Increase standards by way of Medical Direction?

[WolfmanHarris]

I'll preface this thread by saying my knowledge of how things work in the United States is limited to what I've learned from this board and news articles. Our topics are usually geared towards what is going wrong, so forgive me if my perception that the majority of EMS at a system level is broken in the United States is in error. I'm a just a student with no experience and still need someone to wipe my nose from time to time.

The case in Collier County Florida and the revolving door of medical directors in DCFD got me thinking about the differing roles of Medical Direction in EMS. I'd ask those of you in services with excellent medical direction put that aside for now and consider that you are likely in the minority. How can a Medical Director provide objective, independent medical oversight when he or she is employed directly by the service? A Medical Director should have accountability, but should it be to the service whose providers they may potentially decertify? How can a Medical Director under the employ of an EMS service push for higher standards when their pay cheque is being signed by the service fighting against those same standards?

My recommendation is a direct rip off of the Ontario Base Hospital Group (OBHG) and the Base Hospital System in this province. Let's say in your state instead of each service having their own Medical Director, that the state EMS board (or other similar organization) had a council of Medical Directors that meet and determine protocols for all providers in the state. Each of these Physicians represents a regional area for delegation and oversees a regional base hospital. Each regional base hospital will provide QA/QI, CME and review of medical errors and potential decertification or retraining of providers.

For OLMC a list of approved physicians would operate under the guidelines of the Medical Director and regardless of the destination or sending facility would be the only OLMC. During interfacility transfers, Physician orders would either fall under standing protocol or would require confirmation by EMS OLMC.

For QA/QI the Base Hospital's staff would receive copies of all PCR's, and have 100% audit on certain types of call. (i.e. all intubations, cardiac arrests). Regardless of major or minor medical errors that could lead to decertification, the Medical Director can require non-disciplinary CME (on top of normal CME requirements) to rectify perceived problems that may not warrant discipline.

The key to this idea is that Medical Direction would exist entirely separately from the services they delegate to and would be accountable to the State.

I don't know whether I'm describing something that already exists or would be totally unworkable, but if I'm not totally out to lunch, what do you think?

- Matt

P.S. Here is a link to one of the Ontario Base Hospitals in the OBHG that my thoughts were based on.

[spenac]

Interesting idea. It has possibilitys. The biggest problem I see is that most rules are made for city services. Yes thats where most people are located. But many people in my area would be harmed and some even would die if I had the same protocol as services that are less than 20 minutes to hospital. OLMC is not a reliable option as cell phones and even our Satellite phones are not always available to hit or stay locked on. So the state wide group would need to have those that are familiar with those of us at the end of no where.

[WolfmanHarris]

Okay... let's try this. First let's keep in mind that I'm considering this option to the exclusion of others at this point, so while higher education would give us more leeway in protocol and allow for more discretion by the individual providers I'd prefer to leave that aside for now. Plus I believe that high quality independent medical direction would slowly force out medic mills and would help lay the groundwork for higher education (if done right and allowed a free hand).

Would an auxiliary protocol that covers long transport time address much of this? (i.e. greater number of doses of a drug allowed, other opportunities to use a medication) Currently CPAP is an auxiliary protocol in some jurisdictions and the individual service still has discretion on whether they will implement this (for now). Sorry Spenac, without a specific example for the rural vs. urban I'm not sure what problem would need to be addressed. My exposure to urban has shown more laziness than anything else as the main difference, since the providers can get away with just oxygen and transfer for most calls.

- Matt

[spenac]

One example is a nearby ( over 4 hour drive ) city of over 100,000 people does not carry any pain meds. The majority of their transports are under 10 minutes. Every ambulance has at least 1 paramedic.

My nearest hospital is 90 miles away. I have numerous pain management options.

But if all services were required to maintain a higher level of education, then all could and should have available more aggressive protocols. Perhaps have a dual protocol, one for short, but then another if you are at the end of no where.

[WolfmanHarris]

And now we're at the Catch-22 I guess. I'd argue that in the city they should have the same treatment options and know when it's appropriate NOT to use them, but of course without the education to back it up it's potentially putting a loaded gun in the wrong hands. So to prevent this, medical direction would either need more than one set of rules or would be forced to create rules for the lowest common denominator.

For a second I thought including the same protocols for both with the indication including "...with an extended transport/extrication time." but I worry that might just be creating a false sense of accomplishment as those providers for whom that protocol may never apply would have no motivation to learn it and the background needed to go with it. That is unless Medical Direction stuck their thumbs in some pies and included it and a CME requirement for it, regardless of the objections that might arise.

You could be right Spenac about the potential need for two sets of protocols for practical reasons. But the creation of two classes of providers is also problematic.