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The EMS Physician Beyond Medical Direction

The EMS Physician Beyond Medical Direction. Amy Gutman MD prehospitalmd@gmail.com. The Difference Between EMTs & MDs. “I’d say you’re suffering from an arrow through your head, but to play it safe I am ordering a bunch of tests”. Overview. What / who are EM & EMS Physicians?

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The EMS Physician Beyond Medical Direction

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  1. The EMS PhysicianBeyond Medical Direction Amy Gutman MD prehospitalmd@gmail.com

  2. The Difference Between EMTs & MDs “I’d say you’re suffering from an arrow through your head, but to play it safe I am ordering a bunch of tests”

  3. Overview • What / who are EM & EMS Physicians? • Qualifications • What does an EM / EMS physician do all day? • What is a Medical Director?

  4. What is an EM Physician? • EM Residency (3-4 yrs) • +/- Fellowship (1-3 yrs) • Hyperbarics • Toxicology • Pediatrics • Sports Medicine • Neurocritical Care • Prehospital • Geriatrics • Administration • Transport • Cardiovascular Emergencies • Wilderness • International • Research • Ultrasound • Forensics • +/- Masters Degrees • MPA • MEM • MHA • +/- PhD Degree

  5. Residents, Fellows & Attendings • Resident • “Post Graduate Year” (PGY) 1–4 • Chief Resident • Fellow (BE / BC) • 1–3 yrs specialized training • Function as attendings • Attending / Faculty (BE / BC) • Staff or “Faculty” • At academic institutions serve as “Professors”

  6. What Kind of Patients Do We See? • Adults or children with medical or traumatic complaints • Chronic medical conditions to critical illnesses • “90% of what we treat in the ED is preventable illness, 5% is stupidity or ignorance; it’s the remaining 5% that keep ED docs showing up to work every day without going bat-shit crazy.” Dr Jim Small

  7. Patient Trends • 80% adults • 25% >65% • 40% female • 20% pediatrics • 50% <2yrs or 14-16yrs • Mon: • Busiest day • Tues: • 2nd busiest day • Fri/Sat: • Traumas • Slow am, busy pm • Sun: • “I don’t want to go to work” • “I woke up from my drunken stupor & realize that I am injured” • Summer: • High-speed & penetrating trauma & “Men with beer” injuries • Winter: • Low-impact collisions, slips & falls

  8. What Are the Shifts? • Academic: • Usually 10-12 hr shifts • Attendings, residents, students, MLPs, nurses, techs, clerks • Multiple subspecialites 24/7 • Community • 8,10,12, 24 hr shifts • Multiple attendings, MLPs, nurses technicians, clerks, during day • Usually 1 attending at night, 1 clerk, 3 nurses, 1 tech • May have students / residents • Isolated or no subspecialities

  9. Why Do I Have to Wait So Long To Be Seen? • LSU average wait 23 hrs post Katrina • National average 2-6 hrs • Academic / urban centers >8 hrs • Community hospital day 1.5 hrs • Community hospital night 2-3 hrs • Significant abuse of system by patients & other health care providers • Limited access to primary care • Sicker people living longer • More suing = more tests = more time in the ED

  10. Important EM MD Qualities • Ability to multi-task • Tolerate indescribably horrific smells & sights • Never panic • Multi-tasking • Short attention span • Multi-tasking? • Attention to Details

  11. Taking “Don’t Panic” Literally

  12. Gutman’s Pornography Principal of “Sick”

  13. What is a “Trauma Stat”? • Activation of Trauma Team for patient’s meeting particular criteria • Who comes? • EM Attending(s), RNs, support staff • Trauma Attending(s), residents, students • Subspecialty Attending(s), residents, students • Anesthesia • Radiology Techs • OR staff / nurses • Either chaos or a true team effort

  14. 24 yo WM Stab Wound Chest 19 yo WF GSW to Chest

  15. What is an EMS Physician? • MD with prehospital training & experiences • No EMS physicians are alike in training or job descriptions • All are “NQR” & love working long hours for little pay

