Medical Control and Protocols

[txemsdoc]

Hi, thanks for responding...

First, are you really 79? If so, that's excellent to see that someone has maintained an interest in this area rather than withering away But now to the nitty gritty!

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.

I would hazard a guess that my system has the most (if not close to) the largest medical director activity I've heard of. We're at 4 full time docs, 1 part timer (specifically does pedi EMS) and looking for one more. We all have our administrative areas and all have our own take-home response vehicle which we can respond to any EMS or fire call anytime wherever. Additionally, someone is on-call 24 hours a day and all cardiac arrests get called into us (through a centralized communications center which records the call) so we can provide direct oversight if we are not there in person. I can not begin to tell you how many times we ahem 'gently nudge' our EMT's and PM's in the correct direction. For instance, no ETCO2 in a witnessed arrest and you swear you saw the tube pass between the cords? Are you so sure? If we didn't demand what should rightfully be detected by them, we'd have an esophageal intubation. Similarly.. ah, so you want to push another 12 of adenosine for your irregularly irregular narrow complex tachycardia with no p-waves since the first 6 and 12 didn't work? Umm.. how bout no. Now, I know you are saying this is stuff that shouldn't have to happen, but I tell you it does happen. And, I don't think our EMT's and PM's are any more stupid than the average EMT or PM. They pass school. They pass National Registry. They are licensced with the state. And not all of them hate the job.

I agree with you about buildind rapport and trust. However, I (and the PM Supervisors in the system) should not be their brother or buddy. We should be their parent. We aren't there to back them up despite what they did wrong, that's what the union excells at. We are not in a position (as medical directors) to discipline. We can restrict duties (oh, I have to ride on a fire truck now, oh damn) but that's it. Otherwise we 'educate' and hope it doesn't happen again.

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.

I guess in our environment, we have to dictate what to do to ensure it is done. When it is 30 minutes before my shift and I can cut corners, it happens. If it is in the protocols, then a formal disciplanary request can be investigated. If it is something under medical discretion then it's much less concrete. But, I'd agree with you that we can not possibly cover all circumstances. Also, if the protocols were more vague and relied on judgement more, we'd get more of the scenarios like this..."Doc, we're doing chest compressions but instead of 15:2 we're doing 20:2 because it looks like she's about to get a pulse back right at 14 and 15" WTF? That's one way to think outside the box...

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

Well, we cover a lot. General operational guidelines (like how to pick a hospital), describe how to do certain skills (stuff they should already know), a section on each medication we carry, and then adult, pedi, and trauma protocols which incorporate some 60ish emergencies. No, it's not everything and we have a protcol for just 'paramedic discretion when nothing else applies'. And for the last point, I agree but the former is not an option (we just make em EMT's and most wouldn't mind that) and I really don't believe, honestly don't, that it is a lack of education. They don't put what they do know to use, for whatever reason, good or bad.

Yea, I'm a member of NAEMSP and enjoy their conferences for the most part...when they don't 'go cheap' and serve only fish crackers at the receptions

Chris

[txemsdoc]

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 ...

......

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 i nthe 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 c places outside the USA registered / licenced providers don't have to ask for permission to carry out interventions within their approved skill set...

It's not a power play. It's ensuring quality care when I've had enough example of poor care to be worried. When and if I'm proved otherwise, it might change. I'd have people being paralyzed for being confrontational, I'd have bilateral chest decompressions in COPD patients with no breath sounds, I'd have unrecognized esophageal intubations, I'd have torsades never getting magnesium, I'd have long periods of no chest compressions, I could go on and on. These are not all things EMT/PM have to ask for, but I pick up on by being there or on the phone as it is happening.

I said....

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.

You said....

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

The battle for us is to ensure quality care. That's it. The battle is against laziness, passive aggressiveness and general disdain. The battle is against those who won't take responsibility for their actions. And lastly, we're not medical directors who write a protocol and delegate the running of the system and disappear. We are out on the streets more than some of our slower units. We do live fire training with the guys. We respond to all MCI's. We take call 24 hours a day all day. We get in the dirt and water. I don't think anyone would say we don't have experience.

chris

[vs-eh?]

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.

Who only does 6 tubes in the OR? Is that how many how did or the paramedics in your area do? That's wrong in itself, but as has been mentioned that number or even less is often all that is required to "pass". Does me doing 35+ in the OR (not field tubes, just clinical) make me as proficient as the anesthetist educating me? Of course not...It does however give a greater sample size for anatomy, correcting errors, getting educated on airway management, etc...All under an experts direction...Again, at least you'll have greater experience before fucking up in the field. Too many shortcuts are taken, too much responsibility for too little education.

