Guidelines For The Rural Empa July 2021

Guidelines for the Rural Emergency Medicine Physician Assistant
The emergency medicine physician assistant (EMPA) plays a critical role in providing emergency
care as a member of the physician-led health care team in rural communities throughout the
United States. The gold standard of emergency medical care utilizes “The Model of the Clinical
Practice of Emergency Medicine,” and is traditionally provided by a team of medical clinicians
led by a board-certified, residency-trained emergency physician. Recruiting an emergency
medicine board-certified physician in many rural locations is a challenge and is cost prohibitive.
Alternatively, many facilities utilize family practice physicians, physician assistants and other
practitioners. EMPAs with appropriate physician supervision/collaboration, education, training
and other skills provide this care in many of our communities.
PAs in rural America working at critical-access hospitals require special skills, training and
experience that are unique in this environment. The challenges of low volumes combined with
occasional high acuity of critical care medicine present unique stresses that, at times, can
overwhelm the critical access hospital. The rural EMPA must be properly armed with advanced
education and training as well as knowledge of local resources to employ in these moments of
critical care emergencies. Many EMPAs have taken their advanced education and training to
the rural area to provide high-quality care to the patients they serve. SEMPA’s goal is to
establish a benchmark by which a physician assistant can obtain appropriate education and
training with the appropriate skills to thrive in this environment and provide the highest quality
emergency medicine care for these patients.
I. Role of the EMPA in Rural Emergency Medicine and the Critical Access Setting
Many rural and critical access hospitals with very low volume EDs utilize EMPAs as solo
providers. Appropriately trained EMPAs provide advanced care, ideally with the
supervision/collaboration of a board-certified emergency physician. This, however, is not
available in many rural facilities. Administration of patient care with telemedicine access to
emergency physicians (when available) and/or consultation from various internal medicine,
surgery, critical-care, OB, and other specialists can be helpful. The initial role of the rural EMPA
is to examine, diagnose, and recognize critical illness and injury, and begin resuscitation and
treatment. Patients presenting to rural EDs require admission to the hospital as often as
patients presenting to their urban counterparts, and the need for referral to a hospital with
capabilities of a higher level of care is commonplace. The EMPA in the rural setting is often
caring for patients admitted in the hospital as well. Ideally, care is managed in conjunction with
a hospitalist and physicians of appropriate specialty. Communication, ongoing personal
assessment, and evaluation are key in this environment. Follow-up and feedback are helpful to
the many EMPAs, with advanced training and skills, who are successfully practicing in this
environment throughout the country.
II. Job Description and Scope of Practice for the Rural EMPA
There are four parameters that determine the scope of practice for an emergency medicine
physician assistant:
• State law and regulation (or in the case of federally employed PAs, by the federal
employer)
• Practice site policy
• Education, experience, and expertise of the PA
• Determination by the supervising/collaborating physician(s) about what will be
delegated
In rural emergency medicine, the ED medical director, supervising/collaborating physician, and

the EMPA together reach decisions about scope of practice. Because medical practice and
physician/PA practice relationship requirements (or agreements) are dynamic, specific lists of
approved tasks applied to all facilities and to all physician/PA teams are not practical. There are
not any "typical" restrictions regarding PA practice in the ED. The physician/PA team and the
hospital should be aware of any restrictions on the PA's scope of practice found within state
law or hospital policy.
Examples of scope of practice for the EMPA practicing in rural or critical access hospital include,
but are not limited to:
1) Membership on the medical staff, including hospital privileges and voting privileges
2) Active and ongoing involvement in the quality improvement activities in the department
of emergency medicine
3) Taking patient histories and performing physical examinations of a patient and
recording or dictating the history and physical in the medical record
4) Performing a medical screening exam
5) Ordering and performing diagnostic and therapeutic procedures
6) Ordering medications; ordering and interpreting diagnostic laboratory tests, radiological
studies or various other therapies
7) Establishing diagnostic decision-making for each patient.
8) Instructing and counseling patients regarding mental and physical health, including but
not limited to the following: diet, disease, prevention, treatment and normal
development
9) Referring patients to appropriate specialists, health facilities, agencies and resources.
Also referring and conversing with appropriate consultants in regard to patient
management
10) Performing such other tasks, not prohibited by law, in which the EMPA has been trained
and is proficient and credentialed to perform
11) Writing admission orders as requested by the accepting or admitting physician per
hospital and department policy
12) Performing diagnostic/therapeutic procedures, subject to state regulation and PA
training and experience, to include, but not limited to:
a) Abscess incision and drainage
b) Administration of medications and injections
c) Advanced Cardiac Life Support including all procedures
d) Advanced Pediatric Life Support including all procedures
e) Advanced Trauma Life Support including all procedures
f) Anoscopy
g) Arterial puncture and blood gas sampling
h) Arthrocentesis
i) Cast and Splint application
j) Central line placement
k) Dislocation reduction management
l) Debridement of burns, abrasions and abscesses
m) Epistaxis management
n) Extensor tendon repair
o) Fracture Reduction
p) Foreign body removal: eyes, ears, nose, rectum, soft tissue, throat, and vaginal
q) Hemorrhage control
r) Immobilization techniques (spine, long bone, etc.)
s) Intubation - Orotracheal/Nasotracheal/cricothyrotomy
t) Intraosseous needle placement
u) Laceration repair – simple, intermediate, complex
v) Lumbar puncture
w) Nail trephination and removal
x) Nasogastric/Orogastric tube placement, lavage and management
y) Obstetrical patient evaluation
z) Ordering and initial interpretations of radiological studies
aa) Ordering of EKGs with interpretation

