It's a hot summer afternoon in Palm Beach County, Fla., and Palm Beach County Fire Rescue-73 is staffed with three personnel -- two paramedics and one EMT. They have a total of five years' experience, and they're en route to the local trauma center with a head-injured patient. The patient is a 30-year-old victim of a major motor vehicle accident. The accident required extended extrication by the special operations team. On-scene care included C-spine immobilization and a primary assessment.
He moans during transport. Rescue-73 continues their detailed physical and neurological assessments. Then the patient's respirations begin to slow, and Rescue-73 considers intubation. The junior paramedic, who has four months on the job, insists he can intubate. He reaches for the airway roll and pulls out a 7.5 ET tube and some water-soluble lubricant. He meets resistance when attempting to open the jaw. The patient is in trismus and continues to become hypoxic. The paramedic administers 30mgs of Etomidate and inserts the tube into the trachea, and he sees the telltale signs of a successful intubation. The assessment of bilateral breath sounds, absence of epigastric sounds and good waveform capnography on the monitor confirm the tube is in the correct place.
From the preceding description, it would appear the tube was correctly placed. If we made an error, then the following chain of events could have caused serious consequence. This brings up many issues, such as whether other means to secure an airway were available, whether the junior paramedic had sufficient experience in endotracheal intubation and whether he knew the protocols. Also, who has the ultimate authority to oversee these new paramedics, and how could a potential issue have been avoided?
The person with this responsibility is your medical director. In the 1960s, when EMS was beginning, the Miami Fire Department's Dr. Eugene Nagel set some of the standards of physician involvement in EMS. I interviewed Dr. Nagel for this article, and I asked him a few pertinent questions regarding the past, present and future of EMS medical direction.Click here to read the question-and-answer session.
The medical directors of the 1960s thought outside the box -- innovating, teaching, testing, consulting other medical professionals and spending countless hours with the crews. The main principle at that time was to bring a few simple techniques that were proven to work in the hospital setting into the street environment.
The role of the medical director has greatly enhanced the evolution of patient care. Today, EMS providers must understand that they serve as an extension of the medical director. The medical director provides the key to creating quality patient care andcompetent EMS providers. By their presence in the organization, the physician extends medical accountability and clinical supervision. They also have the influence of implementing the newest technologies available to enhance system services, clinical education and continuing education surrounding the latest issues involving prehospital care. The medical director also provides medical licensing to EMS providers for patient care protocols, medications and procedures. With these major responsibilities, the medical director needs to be involved in the management of the EMS system, understand its daily operations, and empower and trust the providers. This is where you as the EMS supervisor must evaluate the personal and professional motivation, as well as performance, of your physician.
Medical accountability ensures that prehospital procedures and the decisions of EMS providers are in accordance with acceptable medical practices. Clinical supervision of EMS providers may be prospective or retrospective. Prospective supervision may include offline and online aspects. Offline prospective supervision provides common EMS protocols, standards of care, policies and special procedures.
The online aspect of prospective supervision involves online medical control by a physician to a field provider. Online direction requires that medical control have knowledge of the provider's patient-care protocols. Retrospective supervision is indirect and includes both EMS response review and quality management issues.
To support EMS providers with medical direction, the medical director must provide up-to-date patient-care protocols. Treatment protocols must meet the standards of care and practice for EMS personnel. These standing orders are used to guide providers when direct medical control isn't established or available. Also contained in the patient-care protocols is a point-of-entry plan, which specifies whether a patient goes to a specialty facility, including trauma, pediatric, cardiac, stroke and hyperbaric, based on their clinical condition. These components must be based on a collaborative effort between the provider and their medical director.
The interface between medical direction and EMS operations is a team effort. EMS providers must know and identify with the medical director, because each and every action they take Ï or, in some cases, fail to take -- reflect upon the medical director. We must remember that a negative outcome or failure to follow medical control may lead to civil or criminal prosecution not only against you but also against the medical director. These actions may result in monetary fines, loss of medical license and incarceration.
Your medical director should have authority over all your service's clinical and patient-care aspects. Although the specific job description is dictated by your service's needs, it should include the necessary qualifications and skills in order to carry out these responsibilities. To optimize medical direction of all prehospital EMS, it should be managed by physicians who have demonstrated the following guidelines set by the American College of Emergency Physicians (ACEP):
- License to practice medicine or osteopathy.
- Familiarity with the design and operation of prehospital EMS systems.
- Experience or training in the prehospital emergency care of the acutely ill or injured.
- Experience or training in medical direction of EMS units.
- Active participation or experience in the emergency department (ED) management of the acutely ill or injured.
- Experience or training in the instruction of EMS providers.
- Experience or training in the EMS improvement process.
- Knowledge of EMS laws and regulations, and dispatch and communications.
- Knowledge of local mass casualty and disaster plans.
Desirable qualifications set by ACEP include board certification in emergency medicine by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine, EMS fellowship training and completion of an EMS medical director's training course. Service as an EMS medical director that began prior to January 1, 2000, can be substituted for the last two requirements.
