The Continuation of Medical Control in EMS

[Kiwiology]

Where I work, we call a physician on the radio when we truly need another opinion on a difficult topic

I agree with you in principle and this is pretty much what we have; you can speak to one of our medical advisors here but I can't even think of an example where we'd want to because it would be so far out there and inconceviably bizzare it's beyond formulation for me!

(Should I give a third SQ epinephrine to this 55 year old woman with severe asthma?

Sorry mate but I have to nitpick here. This sort of thing shouldn't be something you need to consult for really it amounts to "does the patient need it?" in my opinion.

On this topic, we've gone away from giving small boluses of adrenaline IV (I suspect for the reasons you alude to, too many people OD'ing folk on adrenaline) to using an adrenaline infusion; 1mg in one litre started at 2gtt/sec titrated.

Do you agree with my assessment of this STEMI patient so that we can bypass the ED for the cath lab?

Yeah I agree this is something you might want to transmit the 12 lead to CCU for a cardiologist's input but even then I think I'm not sure, it's not something we do here and rely on the Paramedic or ICP interpretation of the 12 lead .... where's that Datascope when you need it?

I've got a difficult syndrome here in a critically ill patient and I'm not sure which path to take...)

While absence of evidence does not mean evidence of absense ... I often spout the same principle as you here for retaining some form of online contact but I am as yet unable to think up an example of when it would be appropriate specifically beyond the broad "sick patient I don't know how to treat".

My thinking on the matter is "hmm, does the patient meet any indications for a medication I can administger? No ... hmm, better support those ABCs and go to the hospital".

Can anybody out there support fiz's argument and provide some example of a time when it was useful for you to consult with a doctor about something abstract?

Even doctors call other doctors to discuss things if they get in a bind. Who's to say that we are too good for that?

I think that some places have gone a bit crazy with medical control and made people call up for silly things like a bit of morphine and that it's been resisted because MC is seen as overly restrictive. Add in people outside North America who have no online direction and viola, you end up with people disliking the notion of online consults.

That brings me to another question; who exactly are you talking to (and taking orders from prn)? Are you speaking to your service medical director or some random doctor in the recieving ED? Here, we would speak to one of our service medical advisors, but like I say, I have never heard of anybody doing it.

[fiznat]

Sorry mate but I have to nitpick here. This sort of thing shouldn't be something you need to consult for really it amounts to "does the patient need it?" in my opinion.

Maybe. If you are on your 3rd dose of epi and the patient is 55 years old (which makes epinephrine a dangerous proposition!), perhaps there is something else that ought to be considered. A lot of epinephrine in an elderly patient is something that isn't to be taken lightly. I agree that neither is respiratory distress, but we too abide by a "do no harm" principle. I personally feel like these kinds of "oh crap" situations deserve fresh eyes, and I don't consider it a personal insult to ask for help or a second opinion.

On this topic, we've gone away from giving small boluses of adrenaline IV (I suspect for the reasons you alude to, too many people OD'ing folk on adrenaline) to using an adrenaline infusion; 1mg in one litre started at 2gtt/sec titrated.

Agreed. Although epinephrine infusions for this particular scenario haven't quite made it to the pages of our local guideline books (they actually do say "paramedic guidelines" on the front). An epinephrine infusion would definitely be the subject of my consultation with OLMC in this case. I understand that a paramedic could likely do this on standing order, but epi infusions are not yet commonplace here and it would definitely be prudent to have a talk about it with the doc before we start making things up based on what we may have read about or heard someplace.

Can anybody out there support fiz's argument and provide some example of a time when it was useful for you to consult with a doctor about something abstract?

Hopefully if anyone can, its me! haha. How about:

1. Extended treatment options for field treatment of severe hyper-k without lab results. This is a dangerous condition that we can do something about in the field, but often do not for lack of definitive lab values (and reasonably so!). A conversation with a doc where the paramedic relays the pertinent clinical findings could lead to a field treatment that otherwise may not have been prudent, which could be life saving. This one is from my own experience.

