Medical Control: Colleagues in Patient Care

“Mike, medical control called. They need to talk to you.”

This can’t be good, I thought. I’d just returned to base from an early-morning alarm—my first as a paramedic—and was still pumped about “making my bones” as an ALS provider. My 60-something cardiac patient, whose sympathetic nervous system had been competing with mine for attention, claimed he had complete relief of his chest pain after oxygen alone. What could be wrong with that?

I asked my EMT partner if we’d forgotten anything. “You mean besides BLS?” she replied sarcastically. She’d already chided me for attaching EKG leads to the patient before we’d checked vital signs or administered O2. I conceded my priorities needed fine-tuning, but doubted the Department of Health knew or cared about the precise sequence of our interventions.

There was no use putting off my return call to medical control. I identified myself and was put on hold. For a long time. Then a businesslike voice interrupted the rhythmic hold tones.

“Hey, Mike, we need your card.”

There it was, I figured: the end of a six-hour career. All that studying and a hefty tuition for what, one patient? How would I explain that to family, friends, bartenders?

Before I could strike a Faustian bargain for a second chance, the voice continued, “Can you fax us a copy? We’re updating our Rolodex.”

Talk about relief—the down-on-my-knees variety. Later, when I was in a less-reverent mood, I recalled how mention of medical control had juiced my fight-or-flight response. I’d overreacted, but why?

As a mere speck in the Petri dish of prehospital care, I wondered how I should view big, bad medical control. Were they a regulatory body? An advisory body? What could they do for me? What should I do for them?

EMS Under Control

Medical control is as old as EMS. Well, almost. It was “physician-staffed ambulances,” not physician-guided practice, recommended in the National Academy of Sciences’ 1966 thesis, Accidental Death and Disability: The Neglected Disease of Modern Society. Still, that paper is widely credited for spurring the transition from marginally trained ambulance attendants to certified, well-equipped prehospital specialists. By the time we were watching Johnny and Roy resuscitate the least-fortunate citizens of Los Angeles, the Highway Safety Act of 1966 and Emergency Medical Services Systems Act of 1973 had stimulated funding for advanced life support technicians supervised by hospital-based physicians.

During the ’80s, medical control became a common term to describe a subset of medical direction mandated by law in most states. “Online” medical control referred to real-time decisions by doctors about prehospital treatment and transport. Detailed direction, sometimes concurrent with care (“Start an IV, attach the monitor, give the drug in the blue box…”), permitted use of medications and procedures previously available only at the ED.

The other part of medical control—“offline”—consists of prehospital advisory and QA/QI activities such as education, case reviews, data interpretation and counseling.

Mark Mosier and Sharon King, paramedics with over 30 years each in EMS, say their early experiences with medical control were much more about following online orders call by call than huddling with physicians about long-term patient care issues.

“It was a mother-may-I system then,” says Mosier, who worked in Oregon and Washington. “We were on a very tight leash, having to call for lots of things we just take for granted nowadays—nitro and aspirin, for example.”

King says there were no written protocols in 1986 when she became a paramedic in Arkansas. “They’d sent us to medic school, and when we came out we were expected to do what we were taught. When we called medical control, there wasn’t much discussion; we’d end up doing whatever they wanted us to do.”

By the mid ’90s, EMS protocols and curricula were competing to introduce cutting-edge practices to each other.

“Standing orders made us a lot more independent, but we also had to be sharper and more responsible,” recalls Mosier. “Still, I felt more comfortable as a medic knowing I had backup at medical control. I wasn’t afraid of them; it was a partnership.”

In 1996 the National Highway Traffic Safety Administration (NHTSA) cautioned, in its EMS Agenda for the Future, that “prolonged out-of-hospital times” were a consequence of lengthy online conversations between prehospital providers and ED docs. These concerns were echoed by Bryan Bledsoe, DO, an ED physician, author and former paramedic, in a 2002 editorial, “Adios, Rampart: Give Medical Control the Boot.” Bledsoe suggested that “aggressive, medically sound standing orders,” rather than real-time control of EMS personnel, is the more efficient, less costly approach to prehospital care.

“Comprehensive, continuous quality improvement” would detect and resolve cases involving substandard treatment, he added.

Caring for Caregivers

Anything that delays definitive care is bad. However, some EMS systems—particularly those with large volunteer constituencies—require closer online supervision of prehospital personnel. Medical directors, under whom medical control operates, usually have the most say about the level of service their systems offer caregivers.

Jullette Saussy, MD, who served as EMS medical director for New Orleans and Washington, DC, favors a centralized base station where a regular group of physicians is always available for consultation. Saussy felt it was part of her job to be accessible 24/7 to her paramedics, most of whom she knew by name and voice.

“In New Orleans it was at the point where I could tell not only whose voice it was, but how critical the patient was from their inflection,” Saussy says.

“Medical directors who are superinvolved with their medics—literally a phone call away—that’s the ultimate medical direction. When providers tell me they’re in situations where they don’t have a doctor to call 24/7, that makes my heart sink. If you feel strongly enough about calling me at 2 in the morning, there’s a reason, and I need to answer the phone.”

