Although physicians are not the primary providers of prehospital care in the United States, field response capability is still considered an essential component of a modern EMS system. As discussed in Chapter 29, the EMS physician must be prepared to go to the scene to ensure the quality of the care in the system through direct observation, provide emergency response for mass casualty situations, and provide advanced level care in some infrequent circumstances. In order to perform these various field activities, the EMS physician must first be able to respond to the field. Several methods of transporting the EMS physician to a scene are available. The EMS physician could drive their private vehicle to a scene, or a field supervisor vehicle or law enforcement vehicle could be used to pick up and deliver the EMS physician to a scene. Unfortunately these solutions achieve the task of delivering the EMS physician but do not simultaneously deliver the equipment needed by the EMS physician to perform their mission. A more efficient and effective deployment of the EMS physician can be accomplished by providing the EMS physician with a specially designed, equipped, and dedicated EMS physician response vehicle (PRV). Various EMS systems have implemented such vehicles into their fleet and include the EMS PRV as a deployable asset in many circumstances. The ideal EMS PRV will allow for the safe, rapid, and efficient delivery of the EMS physician and associated specialty equipment to the scene. The development of such an asset must be a careful and thoughtful undertaking, as there are many factors that must be considered as the vehicle is designed, built, and equipped in order to create an end product that meets the needs of the EMS physician and the EMS system.
Describe the types of physician field response (primary, secondary, and tertiary).
Describe different types of physician teams and task forces.
Describe minimum training standards for safe and effective physician field response.
Give examples of physician field response dispatch criteria.
Discuss types of advanced interventions provided by EMS physicians in the field.
Describe the ideal design qualities of an EMS physician response vehicle.
Discuss specific design details, costs, and benefits.
Discuss interoperability concerns for EMS physicians relating to communications and radio equipment.
Describe EMS equipment appropriate for EMS physician response, and discuss when it is appropriate to exclude items known to be carried by local EMS/fire agency vehicles.
Describe equipment that may be needed to perform EMS physician level interventions.
Describe the proper storage of controlled substances and other drugs in the vehicle.
Discuss mobility concerns and limitations to standard EMS bags.
Describe appropriate PPE levels for various types of operations.
Discuss the design and deployment of special operations trailers for prolonged events.
PHYSICIAN FIELD RESPONSE
When considering field response it is appropriate to categorize the types of responses and to use this organizational scheme when considering the necessary training and equipment. There are three basic types of responses based on dispatch/notification scenarios: primary, secondary, and tertiary (Box 32-1).
When an EMS physician is notified or dispatched as part of the primary response to an emergency call this is considered a primary field response. Participating in a Primary Emergency Response usually requires the EMS Physician to respond in a fully equipped and legally verified emergency response vehicle. Establishing the infrastructure to allow an EMS Physician to respond in this manner often requires working within specific jurisdictional legal and regulatory parameters, as well as ensuring proper liability insurance has been secured. In some systems an EMS physician may be routinely dispatched to possible cardiac arrests or major trauma incidents. In other systems there may not be routine dispatches of the EMS physician, but the EMS physician may, at their own volition and availability, respond primarily to any type of call in order to perform CQI of system performance measures. These calls might include those requiring routine emergency medical care (cardiac arrest, trauma, seizures, etc). If the physician were first to the scene they may initiate care; however, more than likely they will serve in a supportive/oversight role. These calls allow for CQI and education and require the EMS physician to maintain usual prehospital skills and first response equipment. Suspected mass casualty incidents (MCIs) may also prompt a primary EMS physician response but in most situations does not require that the physician possess extra or specialized equipment or drugs. Training in ICS is important, but advanced knowledge of ICS may not be necessary. EMS physicians are prepared for this level of response, as it does not necessitate much preplanning or maintenance of specialty skills, knowledge, or equipment.
