The Continuation of Medical Control in EMS

[rock_shoes]

Even if you have standing orders for pain control, there are likely others here who may have to call for it. My point was simply that our definition of "what is medical control" varies widely across our community here. That point stands.

I believe independant practice as I defined it earlier in the thread does make allowances for the type of situations you are concerned about. A well educated paramedic should be able to function completely independantly within their SOP. IE. working under your own licence as opposed to under a medical directors for everything that falls within your licenced SOP. Though able to function independantly medical consultation should be available to providers for unusual or complex cases. No different than a GP spying something something that seems "out of place" on an x-ray and choosing to consult a radiologist. I think the whole point many of us are trying to make is that medical control should be removed from regular practice and reserved only for situations that fall outside the set standard of practice. Things like on ambulance drug or procedure trials such as pre-hospital thrombolytics for example.

[Kiwiology]

I wasn't trying to call you (or anyone) out specifically, which is why I didn't quote you or use your name at all. Even if you have standing orders for pain control, there are likely others here who may have to call for it. My point was simply that our definition of "what is medical control" varies widely across our community here. That point stands.

Agree. In Los Angeles "medical control" is your best friend because you can't so squat on your on page of orders without it; whereas in Dallas or Seattle it's not so strigent.

I don't think I said that it has to be a doctor, even though I do agree that a physician might make the most sense.

No, it shouldn't have to a be a doctor; see my earlier postings, here if we need some advice the most common perso to ring up is the Team Manager on the ambo phone. Keep in mind that sort of thing is quite rare. Our Clinical Support Managers are not doctors. Yes we have medical advice in Ambulance.

Okay hot shot. The 3rd round of IM epinephrine in a status asthma is an on-line option for us here. Should we all have our "accreditation reviewed?" Things aren't the same everywhere Phil, and there certainly is a little room for thought in this scenario other than pushing the syringe down and hoping for the best.

I'm sorry mate but I do have to agree with Phil here.

Do no harm. Epinephrine increases cardiac O2 demand. ...Or are you simply saying that nobody could definitively prove it was your epinephrine that did the damage, and therefore pushing this drug is okay?

So lets say Nana is two years post-MI but in status asthma, moving very little air, becoming increasingly confused and getting ready to crash. I would have no problem giving this patient adrenaline because in the balance of risk vs benefit what is going to kill her right now? Agreed we might get a few premature complexes and there is the possibility of ischeamia but again, what is the bigger, more life threatning problem?

I agree with what you are saying in notion; that we shouldn't go pushing meds willy nilly without considering the consequences but in this situation or any other situation requiring adrenaline I'd say the patient is at greater risk of dying because of thier asthma/anaphylaxis/cardiac arrest than the percieved notion of myocardial ischeamia.

Now I've heard of sparky people giving somebody with a bit of a rash some adrenaline for "anaphylaxis" and spinning them off into VT .... but that's different.

What a truly idiotic thing to say. Phil, there is more to our patients than we see at face value, and thinking in only two dimensions like this can have really negative effects. If you really believe that a patient does not exist who's presentation will exceed your abilities as a prehospital provider, you either have no experience in the field whatsoever or are a complete fool.

There is more to our patients than what we see at face value. But, once again I agree with Phil in principle. To the thinking and in-tune Ambulance Officer it's possible to build up a good picture about what is happening and begin to treat it while transporting the patient to a higher level of care.

Good examples are fruseomide in cardiogenic pulmonary edema, GTN in inferior (RVI) infarct, suxamethonium in hyperkalemia, excessive fluid in hypovolaemic shock. These are where ambo treatment can be harmful and have very negative consequence. To take it to the extreme of a "symptom only" approach we'd dish out lasix to every SOBer with shitty lungs who didn't get better after a ventiolin because it must be cardiogenic edema, wouldn't bother with 12 leads in chest pain patients etc. Did I mention Los Angeles at all?

This however is not what Phil is saying however it was something I wanted to touch on to address the perception some people might be getting, too often I see people educated under the "top heavy" approach focusing on skills with little foundational knowledge.