2. Tox syndromes. Toxicology is a whole medical sub-specialty, and there is a lot more out there than the usual narcotic/beta blocker/TCA/organophosphate stuff we are more familiar with. A conversation with a physician in an unusual OD scenario can be extremely valuable.

3. Deep ACLS. Management of refractive brady or tachyarrhythmias (wide complex especially) can definitely benefit from a fresh set of eyes. I have absolutely no problem forwarding an ECG to medical control for a 2nd opinion if I am concerned about WPW in a patient that might otherwise get Cardizem, or a potential VT in a patient who is refractive to Amiodorone. These are tricky scenarios that even cardiologists sweat over. Why make this decision on your own if you don't have to?

How about those?

That brings me to another question; who exactly are you talking to (and taking orders from prn)? Are you speaking to your service medical director or some random doctor in the recieving ED? Here, we would speak to one of our service medical advisors, but like I say, I have never heard of anybody doing it.

We talk to the ED attending that picks up the phone. Our local guidelines contain an agreement between hospitals that the receiving attending ED physician is the acting medical control doctor for that particular patient.

Edited March 21, 2010 by fiznat

[Kiwiology]

...I personally feel like these kinds of "oh crap" situations deserve fresh eyes, and I don't consider it a personal insult to ask for help or a second opinion.

Not at all, as they say two-or-three heads are beter than one!

...it would definitely be prudent to have a talk about it with the doc before we start making things up based on what we may have read about or heard someplace.

Aw shucks there goes 90% of the basis for my ambulance practice .....

Extended treatment options for field treatment of severe hyper-k without lab results

Intensive Care Paramedic's can give salbutamol for this, but Technician or Paramedic can but would be steping outside scope of practice. In this situation you'd either call for backup, do it and then write it up or ring up Comms and ask to speak to the regional medical advisor or consultant in ED. I suspect its 100x easier to just do it and write it up later as the RMA may be unavaliable or have no cell coverage, or the consultant you get in ED might have zero interest in helping an ambulance crew.

2. Tox syndromes. Toxicology is a whole medical sub-specialty, and there is a lot more out there than the usual narcotic/beta blocker/TCA/organophosphate stuff we are more familiar with. A conversation with a physician in an unusual OD scenario can be extremely valuable.

But what are they going to have you do specifically? Fluids? Drugs? If you carry the stuff to do something about it then sure, but we don't so I'm not sure how to respond to that, well I suppose I am because I just did!

3. Deep ACLS. Management of refractive brady or tachyarrhythmias (wide complex especially) can definitely benefit from a fresh set of eyes. I have absolutely no problem forwarding an ECG to medical control for a 2nd opinion if I am concerned about WPW in a patient that might otherwise get Cardizem, or a potential VT in a patient who is refractive to Amiodorone. These are tricky scenarios that even cardiologists sweat over. Why make this decision on your own if you don't have to?

If you can ask somebody else for help I say go for it! We cannot transmit ECGs here except one or two places that do thrombolysis 1) because there is really no need for it, 2) it's really, really expensive and 3) it makes the doctors work!

Should your compromised VT patient be refractory to amiodarone; cardiovert.

I can conceede that locally given different drugs and guidelines there may be a need for some form of online consultation; I always say two heads are better than one and do not belittle or look down upon anybody who asks for help.

Even here we do have a system of online contact I've never used it nor seen it used nor been in a situation where I would want to use it.

My point is this - while there should be a system of medical advice and support within Ambulance practice; be it from very, very experienced Intensive Care officers (like is generally the norm here by recall to the watch manager if we get stuck) or a doctor, it should not be required routeinly for standard everyday treatment.

Los Angeles is a shining example of medical control gone a lil crazy.

[aussiephil]

I think there are big differences here in what "on line medical control" means to each of us. I see some people commenting that they have to call a physician and ask about first round analgesia dosing, and I also see people referring to their protocol as "guidelines." These are two opposite ends of the spectrum, and both are represented here.

