UNDERSTANDING THE CHALLENGES OF THE PREHOSPITAL ENVIRONMENT
Yet another benefit of EMS medical director field response is for the physician to gain a better understanding of the highly unique challenges of prehospital patient care. This level of understanding is crucial in protocol development, planning, and resource allocation. Although many EMS medical directors have had direct EMS experience as an EMS provider prior to becoming a physician, this is not universally the case. As EMS systems advance in complexity, the increased need for EMS medical directors has resulted in many non–EMS-trained physicians being asked to oversee EMS programs. This diversity of experience has proven to be a benefit to the science of EMS medical oversight as increased involvement also brings new energies and ideas to the table.
Moreover, each EMS system poses its own unique set of geographic, political, technical, and financial challenges. It is important for the EMS medical director to be intimately familiar with the challenges of the prehospital system that he or she is tasked to oversee. This degree of technical understanding is necessary to operate effectively as a medical director and can only be gained through the regular interactions with EMS personnel and patients in the field.
Field response of EMS medical directors and EMS physicians may directly enhance patient care through the direct application of advanced skills and procedures that are out of the scope of practice for nonphysician EMS providers.4 Some examples may include:
Field amputation of entangled extremities
Awake, fiber-optic intubation
Blood product transfusion
Prolonged treatment of patients who are unable to be transported in a timely fashion to receiving hospitals (Figure 29-1)
EMS physician performing damage control interventions after preforming a field amputation to free a severely injured patient who was hopelessly entangled.
However, the presence of an EMS medical director in the field can enhance patient care in situations even without the need to perform these advanced procedures.5 For example, physicians may be more adept at providing death notifications to family members in cases of field termination of resuscitation. In addition, additional clinical experience may also allow EMS medical directors to counsel EMS providers in making decisions about high risk but infrequently used procedures such as the decision to control an airway in a spontaneously breathing patient via RSI and surgical cricothyrotomy.
Traditional medical education is built around an apprenticeship model which provides graduated degrees of responsibility and training as experience progresses. In the physician-education model with which physicians are most familiar, medical students progress from the preclinical didactic years to clerkship rotations, internships, and residencies. As medical students and residents progress through these education phases, learner-contact time with physician mentors increases in duration and intensity. In particular, during emergency department residency training, experienced attending physicians are generally required to be present “at the bedside” and/or immediately available to resident physicians.
EMS education programs are modeled in a similar fashion with didactic sessions followed by structured clinical rotations in various settings. Learners are given increased autonomy as their training progresses. Unfortunately, this is where the similarity ends. Unlike the physician education model, EMS students are often supervised by preceptors that are generally seasoned EMS personnel rather than physicians. Although these preceptors are expert field providers, as a generalization, they may lack the depth of clinical knowledge and experience that comes with the thousands of educational hours spent by physicians during medical school and residency. Moreover, because of the relative scarcity of EMS-trained physicians, when EMS students are exposed to physician-led educational experiences (such as emergency department, anesthesia, and ob/gyn rotations), the physician mentors in these settings are rarely EMS-trained physicians. Although non–EMS-trained physicians are unquestionably experts at their particular application(s) of clinical medicine, they may not be as familiar with the practical applications of their clinical knowledge to the myriad of technically challenging environments faced by EMS personnel on a daily basis. Lastly, upon completion of their training program, EMS personnel interaction with physicians may become limited to a few brief moments during ED handoffs, continuing-education refresher lectures, and regularly scheduled skill verification sessions.
Placing EMS physicians in the field can very effectively bring the strengths of the physician education model to the realm of EMS. An experienced, EMS-trained medical director who responds in the field can provide expert real-time guidance to a paramedic student who is preparing to perform their first field intubation. In addition, the direct “bedside” presence of the EMS physician can help guide learners and even seasoned paramedics through critical thinking scenarios such as whether or not a patient requires medication facilitated intubation. Moreover, the EMS physician can assist the EMS provider with high-risk, infrequently performed procedures such as needle thoracostomy, cricothyrotomy, and rapid-sequence induction. At the completion of a call the EMS physician can discuss the call with the provider and answer clinical management questions that will benefit the provider in future encounters (Figure 29-2).
EMS physician providing real-time education.
CONTINUOUS QUALITY IMPROVEMENT FROM THE FIELD
Another role of the EMS physician is to provide real-time feedback and quality assurance. Many states require some form of formal ongoing verification of paramedic skill performance to maintain medical command authorization or licensure. Although there are often established methods of skill verification using patient simulators and procedure training mannequins, there really is no better way to ensure that the EMS providers are delivering high-quality patient care than direct observation in the field. Of course although there may be some degree of “Hawthorne effect,” if it serves to increase the overall quality of care that is provided, then the desired result is still achieved. It is important, however, that the EMS physician takes care to ensure that this degree of close field supervision remains well received by the EMS providers. To help accomplish this, when in the field, the EMS physician should be especially conscientious of their tone and demeanor. They should present themselves to their EMS providers as an additional resource to provide help rather than “big brother” who is only waiting to catch them making a mistake. Using phrases such as “What can I do to help?” instead of “Why are you doing that?” will help build this rapport. In addition, the EMS physician should strive to offer as much assistance as possible even with nonpatient care tasks such as carrying bags and equipment as well as cleanup and restocking after the call.
For the EMS physician to be directly able to participate in any of these field activities, various logistical concerns must be addressed. Although they can ride along as an additional crew member in an ambulance, the EMS physician is often much more effective when they can respond autonomously. This generally requires that the physician be provided with an emergency response vehicle which is capable of being equipped with, at a bare minimum, the same medication, equipment, and supplies as an ALS ambulance. The EMS physician will also need additional equipment to perform procedures and medications not normally available. In addition, the EMS physician must be able to communicate directly with the ambulances and the dispatch center. Thus, it should also be equipped with mobile data terminals and two-way radio equipment as well.
There are other issues that need to be addressed to ensure that the EMS physician is available for field responses. In some EMS systems there may be direct financial compensation to the physician or the physician’s group practice for physician EMS. In other models, indirect compensation may be in the form of adequate protected time for EMS activities.