The Continuation of Medical Control in EMS

[rock_shoes]

Taken from the thread A new BCAS.

This whole "practice under DR. Standing Order's or Protocol the current Medical Tradition" so why do we need that autograph ? Does it really make a tangible difference in a court room ... like really ?

Knowing that the world revolves around MDs it may be very difficult to ever change the dominance of this group. That said in todays day and age, quite realistically just WHY do we NEED to have signed orders and approved local protocols in the first place ? A conversation I had the other day with a very knowledgeable individual (ps a AB CUPE guy) his point was this:

Why does a regulated Health Care Professional require confirmation from an entity (MD) that highly likely have never stepped on foot in an ambulance. To practice in most jurisdictions as a Paramedic/RN/RRT ++ do have a very clearly defined scope of practice. If a Paramedic or RN makes an error in medical judgement providing care and just to qualify "NOT practicing beyond legislated scope". Does the MD stand up to support us, and putting his licence on the line ? In most courts we are judged by a group of peer's not MD's if a legal case ensues from a result of action or inaction.

* WE are held directly responsible.

* We are held directly accountable.

* Its OUR licensure, livelihood on the line.

Perhaps WE as regulated health care professionals do not legally require the MD sanctioned signed orders in the first place are we being duped ? After all we are issued a "practice permit" by the applicable governing body's and government. In fact the present advice of the regulating body's is to carry our own malpractice insurance, so compare a Paramedic/RN/RRT "oops rates" to the medical profession, divesting from MDs could just result in way lower insurance rates ? just throwing that out there.

I know this is a diametrically opposed position to present medical tradition, and a touch radical but most likely the MDs (those receiving that phat paycheque to sign off) would come out of their skins if they ever heard drift of this challenge. Yet once again I will be placed on ANOTHER "government to watch list" but it does make some sense to move forward into a new future of Health Care Delivery to my way of thinking and the Health Care Professionals would stop following the "cook book"

Soo .... any spare room in that Northern BC bunker guys ?

cheers

Yup: I know completely off topic, perhaps I need to start a different thread when my symptom's of a serious hangover subside but I got on a roll.

Look out. I think this one might be a bumpy ride! Well worth the trouble IMHO.

Squint is onto something here. This is the kind of end-goal we should all be striving for through education and a strict provider vetting process. It's not something I expect to happen tomorrow but sometime within my lifetime is realistic. There are places where this has been done. I would be very interested in hearing from providers working in those places.

[scott33]

There are places where this has been done. I would be very interested in hearing from providers working in those places.

There are more parts of the world which operate without a MC system - in fact, the US appears to be the exception not the rule. This is possibly why you won't get some foreign system allowing someone with a 120-hour first aid certificate, to act in the role of ambulance clinician / crew chief / etc.

Just Google rest of the world

[Kiwiology]

Just Google rest of the world

Pretty much.

In New Zealand it differs by service.

The predominant service has clinical oversight (managers) who are not physicians and retains several part time medical advisors who are physicians (emergency medicine/intensivists). Collectively the medical advisors and clinical managers make up the Clinical Management Group who are responsible for developing procedure and looking at clinical issues.

The other smaller services may have one or two clinical managers (who are not physicians) and retain a part-time medical advisor (physician).

Under NZ law a standing order from a phyisician or other appropriate licensed healthcare professional is required to administer prescription mediciation so this is the main reason a doctor is still attatched to the ambulance service. Now in the future this will change with the advent of Paramedic and Intensive Care Paramedic becoming regulated health professions with independant rights to carry and administer. They will work under thier own license and not that of the doctor.

We have no online control and do not have to seek orders; we do not work to "protocol" but rather to a guideline which can be deviated from depending upon the individual Officers experience and knowledge provided he has a good cause to do so.

Medical advice as a collegual relationship with subject matter experts will always be retained and I think it is a sensible step because Paramedics are broadly educated on a range of areas but are not experts in say paediatrics or cardiology so we need to draw upon the knowledge of those who are.