Fiz,

I think you will find it was I that used pain relief as an example, thats all it was. It wasn't just about first round doseing, it was about the administration of analgesia. Just so were clear, here is what I said

fail to see why I should have to ask how much pain relief to give to someone.

Changes the relevance of your comment. A protocol is nothing more than a guideline. Again, using analgesia as an example, I can give up to 5mg bolus with repeat doses of 2.5 to 5mg every 2 mins to a max of 5.mg/kg. NO further questions asked.

Personally, I don't think we should ever be without on-line medical control for some things.

Why does it have to be a doctor? We have clinical assistance lines that perform the same function.

Where I work, we call a physician on the radio when we truly need another opinion on a difficult topic (Should I give a third SQ epinephrine to this 55 year old woman with severe asthma?

If you have to ask this question, then you really need to have your accreditation reviewed. Lets see. The person is having severe respiritory distress issues. There is minimal air movement. I give dose 1. Slight implrovment. I give dose 2. Slight improvment. What the hell am i calling for advice or, either the patient needs their airway open to breath, or they die. If they have a cardiac event post epi, was it caused by the epi, or was it caused because the myocardium had been working too hard when they couldnt breathe? This one is a no brainer.

Do you agree with my assessment of this STEMI patient so that we can bypass the ED for the cath lab?

STEMI, I agree, ECG is open to interpretation & you are better to be sure.

I've got a difficult syndrome here in a critically ill patient and I'm not sure which path to take...).

Huh? This is prehospital care. You have a symptom, treat it. I had this discussion in the chat recently. EMS treats symptomatically. It is not up to us to determine most root causes & the person you are discribing needs the benefit of a HOSPITAL with doctors, nurses, & those wonderful things called pathology labs. Treat what you see/find, & get em to hospital, you dont need a doctor to tell you that.

It is my feeling that these calls are open and honest consultations with colleagues, and a recognition that there is a whole lot out there that we Paramedics, or any individual for that matter, doesn't know.

I agree there is much we dont know, however, they are not a consult. they are a CYA tool for lazy medics who fail to use their brain. They are a failsafe method for people to say I only did what I was told, a Neuremberg defence when it all goes to shit. Now your stuff. Treat what you see/find, get rid of medical control.

Even doctors call other doctors to discuss things if they get in a bind. Who's to say that we are too good for that?

Yes doctors consult, but they are usually having a consult over a patient who has more care than they can poke a stick at. They have usually got the patient through the critical period & are looking at the case retrospectivley to determine future treatments & how they may have improved past treatments.

[fiznat]

Aw shucks there goes 90% of the basis for my ambulance practice .....

lol

Intensive Care Paramedic's can give salbutamol for this, but Technician or Paramedic can but would be steping outside scope of practice. In this situation you'd either call for backup, do it and then write it up or ring up Comms and ask to speak to the regional medical advisor or consultant in ED. I suspect its 100x easier to just do it and write it up later as the RMA may be unavaliable or have no cell coverage, or the consultant you get in ED might have zero interest in helping an ambulance crew.

So you're agreeing with me right? This is a good place to call on-line medical control. You suggest that crews might "just do it and write it up later," but come on. You gotta have a discussion with the doc. God forbid they turn out to actually be HYPO-k (which can present similarly)! Also, issues with cell coverage and disinterested ED staff should be nonexistent in a system that utilizes on-line medical control properly, which is what I assume is what we are discussing here...

But what are they going to have you do specifically? Fluids? Drugs? If you carry the stuff to do something about it then sure, but we don't so I'm not sure how to respond to that, well I suppose I am because I just did!

I don't know! That's really the point of calling medical control! There are a whole lot of treatment options out there that we don't know about, and even some that I wouldn't try without talking with a doc first. What about giving Calcium Chloride (or gluconate) to a Cardizem overdose? Would you really ever try that without talking to a doc first?

If you can ask somebody else for help I say go for it! We cannot transmit ECGs here except one or two places that do thrombolysis 1) because there is really no need for it, 2) it's really, really expensive and 3) it makes the doctors work!

