Primary Care Paramedics? I think it’s time

Clinically speaking, there’s a whole lot of medicine out there that I don’t know.

I mean, paramedics like me go though a few thousand hours of training in emergency medical care. We get a few years of classes covering the things we need to know about treating the most common of truly emergent medical conditions. Heart attacks? Check. Strokes? Check. Airway Management and Respiratory Support? Check and Check. We paramedics are experts in the acute medical emergency. If you’re dying, we are well equipped and trained to support you until a doctor and a team of medical people in a hospital can take over your care. If you have a medical emergency somewhere outside of a hospital emergency room, we’re the first people you want to see.

The Medic is In

But, what if you have a particularly nasty case of Strep Throat?

Well… that’s called “Primary Care” and it covers a lot of non-emergent medical conditions. Strep throat hurts and it makes a person feel like crap. The times that I’ve chanced to become infected with a nasty strain of Strep “A” it’s made me feel like a warmed-over Code Brown Sandwich. It sucks being sick and that’s why people go to the doctor. Patients present to doctors’ offices for myriad reasons. Pink Eye, Influenza, the “creeping crud”, bronchitis, and gastrointestinal problems are common occurrences there. When I worked at an urgent care clinic we saw plenty of those. Up to two-hundred patients per day came in with just these kinds of complaints. There were lacerations, fractures, and other kinds of cases that came in too. Rarely did we need to call for an ambulance and while we did sometimes advise people to go to the ER on their own, that was rare as well. A good primary care doctor can catch most minor conditions and adequately treat them right there in the clinic, negating any need for an expensive emergency room.

However, the problem lies in actually getting access to a primary care physician to take care of you when you’re sick.

Yesterday, my mother-in-law (I call her “MIL” for short) called me up. One of the people she works with had an injury to his fingernail. He tore a good part of it clean off while working out in their warehouse. It hurt, of course, and it was bleeding. Their company is a small five person shop that they’re building from the ground up. A Workers’ comp claim would go right against their small and shared pocketbook and start-ups don’t have the cash for that kind of stuff. She wanted to know the proper first-aid for this and was trying to avoid the doctor. He was too. As owner of the company he didn’t want to have to pay for it and a fingernail injury just doesn’t seem all that severe. Still, it hurt and they were worried about infection. The guy understandably wanted proper treatment.

I told him that fingernails either grow back, or they don’t. Eventually it would be fine if he cleaned it with mild soap and water and put a non-adhering bandage over the nail bed to keep it clean and protected. I told him in a day or so to put some Vaseline-based antibiotic cream on it as well to keep it moist and stave off infection.

Don’t worry, I wasn’t practicing medicine without a license. I have my First-Aid Merit Badge from the Boy Scouts of America and that was covered somewhere in there, I’m sure. However, you’re right to think that fingernail injuries aren’t covered anywhere in the National Standard EMT or Paramedic curriculum. We are taught to bandage it up and take it to an Emergency Room.

Yep, if he would have presented to my care on the ambulance, I would have had to transport the guy to the ER for a physician to do what I told him to do. If he refused the $500 (or so) transport fee and the (astronomical) ER fee, I would have had to have him sign an “Against Medical Advice” (AMA) refusal form and could not legally give him any medical advice other than to be transported to the ER.

It’s maddening.

Fingernail guy didn’t have an option for treatment where he was other than to go to the ER. In the area where he was located, there aren’t any Urgent Care facilities. There certainly aren’t any cheap ones anywhere you go, but their cost is much lower than the local ER he was near. He didn’t have an option, so he had his coworker call her son-in-law (SIL) for advice. I gave it, and saved everyone involved a few hundred if not a thousand dollars. Sure, the guy could have called his primary care physician and gotten an appointment a month later… but I would think that as a self-employed small-business owner he probably doesn’t have access to health insurance at a less-than-oppressive cost.

A while back, I wrote the piece “Did I do Good?” regarding what I think EMS 2.0 should become. I think that Paramedics should be educated and empowered to step into the realm of primary care and be able to provide primary care in the field. Now to be sure, as Rogue Medic will point out, there’s evidence that states that Paramedics and EMTs are bad at triage and we are not currently equipped with the right education to provide these services at this time. However, I think that educating a group of excellent paramedics to the proper standards, giving them the proper tools, and empowering them with the proper legal authority could revolutionize healthcare.

