More than 200 people in Denmark have now been infected with a mutated version of the coronavirus.

Large areas of North Jutland, the country's northernmost region, have been placed under lockdown and prime minister Mette Frederiksen ordered a cull of all 15 million mink in the country's farms.

What is mink-related coronavirus?

Mink-related coronavirus refers to several mutated versions of Covid-19 that developed when mink caught the virus from humans working on Denmark's farms.

Mink have in turn infected humans with a mutant version of the virus.

Denmark's State Serum Institute said several mutant versions of the virus had been found in mink, some of which have mutations in the spike protein, which is significant in the bodys immune response and is a key target for vaccines.

Will the outbreak affect future vaccines?

Announcing the new lockdown measures, Ms Frederiksen said the mutated virus was a serious risk to public health and to the development of a vaccine.

Ms Frederiksen cited a report which said the mutated virus had been found the weaken the body's ability to form antibodies, potentially meaning current vaccines under development would not be able to provide immunity.

Some scientists outside Denmark however are sceptical about the impact the mutation could have on a possible future vaccine.

A single mutation, I would not expect to have that dramatic an effect, said Marion Koopmans, head of virology at Erasmus Medical Center in the Netherlands, where analysis of viruses from an earlier outbreak among mink was conducted.

Its almost never the case that its such a simple story of one mutation and all your vaccines stop working, Emma Hodcroft, a virus expert at the Institute of Social and Preventative Medicine in Bern, Switzerland, told Stat News.

The World health organisation's chief scientist also urged calm, saying researchers will need to wait before coming to a conclusion on whether the mutation will affect vaccines, adding that there was no indication it would.

What does this mean for Danish mink?

Denmark is the world's largest mink fur exporter, producing an estimated 17 million furs per year.

Kopenhagen Fur, a cooperative of 1,500 Danish breeders, alone accounts for 40 per cent of global mink production.

The Danish government has ordered a cull of all minks in the country's 1,139 farms.

Danish fur farmers said the cull may spell the end of the industry in the country.

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What is mink-related coronavirus? - The Independent

When the novel coronavirus began to spread across China, researchers at the Duke Human Vaccine Institute (DHVI) sprang into action and they havent slowed down since. They are collaborating with each other and with other institutions to unlock the secrets of the virus that causes COVID-19 and to develop tests, vaccines, and treatments.

Weve done more work faster than we have ever done before, making real progress on antibodies, tests, and a vaccine, says Barton Haynes, MD, the Frederic M. Hanes Professor of Medicine and the director of DHVI.

DHVI researchers are attacking the new virus by applying knowledge, experience, and technology gained from years of working with HIV, influenza, and other viruses.

All the work weve done has allowed us to transition on a dime, Haynes says. All the vaccine constructs weve developed were immediately repurposed for COVID-19.

And vaccine designs are only the tip of the iceberg. DHVI faculty are also developing and running assays and tests, accessioning and distributing blood and tissue samples for studies, and isolating antibodies from infected individuals. Using approaches from a number of different disciplines, they are putting together a holistic picture of how the immune system and the novel coronavirus interact.

Two long-running programs at DHVI set the stage for the swift response. One is the HIV vaccine research program funded by the National Institute for Allergy and Infectious Disease (NIAID). A series of three grants from NIAID have provided continuous funding since 2005 of the Duke Center for HIV/AIDS Vaccine Immunology (CHAVI), Duke Center for HIV/AIDS Vaccine Immunology and Immunogen Design, and Duke Consortia for HIV/AIDS Vaccine Development (CHAVD). The other is a pandemic preparedness program funded since 2017 by the Department of Defenses Advanced Research Projects Agency (DARPA).

All the work weve done has allowed us to transition on a dime, Haynes says. All the vaccine constructs weve developed were immediatelyrepurposedfor COVID-19.