Should your compromised VT patient be refractory to amiodarone; cardiovert.

I concede the point about VT (I guess), but the point still stands. ECG transmission for complex arrhythmia management is a valid use for on-line medical control.

My point is this - while there should be a system of medical advice and support within Ambulance practice; be it from very, very experienced Intensive Care officers (like is generally the norm here by recall to the watch manager if we get stuck) or a doctor, it should not be required routeinly for standard everyday treatment.

Agree 100%.

[Kiwiology]

I have to say I agree with Phil, all systems have some sort of clinical support (as does ours) but that it does not always have to come from a doctor.

Each watch here has a Team Manager who is an Intensive Care officer and a very, very experienced one at that. They are the default clinical support, one of the Officers I was with the other night rang up the TMO to ask about ketamine, and within ten minutes the patient was shitfaced and floating in orbit!

When stepping outside of scope of practice, we can eithr ask an Intensive Care Paramedic or a doctor be it an ambulance medical advisor or the senior physician (consultant) in the ED we are going to. This sort of thing is pretty rare.

It's 100x easier to ring up the TMO on the ambo phone.

Within some systems in the UK the clinical support is from Paramedics, here it's generally from IC Paramedics, don't know about Australia but I know Victoria has the "Clinician" who is an IC Paramedic, I guess your clinical support shouldn't always have to come from a doctor although might be helpful to have one around once or twice.

I must also agree very much with Phil and say medical support and advice in Ambulance should not be an adjunct to replace poor education and subcompetence. Did I mention Los Angeles already?

[WelshMedic]

Hello all,

This is an intersesting subject which shows the differences between different countries. Most of the salient points have been made but there is one aspect that springs out to me:

Although MedCom is generally bemoaned within the profession, it appears that our US colleagues are not quite ready to go it alone. I have been in EMS for more than 15 yrs and have contacted an MD just once in that time. Other than this one incident which involved a very complicated post transplant patient, I cannot think of a single moment when I felt the need to speak to a doctor. Not that I think I'm God but because my education and experience guides me in my patient care.

MedCom is, to my mind, delegating responsibility. You know what to do and how to do it, but insist on holding someone's hand to do so. Take STEMI, for example. 12 lead interpretation is a cornerstone of EMS. I have no problems at all with getting the cath-lab up at 3am because of an acute MI. ALthough I realise there are some potential pit-falls such as pericarditis, I am pretty sure that I have never given out a false alert. Even if it were the case: better safe than sorry!

The profession does need more education (is there such a thing as too much education?) but I also think that the profession needs to recognize the leaps forward that we have made in the last 20 years. And to stand up and be counted!

WM

[usmc_chris]

I do believe that "medical control" as we know it here in the US is an outmoded concept. That being said, I STRONGLY agree that some sort of online "medical consultation" SHOULD be available, whether it be with an agency medical director, an attending physician at the receiving hospital, or even, depending on the system, a more experienced/educated Paramedic with your agency such as a supervisor. I would suggest that as long as the education of Paramedics, especially in the US, is as it is, this is absolutely necessary.

That being said, I also agree with all of you that greatly increased educational standards are necessary - I forsee three levels. I am speaking with reference to US educational credentials as I have experienced them, as this is what I know best.

1. An EMT/EMR/CFR (whatever you want to call it) - these personnel would have a greatly expanded coursework (minimum 3 times the number of didactic hours with about 5 times clinical hours - if you're going to measure that way), and would be permitted to work either in a first response capacity, such as with a fire department, or with an IFT agency. I don't believe that many of our BLS IFT transfers require more highly educated Paramedics, or do I believe that 911 ambulances should be performing these transports. While "grandma" absolutely deserves to be transported home from the hospital with dignity, her non-ambulatory status and being oxygen dependent do not, in my opinion, justify taking an ambulance out of service. This practice both decreases the number of ambulances available for emergencies, and decreases the number of emergency patients Paramedics are in contact with, because they are too busy performing these transports, especially in so-called "high-performance" systems.

