I Still Have a Dream

dream is about a new type of out of pre-hospital healthcare provider
who cares for the sick and injured at home, work, or public location.
The Paramedic Physicians Assistant, or PPA for short, could
redistribute valuable healthcare resources. They could help reduce ER
diversions, long delays in treatment, while cutting costs. They would
be educated to render comprehensive care to the pre-hospital patient.

a person would first be an experienced Paramedic that then completes PA
School, with an emphasis on Emergency Medicine. Then they would
complete a 1-year ER internship at a major medical center. I remember
two such programs that once and may still exist for PA’s, one in
Southern California and one in Minneapolis. They work the PA’s hard for
a year doing casting, suturing, learning advanced diagnostic techniques
and all treatment therapies specific to the Emergency Department. I
heard about one such program where the PA’s did virtually everything in
the ER, with a Coordinating Physician directing several PA’s at once. I
envision this ultimately as a single, integrated baccalaureate degree
program. In the UK this type of program is now being considered, but perhaps with a less well rounded educational foundation.

take these PPA’s, and put them on a whole new type of response vehicle.
It would have about 30 unit dose medications in a mini-dispenser, a
built in mobile X-Ray, Casting and Suturing stations and materials.
Tabletop ABG and basic mobile Laboratory would complete the package. Of
course they would have state-of-the-art emergency equipment, complete
with 12 lead ECG, CPAP, and Automatic Ventilator. This is not future
think. This level of technology has been available for many years. How
would this new type of professional work in the field?

take an example; Sally called Friday night with shortness of breath.
She has decent blood gases and Pulse Ox, with a low-grade fever and
pneumonia confirmed by X-Ray. She has a good family support system and
can follow directions well. So you bang her with a gram of Rocephin,
give her a 3-day supply of oral antibiotics, and put her back in her
house. Give her a referral card, if she does not already have a family
doctor. Done.

if her oxygen saturations are low and she will need oxygen, or if she
does not have family to watch her, or if you are uncertain about how
well she will follow your directions, she would need to be admitted.
You call up her doctor and report the situation. He agrees she needs a
hospital bed. So you ring up the receiving hospitals Nursing Supervisor
and get a bed assigned. You finish working the case up, complete with
the Floor Nursing Orders done, and roll her in the hospital door and
straight up to her room for the night. Only if she is real sick and/or
does not have a doctor will she need to see the Emergency Room
Physician. Isn’t that what they are for anyway?

end results are the patient gets the care they need, and they don’t
wait for hours. They save a small fortune off their bill. Everybody
should be happy right? Emergency Room diversions are dramatically
reduced because they see fewer non-critical cases. Insurance Companies,
PPO’s and HMO’s cut about a third off their total emergent care costs.
We all get better insurance at lower prices. We get these savings while
creating a new valuable type of healthcare professional that starts
around 75-90K per year, and is well worth it. Livable pay results in
longer careers, with more experienced people now the norm rather than
the exception. The EMS System starts working again. Clearly it is not
working well now, yet we keep doing what we have been doing, because that is
the way we have always done it. It is time for a change.

that is what I said over 15 years ago, when I first proposed this
concept. Instead of designing an education around the real needs of the
pre-hospital healthcare patient, we designed it around the needs of the
sponsoring government entity, volunteer community, or ambulance business operator. Somewhere
along the way we forgot about the patient. I thought this rather simple
and obvious solution would by now have been adopted in some form. But
we have resisted positive change. In fact if any real change has
occurred, it has not been to the improvement of patient care,
healthcare costs, or our communities needs. 

public waits longer and longer, for higher and higher cost care, which
is not getting any better. Think about it, the Paramedic Physicians
Assistant could be an answer to our worsening emergency care crisis. It
would also be a great job, and provide a hopeful future for today’s


About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I have written a lot about EMS Technology on the Paramedic Blog, the Insights on Innovation column for EMS1.com, on AmbulanceWorld.com and Multibriefs.com. I can be reached directly at 573-240-0002.
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One Response to I Still Have a Dream

  1. Robert says:

    Did you happen to reaqd the original proposal at emsscopeofpractice.org? The web page is no longer there, but ORIGINALLY, it had a proposal for an Advanced Practice Paramedic that did alot of what you are proposing. Of course, the last rewrite didn\’t mention this. I wonder if it was lobbied against or if someone just didn\’t think a Paramedic is capable?

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