Sitting down at your station one night finishing paperwork, you’re startled from your daydreaming by a knock at the door. You get up, and answer it to find one of the off-duty firemen from the town standing there at the door. He looks like heck warmed-over. He’s pale, sweaty, and his respiratory rate is elevated. He says He’s “Glad it’s you on tonight” and that he feels worse than he looks. He asks if you can “Check him out” since you’re “all medical and stuff”.
Treating this like a walk-in medical call, you help the guy walk into the back of the ambulance and have him sit on the bench seat. Your fire and EMS departments aren’t connected so you’re not really on a first name basis with the guy, but you know him from sight and know him from seeing him around the town on calls and social things and such. He just looks sick, he says that he’s having a bit of trouble breathing and that he feels like he’s freezing one minute and hot the next. He also says that he’s been coughing up “all kinds of stuff” for the last few days.
Putting on your best caring EMS provider face, you begin your assessment. He’s a 26yo Male patient in generally good health and with good appearance other than for right now. His skin is very warm and moist to the touch and he seems to have a fever. His pulse is rapid and bounding at around 120bpm, but that decreases after a few minutes of rest as does his respirations. He states that for the last few days he’s been sick. It started with a sore throat and some sinus gook and now has “gotten into his chest”. You listen to his lungs and hear some diminished sounds in the bases bilaterally with diffuse rhonchi throughout. His abdomen is soft and non-tender but says that he’s had some mild bouts of diarrhea. He complains of exertional dyspnea and his BP is way high at 184/98. His temperature is 101.4 degrees F taken at the tympanic membrane.
So based upon the assessment, you’re thinking that he’s got a respiratory infection, probably bronchitis. Just because you can, you run a 12-lead EKG which is otherwise normal other than for the sinus tachycardia. His pulse ox is 94% on room air. He says that he doesn’t have insurance and that he can’t afford the emergency room, but that he’s willing to pay for a visit to the urgent care doctor if you think he should go in.
Now, faced with the above, as I have been a few times in my career, you have a few options here. You could do what we’re supposed to do by the book and recommend transport to the ER even though you know the guy’s condition probably isn’t life threatening right now. You could also tell him that you think that he may have a respiratory infection and that while he should see the doctor as soon as he can, that he probably doesn’t need the emergency room.
Usually, I choose to tell my buddies that they should consult their regular doctors or go to an urgent care clinic instead of going to the ER. Sure, in cases where I thought they had a life threat or needed immediate care above the level of the local Urgent Care, I’ve transported my friends a few times. However, most of the time I give them my assessment findings written down on a piece of paper, hand them a copy of their EKG if I took one, and send them on their way to the non-ER doctor.
The last time I did this, it hit me: I’m conducting a physical when I do this. Sure, in the above case and in the cases where I’ve done this before it is a complaint-based assessment, but a patient examination is a physical exam. When I write my assessment findings on a sheet to give to the doctor, I’m writing them on a physical examination form. While my assessment isn’t as in depth as that of a physician, it certainly is better than not being examined, and a paramedic has specific training in detecting disease processes that may go undetected by a patient and their families.
(Note: In all of the cases where I did not transport the patient to the hospital, I did obtain a proper refusal form after educating the patient about their condition as best I could. They made the decision, not me.)
If you type “Annual Physical Exam” into Google, you’ll see quite a few articles about the topic, including a study published in the Archives of Internal Medicine and this article published in US News and World Report basically, they say that Preventative Health Exams account for approximately 8.0% of all ambulatory care visits costing approximately $7.8 billion in health care costs. They also say that the cost of providing these services may outweigh the benefits of receiving them. In 2005, a survey of 800 Primary Care Physicians reported that 65% of them recommended an annual physical, that 74% felt that it improved early detection of illness, and that 94% felt that it improved patient-physician relationships, there is currently “No major North-American clinical medical association” that “currently recommends that health adults get a physical each year.”
So there’s a debate being held in healthcare circles. On one hand, patients probably perceive a benefit to the annual physical exam, and certainly the people who have disease processes detected and stopped with early intervention see a very tangible benefit. There are also a majority of physicians that when questioned individually state that they see a benefit to the exam. However, there is also the fact that the costs probably outweigh the benefit of the exam, even though “preventative care” is batted about in the current healthcare debate quite a bit and most organizations and physicians recommend health screenings for specific disease processes that benefit most from early detection.
My opinion is that when the cost outweighs a benefit, there is the choice to either forgo the benefit or find a way to decrease the cost. I am suggesting that we can decrease the cost to the overall healthcare system as well as increase the availability of preventive care by introducing paramedics into the debate. I believe that paramedics could provide a more than adequate annual physical examination in most cases for a large subset of the population. In fact, most of us probably already do without thinking about it. The articles state that 80% of preventive health care is provided within the context of complaint-based ambulatory care visits. I would say that paramedics in ambulances provide this care to the rest of the population. I’d also say that we provide a lot more patient education on chronic health issues to a larger segment of the underserved population than any other healthcare provider. Think about it, how many times have you personally attended to a patient who called you for a complaint such as a “fall” and upon assessment found evidence of an undiagnosed chronic condition? I have, and I like to think that with a thorough assessment on every patient, I can improve their overall health more so than just helping them with their current complaint.
To implement this plan, I would think that functionally, paramedic training already gives us a strong background to provide a detailed physical exam. We would, however, have to undergo more intensive training in examination skills and pathophysiology to be able to detect subtle underlying signs and symptoms of disease processes, mental health and substance abuse issues, and sexual health problems. I would envision that there would be a detailed and formalized set of procedures, tests, and paperwork that would be completed in full that should be pre-agreed upon with the Primary Care Physicians in an ambulance service’s wider sphere of influence. Tests such as a random fingerstick glucose, a monitor strip, and a baseline 12-lead EKG could be obtained as well as a review of the patient’s social and other risk-factors. These findings would then be forwarded to the patient’s personal physician, or could be given to the patient to bring to a physician of their choosing.
This is an easily implemented service that we could be providing our communities with tomorrow with the right planning. The chance to improve the overall health of our patients exists coupled with a chance to decrease overall healthcare costs. It’s also another potential revenue source for ambulance services, which is sorely needed in order to implement EMS 2.0 and improve the EMS profession for tomorrow. Imagine the revenue boost to your service’s and your bottom line if every crew started performing ten physicals a day for $50 a pop. It’s a bargain for the patient, but would be a boon for us.
Paramedics are underutilized for our skill sets and education, this is a way that we can further contribute to the health of our communities while improving our profession overall.
US News and World Report “Do You Actually Need a Physical Exam” – http://health.usnews.com/articles/health/2007/09/24/do-you-actually-need-a-physical-exam.html
Archives of Internal Medicine “Preventive Health Examinations and Preventive Gynecological Examinations in the United States” – http://archinte.ama-assn.org/cgi/content/abstract/167/17/1876