  16. Qualifications • Board eligible / certification • EM, IM / FP, Surgery, Pediatrics • National qualifications from DOT, NHTSA, FEMA (NIMS / HEICS) • Experience in: • 1) EMS teaching (NAEMSE) • 2) Direct prehospital care • 3) EMS administration & management • 4) Medical Direction (NAEMSP) • 5) EMS-specific CME hours • 6) Prehospital Fellowship or formal training

  17. EMS Fellowships • 1-2 yrs specialized training in prehospital medicine at academic institutions, fire departments or the government • 15-20 fellows / year • “Sub” Sub Specialties: • Clinical Research • Medical Control • Wilderness • Toxicology • Disaster / Mass Gathering • Administration • Public Health / Public Policy • Dignitary Protection • Education

  18. 2 Decades of Job Prep • High school EMT / Rescue • College EMT-I, instructor, FF, got a few majors • PA school with subspecialties in surgery & EM • Medical school & EM sub-internship • Surgical residency PGY1-2 • EM Residency, Chief Resident, FD Residency Medical Directorship • Prehospital EM Fellowship, Medical Directorships, Flight Physician

  19. What Does an EMS Physician Do All Day?

  20. 10% Personal Time 10% EMS Education 10% EMS Administration 45% Deal with assholes, drug-seekers, drunks & whiners 25% Care of actual sick & injured patients How I Spend My Days

  21. CQI/QA • Protocol Development • Policy Review • National / Regional Committees • Tactical • Aeromedical • USAR • Toxicology • Wilderness • MCI • Prehospital • Hospital • Governmental • Direct • Indirect • Prospective • Retrospective • Texts / Journals • Political Lobbying • Fire vs. EMS • Government

  22. Adminstrative • Paperwork, Paperwork, Paperwork • Protocol development • Standard of care compliance (“CQI / QA”) • Policy evaluation/modification • Meetings • Personnel “Issues”

  23. Educational • Mentoring • Medical / Allied Health / Paramedical students • Residents • Lectures • Grand Rounds • Prehospital Continuing Education • Conferences • Personal • Continuing Education

  24. Flight Physician • 10% of medical directorships focus solely on flight transport • Fixed wing or helicopter EMS • “Transport EMS” includes coordination of flight, water & ground transport

  25. Ooops

  26. Emergency Airway Kit (Adult & Pediatric) BVMs / ETCO2 continuous waveform King LT / Bougie Cricothyrotomy Pericardiocentesis Drugs: 4 ACLS 4 Narcs 4 RSI 4 Benzos 4 TBI 4 Antiemesis 4 DM 2 Monitors / Defibrillators Pacer Pads / Leads 2 Radios 2 Helmets 2 Headsets 2 Sharps Containers Vomit Bags Portable Suction Teddy Bear Wall Suction S/M/L Gloves Tape & Carabeeners (everywhere) Trauma Blanket Ventilator / CPAP O2 Tank (wall & portable) BP Cuffs Stethoscopes Glucometer Stretcher Restraints Space Heater Fan 4 Survival Kits 16 IV Start Kits 4 IVF Liters FAST IO Sternal IO 2 Units PRBC 500cc Mannitol 2 (3) Channel Pumps 1 (4) Channel Pump Towels Gauze ABD Pads Syringes 19 g Needles

  27. Special Operations • Urban Search and Rescue (USAR) • Nuclear, Biological and Chemical (NBC) Counter-Terrorism • Emergency Medical Services • Tactical Emergency Medicine (TEMS) • Mass Gathering/ Mass Casualty Medicine • Hazardous Materials • Dignitary Protection

  28. Worst Case Scenario Tabletops • Dirty bomb explodes at Union Terminal on a windy day • 500 Adult Casualties: • 50 Black, 150 Red, 150 Green, 150 Yellow • 150 Immediate Pediatrics: • 50 Black, 75 Red, 25 Green or Yellow • 2nd & 3rd incendiary devices detonated • Train station affected (fertilizer – carrying trains) • I-71/75 bridge • 250 additional casualties within 4 hours • 10 hospitals, 3 states, 1,500 medical personnel

  29. Dignitary Protection • Medical back-up for “special-ops” • Presidential / Secret Service • FBI • SWAT • “Special People” • Portable ED • Ibuprofen to cricothyrotomies

  30. Mass Gathering Medicine • Coordinate w/ regional & multi-state resources to provide crowd-based care • 50 to 200,000 persons • Political demonstrations, fireworks displays, festivals • Coordinate hundreds of prehospital personnel & volunteers

