Medical Control and Protocols

[txemsdoc]

Hi,

I've read a lot of discussion about good vs bad systems, aggressive systems, etc... and some of it relates back to the level of medical control in the field and how much it intrudes into the daily activities of a paramedic or EMT. I realize that rules in this area differ state by state, but in Texas, the medical care is delegated to an EMT or PM and the medical director is ultimately responsible for the care given. It follows then, that a conscientious medical director would want to know what care is given, by whom, and how much he/she can trust them.

I'm left with the impression that a great many people here think that an ideal system has no direct medical director involvement during the actual care of the patient. But I am left wondering why, if this was your stance and you want to practice medicine independently, you didn't go to medical school on your own? People here talk about thick protocol books as if it is a bad thing as well. Because Rosen is thick, does that mean it is bad too? Protocols should be specific and address every medication you have at your disposal and when you are allowed to do certain procedures. Because, yes, in my neck of the woods, the medical director allows you to act for him/her.

I think that the medical director's priority is not the happiness of the EMT's and paramedics. It is not to allow them to do what they want. They do not know best and are occasionally driven by what's best for them, not the patient. The medical director's main priority is the well-being of the citizens in the area his/her agency serves. And sometimes that priority trumps the desires of EMT's and paramedics.

I realize this may be inflammatory here, but I'm truly interested in your thoughts and I realize that some things differ state by state and I base my comments on Texas.

Chris

[JakeEMTP]

In my little corner of the Country, we are required to do a scope of practice skills test as well as have an interview with the medical director before we can actively work in the county. After all, it's is his medical license we are working under and he has every right to know who is preforming under it. If he is not comfortable with some of your responses and doesn't feel comfortable with you as a provider, you can't function in the county, period. Whether you are a certified/licensed EMT/Paramedic is irrelevant.

I for one, do not have a problem with this. The protocols are reasonable and they are also flexible with on-line medical control. This means if I/we feel we could help a pt by administering another dose, or a different drug and if it sounds feasible, we will get the go ahead to do it.

[Ridryder 911]

First welcome to the site !

Having an active medical control is essential for development of having a progressive EMS. However; just having one is not the key. As a medical director are you very active ? A physician(s) should be developing a rapport and trust. Performing testing, observations, ride alongs and education classes can be increasing trust between the physician and EMT's. Yes, they work under your license, and yes you are responsible. However; what many do not understand you have power to see what and whom and the calliber of medics that is being hired. If I was a physician, I would want those to have autonomy, and knowledge..not a bunch of trained "chimps" that follows protocols. You are the one that can make that difference.

Protocols should be written as suggestions or guidelines, and never direct "what to do"; as well having a thick protocol does not mean they will improve or deliver better care. They should had been educated in the professional & medical standards that you expect in delivery of care. Again, you can control this without step by step protocols. Each subject or situation should not have to be written out, if they need one, then again there is an education problem. You as a medical director apparently feel that they are not able to make rationale decisions upon their license level, or is it that you are covering your ass because of the potential incompetence that could cause litigation? Even having a step by step protocol can actually increase litigation's, by medic not following each letter of the protocol for every situation one increases the chance. That is why more and more emphasis is placed on education, QI, and protocols for specific problems or illnesses.

As well how much can one really cover on protocols? Do you really need a section for everything? I hope not ... again they should be generalized guidelines, with the bottom line " upon description of the Paramedic". If you do not feel that you are able to trust them with this type of descisions then there needs to be some house cleaning or education.

I highly suggest you check out National Association of EMS Physician web site : http://www.naemsp.org/ There is several EMS medical control that have developed systems and education for EMS personnel.

Respectfully,

R/r 911

[whit72]

I am certified as an emt in one state with medical control, I am also liscensed in another state. the latter is definitley a more aggressive sytem with ever changing protocols which allows EMT to give multiple drugs, intubate and also defib. not aed. In the medical control state they are very weary of intoducing new medications and procedures. The protocols are law in the certified state, in the lic. state they are guidelines that can be deviated from. I am not sure which one is better, they both have their benefits, seasoned EMTs and medics do thrive in the lic. state. It could however become troublesome for new emt's who have not had the experience.

Contray to popular belief on this site MEDICS and EMTs do not come out of school with necc. knowledge to perform their job sure they know how to treat chf, copd, but half of them cant tell the difference between the two that comes with experience. I work with both types of emt ones that shouldnt be allowed to make a decision and ones that you would never question the ones they made. That is why you need protocols because the level of experience and competency is to broad.

lic. state meds.

ASA

ALBUTEROL

NITRO

RECTAL TYLENOL

IM GLUCAGON

ORAL GLUCOSE

RACEMIC EPI

EPI PEN

IM EPI

NEB EPI

IPECAC

CHARC.

O2

SKILLS

INTUBATION

BLOOD SUGARS

DEFIB

CERTIFIED STATE

O2

ASA

EPI PENS

ORAL GLUCLOSE

SKILLS

NEBS

BLOOD SUGARS

MED CONTROL DOSENT ALLOW EITHER ONE.