I think the whole "remote control medicine" concept of having to ask for permission to do something is a slap in the face of professionalism of ambulance practice and should go by the wayside if education and training are appropriately sufficent. I mean I cannot think of any circumstance where I would want to talk to a doctor on any of the jobs I have been to.

There should always be medical advice in Ambulance, ambo's are not subject matter experts, but the concept of "online orders" and "permission-based-paramedic" is outdated and a bit of a laugh to be honest.

[tniuqs]

Taken from the thread A new BCAS.

Look out. I think this one might be a bumpy ride! Well worth the trouble IMHO.

Squint is onto something here. This is the kind of end-goal we should all be striving for through education and a strict provider vetting process. It's not something I expect to happen tomorrow but sometime within my lifetime is realistic. There are places where this has been done. I would be very interested in hearing from providers working in those places.

Hey isn't that copyright infringement ? (sorry folks an inside joke)

Yes this would be a bumpy ride as one would not only be taking the authority away from the GOD's but also affecting their pocketbook, that said it could be a more cost effective delivery not paying the rather large sums of cash for the one monthly (if that happens) or the lets grab a beer or lunch "meeting" to comply with the medical control issue for the paper audit.

In my personal experience in Industry EMS and in services rural the signature on a piece of paper just amounts to a very expensive "Notary Publics" er John Henry. I am frequently instructed to contact the receiving MD in a rural facility who in many cases is only receiving an information / notification and cutesy patch of incoming.

Perhaps restructure a fee for service in that regard for the receiving MD ONLY ... I mean fair is fair after all.

We have no online control and do not have to seek orders; we do not work to "protocol" but rather to a guideline which can be deviated from depending upon the individual Officers experience and knowledge provided he has a good cause to do so.

Medical advice as a collegual relationship with subject matter experts will always be retained and I think it is a sensible step because Paramedics are broadly educated on a range of areas but are not experts in say paediatrics or cardiology so we need to draw upon the knowledge of those who are.

Kiwi it work's pretty much the same way here for on line advice because the comms problems with cell phone are a large complicating variable.

[Kiwiology]

Kiwi it work's pretty much the same way here for on line advice because the comms problems with cell phone are a large complicating variable.

That's a little bit of a problem here too I supposed in some parts.

Back in the seventies when Paramedic's got ten weeks of education in the spare room down at the fire station or hospital then yes online control was very much needed. We have now progressed far-and-beyond that at least outside the US anyway (sssh don't tell the Houston Fire Department....) which means that there is less of a need for online medical oversight.

As I said before .... there should always be medical advice in Ambulance, ambo's are not subject matter experts, but the concept of "online orders" and "permission-based-paramedic" is outdated and needs to go.

[rock_shoes]

Hey isn't that copyright infringement ? (sorry folks an inside joke)

Maybe. Better lock my doors and check my phone for bugs while I'm at it.

Kiwi it work's pretty much the same way here for on line advice because the comms problems with cell phone are a large complicating variable.

I've only ever called in for medical advice once. We were 2 hours up a 4x4 road with a woman having full contractions less than 2 min apart. Her membrane hadn't yet ruptured in spite of everything else being "ready to go". The only way to make any contact was to use the patient's home landline. The rural/remote adventures are often the best eh.

Other than the above mentioned call I've never made contact with medical control or been reprimanded for failing to do so. Heck I've never even met or spoken to most of the medical directors I've worked under.

[aussiephil]

I have stated before tha whole US system needs a complete review. The notion of an EMT-B (sorry guys) really should no longer exist. There is evidence (we do work on evidence based parctice these days) for early cardiac reperfusion through the use of ASA nitro & O2, this is just 1 example.

We need a medical director, there is no dispute about that, but they should be an advisor only, sign off on a protocol & pharmacology & then start a new review, looking at current evidence based practice. Other than this there should be complete autonomy with the officers on scene & with the patient.

I do, however, have 1 exception to this rule. There are services worldwide that have conducted, are conducting or have introdced thrombolyasis for STEMI. To the best of my knowledge these are all done with the approval of a doctor. This should continue as this means that all personnel who can start a line can use these drugs. This will lead to improved patient outcomes.

