ON-LINE MEDICAL COMMAND

FOR RESIDENT PHYSICIANS

INTRODUCTION

Prehospital Medicine

• Medical care occurring before or during transportation of patient to the hospital.
• Can occur via different modalities:
• Basic Life Support (BLS)
• Advanced Life Support (ALS)
• Critical Care
• Ground vs. Air
• Response vs. Interfacility

TYPE OF PREHOSPITAL PROVIDERS

Prehospital Provide Scope of Practice

• Decided by state.
• Varies from state to state.
• Places limitations on actions and skills that the prehospital provider can perform while working in that state.
• Provider cannot practice beyond scope of practice established by the state, even with a physician order.

Ohio Paramedic Scope of Practice

https://ems.ohio.gov/static/links/ems_scope_practice.pdf

First Responder

• Basic first aid
• CPR
• Rescue breathing
• Bandage/splint
• AED

EMT-Basic

• Patient assessment
• Hemorrhage control
• Splint/MAST
• Immobilization
• Extrication
• CPR
• Childbirth

EMT-Intermediate/Advanced

• IV of normal saline
• Variable state to state
• Can administer some medications.
• Intubation vs. Rescue Airway.
• Can intubate in Ohio.

EMT-Paramedic

• Full ACLS
• Cardiac monitoring/rhythm recognition
• IV therapy
• Parenteral medications
• Defibrillation/cardioversion
• Intubation/advanced airway
• Needle decompression
• Advanced Certifications: CCT-P, FP-C

Emergency Medical Dispatcher (EMD)

• May/may not be certified at other level
• Use of protocols for dispatch priority
• Assess for level of response
• Provide pre-arrival instructions

Prehospital Nurses

• Makes prehospital transport critical care level.
• Different models:
• Dedicated prehospital nurse vs. “floating” ICU/ED nurse.
• Advanced certifications:
• CTRN, CCRN, CFRN.

TYPES OF MEDICAL DIRECTION

Off line Medical Direction

• Establish patient care standards
• Protocols & standing orders
• Special situations
• Non-transport
• Transport destination
• Dispatch & response criteria
• Accomplished through prospective and retrospective medical direction.

Prospective Medical Direction

• Training.
• Testing and certification of providers.
• Protocol development.
• Operational policy and procedures development.
• Legislative activities.

Retrospective Medical Direction

• Medical audit and review of care
• Process improvement.
• Direction of remedial education.
• Limitation of patient care functions if needed.

On-line (Concurrent) Medical Direction

• Immediate physician consultation
• Interventions requiring MD order
• Special situations
• Advise ED of critical incoming patient
• Allows deviation from protocols
• Allows immediate QA/QI
• Provide for teaching opportunities

On-line Medical Direction

• Based at receiving hospital
• Units talk directly with receiving hospital
• Can establish a physician/patient relationship
• Centralized
• Designated command center for all units
• Use of surrogates
• Special training (e.g., RNs)

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On-line Physician

• Know level of service/provider
• Be familiar with each medic’s skill level if possible
• Know service protocols
• Be aware of equipment available
• Know available medications
• Base Station Certification might be necessary depending on state.

ON-LINE MEDICAL DIRECTION

▪ The concurrent interaction between a prehospital provider

and a responsible physician by radio, telephone, or in

person

▪ Paramedics transmit information regarding patient

evaluation to the physician and then perform any further

evaluation, procedures or treatments as instructed

Communications Etiquette

• Be professional
• Identify yourself and medical command number
• Identify unit you are speaking to
• Be precise
• Maintain confidentiality
• Explain ALL refusals
• Avoid slang and “10” codes- keep language plain as possible!

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ON-LINE MEDICAL DIRECTION: TIPS

▪ ALWAYS be professional

▪ Speak clearly, slowly and courteously

▪ Ask questions to clarify issues surrounding the patient’s

condition, but keeping the consult concise is a priority

▪ Ask the opinion of the field person as to the state of the

patient or suggestions for field intervention

Patient Report

• Don’t be afraid to ask for more information.
• ASK FOR VITALS if they don’t give it to you!!!!
• Take it yourself (i.e., avoid surrogates) if:
• Active medical direction
• Unstable patient
• Special situation
• Scene information.
• Opportunity for teaching if time allows.
• Explain your decisions.

ON-LINE MEDICAL DIRECTION: TIPS

▪ If asked for orders, you should respond promptly, but you

don’t need to respond instantaneously

▪ Avoid transmitting a long list of orders and expecting

multiple tasks to be performed rapidly

▪ Medics should repeat back any specific orders that you

have given before completing the consult. This is a

check-back that can help reduce errors.

OUR MEDICAL COMMAND SERVICES

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▪ Emergency Physicians at UH provide on-line medical

direction for a variety of services…

• University Hospitals AirMed
• University Hospitals Critical Care Transport
• Physicians Ambulance
• Community Care Ambulance
• Local EMS Agencies under UH Medical Command
• Cleveland EMS

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• Each of these services have DIFFERENT protocols…

OUR MEDICAL COMMAND SERVICES

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▪ Emergency Physicians at UH provide on-line medical

direction for a variety of services…

• University Hospitals AirMed
• University Hospitals Critical Care Transport
• Physicians Ambulance
• Community Care Ambulance
• Local EMS Agencies under UH Medical Command
• Cleveland EMS

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OUR MEDICAL COMMAND SERVICES

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▪ Emergency Physicians at UH provide on-line medical

direction for a variety of services…

• University Hospitals MedEvac
• University Hospitals Critical Care Transport

Attendings ONLY!

TAKING THE CALL

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▪ Calls are received by the EMS QB and patched into the resident’s portable phones.

