Deb Funk, MD, FACEP, NREMT-P

This month, EMS Magazine introduces "10 Minutes With," a new bi-monthly column that will present brief interviews with EMS leaders involved in many facets of emergency medical services. Future interviews will cover such topics as EMS research, legal issues and education. Suggestions for topics and subjects can be sent to the author at rbarishansky@onebox.com.

Since the beginning of modern-day EMS, the use of medical control—either through standing orders/protocols or through direct communication with hospital-based personnel—has been a constant. Recent years have seen a shift away from the more parental "Mother, may I?" oversight days of strict medical control in favor of a collaborative approach, more appropriately termed "medical direction." For our first column, which focuses on medical direction, I spoke with Deb Funk, MD, FACEP, NREMT-P, medical director of Albany MedFlight based in Albany, NY. Dr. Funk is active with the New York State chapter of the American College of Emergency Physicians (ACEP), sits on several committees of the National Association of EMS Physicians (NAEMSP) and has served as the medical director for NAEMT's Advanced Medical Life Support (AMLS) program. Additionally, Dr. Funk is a graduate of the National EMS Medical Directors course and has published numerous books and articles on prehospital clinical care and the role of the medical director in EMS.

What is the role of a medical director in EMS?

The medical director should provide direction to an EMS system regarding medical issues. Specifically, a physician should oversee and participate in any aspect of the EMS system that has to do with the practice of medicine: protocol development, research, education, quality assurance and improvement, and actual practice.

While there will likely be nonphysician personnel supervising each of these areas as well, the medical director should be closely involved and provide general oversight. Direct, visible involvement of the medical director is useful in establishing and maintaining credibility and in fostering a good working relationship with the medical staff.

It is important to realize that an EMS physician medical director must be appropriately compensated for his/her time. If the individual must work significant hours elsewhere in order to make an adequate salary, time devoted to system medical direction will be limited. These costs must be included as a necessary budget item.

Do BLS agencies (using albuterol, EpiPen, etc.) need a medical director? What about those not performing those types of advanced procedures?

Yes and yes. First of all, New York and many other states require that an agency using such advanced procedures have physician oversight. Beyond this, it simply makes sense. BLS providers receive significantly less training than more advanced providers, yet they have the least medical oversight. While the procedures they are expected to perform are generally less involved, there is a certain amount of medical decision-making in their practice. It is essential for that decision-making to be reviewed and reinforced or remediated, when needed, by a physician. Even agencies that do not utilize the more advanced modalities such as albuterol and EpiPen could benefit from medical oversight and physician involvement in their education, practice and quality assurance.

That being said, there is a shortage of EMS physicians, and it is sometimes difficult to find a physician medical director for multiple small BLS agencies. Each EMS system should address this problem in a way that is most appropriate for their circumstances.

How do you see the EMS industry addressing the issue of correcting medical mistakes?

Unfortunately, many systems correct mistakes through punitive actions against the individual provider. A more beneficial approach is to identify the cause/causes of the error and attempt to not only remediate the individual but also take steps to prevent a similar situation in the future. Additionally, it should be recognized that if one person made an error, others can make the same mistake, and thought should be given to providing additional training on the topic to the entire agency or system and to making changes to prevent such an error from occurring again. An example is an inappropriate dose of a medication given to a pediatric patient. This is a mistake that can be made by any of us and can result in significant harm to a patient; therefore, a process should be put in place that reduces the possibility of such an error. The response to such an incident might include requiring use of a length-based resuscitation tape and detailed calculations documented for any medications or fluids given to a pediatric patient.

Does EMS need to move away from punitive discipline for clinical errors? How do you suggest this can occur?

Absolutely. Punitive discipline for clinical errors leads to concealment of issues. This is harmful in many ways. It is imperative that we encourage providers to draw our attention to mistakes and near-mistakes so that we may address the issue in an environment that encourages learning. As I previously stated, if one person made an error, others could as well. Therefore, we have to analyze the incident and determine if a process change is in order (see the example in the previous answer), or if further training is needed for the group.

Self-disclosure in a group setting such as a continuous quality improvement meeting is hard to get used to, but can be an incredible learning experience. The entire group can learn from one person's experience, eliminating the need for each person to make the same mistake.

Culture change might be difficult, but it is necessary for this to be effective. An approach that is nonpunitive and encourages learning will bring this change about. It will take time for providers to realize that sharing their own practice challenges in a group setting will result in constructive feedback and support from peers and management alike. However, repeat offenders, those who don't make an effort to improve and especially those who attempt to hide errors, must be dealt with through appropriate disciplinary procedures.

Do states need a physician or physician panel as an EMS medical director?

Physician oversight is necessary at any level of medical practice in EMS. It seems appropriate that one person be responsible to make the final decisions regarding policy and procedure; however, this person should receive advisement from a physician panel or committee that represents the interests of all groups throughout the area in question, state or nation. Such a diverse panel would be useful to assure that the needs of every system are addressed, as these needs may be significantly different from one area to another.

What are appropriate selection criteria for a medical director?

NAEMSP has published a position statement that describes the qualifications of a physician medical director. By necessity, it is broken down into Essential, Desirable and Acceptable qualifications. In addition, the statement discusses the necessary training for these physicians. The ideal candidate for an EMS medical director is a licensed, practicing emergency physician who is familiar with local and regional EMS activity and has completed an EMS fellowship. The numbers of such individuals are not sufficient to oversee all of the country's EMS agencies; therefore, some compromise may be necessary. The bottom line is that an interested physician with the appropriate medical expertise and background can obtain the training necessary to familiarize him/herself with the needs of the agency. The key is in finding a motivated physician who is able to invest time into the agency to provide appropriate oversight.

Conclusion

Medical directors act as a linchpin to the center of the EMS model. We in the prehospital arena need to work together with the medical community, specifically EMS physicians, to address all of the issues discussed here for the future health and success of our industry.