  31. Medical Direction • Prehospital jurisdictions must have medical direction provided by state credentialed licensing boards • Improves relations between EMS agencies, the public & other medical professionals, enriches education, & fosters working relationships between physicians & providers • Physician-directed system provides accountability, ensuring quality & risk management evaluation

  32. Medical Director Roles • Medical direction provides operational framework & authorization to provide prehospital emergency care • Ultimate responsibility & authority remains with the physician as providers work as an extension of the physician’s license • National Research Council’s Subcommittee on EMS System Medical Direction defines 3 basic functions: • Ensure prehospital personnel have expert medical direction • Ensure continuing high-quality field performance • Provide means for monitoring quality of field performance

  33. Medical Direction • Development, updating of SOPs including triage protocols • Regional, State, National data reporting • Monitoring quality control including: knowledge, skills & performance of providers, medical control, dispatch • Audits of targeted areas • Monitoring dispatch & response times, instructions given over the phone & priority dispatch methods • Continuing education, certification & recertification • Active in local, state, regional & national EMS organizations • Active in disaster preparedness within his/her region. • Community, media & public liaison • Disciplinary action in the event of a breach of the standard of care

  34. On-Scene Medical Direction

  35. Indirect Medical Direction • Direction given to provider using direct communication including telemetry • Outside of SOPs, each patient interaction involving advanced skills requires supervision by physicians. The responsibility is primarily delegated to physicians at designated base hospitals

  36. SHREVEPORT LA FIRE DEPARTMENTHonorary Captain / Resident Medical Director

  37. SFD SUPER 1

  38. Cincinnati Fire DepartmentEMS Fellow / Assistant Medical Director

  39. COOL CINCI FD PICS

  40. Research • Improve patient care, cost–effectiveness & system performance • Identify operational issues in need of scientific evaluation • Identify funding & form collaborative relationships • ANYONE can publish! - “Clinical”, “Bench” & Translational” • Most research is in some way biased & flawed. “Lies, Damned Lies, & Statistics” • Be careful what you read • Be more careful what you use!

  41. 5 EMS Studies you Need to KnowCompression-Only CPR Effective • Bystanders reluctant to perform CPR on strangers • Successful CPR based upon circulation / effective compressions not ventilation • Outcomes: • Bystanders more likely to perform compression-only CPR • Patients who had compression-only CPR had similar or better outcomes than those with standard CPR

  42. 5 EMS Studies You Need to Know: Intubation Associated with Decreased Survival in Pediatric Cardiac Arrest • Cause of arrest likely respiratory • Average EMT-P / EMT-I performs < 0.5 pediatric ETI / yr • Outcomes: • Pts with effective BVM ventilation did better than those with prehospital airway placement attempt • Longer scene time, greater # attempts, RSI complications, ETT misplacements

  43. 5 EMS Studies You Need to KnowTiered Staffing vs All ALS • Basic skills provided by experienced prehospital providers saves lives however there are professional & financial incentives to increase ALS coverage • Outcomes: • No clear model of staffing is best though 2 models with clear advantages: • BLS initial response with ALS intercept • 1:1 Experienced EMT with Experienced Medic teams • Outcomes intimately tied to good basic skill performance

  44. 5 EMS Studies You Need to KnowEarly Stroke Identification Saves Lives • Though stroke mimics many medical syndromes, EMS stroke scales identify patients with stroke syndromes • Outcomes: • Survival increased when prehospital providers applied a stroke scale, identified an evolving stroke & rapidly transported pt to a “stroke center” within 90 minutes

  45. 5 EMS Studies You Need To Know: Prehospital STEMI Identification saves lives • STEMI pts with onset of pain to start of cath lab < 90 mins is associated with better functional outcomes • Outcomes: • Pre-notification decreases time to catherization lab, improves survival & functional outcomes • ED MD patient “clearance” & registration takes < 5 minutes • UC Vanguard Physician Group 2008 • Time to cath lab w/o prehospital notification: 75 mins • Time to cath lab with prehospital notification: 35 mins • Community hospitals without cath labs or ability to rapidly transfer are actually moving” backwards” to TPA

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