The emergency physician and medical control in advanced life support

The Journai

of Emergency

Me&me,

Vol 3, pp 31-35,

Prlnted

1985

n the USA

CopyrIght % 1985 Pergamon Press Ltd

??

Prehosipita!

Care

THE EMERGENCY PHYSICIAN AND MEDICAL CONTROL IN ADVANCED LIFE SUPPORT James E. Pointer,

MD

Associate Chief, Emergency Department, Hlghland General Hospital, Oakland, California. Medical Director, Emergency Medical Services District. Alameda County, California Repnnt address: James Pointer, MD, Emergency Department, Highland General Hospital. 1411 E. 31 st Street, Oakland, CA 94602

of emergency physicians in the emergency medical services (EMS) system.“,’ It was obvious that the emergency physician suffered from serious misconceptions about the EMS system.6 A review of pertinent literature does not reveal systems that do not require physician control. Traditionally, medical control in ALS is prospective, ongoing, and retrospective.’ The EMS system must provide strong physician input for each of these components. For prospective control, medical consultation, preferably multidisciplinary, is necessary to establish and revise treatment, transportation, and communications protocols. The system must strictly define standing-order criteria and must regulate carefully the tracking and documentation of unusual field circumstances. The ALS base hospital physician must be available and willing to provide medical control on an ongoing basis. It is the physician who is best equipped to appreciate the subtleties in field assessment to solve perplexing clinical problems, to appropriately modify treatment protocols, and to respond to pertinent medicolegal issues. The physician is also essential in

0 Abstract -A large urban emergency medical services district (EMSD) in California set certification, recertification, and continuing education standards for advanced life support physician medical radio operators. The EMSD attempted to encourage physician participation and to maintain a high level of medical control. The standards have been well received. There is enthusiastic physician support and widespread physician involvement in the advanced life support system. 0 Keywords- medical control; emergency medical services; advanced life support; paramedics

Introduction Medical control is an essential element of prehospital advanced life support (ALS). In most jurisdictions, medical control is the stated legal responsibility of a local medical director and the ALS emergency department physician.’ The need for strong medical control cannot be overemphasized. Failure of physicians to provide continuous strong input into the ALS system may result in compromised field care.2.3 Early papers are vague on the exact role

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Prehospital Care focuses on the issues and practices that directly affect the type and quality of care administered by the emergency physician in the emergency department, and is coordinated by Peter Porn, MD, University of Colorado Health Sciences Center, Denver, Colorado.

RECEIVED: 11 December

1984; ACCEPTED:

20 April 1985

31

0736-4679185 $3.00 + .OO

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maintaining retrospective medical control through tape reviews and other educational sessions. The physician reviews field care and prescribes necessary remediation. Through formal and casual audit and evaluation, a more global overview of base hospital or field ALS management is obtained. Although many jurisdictions utilize audit and evaluation to ensure quality control, there is no hard data demonstrating that such audit results in an improvement in field care. The difficulty in establishing and measuring evaluation criteria for prehospita1 care may account for this finding. There are 17 ALS receiving hospitals in Alameda County, California, a predominantly urban area of 1.1 million persons. By the time the emergency medical services district (EMSD) establishes full-time paramedic service in all areas of the county in early 1986, the four base hospitals will each handle an average of 400 to 500 ALS calls monthly. In Alameda County, the EMSD medical director, an emergency physician, conducts quarterly medical and procedural evaluations of the base hospitals. Physician review of base hospital direction in this system has brought about subsequent improvement in care. The medical director uses a checklist, tape review, and narrative as evaluation tools. In most locales, nursing personnel may legally serve as medical radio operators (MROs) and may provide direction to paramedics under ALS medical treatment protocols. In Alameda County, nurse MROs are required to take and successfully complete a loo-hour course in medical, legal, and procedural aspects of prehospital care. Each candidate must complete an Advanced Cardiac Life Support Course and an ALS provider ambulance ride-along. The base hospital liaison nurse or physician must audit the nurse MROs first ten taped ALS calls. There is a mandatory sevencall per month criteria, and there are formal tape review and continuing education requirements. In areas that utilize nurses as MROs, there often develops a tendency to infre-

