Why Losing a Medical Director Can Be So Disruptive

The unexpected passing late last year of respected EMS medical director Craig Manifold, DO, shook up the EMS community both in his home jurisdiction of San Antonio, Tex., and nationally as well.

On a larger scale the sudden loss of Manifold cast a spotlight on the medical director position and its pivotal role in the provision of emergency medical services. To explore this topic in depth, EMS World recently spoke with E. Stein Bronsky, MD, and Joshua Hartman, MBA, NRP. Bronsky is co-chief medical director for the Colorado Springs Fire Department and AMR in El Paso County, Colo. Hartman is senior vice president of public safety for EMS World and its parent company, HMP Global, and a paramedic with the Chevra Hatzalah Volunteer Ambulance Corps in New York City. 

EMS World: What impact does the unexpected loss of a medical director have on an EMS agency?

Hartman: The unexpected loss of our medical director, Dr. Richard Friedman, in 2018 had multiple impacts. First he was one of the most revered and respected members of our organization and the medical leader. The loss of someone of this caliber and dedication is truly heartbreaking personally and professionally for all of us. Additionally his untimely passing left a void in the corps that needed to be filled, which was difficult to do given all Dr. Friedman did for the organization.

Bronsky: When an EMS agency suddenly loses a medical director, it’s losing one of the foundation blocks that keep it secure and operational. This is because the practices of an EMS agency are usually created and signed off by the medical director. To be specific, every single medical provider within an EMS agency who is going out and performing any type of medical act is doing so as an extension of their medical director. 

Since EMTs and paramedics are not independent providers, they must have complete oversight on all practices. This is where their medical director comes into the picture. They personally approve every act performed medically in the prehospital environment. 

As well, when EMTs and paramedics are trained, the medical director is the one who signs on the dotted line that says, “I have approved everything being taught to these providers. I am personally verifying that they have successfully passed this training and are competent to perform care to the general population.”

So if all of a sudden you lose that medical director, it’s like having the rug pulled out from underneath you. You no longer have this foundation supporting daily operations and long-term planning and goals.

What else makes medical directors so vital to their EMS agencies?

Bronsky: There are so many idiosyncrasies that come with every EMS system. The medical director is a vital team player in creating and guiding the culture of each system. This is not something that can be learned from a book. If a medical director were suddenly to disappear, some of the cultural foundation of the organization is destabilized. 

Hartman: Generally they are the liaison to the medical community—whether that’s to the regional, municipal, or state government or other agencies. They often represent and are the face of the organization to external healthcare stakeholders.

Medical directors also play a key role in influencing government authorities with respect to funding and regulations.

Bronsky: Very true. This is why it is always in the medical director’s best interests to be very involved with all local regional, state, and national stakeholders that directly and indirectly influence EMS functionality.

For instance, EMS agencies provide a lot of medications to their patients in the course of care. Then we have the DEA (Drug Enforcement Administration) focused on managing controlled substances in our country and creating all the rules that govern diversion.

An EMS medical director is obligated to maintain a dialogue with the DEA so they understand our use of controlled substances in the field. The medical director should also be playing an advisory role in the creation of new DEA regulations so the rules permit the appropriate use of these substances by EMS agencies in a prehospital setting.

I cite this example because Craig was really the foremost EMS medical director in the country with respect to talking with the DEA about making sure federal rules were aligned with the needs of EMS and the appropriate medical treatment of the general public.

Having fleshed out the multiple roles of a competent EMS medical director, what are the challenges in finding their replacement on short notice?

Hartman: There are many responsibilities, not the least of which is the development of protocols and provision of education to the providers within the organization. On top of that, the need to have a good working relationship with external stakeholders is important. Finally the logistics of dealing with issues surrounding controlled substances and their distribution can be very tricky to deal with on short notice as well.

Bronsky: Because the medical director’s job is so shaped by the person fulfilling that role, bringing in a new person quickly can change the situation radically at an EMS agency. In particular, there’s no guarantee the new person is going to be like-minded to the person they’re replacing, let alone a good leader and somebody who can help move the EMS system forward in the ways everybody had planned for and expected.

Can an EMS agency minimize the disruption by having an assistant medical director who can assume command?

Bronsky: Yes and no. When it comes to medical directors, many EMS systems have a second in command. If the head medical director becomes unavailable, then the assistant basically knows what’s going on and can fulfill the medical director’s duties, assuming the management system has been designed correctly beforehand.

This said, there’s no guarantee the second in command has the same leadership skills and experience as the person they’re replacing. Even if they do, there will be a learning curve as the new person gets up to speed. 

Hartman: This is absolutely a necessity. Having someone else available to take over, either on a short-term or permanent basis, is imperative for the continuity of patient care and organizational operations.

Finally, what is the best selection process for finding medical directors like Craig Manifold?

Bronsky: As a baseline, you want to hire a medical director who has the appropriate emergency medical training and certifications for the job. They need to have experience in prehospital medicine and have demonstrated real competency in this area.

After this you get into the intangibles. You have to decide what leadership and personality attributes are necessary to do the job well. Having good people skills and a passion for EMS matters, as does a solid track record. Craig Manifold had all these qualities and much more. This is what makes his shoes very difficult to fill.

Hartman: In addition to the obvious, that the person needs to be a physician, I now believe we have enough physicians with EMS fellowship experience that except for rare exceptions, we should only be considering candidates with EM and EMS experience. In addition, the person must have the respect of the EM and EMS communities as well as the bodies that oversee them.  

Sidebar: A Pivotal Role

The unexpected September 20, 2020 passing of prominent emergency physician Craig Manifold, DO, who served as medical director for the National Association of Emergency Medical Technicians (NAEMT), left a large hole in the hearts of his family, friends, and fellow medical professionals. But Manifold’s sudden demise also left a big gap in the Texas EMS sector, due to his deep involvement with San Antonio fire and EMS agencies.“At the time of his passing, he served as EMS medical director for multiple ground, air, law enforcement, fire-based, private, critical care, and U.S. governmental agencies,” said Manifold’s official obituary. “The Texas Governor’s EMS and Trauma Advisory Committee Medical Director Committee and Texas Preparedness Council also benefited from Dr. Manifold’s expertise and involvement.”

“The death of a colleague is always difficult to deal with, but adding to this tragedy is the fact that Dr. Manifold served as EMS medical director for about 20 different public safety agencies, plus the San Antonio Zoo,” says colleague C.J. Winckler, MD, LP, an assistant clinical professor at UT Health San Antonio and deputy medical director for the San Antonio Fire Department. “It has left a void the medical community is struggling to fill.”

“In this state all the direction to EMS crews comes from the EMS medical director,” says another Manifold peer, David Miramontes, MD. Miramontes is an assistant clinical professor at UT Health San Antonio who also serves as EMS medical director to numerous agencies, and he worked just across the hall from Manifold’s office. “They play a very big role as to the scope of EMS practices, protocols, and functions in the field. 

“If there’s a lesson to be learned by Dr. Manifold’s sudden passing, it is the necessity of having a detailed succession and management plan to deal with such circumstances,” says Miramontes. “It also helps to have another outside fire or EMS agency step up to help with related necessities such as preparing a fire department funeral with full honors, since having to do this in-house when coworkers are grieving is very emotionally demanding.” 

James Careless is a freelance writer and frequent contributor to EMS World.