Effective Strategies for Contacting Online Medical Control

When I was a new provider, I was intimidated by the idea of contacting online medical control (OLMC). Who is on the other side of the phone? Will they judge my care based on my presentation? Will they grant my orders? Will they reject them?

Contacting online medical control can be a daunting task. In this article I propose an approach I use personally prior to any OLMC or medical director contact and have found extremely effective. OLMC contact works differently in different places, so adapt this approach to your agency’s usage of medical control. I currently practice in New York City, where there is either a single or double paramedic response unit. We generally contact a local hospital or the Fire Department of New York (FDNY) for OLMC orders and direction.

Preparation

First impressions matter. You want your first call to be your best call and the only one you will make. You are essentially a “salesperson” to advocate for your patient. In sales courses you are taught to begin with your end goal and work backward. Ensure you have all your ducks lined up before you call.

• Are you calling OLMC to get medication orders?
• Do you need permission to divert to a different hospital?
• If you are discussing a transport, did you check the ETAs to the other area hospitals first?
• Is this an RMA/AMA with a high index of suspicion?
• If you are requesting a medication, do you know the dose you are requesting? Do you know what protocol it’s listed under?
• If you are requesting a cardiac arrest termination, do you know the EtCO2?

The level of information can vary by provider certification level, education, and expertise. Be prepared prior to initiating the phone call; anticipate any potential questions and have answers at the ready. A short mental rehearsal is important. You may find it helpful to write down some key words you want to recall on the back of a 4x4 wrapper or in your phone’s notes.

Making the Call

Immediately after initial contact with the physician, do 3 things.

• Identify yourself.
• State your end goal.
• Establish a clear line of communication.

Identify Yourself

It is ideal to state your name, unit, and rank: “Hi, this is Paramedic Smith with Medic 29.” We may forget to identify ourselves on a recorded line. This can be an issue with quality assurance, or the physician may stop you and request your information.

State Your End Goal

Let the physician know your ultimate goal prior to starting your presentation. An example: Imagine you’re walking on a street and see a street artist. You’re watching the artist draw on a blank canvas, but you have no idea what they’re sketching. As you watch the artist, you notice various items being drawn—a roof, seats, and wheels. Finally, when the artist is done, you see a drawing of a sports car.

Now imagine one thing changes: Before the artist draws on this blank canvas, they tell you they will be drawing a sports car. How much easier would it be to predict the outcome of the drawing? There is no more speculation about each item that is drawn; instead, your imagination is now focused in on that ultimate image of the car.

A similar concept applies here. State the end goal and then present. This is paramount to a successful phone call, as the physician will know why you’re stating certain things in your presentation. I typically say something like, “I am calling for sedation to intubate a crashing asthmatic.”

Establish a Clear Line

Especially on critical calls, we often begin presenting our story as soon as the physician gets on the line. We may be in areas with poor service, or the connection may be lacking. Some physicians may not be ready and need to log into a computer system or grab a notepad. Say something like, “Can you hear me OK? Are you ready for my presentation?”

Present Your Case

This can vary with the reason for the OLMC contact. Review Table 1 for some specific items to keep in mind.

• Start with the patient’s age, gender, and chief complaint.
• State any pertinent positives or negatives.
  • The physician likely does not care about pulse motor assessment or pupillary response in a CHF patient you feel needs to be intubated.
  • Additionally, put yourself in the physician’s shoes and try to address any questions you would want answered if you were them. For example: If you have a patient who requires rate control for atrial fibrillation with RVR, be proactive and let the physician know the patient isn’t suspected to be hypovolemic, isn’t hyperthermic, and has no signs of infection. If you are requesting an order for intubation, discuss measures taken prior such as BVM or CPAP.
• HPI, or history of present illness, should be left to the most pertinent points of the call you’re on. Going off on a tangent may confuse the physician and you as well. Zone into what is important now. For example, letting the physician know the patient is on Prilosec is probably not important if you are asking for orders to stop seizures with status epilepticus.
• Any interventions already provided and any responses.
• Current vital signs and any significant trends.

Request for orders: I like to phrase this as, “We would like to administer_____. Is this OK?” You can mention the protocol, you can mention the specific reason. The idea is to eliminate any back and forth that is not necessary.

Once the physician grants the request, repeat the order back to them. Closed-loop communication will help avoid medication errors and protect you in case of potential liability.

Tips for Providers

Visualize yourself on the phone and practice delivering a presentation with a partner, friend, or family member. Prior to the phone call, jot down some reminders to help you stay on track. You might even want to record yourself presenting and listen back to see if it went well.

Tips for Preceptors

Early in the paramedic student's course, encourage the student to present "OLMC orders" to you as if you were the physician on the line. Once you and the student feel comfortable, allow them to actually make the phone call. They may need a bit of encouragement to overcome their fears. As a preceptor, I will generally inform the physician that there is a student and request that the student presents. A successful phone call by a student can be a huge confidence boost.

Tips for Educators

When it comes to OLMC presentations, some EMS education programs are better than others. During simulation scenarios and evaluations, have students give complete presentations. Make things more realistic by having an instructor serve as the “OLMC physician” or “medical director” for the day. A phone extension to an instructor or quick cell phone call would be ideal. It’s even better if the instructor isn’t involved in those scenarios; that way it remains objective and as realistic as possible.

Conclusion

Ultimately this is a guide for a successful OLMC presentation. Each case presents unique challenges, and each physician or medical director is different. They are the doctors, and we operate under their licenses and therefore their orders. Just because you believe something is appropriate for a patient does not mean we are seeing or taking the entire picture into account.

It is often said, "A good PCR is a reflection of good patient care." Similarly, an organized OLMC presentation can reflect good care provided. The process of contacting OLMC becomes more enjoyable as you gain confidence and improve your presentation skills. Once mastered, the positive OLMC encounter affords you the opportunity to better advocate for your patients and eliminate potential barriers to care. 

David Skolnick, NRP, CIC, FP-C, CCEMT-P, is a field paramedic and educator in New York City and Nassau County. His prehospital interests include airway management, resuscitation, and simulation. Reach him at dovidskolnick1@gmail.com.