In some ways that is your doctors fault as much as the systems...

For instance, no ETCO2 in a witnessed arrest and you swear you saw the tube pass between the cords? Are you so sure? If we didn't demand what should rightfully be detected by them, we'd have an esophageal intubation. Similarly.. ah, so you want to push another 12 of adenosine for your irregularly irregular narrow complex tachycardia with no p-waves since the first 6 and 12 didn't work? Umm.. how bout no. Now, I know you are saying this is stuff that shouldn't have to happen, but I tell you it does happen. And, I don't think our EMT's and PM's are any more stupid than the average EMT or PM. They pass school. They pass National Registry. They are licensced with the state. And not all of them hate the job.

Doc, with all do respect that is as much your doc's fault as it is the paramedics. You are the one's that allow them to practice. You should also be the one's pulling them off the road after these types of instances for CE and remediation. If they can't tell the difference between afib and an SVT (as much as a 3 lead can tell you), or they can't confirm a tube outside of looking at a waveform on a screen and swearing they saw it pass between the cords, there is a big problem in your system. Especially, if this happens with any kind of consistency...

[whit72]

Well I believe you should do at least that many in the field, before you are allowed to tube as a working medic. I do not tube as an EMT where I work, but the medics do I believe 6-10 in the OR and one in the field for their points. Thats all. What is scary is in the other state I hold a lisc. in their EMTs tube and we never have to intubate a live person to get et card, I have since let mine expire. Again I dont nec. agree with the protocols all the time, but someone must believe its beneficial.

[txemsdoc]

Doc, with all do respect that is as much your doc's fault as it is the paramedics. You are the one's that allow them to practice. You should also be the one's pulling them off the road after these types of instances for CE and remediation. If they can't tell the difference between afib and an SVT (as much as a 3 lead can tell you), or they can't confirm a tube outside of looking at a waveform on a screen and swearing they saw it pass between the cords, there is a big problem in your system. Especially, if this happens with any kind of consistency...

Well, I don't feel 'fault' per se, as much as exasperation. I think a lot of it is specific to my system. There are firefighters on engines and ladders and then EMT's and PM's doing EMS. If we don't like their care, we can take them off EMS and then they go to fire. But, that's what they wanted to do when they joined and they would probably kiss me. They do lose a bit of money but not enough to be substantial. So, we're stuck trying to motivate people to do a job they would rather not do. For the last few years, we've had one-on-one counseling/education led by a physician when these things happened, and I don't think it has helped one bit. As I said before, I don't think it is an educational problem. I need to find the book, "how to motivate someone to do what they don't want to do". It puts me in such a odd position or mindframe. I don't understand how someone could not do all they could to help someone..I wouldn't have gotten into medicine if that was the case.

I should couch my remarks in the fact that we have almost 350 PM's and some 3500 EMT's so education is slow and arduous. Also, a sizable percentage do not meet the good-for-nothing descriptions I've given forth in my earlier comments.

Chris

[Mediclcems]

The battle for us is to ensure quality care. That's it. The battle is against laziness, passive aggressiveness and general disdain. The battle is against those who won't take responsibility for their actions. And lastly, we're not medical directors who write a protocol and delegate the running of the system and disappear. We are out on the streets more than some of our slower units. We do live fire training with the guys. We respond to all MCI's. We take call 24 hours a day all day. We get in the dirt and water. I don't think anyone would say we don't have experience.

Can you please come to Florida and run our department??????

[Scaramedic]

I realize this may be inflammatory here...

...when they don't 'go cheap' and serve only fish crackers at the receptions

Chris

Damn right it's inflammatory, bad mouthing fish crackers, I love fish crackers jeesh!!!

The problem I have seen is protocols tend to become "what I can do" not "what I should do." Many Medics & EMT's get caught up in the skill parts of protocols, and forget the assessment part of their protocols. The scenarios you mentioned were not failures of protocol, they were failures to properly assess the situation and/or the patient. Hands on MC is one solution, better training in assessment in another.