[Ridryder 911]

If you come out from school not knowing differential between medical ailments or not knowing how to perform assessment techniques and having the knowledge of the current medical treatments, then you came from a piss poor school or are a poor student/ medic. You should not be performing patient care. What are we producing out there ?

Yes, clinical experience is necessary and definitely is needed, to hone the skills not to teach what the illness is. Having cookbook protocols is not the answer. No matter how many protocols you may have in your book, one still needs to have and posses assessment skills to make the determination of the clinical impression (diagnoses). If one does not know the treatment regime of treating medical illnesses or emergencies, then we have more problems in education than I realized. What was taught in you education ? Again, this adds more support of formal education and the removal of training, as well as the proof of not allowing those lower than Paramedic level administer medications and perform ALS skills.

Again, how much reading and studying do most medics actually perform? ...Do you assess all patients, so clinical experience can be obtained?

There is no excuse of having poor knowledge, and not being able to perform and deliver at a competent level. It is a shame that it continues! Ignorance is NOT blessed nor should it be allowed or tolerated!

Sorry, Doc ; I now see why physicians are getting more concerned about protocols...it is not that way everywhere.

R/ r 911

[zippyRN]

Hi,

I've read a lot of discussion about good vs bad systems, aggressive systems, etc... and some of it relates back to the level of medical control in the field and how much it intrudes into the daily activities of a paramedic or EMT. I realize that rules in this area differ state by state, but in Texas, the medical care is delegated to an EMT or PM and the medical director is ultimately responsible for the care given. It follows then, that a conscientious medical director would want to know what care is given, by whom, and how much he/she can trust them.

these you achieve by good QA programmes, adequate training and Education, and involvement in service provision, not by making the guys and girls out on the road ask for permission to do things you have provided them with the education to do ...

I'm left with the impression that a great many people here think that an ideal system has no direct medical director involvement during the actual care of the patient. But I am left wondering why, if this was your stance and you want to practice medicine independently, you didn't go to medical school on your own?

If medical direction are there to answer questions outside the protocol / guidelines, if medical control physicians are prepared to come out to scene where there is a clear need - that's great - that's what our medical directors in the NHS and Voluntary sector do

making people ask for permission to do their jobs is nothing other than a power play ... needless to say in most places outside the USA registered / licenced providers don't have to ask for permission to carry out interventions within their approved skill set...

People here talk about thick protocol books as if it is a bad thing as well. Because Rosen is thick, does that mean it is bad too? Protocols should be specific and address every medication you have at your disposal and when you are allowed to do certain procedures. Because, yes, in my neck of the woods, the medical director allows you to act for him/her.

protocol books are bad full stop, clinical guidelines are very good , the UK works to clinical guidelines ( www.jrcalc.org.uk) but has the advantage that paramedics work to their own registration, however the organisation is still vicariously liable to a degree and is liable for all the actions of technicians, middle tier , PTS and first responders

I think that the medical director's priority is not the happiness of the EMT's and paramedics. It is not to allow them to do what they want. They do not know best and are occasionally driven by what's best for them, not the patient. The medical director's main priority is the well-being of the citizens in the area his/her agency serves. And sometimes that priority trumps the desires of EMT's and paramedics.

only where there is a power battle between the road staff and the medical directors - especially where medical direction is provided by physicians with no appreciable field experience...

[zippyRN]

http://www.asancep.org.uk/JRCALC/

might work better to get to the JRCALC clinicla guidelines

[whit72]

You must live under a rock, So if every paramedic is prepared when they finish school why do you want them to have B.S. in paramedicine, you are contradicting yourself. Yeah you shouldnt be practicing medicine but they are, in every state in the country. Some better then others.

[vs-eh?]

the latter is definitley a more aggressive sytem with ever changing protocols which allows EMT to give multiple drugs, intubate and also defib. not aed. In the medical control state they are very weary of intoducing new medications and procedures.

lic. state meds.

ASA

ALBUTEROL

NITRO

RECTAL TYLENOL

IM GLUCAGON

ORAL GLUCOSE

RACEMIC EPI

EPI PEN

IM EPI

NEB EPI

IPECAC

CHARC.

O2

SKILLS

INTUBATION

BLOOD SUGARS

DEFIB

CERTIFIED STATE

O2

ASA

EPI PENS

ORAL GLUCLOSE

SKILLS

NEBS

BLOOD SUGARS

MED CONTROL DOSENT ALLOW EITHER ONE.

For an EMT, that is a ridiculous scope of practice. And in many ways exceeds (yet again) what a PCP an do with 1600ish hours of total education included in their 2 year college diploma. I honestly don't understand the reasoning for letting an EMT intubate. I assume this is for cardiac arrest only. Intubation doesn't save live's in a cardiac arrest. Proper BLS airway management and ventilation will do just as well in 95% of the cases in an uncomplicated airway. That is what should be paramount (and is in the new ACLS), not jamming tubes in throats...

What was your didactic/clinical/preceptor time?

[whit72]

It is what it is, those are the protocols like it or not. So six tubes in an OR makes you proficient at intubating? Whats the problem you have with it the intubating or the drugs? I think the racemic epi has been removed from the protocols, I do not work in that state anymore.