2. A Paramedic/Primary Care Paramedic - these personnel would have, at minimum, an Associate's degree. Every 911 ambulance would have a minimum of two Paramedics. I believe that a more traditional educational setting, and requiring degreed Paramedics, would lead to better practitioners. I don't believe that the standard Paramedic course, of whatever length, is adequate education. I don't think you can have a single instructor teaching every subject, with class 2-3 nights a week for 10 weeks - 18 months+, depending on the program, and produce providers of the level that we really need to have in prehospital medicine, unless these providers are willing to educate themselves further, on their own initiative, to achieve excellence. We need to provide Paramedics with the tools to succeed while they are still in the educational loop. Paramedics, in my opinion, may have less of a "skill set" than what we typically think of as a Paramedic in the US, but would still be able to handle 75% + of our typical "ALS criteria" calls - i.e. chest pain, shortness of breath, seizures, diabetic emergencies, etc.

3. An Advanced Care Paramedic/Intensive Care Paramedic - these personnel would have, at minimum, a Baccalaureate degree, and would have more advanced pharmocological interventions and advanced airway management. Some of the more rare conditions that we respond to would be the realm of the more "advanced" provider. I feel that by limiting the not necessarily more difficult, but are easier to "screw up," leading to poor patient outcomes, to a much fewer number of providers, we will greatly reduce the chance for error. Using the 80/20 rule that several people in my system, whom I believe to be reliable, have said does apply - 80% of our major medical errors, system-wide, come from 20% of the interventions performed - often the medications we use more infrequently.

I know I have deviated from the topic at hand slightly, but I had a reason for doing so (in my mind). By increasing the standards, whether it be as defined above or otherwise, we will reduce the need for online contact. In the current system in the US, from what I have read and heard from other people, most systems that require two Paramedics on an ambulance do so not because they feel it is in the best interests of the patient, but because they feel that their Paramedics aren't good enough to practice on their own. This is not to say that Paramedics necessarily should be working on their own with an under-educated "technician" as their partner, but it is a sad state of affairs. This is typically in the systems with 10 week Paramedic courses. These providers absolutely NEED somebody else, with a higher level of education, to contact, even if they do have a second Paramedic standing next to them. For the systems who run ALS/BLS ambulances, their partner is somebody who has a 120-hour "education" behind them, and in many instances the ink is still damp on their certification/license. This is not somebody who will usually be terribly helpful when attempting to discuss a differential diagnosis on a difficult patient.

By increasing educational standards, and making it so that only more highly educated Paramedics are responding to "emergencies," however you define those, you ensure that two highly educated personnel are available, and they have each other as resources. Online medical CONSULTATION may still be useful in very limited circumstances, but it is much less of an absolute NEED that I see, in my honest opinion, medical control being in many areas of the US today.

For those not familiar with the educational credentials I refer to, an Associate's degree is usually about 2 years in length with 60-70 credit hours required (a credit hour being defined, typically, as a unit measurement of a course, in which you would be expected to spend one hour per week, for a 15-week semester, in lecture, and one hour per week on homework/studying - a typical course, such as Anatomy & Physiology I, would award 3-4 credit hours). A Baccalaureate/Bachelor's degree would typically take 4 years to complete, with 120-130 credit hours required for completion.

Sorry for my long-winded post - thanks for listening.

[Kiwiology]

Good post Chris. I agree with you wholeheartedly.

Until education and preceptorship in the US comes out of the dark ages then I don't see medical control going anywhere soon.

To give you an example; from 2011 the new program will look like this here

Ambulance Technician: Diploma, basically a safe level for the vollies; LMA, nebules, nitro, glucagon etc

Paramedic: Bachelors Degree plus one year preceptorship; can do IVs, adrenaline, 12 leads, cardiovert etc

Intensive Care: 2-3 years exp as a Paramedic + Post Grad Diploma + one year internship; ALS

[fiznat]

I think you will find it was I that used pain relief as an example, thats all it was.