Another issue I have seen in some of the systems I have worked is lack of consistency in MC. Some systems you contact the destination hospital and speak to the on duty Doc. In this situation you might speak to a ACEP Doc or a Dermatologist moonlighting in the ER. There is great inconsistency between Docs not to mention between hospitals. Another system is where you have something like a Medical Resource Hospital (MRH). All medical control for the region is handled in one call center staffed with an MD who has trained and tested on the regional protocols. This delivers a greater consistency to medical control and a better overall communication between field personnel and the Docs.

Oh yeah, don't be bad mouthing fish crackers!!

Peace,

Marty

:joker:

[vs-eh?]

So, we're stuck trying to motivate people to do a job they would rather not do. For the last few years, we've had one-on-one counseling/education led by a physician when these things happened, and I don't think it has helped one bit. As I said before, I don't think it is an educational problem. I need to find the book, "how to motivate someone to do what they don't want to do".

But I do think it is a lack of education and lack of services and doctors putting their foot down in these situations. I don't believe it is a lack of motivation. They are calling you for 12mg more of adenosine and obviously describing to you a tachy irreg/irreg rhythm. They obviously do not know why they are giving adenosine and are obviously oblivious to their error when calling you. More often than not these same patients will be on medications (as you well know) which would also clue them into a likely afib history. Multiple check points here that they aren't recognizing/knowing. They should be saying "Doc, I think I made a mistake and gave adenosine it a pretty obvious afib, sorry. Maybe we'll try rate control a CCB or a beta blocker maybe. What do you think..." They obviously don't know how to properly confim a tube and obviously aren't looking for correctable causes/reasons for possible misplacement. These are BASIC aspects of ALS care that are obviously not being attended too.

If you truely think it is simply a "lack of motivation" to not be able to differentiate between afib and an SVT, then that is a dangerous bit of laziness. Who's to know that they will know when to tube someone, to do a chest needle, etc...

I work in a large city, for a large service, under a large hospital. I am well aware of the time it takes (months) to get through a single CME, and we have several per year. When things like you describe happen, based on severity, they are remediated, demoted to a lower scope of practice (and therefore theoretically less dangerous), moved to another area of the service/city (i.e. not on the road with EMS and certainly not to a more preferable position), or fired. It's that simple.

Our service and doctors don't fuck around. They drop the hammer when it's needed.

[Ace844]

Well I believe you should do at least that many in the field, before you are allowed to tube as a working medic. I do not tube as an EMT where I work, but the medics do I believe 6-10 in the OR and one in the field for their points. Thats all. What is scary is in the other state I hold a lisc. in their EMTs tube and we never have to intubate a live person to get et card, I have since let mine expire. Again I dont nec. agree with the protocols all the time, but someone must believe its beneficial.

"Whit,"

Your Mass and RI associated BLS experience and education do not necessarily transfer across the board. Both states have a large element of 'scary' to them at the BLS level, and for the most part the same applies at the medic level as well. To assume that the 'Safety' medic style classes here are the norm or 'the standard' is poor judgement at best...!!! 6 Tubes..Come on, thats BS, and yes I know that the state now accepts 'mannequin' intubations to allow some to test. THAT IS SAD!!!! The national and state requires at MINIMUM 20 ETI's... So someone is yanking your chain. I won't even go into how SCARY RI BLS CARE IS!!! As far as my medic program I did over 1 month full time in the OR and got over 70 ETI's. Again, be careful transferring your microcasm to other areas. Yes, some of them have the same or worse, even slightly different problems. There are alot of reasons for this. One of the BIGGEST is lack of both ADEQUATE EDUCATION and TRAINING!!!!

out here,

ACE844

out here,

ACE844

[Ace844]

"TXEMSDOC,"

Welcome ot EMTCity!! I'm glad we've got another doc posting here to add to our already too small number of MD's. Based on your posts you and your colleagues sound like at heart your an involved and progressive group of docs, who wish for your patients to have access to the best prehospital clinical care available. Perhaps though, you may consider trying a different approach.

In my state on the South Shore there were a small cluster of FD based services similar to what you describe in your area. The docs got fed up with the gross negligence and constsnt 'counciling' of what should have been basic knowledge. After a year of 'progressive' involvement they went to the state and had those services ALS liscences 'pulled' for those infractions. The paramedic (ALS) coverage was avilable via non-tranport and transport units in the surrounding communities. This move was drastic, but it 'forced' change in the system and it is slowly 'imporoving' to where it should be at baseline. I also hear there is hope that with the personnell changes and everything else that this may actually evolve into a better system than it was to begin with. Food for thought.

Hope this helps,

ACE844