The Continuation of Medical Control in EMS

[Kiwiology]

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.

And it's just close enough to the surface that some will justify it until the end of time.

Even Paul Pepe over at BioTel is letting is 20 week patch factory graduates interpret "Guidelines" now, I am suprised, but he is a good medical director.

...quickly realise the difference between the medical professionals and the protocol monkeys.

Did I mention Los Angeles recently?

[WelshMedic]

Hey Dwayne,

Don't apologize, I didn't take it personally because I knew I hadn't done anything wrong. As far as your mentors here are concerned, I couldn't agree more. I sometimes think that if I had half the knowlegde of those two individuals here then I'd be a bloody fantastic practitioner.

I hadn't really thought about it before, but I guess you are right when it comes to Aaron (FizNat). He is willing to admit his mistakes and that makes him, per definition, a good provider. We've never met, but I think I could trust him with one of my own.

I am left a little baffled about your comment on ilness...who did you mean?

Carl aka WM

[zippyRN]

I let this thread run before replying

from what I can see there are a few key issues

1. the legal and professional position of the paramedic

1a. legal first - this depends on your local laws about the use of medical devices and the possession, , 'supply' and 'administration' of medication

If your local laws require medical devices to be sold 'by or on the order of a physician' then you are somewhat snookered if the law makers won't change - you must have a Medical director to be nominally responsible for the acquistion of supplies and equipment, if this is not the case then there is no requirement with regard to medical devices.

If your local laws require that a Medical Director sets the protocols/ procedures or guidelines for administering medications and/or the law requires a physician sign off on the drugs orders - then you are stuck with requiring a medical director, However if as in the UK the majority of your Drugs are given by paramedics under specific legislation ( e.g. the 'statutory exemptions' from requiring a prescription enjoyed by Paramedics and various other groups of Health Professionals in the UK and for 'any person' in relation to administering certain meds like IM adrenaline or glucagon) then perhaps you do Need a medical director - unless, again like the UK there are drugs you wish to give that aren't in the exemption but you can provide another means for paramedics to have access to and administer or even supply the drug - in the UK case it;s 'Patient Group Directives' and similar legal mechanisms ( as certain drugs or routes don't actually require a full blown PGD).

1b. The professional position of the Paramedic - is the paramedic a registered health professional in his/her own right , does the legislation require them to have a medical director or can they function as a paramedic , order and use their own medications and supplies etc etc

2. Safe preparation for practice

it is interesting that the USA despite have a supposedly standardised system of Qualifications for ambulance personnel has so many local variations and programmes which are both short on time ( in the class room and out on the road as a student ) and academic accreditation. Aus and Canada have made huge strides towards education even if professional regulation has lagged behind , the UK has made the jump with professional regulation and education is now on the catch up - despite the fact that 'traditional' IHCD route paramedic training has already been assessed as equivalent to NQF level 4 ( a bachelors degree is NQF 6 , school leaving qualifications are NQF 2 or 3 university entry is at NQF level 3) ...

the short duration of EMT-B and i-85 courses is one of the reasons the USA is stuck with medical control at present and until the water fairies stop seeing EMS as a way to prop up their budget for big red trucks, and 'helmet and pole polish' and start working in a much more integrated way on the fire and rescue side then not much progress will be made

3. integration and critical mass of personnel within the service

it's interesting to note a common factor in the UK, Canada, Aus and NZ is that the Ambulance service is by and large composed of larger regional services rather than services based around a locality or muncipality ... there's a dozen or NHS ambulance services that cover the whole of the UK, NI, Scotland and Wales have one each, the rest are regional services in England ... the AUs model is based on state wide services in the main and Canada has at least a degree of co-ordinatation and management oversight on a province basis - a larger service makes it easier for the service to take control of professional standards and will reduce the number of 'Medical Directors' potentially to one per service - although within that regional service there may be assistant medical directors as well as on call clinical advisors and field physicians etc but there's only one on the Board ...

[Kiwiology]

Zippy, sounds lke your NQF and ours are almost identical.

Our old Technician qualification was at level 4 (one above school leaving) and Intensive Care Paramedic was at level 5.

The new qualifications are Technician level 5, Paramedic equiv to level 7 (Bachelors Degree) and Intensive Care Paramedic is equiv to about level 8 (Post Grad Dip).

I say equivalent because Paramedic and Intensive Care Paramedic are university qualifications which here, do not sit on the NQF.

[aussiephil]

Dwayne, mate,

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.