The DARPA Pandemic Preparedness Platform (P3) seeks to develop strategies, technologies, supply chains, and expertise to make it possible to rapidly produce antibody-based treatments for any novel pathogen. These treatments, which can also be used for temporary prevention, are sometimes called passive vaccines or medical countermeasures.

Greg Sempowski, PhD, professor of medicine and pathology and leader of the P3 program, says, Im incredibly proud of how well our staff and scientists have stepped up. They have worked very long hours to quickly bring on all the systems needed to support this type of research. Its not easy. Having really high-quality people who are committed is an enormous asset.

DHVIs work on COVID-19 is being supported with emergency funding from the National Institutes of Health (NIH), supplements to existing grants, and $17million allocated to Duke by the North Carolina legislature.

Antibodies play a crucial role in the development of vaccines, treatments, and even some kinds of COVID-19 tests, so the first order of business was discovering antibodies capable of neutralizing the new virus, SARS-CoV-2.

Once we have the antibodies in hand, there are lots of different things we can do with them, says Michael Tony Moody, MD, associate professor of pediatrics. The key thing is getting the antibodies in hand. Moodys lab was one of several that collaborated to do just that.

DHVI researchers isolated more than 2,500 antibodies from individuals infected with COVID-19 in only ten weeksa remarkable feat.

Kevin Saunders, PhD, associate professor of surgery and director of research at DHVI, says, The antibody isolation technique that we use was developed under our HIV research programs over the last 15 years. Weve really learned how to do that quickly and in depth. Thats why we could get to 2,500 antibodies in a matter of weeks.

Of those antibodies, DHVI scientists have identified some with potent and complementary neutralizing powers against SARS-CoV-2. Together or individually, these antibodies could be a powerful treatment for people in the early stages of infection. They could also be used as a temporary preventative for people at high risk of exposure, such as healthcare workers.

One of these antibodies will be tested as a preventative in a Phase I trial in early 2021. Rather than manufacturing the antibodies, which is very time consuming, DHVI will manufacture mRNA molecules, the genetic blueprints that tell the body how to make the antibodies.

This effort is being supported by an additional $7.6 million grant from DARPA. Emmanuel Chip Walter, MD, professor of pediatrics, who directs the DHVI Clinical Trials Unit, will be running the trial. The manufacturing will happen onsite in DHVIs current Good Manufacturing Practice (cGMP) facility, directed by Matthew Johnson, PhD.

These potent antibodies are also being used to create a test for COVID-19. Because they bind so well to the virus, the antibodies will attract SARS-CoV-2 like a magnet. This type of test could be faster and less expensiveand therefore more widely availablethan polymerase chain reaction (PCR) tests.

A long-lasting vaccine, sometimes called an active vaccine to distinguish it from antibody treatments, is also a priority at DHVI.

An active vaccine spurs the body to create not only effective antibodies, but also memory cells that can churn out more of those antibodies in the future if needed.

Dozens of vaccine candidates are already being manufactured and tested around the world. This first wave of vaccines will doubtless slow down the spread of COVID-19, but its possible, even expected, that they will provide less than full protection.

DHVI is working on vaccines that will plug some of the holes. Were thinking about a second wave of vaccine with enhanced immunogenicity, Saunders says. DHVI vaccines may be able to provide a boost to some of the front runners if they turn out to have a low potency or not to be effective in a particular population, such as older adults.

A multidisciplinary understanding of SARS-CoV-2 antibodies is crucial to this effort. We really go deep, Saunders says. Weve looked at a more global picture of antibody response. That global picture is the necessary foundation for designing a highly effective vaccine.

The power of the DHVI is that we have people who think about the problem in a different way, but we all come together and use our skill sets to make the biggest impact on the same problem, Saunders says.

Kevin Wiehe, PhD, associate professor of medicine, studies the genetic sequences of antibodies using computational methods. He looks at how the antibody sequences from people with COVID-19 evolve as their infections progress. We normally do very deep sequencing so we can get hundreds of thousands of antibody sequences from an individual at any time point, he says. We can see the initial antibody response, which is potentially different than the [mature] antibody that occurs later.

