0518-x

4  Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma (FAST) [Updated 2019 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470479/

5  Cureton, E. L., Ereso, A. Q., Sadjadi, J., & Victorino, G. P. (2008). QS243. The Heart of the Matter: Utility of Ultrasound of Cardiac Activity During Traumatic Arrest. Journal of Surgical Research, 144(2), 363–364. doi: 10.1016/j.jss.2007.12.490

6  National Tactical Officers Association (2018) Tactical Response and Operations Standards for Law Enforcement Agencies. Accessed from: http://ntoa.org/pdf/swatstandards.pdf

7  Clarke, J. L., Bourn, S., Skoufalos, A., Beck, E. H., & Castillo, D. J. (2017). An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions. Population health management, 20(1), 23-30.doi:10.1089/pop.2016.0076

Article written and photos provided by Colton Peltz

On January 13, 2020 the Missouri State University Physician Assistant Cohort of 2021 officially began didactic year. We completed 9 weeks of vigorous course work and each developed a daily routine to manage the sheer volume of material. Talk of a worldwide virus, known as Covid-19 (SARS-CoV-2), began to circulate and raised questions regarding the remainder of our semester. Our program faculty have been completely transparent when keeping us up to date with the university’s response. Our professors began developing contingency plans to continue our education remotely in the event that seated classes were canceled. At the end of week 9 the decision to transition to online classes was confirmed. This decision was made in an attempt to practice “social distancing” by limiting large gatherings and in-person contact at the university.

Our faculty have developed virtual course material allowing us to continue our education from home. Currently, we are meeting with our instructors and fellow classmates daily through live virtual Zoom classrooms. These live meetings hold us accountable and provide an opportunity to engage in discussion and group study. During this unprecedented time of closures and disruption, I have no doubt that the MSU Physician Assistant Cohort of 2021 will continue to adapt and overcome in order to play our part in “flattening the curve”.

Q: How is this impacting your studies?

Online PA school? Unfortunately, this is currently the nationwide reality. Our classes have been switched to online “distant” learning for the remainder of the spring semester.

PA School is incredibly difficult even under normal circumstances and adapting to remote learning has been challenging. Our professors have been incredibly flexible and are accessible via email or phone throughout the day. It is comforting to know that our professors are working around the clock to provide us the same level of education that we would have received in the classroom. After a few days of technical difficulties and confusion our cohort has developed a new self-isolation study routine. I am confident that we will continue to excel, and I am thankful that the quality of my education has not been sacrificed despite the current response to a global pandemic.

Q: Will this impact your graduation?

Missouri State University physician assistant didactic year students are still scheduled to graduate on time in December of 2021.

Q: Where are students located at this time?

At this time, we have students completing their course work all over the state of Missouri. We have students that have traveled back to their home state of Minnesota, Oklahoma, and Iowa as well. We miss seated classes with our professors and fellow classmates but are enjoying the quality time at home with family while in quarantine.

Q: How is the pandemic impacting your class? What are general issues they are facing?

After 9 weeks of seated courses our cohort has developed a great sense of camaraderie. We share each other’s joys and frustrations. Through Zoom meetings and conference calls we have remained in daily contact with our classmates to provide mental and emotional support.

We have multiple students in our cohort that have children. On top of the rigorous demands of PA School, these SUPER MOMS and DADS are also homeschooling and caring for their children at home.

Technical difficulties are inevitable. With constant notifications it is easy to miss an assignment or forget about a Zoom meeting. Our instructors have taken the time to compile the weekly objectives for each course in a to-do list which is sent out to us at the beginning of each week. If we weren’t tech savvy at the beginning of the semester, we sure are now!

Q: Has this reshaped your view on patient care or the PA profession?

Absolutely. Physician Assistants are contributing to the healthcare system amidst this global pandemic alongside incredible physicians, nurses, respiratory therapists, EMTs, Pharmacists, CNAs, ER techs, Hospital maintenance staff, and more.

The versatile nature of our profession allows PA’s to switch medical specialties throughout their career. This aspect of our profession has been invaluable during these times because PA’s are switching from their respective specialties to Emergency Medicine and Urgent Care to directly care for COVID-19 Patients.

COVID-19 will not deter us from pursuing our dream career. We are no stranger to adversity. By practicing unmitigated daily discipline, we will persevere and graduate to become competent, compassionate providers.

Article written and photos provided by Emily Suchanek

On December 7, 2019, I addressed my classmates, faculty, and our friends and families at the annual White Coat Ceremony. We had just completed our didactic year of learning, and after winter break, we were to embark on the second half of our PA education, clinical year. After sitting in class learning for 394 days and passing 63 exams, we were finally able to put our knowledge to work in real-life clinical settings with real patients.