Every community has a group of paramedics and/or EMTs and nearly every community (I would say every, but I have no stats in front of me) has less-than-optimal access to primary care across the spectrum of patient populations. To me, there is a clear solution that makes sense. Could Paramedics, once properly educated, equipped, and empowered, provide limited primary care services, appropriate triage, and transfer in the field? How about at fixed sites and clinics? We could follow protocols, utilize tele-medicine, and function much as we do now, but with a much lower-acuity class of patients.

Sure, there are Nurse Practitioners, Physicians’ Assistants, and other healthcare providers that can provide these services, but let them work with us as we work with them. There doesn’t have to be an adversarial relationship. We all have different training and that one set can be used to compliment the other. 

EMS 2.0 is about thinking outside the box for EMS. It’s about finding new ways to face the challenges. Thinking the way we have in the past won’t fix the problems that it failed to fix before. My belief is that with Paramedics providing Primary Care, we would greatly increase access to care, more properly triage patients to the proper healthcare pathways, save gobs and gobs of money, and just might “fix” this whole healthcare mess without all that legislation and legal wrangling.

Any suggestions on where we begin?

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  • Gulfmedic

    Remote paramedics offshore have been doing this for years….

  • rigmedic

    I am an offshore paramedic and we really are a primary care provider when we are out there. With a week of extensive training along with our paramedic training we are “better trained” than a majority of physicians in other countries as put by one of my instructors. Essentially we can do almost anything a family practice doctor can do minus x-rays. I completely agree with your post and think that this is a very obtainable outcome.

  • baheyman

    i recently had the oppertunity to have a medic from the Netherlands ride with me for a day at my suburban philadelphia service. in the netherlands, to become a medic, u first need to be a nurse, and then a critical care nurse, and then you can try to become a medic. the only other level is ambulance driver, which unlike in the USA is a respected position, where you assist the medic in getting set up for the trip and then drive. the medics there, this guy said, can determin whether or not someone needs transport…they can treat and release. if you have a cut, they can clean it, suture it, and send you on your way. if you have an asthma attack, they can treat you and let you go, telling you to call back if it happens again. not only does this cut out on the financial toll of the system, but it cuts out the frequant fliers that only want a ride to get off the street and get a meal. is also cuts out time in service, keeping units available for actual medical emergencies…when will we learn?

  • SpotsyMedic

    Bravo! We’re not that far off in many respects right here, in certain circumstances. For instance, I work with a very large entertainment company as a theme park medic. Our property alone sees 50,000+ visitors a day during our operating season. We were able to obtain an amended set of protocols that allow us to “treat and release” minor complaints. We currently offer extended paramedic training, such as Critical Care Paramedic… why not develop the same type of course for Primary Care? Introduce a whole new certification/licensure level; “Primary Care Paramedic.” We’re already 95% of the way there. All we need now are forward thinkers to develop the curriculum, and someone with the stones to allow us to pilot the project. Any input out there from MD’s?

  • in_the_city

    I agree with you in theory. But in practice this could never happen with out a complete overhaul of the current paramedic curriculum. A completely different mindset would have to be drilled into peoples heads from day one. Its a whole different ball game when you stop stabilizing for TRANSFER to definitive care and you ARE the definitive care.

    I’m not even going to mention the opposition this would get from nurses and doctors who would get all old school and feel that we were stealing their turf…. Or the insurance company’s that wouldn’t be able to bill because no one provided transport.

    Like I said: I’d love to be able to work like this, but with out complete change in the system we’ll never get there.

  • MNmedic

    I couldn’t agree with this discussion more. I have had this conversation with myself and my colleagues many times. I hope during my career there comes a day when the education requirements for all pre-hospital providers is substantially higher than it is today. In addition this I feel we need to create a step up from the paramedic level, i.e. an advanced practice paramedic. I would call them a “Paramedic Practitioner”. They should be on par with NP’s and PA’s in education.

    I think about rural ER’s that are filling their provider positions with PA’s who have a very broad education with minimal emergency training. Why not create an advance practice paramedic to fill these roles? They already come with a strong background in the worst of the worst. Now they just need training on the continued care of critical patients as well as assessment and treatment of non-acute patients. These same people would be ideal critical care transport medics and primary care paramedics.