I wasn't trying to call you (or anyone) out specifically, which is why I didn't quote you or use your name at all. Even if you have standing orders for pain control, there are likely others here who may have to call for it. My point was simply that our definition of "what is medical control" varies widely across our community here. That point stands.

Why does it have to be a doctor? We have clinical assistance lines that perform the same function.

I don't think I said that it has to be a doctor, even though I do agree that a physician might make the most sense.

If you have to ask this question, then you really need to have your accreditation reviewed. Lets see. The person is having severe respiritory distress issues. There is minimal air movement. I give dose 1. Slight implrovment. I give dose 2. Slight improvment. What the hell am i calling for advice or, either the patient needs their airway open to breath, or they die.

Okay hot shot. The 3rd round of IM epinephrine in a status asthma is an on-line option for us here. Should we all have our "accreditation reviewed?" Things aren't the same everywhere Phil, and there certainly is a little room for thought in this scenario other than pushing the syringe down and hoping for the best.

If they have a cardiac event post epi, was it caused by the epi, or was it caused because the myocardium had been working too hard when they couldnt breathe? This one is a no brainer.

Do no harm. Epinephrine increases cardiac O2 demand. ...Or are you simply saying that nobody could definitively prove it was your epinephrine that did the damage, and therefore pushing this drug is okay?

Huh? This is prehospital care. You have a symptom, treat it. I had this discussion in the chat recently. EMS treats symptomatically...

What a truly idiotic thing to say. Phil, there is more to our patients than we see at face value, and thinking in only two dimensions like this can have really negative effects. If you really believe that a patient does not exist who's presentation will exceed your abilities as a prehospital provider, you either have no experience in the field whatsoever or are a complete fool.

I agree there is much we dont know, however, they are not a consult. they are a CYA tool for lazy medics who fail to use their brain. They are a failsafe method for people to say I only did what I was told, a Neuremberg defence when it all goes to shit. Now your stuff. Treat what you see/find, get rid of medical control.

Wrong. See above comment.

Yes doctors consult, but they are usually having a consult over a patient who has more care than they can poke a stick at. They have usually got the patient through the critical period & are looking at the case retrospectivley to determine future treatments & how they may have improved past treatments.

Wrong again. Spend some time in the ED and follow a doctor around. You'll see. Nobody knows everything, and it is expected that individual providers will seek the advice and experience of those around them. That is part of what it means to be a professional. Doctors consult all the time. Before, during, and after both critical and routine care.

Although MedCom is generally bemoaned within the profession, it appears that our US colleagues are not quite ready to go it alone....MedCom is, to my mind, delegating responsibility. You know what to do and how to do it, but insist on holding someone's hand to do so....

I don't purport to represent all US paramedics of course, only myself. You are correct though that I am reluctant to conclude that we should "do away" with on-line medical control consultation. I'm not trying to say that paramedics should be calling doctors every day to ask for permission or help, only that they should have that option when things start to get out of scope. It may not have happened to you in a long time, but it does happen, and I feel it should be part of our professional humility to leave ourselves a lifeline if needed.

Take STEMI, for example. 12 lead interpretation is a cornerstone of EMS. I have no problems at all with getting the cath-lab up at 3am because of an acute MI. ALthough I realise there are some potential pit-falls such as pericarditis, I am pretty sure that I have never given out a false alert. Even if it were the case: better safe than sorry!

Even though this was my example, I do agree with you. I feel that paramedics are quite capable of identifying STEMI on the 12 lead ECG on their own. In fact, good peer-reviewed research has shown that we can do this quite well. The problem in my area is that even though we may have gained some trust and respect from the ED physicians we deal with every day, we have almost none of that from the interventional cardiologists that we hardly ever see. To them, we are ambulance drivers, and I imagine they have a hard time answering that 3am call at the request of a technician. I only mentioned this because it is one of the main reasons I have called medical control in the recent past, and even though I feel it could be an unnecessary step, it has been successful for me and my patients.

The profession does need more education (is there such a thing as too much education?) but I also think that the profession needs to recognize the leaps forward that we have made in the last 20 years. And to stand up and be counted!