The Continuation of Medical Control in EMS

[aussiephil]

I have to ask WM, Kiwi and Aussiephil, do you guys not have any standing orders or can you just practice willy nilly? There are very few interventions I need to call for. I, like you, am capable of assessing my patient's and treating them accordingly. I agree most of the time with what you all have to say. Sometimes though, this "holier than thou" attitude is a little condescending. Not all of the medic's in the US attend medic mills, and function in a "mother may I" system.

Jake,

I can only speak for myself.

We have protocols for each drug we use, & for each illness we go to (in broad terms). These do, as I stated in an earlier post give us the latitude to move & make decisions based on what we are presented with. For example, if we attend a seizure patient, we can choose IM or IV deivery, or both, our choice, to a total max dose of 15mg of versed. (Adults) It is recommended for 3mg IV doses, or 7.5mg IM doses, however, we can & I have on more than one occasion, adjust that dose to suit the patient, Better to have to give a bit more than to OD on an initial dose.

If youpercieve this as a holier than thou mentality, for may part, it is nott meant to be. I simply answered a question with my opinion & responded accordingly to other threads that have specifically questioned me. I stand by the opinion that med control is an antiquated system that should be deleted. I will not try to make it sound any prettier than what I said. We are entitled to disagree but that does not make anyone holier than thou. I hope you read all of my posts in relation to this, especially the one where I said

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.

& further I stated

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.

Phil

[Kiwiology]

I have to ask WM, Kiwi and Aussiephil, do you guys not have any standing orders or can you just practice willy nilly? There are very few interventions I need to call for. I, like you, am capable of assessing my patient's and treating them accordingly. I agree most of the time with what you all have to say. Sometimes though, this "holier than thou" attitude is a little condescending. Not all of the medic's in the US attend medic mills, and function in a "mother may I" system.

No we do not practice willy nilly and must stick within our scope of practice. Our "protocol" varies by which service you work for, the predominant operator has "procedures" which are a little tighter where the other service I have experience with has "guidelines".

In contrast to the some parts of the US where "I have to do what the doctor says" we do not have to follow our guideline to the letter. We picked up a guy who we thought was having some sort of cardiac event but weren't really sure so rather than go down the ischemia protocol and dose him up on GTN, we gave him some aspirin because in our judgement that would be more beneficial.

Every patient here does not get oxygen and when they do it's 2-3 litres on an NC 99% of the time, if we gain venous access it's with a lock and no fluid is hung, not everybody who is bradycardiac gets atropine etc. While these are not examples of "online" control they are indirect examples of the variety of "control" that exist in some parts of the US.

While I think this is a seperate issue from having to call for orders to give midazolam etc it demonstrates that the US system is still very much under the thumb of a doctor and while some medical directors have a lot of flexibility in how thier people deliver care, some do not and are on them like a fly on shit; be it through standing orders which must be followed to the letter or through having an overbearing need to call for treatment orders.

Down here in Kiwi and Australia moves are being made at the moment to remove the need for Ambulance Officers to practice under the license of a physician and give them thier own license, own professional body and independant prescribing rights which remove the need for an instrument of delegation.

[fiznat]

For example, if we attend a seizure patient, we can choose IM or IV deivery, or both, our choice, to a total max dose of 15mg of versed. (Adults) It is recommended for 3mg IV doses, or 7.5mg IM doses, however, we can & I have on more than one occasion, adjust that dose to suit the patient, Better to have to give a bit more than to OD on an initial dose.

In contrast to the some parts of the US where "I have to do what the doctor says" we do not have to follow our guideline to the letter. We picked up a guy who we thought was having some sort of cardiac event but weren't really sure so rather than go down the ischemia protocol and dose him up on GTN, we gave him some aspirin because in our judgement that would be more beneficial.

This is exactly how we practice over here. I'm really not sure where you are getting this "US paramedics are under the thumb of their physicians" bias, but it really isn't the case (at least not where I work). Those examples you mentioned (above) to illustrate your autonomy may just as well have been written by me or one of my coworkers. That kind of clinical judgement is absolutely standard practice. I'm quite sure that your and my day-to-day practice is more similar than you seem to think.

I was never talking about routine patients and routine clinical choices (versed dosage and withholding a spray of nitro is routine. So is deciding whether to hang a bag or start a lock... jeez). I'm talking about the need to maintain an open line of communication with a physician for the extreme cases where we meet the limit our of medical training.