    So where do we start? In my opinion, the one thing that holds back paramedics the most is the allowance, and actual promotion of, lower quality education. If we want the public to trust us with their primary care, we need to raise our standard level of education. The first step being to eliminate of the non-degree paramedic programs. The fact that somebody can be a paramedic on the street with a 14 week medic course, in the big picture, severely damages our image and standard of care. Yes, I realize that there are fantastic paramedics out there that graduated from these programs. These isolated paramedics however don’t change the fact that these programs are lowering the overall quality of care. We need every paramedic to have at least an associates degree with full courses in A&P, bio, chem and some generals in communication and composition. I simply will not trust a paramedic to diagnose my strep if he/she can’t compose a sentence. I feel that this needs to happen before we can even ask the public to trust us with their primary care.

  • Easyduzit25

    This is a Great Idea. yes, it would take a little more training and time. the biggest problem is like stated above the AMA (doctors) would throw a Hissy fit like they did when Pharmacists were required to earn a Doctorate in order to get a license, the idea of having Pharmacists be directly involved in patient care in this country has been thrown around since the 1970′s even though these guys are the people who do the most Continuing Ed on Drug interations and Drug therapy…. anyway the AMA has been fighting this for around 40 years now? and the Pharmacists curriculum has been modified to have more interaction with patients in a Physician type of environment if these guys cant be seen as partners with Doctors. I can see the AMA commiting Hari Kari if Paramedics are given license to practice primary care even in a limited aspect. Its all about protecting thier pocket books.

  • Guest

    I googled primary care paramedic and apparently in Canada this concept of a primary care paramedic is already up and running.

  • Guest 11

    It already has in MN and other areas, though limited, since it is in its infancy and is being called community health paramedics http://www.communityparamedic.org

  • lifeline-1

    the primary care medic program is already up and running in america! it has been for decades! the problem is that paramedics and doctors on this side of the wire dont want to acknowledge anything or give credit to anything the military does. military medics go through a course called LPC limited primary care during medic school at fort sam houston. you gert further education as you progress in rank or position. it doesnt take a lot just the desire and the willingness to to come to the military and say “how are yall doing that” it doesnt take a doctor to treat everything. like you said in the article, imagine how many frequent fliers you would keep out of the e.r.

  • Ckemtp

    I strongly support the Community Paramedic program. Gary Wingrove et al have done great things for EMS up there in MN and when I get my wrinkles ironed out, I plan to bring it to WI as well. You may want to also check out http://WECADEMS.com to see the Comm. Paramedic program that Chris Monterra et al have running.

  • newbie

    Change the mindset that we are there for true emergencies only. The reality is that due to an uneducated public in simple home remedies, knowledge of when something is truly severe, difficulty accessing “primary care” and a host of other reasons, we are the front line. Like it or not, we will get called for non emergencies and once we accept that it will be easier to see ourselves as being more than acute care specialists. The trouble is how do we get physicians and others to see how we can fill this gap and help educate us thereby changing and increasing our role in healthcare in general.
    I also believe the NREMT could advocate for raising the education requirements to include mandated college courses and include electives similar to those taken by other medical professionals.(I do not know if they do so now.)
    In the end the more we know the more we benefit the patient.

  • http://twitter.com/paramedic0750 stephan deguise

    amen !!! what else to say

  • Beenyman

    What if we approach this from a different angle, instead of trying to contort the current system in a way that could potentially break it….

    If we were suddenly known as “Primary-Care” providers, the amount of non-emergency calls we go out on would sharply (DRASTICALLY) increase. The current system would be overloaded, more and more equipment would have to hit the street and telemetry-physicians would never have a moment off from Telemetry to tend to a patient in their own facility.

    Nurses at all levels, ER staff, and clinic personnel (Urgent cares and all) would all be looking for work. Suddenly we would find ourselves with an enormous overabundance of Nurses and Techs and nowhere near enough physicians.

    So, what do you suppose is a better solution? Me, I think that it would be easier if, those who wanted to practice Primary Care, would go out and get licensed to do so instead of flipping the whole system (not just emergency-care….the whole medical system as we know it) on it’s ear.

    I see this as a “My two-years of school (in a limited niche of the medical field) should be just as good as your pre-med, gross anatomy and general practitioner training that may have taken 10+ years to complete.” You want to further your education? I would encourage it. It will help you as an EMT / Paramedic. As long as you practice within the scope of your position. It is, after all, the career in Emergency Pre-Hospital care you chose to pursue.

    Paramedics (and EMT’s) were “invented” to do a very specific job, one which you outlined well in your article. I happen to think (and I’ve worked in both Urban and Rural areas) we have a pretty darn good system. It was designed to handle Emergencies and it does a damn-fine job of it.

    If you want to practice Primary Care, get the type of certification that allows you to do it. From there, and under medical direction of course, you can create your own small business providing Primary Care to patients in the home “on-call.”