James E. Pointer

quently involve physician MROs. Nursing personnel become accustomed to this duty, and physicians may feel that paramedic direction is more appropriate for nursing. In many emergency departments, physicians may be overburdened with clinical responsibilities, some in distant areas of the hospital. Emergency department physicians may also feel uncomfortable handling paramedic radio calls because of their unfamiliarity in operating the console or with communications or medical protocols.’ In these departments, nurses direct field care over which physicians bear the medical and legal responsibility. Physician medical control only nominally exists. Although many physicians voluntarily direct field care and become involved in the ALS system, many are reluctant to do so for the reasons above. Although Alameda County did not establish paramedic service until 1982 and was the last San Francisco Bay Area county to do so, the EMSD learned a great deal from the older surrounding systems. To encourage physician participation in the ALS system, the Alameda County EMSD enacted certification and continuing education requirements for emergency physicians employed at ALS base hospitals when the ALS system was initiated. California law requires base hospital contact except for performance of five lifesaving procedures9 The EMSD utilizes “standing orders” only for cases of disrupted communications. Aside from the yearly call requirement, physicians must communicate with paramedics in all cases utilizing certain drugs, percutaneous transtracheal ventilation, and pleural decompression. Any deviation from written protocol requires physician intervention. The system strongly encourages the nurse MRO or paramedic to request physician consultation freely. Any unusual field circumstance (e.g., physician-on-the-scene) requires physician communication. On the average, nurse MROs manage 65% of calls; physicians are involved in the remainder. At the one teaching base hosptial the physician figure is higher, 40%. Field personnel, in

Medical

Control

In Advanced

general, prefer to work with nurse MROs until a treatment or assessment problem with which they feel uncomfortable occurs. Then they freely consult with the physician, most of whom they know by name.

Method ALS Physician

MRO Certification10

The EMSD requires a certified nurse and physician MRO present in the emergency department 24 hours a day. All emergency physicians must complete the certification requirements within 90 days of employment. An uncertified physician may not talk on the paramedic radio but may give medical consultation to the nurse MRO. The county requires a number of reasonable prerequisites: completion of a 16-hour physician MRO course, field observation experience, and a review of the physician’s first ten ALS calls (Table 1).

ALS Physician

33

Life Support

MRO Course

Each prospective base hospital emergency physician must complete a 16-hour didactic and laboratory course as a requisite to certification. The faculty includes the EMSD medical director, two or three prehospital care coordinators who administer and organize the course, and five or six paramedics, liaison nurses, and physicians to administer the skills tests. All candidates receive a comprehensive syllabus prior to the two-day course. The first four hours of day 1 introduce the physician to the system by lecture and slide presentation. Experienced paramedics provide a field perspective during the next two hours. The physician candidates receive orientation and practice for the skills examination during the last two hours of day 1. The skills testing is the backbone of the course. Each physician receives six scenarios from broad treatment and communication areas. A scorer acts as “paramedic” and sits across

Table 1. ALS PhysicianMRO CertificationCriteria6 1, License to practice medicine

2. Practice at ALS base hospital emergency department 3. Documentation of completion of 16-hour ALS physician MRO course 4. Documentation of completion of eight hours field observation on approved ALS unit. 5. Successful performance on the physician MRO skills and written examinations. 6. Proof of current certification as an Advanced Cardiac Life Support Provider 7. Review by base hospital liaison physician and EMS medical director of first ten ALS calls directed by the physician

the table from the physician with a screen interposed. As the paramedic develops the scenario, he or she records numerically, on a standard form, errors that the physician makes on medical treatment or communication protocol. The errors are weighted depending on the seriousness; 30 incorrect points constitute failing marks. The EMSD medical director counsels those physicians who make minor errors. Those physicians who make serious mistakes must repeat the testing area using a different scenario.” On day 2, the physician receives the actual skills testing and a regional written examination, which tests six broad clinical areas (Table 2).

ALS Physician MRO Recertification and Continuing Education Requirements’o

The EMSD established reasonable criteria to ensure continued and ongoing physician participation. The county requires recertification biannually through an eight-hour course, as it does for paramedics and base hospital nurses. Physicians must log at least ten complete calls per year. These calls must not include those in which the physician provides consultation to the base hospital nurse. Criteria for tape review and other continuing education activities address physician management of paramedic sessions. Whenever possible, the EMSD or base hospital offers continuing education credits (Table 3).