I fail to see why I should have to ask how much pain relief to give to someone. Knowledge & experience will tell me.

Get rid of med control, overhaul the system to remove a EMT _ B's (an upgrade would be the best option) & provide better overall care to your patients.

[rock_shoes]

We need a medical director, there is no dispute about that, but they should be an advisor only, sign off on a protocol & pharmacology & then start a new review, looking at current evidence based practice. Other than this there should be complete autonomy with the officers on scene & with the patient.

I do, however, have 1 exception to this rule. There are services worldwide that have conducted, are conducting or have introdced thrombolyasis for STEMI. To the best of my knowledge these are all done with the approval of a doctor. This should continue as this means that all personnel who can start a line can use these drugs. This will lead to improved patient outcomes.

I'm thinking eliminate medical control for everything that falls within a provider’s standard SOP. IE. These are the medications and routes of administration you can use. These are the procedures you can perform. Beyond that use your best judgement. If you're unsure medical consult is available. No more working under someone else’s license when working within your SOP. For operations outside of a provider’s SOP such as STEMI thrombolytic trials by all means involve some type of medical control.

The SOP would of course require continual updating and review with evidence based input from relevant parties. Providers, physicians etc.. Allowing paramedics this kind of latitude would absolutely demand a strong educational background. Because this type of practice is largely independent, providers working under such circumstances absolutely must demonstrate superb diagnostic and clinical skills. If this is the direction paramedics want to go in, the education and vetting process must match the level of responsibility. Some jurisdictions have done a much better job of this than others and as such deserve to meet such goals sooner.

[Kiwiology]

We need a medical director, there is no dispute about that, but they should be an advisor only, sign off on a protocol & pharmacology & then start a new review, looking at current evidence based practice. Other than this there should be complete autonomy with the officers on scene & with the patient.

This is exactly how we work here in NZ

I do, however, have 1 exception to this rule. There are services worldwide that have conducted, are conducting or have introdced thrombolyasis for STEMI. To the best of my knowledge these are all done with the approval of a doctor. This should continue as this means that all personnel who can start a line can use these drugs.

I think the one service here who is regularly using thrombolysis (not on a "trial" basis) is doing so without using telemetry now, could be wrong; I know they WERE a few years ago when it was fairly new.

I'm thinking eliminate medical control for everything that falls within a provider’s standard SOP. IE. These are the medications and routes of administration you can use. These are the procedures you can perform. Beyond that use your best judgement. If you're unsure medical consult is available. No more working under someone else’s license when working within your SOP. For operations outside of a provider’s SOP such as STEMI thrombolytic trials by all means involve some type of medical control.

The SOP would of course require continual updating and review with evidence based input from relevant parties. Providers, physicians etc.. Allowing paramedics this kind of latitude would absolutely demand a strong educational background. Because this type of practice is largely independent, providers working under such circumstances absolutely must demonstrate superb diagnostic and clinical skills. If this is the direction paramedics want to go in, the education and vetting process must match the level of responsibility. Some jurisdictions have done a much better job of this than others and as such deserve to meet such goals sooner.

I agree there should be no requirement to ask for a doctor's permission and that you should be able to independantly use your scope of practice. As you say rock socks that would require a big increase in education and clinical quality assurance for the US.

[fiznat]

I think there are big differences here in what "on line medical control" means to each of us. I see some people commenting that they have to call a physician and ask about first round analgesia dosing, and I also see people referring to their protocol as "guidelines." These are two opposite ends of the spectrum, and both are represented here.

Personally, I don't think we should ever be without on-line medical control for some things. Where I work, we call a physician on the radio when we truly need another opinion on a difficult topic (Should I give a third SQ epinephrine to this 55 year old woman with severe asthma? Do you agree with my assessment of this STEMI patient so that we can bypass the ED for the cath lab? I've got a difficult syndrome here in a critically ill patient and I'm not sure which path to take...). It is my feeling that these calls are open and honest consultations with colleagues, and a recognition that there is a whole lot out there that we Paramedics, or any individual for that matter, doesn't know.

Even doctors call other doctors to discuss things if they get in a bind. Who's to say that we are too good for that?