What Phil means, and what I agree with very much and have seen people get stuck, is that we shouldn't sit on scene for an hour looking at the cardiac monitor with the pathophysiology book out going "hmmmm, I wonder if it's this or that" and meanwhile your patient has arrested thirty minutes ago but you didn't notice because you had your nose stuck in that cardiolody epidemiology manual.

I don't purport to represent all US paramedics of course, only myself. You are correct though that I am reluctant to conclude that we should "do away" with on-line medical control consultation. I'm not trying to say that paramedics should be calling doctors every day to ask for permission or help, only that they should have that option when things start to get out of scope. It may not have happened to you in a long time, but it does happen, and I feel it should be part of our professional humility to leave ourselves a lifeline if needed.

So things have really gone to shit major; you have a critically sick patient who you just have no idea how to treat. Do you put patient in ambulance and take them to the hospital or piss around on the ambo phone ringing up and doing a consult because your arse has puckered up so much you're gonna be pooing orally for the rest of your days?

Again I'm not knocking the idea of getting help and support as they say two or three heads are better than one but .... the situation would have to be so far out there that I just can't think of what it would be or what is in that ubiquidos green bag that might be able to treat it.

Below are our drugs, can you think of some alternative use for them that I can't which might necessitate calling up and doing a consult?

- Adrenaline

- Amiodarone

- Aspirin

- Atropine

- Entonox

- GTN spray

- Salbutamol neb

- Glucagon IM (don't carry enough for a BB OD)

- Ceftriaxone

- Fruseomide

- Ondansetron

- Morphine

- Midazolam

- Naloxone

- Ketamine

Even though this was my example, I do agree with you. I feel that paramedics are quite capable of identifying STEMI on the 12 lead ECG on their own. In fact, good peer-reviewed research has shown that we can do this quite well. The problem in my area is that even though we may have gained some trust and respect from the ED physicians we deal with every day, we have almost none of that from the interventional cardiologists that we hardly ever see. To them, we are ambulance drivers, and I imagine they have a hard time answering that 3am call at the request of a technician. I only mentioned this because it is one of the main reasons I have called medical control in the recent past, and even though I feel it could be an unnecessary step, it has been successful for me and my patients.

Now this is a sort-of-maybe-possibly deal. I've recently had the "5am stare" going on at an ECG strip that I just couldn't work out, I was tired and just not sure. Now this case wasn't serious and no intervention was needed but I just couldn't work that ECG out! If you guys are going to be pushing adenosine or cardizem or something after 12 hours of getting smashed with P1 jobs and 20 minutes sleep then it would be a good idea to either call telemetry with the ECG or .... put more vehicles on the road!

A well educated paramedic should be able to function completely independantly within their SOP. IE. working under your own licence as opposed to under a medical directors for everything that falls within your licenced SOP.

You're onto it rock socks ... this is how we Kiwi's work.

[CBEMT]

So lets say Nana is two years post-MI but in status asthma, moving very little air, becoming increasingly confused and getting ready to crash. I would have no problem giving this patient adrenaline because in the balance of risk vs benefit what is going to kill her right now? Agreed we might get a few premature complexes and there is the possibility of ischeamia but again, what is the bigger, more life threatning problem?

The bigger, more life-threatening problem is that poor dumb SOBs like me have to stop and call for permission to give her the 1:1000 in my area. She meets both criteria- cardiac history, and elderly. And there have been providers dinged for not calling in when it turns out that there was a negative result.

I'm sure Nana won't mind waiting.

Below are our drugs, can you think of some alternative use for them that I can't which might necessitate calling up and doing a consult?

Not really.