We paramedics need to face the fact that one year of abbreviated training with no real prerequisites is NOT a substitute or in any way equal to an actual medical education. I just do not understand what makes some paramedics think that they can handle a really sick patient as completely or skillfully as a physician, simply because they are "on the street." Such thinking is hubris. ...And just because you only have so much in your bag doesn't mean it is okay to put the blinders on and cut ties with the physician. Good medicine doesn't become something else simply because you decide to narrow your own field of vision.

There is so much out there that we don't know, we should count ourselves lucky if we understand enough simply to ask the right questions. That isn't a result of systemic "inadequacies" or in any way an effort to "keep education standards low" (both which are insulting, by the way). This is respect for the importance of our job and the profound effect our actions can have on a person's life. Sometimes realizing his own weaknesses is the biggest strength a person can have.

[Kiwiology]

This is exactly how we practice over here. I'm really not sure where you are getting this "US paramedics are under the thumb of their physicians" bias, but it really isn't the case (at least not where I work). Those examples you mentioned (above) to illustrate your autonomy may just as well have been written by me or one of my coworkers. That kind of clinical judgement is absolutely standard practice. I'm quite sure that your and my day-to-day practice is more similar than you seem to think.

Not saying it is not how you might practice; look at places like Los Angeles where the Paramedics are given very, very limited autonomy to actually do anything of any real substance and must ring up on the Johnny and Roy phone to get permission.

I know Paramedics in the US who do not use locks they must run an IV bag because thier medical director will not allow locks.

These are two examples of "medical control", allbeit the latter is different from your original topic but I think it's important none the less.

I'm talking about the need to maintain an open line of communication with a physician for the extreme cases where we meet the limit our of medical training.

I have yet to see personally or be referenced to a good example of such an "extreme" case where contact with a medical control physician would be of benefit.

We paramedics need to face the fact that one year of abbreviated training with no real prerequisites is NOT a substitute or in any way equal to an actual medical education. I just do not understand what makes some paramedics think that they can handle a really sick patient as completely or skillfully as a physician, simply because they are "on the street."

Nothing, I do not and never will think that. That is why most of the patients I have encountered end up at the hospital where the physician is!

Such thinking is hubris. ...And just because you only have so much in your bag doesn't mean it is okay to put the blinders on and cut ties with the physician. Good medicine doesn't become something else simply because you decide to narrow your own field of vision.

No good medicine does not come from being narrowminded nor too open minded. It also comes from realising one's place within the food-chain, so to speak.

There is so much out there that we don't know, we should count ourselves lucky if we understand enough simply to ask the right questions. That isn't a result of systemic "inadequacies" or in any way an effort to "keep education standards low" (both which are insulting, by the way). This is respect for the importance of our job and the profound effect our actions can have on a person's life. Sometimes realizing his own weaknesses is the biggest strength a person can have.

I agree and you touch on a very good point. Realising weakness is a strength; so realise that those nations that do not require medical control contact or controlling, prescriptive practice have far superior education standards than the US which has some of, if not the, lowest EMS education standards in the developed world.

While not all encompassing, I'd bet that a good degree of the "medical control" that exists in the US be it through standing orders, protocol or requirements for online contact exists because your education is inadequate.

Did I mention Los Angeles recently?

I am not painting your entire country and its multitude of systems at being opressive and backwards operations and fully realise there are many systems in the US who have a fantastic setup for medical oversight and whos medical director(s) allow freedom and flexibility for thier Paramedics. Then, there are those systems who do not and that is really what we need to focus on if any real change is going to be made.

Case in point; BioTel which runs the medical control for the Dallas-Fort Worth metroplex EMS system, made up entirely of Firefigher/Paramedics who go to (ironically) a 24 week patch factory tech class, has very flexible Guidelines for treatment which thier Paramedics may deviate from if they feel justified in doing so.

Edited March 26, 2010 by kiwimedic

[DwayneEMTP]

Can you give me any examples because I can't think of any??

About 8 weeks ago or so I had an 82 y/o man that had gotten confused and taken several days worth of medications together. When I got to him he was unresponsive, had pinpoint pupils, brady at around 40, was exhibiting mild seizure like activity, incontinent to urine, diaphoretic, nose running all over. In his med list was beta blockers, benzos, narcs, tricyclids, and he was believed to have washed them down with half a bottle of dish soap. You can probably guess that he had dementia meds as well.