Other DHVI scientists are looking at the other side of the equationthe virus. SARS-CoV-2 is covered with spike proteins that allow the virus to infect cells. These spikes are where antibodies attach.

Rory Henderson, PhD, assistant professor of medicine, uses computer simulations to identify mutations in the spike protein that alter its shape, or conformation. In an actual infection, spike proteins change conformation frequently. But in a vaccine, some of these conformations will do a better job than others at spurring the immune system to produce effective antibodies. Its been remarkable how quickly we were able to go from not knowing anything about the coronavirus to having these designs, Henderson says. If one of the shapes is preferred, we already have that particle ready for a vaccine.

This speed was made possible by previous HIV work. Henderson says, We repurposed all of the techniques and tools we used for HIV and applied those to the coronavirus spike.

Priyamvada Acharya, PhD, associate professor of surgery, puts it this way: We have been studying a very difficult virus for a long timeHIV 1. So we have gained some superpowers.

Acharya examines the engineered spike proteins at the atomic level in the Titan Krios cryo-electron microscope to make sure their shape is what was expected. Then the spikes can become ingredients in vaccines, either as mRNA or manufactured proteins. Indeed, some are already being evaluated in animal studies. Acharya uses the cyro-EM to take a look at samples from the studies to see if good antibodies are being produced and how they interact with the spike. So far, the results have been promising.

While DHVI researchers are working on new-and-improved vaccine designs, they are also participating in the nationwide effort to get the first wave of vaccine candidates evaluated as quickly as possible by serving as a clinical trial site. Phase 2 and 3 clinical trials require tens of thousands of volunteers at multiple sites across the country. DHVI enrolled more than 80 volunteers for the Phase 2/3 trial of the Pfizer vaccine candidate, and is now enrolling even more participants for a trial of AstraZenecas vaccine.

Walter, who is leading this effort as head of the DHVI Clinical Trials Unit, says, DHVI is pretty well positioned because of its experience with HIV, ranging from vaccine discovery to the ability to implement clinical trials. Shifting to COVID was challenging, but we had the resources to do it.

Walter also leads Dukes participation in the nationwide series of trials to test treatments for patients hospitalized with COVID-19. The first trial studied remdesivir alone, and subsequent trials tested it in combination with other medicines. The first study showed decreased time hospitalized for patients who got remdesivir, hence it became standard of care, Walter says.

Beyond vaccines, DHVI is also pursuing other avenues, including testing and diagnostics. Thomas Denny, DHVI chief operating officer, and his lab assisted with testing in the early days of the pandemic, when clinical labs were overwhelmed. Denny led a team at DHVIthat also designed and implemented the surveillance testing of students, staff, and faculty being used on campus this fall. As part of the campus testing program, DVHI has processed almost 100,000 tests since August 2.

Denny is also working on designing more sensitive assays that can determine not just whether the virus is present or not, but in what amounts. With a lot of viral infections, like HIV, weve learned over the years that being able to quantify the viral amount has been useful as a signal with respect to disease prognosis or response to therapy, he says. If the same is true for COVID-19, that information could be used to guide clinical decisions. Denny is analyzing samples from COVID-infected adults and children who are participating in observational studies at Duke. He will compare the results of his assays with notes on their clinical condition to look for correlations between viral load and disease progression.

Dennys lab also developed assays to look for antibodies to SARS-CoV-2 in the blood, which could, among other things, be used in seroprevalence studies to show how many people have recovered from COVID-19.

Christopher Woods, MD, MPH, professor of medicine, and his team are coming at diagnostics from a different directionlooking at the immune response. The idea is that samples from an infected person will contain not only the pathogen, but also biochemical signals of the immune response. In fact, the immune signals may be easier to detect in early stages of infection than the pathogen, which is only just beginning to multiply. Woods has a track record in this area: he and his team have been able to distinguish viral from bacterial infections based on the immune response, and to identify infections 36 to 48 hours before the onset of symptoms.