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James

Table 2. Components of the ALS MRO Course

E. Pointer

Table 3. ALS Physician MRO Recertification and Continuing Education Criteria6

1. Day l-8 hours a. Lecture: Medical Control Considerations (1) Philosophy of medical control (2) Legislative basis of medical control (3) The physician MRO and the law (4) Components of medical control b. Lecture: Members of the ALS Team Base hospital nurse MRO, emergency medical technician, paramedic, physician MRO, liaison nurse, liaison physician, EMS medical director, county health officer, state EMS officials. c. Lecture: Soecial Considerations for the Phvsician MRO’ (1) Pronouncement of death in the field (2) Physician on the scene (3) Patients signing against medical advice (4) The terminally ill patient (5) Special protocols and procedures (6) Consultation with nurse MRO (7) Standing orders Lecture: Review of ALS Treatment and Communications Protocols The paramedics perspective (1) Lecture/round table: expectations by paramedics of physician MROS (2) Tour and demonstration of paramedic rescue and transport vehicle Demonstration: Blind medical control-a simulated card game that demonstrates trust intrinsic to MRO-paramedic relationship g. Practice MRO Skills examination with faculty 2. Day 2-8 hours a. MRO skills examination-one-on-one scenarios that test physician MRO on broad protocol categories: cardiac arrest, altered level of consciousness, hypovolemia, dysrhythmia, dyspnea, difficult communications b. MRO written examination-standardized threehour examination on all aspects of prehospital care

Discussion Alameda County requires base hospital ALS physician participation to ensure system medical control. To date, there has been essentially no negative feedback on the rationale or process for base hospital physician MRO certification, recertification, and continuing education. The EMSD has certified nearly 50 physician MROs. As

1. Direction and documentation of at least ten ALS calls per year 2. Attendance at two formal tape review sessions per year (four hours) 3. Selection of one activity from the optional category per year: a. Facilitation of tape review sessions ALS b. Clinical rounds/clinical preceptorship units d. Prehospital care lectures/educational seminars for ALS personnel e. Attendance at additional tape reviews 4. Attendance at and successful completion of an eight-hour recertification course every 2 years 5. Base hospital liaison physician’s performance monitoring 6. Physician MRO is responsible for maintaining and submitting continuing education record to EMS on a yearly basis

the system has grown, physician involvement has also increased. As many as 12 base hospital physicians have attended individual tape reviews. Nonemergency staff and resident physicians at the four base hospitals often attend the ALS tape reviews and clinical rounds. Each hospital emergency department has a small dedicated group of physicians who volunteer for increased participation in the EMS system because it is rewarding and fun. Cooper and Ornate’* described a seven-hour base station course that was not a prerequisite for certification within the EMS system. They cite several areas of “increased physician learning and awareness” that resulted from the course.” The Alameda County MRO requirements do not simply coerce the physician into compliance. These guidelines introduce the base hospital MRO to the system, remove the intimidation of the radio console and protocols, and ultimately provide positive, enthusiastic physician involvement. It is most important that the goal to which the EMS system strives is that of high-level, ongoing medical control.

REFERENCES I. California Health and Safety Code 1980 (Senate Bill 125), Division 2.5, section 1797-1799, p. 108. 2. Pons P: Medical control of prehospital care. J Emerg Med 1984; 1:449-450.

3. McSwain NE: Medical control of prehospital care. J Trauma 1984; 24:172.

4. Hooper EP: Emergency medical services: 1979. N Engl JMed 1979; 301:118-121.

MedIcal Control in Advanced

Life Support

5. Organization of emergency medical services. West J Med 1979; 130:83-89. 6. Yolles TK, Kelman HR. Varma AO, et al: Physician knowledge and attitudes toward an emergency medical services system. Ann EmergMed 1981; 10:2-10. 7. M&vain NE: Medical control-what is it? JACEP 1978; 114-116. 8. Rosen P, Dinerman N, Pons PT. et al: Prehospital care: An integrated concept of emergency medicine. Topics Emerg Med 1980; 2:19-26.

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9. California Health and Safety Code (Title 22), Division 9, Chapter 4, Section 100141(d) IO. Alameda County Health Care Services Agency, Emergency Medical Services: Certification of ALS base hospital physician. Advanced L!fe Supper/ Prehospital Care Policy 1983; 200.4:20-21. 11. Standardized skills testing. JEMS, December 1980, pp. 36-39. 12. Cooper MA, Ornato JP: Involving and educating base station physicians in paramedic programs. Ann Etnerg Med 1980; 9:524-526.