My original thought was fluids, narcan, atropine, intubation, but was afraid that nuking some of his narcotics might increase the seizure activity, which I could live with at this point, but didn't want to make worse thus forcing me to treat it with more benzos. I could have just protected his airway and ran with him the 25mins to the hospital but I knew the odds of him coming off of a vent once on were poor. Intubation was the easy answer, but possibly not the best for my patient.

He has such a rainbow of meds onboard, in unknown doses, that I wasn't really sure what to do (pharmacologically) but knew that if I had the tools, but not the knowledge, to treat him without intubation that I wanted to do so.

Now, it sounds like what our friends on the wrong side of the planet have been saying in this thread is, "You're a medic. Make the hard decisions! Narcan, Atropine, intubation and write it up later! Do your job!"

Why would I choose to do so when I had access to superior information? Now, of course what I got from med control was narcan, atropine, fluids and intubation so that they could sort it all our when they had labs, but that's not really the point. Had I chosen not to call for med control, I wouldn't have gotten jammed up. I could have kept this pt alive without advice, but perhaps would not give him his best chance at recovery.

Why am I somehow less of a provider because I called a doctor instead of calling a coworker? And no, this had nothing to do with covering my ass.

How is this situation different in the field than in the hospital? (Someone made a comment akin to it being advantageous to call an advanced care medic (something like that) instead of a doc because docs don't work prehospital.)

If calling your advanced care medics for advice is just as good as calling a doctor, then why do you have doctors? Why not simply staff your hospitals with ACPs?

I get a little tired of the whole, "Though we have access to online advice, I've never used it because I'm a medic and know how to do my job..blah, blah." I think that most of us that choose to put ourselves out there for judgment on this forum have some idea how to do out jobs. Berating others for using all of the tools at their disposal seems ignorant to me.

And to say that you have nothing to gain by getting a second opinion on an ECG, because you know your job, tells me that you've never been around two or three cardiologist discussing the same strip at the same time.. :-)

I had a kid with a severely dislocated knee. I had good pulses, it's just that his knee originally made an L instead of an I. I intended to control his pain with morphine but then wasn't really sure what they were going to use to sedate him when I got him to the hospital, though I was confident that they'd want to relocate the knee right away. I called in to ask what they'd prefer for pain management. I wasn't asking permission to treat, only what would be most conducive to getting this kids knee back in place in the shortest possible time. They told me what they preferred, I delivered it, and life went on. I grabbed a ruler and checked immediately but didn't notice that my penis had shrunk to any noticeable degree for me having talked to someone else about my patient.

Those were two of the three times that I've contacted medical control. The third because I intended to disregard orders given to me by a transferring doctor that I believed were proving to be detrimental to my pt. Yea, on that call I just wanted to cover my ass...

Interesting thread I think. But I have to say to the non Americans that when you make the argument that, "You need med control because you're systems sucks so bad you'll likely screw the pooch without it. Someday you'll be as smart as we are and actually know how to treat patients at which point you won't need such silly things any more." that you come off as arrogant and unbelievable. I believe your training is likely Superior to most of ours, but I don't for a second believe that it's superior to your doctors. And your doctors, believe it or not, ask for advice all the time.

Thanks for your thoughts all...

Dwayne

[Dustdevil]

Dwayne, I could not be prouder of you if you were my own son. Watching you transition from the hopeful student into the consummate professional has truly been one of the most satisfying experiences in the last few years of my life. If we could somehow bottle your critical thinking skills, we could create a master race of medics that would ensure the rapid progression of our profession.

When I precept or mentor a new medic, there is one concept that I stress above all others. That is to think critically and thoroughly evaluate EVERYTHING you do. Don't make a single move that you have not thought through. Don't do something just because that's how everyone else does it. Don't do something just because it's the easiest or fastest way. Don't do it just because it's the way you've always done it. Don't even do something just because it's the way you were taught in school, until you have thoroughly evaluated it from every angle and convinced yourself that it is the BEST way to do it. Everything from patient care, to how you drive, to how you chart, to how you make up your cot, to how you study, dress, and relate to your partner should be given that same level of consideration.