We have not had great success [in the past] being able to distinguish different types of viral respiratory infections, he says. Until COVID. He and his team have found a unique signature in blood samples that indicates the immune system is mounting a response to SARS-CoV-2 infection. The samples used in that study were from people who were past the early stages of infection, but Woods is planning future studies to see if the signature is present in the pre-symptomatic phase of COVID-19. If so, a diagnostic test for that signal could help curb the spread of the disease and allow earlier treatment.

Sallie Permar, MD, PhD, professor of pediatrics, molecular genetics & microbiology, immunology, and pathology, is working to understand the immune response to COVID-19 in children. Although children do get the disease, they are more likely to have no or few symptoms than adults. However, some children experience a severe inflammatory reaction to COVID-19, called Multisystem Inflammatory Syndrome in Children (MIS-C).

Not only do we want to understand what about infant or pediatric infections leads to the lack of disease during the acute infection, Permar says, but also what are the factors that lead to post-infection inflammatory syndrome?

To help answer some of these questions, Permar and Maria Blasi, PhD, assistant professor of medicine, are doing a study in non-human primates to track the immune response over the course of infection in adults and infants. They are also studying adult and infant lung cells in the lab to see how the cells respond to infection.

DHVI researchers are also studying children in several ongoing observational trials. These trials include infected children as well as children who are uninfected (at least initially) but living with someone who is. The children are being followed over time to learn more about immune activity and clinical symptoms during infection, recovery, and beyond. We dont yet know what a long-term response to the coronavirus is, Permar says. Well be studying them for at least a year.

While the Haynes, Saunders, and Sempowski labs were isolating antibodies from COVID-infected individuals, they also looked at a sample from a person who had been infected with another pandemic-causing coronavirusSevere Acute Respiratory Syndrome (SARS)in 2003. They discovered that some of the SARS antibodies from that individual also neutralized SARS-CoV-2.

That raised a tantalizing question: Might it be possible to design a vaccine that elicits cross-protective antibodies? Such a vaccinea pan-coronavirus vaccinewould protect against multiple coronaviruses, including Middle East Respiratory Syndrome (MERS), which emerged in 2012, as well as other as-yet-unknown coronaviruses.

SARS-CoV-2 is not a one-off event, Saunders says. There seems to be a coronavirus pandemic every eight to ten years. Were looking at the future pandemics and trying to predict what that will look like and to see if we can generate immunity for those types of viruses.

DHVI has already begun working with scientists at UNC-Chapel Hill on a pan-coronavirus vaccine.

Its only a matter of time before the next coronavirus outbreak, Haynes says, and we will be ready for it.

Top photo: Emmanuel "Chip" Walter, MD, head of the DHVI Clincal Trials Unit, gives a nasal swab to Kristin Weaver, a healthy participant in the Pfizer vaccine clinical trial.DHVIenrolled more than 80 volunteers for the Phase 2/3 trial of the Pfizer vaccine candidate. Photo by Lindsay Key.

Mary-Russell Roberson is a freelance writer in Durham. She covers the geriatrics and aging beat for the Department of Medicine in the Duke University School of Medicine.

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Years in the Making: Duke Human Vaccine Institute researchers attack COVID-19 - Duke Today

The need for healthcare in the U.S. is increasing, and many organizations are exploring alternative options to meet that demand. One possible solution could be EMS physician assistants (PAs).

PAs are medical professionals who can diagnose and treat patients, interpret laboratory data, and prescribe medications.1 In 2018 the PA field was the fifth-fastest-growing in the U.S.,2 and currently degrees are offered through 75 postgraduate PA programs with 25 specialties,3 with a third of those programs focusing on emergency medicine. However, despite the original PAs originating from military EMS in 1965,4 no program today concentrates specifically on EMS.5 To be able to deliver proficient EMS care, a provider must be well versed in the unique challenges, interventions, and situations posed by the EMS setting, all of which require education from specialized training programs.6

The purpose of this article is to propose such a program: a postgraduate EMS-focused PA program that would work to expand the current availability of PA education and prepare the EMS community to allow trained PAs to practice in the EMS setting.

