This last week has been fairly busy; it's the week of PALS, grades are being pulled together and finalized for submission. I'm prepping to take the NAEMSE instructor course soon (and wondering WHAT I've gotten myself into this time!), and still trying to keep the clinical edge on the ambulance. Then, I was sent a link by a friend who's been VERY supportive of this blog getting on its' feet (I appreciate it Lungs, but you're killing me here!);
http://journals.lww.com/em-news/Fulltext/2013/04000/Special_Report__Is_Direct_Medical_Command.1.aspx
Lungs knew I couldn't resist.
This story raises addresses so many of the big questions in my mind when it comes to the interaction of medical directors and the EMS personnel they oversee. I thought I'd put them out there, and then hopefully we can discuss one or more of them in the comments.
Just what exactly is a medical director supposed to do in an EMS service?
My last big purchase of EMS literature was the National Association of EMS Physician's "Emergency Medical Services: Clinical Practice and Systems Oversight". It's a four-volume set that discusses all aspects of an EMS system, and here's the interesting part; they talk about the substantial role that the physician should play in influencing or managing those areas. It's a vast difference from what I've experienced in actual EMS services. At one of the services I work at part-time, all I have is a name; no one has actually physically been in the same room as the medical director. At the other one, the medical director comes in about once a year to update the protocols and also historically delivers a lecture at the service's annual conference. I'm fairly certain that were I to walk up to either of them in street clothes, neither would know who I was.
Why is there such a discrepency? I think it boils back to the old engineers' saying: "Good, fast, and cheap. Pick any two."
A medical director is supposed to be the authority in all clinical care by all the employees; that includes education, supervising prehospital care, and quality assurance and improvement. Since medical care costs money, that medical advocacy rightly spills over into operational, logistical, and fiscal aspects of any EMS service. EMS is really a unique animal; the physician community seems to realize this, given the recent addition of EMS as a specialty recognized by the American Board of Medical Specialties. There can now be board-certified EMS physicians, just like EM, ortho, critical care, and surgery. These are well-educated, experienced docs who recognize that EMS is unique.
Why have we, the EMS providers and managers, failed to realize that?
Many medical directors are paid a pittance compared to what they're tasked with, or worse, asked to volunteer. The article rightly points out that EMTs and paramedics receive a fraction of the formal education of physicians, yet we're often asked to function autonomously or semi-autonomously in critical situations; that's bound to make somebody's malpractice insurance go up and possibly cause a stress ulcer or two. And we want our medical directors to undertake this burden for as little as nothing?
Can we really blame them for being absentee medical directors?
Why do we even have online medical control? Why do we have these ridiculous restrictions on what we can do on standing orders, like performing a cric or sedating before we cardiovert unstable V-tach? Why do I get permission for 1mg of morphine for a patient with a shattered femur?
I think we just found the answer to that one.
The article correctly, in my opinion, points out that now, most online medical control is being provided by extremely busy physicians who don't have significant out-of-hospital experience; they may or may not know you by the sound of your voice, they probably don't have a lot of time to chitchat with you as they scamper around to see ever-increasing numbers of patients and learn about your knowledge and experience. Who would they talk to if they wanted to learn more about the EMS system? The medical director, who may not know you either?
I see a pattern here; the less involved your medical director is with the clinicians, the more on-line medical control in the protocols, and the more conservative on-line direction you get. This only makes sense to me; if you're a doctor, how much risk to your prestigious, expensively-acquired livelihood are you prepared to take for a volunteer gig? If you're an ED doc huddled over a radio, how much leeway or power would you want to give to someone who you don't know, whom no one with a medical degree will vouch for, and who cops an attitude anytime you ask why they did or didn't do something to their patient?
How do we fix this?
Let's start at the source. I think it's time we redefined what "medical direction" and "online medical control" are.
A "medical director", at least according to what I read from the NAEMSP, is more of a "physician mentor". He or she is heavily vested in the success of an EMS program; works to make sure that medical education is appropriate, acts as a preceptor and resource during prehospital care, and works retrospectively to make sure that an EMS system is providing good quality clinical care (this includes weighing in on things like ambulance deployment and new medical equipment). Since they provide such an invaluable service to the EMS system, the EMS system compensates them appropriately for the work they put in on behalf of the service. We need to recognize that "good" is part of the engineer's triad that simply can't be sacrificed. With a high-quality physician mentor on board, online medical direction changes; the ED docs recognize that a fellow physician is confident enough in EMS clinicians to stake their name, reputation, and livelihood on their actions. Protocols can become less dependent on taking the ED physician away from their already busy shift.
Online medical direction shifts to a concept of "ED consultation". With a good physician mentor as an ally, there is far less need to call the ED and ask for permission to do things. As clinicians, however, we gain an understanding that the actions or inactions we take in the ambulance have consequences to the hospital staff; they, like the patient, have to live with what we do. Online medical direction starts to move to those cases where we either don't know what to do, or want to make sure that hospital care is consistant with prehospital care. "Hey doc, I've got this patient.....how do you want me to manage this for you?".
If we want to redefine our profession for the betterment of our patients, we also need to redefine our relationships with those who have the ultimate say in medicine; the physician. Our link to the medical community is our medical director. It's time to stop neglecting that relationship and start building a lasting bridge to the medical community.
Following the engineers' triad, of course.
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