The skill of thinking critically like that cannot be taught. It can only be stimulated. But some people simply cannot do it, no matter how hard they try. They still get by for a full career without killing too many people. And on the surface, they look as good as any other medic (or nurse, or doctor). But there is a clear and palpable difference. Dwayne just demonstrated that difference for us. And it is the very foundation of professionalism.

Edited March 26, 2010 by Dustdevil

[Kiwiology]

My original thought was fluids, narcan, atropine, intubation, but was afraid that nuking some of his narcotics might increase the seizure activity, which I could live with at this point, but didn't want to make worse thus forcing me to treat it with more benzos. I could have just protected his airway and ran with him the 25mins to the hospital but I knew the odds of him coming off of a vent once on were poor. Intubation was the easy answer, but possibly not the best for my patient.

That is my thought too right off the bat;

- Fluids for tricyclics

- ? naloxone for opiods, caution seizures

- ? atropine for bradycardia, I'd probably give it

- Nothing for benzo's specifically, don't carry flumazanil and don't want it

No medical control required.

Now, it sounds like what our friends on the wrong side of the planet have been saying in this thread is, "You're a medic. Make the hard decisions! Narcan, Atropine, intubation and write it up later! Do your job!"

Maybe but I do not look down on those who seek clarification or assistance when they feel they need it. I never have and I never will.

Why am I somehow less of a provider because I called a doctor instead of calling a coworker? And no, this had nothing to do with covering my ass.

You are not.

How is this situation different in the field than in the hospital? (Someone made a comment akin to it being advantageous to call an advanced care medic (something like that) instead of a doc because docs don't work prehospital.)

If calling your advanced care medics for advice is just as good as calling a doctor, then why do you have doctors? Why not simply staff your hospitals with ACPs?

Obviously there is disparity between an Emergency Medicine Consultant and an Intensive Care Paramedic.

I get a little tired of the whole, "Though we have access to online advice, I've never used it because I'm a medic and know how to do my job..blah, blah." I think that most of us that choose to put ourselves out there for judgment on this forum have some idea how to do out jobs. Berating others for using all of the tools at their disposal seems ignorant to me.

I am not berating people for using online advice but I do not think it is necessary really.

And to say that you have nothing to gain by getting a second opinion on an ECG, because you know your job, tells me that you've never been around two or three cardiologist discussing the same strip at the same time.. :-)

If you are pushing things like adenosine and cardiazem then maybe because I have heard of people misdiagnosing SVT.

I had a kid with a severely dislocated knee. I had good pulses, it's just that his knee originally made an L instead of an I. I intended to control his pain with morphine but then wasn't really sure what they were going to use to sedate him when I got him to the hospital, though I was confident that they'd want to relocate the knee right away. I called in to ask what they'd prefer for pain management. I wasn't asking permission to treat, only what would be most conducive to getting this kids knee back in place in the shortest possible time. They told me what they preferred, I delivered it, and life went on. I grabbed a ruler and checked immediately but didn't notice that my penis had shrunk to any noticeable degree for me having talked to someone else about my patient.

No I don't think it will. What did the hospital tell you to give the patient?

Not sure I would have rung up here, sure I'd pop the kid with some nox or maybe a bit of morphine to take his pain away but if the little bit of morphine we give the patient makes it somehow problematic for the hospital team then it'd be something out of the blue.

Pain is a great narcotic antagonist so it's not like I'd give the patient so much morphine that when they reduce his knee he'd pass out and respiratory arrest.

Interesting thread I think. But I have to say to the non Americans that when you make the argument that, "You need med control because you're systems sucks so bad you'll likely screw the pooch without it. Someday you'll be as smart as we are and actually know how to treat patients at which point you won't need such silly things any more." that you come off as arrogant and unbelievable. I believe your training is likely Superior to most of ours, but I don't for a second believe that it's superior to your doctors. And your doctors, believe it or not, ask for advice all the time.

Our training is not superior to a doctor, never will be. I am not superior to you in any way shape or form.

We do not intend to come off as arrogant and condescending and I do not believe all medical control contacts in the US are because the provider is undeducated or worried about liability.

That said I just don't think online medical control is really necessary.