A secondary response for physicians is usually one that is brought on by recognition of field providers that the physician’s presence would be beneficial, or is necessary due to unusual circumstances. Some complex medical decision-making situations are better mitigated by direct field contact rather than over radio communications due to the level of communication required, or in the case where contact with others on scene would significantly change a potential outcome for a particular patient (eg, difficult or confusing refusal situation in which life/limb threats are present and family or law enforcement is not providing expected assistance). In cases of prolonged extrication or in which amputation may be needed in order to free a critically injured patient, providers may call for the EMS physician. Special equipment, medications, and training are required in order to provide these services. Tactical medical support may be called for an active shooter or other active police actions. Proper preplanning, training, and equipment must all be in place in order to ensure maximum effectiveness with minimum risk. Support of fire ground operations and technical rescue requires rehabilitation and medical surveillance of firefighters and rescuers. In order to provide this secondary response the physician must have participated in preplanning, have knowledge of specific policies and procedures, and have access to rehabilitation providers and supplies. These requirements mean a higher level of preparation and maintenance of specialty skills, knowledge, and equipment will be necessary for the EMS physician response vehicle/program.
Box 32-1 Types of EMS Physician Field Response
Primary—routine emergency calls, CQI/education, MCI
Secondary—complex medical decision making, advanced field intervention (ie, field surgery), tactical medical support, rehabilitation services for firefighting, and rescue operations
Tertiary—prolonged MCI, prolonged disaster relief, wilderness search and rescue, urban search and rescue
When a prolonged medical support operation is called for or anticipated, EMS physicians may respond for a prolonged duty cycle. This is very different than other emergency responses and requires consideration of potential unavailability for the other two types of response if the responding physician is the only active physician asset in the system. Prolonged MCIs lead to a need for continued field care and delay of patient transport to the hospital. The EMS physician will provide treatment and likely authorize advanced scope of practice to on-scene EMS providers under their direct supervision. When an event is expected to last greater than 24 hours, then a sustained disaster medical response may be called for. In cases of natural disaster, terrorism acts, wilderness search and rescue, and urban search and rescue operations, the EMS physician team may be tasked with providing or coordinating medical operations. In some circumstances, Medical Reserve Corps (MRC), Disaster Medical Assistance Teams (DMAT), or other medical assistance networks may be engaged and will likely alleviate the need for continued reliance of the local EMS physician(s) once they are fully deployed.
TEAMS AND TASK FORCES
As discussed in Chapter 29, there is no current and meaningful data that quantify and characterize the various types of physician responders and response programs. Agency medical directors have provided response to the field for as long as there have been EMS medical directors. This has been done in a number of different forms including ride-alongs, staffing the ambulance or helicopter, and in individual physician vehicles (some emergency vehicles, others not). Field response physicians have ranged in type from fellowship-trained EMS physicians to emergency medicine residents, to surgeons and anesthesiologists.
Although it is clear that organized field response by physicians has been in place in some communities for many years, there exists some variability in the form that this may take. The predominant model that appears to be growing, and will likely be considered the standard in the future, is that of the trained EMS physician responding as part of an organized EMS system. This type of responder is many times the medical director of an agency or the system, and has met certain training, equipment, and logistical standards. These physicians are also some times part of a system-wide EMS physician response team (eg, Buffalo, NY; New York City, NY; Minneapolis, MN; Philadelphia, PA; Pittsburg, PA; Syracuse, NY; etc). Although there are still systems that allow emergency medicine resident physicians to respond in emergency vehicles with little to no supervision as part of their residency training experience, this is not the recommended model of providing this service to the community. Just as internal medicine residents would not perform endoscopy or cardiac catheterizations without supervision, this subspecialty requires training and experience that residents do not yet possess. Residents should be closely supervised in the field due to the unique area of medicine being practiced, procedures required typically being out of their scope of education, and the specific challenges and risks associated with field response. EMS fellows are generally well trained in this area and are given a graded level of responsibility to ensure effectiveness of the field response service with a requirement for levels of supervision that are predefined based on circumstances.
