Issue Brief Physician Assistants in Emergency Medicine Since the earliest days of the physician assistant (PA) profession In 1999, the American College in the mid-1960s, PAs have practiced in the fi eld of emergency of Emergency Physicians (ACEP) medicine. Of the estimated 50,000 clinically practicing PAs, 10 surveyed PAs to identify their work percent (5,000) work in emergency medicine.2 environment, postgraduate needs, PAs practice medicine with the supervision of licensed and the procedures PAs perform. physicians. PAs serve in many aspects of emergency medicine, George Molzen, M.D., ACEP board including pre-hospital patient care, patient triage, fast track, liaison to the task force conducting trauma, and selective administrative functions. Their work the survey, concluded that PAs are is not limited to emergency departments. They also provide in emergency departments “side by emergency care for patients in various settings, such as critical side with the physicians, picking up care units, pre-hospital situations, and ground or air transport. the next patient.” The ACEP report showed that patients usually are Practice Credentials randomly assigned to PAs (see Chart PAs are trained in intensive medical education programs 1). A high percentage of PAs perform accredited by the Accreditation Review Commission on endotracheal intubation and fracture Education for the Physician Assistant. The average PA reduction (see Chart 2). A little more program curriculum is 26 months. The typical PA student than half (52 percent) of the patients is at least 28 years old, has a bachelor’s degree, and has four seen by the PA respondents are also years of health care experience prior to admission to a PA seen by a physician. The physician program. The programs are offered at medical schools, in the emergency department rarely colleges and universities, and teaching hospitals. There are or never sees 28 percent of the currently three postgraduate programs for physician assistants patients seen by the PAs. Of 700 PAs in emergency medicine. Postgraduate programs are not a surveyed, 351 responded.1 Further requirement for PA practice. fi ndings are detailed in the charts on After graduation, PAs are required to pass the national page 3. certifying examination before they can practice. Only graduates of accredited programs may take the exam, which is developed by the National Board of Medical Examiners and administered by the independent National Commission on Certifi cation of Physician Assistants. (Many states provide temporary approval until the new PA graduate takes the next available exam and receives his or her scores.) To maintain certifi cation — required by some states and many employers — PAs must complete 100 hours of continuing medical education every two years and take a recertifi cation examination every six years. Only those with current certifi cation can use the credentials “Physician Assistant-Certifi ed” or “PA-C.” PAs do not have specialty boards. PAs must apply for and receive state approval (licensure, certifi cation, or registration) before practicing. Forty-eight states plus the District of Columbia many diagnostic and therapeutic procedures permit delegated prescribing by PAs. Nearly all including, but not limited to, abscess incision include controlled substances as part of this authority. and drainage; administration of medications All PA educational programs have pharmacology and injections; Advanced Cardiac Life Support; courses. Nationally, 78 hours is the mean number Pediatric Advanced Life Support; analgesia and of required hours of formal classroom instruction in sedation; anoscopy; arterial puncture and blood gas pharmacology. Most of the instruction is comparable sampling; arthrocentesis; cast and splint application, or identical to that offered to medical students. removal, and management; central line placement; The PA Role dislocation reduction management; debridement of burns, abrasions, and abscesses; epistaxis As members of health care teams headed by management; extensor tendon repair; foreign body physicians, PAs provide medical and surgical services removal; ears, nose, rectum, soft tissue, throat, that would otherwise be provided by physicians. vaginal, and gastric lavage; Heimlich (small gauge) Each PA’s responsibilities depend on the type valve insertion; immobilization (spine, long bone, of practice, his or her experience, the working soft tissue) and transportation; endotracheal and relationship with the supervising physician, the nasal intubations; intraosseous needle placement; physician’s or institution’s decisions about what can simple, intermediate, and complex laceration repair; be delegated, and state law. Although by law PAs diagnostic lumbar puncture; nail trephination are dependent practitioners, typically they exercise and removal; nasogastric tube placement and considerable autonomy in clinical decision making. management; ordering and performing initial The relationship between the physician and PA is interpretations of simple plain x-ray fi lms with one of mutual trust and reliance. The physician second reading by supervising physician (or trusts the PA to provide physician-quality care to radiologist) for collaboration and correlation with patients seen by the team and to consult with the clinical fi ndings; ordering and interpreting EKGs physician on those cases that are outside the PA’s with immediate second reading by supervising expertise or scope of practice. The PA trusts the physician; paracentesis; regional block anesthesia physician to be available for supervision, to provide including double cuff method Bier block; rust learned advice, and to accept the care of patients ring removal using slit lamp; ocular tonometry; with serious or complex problems. thoracentesis; thoracostomy tube insertion; urethral The Society of Emergency Medicine Physician catheter placement and management; venous access Assistants (SEMPA) offers guidelines on the role and peripheral cut down; and wound care. 3 of PAs in emergency medicine. According to Hospital Issues SEMPA, PA practice commonly includes, but is not limited to, taking patient histories and performing The American Academy of Physician Assistants physical examinations; recording or dictating the (AAPA) recommends that when a PA and a information into the patient chart; performing physician begin practicing together, they discuss or assisting in the performance of laboratory and their professional relationship and how they will patient screening procedures; performing diagnostic function as a team. Both parties should understand and therapeutic studies; ordering and interpreting how they will work together. They should evaluate diagnostic laboratory tests and radiological their practice arrangement on an ongoing basis. studies; ordering medications and other therapies; In general, PA practice is not delineated by detailed instructing and counseling patients; referring treatment protocols. Emergency departments may patients to appropriate community resources; and be an exception to the rule, because physicians obtaining patient management consults. commonly use protocols and clinical guidelines in PAs working in emergency medicine perform emergency practice. When physicians use protocols or clinical guidelines, it is appropriate for PAs to use them, too. What is not appropriate is defi ning PA supervision. (Federally employed PAs need not be practice by the use of detailed protocols specifi cally licensed, but should meet the graduation and/or written for PAs. PA education, like physician national certifi cation requirements.) education, promotes the development of practical PAs should be members of the medical staff. PAs are providers of physician services. They exercise skills in clinical problem solving and decision a high level of decision making and autonomy in making. It is more practical and establishes better providing patient care, although they practice as teamwork and communication when the PA and supervised members of physician-directed teams. physician work together under a broad practice It is important that PAs participate in the system agreement that allows the PA to exercise his or her in which medical care policies are made and clinical judgment while consulting the supervising communicated. physician as appropriate and necessary. EMTALA Issues Hospital Privileges The Emergency Medical Treatment and Labor Act To provide patient care in the hospital, PAs and (EMTALA) touches on PA practice in three main their supervising physicians must seek delineation areas: performance of medical screening exams, of their clinical privileges. The criteria for granting authorizing patient transfers, and taking call in clinical privileges to PAs should be outlined in the emergency departments. medical staff bylaws. The bylaws should include Performing medical screening examinations is a defi nition of physician assistant, generally a common part of PA practice in an emergency conforming to the defi nition used in state law and department. The EMTALA law and regulations to the general defi nition of a PA used by the AAPA. allow PAs to conduct medical screening exams Sample Defi nition of Physician Assistant as long as written hospital policy specifi es that From AAPA: PAs are among the providers the hospital deems A physician assistant (PA)(PA) is an individual qualifi ed to conduct them. Individual PAs must be who is a graduate of a physician assistant granted authority through privileges or some other program approved by the Accreditation Review