EMS in the United States is a hierarchical care delivery system, with physician leaders working in partnership with EMT/paramedic providers to rescue, care for, and transport patients. Alternative system structures are possible, and work well in other countries and settings. These include both systems with more physician involvement (physicians routinely staffing ambulances), and systems where EMS providers organize and manage their system with little or no physician input. The US model includes a robust prehospital emergency care network in which care is directly provided by predominantly nonphysician prehospital providers. The physician role in this type of system is heavily weighted toward oversight and direction of the system and through direct contact with providers in the field when called for medical control. This chapter will provide an overview of these topics and following chapters will provide greater detail on each of the elements discussed.
Define the terms medical control, medical direction, and medical oversight.
Describe online (telecommunications and in person) and off-line medical direction.
Discuss qualifications for providing medical direction.
Describe proper base-station training for EM and EMS physicians.
List the components of medical oversight.
PHYSICIAN ROLES IN THE EMS SYSTEM
Although not explicitly stated in some of the original governmental documents describing the EMS system in the United States, medical direction and physician oversight have always been key components to the development and operation of prehospital emergency care services. Although it has been surmised that physician involvement was always assumed, later documents specifically call for medical oversight. This function has evolved over time and can be described in terms of four general types of physician involvement.
Online medical control, also known as direct medical control, refers to consultation between EMS providers and a physician, typically by radio or telephone, to guide care for an individual patient or EMS incident. These physicians are usually required to take a base-station course and maintain up-to-date knowledge of the EMS treatment protocols. The majority of the physicians providing this type of medical control are not EMS physicians or EMS agency medical directors. Typically, they are the emergency physicians on duty in receiving emergency departments (Figure 4-1). However, in some cases they may also be assigned this duty exclusively when working a medical control shift in a larger system. Another form of online medical control is on-scene medical control. This refers to the presence of the physician at the patient’s side during EMS care, working directly with EMS providers to deliver care (Figure 4-2). These physicians may be referred to as EMS physicians or flight physicians. When the on-scene EMS physician is also the medical director, this allows for four components: (1) provision of orders and direction of care, (2) evaluation of provider performance, (3) provision of postincident education, and (4) evaluation of system design and operational parameters. Physicians responding to the field should have proper training, awareness, and equipment. Minimum requirements include operational proficiency in operation of an emergency vehicle, radio communications, scene size-up and safety, proper attire and personal protective equipment, use of EMS equipment, and regional procedures for utilization of prehospital resources and response plan(s) for mass casualty incidents and disasters.
Off-line medical control, also known as indirect medical control, typically refers to physician duties performed at an ambulance service or local level. The physician reviews care reports and other data to provide feedback on care delivered to improve quality and other aspects of care. The medical director will oversee continuous quality improvement (CQI) programs, primary and continuing education programs, verification of skills and competencies, criteria for determining overall fitness for duty, and the controlled substance handling and antidiversion program. Off-line medical control also includes development of medical care policies, protocols, and procedures. This type of medical control also includes the authorization of licensed prehospital providers to participate in care as a member of an agency or system. It may also include the authorization of ambulances and other response vehicle for use in patient care and to care medical equipment and medications.
Medical direction is sometimes considered the same as off-line medical control. Although it does include this activity, it is a higher level of involvement at the agency level. This refers to advising agency administrators on minimum standards for providers, setting educational standards, reviewing policies and procedures, and advising on medication and equipment choices. Despite some administrative functions, the medical director is not the EMS system administrator in the vast majority of cases. Administrative directors (CEO, COO, director of operations, etc), as opposed to medical directors, typically focus on finance, human resources, staffing, contracts, political relations, and protection of corporate interest.
Medical oversight is typically performed by a medical director(s) at the local, regional, and state levels, in collaboration with regulatory authorities, regional/county medical directors, and advisory committees in many jurisdictions.1 In addition to the duties described under off-line medical control and medical direction, medical oversight involves interaction with local, regional, and state authorities and stakeholders. Medical oversight requires a broad understanding of the emergency medical system as a whole and ensuring proper policies and procedures exist to ensure safe transitions of care and the utilization of appropriate resources in the field.