However:

- Adrenaline

- Amiodarone [Have to call]

- Aspirin

- Atropine

- Entonox [Don't have]

- GTN spray

- Salbutamol neb

- Glucagon IM (don't carry enough for a BB OD) [us either]

- Ceftriaxone [Don't have]

- Fruseomide

- Ondansetron [Don't have]

- Morphine [Have to call]

- Midazolam [Have to call]

- Naloxone

- Ketamine [Don't have]

Edited March 23, 2010 by CBEMT

[Kiwiology]

The bigger, more life-threatening problem is that poor dumb SOBs like me have to stop and call for permission to give her the 1:1000 in my area. She meets both criteria- cardiac history, and elderly. And there have been providers dinged for not calling in when it turns out that there was a negative result.

I'm sure Nana won't mind waiting.

Oh yeah you're onto it, hang on Nana I have to call the doctor to .... aw poo Nana had a respiratory arrest.

- Morphine [Have to call]

- Midazolam [Have to call]

Wow that's pretty bad, sorry to hear that mate

[aussiephil]

I wasn't trying to call you (or anyone) out specifically, which is why I didn't quote you or use your name at all. Even if you have standing orders for pain control, there are likely others here who may have to call for it. My point was simply that our definition of "what is medical control" varies widely across our community here. That point stands.

I do believe I answered that. A medical Direstor is your medical (or should be) control. They approve what your SOP, Protocol or guideline should be. Add to that a Medical Advice Line, with the ability to add suggestions to yout treatment options, leaving the final decision to you is a different story.

I don't think I said that it has to be a doctor, even though I do agree that a physician might make the most sense.

Why? Does the Physician have experience in Pre Hospital Care? There is a difference in what you do on scene compared to what is done in a more controlled ER. Discussion with a more appropriate person, experienced in pre hospital care can be of more benefit in many instances.

Okay hot shot. The 3rd round of IM epinephrine in a status asthma is an on-line option for us here. Should we all have our "accreditation reviewed?" Things aren't the same everywhere Phil, and there certainly is a little room for thought in this scenario other than pushing the syringe down and hoping for the best.

Then there should be a review of your protocol SOP or whatever you want to call it. The person described as asthma extremis needs epi, so lets look at it, regardless of needing online approval, use your brain. The patient is tachycardic, elderly, history of heart disease. The person also has a severe airway limitation , so, do we risk increasing their tachycarida, thereby increasing oxygen use & opening the airway, or, alternativley we allow the wheeze to stop & let them die? Not much choice hey hot shot?

Do no harm. Epinephrine increases cardiac O2 demand. ...Or are you simply saying that nobody could definitively prove it was your epinephrine that did the damage, and therefore pushing this drug is okay?

I am simply saying one way there is a risk of death, lack of action seriously increases that risk due to lack of air movement.

What a truly idiotic thing to say. Phil, there is more to our patients than we see at face value, and thinking in only two dimensions like this can have really negative effects. If you really believe that a patient does not exist who's presentation will exceed your abilities as a prehospital provider, you either have no experience in the field whatsoever or are a complete fool.

So we dont treat syptomatically? OK let me ask you this, because the 7 years I have in the field according to you makes me a complete fool. If you attend to a person with chest pain, what are you treating. This patient needs, O2, ASA, Nitro, Morphine, troponine assessment, possibly thromblytics, stenting, diet & lifstyle reviews, as well as some ICU time. So what do we treat? we treat the chest pain, we do that through vasodilation & inhibiting platlet aggregation, maximising O2 supply delivery & decreasing the pain with morphine (although it does have some coronary artery dilation properties, in the elderly however this is questionable) therby reducing the patients anxiety levels. Do we lecture the patient ablut the pack a day smoking habit they have, or the deep fried diet they have? Do we discuss the fact that they are a 500 pound tub of lard & they need to exercise? No way. That is innapropriate & something for the doctor to address at a more appropriate time. We treat the symptom, not the cause.

Wrong again. Spend some time in the ED and follow a doctor around. You'll see. Nobody knows everything, and it is expected that individual providers will seek the advice and experience of those around them. That is part of what it means to be a professional. Doctors consult all the time. Before, during, and after both critical and routine care.

That is what I said. I have spent time in an ER, watching & learning, I have watched a major multisystem trauma be handled by a team of doctors under the direction of an intensivist. The conductor. Unfortunatley, we do not have that in EMS, but we have each other. We bounce off partners & determine the best course of treatment for the patient in front of us at the time.