    This is a free-enterprise system, right? Why does it always have to be up to the government to change things and supply us with the means to do what we can do ourselves? Just because they have it in Switzerland or Canada or Timbuktu, doesn’t mean it will work (and be good for us) here in the U.S.

    Who, by the way , if not Workman’s comp insurance or the business itself, is expected to pay for your “Primary Care” services provided to your acquaintance with the torn-off fingernail? If I have this right, they were trying to avoid the EXPENSE, not the medical treatment he needed. To me, the subject in the article is not about “Primary Care Paramedics” it’s a medical and insurance expense problem….which starts us on a whole new conversation.

    I stand very much against the author’s idea, for many reasons (not just political, either) I don’t have time to list them all here.

  • Jon

    Oddly enough, this idea has been implemented in many, many areas around the country. I had a discussion a while back with my boss about the DC fire department. They have (as far as I am aware) medics, nurses and PAs that will ride together in a quick response unit to medical calls, and when not on a call will respond to non-emergent medical calls for the sick. I have heard nothing but greatness from everyone involved in programs like these, and as a Minnesotan I am always amazed with the state of the art healthcare we have, but still wondering why we don’t take a step back to conquer other issues before buying new fancy gadgets!

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  • Anthony R.

    I am a Medic in NC, and am a huge proponent for a Paramedic Practitioner or an Advanced Practice Paramedics if you will. The need is obviously out there, and EMS personnel nationwide are a huge untapped resource. Many of us are forced into nursing after a few years of practice even though most hate the prospect of becoming a nurse, because there is no room for clinical advancement in EMS. The problem is that we need an institution like Duke, or George Washington U. to develop a 4 year B.S. program. And for the PA’s and NP’s that argue you can’t practice medicine with a Bachelor’s degree, let me point out that Stanford still produces PA’s with only an associates. degree and a few science prereq’s! But because medicine is a buisness and EMS is famous for barely making a dime, this has as much a chance of happening as does the US Public Health Service taking over EMS service nation wide, or having true national standards of practice.

  • Anthony R.

    Reading through the comments I would like to add that in urban areas as well as in deeply rural communities EMS and the ED are being used for primary care already. I know that in my service easily 98% of my patients have no business going to an ED. And I am sure that a good number of services are similarly called on a daily basis for primary care complaints. Offshore, remote duty, and military medics are already providing primary care. This is all true.

    Our two biggest problems are simply education standards and the combined MD and RN community. Neither of which wanted PA’s, and likewise will commit martyrdom to stop the advancement of medics into primary care nationwide.

    Let me also remind everyone that we have a major primary care provider shortage in the US, because physicans can make much more in other specialties, and because while the AMA has been fighting other providers moving into the primary care realm, they have also been refusing to approve accreditation of any new medical schools. Meanwhile NP schools have been popping up like weeds to fill the gaps, and it has become more difficult to get into PA school than it is to get accepted to a traditional medical school.

    The arguement that insurance would have no one to bill is rediculous. We all want to get paid, and insurance companies would be our biggest ally in this because they could reimburse Medics at a slightly lower rate than PA’s.

    Finally, I am all about free enterprise, and as a very right leaning individual, I am against most forms of regulation, but MD’s, RN’s and yes even us medics are licensed by our respective states or commonwealths. It is the legislatures that determine what we can legally do. So lobbying the legislatures will be necessary to getting this done. It shouldn’t be hard. Like the insurance companies, legislatures are very interested in saving expenditures, especially MEDICAID costs.

    So, in addition to educating ourselves to a higher standard we need to educate the powers that be as to what services we are already being called upon to provide.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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    Patient Friendly Jokes
    Have you heard my construction joke? I'm still working on it.... (Credit to my youngest daughter for that one. My partners are absolutely sick of hearing that joke...) On another note, what a fantastic blog. If you are ever in SW Missouri, stop by and say hello. Thad Torix - EMS Instructor & Clinical Coordinator…
    2014-11-03 18:27:00
    mr618
    Welcome to the Club
    Well said, Chris. We can't save everybody, but the ones we don't save tend to stick around a lot longer than the ones we do save.
    2014-10-18 14:40:00
    Steel City Medic
    Welcome to the Club
    Particularly appropriate for me this week. Thanks.
    2014-09-23 21:46:00
    DiverMedic
    Welcome to the Club
    Very well done, Chris.
    2014-09-17 22:15:00

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