In 2010 EMS was officially recognized as a subspecialty of emergency medicine,7 and the National Associated of EMS Physicians (NAEMSP) responded by accrediting EMS fellowships in 2012 to formally educate EM physicians to handle the unique situations EMS providers face.8 At this time 61 NAEMSP-accredited EMS fellowships are available to EM physicians in the United States.9

With the development of physician EMS fellowships also came physician response units, vehicles staffed by emergency medicine (preferably EMS) physicians and fellows dispatched directly as scene responders, usually alongside or in addition to the usual first responders. Physician response units have been shown to be efficient ways of delivering care beyond the scope of a regular ambulance.10

As PAs in the field would function as physician extenders, their most obvious entry into the world of EMS would be as an extension of current physician response units. Proposed functions would involve both prehospital care and administrative functions. As PAs can have vast differences in their scope of practice, this article primarily reflects the laws of Missouri. Consult and abide by relevant laws and regulations when adapting this information to your state.

With few exceptions, most PA programs graduate students with a focus on primary care medicine. Many PA programs provide only a single rotation in emergency medicine.

To assure new PA graduates can function in high-speed emergency medical situations, additional education in EM should be a requirement. This should be continued over the course of the PA EMS fellowship and, as in any realm of medicine, after graduation.

Specific emergency-based certification courses such as Advanced Cardiac Life Support, Pediatric Advanced Life Support, Basic Life Support, Advanced Trauma Life Support, the Incident Command Systems, and awareness-level hazardous-materials education should be considered mandatory and obtained within the initial month of training, prior to any scene response. It is essential for the initial month of training to focus on core emergency medicine topics, along with basic EMS scene safety, to provide some assurance the PA is proficient in EM and has a good foundation for the continued addition of EMS-specific knowledge.

For any EMS PA fellowship program to have credibility, it should have education goals aligned with the proven process of the physician EMS fellowship curriculum. Therefore, one major difference to consider is that EMS physicians seeking EMS fellowships already have had an intense EM residency, while PAs have general medicine experience. That makes EM education a necessity for the EMS PA candidates success.

Physician EMS fellowships are at present accredited by the Accreditation Council for Graduate Medical Education (ACGME),11 whose education goals are outlined in Section IV of the ACGME Program Requirements for Graduate Medical Education in Emergency Medical Services. A postgraduate program for PAs should strive to follow the example set forth in the EMS physician fellowship. PAs should be required to take similar coursework to the EMS physician, including courses in incident management, tactical medicine, emergency medical dispatch, and disaster management.

Proposed prehospital functions for EMS PAs would include critical care (trauma, cardiac arrest, mass-casualty/mass-gathering events); tactical operations; high-risk refusals; and mobile integrated healthcare, including high-use individuals and low-acuity patients.

Trauma and Critical Care

An EMS PA would be a prime candidate to deliver emergent critical care during complex traumas, cardiac arrests, and mass-casualty incidents (MCIs). Having a provider capable of bringing additional tools and skills to the prehospital response, such as point-of-care ultrasound (POCUS), has the potential to improve patient outcomes.12 Advanced intravenous access, including central venous catheterization in critically ill patients, is also improved with the use of POCUS.13 Advanced Trauma Life Support recommends early ultrasonography in trauma patients by utilizing expanded focused assessment using sonography in trauma (eFAST) exams.14 Completion of these exams with positive results has been shown to decrease time from injury to arrival in the operating suite.

