Physicians in the Field
How often do EMS providers wish the medical staff they encounter in the emergency department really knew what goes on in the prehospital setting?
New Orleans EMS (NOEMS) has enjoyed the benefits of working closely with resident physicians for decades. The physicians gain from the experience, too, says Jeffrey M. Elder, MD, FAAEM, and EMS and medical director for NOEMS.
“We started with the Louisiana State University emergency medicine residency program,” says Elder, “and we’ve had resident physicians riding with us for as long as anybody can remember.”
The residents do two-week or one-month EMS rotations, Elder says. They ride in sprint cars with paramedics and respond to all critical calls. And during their 12-hour shifts, they’re online medical control for the entire NOEMS system.
According to Elder, around 2007 NOEMS was even able to secure funding to start an emergency medicine fellowship program. Four full-time fellows went through the program before NOEMS lost the funding. But the agency still has one physician, its associate medical director, Dr. Elizabeth Clement, who’s doing a fellowship with NOEMS in addition to an ultrasound fellowship.
“Really what this program allows us to do is get a physician in the field who’s knowledgeable about our practices, protocols and how we do things at NOEMS,” Elder explains. “Our goal is not to take anything away from what the paramedics do in the field—really it’s just to supplement it. They can do the same things as the physicians 99% of the time. Even today when I’m out running calls as the EMS and medical director, I’m doing the same things the paramedics are doing. Occasionally we’ll do some different stuff—some of our physicians can RSI in the field—but for the most part it’s really just an extension of medical control.”
In addition to some of the physicians carrying RSI medications, about the only other significant difference between the residents and NOEMS medics is that the physicians have portable ultrasounds. Clement is particularly well-versed. “She’s been using that in the field,” Elder says, “and we’re kind of introducing that to our crews. Long-term we’d like to use it as a starting point for a program to train our medics on using point-of-care ultrasound in the field.”
“The biggest benefit” to having the physicians along, Elder adds, “is that it gets the paramedics and physicians working together, and it really builds that relationship. If there’s an education component to it, that’s great too. If there’s a complicated CHF patient, for example, a physician can talk a paramedic through why we do certain things we do. And when you’re dealing with residents who have little to no prehospital experience, the medics teach them a lot too. I got my first EMS experience as a resident here working with NOEMS, and I learned a lot from our medics who had been doing this for years and years.”
One way Elder says the resident physicians can really assist the regular EMS crews is with patients who need but refuse transport. “The responding crew might call in and request the doctor,” he says. “Sometimes just having the physician show up, evaluate and talk to the patient can get them to go to the hospital if they need to. And, to be honest, sometimes just talking to them over the radio can get patients to go, using nothing different than what the medics do, other than saying, ‘This is Dr. So-and-So, I really think you should go.’ You’d be surprised how many times people say OK, they’ll go.”
For NOEMS, having the physicians on scene is commonplace after so many years, but Elder admits there’s a learning curve for new medics and experienced medics who come to New Orleans from other services. “If you’re from a rural service and you’re used to just you and your partner in an ambulance, it’s a little bit different if now all of a sudden you have an extra paramedic, a physician and other people on scene,” Elder explains. “What I try to tell all the physicians who work with us is to be there as a resource. It’s not our job to jump in and do all the intubations and procedures. The medics know how to do all that stuff. We’re there as a resource and an extra set of hands. If all you do on that call is help lift a stretcher and get a patient in the back of a truck, you were there, you talked to the crew—for us that’s a win too.”
Elder acknowledges not every EMS agency is going to be lucky enough to be near an emergency medicine residency program so it can start a similar program of its own. But while that’s the easiest way to incorporate on-scene physicians, it’s really just a matter of talking to your local medical community and medical director.
“See who’s interested, and even if it just starts off as saying, ‘Hey, doc, do you want to ride for a little bit to see how this works?’ that’s a big piece of it,” Elder says. “You just get people out there to see what crews really do in the back of a truck or in somebody’s home, see how different medicine is in the field versus when you get to the hospital. A lot of times that will open some eyes. And the goal is also to get the best-educated prehospital crews out there. I think this is a good way to help move that mission along.”