Petty name calling is not needed, if you disagree with me, I am sure you are intelligent enough to argue your point without resorting to schoolyard name calling.

[fiznat]

Does the Physician have experience in Pre Hospital Care? There is a difference in what you do on scene compared to what is done in a more controlled ER. Discussion with a more appropriate person, experienced in pre hospital care can be of more benefit in many instances.

As a matter of fact, several of our ED docs here are ex-paramedics. That aside though, I disagree with your point that good medicine is something different in the field than it is in the hospital. Good medicine is good medicine, no matter where you are.

So we dont treat syptomatically? OK let me ask you this...

I believe that our intention is to treat medical problems (pathology). Not symptoms. I took issue with you saying the following (from previous post):

This is prehospital care. You have a symptom, treat it....It is not up to us to determine most root causes...

I think this is shortsighted, and the kind of thinking I really loathe in a coworker. It may or may not be the case with you personally, but when I read this comment I feel it smacks of a sense of contentment with ignorance. A robot can "treat symptoms." A clinician thinks about pathology and root causes (and THEN treats). How would you categorize yourself?

That is what I said. I have spent time in an ER, watching & learning, I have watched a major multisystem trauma be handled by a team of doctors under the direction of an intensivist. The conductor.

It isn't what you said. You said that doctors only consult on critical patients and even then, only AFTER the patient had been stabilized. You say that right here:

Yes doctors consult, but....They have usually got the patient through the critical period & are looking at the case retrospectivley....

The distinction is important because I am pointing out that doctors consult THROUGHOUT the care of both critical and routine patients. It is an example, I think, of a professional humility and a responsibility that EMS shouldn't toss away lightly. Given time and available circumstances, I think we too should be consulting on a routine basis. It is a healthy feature of good medicine, not a kick to a Paramedic's ego.

Unfortunatley, we do not have that in EMS...

Yes we do! It's called on line medical control!

Petty name calling is not needed, if you disagree with me, I am sure you are intelligent enough to argue your point without resorting to schoolyard name calling.

I don't think I directly called you any names, but I guess I apologize. I feel strongly about a lot of this stuff and sometimes I get carried away.

Edited March 24, 2010 by fiznat

[Kiwiology]

I think this is shortsighted, and the kind of thinking I really loathe in a coworker. It may or may not be the case with you personally, but when I read this comment I feel it smacks of a sense of contentment with ignorance. A robot can "treat symptoms." A clinician thinks about pathology and root causes (and THEN treats). How would you categorize yourself?

That is not what Phil is saying. He is saying it is not up to Ambulance Officers to fix what has caused the problem hmm, let me see if I can give you examples

- You dish out some midaz to a seziure patient who had a siezure because they have a massive brain tumor; are you a neurologist?

- You give O2, GTN, ASA, CPAP and a bit of morf to a CHF patient who has CHF because of his poor lifestyle and eating McDs 24/7; is it our job to give him a lecture about his lifestyle and diet, no, and don't think I don't feel like it sometimes!

- An old lday who lives alone has trouble remembering when to take her insulin and becomes acutely hyperglyceamic; is it my place to make sure she complies or to deal with her her more pressing problem is massive dehydration?

- Some dude tried to scale a retaining wall on his BMX after 12 beers and broke his foot; should I counsel him on not doing dumb shit when drunk?

I am not saying we should be dishing out treatment willy nilly without proper knowledge of pathology and physiology (eg GTN in RVI, frusemide in CHF, suxamethonium in hyperkalemia).

What I think Phil is saying, and I wholeheartedly agree, that ambo's provide a level of care (which is some cases very highly sophisticated) but that our place in the chain should be realised.

[brentoli]

- You give O2, GTN, ASA, CPAP and a bit of morf to a CHF patient who has CHF because of his poor lifestyle and eating McDs 24/7; is it our job to give him a lecture about his lifestyle and diet, no, and don't think I don't feel like it sometimes!

