Physicians on ambulances? As a career?

[Just Plain Ruff]

mikey, I believe that your thoughts on Princess Di are correct. I do believe that she was worked on for over 40 minutes but I think much of that time was extrication as well as treatment. Not sure. But I do know that the hospital was waiting on the ambulance and they were getting pretty frustrated with the crews not transporting her.

Makes me wonder just how bad her injuries were at the scene that required them to stay and play rather than load and go. Were there some interventions that were required absolutely before they could get her on the road.

[ERDoc]

What interventions could they have been doing that would have taken that long?

[Just Plain Ruff]

not sure what interventions but....

my thoughts are that she was dead on their arrival and they did not want to be the ones associated with Princess Diana's death. That's my thoughts.

[ERDoc]

They are not going to pronounce someone that famous in the field short of decapitation. According to the link above, the paparazzi heard her talking to the responders, so who knows. Either way, her injury was not survivable but it makes you wonder what they were doing that took so long.

[Just Plain Ruff]

They are not going to pronounce someone that famous in the field short of decapitation. According to the link above, the paparazzi heard her talking to the responders, so who knows. Either way, her injury was not survivable but it makes you wonder what they were doing that took so long.

No what I meant was that they were trying to figure out a way to not be associated with her death, not that they weer calling her in the field. Make more sense? Prolly not. But anywho.

[systemet]

They are not going to pronounce someone that famous in the field short of decapitation. According to the link above, the paparazzi heard her talking to the responders, so who knows. Either way, her injury was not survivable but it makes you wonder what they were doing that took so long.

There's a page here (obviously low-quality source, and likely biased with the URL "diana speaks") http://www.dianaspeaks.info/AutopsySummary.html

It suggests a chronology where the crash happens @ 0025, fire arrives at 0032, and the MICU arrives @ 0040. Apparently she was perfusing enough to be screaming in pain, and receives fentanyl / midazolam from an IV line initiated @ 0045, prior to extrication. It's unclear from this site whether this was to facilitate airway managment, or for extrication (doses unavailable in source). This was a few years ago now. I think today, the answer would probably be a small aliquot of ketamine. She arrests five minutes later @ 0050, it sounds like "during extrication".

She's subsequently intubated, and they requests a transport destination w/ a surgical ICU bed at 0119, subsequently receiving direction to transport to a hospital four miles away @ 0129. She arrived with a pulse, strangely "without severe external injuries" @ 0206, which seems like an awfully long time to drive four miles. She rearrested at or before 0216.

--------

Again, this source is probably very unreliable, and likely inaccurate. But based on this information, I'd assumed they'd thoracotomised her in the field, and were attempting some form of surgical correction. Apparently though, she wasn't thoracomtised until after her second arrest, where they (according to this source), found a partial rupture of a pulmonary vein near left atrium. They continued resuscitation until 0400.

My suspicion is that the extrication itself chewed up a sizeable chunk of the on-scene time. But I can't account for the prolonged transport time. Also, according to this source, there was no chest tube on arrival.

To me, you witness a traumatic cardiac arrest, you immediately drop both sides of the chest, intubate and bolus fluids. I would assume that a physician-led team would, at the very minimum, throw in a pair of chest tubes, and consider opening the pericardium (at least in the pre-portable ultrasound era). Of course, here the blood in the chest, and the PPV was probably doing something to tamponade the venous bleed that killed her.

[systemet]

Edit:

There's also this, on-line. It has the trappings of a journal article but isn't indexed on pubmed. It also deal with a lot of low quality data.

http://ispub.com/IJRDM/1/2/12892

[edogs334]

I know that this post is over a year old, but in case any other people want info on this subject, I'll go ahead and post the information I know:

People who've already posted on this board are right- physicians whose primary, full-time function is direct pre-hospital field care are few and far between in this country.  Physicians are more utilized in direct EMS patient care in other countries- such as the UK.  Go on Youtube and search  "London Ambulance Service Doctors" Or https://en.wikipedia.org/wiki/Gareth_Davies_(doctor)  Or https://londonsairambulance.co.uk/our-service/our-people  

There is also an organization called the National Association of EMS Physicians (NAEMSP)- an organization consisting of EMS medical directors and other physicians who have a professional interest in EMS.  You might want to try contacting them for more information and perspectives.  They have worked to advocate for EMS in the greater healthcare community, as well as to make EMS a recognized subspecialty of Emergency Medicine.  In fact, a physician I worked with was one of the first to take the EMS subspecialty board certification exam a few years ago.  http://www.naemsp.org/Pages/default.aspx

There are also a few HEMS (Helicopter EMS) services in the US- as people have mentioned- that still utilize physicians as direct patient care providers on their aircraft.  University of Cincinnati AirCare is one of them: http://www.aircareandmobilecare.com/Staff.aspx    UCAN (University of Chicago Aeromedical Network) is another: http://www.uchospitals.edu/professionals/ucan.html

University of Maryland Shock Trauma Center (STC) has a physician response team called the GO-TEAM, which consists of a trauma surgeon and a CRNA, who respond via air or ground ambulance. http://umm.edu/programs/shock-trauma/professionals/ems/go-team   I believe New Jersey also has a similar team.  Keep in mind, though, that EMS response is not the team members' full-time responsibility.  They work in their respective roles in the hospital and are called out on a case-by-case, emergency basis.

One of the physician medical directors of the service I volunteered with was also a member of a volunteer fire company in that system, and had an SUV with a county radio designation.  In this capacity, they would respond to calls when they felt the patient might benefit from their EM physician scope of practice on scene or during transport. 

There are also emergency medicine (EM) physicians who serve on SWAT teams as tactical physicians- something I've heard of, but honestly don't know much about.  

Another career goal to consider is to become the full-time medical director of an EMS service- like what Dr. Brent Myers did with Wake County EMS in NC.  These positions are few and far between, though, and are considered the pinnacle of physicians' careers who have a passion for EMS- achieved after many years of education, training, perseverance and networking.  There are many EMS physician medical directors out their who practice emergency medicine full-time in their respective hospital emergency departments, yet serve as medical directors on a part-time basis (or as part of their administrative responsibilities).   

If you really want to become a physician in the U.S. and still have an involvement in EMS, you might want to make your peace with practicing EM full-time in a hospital emergency department.  Like ParamedicMike said, you can complete an EMS fellowship after residency.  This would give you added experience and credentials to become an EMS medical director, as well as to function in the field on a part-time basis (whatever your system and time constraints allow you to do so).  

 

Edited September 17, 2015 by edogs334

[Just Plain Ruff]

I worked at a small service, hospital based,  On very slow nights the physician on duty(medical director he was) would often ride out on calls with us.  Granted only the good calls that he thought would be exciting.  He got a couple of really good fun calls but often times he was more in the way then not.  

 

He finally just decided to stay in the ED and wait for us to bring the patient to him.  It wasn't a trust issue, but more of a boredom issue.  By the time we got the patient to the ED, 80% of the treatment had been done.  Most everything he had to do was a physician evaluation, labs, xrays and either admit orders or transfer/discharge em.  Many times he would just direct admit em if he was their primary care doctor as well.  

Edited September 17, 2015 by Ruffmeister Paramedic

[MedicNorth]

Chances are that you could work on an ambulance, but would have to stay within the scope of practice for a paramedic, mostly because the company you are working for would stock the unit to that level, and would be insured to that level. That would be extremely frustrating for someone who had invested the years and money to get the MD. I don't understand why a busy ER would not suit you - So much more you can do with the skilled staff, the support, the tools to do the job.

If it is the rush, believe me, it wears off after a while.