Blue pod Resident

Green pod Resident

Blue pod Attending

Green pod Attending

▪ When answering, identify yourself by name and DOC

number:

EMS QB:

Doc:

EMS QB:

Doc:

I have Cleveland EMS Medic 6 for orders.

OK.

(patches in medic) Medic 6, you have doc #2.

This is MD#2, Dr. Luk. Go ahead.

EMS MEDICAL COMMAND

▪ UHCMC provides on-line medical command to several

area EMS agencies:

▪ Cleveland EMS

▪ Shaker Heights Fire Department

▪ Cleveland Heights Fire Department

• East Cleveland Fire Department

▪ Case EMS

▪ UH as a system provides medical command to 270+ EMS agencies.

CLEVELAND EMS

▪ UH shares on-line medical command with Metro for

Cleveland EMS.

▪ UH physicians provide medical command on EVEN days.

(Thus, the even medical command numbers.)

▪ If there are problems with Cleveland EMS, a call should

be made to the “RED CENTER” via the EMS QB to speak with a

supervisor in real time.

UH EMS MEDICAL COMMAND

▪ The Heights-area and East Cleveland fire departments use UH as

their on-line medical command every day regardless

of their destination hospital.

▪ Protocols are very aggressive and allow a great degree of

independence for paramedics on these services.

▪ Current protocols for the entire UH

EMS Medical Command system is on-line at:

� https://www.uhems.org

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UH EMS MEDICAL COMMAND

UH EMS MEDICAL COMMAND

UHCMC EMS Division Website

UH EMS MEDICAL COMMAND

▪ Most common issues:

▪ 12-lead EKG transmissions

▪ Field pronouncement

• RMA (refusal of medical assistance)
• Refusal of Care

AMTC 2007

12 LEAD EKG TRANSMISSIONS

▪ All of the UH Medical Command services can transmit

12-lead EKG’s from the field.

▪ If you receive an EKG with a STEMI and the patient is

coming to UH, please talk to the attending about activating

the Cath Lab BEFORE the arrival of the patient.

FIELD PRONOUNCEMENT

▪ There is a field pronouncement protocol in place for EMS

agencies under UH Medical Command

▪ If an advanced airway is in place (ETT, LMA, Combi-Tube, King

LT, etc), the patient has received TWO rounds of ACLS

medications, and the patient remains in asystole in TWO leads,

the paramedics should seriously consider a field pronouncement.

*Also consider asking for ETCO2 < 10.*

• It is dangerous (& usually futile) to transport these patients.
• If a patient was moved to the ambulance in order to achieve adequate evaluation or due to scene safety, patient can be pronounced in the ambulance, BUT patient must then be transported to the ED.

FIELD PRONOUNCEMENT

FIELD PRONOUNCEMENT

RMA’s

▪ The appropriateness of each non-transport decision

depends on the specific circumstances of the situation.

▪ Requires an adequate clinical evaluation and an

explanation of the risks and benefits to the patient.

▪ The medics will typically indicate their level of comfort with

the patient refusing (more often than not, they are correct).

▪ Sometimes determining someone’s capacity to refuse can

be tricky; consider having the medics put the patient on the

phone allowing you to talk to the patient yourself (and

recording it).

Definitions

• Capacity is a clinical determination that addresses the integrity of mental functions. 
• Competency is a LEGAL determination that addresses societal interest in restricting a person’s right to make decisions or do acts because of incapacity. 
• In other words…

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Definitions

• COURTS decide COMPETENCY.

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• WE as MEDICAL PROVIDERS decide MEDICAL DECISION-MAKING CAPACITY.

Assessing Medical Decision Making Capacity Over the Phone

• AAO x 4 (person, place, time, and event).
• Who are you?
• Where are you?
• When is it?
• Who is the President?
• What happened?
• Repeat 3 objects I say.
• Concentration:
• Serial 7’s (make sure they can do math).
• Spell “WORLD” backwards (make sure they know to how to spell it forwards first).
• Short term retention:
• What are the 3 objects I told you about earlier?

BLS/ALS TRANSPORT

MEDICAL COMMAND

▪ Generally provides non-emergent transport for patients.

▪ Occasionally, a patient will decompensate during transport;

this may result in a call to on-line medical command.

▪ Consider having the ambulance crew take the patient to the

ED at the receiving hospital (or the closest ED available) if

there is concern for a drastic change in condition.

• Medics may also call you due to concern that patient is not appropriate for ALS transport. In this case, ask to talk to referring physician and ask them to consider CCT.

CASE EMS

▪ A student-run BASIC LIFE SUPPORT first response

service on the CWRU campus.

They operate at a BLS level and therefore, do not carry ALS-level medications.

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▪ For serious patients, Cleveland EMS, Cleveland Fire, or

Cleveland Heights Fire will generally be en route or on-

scene to provide ALS care and transport.

• Most calls involve intoxication among undergraduate students.

SOME FINAL WORDS

▪ Adult ED Physicians NEVER take medical command for

pediatric patients. If you get a call for a pediatric patient, it

is a mistake.

▪ Dr. Luk (or someone covering) is ALWAYS available

to assist with unusual EMS or critical care transport issues

or problems; have him paged by the TRC if there is an issue.

PREHOSPITAL PHYSICIAN RESPONSE

What information do you give 911?

What information do you give 911?

• Location, location, location.
• Address/intersection.
• Landmarks relative to your location.

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• Keep it short and sweet.
• Limit clinical information.
• Number of injured/sick.

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• Don’t spend a lot of time giving them a lot of medical history over the phone.

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First Priority as a First Responder?

First Priority?

Scene Safety

Scene Safety

Initial Assessment?

Initial Assessment?

Physician on scene

Physician on scene