- An old lday who lives alone has trouble remembering when to take her insulin and becomes acutely hyperglyceamic; is it my place to make sure she complies or to deal with her her more pressing problem is massive dehydration?

- Some dude tried to scale a retaining wall on his BMX after 12 beers and broke his foot; should I counsel him on not doing dumb shit when drunk?

So, should EMS not have any role in social services? When you have an elderly who breaks a bone on a throw rug on the wood floor, are you just going to ignore that situation? When you are in a house on a public service call, and hear a smoke detector with the low battery chirp, are you ignoring that too?

EMS is the closest to social services many people see, that are in need of it. While that is off the topic at hand, at the same time I think your examples are a little off and not relevant.

[Kiwiology]

So, should EMS not have any role in social services? When you have an elderly who breaks a bone on a throw rug on the wood floor, are you just going to ignore that situation? When you are in a house on a public service call, and hear a smoke detector with the low battery chirp, are you ignoring that too?

EMS is the closest to social services many people see, that are in need of it. While that is off the topic at hand, at the same time I think your examples are a little off and not relevant.

No, this is where there is expanded possibilites for EMS to refer to the falls team, GPs, social services etc

How are my examples not relevant?

[aussiephil]

That is not what Phil is saying. He is saying it is not up to Ambulance Officers to fix what has caused the problem hmm, let me see if I can give you examples

- You dish out some midaz to a seziure patient who had a siezure because they have a massive brain tumor; are you a neurologist?

- You give O2, GTN, ASA, CPAP and a bit of morf to a CHF patient who has CHF because of his poor lifestyle and eating McDs 24/7; is it our job to give him a lecture about his lifestyle and diet, no, and don't think I don't feel like it sometimes!

- An old lday who lives alone has trouble remembering when to take her insulin and becomes acutely hyperglyceamic; is it my place to make sure she complies or to deal with her her more pressing problem is massive dehydration?

- Some dude tried to scale a retaining wall on his BMX after 12 beers and broke his foot; should I counsel him on not doing dumb shit when drunk?

I am not saying we should be dishing out treatment willy nilly without proper knowledge of pathology and physiology (eg GTN in RVI, frusemide in CHF, suxamethonium in hyperkalemia).

What I think Phil is saying, and I wholeheartedly agree, that ambo's provide a level of care (which is some cases very highly sophisticated) but that our place in the chain should be realised.

Well said Kiwi, I do believe I tried to say that but I may have said it in Khazakstaki or Swahili.

There is a complete difference in understanding what is happening & treating the root cause. We usually develop a provisional diagnosis, we advise the hospital what we see, but it is not up to me to tell an acutely ill person who is suffering with ischaemic heart disease to lecture them on losing weight, quitting smoking & exercising as well as dietry modifications. We are called to an acute problem. We treat the symptom. We should understand what our treatment is doing, how it will benefit the patient, but the patient described doesnt need me farting about talking to someone (mass) debating over what to give them. ASA, Nitro, O2 Morphine & diesel. Minutes mean muscle. Playing around on scene could cause infarction of muscle. If me being more concerned about getting my patient to difinitive care makes me a robot, then so be it. My patient needs to be in hospital for difinitive care, regardless of it being a medical or trauma issue.

Give me the tools to treat my patients sufficiently to do that. That is my job. I am not a doctor & can only offer limited treatments. I know the pathophys. I also know my limitations. Medcontrol will not help with either of those.

So, should EMS not have any role in social services? When you have an elderly who breaks a bone on a throw rug on the wood floor, are you just going to ignore that situation? When you are in a house on a public service call, and hear a smoke detector with the low battery chirp, are you ignoring that too?

EMS is the closest to social services many people see, that are in need of it. While that is off the topic at hand, at the same time I think your examples are a little off and not relevant.

Brent,

what you are talking here is a whole of health issue. We do it here. We refer, in some cases to aged care teams. We also advise directly to the hospital of what we find. So yes, but that is not our

primary

role, it is an adjunct to it. Edited March 24, 2010 by aussiephil