One other model of physician field response is that of the surgical go team. Go teams are usually deployed with the notion that the key physician intervention is a surgical procedure that is outside the scope of a prehospital provider, and that hospital-based physicians possess specific skills that are needed in the field. These teams are based out of trauma centers (eg, Baltimore, MD; Columbus, OH) and members of the team must receive training in scene safety, EMS operations, and technical rescue operational awareness. Typically field surgical procedures are not performed in the same way as in the confines of the hospital and variations of the techniques must be taught to these physicians. The advantage of this type of program is that is has a direct connection to the trauma center and members can potentially provide a smooth transition to the hospital trauma services. The disadvantages of this type of program are that: the program does not address any of the other important roles of an EMS physician, there is a potential significant delay mobilizing a hospital-based team versus an on-call EMS physician team that may already be in the field, and the team is reliant on an outside agency to provide transportation to and from the scene. Most of the techniques that would be provided are now considered EMS physician interventions (surgical airway, thoracostomy, amputation, thoracotomy, perimortem C-section, etc), and it is possible that hospital-based teams may not be needed for acute response in the future as EMS-based physician response becomes available in more communities. These surgical go teams may still be very valuable as part of the sustained response to major disasters as part of the effort to care for large numbers of victims in the field until other disaster medical relief assets arrive.
MINIMUM FIELD TRAINING FOR PHYSICIANS
EMS physicians responding to the field should have training in a formal emergency vehicle operators course (EVOC). It is also advisable that all physicians performing field response be educated in basic principles of EMS operations and medical direction due to the nature of their interactions with EMS providers. Most physicians who have not received fellowship training in EMS medicine will benefit significantly from attending a medical director’s course (eg, NAEMSP National Medical Directors Course and Practicum, Ohio ACEP EMS Medical Directors’ Course, CITF Online Guide for Preparing Medical Directors). Even veteran EMS medical directors and physicians who are previous prehospital providers will benefit from advanced medical director courses and attending EMS medical director symposia. In addition to EVOC, minimum training should include scene safety concepts, ICS and NIMS, hazardous materials awareness, fire ground operations awareness, technical rescue awareness, radio operations, and local protocols and disaster plans.
PHYSICIAN NOTIFICATION AND DISPATCH CRITERIA
One method of providing EMS physician response is for there to always be an EMS physician “on the air” and responding to calls as they come. In almost every system this is impractical and at the best will not ensure comprehensive coverage. Instead, developing a set of criteria for alerting the EMS physician(s) (via text messaging, tone pager, or other means) seems much more practical. In order for this concept to work properly within an EMS system, stakeholders must be involved in the process and understand the implications of physician field response. When setting criteria for use by a dispatch center, two different type of alerts must be considered: notification and dispatch. Dispatch implies that the communications center dispatcher has the right and capability to send the EMS physician(s) to a scene and implies that there is no need for confirmation of the need after the criteria have been met. Notification, on the other hand, is when an alert is sent, making the physician(s) aware of the situation without the implied automatic response of a dispatch. Although a seemingly insignificant semantically difference on the surface, this concept has operational significance and should be considered based on the availability of the EMS physician resource and the relationship the physicians have to the system. Notification usually requires a call back from the physician to ask for information or to confirm availability and response. Dispatch should be more efficient, in that the implication is that the physician will go en route without the need for confirmation of the details of the call. When the EMS physician is the agency medical director who is in solo practice, this presumes they are on call 365 days/year, 24 hours/day, and a notification-only arrangement may be most appropriate due to the likely unpredictability of the response. If the EMS physician is on-call as part of a robust, well-staffed, EMS physician response team, it may be more appropriate to use dispatch criteria, especially if the team physicians are under contract to provide this service. In some cases, it may make sense to have a mixture of both, as some situations may necessitate a physician response based on operational design of the system (eg, tactical medical support), whereas other situations may only benefit from the response in some calls of that type. In either situation, having notification and/or dispatch criteria should not inhibit a medical director from responding for CQI and education purposes (without lights and siren) when they have not been sent an alert. Some systems have developed specific criteria for notification and dispatch (Box 32-2).