Ultrasound can also be seen in confirmation of cardiac standstill during cardiac arrest events. In the event of cardiac standstill, the possibility of successful resuscitation drops extremely close to 0%.15

Another tool PAs could bring into field response is skilled video laryngoscopy. Video laryngoscopy has been shown to improve success rates in urgent intubations and decrease esophageal complications.16,17

In the event of an MCI or prolonged extrication, PAs can assume the important role of monitoring the critically ill patient. Interventions could include end-tidal carbon dioxide monitoring and pulse oximetry for evaluation of ventilation in both intubated and nonintubated patients.18 PAs can also insert arterial catheters for arterial blood pressure monitoring, rather than central venous catheters for central venous monitoring. Additional critical care monitoring skills would include placing a urinary catheter to monitor urine output (for severely prolonged extrication) and core temperature monitoring.

Mass-Gathering Events

During mass gatherings an influx of stable patients could present to a medical station. In these events a PA can provide online, on-scene medical control for prehospital providers. PAs have been able to decrease hospital lengths of stay when placed in triage, so it can be inferred they are capable of identifying the appropriate needs and dispositions for patients with acute presentations.19 Having a PA on scene may also help decrease the number of patients transported to a hospital or identify subtle presentations of more serious illnesses.

Tactical Operations

During law enforcement tactical operations, where situations demand deviation from established protocols, PAs can provide a higher level of care for officers and patients. All SWAT teams accredited by the National Tactical Officers Association require medical support, so having a PA on the team may prove beneficial not only for acute care of the ill and injured but for the preventative and long-term care of the team.20

High-Risk Refusals

Most EMS systems document that between 5%20% of their call volume results in patients refusal of medical treatment, with some systems indicating 30%.21 Many of these patients, especially those older than 65, will require some kind of follow-up care.22 These older patients are also more likely to die because of their illness within a week of their medical contact.23 Pediatric patients are also high-risk refusals due to the inclusion of parents and their requests. Psychiatric patients are also high-risk; therefore PAs may be able to bring additional medications not normally carried on ambulances for violent patients. They may also be able to provide a more thorough assessment, with the possibility of alternative dispositions to the ED.

High-Frequency Users

High-frequency users of EMS can also be reduced up to 30% through education and by providing the appropriate resources for alternative, more appropriate dispositions.24 In one example of a community paramedicine program in North Carolina, high-frequency user visits to the ED were cut by more than half under a program using paramedics with additional training.25 Utilizing PAs with prescriptive authority could reduce ED use even more.

Low-Acuity Patients

EMS providers are frequently dispatched to low-acuity, nonemergent patients, who often overlap with the high-frequency user subset. The Los Angeles Fire Department implemented a nurse practitioner-staffed ambulance that responded to many of these calls. In the first six months, their treat-and-release rate was 52% for the 329 patients to whom they were dispatched.26 One study noted that low-acuity ambulance users often had insurance and a primary care provider but lacked private transportation compared to those presenting via private transportation.27

These patients also believed enough ambulances were available for calls of all acuities and said they would continue to utilize ambulances for medical transportation.27 Another study demonstrated a reduction in ED visits through using other resources, such as telemedicine and urgent care centers.28 PAs could further reduce ED visits by appropriately triaging lower-acuity patients to these established resources.

ACEP suggests physicians with board certification in EMS are best prepared to fill the role of an EMS medical director.29 This role also includes dedication to continued EMS provider education, community evaluation, QI/QA, and EMS-focused research. The EMS PA can fulfill this role as an assistant medical director (though in Missouri EMS medical directors must be board-certified physicians).29,30

Administrative duties of the EMS PA can be subdivided into three categories: education (community and prehospital provider), QI/QA, and research.

Education

An EMS PA could provide medical education to two distinct audiences: the general community and EMS providers.

For community education, opportunities exist in settings such as community health fairs, specific targeted campaigns, and the promotion of celebration weeks (e.g., EMS Week, Health Literacy Week, etc.). These efforts should be focused on spreading health awareness, communicating the availability of resources, and assisting in the first steps toward health improvement.

For prehospital providers EMS PAs could teach initial education courses and provide continuing education on focused topics or skills with the appropriate simulation materials.