We began our first of eight, 6-week clinical rotations in January. In early February, after surviving our first clinical rotation and EOR (end of rotation) national examination, we embarked on our second rotation. I was at a family medicine clinic in Bolivar, MO. On the fourth week of my second rotation, talk of a worldwide virus started to circulate at the clinic. At patient’s annual Medicaid visits, my preceptor instructed me to start adding, “you might have heard of the coronavirus, and with your age and medical conditions you would be classified as a ‘high-risk’ individual, so try to limit your travel, keep washing your hands, and avoid touching your face” at the end of patient’s visits. By the fifth week, patient’s with non-emergent appointments (i.e. annual visits, follow-up for hypertension or diabetes) were being called to reschedule for later in the summer. The sixth and final week at the clinic we were down to only seeing same-day patients, functioning like an urgent care. My preceptor was gowned in full PPE and the patients that came in with a chief complaint of “cough” or “fever” were instructed to wait in their car until their visit time, come in through the back door bypassing the waiting room, and were given a surgical mask.

When it was time for our second EOR days on campus, coronavirus had been renamed COVID-19, declared a global pandemic, and minor steps were being taken to prevent and slow the spread. We were unable to take our exam and meet as a whole cohort due to the limit on large public gatherings. We were told that rotation #3 has been cancelled because of hospital systems not allowing students; due to PPE shortages and to cut down on our COVID exposure. We finished our examination and returned home to have the longest (unexpected) break yet in PA school. Now, stay-at-home orders have been placed to “flatten the curve,” schools have been closed for the rest of the semester, and hospitals and clinics have been reduced to caring for COVID+ patients only; no visitors, no elective surgeries, no in-person office visits.

Q: How is this impacting your studies? How will you make up this lost time? Will this impact your graduation? Are you going to be missing out on any clinical experience?

Per ARC-PA (the PA program accrediting body), we are to make-up the lost hours/rotation. After sending the notice that rotation 3 was cancelled, faculty also told us that the plan is to add an additional rotation 9 to the end of our clinical year in December/January. We are hoping hospital systems will begin to allow students back into their institutions and we can continue with rotations 4-8 as planned, plus the additional make-up rotation 9. If everything goes as planned, we will still be able to graduate in December of 2020 and sit for national certification boards in mid-late January. Faculty has been looking into different options to add to our clinical learning in the meantime via online learning modules and virtual OSCEs (objective structured clinical examinations). This is intended to keep our history and physical examination skills strong and for us to work through our assessment and plan of a patient’s work up. Despite the cancelled rotation and this unexpected break, in the end, we will complete all seven of our core rotations plus our elective rotation as previously scheduled, just on a modified timeline.

Q: What are you doing over this time? Are any classmates volunteering?
While we do not have any concrete assignments due over this break time, we are all working and continuing to learn. As a part of our clinical year education, we are to complete a research project that encompasses a paper and poster presentation. Usually, these projects are completed throughout the year with final drafts due in November. Many of my classmates, including myself, are taking advantage of this time to complete our research projects early. We are also using this time to brush up on our clinical medicine knowledge using the topic lists and blueprints created by PAEA, the makers of the EOR examinations. Many of my classmates that are not from the Springfield area traveled back home to spend time with their families. A few of my classmates have reached out to local organizations looking for volunteers to assist the frontline workers with the pandemic. Faculty is keeping us well-informed during this time as well. They are working around the clock to help my cohort and the didactic class through this unprecedented time of virtual learning. Our class has weekly Zoom meetings to stay updated and all faculty is always accessible via email.

Q: How is the pandemic impacting your class? What are general issues they are facing?
While we are all very excited for clinical year to continue our education in the “real world,” we have been nonstop learning and studying for the past year. I know myself, along with my classmates, have welcomed this unexpected break to slow things down and refresh. A handful of my classmates have children and families that they are able to finally spend quality time with while in quarantine. It is definitely disheartening to have things paused, but we know that this is happening not only to us, but to students and programs across the nation and worldwide. Faculty has been nothing but supportive and transparent with us. I have learned to adjust my expectations and be flexible. We are all at a standstill and are at the mercy of the hospital systems to “allow” students back into their facilities to start to learn again. We are all staying positive throughout this time and are hoping we can restart as soon as safely possible.

Q: Has this reshaped your view on patient care or the PA profession?
Since COVID-19 has been labeled a global pandemic and is on the forefront of everyone’s minds, it has made the nation realize the importance of the healthcare and the people that work within it. My classmates and I all worked in healthcare before PA school, were immersed in it while on rotations, and will rejoin it as providers after school. We are all aware of the amazing, hardworking, devoted people that work behind the scenes. It is great to see this highlighted in the news and on social media amidst the sadness that this virus has caused. These workers are upholding the Hippocratic oath that we all took during our White Coat Ceremony. They are risking their own lives to save others. Even a few MSU PA graduates have signed up to work short term contracts in high-volume areas like NYC. I am proud to (in the future) be a part of the brave individuals that have been working on the front lines to fight COVID and save people’s lives.