bb) Paracentesis
cc) Procedural sedation management
dd) Local and Regional block anesthesia including double cuff method/bier block
ee) Slit lamp diagnostic and rust ring removal
ff) Tonometry, ocular
gg) Thoracentesis
hh) Thoracostomy
ii) Bladder catheter placement and management
jj) Emergency ultrasonography
kk) Venous access, peripheral and central
ll) Wound care
mm) Other interventions or procedures as directed by the
supervising/collaborating physician
III. Recommended Training for the Rural EMPA
There are a number of ways in which an EMPA can obtain the appropriate skills to thrive in the
rural environment or in a solo practice environment. Most ideally, the EMPA can attend a
postgraduate training program to develop the necessary skills. These are formal supervised
postgraduate programs modeled after emergency medicine residencies and the Accreditation
Council for Graduate Medical Education (ACGME) guidelines, with required didactic education,
clinical rotations, competencies, and oversight. Alternatively, the EMPA can obtain their original
training and, under close mentorship, learn and develop the skills by working closely with an
emergency physician. Working over two years in a high acuity system in conjunction with
repeatedly attending CME courses specifically designed to develop critical care skills, technical
skills (like airway management, venous access, point of care ultrasound (POCUS)), and other
procedures, the EMPA can develop the experience, comfort level, judgment, and technical skill
to manage critical care patients in the rural emergency department. There are several courses
continuously available to obtain these skills. The competency of the rural EMPA must be
established by a board-certified emergency physician to ensure quality of care. NCCPA EM-CAQ
is also valuable to establish a benchmark of EMPA skills required in the emergency department.
Below are the recommended minimum qualifications required for an EMPA practicing in the
rural setting with potentially critically ill or injured patients.
1. NCCPA Certified PA
2. Valid Medical License in State(s) of Practice
3. Current Certifications
a) BLS
b) ACLS
c) PALS
d) ATLS
e) NRP
4. Minimum of two (2) years of full-time experience managing patients in a high-acuity,
high-volume main ED managing patients
5. Extensive emergency medicine related CME with documentation of training and
proficiency
Additional recommended training qualifications:

a. EM Fellowship
b. NCCPA EM CAQ
c. CALS
d. ENLS (neuro)
e. RTTDS (Rural Trauma Team Development)
f. APLS
g. Fundamental Pediatric Fundamental Critical Care Support (PFCCS)Critical Care
Support (FCCS) course
h. Emergency OB workshop
Below is a list of resources available for the EMPA to obtain additional education, training and
skills.
SEMPA Emergency Medicine Resources
A. SEMPA 360 Annual Conference – multiple lectures and procedural and interactive
practice-based workshops
B. EM Academy Lecture Series
C. SEMPA Live Events and SEMPA Live On Demand Monthly Lectures
D. Emergency Medicine Toolkit for Practicing PAs
E. Free Open-Access Medical Education recommendations
F. SEMPA Procedures Course
G. SEMPA Ultrasound Course
Other resource include, but are not limited to:
A. EM Boot Camp
B. Emergency Medicine Core Training https://emcoretraining.com/
C. Difficult Airway Course: https://www.airwaycam.com/ or
https://www.theairwaysite.com/
IV. Skills and competencies required to prepare for this arena
A. Documented procedural competencies:

• Intubation and difficult airway management
• Emergency cricothyroidotomy
• Chest tube insertion
• Ventilator management
• Procedural sedation
• Rapid sequence induction
• Fracture and dislocation management
• Slit lamp and tonometry
• Intraosseous placement
• Central line placement
• Capnography
• Advanced EKG interpretation
• Radiographs, Computerized Tomography, Magnetic Resonance
Imaging, ultrasound basic interpretation
• Simple and advanced wound closure
• Cardiac resuscitation (to include cardio-version and cardiac pacing)
• Arterial access for blood gas and monitoring
• Lumbar puncture
• Bedside ultrasound
• Arthrocentesis and injection
• Additional skills as determined by collaborating/supervising physician
B. Demonstrate and document team leadership, knowledge and skills in the

management of the following presentations through patient, cadaver or
simulation laboratory teaching:
• Cardiac arrest and dysrhythmias
• Shock
• Sepsis
• Stroke and altered mental status
• Respiratory arrest and respiratory failure
• Acute Care Trauma
• Unresponsive patient
• Overdose and toxicological emergencies
• Diabetic ketoacidosis and other endocrine and metabolic emergencies
• Obstetric and gynecologic emergencies
• Pediatric emergencies
• Febrile neonate and child
• Oncologic emergencies
• Hazardous material exposures
• Mass casualty events
• Other situations as determined by practice site

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Guidelines for the Rural Emergency Medicine Physician Assistant

In rural emergency medicine, the ED medical director, supervising/collaborating physician, and

aa) Ordering of EKGs with interpretation

III. Recommended Training for the Rural EMPA

Additional recommended training qualifications:

Other resource include, but are not limited to:

IV. Skills and competencies required to prepare for this arena

A. Documented procedural competencies:

B. Demonstrate and document team leadership, knowledge and skills in the

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