Quality Improvement

Since quality improvement is also among the responsibilities of the medical director, this task could be completed by a PA working as an assistant medical director. Responsibilities would include chart review, identification of common errors, and developing training courses and education materials to assist in continual improvement.

Research

Evidence-based practice has been shown to improve overall patient outcomes, and a commitment to research is another responsibility of the EMS medical director that could be executed by an EMS PA: seeking out new areas to investigate, completing or coordinating projects, and performing original research. Additionally, PAs could locate peer-reviewed, evidence-based best practices and develop new policies and protocols to incorporate them.

Several barriers likely exist to the immediate implementation of an EMS PA program such as the one described above. The first and foremost is obtaining funding. Most fellowship programs provide the student with a stipend, but there are also costs like liability insurance, vehicles, uniforms, training courses, and medical insurance. Ways to cover these costs include insurance reimbursement for patient care hours, grants, donations, and university input.

Furthermore, the emergency medical dispatch system must be assessed to ensure correct analysis of calls for the dispatch of appropriate resources. Studies have shown protocol-based EMD systems are consistently more accurate than those without EMD protocols.31

Because of a lack of current PA providers in the EMS setting, it is important that procedures, protocols, and policies be examined to ensure liability coverage.32 These policies should be set with the direct input of the division chief/medical director. They should specify who has ultimate on-scene authority for patients should a difference in opinion ever occur on the treatment plan.

As with all postgraduate academic programs, an EMS PA program must be affiliated with a university. Many existing physician response units are already aligned with major academic centers. This would also be beneficial toward future EMS research.

A prehospital-focused EMS PA postgraduate education program would be relatively easy to implement once these few small barriers are overcome. These providers would have the ability to improve the care and functioning of EMS, contributing to a more appropriate allocation of resources, reduced ED utilization, increased cost savings, and better overall health literacy.

1. American Academy of Physician Assistants. What is a PA? http://www.aapa.org/what-is-a-pa/.

2. Bureau of Labor Statistics. Fastest Growing Occupations, http://www.bls.gov/ooh/fastest-growing.htm.

3. Association of Postgraduate PA Programs. Postgraduate Pas Programs Listings, https://appap.org/programs/pa-programs-listing/.

4. American Academy of Physician Assistants. History of the PA Profession, http://www.aapa.org/about/history/.

5. Wright D. Physician Assistant Emergency Medicine Postgraduate Programs and Their Focus on EMS Education. Unpublished, 2019.

6. Widmeier K. Specialty Certifications in EMS. J Emerg Med Serv, 2015; http://www.jems.com/2015/09/08/specialty-certifications-in-ems/.

7. American College of Emergency Physicians. EMS the Newest Subspecialty of Emergency Medicine. ACEP Now, 2010 Nov 1; http://www.acepnow.com/article/ems-newest-subspecialty-emergency-medicine/.

8. National Association of EMS Physicians. EMS Subspecialty, https://naemsp.org/career-development/ems-subspecialty/.

9. National Association of EMS Physicians. Fellowship Programs, https://naemsp.org/career-development/fellowship-programs/.

10. Bell A, Lockey D, Coats T, Moore F, Davies G. Physician Response UnitA feasibility study of an initiative to enhance the delivery of pre-hospital emergency medical care. Resuscitation, 2006; 69 (3), 38993.

11. Accreditation Council for Graduate Medical Education. Emergency Medicine: Program Requirements and FAQs, http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/7/EmergencyMedicalServices.

12. Btker MT, Jacobsen L, Rudolph SS, Knudsen L. The role of point of care ultrasound in prehospital critical care: a systematic review. Scand J Trauma, 2018; 26(1): 51.

13. Palepu GB, Deven J, Subrahmanyam M, Mohan S. Impact of ultrasonography oncentral venous catheter insertion in intensive care. Indian J Radiol Imaging, 2009; 19(3): 1918.

14. Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma. StatPearls [Internet], http://www.ncbi.nlm.nih.gov/books/NBK470479/.

