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Patient Care

The Practicing PA-ramedic: Home Sweet Medical Home

A possible next step from paramedic on the career ladder is physician assistant. What’s that job like? Gain some insight with this new series, “The Practicing PA-ramedic,” which follows the journey of NRP-turned-physician-assistant Sarah Bowman.

You might wonder exactly what a typical day looks like for a PA. In the express care clinic, patient volumes consistently keep me pretty busy—great for those folks who can’t stand a slow station. Just the other day I was able to help 23 patients during my 10-hour shift (full disclosure: I am still striving to improve on time management and efficiency, which I hear doesn’t happen overnight).

The dental abscess patient who just walked in needs scheduled for an urgent visit with a dental provider. A quick call to my colleagues nearby confirms my patient can head over and be first in line for a walk-in appointment.

As soon as I hang up the phone, my medical assistant (MA) looks up from her work station to tell me my next patient has a positive urine pregnancy test. While I briefly review the patient’s chart, my MA spends a few moments reviewing a pregnancy information packet with the patient. I know I can help get her first visit scheduled with one of our midwives. It’s a close-knit community of providers; I went snowshoeing with one just last week.

An infant with a fever and a rash (and anxious parents) sits in the exam room while I ask a pediatrician to walk down the hall to put eyes on my patient and review a treatment plan. I still have a lot to learn about the seemingly endless varieties of rashes that can present in a clinic, despite a full month in dermatology for an elective rotation (thanks to some amazing clinical preceptors, I’m leagues ahead of where I was as a paramedic).

Next, a set of forms waits outside an exam room, with a child here for a school physical and flu vaccine. Noting the child’s obesity during the visit, I can also get a referral placed to see a specialist from the diabetes and nutrition team while the child waits for an opening with the primary care provider (PCP).

The patient in the next exam room needs refills on diabetes medications; I can handle the request directly or work with staff to get him to his PCP for a same-day visit, or at least on the schedule soon.

Closing the Gaps

If you’ve spent time in EMS, you know how frequently people who need med refills end up calling 9-1-1. I still remember a patient who walked into the fire station requesting transport to the ED “to refill my inhaler.” I’m now able to write that refill and work with my patient to get it filled and schedule a follow-up visit (our in-house pharmacy comes in handy; see more below). As a PA I’m glad I can close some of these care gaps, doing my part to limit the flow of patients heading to their local ED for non-life-threatening problems.

After I finish catching up on charts while sneaking in a few sips of lukewarm coffee, there’s a patient with anxiety about a recent major life event. I take a deep breath, knowing I can have a behavioral medicine provider start an integrated visit and schedule a follow-up, all without the patient leaving the exam room.

In the event there’s urgent concern for self-harm or harm to others, we also have access to a crisis team not unlike the one I worked with as a paramedic. It’s notable that not only PAs but all health professionals in Washington have to complete suicide-prevention training. Every patient has unique needs, and it’s remarkable how well the role of PA still lets me do what I loved most about being a paramedic: helping people.

As soon as my febrile, coughing, and tachypneic patient comes back from radiology, I simultaneously call my supervising physician and ask him to review the chest x-ray for what looks like signs of consolidation in the lower left lobe and send it to a radiologist to confirm the read. As a paramedic, I spent more time reviewing ECGs than plain films. I wish I could tell my paramedic self to learn more about reading x-rays from the ED docs. 

The rapid strep test and urine results from two more patients are ready, fast enough that I can wait for them before sending anyone home with a treatment. If they can’t wait, I can have my staff call to let them know they can come back and pick up a prescription through our in-house drive-through pharmacy. Last time I went through the drive-through myself, even my sweet pup got a little crunchy treat! There’s something to be said for the kindness of people in smaller towns.

Next I get a complicated patient needing a medication that is off-formulary, and I’m not sure about dosing. I can walk to the pharmacy to ask a pharmacist what we have in stock right now and what might be the most affordable option.

If we haven’t done it already, I can help my patient meet with member services, which can share information on insurance or financial assistance. If needed care isn’t affordable, there’s a fund for that, primarily made up of contributions from clinic staff, aptly named the Helping Hands Fund.

Just when I think I might be able to go refresh my coffee, a strange sound comes from the check-in window, and my MA perks up. I hear it too—it’s the grunting cry of a feverish and less-than-pink infant. We rush them into the exam room and quickly decide this is beyond the scope of what we can manage from the urgent care setting. (I might not be in the back of the ambulance anymore, but the deeply ingrained PALS training from years of practice and training hasn’t left me.)

After transferring the patient’s care to the emergency department for respiratory distress, the day continues. I am not sure of the final disposition of our patient (and likely won’t find out) because my link in the chain of care has come to a close. Also, I look up from my empty coffee mug and see I have a half dozen more patients lined up in the queue, and I smile, knowing my team is ready to rock.

A Harmonious Blend

I’m incredibly fortunate I get to practice medicine in a primary care medical home (PCMH), where an integrated blend of services comes together in a harmonious way.

What is important to note is not all clinics that provide urgent care work the way I’ve just described. If you loved hearing about these experiences working in a clinic where we focus on providing comprehensive, accessible, patient-centered, high-quality, and coordinated care, transitioning to the PA role and working in underserved primary care might be right for you.

Sarah Bowman, NRP, MCHS, PA-C, is a physician assistant at Columbia Valley Community Health in Wenatchee, Wash., and a recent graduate of the University of Washington School of Medicine MEDEX Northwest physician assistant program. She has worked as a paramedic in Alexandria, Va., and began her career as a volunteer EMT with the Fairfax County Fire and Rescue Department. Sarah has experience as a paramedic, physician assistant, and EMS educator. Follow her on Instagram (@thepracticingpa) for more.

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