TOTWTYTR writes –
Do we routinely need the telepresence of an ED physician in the back of an ambulance? Frankly I doubt it. I’ve been doing this long enough that I remember when paramedics were so new that we had to call in for permission to start an IV. We could intubate (cardiac arrest patients only) on a standing order, but that was about it. Back then we spent a lot of time on scene at many medical calls and spent a lot of time talking to doctors on the radio.
The irony is that we now realize that the intubation is often not good for patient care, particularly in non-respiratory cardiac arrest. The one thing originally permitted by the doctors on standing orders (intubation) is now a rarity, because it is not what the patient needs. While decreasing intubation of corpses, the addition of high-dose NTG (NiTroGlycerine) and CPAP (Continuous Positive Airway Pressure) to hypertensive CHF standing orders and elimination of furosemide (Lasix) from CHF standing orders means that there is much less need for intubation.
Rather than just intubating patients, we need to be better assessing them, avoiding harmful treatments (Lasix), and treating them expeditiously, rather than dragging them in front of the camera in the back of the ambulance. One thing an unstable patient does not need is to be hustled into a TV studio.
Wait, how is my makeup? Dr. Hottie is working and this is my big chance. Do these BDUs make my butt look big?
This is just technology that will allow absentee medical directors to come up with more creative excuses for neglecting their patients with Mother-May-I protocols.
Now, if I were an independent duty medic in a remote location, the technology outlined in this article would help a lot.
Of course, if I am an independent duty medic in a remote location, my patient will not be in the emergency department in front of an emergency physician in less than half an hour, or even in less than an hour. The circumstances are tremendously different.
We need to teach medical directors to provide competent oversight, not how to find the Horizontal control knob on the TV.
What happens when the equipment is not working properly?
How will the patients ever survive?
White’s idea isn’t new. About five years ago I had a long running email discussion with a man who had developed this type of system and had convinced the Tucson FD to give it a trial. I asked him the same questions I’m posing here, but he had no answers.
Both TOTWTYTR and I know a medic who moved to Tucson. One of the smartest medics around. Gene moved from Texas, where he only had to contact medical command for permission rarely. Tucson requires that the medics call medical command for permission to urinate between calls. OK. I exaggerate, but not by much.
We learn what we do.
When we teach people to call up and paint a picture, we get a variety of responses. Some will paint a picture created to push the medical command physicians buttons, so that the medical command physician will say that the medic can give the orders the medic sees as appropriate for the patient.
The information presented to the medical command physician is at the discretion of the medic. Just because the medical command physician may have a sheet he needs to fill out with gender, age, vital signs and other occasionally pertinent stuff doesn’t mean that we will give it to him the way he wants it. This is a negotiation. We are negotiating for the patient. He is negotiating for Kindergarten Memorial Hospital.
Knowing which doctor is providing medical command in which hospitals is also important. Dr. No Narcs is on at KMH, but Dr. Candyman is on at Laissez-Faire Medical Center. If I have a patient with significant pain, I would have to be a sadist to knowingly call Dr. No Narcs. The same would be true, even if I have a reality TV studio in the back of the ambulance.
And if a medical command physician has not had a good night’s sleep, or is fighting with the spouse (or kids), why should those who call 911 be the ones to suffer?
One of the things that many places have realized. EMS has a long history of treating patients appropriately on standing orders.
Medical command permission requirements allows incompetent medics to remain employed longer and harm more patients.
Medical command permission requirements allows incompetent medics to avoid responsibility for their incompetence.
How is this a good thing?
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Imagine improving the assessment and critical judgment of EMS providers, rather than substituting technology for quality.
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