King, who recently retired from LifeNet EMS of Hot Springs, AR, agrees it’s important to have unlimited access to your medical director.

“We’re lucky we have Dr. (Karl) Wagenhauser,” she says. “He really works at establishing a rapport with his medics. When one of them calls, he knows who they are and what level of experience they have. You can call him in the middle of the night, and he won’t get mad. He’d much rather have you call when something strange is going on so he doesn’t have to question you later about why you did what you did.”

In most EMS systems, it’s not the medical director but rather ED docs who routinely answer the phone or radio when field practitioners have emergent patient-care issues. Offering remote support isn’t a natural act for all of those physicians, some of whom know little about EMS.

“You have to be a really good listener,” says Saussy, who started as a paramedic in New Orleans. “Understand the prehospital protocols and how to apply them. Know your options and be able to make quick decisions about things like dosages and destinations.

“Physicians who don’t have a good feel for EMS tend to think prehospital direction isn’t important, that patients should just be brought in for treatment. If we’re going to have that mind-set, why not go back to hearses for ambulances and just drive really fast?”

Matt Giacopelli, a paramedic for York (PA) Regional EMS who spent several years assisting online medical control in another state, thinks it’s ideal for medical control physicians to have prehospital experience but would settle for them understanding EMS capabilities and limitations.

“We occasionally get docs who tell us to give meds we don’t carry,” he says. “Then we’ll run into problems when they don’t listen to what we’re saying and start asking questions we’ve already answered.

“When our transports take only a few minutes and we’re trying to expedite care, it doesn’t leave much time to talk.”

Patience With Patients

Mohamud Daya, MD, medical director for Oregon’s Tualatin Valley Fire & Rescue (TVF&R), wants medical control physicians to have a big-picture feel for EMS.

“When those doctors are online,” Daya says, “they have to understand not only the medical issues but also the limited healthcare resources available and the ability to not always transport. Not all medical control physicians are comfortable managing those risks.

“We need to do what’s best for the patients in the settings they’re in. Sometimes that means transport, sometimes other things.”

Oregon Health & Science University Hospital, where Daya is EMS section director in the Department of Emergency Medicine, has started a consultation program with a couple of Portland-area nursing homes. Those facilities can contact ED physicians directly for advice on patient dispositions before EMS gets involved.

“When there’s a question about whether a patient should be transported, the ED does a consult with the nursing facility and actually has a chance to speak with the patient,” Daya explains. “In the one case I was involved in, the patient didn’t get transported because what they needed could be done at the nursing home.

“I’m hoping to integrate this service with medical control.”

Validating alternatives to transport can involve labor-intensive negotiations between patients and practitioners. Kevin Pesce, medical control supervisor at Stony Brook Hospital, which provides on- and offline support to Suffolk County (NY) EMS, says about 3,500 (17%) of the 20,000 calls his department handles a year are refusals. The county’s medical control physicians team with on-site responders to identify high-risk criteria and help patients make the best transport decisions.

“We convince about 20% (of refusals) to go to the hospital,” Pesce says. “Of that 20%, a third get admitted. That makes all those consultations worthwhile.”

Less-Common Roles

According to Pesce, aggressive management of refusals is just one aspect of prehospital care where medical control can shine.

“We have a much larger role in destination decisions than when I started 10 years ago,” Pesce says. “Stroke centers, trauma centers and pediatric centers are all part of that, but the big one is STEMIs. Almost all the 12-leads done in the field are transmitted to medical control so we can notify PCI centers. Working with EMS crews that way, we’ve reduced our average door-to-balloon time by over 30 minutes.”
An offline responsibility of Suffolk medical control that’s a reflection of their large volunteer component is tracking invasive procedures.

“Any IO that’s done in the field, any intubation, King airway, needle decompression or cric gets followed up with the receiving hospitals to make sure the devices were properly placed and working,” Pesce says.

At TVF&R, Daya extends medical control to dispatch centers. “That’s a piece we can influence tremendously as medical directors,” he says, referring to the monitoring of prearrival instructions and timeliness of response. “We tend to send everything lights and sirens and focus on short response, regardless of whether the problem is chronic or acute. There’s certainly room for improvement.”

Daya also mentions employee safety as a medical control concern: “I’m talking mainly about promoting protection against infectious diseases, but it also involves monitoring the work of hazmat and search-and-rescue teams. I try to separate those needs from minor, day-to-day injuries.”

An evolving role with even more potential, says Daya, is mobile integrated healthcare.

“It’s not clear to me where we’re going with that, but as medical director, I see medical control involvement someday, possibly in the area of resource allocation.

“Keeping patients healthier and stable in their homes requires a different mind-set from 9-1-1. You need more time and access to medical records. For example, we had a COPD patient with worsening dyspnea because she’d run out of her prednisone. Instead of transporting her, which she wouldn’t have consented to, we took the time to provide steroids for her at home as a bridge to her next prescription.

“This form of medical control is harder for a physician who’s also seeing patients. The challenge is to fit what you can in the time allotted.”

