The Emergency Medical Services (EMS) system in the United States functions primarily under the philosophy that EMS should – as efficiently as possible – assess, treat, and then quickly transport a patient to the appropriate hospital for definitive treatment by physicians. If needed, Medical Control (MC) is supplied off-line in protocols or online via various communication technologies. The paramedic-driven EMS system used in the United States was developed not because it was an inherently better design, but largely because of economic reasons – including a relative shortage of available physicians. It is undeniably less costly and time consuming to train paramedics rather than physicians, and paramedics are considerably less expensive to pay.
One of the more direct references to pre-hospital roles for physicians can be found in the NAEMSP (National Association of EMS Physicians) position statement on Physician Clinical Responsibilities. In that statement, NAEMSP recommends that EMS-system physicians “maintain a presence in the field to provide on-scene medical direction, assess compliance to protocols and policy, observe the quality of patient care, and be a resource and teacher.” It is not specified whether the “presence” specified necessarily needs to be a physical presence at the scene.
In a related 2002 publication, Prehospital Systems and Medical Oversight, NAEMSP cites the following examples of situations in which dispatchers may alert EMS physicians that they may be needed for an on-scene response: multiple/mass casualty incidents; major vehicle collisions in which there is an “entrapment” possibility; specialized rescue situations (heavy rescue, trench, confined space, water/swift water, vertical); major airport alerts (airplane crash); hazmat (hazardous materials) incidents; WME (weapons of mass effects) incidents; and tactical situations in which hostages have been taken.
Also: significant structural fires and/or major fires involving human victims; structural collapse situations with entrapment possibilities; incidents in which difficult airways are anticipated; incidents where there might be a need for field amputations; complicated incidents involving a possible field termination of resuscitative efforts; mass-gathering events – particularly and specifically including major political or media events; and “unusual” medical situation (an anatomical oddity, for example, or the use of an unusual home medical device).
A Relevant Surprise & Conglomerate Inventory
A relevant question, based on the preceding, is this: Does the lack of commentary on the record by notable emergency medical associations mean that Medical Control away from the hospital does not exist in the United States? Surprisingly, perhaps, to at least some American paramedics and EMTs, the answer is that there already are some U.S. EMS systems that routinely put physician responders in the field. Those systems share a number of common elements including the specific circumstances in which physicians are dispatched to emergency scenes, what they are expected to do, and are capable of doing, on those scenes, and what type of vehicles and medical equipment they are likely to both need and use.
In the same 2002 Prehospital Systems publication mentioned earlier, NAEMSP suggests the following equipment and drug inventory for EMS physicians: a monitor/defibrillator; an airway management kit with endotracheal tubes/laryngoscope; oxygen delivery systems; a bag-valve-mask device; a medical kit with IV-access supplies; a scalpel, 4×4 gauze, and tape; a high-powered flashlight; rescue blankets; communications equipment (specifically including a radio, a pager, and a cell phone); proper identification (card or badge); a fire extinguisher; flares; and binoculars.
In addition: foul-weather clothing; reflective clothing/vests; bullet-proof vests; splints/immobilization devices; hazardous materials manuals; and, last but not least, a drug pack filled with such medicines as epinephrine, atropine, lidocaine, dextrose, nitroglycerine, furosemide, diazepam, the drugs needed for rapid-sequence intubation, 2-PAM, and a cyanide kit.
Several programs – such as those in Houston, Texas; New Haven, Conn.; and some areas of New Jersey – actually provide for a physician responder as a routine component of incident-scene EMS operations. In those programs, the physicians are used both for high-priority single-patient and for lower-priority multiple-patient calls. In Houston, a staff of four physicians, assigned on a four-day rotation, provides 24-hour coverage of online and/or on-scene medical direction for all patients considered to be critical. In addition to being automatically alerted, along with the EMS supervisor, when units are sent to critical medical cases or trauma responses – e.g., motor vehicle crashes with entrapment, gunshot wound in a child, multiple victims – these doctors may respond to scenes as they see fit, allowing them to see and be seen in and as part of the overall Houston medical system.
The New Haven area has a dedicated physician-response team staffed by seven EMS physicians and two physician assistant/emergency medical technician–paramedics (PA/EMT-Ps). According to Dr. David Cone, MIC medical director of the New Haven Sponsor Hospital Program, the team is dispatched, following a request by an incident commander, an average of two to three times a month. About half of the calls are for “clearing” patients at school-bus crashes and similar events with several low-injury and no-injury patients. The remainder of the calls usually are related to prolonged extrications, industrial accidents, and similarly complex situations.
Response calls are also “jumped” for quality assurance (QA), educational, and research purposes. The team is certified and the vehicles both inspected and licensed by the state. All of the personnel staffing the team have had previous ICS (incident command system), hazardous materials operations, and emergency vehicle operations training. These units have system vehicle designations and are available through the main dispatch entity via a standardized call-out procedure.
A Degree of Unusual Expertise & Advanced Capabilities
Here it should be emphasized that it takes more than a medical degree and advanced emergency life support courses – e.g., Advanced Cardiovascular Life Support, or ACLS; Advanced Trauma Life Support, or ATLS) – to effectively operate as an on-scene MC physician. Training in basic and advanced ICS subjects, hazardous materials and/or CBRNE (chemical, biological, radiological, nuclear, explosive) situations, and emergency vehicle operations, as well as being in-serviced into local EMS system operations and prehospital scene safety, are all both important and necessary. In systems where response works to enhance the provision of prehospital care, physicians should have experience in emergency medicine, a thorough knowledge of EMS policies and protocols, and an understanding of the various levels of providers’ skills and scopes of practice as well as an overall familiarity with local emergency-response resources.
One important question remains, though: Do these examples mean that EMS providers in other areas of the United States should expect to see their medical directors or MC physicians assigned to a call sometime in the near future? The answer is “Not necessarily.” Most paramedics and EMTs probably would prefer not to have a doctor looking over their shoulder on a call. In New Haven as well as New Jersey, for example, despite a well planned protocol and dedicated units, the number of formal requests from field personnel for the physician team to respond to a call are still fairly low. Also, given the overwhelming patient volume already being experienced in the nation’s emergency rooms, the likelihood of an attending MC physician running out the door at the sound of an ambulance pager is a bit unrealistic.
However, with carefully considered response policies and protocols – combined with ready, willing, and able medical directors and/or MC physicians who have both the training and the equipment needed – in-the-field physician responses are a possibility that both sides of this idea should carefully consider. For EMS providers, the potential benefits of having physicians as part of an emergency response – e.g., large-scale triage assistance, specialty care above the scope of practice or training of a paramedic, immediate availability for medical consultation/command, first-hand quality improvement/quality assurance feedback for protocols, one-on-one teaching opportunities – should not be overlooked. As for medical directors and MC physicians who put their collective licenses on the line everyday, the value of having the ability to directly observe an EMS system functioning in real time is immeasurable.
Raphael M. Barishansky, DrPH(c), is a consultant providing his unique perspective and multi-faceted public health and emergency medical services (EMS) expertise to various organizations. His most recent position was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. He is also currently a doctoral candidate at the Fairbanks School of Public Health at Indiana University.