Box 32-2 Example EMS Physician Notification and Dispatch Criteria
|Onondaga County, NY—Notification Criteria||City of Pittsburg, PA—Dispatch Criteria|
|The physician response team will be notified by the EMS dispatcher on any of the following incidents:||Listed are the guidelines for dispatching the medical command physician:|
PHYSICIAN-SPECIFIC AND ADVANCED INTERVENTIONS
In addition to augmentation of the clinical care provided by the EMS system providers, physicians can maximize their effect on patient care by coordinating care in unique situations. In mass casualty/disaster response most systems have a mechanism in place by which all components of the EMS protocol are to be treated as standing orders, alleviating some of the need for radio traffic that may not be feasible at the time. In addition, the presence of the EMS physician(s) allows for a greater conversion to standing orders and may lead to situation specific standing orders to be put in place during the event. Providers can then be used in an advanced practice role rather than limiting their care to protocols and standing orders that were designed for routine emergency medical care. This type of coordination of care expands the utility of the physician far beyond their own ability to care directly for patients.
The provision of field surgical procedures will require the physician to carry the proper equipment, medications, and supplies needed for these interventions. Field surgery techniques are detailed in Chapter 64. Determining the need for extreme measures requires in-depth understanding of acute critical care medicine and the capabilities and resources available within the EMS and hospital system. By the nature of the critical injuries usually present in such cases, these interventions are potentially time sensitive (Box 32-3). In addition to knowing the indications for each procedure, EMS physicians must train to establish proficiency in performance of the procedures themselves, which may require simulation and cadaver lab time to ensure proper instruction and maintenance of skills.
Box 32-3 EMS Physician Field Surgical Procedures
Perimortem cesarean section
aDiscussed in Chapter 59.
EMS PHYSICIAN VEHICLE DESIGN
The development of an EMS physician field response program requires careful thought, planning, and execution. Most agencies will likely find merit in adopting a project management approach that divides projects into five phases: Project Conception, Project Definition and Planning, Project Execution, Project Progress Monitoring, and Project Completion. Figure 32-1 applies this phased approach to the process of designing and constructing a PRV program.
The Project Conception phase of the project management plan is a critical aspect of any EMS PRV program. One of the first tasks that should be addressed is the need to involve and educate the various constituents and stakeholders in the response jurisdictions that will be impacted by the addition of this specialized resource to the community. If proper “buy-in” is not obtained from key representatives or agencies before the PRV is obtained and deployed, the EMS PRV program may not realize its full potential.
Concurrent to establishing these key relationships, a needs assessment and feasibility evaluation of the proposed EMS physician field response program should be completed. Conducting a hazards risk assessment (HRA) to identify the actual and potential events that may occur within a certain response area is an important part of the needs assessment. Upon completion of the HRA, a cascade of questions will follow, as highlighted in Box 32-4. The answers to these questions will help guide the development of an EMS physician field response mission framework and will identify the specific intellectual, technical, and capital requirements that must be met to accomplish the field response missions.
Box 32-4 Key Questions Triggered by a Hazards Risk Assessment
What type of medical care must the EMS physician be able to provide?
What type of trauma care must the EMS physician be able to provide?
What type of administrative and field leadership support must the EMS physician be able to provide?
What additional services are desired from the EMS physician?
What training does the EMS physician need in order to meet these needs?
What equipment must the EMS physician have available in order to meet these needs?
Ideally, defining the field response missions will precede the acquisition of the vehicle intended to serve as the PRV. If the missions are focused mainly on responding to routine EMS calls and performing in-field QA in an urban setting, the response vehicle design and equipment needs will differ significantly from the needs required to perform a mission involving advanced extrication techniques or high-angle rescue in a wilderness environment. A specialty medical response mission may require the EMS physician to treat conditions like crush syndrome, amputate entrapped limbs, perform a surgical airway, or perform other surgical procedures such as those discussed in Chapters 59 to 64. Additional missions including aspects of technical rescue may obligate the response vehicle to carry personal equipment for the physician such as ropes, water rescue gear, or specialty personal protective equipment (PPE). The field response missions will define the equipment needed by the EMS physician to perform these missions. Then, the size, shape, quantity, and other characteristics of the EMS physician’s equipment will determine certain characteristics of the vehicle that will be used to transport both the equipment and the EMS physician to the field.