EMSPA Guidelines

Guidelines for the Emergency Medical
Services Physician Assistant

For more than 50 years, physician assistants (PAs) have been an integral partof the physician-led health care team. They have shown success in patient care, safety and access across many fields of medicine. From handling large panels of primary care patients to complex sub-specialty care in medicine, PAs have proven their ability to successfully adapt to these roles. Since the late 1960s, Emergency Medical Services (EMS) pre-hospital medicine has been an emerging field and PAs have quickly adapted into the EMS environment. In many states, PAs have been serving in roles such as assistant medical directors, advanced field care providers, and mobile integrated healthcare providers for many years, if not decades. However, until now, the role of the Emergency Medical Services Physician Assistant (EMSPA) has not been clearly defined. Like many fields of medicine, there are opportunities that an EMSPA can be utilized to add value to an EMS system enhancing patient outcomes.

This document is to help define how an EMSPA could be utilized and is not intended to be a rubric of how an EMSPA should be utilized. These are some of the larger areas that EMSPAs have shown to be successful and the paths they have taken to get there. This document does address the level of education and recommended training of those PAs interested in this growing field of pre-hospital medicine.

EMS Field Response Alternative Dispositions

The EMSPA is well equipped to diagnose and treat many illnesses and injuries on the scene avoiding clinic or emergency department visits. This is one area that a PA can add value to the entirety of the health care system. As we are all aware, the emergency department (ED) is the safety net of America's health care system today. Many of those seeking care in the ED could be served by a primary care provider or urgent care. EMSPAs in the field, responding in real time to 911 calls, can help mitigate some of this burden by treating at the scene or referring to the appropriate clinic. EMSPAs are able to obtain history and physical exam, diagnose, and treat patients at the site of their emergency, freeing up both an emergency ambulance and the emergency department.

EMS Field Advanced Practice

In today’s 911 system EMS request for high acuity, critical care patients are a small subset of calls. Paramedics have thorough training in recognizing these critically ill patients and providing protocol-driven advanced cardiac life support, airway management, CPR and fluid resuscitation.  Some systems will even administer blood products to those suffering from a life-threatening hemorrhage.

While paramedics are well trained and proficient at algorithmic resuscitation, their scope of practice can limit various field interventions that have proven life altering. Having PAs with emergency and critical care experience to help tailor resuscitative efforts to the underlying cause of a hemodynamic collapse or perform life-saving procedures, have a profound opportunity to reduce morbidity, mortality and potentially hospital stays. Further, it allows the PA and paramedic to work side by side, discussing cases and opening a door for bedside education.

EMS Field Response Interfacility Transfers

Hospitals often need to transfer patients from one facility to another. Many of these are routine and require little more than basic monitoring. Some of these transfers, however, are for higher levels of care and require specialized equipment, training and expertise. Patients can be on multiple mechanical devices, supportive drips, and/or a ventilator. Talented paramedics and nurses usually work on protocols, some with great skill and flexibility. EMSPAs are not bound to protocol and can augment the care between facilities by bringing a higher scope of practice and understanding of pathophysiology of the presenting conditions. The ability to troubleshoot a ventilator and titrate drips along with maintaining other hemodynamic modalities is an is an ideal opportunity for incorporating the experience, education and training of an EMSPA.

EMS Field Response Mobile Integrated Healthcare

Mobile Integrate Health Care (MIH) is a name for services that has been growing in popularity lately and is defined as an interdisciplinary approach to mitigating the social and health care needs of a vulnerable population, usually in the streets or person's residence. Many of the patients or clients of these teams have a multitude of social, psychological, economic and medical needs. Having a EMSPA as a member of the out-of-hospital team or leader of this team can help bridge the gap of these needs. The training of an EMSPA will ideally address the psychological and medical needs, and provide a comprehensive assessment and plan while working with social services partners to best serve an individual. It should be noted that MIH teams must address the needs of the demographic they serve, meaning that not all MIH teams will be made up of the same individuals nor have the same mission. Any MIH team – regardless of their mission – would benefit from the services and experience of an EMSPA.

Assistant Medical Director

The EMSPA has unique training and experience which can lead to a beneficial administrative partnership with the physician-lead Office of the Medical Director (OMD) team. EMSPAs are trained in the medical model, and many have vast EMS experience creating a bridge between the field crews and the medical community. The opportunities for support and expansion of current programs are limitless. Some of the common utilization is in daily task management, field education, ongoing training, periodic performance reviews, quality assurance, chart review and protocol research and development. In conjunction with other training entities, the EMSPA can provide observation and testing, create and manage performance improvement plans, and oversee progression of EMS staff. As part of the team, the EMSPA is uniquely suited to foster cooperation with other agencies including bordering fire and EMS partners, human services, and other public safety entities such as police, sheriff or public transport authorities. An EMSPA also has the knowledge base to act as a liaison between EMS partners and hospital partners to facilitate cooperative task forces focused on improving patient outcomes. The EMSPA can provide departmental representation on local and state EMS committees focused on improving the wider scope of EMS care. By having an EMSPA partner physician OMDs can focus their time on initiatives that align with their interests while their PA partner can take on those tasks that interest them, allowing the program to diversify and best meet the needs of their constituency. The EMSPA’s certification level also allows for a potential direct or indirect online medical control in conjunction with physician-directed care. In addition to assisting with traditional medical director duties, the EMSPA and physician medical director can collaborate to develop programs uniquely suited to their communities and departments. Flexibility and innovation can be maximized to suit the individual EMS system.