You & I have talked & you know my position. The situation you described was a good one, the fact you had med control state you were doing the right thing was a bonus. I say that because you are a thinking medic. You think about your patient first, their outcomes & how you can make them better. There are those however who are more concerned with a CYA mentality, an attitude of yeah i got he bit of paper that says I am a medic, but i will fall back on med control to make the final decision for me. These guys are putting the advancement of our great (sans fire) profession. They are in all services worldwide.

That said, this thread was about a predominatley American issue, Med Control. While it may appear to be a bashing, it is criticisms that we, standing on the outside see, a devils advocate position. The thread is in essence asking if med control should be maintained or removed & the debate has continued to & fro with those in favour & thise against holding handbags at 10 paces. (Yep, i am one of them!!!!!). I have never claimed my education is superior, only that our training & levels are different & have suggested that a review as to the appropriatness of current levels in the US (This is a US based site & most members are from the US) & maybe they should be reviews, with some (EMT-B in particular) upgraded to make them more appropriate for current worldwide practice. The education content itself needs to be addressed, especially when in the chat I have heard outdated principals of the golden hour etc are still taught as gospel. How can we be taken seriously when this is the case?

I am a firm believer in removal of med control because I do not see any overall benefit. I support Clinical assistance, either online or on phone, specifically for what you describe, but does it really need to be a doctor? My service has sucessfully introduced a referral program where a triage nurse sits on the phone & takes a Hx from a patient prior to dispatch if the person has answered specific questions in the initial call, & they are now being routinly not taking up ambulance time & resources. With the advent of PDA & smartphones, we now have unprecedented acces to publications that give us a full detail of every drug on the market, would we not be better to utilize these, with our education to make a judgement? Yes med control is foreign to me, does it make it wrong? Not really. Could EMS in the US be done better? Most definitly. Is the US alone in this? HELL NO.

Anyone who is deluded enough to believe thet work for a eutopian service is publicly masterbating & should be locked up in the funny farm. Medicine, or more correctly, All medicine is a perpetually evolving animal that we, as professionals & as a profession need to be perpetiually advancing our knowledge & skills with current practice. Med control, as dust said, is a hang over from the 70's, we have changed a lot since the 70's, so why have we not changed from a med control environment into more modern & appropriate practice?

[DwayneEMTP]

As far as your mentors here are concerned, I couldn't agree more. I sometimes think that if I had half the knowledge of those two individuals here then I'd be a bloody fantastic practitioner.

I think that that is why I sometimes get a little rabid about trying to protect the integrity of the City. I show up, pay my few dollars, and sit back while folks like that paint me with their experience. They started it, made it grow, gave it a spirit and a soul, now all we have to do is protect it.

Wanna hear something really dumb? I had a dream one night a long time ago that I'd won the paramedic of the year award. As they're explaining all of these amazing calls I ran I kept interrupting saying, "But no, that wasn't me, Rob (Dustdevil) taught me to think like that. No, that wasn't me either, see because ak (Yeti) showed me how to do that. Well, no, I didn't really figure out that problem because so and so told me to watch out for that if this should ever happen!" It's truly is how I see EMS, just a big team, sharing and challenging each other's ideas hoping that we create this mombo group intelligence that's there when we need it. And we get access to that for $10? Are you kidding me?

I hadn't really thought about it before, but I guess you are right when it comes to Aaron (FizNat). He is willing to admit his mistakes and that makes him, per definition, a good provider. We've never met, but I think I could trust him with one of my own.

I used to read his case studies and think, "Oh shit. I would have changed that! I would die if anyone knew I'd made that mistake!" But of course I do make them, I just don't have his courage and commitment to showing them to the world so that they are allowed to learn from them. I'm trying though...And yeah, I'd trust him with one of my own. If you've not read his blog, http://babymedic.blo...&max-results=11 you should. It's just like his posts, and if you really care about doing good medicine, you'll find plenty of yourself there as well I think.

baffled about your comment on ilness...who did you mean?

I can't find that reference. Can you be more specific?

Dwayne

[fiznat]

I really appreciate that we can go back and forth about this for so many pages, and avoid (for the most part haha) letting the thread degenerate into a shouting match. Everyone up to this point has been willing to pull back for a moment and reflect, and I think that speaks volumes about the quality of characters on here. I know I can be an ass sometimes haha but as I said before I do feel strongly about this stuff and I don't mind arguing about it at length. None of it is personal.

Anyways, I called medical control yesterday and I was thinking about you guys. Here is the scenario.