Derrick Rocker, DC, is a recent graduate of the MSU PA program. On Friday, December 13, he received his master’s degree with the Class of 2019. Classmates describe him as “humble, intelligent, and kind with a contagious smile.” Preceptors shared, “Derrick was an excellent assistant in both clinic and in the operating room. Prompt and professional.” With a doctor of chiropractic and a master of science in physician assistant studies, we’re excited to see what’s next for Dr. Rocker; soon to be PA-C.

Hometown

Franklin, Nebraska

Colleges attended and degrees earned

Missouri State University- Master of Science in Physician Assistant Studies

Cleveland University- Kansas City- Doctor of Chiropractic

University of Nebraska-Lincoln- Bachelor of Science in Animal Science

Previous health care experience

I worked as a chiropractor at a small medical clinic in rural Nebraska. I had a very unique opportunity for a chiropractor as I worked at the same clinic as our medical doctor, nurse practitioners and physician assistant and often collaborated with them to care for patients.

Interesting fact about yourself

I did a lot of traveling during my clinical year! While most students do the majority of their clinical rotations in Springfield and the surrounding area, I chose to do my rotations at distant clinical sites in Nebraska, Missouri and Oklahoma. I loved traveling around and spending time in places that I probably would not have visited otherwise.

Why did you decide to become a PA?

While I was working at the medical clinic with doctors, nurse practitioners, and a physician assistant, I got to see the wide variety of conditions that they were treating and overtime I decided that I would like to do that as well. I chose physician assistant over other routes for medical training as I liked that you get a wide base of medical knowledge in PA school and are then able to work in such a wide variety of specialties.

Describe your experience in the program.

My experience in the program was great! I liked the small class size which allowed for plenty of hands-on time in the lab. We also had many doctors and physician assistants come to class to teach us about certain topics which gave us many opportunities to learn from people practicing in the field. I enjoyed my clinical rotations and feel like I had great opportunities to learn from knowledgeable providers. As someone who moved a long way from home to go to PA school at Missouri State, I can say that it was totally worth it and I would do it again in a heartbeat!

What do you like best about Missouri State’s PA program?

The faculty, staff and my classmates! The faculty and staff were very nice and more than willing to help if you needed it! PA school can be pretty stressful at times, but my classmates always helped each other get through the rough patches and we managed to have a lot of fun along the way!

What is the best piece of advice you’ve received so far?

Keep an open mind! I think most students going into PA school have some idea of a specialty or type of job that they would like to purse, but I think it’s important to keep your options open. As you go through the program you are exposed to so many different possibilities that you may not have considered before. Throughout the program I constantly changed my mind about what I wanted to do after graduation, you might be surprised about what specialty you end up enjoying!

What specialty do you want to pursue? Why?

I did my elective rotation in Neurosurgery and really enjoyed it! I like that I get to care for patients in a variety of settings including the clinic, hospital and OR.

The MSU Physician Assistant Studies Department is pleased to announce that Dr. Roberto Canales has been selected as program director and department head. Dr. Canales will begin his term February 1, 2020.

Dr. Steven Dodge, current program director and department head, announced his upcoming retirement earlier this fall after fifteen years of service to the MSU PA Program. “I have elected to step down from leadership roles in our department and to retire from full-time teaching due to age-related health factors. I have full and absolute confidence that under Dr. Canales’ dynamic leadership the MSU PA program will enjoy a new burst of growth along the path to excellence” said Dr. Dodge.

Dr. Canales shared, “I am both honored to serve and thrilled at the opportunity. The MSU PA program has an excellent team of faculty and staff, as well as clinical training sites in the community. Together, we will continue to graduate competent and capable physician assistants ready to deliver quality health care to diverse populations.”

Dr. Canales is currently serving as the associate program director and admissions director in the MSU physician assistant studies department. Joining the department in 2002, Dr. Canales has taken on many roles including interim academic coordinator, admissions coordinator, interim program coordinator and most recently associate dean of faculty for the McQueary College of Health and Human Services. He also serves as chair of the family medicine and internal medicine Physician Assistant Education Association Exam Development Board.

Prior to his time at Missouri State University, Dr. Canales served as a faculty member at the University of Texas Medical Branch School of Allied Health Science Physician Assistant Studies program (1994-2002). He is also veteran of the US Army Reserves.

Dr. Canales holds a BS in Physician Assistant Studies and MS in Health Education and Promotion from the University of Texas Medical Branch as well as a Doctorate of Health Sciences from Nova Southeastern University.