[WelshMedic]

Dwayne,

You have made some good points in your very eloquent post. So much so that you get gushing compliments from the Dust himself...so your day can't be ruined anymore.....However:

But I have to say to the non Americans that when you make the argument that, "You need med control because you're systems sucks so bad you'll likely screw the pooch without it. Someday you'll be as smart as we are and actually know how to treat patients at which point you won't need such silly things any more." that you come off as arrogant and unbelievable. I believe your training is likely Superior to most of ours, but I don't for a second believe that it's superior to your doctors. And your doctors, believe it or not, ask for advice all the time.

That is very definitely NOT what I said. I said, in fact, the opposite:\

I can't help but wonder (genuinely wonder - this is NOT intended to be an inflammatory comment) whether our US colleagues have so gotten used to being told that they are at the bottom of the chain that they have started believing it themselves?

I know from experience that there are some damn good people out there that don't need handholding. That was my point: there is nothing wrong at all with a friendly consultation in your patient's best interest. Heck, I've done it before now because I wasn't sure of the right path to take. However when it becomes mandatory before carrying out an ALS intervention, then it becomes a whole new ball-game. That's where I draw the line.

In reference to Jake's question about SOP's: yes Jake, we have a national protocols which are set every 3 years by a committee of EMS and hospital professionals. This book is then published in pocket-sized format which we are required to carry. It's an important framework, but we can and do make exceptions if in the interests of a particular patient.

WM

[Dustdevil]

I can't help but wonder (genuinely wonder - this is NOT intended to be an inflammatory comment) whether our US colleagues have so gotten used to being told that they are at the bottom of the chain that they have started believing it themselves?

I think that's a great observation. It is indeed a very common factor in US EMS. The original medics in the US were founded on the concept of being the so-called "eyes and hands of the physician". That mindset has persisted all these years, just below the surface. Way too many medics have never been forced to step outside of their flowchart protocols and use their heads to think for themselves. They are still living the "eyes and hands" life from the 1970s. And honestly, that's probably a good thing in most of the country.

Besides Dwayne's obvious aptitude for the practice, he was also blessed with a rookie gig that gave him a lot of rope and let him develop in a very independent, sink or swim atmosphere, where he quickly realised the value of critical thinking. There is no better place than Iraq to quickly realise the difference between the medical professionals and the protocol monkeys.

[DwayneEMTP]

Dwayne,

You have made some good points in your very eloquent post. So much so that you get gushing compliments from the Dust himself...so your day can't be ruined anymore.....However:

Shoot, you guys never ruin my day with your opinions. I cherish them. And Dust is very kind. Without his advice throughout my medic education I would be less than, or at least no better than those that make me crazy now. There are very few opinions that I hold that have not been shaped, or at least colored by his council. When I became a member here he was THE critical voice of EMTCity, he and akflightmedic. He's unwell now, and unable to contribute as much as he used to, but I still regularly go to him for advice, personal and professional. We're going to lose him here in the not too distant future and EMS in general will be much worse for it.

...That is very definitely NOT what I said. I said, in fact, the opposite:

My fault here brother. After going through a gazillion pages of posts I'm afraid that I kind of rolled many of the contrary opinions up together in my head. It was laziness and I apologize for it. Without going back through all of the posts I truly can't tell you which of poster gave which opinion. It wasn't my intention to put words in your mouth.

I know from experience that there are some damn good people out there that don't need handholding. That was my point: there is nothing wrong at all with a friendly consultation in your patient's best interest. Heck, I've done it before now because I wasn't sure of the right path to take. However when it becomes mandatory before carrying out an ALS intervention, then it becomes a whole new ball-game. That's where I draw the line.

Agreed. Our medical director looks at us very closely if he sees us calling in with simple questions or 'cover your ass' calls. I love to have it, though as mentioned above have almost never used it. I simply took exception with those that, to my way of reading, seemed to be implying that it should no longer exist because if you need it you shouldn't be practicing anyway. And also I guess because if you look back through Fiznat's case study postings you'll see that he is one of the incredibly rare members here that is fearless when it comes to allowing people to judge him. He is one of my favorite posters here and was taking a beating because he couldn't overcome the "Why would you ever need it?" query, without getting a reply of, "Then perhaps you shouldn't be a medic" when he revealed things he may choose to seek help on. It pissed me off that he was being beat to death with bullshit, but was unwilling to use bullshit to defend himself.

Again, it wasn't my intention to point a finger at you, or to misrepresent your thoughts, I simply didn't bother to reference by comments properly.

Thanks for you reply man...

Dwayne