Helping Medical Control Help You

Squeezing medical control contact into already-limited prehospital time is often difficult for EMS providers too. When I started riding as a medic, I was preoccupied with following a “script”: who I was, where I was, what I had, etc. Often I’d leave something out, then try to insert it awkwardly:

“Medical control, I have a 66-year-old female short of breath who hasn’t responded to two nebulizer treatments. She has a history of COPD and diabetes. This is Mike, by the way.”

Or I’d go on about something relatively unimportant:

“Medical control, this is Mike with a 42-year-old cardiac patient who’s having chest pain. He’s on nitro and Colace, which he says he only takes when he’s really constipated—the Colace, not the nitro.”

Saussy suggests a few simple guidelines for new medics to follow.

“Go introduce yourself to medical control. Figure out who your medical director is, get his or her phone number, then call them and say you’d like to know they’re available.

“When you contact medical control with a report, tell them what you’ve done and what you’d like to do. Don’t ask ‘What do you want me to do?’ You need to be confident.”

Daya says it’s important to know why you’re calling.

“Sometimes when we hear from EMS, it’s clear there hasn’t been enough thought given to the purpose of the call. It’s always good to do your assessment, collect a set of vitals and make sure you have all your information.”

Mosier offers advice he gave a new medic during an orientation program 20 years ago: “I told her, ‘Develop a relationship with your medical director and know your standing orders like your patients’ lives depend on them.’”

Giacopelli adds, “Know what you’re going to say, know what you want. Give a clear and concise report. The more you sound like you know what you’re doing, the more likely they are to give you your orders. You know what information you need to make these decisions; doctors need the same.”

Probing Protocols

When I was in medic school, we’d often get tested on protocols—state, city and county. They were different from each other—sometimes only in subtle ways, but enough to confuse us during exams. As a matter of self-preservation, we’d make sure our preceptors identified the jurisdictions we were hypothetically working in before we’d dare verbalize our interventions.

About six months after graduation, I realized my approach to patient care needed a 180-degree adjustment: Instead of basing my initial treatment plan on a memorized page of protocols for a particular region, I began to consider “good medicine” first, then tried to fit what I wanted to do into the appropriate guidelines. Therein lies one of the biggest challenges for new EMS providers at any level.

“What I worry about is that everything tends to be defined by protocols,” says Daya. “You cannot write a protocol for every single condition. People have to be able to use their heads and integrate what they’re seeing with policy. Let’s say you have a (systolic) BP of 101 and I want to give you a sedative like Versed, which has a hypotensive effect. The protocol says that’s OK because the BP has to be 100 or above, but that doesn’t mean you’re going to push the full 2.5 or 5 milligrams. Start with, say, 1 milligram; you can always give more. That’s how I think people sometimes struggle just following the book. Medicine isn’t about protocols. We’re trying very hard to put people into baskets that say they’re either this or that. That’s easy when it’s obvious, but there are lots of unknowns in between. You have to be willing to think outside the box, ask for help and always consider patient safety first.”

From Guidance to Collaboration

Medical control can be much more than regulators and gatekeepers, but both prehospital and hospital personnel have to embrace a mutual interest in the best possible outcomes. Saussy offers an example: “I was sitting with a trauma surgeon who said, ‘Frankly, I don’t care what EMS has to say; I just want to know the blood pressure, and that’s it.’ We’re talking about improving our trauma systems, and he doesn’t want to hear what EMS has to say? I told him about how it was at Charity (Hospital in New Orleans), where the room would get quiet when EMS came in. They’d give their report, and we’d listen, because that was the way patients entered our system. You may not value their information because it hasn’t always been helpful, but if we’re going to call ourselves a system, we have to be accountable for what EMS does and look for opportunities to give them feedback about their decisions, right or wrong.

“There are places that hate to do medical control, where they just tell EMS, ‘Bring ’em in.’ I don’t see how that serves anyone. The mission of medical control should be not only consultative but collaborative. That means establishing a learning environment for the medics and not forgetting that we’re all here for the patients.”

Bibliography

Bledsoe B. Adios, Rampart: Give medical control the boot. J Emerg Med Serv, 2002 May; 27(5): 168.

Boyd D, et al. Medical control and accountability of emergency medical services (EMS) systems. Vehicular Technology, IEEE Transactions, 1979 Nov; 28(4): 249–62.

Diehl D. The emergency medical services program. To Improve Health and Health Care, Volume III. Robert Wood Johnson Foundation, 2000.

Henry M, Stapleton E. EMT Prehospital Care, 3rd ed. Mosby/JEMS, 2003.

National Highway Traffic Safety Administration. Emergency Medical Services Agenda for the Future, ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf.

Pozen M, D’Agostino R, Sytkowski P, et al. Effectiveness of a prehospital medical control system: an analysis of the interaction between emergency room physician and paramedic. Circulation, 1981; 63: 442–7.

Rajasekaran K, Fairbanks R, Shah M. No more blame & shame. EMS World, EMSWorld.com/10320867.

Sanders M. Mosby’s Paramedic Textbook, 2nd ed. Mosby, 2001.

Mike Rubin is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.