Areas of EMSPA utility at the direction of physician directors include but are not limited to:

1. EMS operations
2. Coordination between interagency medical directors and hospitals
3. Peer review committees
4. Quality assurance and process improvement, chart review
5. Review and development of patient treatment protocols
6. Medical priority dispatch system policies and procedures
7. Clinical education
   1. Initial paramedic education
   2. Continuing education
   3. Bedside teaching
8. Consultation - provide online medical direction for field crews
9. Required equipment and pharmacology par list and acquisition

Supervisory/Collaborative Agreement

1. Specific to Physician Medical Director, Hospital and EMS system as developed by the physician and EMSPA in accordance with state statute and licensing
2. Advanced field treatment modalities at the discretion of the supervising/collaborating physician medical directors
3. Oversight for administrative and Field Operations as outlined by the physician and the EMS system
4. Documentation as required by state licensing agreement and group/facility requirement

Emergency Medical Services Core Privileges

Core privileges for EMSPAs are based on emergency medicine core privileges and include the capability to assess, evaluate, diagnose, promote health, stabilize, manage and treat acute and chronically ill and injured patients of all ages who summon EMS or are defined as a patient by the EMS protocols, with any symptom, illness, injury or condition. The core privileges include those procedures, diagnostics and other such procedures that are extensions of the same as noted above. There are circumstances and situations in medicine that will not be defined clearly above. In that situation the EMSPA is authorized to stabilize and treat the patient in any way possible to preserve life and limb as outlined by the medical director. 

Recommended Training/Qualifications/Competencies

1. NCCPA Certified PA
2. Valid Medical License in State(s) of Practice
3. Current Certifications
   1. BLS
   2. ACLS
   3. PALS
   4. ATLS
4. One of the following as minimum requirement:
   1. EMSPA Fellowship OR
   2. EMPA Fellowship plus scene response safety training OR
   3. Minimum of two years of full-time experience in the main ED AND minimum of two years of full time ALS experience in the prehospital setting

5. National Association of EMS Physicians (NAEMSP) Medical Directors Course OR other equivalent training (local/state course)

Other potentially helpful recommendations include:

1. Emergency Neurological Life Support (ENLS)
2. Wilderness Medicine
3. Tactical Emergency Casualty Care (TECC)
4. Field use of point of care ultrasound (POCUS)
5. Critical Care Course
6. NCCPA EM CAQ
7. Comprehensive Advanced Life Support (CALS)
8. Difficult Airway Course
9. Procedures Course

Appendix I

Recommended Procedural Competencies

Competency as defined by system medical director

1. Advanced airway maneuvers
2. Vascular Access
3. Thoracostomy
4. Pericardiocentesis
5. Point of care ultrasound
6. Fracture and dislocation reduction
7. Simple and complex wound repair
8. Basic Lab acquisition and interpretation
9. ECG interpretation
10. Regional Nerve Blocks
11. Any procedure, at the discretion of the medical director, that is within the training, education and scope of the physician medical director.

Appendix II

Recommended Treatable Conditions

Medical Conditions to Treat and Release including, but not limited to:

1. Upper Respiratory Tract Infections
2. Pharyngitis
3. Headache
4. Urinary Tract Infections
5. STIs
6. Medication Refills
7. Epistaxis
8. Influenza
9. Bell's Palsy
10. Cellulitis
11. Mild Asthma/COPD exacerbations
12. Catheter dislodgement/Removal/Replacement
13. Allergic Reactions
14. Hypertension
15. Non-infectious Rash/Skin conditions
16. Dental pain
17. Dehydration
18. Stable lower respiratory tract infection

Trauma/Surgical Conditions to Treat and Release including, but not limited to:

1. Abscess
2. Laceration/wound repair
3. Nail Trephination
4. Ingrown Nail Treatment/Removal
5. Muscle strain/spasms
6. Sprains
7. Joint and Fracture Reductions
8. Simple fracture care and splinting
9. Foreign body removal
10. Insect bites/stings
11. Non traumatic back pain

References

American College of Emergency Physicians Policy Statement, 2020:  Guidelines Regarding the Role of Physician Assistants and Nurse Practitioners in the Emergency Department

Advanced Practice Providers in the Field: Implementation of the Los Angeles Fire Department Advanced Provider Response Unit

Stephen Sanko, MD, Saman Kashani , MD, MSc, Terrance Ito, RN, DNP, Aaron Guggenheim, MPH, Shangnon Fei, BS & Marc Eckstein, MD, MPH

Pages 693-703 | Received 27 Mar 2019, Accepted 04 Sep 2019, Accepted author version posted online: 17 Oct 2019, Published online: 11 Dec 2019

Journal of the American Academy of Physician Assistants: April 2017:  Using PAs in prehospital environments to reduce ED and EMS overuse

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Jun 2016: Solo emergency care by a physician assistant versus an ambulance nurse: a cross-sectional document study

EMS WORLD, November 2020:  The Benefits of an EMS PA Program

Annals of Emergency Medicine, Oct 2011: Physician Assistants' Productivity in a High-Acuity Emergency Department

Western Journal of Emergency Medicine, Jan 2021: Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency

The Journal of Physician Assistant Education: Volume 15 - Issue 2 - p 88-90:  Initial Practice Patterns of Physician Assistants With Emergency Medical Services Experience

Prehospital Emergency Care, Oct 2020:  Code of Ethics for EMS Physician Medical Directors

Annals of Emergency Medicine  February 2013, Pages 175-184:  EMS Triage and Transport of Intoxicated Individuals to a Detoxification Facility Instead of an Emergency Department

NAEMSP Blog, Feb 2020:  EMS Physician Assistants: Are They The Next Paramedic Practitioner?

Missouri State University Physician Assistant Studies Blog:  EMS Physician Assistants: An Opportunity for Expanded Pre-hospital Healthcare