22 year old male, driver in a car vs. car motor vehicle accident. This driver struck a parked car on the opposite side of the road, after witnesses saw him slumped over the steering wheel running a stop sign just previous to the site of the crash. There was some damage to the front of the patient's car, but really nothing too major (estimated speed 20 mph). No intrusion into the passenger compartment, no airbag deployment. On our arrival the patient was walking around outside the car, smoking a cigarette and completely without complaint. He is alert and oriented, GCS 15, but looks a little "off." He is profusely diaphoretic, tachycardic at 150, hypertensive at 160/100, incontinent to urine. Trauma assessment is completely negative. It took me 15 minutes to convince him to go to the hospital.

I called in a routine notification radio patch to the hospital to let them know we were coming, but asked to speak to a doc quickly. The reason was, because this patient was involved in a MVC and has abnormal vital signs, the general practice is to do a "trauma activation." A trauma activation involves calling a bunch of medical residents, trauma surgeons, nurses, etc to the "trauma room" and do a rapid trauma assessment and treatment. It is very resource intensive and is in general very distressing to the patient. My discussion with the doc centered around whether this was a "pre crash" problem or a "post crash" (trauma) problem. I believed that the story we got from witnesses supports that this patient's condition caused the crash, and not the other way around, and that the patient might not need a "trauma" activation but rather a medical one. In addition, the trauma side of this scenario was very weak, with only minimal damage to the patient's vehicle and a reported low speed collision. I spoke with the doctor for maybe 45 seconds, and because we had that talk before we got there, the doc and I were able to both streamline care for this patient as well as maximize resources within the hospital.

Edited March 26, 2010 by fiznat

[aussiephil]

22 year old male, driver in a car vs. car motor vehicle accident. This driver struck a parked car on the opposite side of the road, after witnesses saw him slumped over the steering wheel running a stop sign just previous to the site of the crash. There was some damage to the front of the patient's car, but really nothing too major (estimated speed 20 mph). No intrusion into the passenger compartment, no airbag deployment. On our arrival the patient was walking around outside the car, smoking a cigarette and completely without complaint. He is alert and oriented, GCS 15, but looks a little "off." He is profusely diaphoretic, tachycardic at 150, hypertensive at 160/100, incontinent to urine. Trauma assessment is completely negative. It took me 15 minutes to convince him to go to the hospital.

I called in a routine notification radio patch to the hospital to let them know we were coming, but asked to speak to a doc quickly. The reason was, because this patient was involved in a MVC and has abnormal vital signs, the general practice is to do a "trauma activation." A trauma activation involves calling a bunch of medical residents, trauma surgeons, nurses, etc to the "trauma room" and do a rapid trauma assessment and treatment. It is very resource intensive and is in general very distressing to the patient. My discussion with the doc centered around whether this was a "pre crash" problem or a "post crash" (trauma) problem. I believed that the story we got from witnesses supports that this patient's condition caused the crash, and not the other way around, and that the patient might not need a "trauma" activation but rather a medical one. In addition, the trauma side of this scenario was very weak, with only minimal damage to the patient's vehicle and a reported low speed collision. I spoke with the doctor for maybe 45 seconds, and because we had that talk before we got there, the doc and I were able to both streamline care for this patient as well as maximize resources within the hospital.

Cant this be doen if you pass an appropriate full report to the hospital. Eg, driver Gender, age, apparent injuries, signs & symptoms? this is an obvious S7S that can be passed & then the hospital makes a decision.

[Kiwiology]

Cant this be doen if you pass an appropriate full report to the hospital. Eg, driver Gender, age, apparent injuries, signs & symptoms? this is an obvious S7S that can be passed & then the hospital makes a decision.

I agree. If this were here we'd just ring up on the ambo phone and tell them what we had as Ambulance Officers' do not have the right to request a "trauma" activation like in the US; that is something the hospital decides.

Fiz does raise a point however when we have a choice of dstinations (which is only in one or two places here) we can ring up the hospital and speak with the Consultant (senior board certified emergency medicine physician) about which hospital it is better to take them to.

While bypass policies generally eliminate the need for this but I suppose it does happen every once in a while.

[WelshMedic]

I can't find that reference. Can you be more specific?

Dwayne

Correct me if I'm wrong but I thought you mentioned either AK or Dust being ill and not able to post much these days?

Send me a PM if you think it's more appropriate.

Carl.

PS - And yes, I read Aaron's blog AND show it to all my students..

Edited March 26, 2010 by WelshMedic