It's important to find out if your medical director has the necessary instructional background and ability to teach your staff new treatment modalities, EMS equipment troubleshooting and continuing education practicum. They should carry a department radio so they're "on-line" for troubleshooting or medical direction.
It's also important to determine whether your medical director has participated in an EMS fellowship program. These programs typically last one to two years and can be found all over the country at most large medical teaching institutions. They're designed to prepare the EMS physician for a career of leadership in out-of-hospital care. EMS fellows develop their skills through a combination of didactic lectures, research projects and direct participation as operational medical directors for the area represented. Depending on the location of the program, they provide an opportunity for exposure to aeromedical response, tactical medicine, disaster/mass casualty incidents, fire-service medical support or fire-based medical services and specialized rescue situations including USAR operations.
When we discuss the responsibilities of the medical director, we often use such words as "develop," "promote," "ensure" and "interact" to describe the job functions. These job functions may include developing new protocols that concur with new AHA guidelines or ensuring staff is adequately trained, interacting with colleagues from local and state agencies, and being on teams, committees or task forces in EMS research or planning. These are all functions EMS supervisors should revisit with their current medical director or consider when searching for a new one.
According to ACEP, physicians functioning as medical directors should do the following:
- Serve as patient advocates.
- Set and ensure compliance with patient-care standards.
- Develop and implement protocols and standing orders.
- Develop and implement the process for the provision of concurrent medical direction.
- Ensure the appropriateness of initial qualifications of out-of-hospital personnel involved in patient care and dispatch.
- Ensure the qualifications of EMS providers and dispatch are maintained on an ongoing basis.
- Develop and implement an effective process-improvement program for continuous system and patient-care improvement.
- Promote EMS research.
- Maintain liaison with area hospitals, emergency departments, physicians, prehospital providers and nurses.
- Interact with regional, state and local EMS authorities to ensure standards, needs and requirements are met and resource utilization is optimized.
- Arrange for coordination of such activities as mutual aid, disaster planning and management, and hazardous materials response.
- Promulgate public education and information on emergency prevention.
- Maintain knowledge levels appropriate for an EMS medical director through continued education.
The issue regarding medical authority is one of the toughest a medical director must face because it involves hiring qualified individuals, certifying or decertifying providers, and establishing equipment-usage standards and treatment protocols. The medical director should solicit input from a proactive staff regarding the hiring process and what to include in a written test, oral interviews and scenario-based testing stations.
Decertifying procedures are one of the hardest, yet most important, functions a medical director has to perform. If the standard of care is violated, it not only reflects upon the person and the agency, but also the medical director. Protocol violations, deviations without justification and medication errors are all topics that need to be addressed.
The research, purchasing, usage standardization and implementation of equipment is another important aspects of medical direction. As an extreme example, you more than likely have never been given new equipment without training and direction on its use. Obviously, this should never happen. Remember to empower your staff, promote and surround yourself with innovators, and finally when all else fails put together an equipment committee and make sure your medical director is involved.
ACEP states that, unless otherwise defined or limited by state or regional requirements, the medical director has authority over all clinical and patient care aspects, including the following:
- Recommend certification, recertification and decertification of EMS providers to the appropriate certifying agency.
- Establish, implement, revise and authorize the use of system-wide protocols, policies and procedures for all patient care.
- Establish criteria for initial emergency response and determining patient destination.
- Ensure the competency of personnel who provide on-line medical direction to EMS.
- Establish the procedures or protocols for non-transport of patients.
- Require education and proficiency testing for first responders, EMTs nurses, dispatchers, educational coordinators, and online and offline physicians.
- Implement and supervise an effective process improvement program.
- Remove a provider from medical care duties for due cause, using a review and appeals mechanism.
- Set or approve hiring standards for personnel and equipment involved in patient care.
The EMS system has an obligation to provide the medical director with the resources and authority commensurate with the responsibilities outlined above. This includes compensation for the time required, necessary material and personnel resources, liability insurance and a written agreement that delineates the medical director's authority and responsibilities and the EMS system's obligations.
I cannot express the importance of the medical director and the impact they have upon your system enough. An uninvolved medical director is a wasted resource and potential liability. Having an active medical director who's involved in your service's performance is key to your future success. The personnel you hire, the protocols you practice, and the equipment you utilize will be better if your medical director is involved.
Cameron Bucek, AS, EMT-P, is an EMS captain with Palm Beach County Fire Rescue. He has 19 years of fire-and-rescue experience. Heis a fire/EMSinstructor for Palm Beach Community College and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in EMS management.
- American College of EmergencyPhysicians.www.acep.org
- Davis R: "Doctor in charge rarely call the shots." USA Today. May 5, 2005.www.usatoday.com/news/nation/ems-day2-directors.htm
- Evans B: "Is there a Doctor in the House?" Fire Chief Magazine. March 3, 2007.http://firechief.com/volunteers/firefighting_doctor_house/
- U.S. Fire Academy Fire and Emergency Services Higher Education (FESHE) Model Curriculum.www.usfa.dhs.gov/nfa/higher_ed/feshe/feshe_model.shtm