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Since all emergency departments (EDs) by their very nature have frequent contact and an ongoing relationship with emergency medical services (EMS) units and the providers who staff them, practice diversification in EMS is one of the most common and logical strategies for emergency physicians and nurses. A substantial percentage of ED patients arrive by EMS (10%-30%, depending on location, acuity, availability of primary care, and other factors), so interaction with out-of-hospital providers is a daily occurrence and a necessity in emergency medicine.1

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An additional necessity is interacting with the EMS medical director, who is a physician with specialized interest and knowledge of patient care activities unique to the out-of-hospital environment.2 Often referred to as the operational medical director (OMD), the physician oversight that they provide is legislatively mandated in all 50 states. Thus, the EMS medical director is a legal and operational requirement. In the past, EMS physicians came from many different training venues, but the vast majority of them are now emergency physicians.3 Since the OMD will have an important impact, directly and indirectly, on the practice of emergency medicine, many physician groups wisely choose to pursue diversification of their practice so that one or more of their members serve as EMS physicians. Box 55-1 lists several reasons why diversification in EMS is an attractive option (each of which is discussed next).

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Box 55-1 Reasons to Pursue Practice Diversification in EMS
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The oversight provided by the OMD extends through all phases of out-of-hospital care, from selection and training through communications, and all components of field care. Ultimately, this physician is responsible for the care provided to patients in the field and for ensuring that the quality of that care is appropriate and considered standard. Guidelines describing the performance, qualifications, and activities of the OMD have been developed by the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), the National Highway Traffic Safety Administration (NHTSA), and the Health Resources and Services Administration (HRSA).4-6

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Medical direction comprises both indirect or off-line and direct or online oversight. Indirect medical direction includes medical protocol development, dissemination of the protocols to the ED and medical community, education of field providers and supervisors, prospective and retrospective quality and process improvement review, and provision of quality improvement information from the ED and inpatient stay to continuously update and improve field care. Direct medical oversight refers to concurrent interactions between the EMS physician (or their designees) and the field provider, whether through direct observation or radio communication.

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In most cases, the EMS physician has a contractual arrangement with the EMS agency, detailing the authority to develop, ...

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