MEDICAL CONTROL, DIRECTION, AND OVERSIGHT
The four EMS physician roles (online medical control, off-line medical control, medical direction, and system oversight) may overlap, have multiple and ambiguous titles, or receive variable focus depending on individual system parameters, but they should be understandable as a progression from direct patient care through consultation regarding that care, review of care, and system design/oversight to optimize care.
Medical control, both on-scene (EMS physician) and online (direct), implies a concurrent process with patient care. In other words, the physician input occurs during the care of a specific patient or patients (in a multiple casualty incident where simultaneous consultation occurs regarding a group of patients). The on-scene EMS physician may be an integral part of the ambulance or helicopter crew, serve in a responding supervisory role for a region or system, be a service medical director who supports the service through scene presence, or may be a member of a major incident, search and rescue, or disaster response team. These physicians should be integrated and accepted members of the EMS scene presence, and their role (which may vary significantly) should be clearly understood by the EMS providers, the EMS physician, local emergency departments/hospitals, and the system oversight authority. Otherwise, conflict may occur between the on-scene EMS physician and the system’s physician substituted judgment as reflected in guidelines and protocols. Online (direct) medical control also occurs concurrent with patient care, typically during a telephone, radio, or computer communication between EMS providers and an emergency physician at the intended receiving hospital, “resource” hospital, or designated medical control base station (or telemetry station). The online medical control physician must be rapidly available, have sufficient understanding of the communications technology employed and the EMS system to interact in a helpful manner, and be able to promptly provide concise guidance to EMS providers based on current protocols and available drugs and equipment.
Medical direction typically includes both off-line (indirect) medical control and other functions of a service or system medical director, such as training, quality assurance, pharmaceutical, and other responsibilities. However, in many jurisdictions, off-line medical control is provided by a physician or committee at a designated hospital or governmental entity. In these situations, quality assurance review of EMS charts is augmented by (HIPAA-appropriate) access to emergency department and hospital records. Ideally, the service medical director collaborates with the off-line medical control process to institute quality improvements when the two functions are performed by different people or institutions.
EMS system oversight is a collaborative process that includes physician consultation with a regulatory/licensing authority (often at the state department of health, public safety, or department of transportation) and cooperation with various committees and boards comprised of physicians, EMS providers, and other stakeholders (hospital staff, specialty clinicians, representatives of various interest groups, etc). Physicians involved in system oversight must have an understanding of public health, financial and political influences on the system, human resources issues, and other administrative aspects of EMS. In some states, a physician medical director holds strong authority over system design, scope of practice, and other aspects of EMS practice. In other cases, the state-level authority functions in an empowering and coordinating role, and most aspects of EMS practice are controlled at a regional, county, or even individual service level.
PHYSICIAN KNOWLEDGE AND INVOLVEMENT IN EMS
In order to prevent substandard medical control, direction, and oversight, systems should require formal standardized training for physicians providing these important functions.
The most basic qualifications for physician involvement in EMS apply to online medical control physicians. These physicians are in communication with EMS providers during patient care. Therefore, they must understand the local EMS system, including provider levels and scope of practice, use of guidelines and/or protocols, and communications technology. There may be additional knowledge required depending on the use of special EMS resources (tactical teams, urban search and rescue teams, wildfire or wilderness EMS providers, mass or sports event EMS, etc) in the area. In almost all cases, they should be emergency physicians or pediatric emergency physicians as indicated by patient age. Prompt availability for consultation implies either presence in an emergency department or a system where the online medical control physician is designated to provide this service and equipped with the necessary communications tools. Training for these physicians, assuming that they are residency trained in emergency medicine and have immediate access to relevant documents (guidelines, protocols, patient destination plans, etc) can be brief, likely fewer than 5 hours, and may be significantly amenable to online or other distance learning techniques. While many of these topics are covered in the emergency medicine residency curriculum, local system variation mandates additional training/orientation. After confirming initial competence, recurrent training and verification are necessary when there are system changes (protocol updates, new treatments, changes in destination plans, etc). Specific topics that should be covered in training include a number of important introductory concepts (Table 4-1).