15. Cureton EL, Yeung LY, Kwan RO, et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg, 2012 Jul; 73(1): 10210.

16. Kory P, Guevarra K, Mathew JP, Hegde A, Mayo PH. The Impact of Video Laryngoscopy Use During Urgent Endotracheal Intubation in the Critically Ill. Anesthesia & Analgesia, 2013; 117(1): 1449.

17. Sakles JC, Mosier JM, Chiu S, Keim SM. Tracheal Intubation in the Emergency Department: A Comparison of GlideScope Video Laryngoscopy to Direct Laryngoscopy in 822 Intubations. J Emerg Med, 2012; 42(4): 4005.

18. Andrews FJ, Nolan JP. Critical care in the emergency department: monitoring the critically ill patient. Emerg Med J, 2006; 23(7): 5614.

19. Nestler DM. Effect of a physician assistant as triage liaison provider on patient throughput in an academic emergency department. Acad Emerg Med, 2012 Nov; 19(11): 1,23541.

20. National Tactical Officers Association. Tactical Response and Operations Standards for Law Enforcement Agencies, https://ntoa.org/pdf/swatstandards.pdf.

21. Hipskind JE, Gren J, Barr D. Patients Who Refuse Transportation by Ambulance: A Case Series. Prehosp Disaster Med, 1997; 12(4): 4550.

22. Vilke GM, Sardar Wm, Fisher R, Dunford JD, Chan TC. Follow-up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care, 2002 OctDec; 6(4): 3915.

23. Page D. Cancel with care. Which refusals can risk patient safetyand your career? J Emerg Med Serv, 2010 Dec; 35(12): 5661.

24. Pecci AW. Community-Based Program Cut ED Visits by Nearly 30%. Health Leaders, 2017 Oct 4; http://www.healthleadersmedia.com/clinical-care/community-based-program-cut-ed-visits-nearly-30.

25. Clarke JL, Bourn S, Skoufalos A, Beck EH, Castillo DJ. An innovative approach to health care delivery for patients with chronic conditions. Popul Health Manag, 2017 Feb; 20(1): 2330.

26. Eckstein M, Ito T, Guggenheim A, Sanko S. Nurse Practitioner Response Unit Launched in Los Angeles. J Emerg Med Serv, 2017; 42(2).

27. Pearson CP, Kim DS, Mika VH, et al. Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization. Am J Emerg Med, 2018 Aug; 36(8): 1,32731.

28. Poon S, Schuur J, Mehrotra A. 172 Trends in Site of Care for Low-Acuity Conditions Among Those With Commercial Insurance, 20082015. Ann Emerg Med, 2017 Oct; http://www.annemergmed.com/article/S0196-0644(17)31099-5/fulltext.

29. American College of Emergency Physicians. The Role of the Physician Medical Director in Emergency Medical Services Leadership, http://www.acep.org/patient-care/policy-statements/the-role-of-the-physician-medical-director-in-emergency-medical-services-leadership.

30. Missouri Code of State Regulations. Rules of Department of Health and Senior Services, Division 30Division of Regulation and Licensure, Chapter 40Comprehensive Emergency Medical Services Systems Regulations; http://www.sos.mo.gov/CMSImages/AdRules/csr/current/19csr/19c30-40.pdf.

31. Clawson J, Olola CHO, Heward A, Scott G, Patterson B. Accuracy of emergency medical dispatchers subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocols recommended coding based on paramedic outcome data. Emerg Med J, 2007 Aug; 24(8): 5603.

32. National Association of EMS Physicians. EMS Physician-Performed Clinical Interventions in the Field Position Statement, https://naemsp.org/NAEMSP/media/NAEMSP-Documents/EMS-Physician-Performed-Clinical-Interventions-in-the-Field.pdf.

David Wright, MS, PA-C, NRP, is a physician assistant working in the Division of Pediatric Emergency Medicine at Washington University in St. Louis.

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The Benefits of an EMS PA Program - EMSWorld