EMERGENCY FORUM
Medical C o n t r o l - - W h a t Is It? Norman E. McSwain, Jr, MD, FACS New Orleans, Louisiana
Medical control is essentially divided into three phases: prospective, immediate and retrospective. Adequate medical supervision of any paramedic system is necessary to guarantee quality of medical care. Anything short of physician control of prehospital medical care would be to abdicate our responsibilities to our patients. McSwain NE Jr: Medical control - - w h a t is it?JACEP 7:114-116, March, 1978. medical control; emergency medical technician, standing orders.
INTRODUCTION While i n i t i a l t r a i n i n g of emergency medical technicians (EMTs), and, to a lesser extent, the necessity for their c o n t i n u i n g education is understood and accepted, the concept of medical control has been in limbo. Either medical control actually exists but u n d e r other names and so is n o t h i n g really new or medical personnel (particularly physicians) and the directors of emergency medical services (EMS) stick their heads in the sand and say, "We don't need it. Our system can work without it." The medical c o m m u n i t y m u s t accept the responsibility to see t h a t medical control is accomplished properly a n d that the guidelines are understood. Otherwise, medical care will be given in the prehospital period with no quality assurance. This can m e a n poor care rendered while the patients suffer. Medical control can be divided into three phases: prospective, immediate and retrospective.
PROSPECTIVE Protocols and s t a n d i n g orders u n d e r which the EMS system f u n c t i o n s should be developed prior to system initiation. The protocols are standards for p a t i e n t care in the usual, accepted circumstance, yet standards t h a t should be deviated from if the patient's medical condition dictates. This deviation, accomplished in the '~immediate" phase of medical control, should occur only on the direct order of a physician based on information delivered via radio from the EMT and w i t h i n guidelines established by the medical community. Protocols are guidelines to coordinate p a t i e n t care for both the emergency physician and the EMT in the field and m u s t be carried out u n d e r direct voice communication with the physician. The protocols as i n - d e p t h p a t i e n t care m a n a g e m e n t schemes based on t r e a t m e n t conditions such as coma, shock or cardiopulmonary arrest are not necessarily based on specific disease diagnoses. They are used in the identification, diagnosis, and t r e a t m e n t of the existing condition even when a specific diagnosis has been established. Protocols should be developed as a step-wise system for patient condition, not diagnoses, such as t r a u m a , cardiac arrest, p u l m o n a r y edema, hemorrhagic blood loss, angina, pneumothorax, to encompass the 20 or 30 most common condit i o n s seen in the field. Protocols can be w r i t t e n specifically with each step in mana g e m e n t of the p a t i e n t outlined in detail or as a '~yes-no" cascade (Figure 1). From the Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas. Dr. McSwain is now at the Department of Surgery, Tulane University School of Medicine, New Orleans. Address for reprints: Norman E. McSwain, Jr, MD, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112 7:3 (Mar) 1978
JACEP
114/57
PROTOCOL EMT WILL: 1. Administer O2/nasal cannula or mask 6-8 liters/min. - - if no pre-existing pulmonary disorder exists. If so, 2 liters/min and position patient in upright position or position of comfort. 2. Start IV of D5W to K.O. 3. Apply monitor electrodes and transmit telemetry if available. 4. Administer lidocaine 50 mg bolus in the event of pulse greater than 50 and more than 6 PVCs/min, or multifocal PVCs, or ventricular tachycardia. 5. Do brief physical exam general appearance vital signs high or low neck vein distention, rales, peripheral edema
Standing Orders
6. Obtain brief history onset, nature, location, duration, radiation, aggravating and alleviating and associated symptoms of the pain dyspnea, nausea, vomiting, sweating, dizziness, palpations 7. Radio physician as rapidly as possible with: age, sex, chief complaint, history as above physical exam, and field treatment Physician's Orders 1. Start IV with D5W to K.O. if not initiated. 2. Transmit EKG by telemetry - confirm rhythm on scope in field 3. M o r p h i n e S u l p h a t e (tubex) 4-6mg IV titrated:
Indications severe chest pain rales
The flow of p a t i e n t care should proceed in o r d e r l y fashion from initial identification to the final treatm e n t and should include m o n i t o r i n g a n d i d e n t i f i c a t i o n of t h e p o i n t at which hospital contact is established. Protocols c a n be d e v e l o p e d by one or two i n d i v i d u a l s knowledgeable in the provision of prehospital care or by a c o m m i t t e e . However, t h e y s h o u l d be s u b m i t t e d to t h e c o m m u n i t y m e d i c a l society fbr approval prior to initiation. Revisions will probably be required as deficiencies of these protocols are identified by actual use.
Contraindications Hypotension Patient has taken alcohol or other depressants Patient known or suspected to have pulmonary disease Asthmatic patient
Other Medications Pulse
S t a n d i n g orders, a p a r t of protocols, are those specific, step-by-step t e c h n i q u e s of p a t i e n t c a r e accomplished before e s t a b l i s h i n g radio contact with the hospital. They are usually used only w h e n a t i m e delay in e s t a b l i s h i n g radio contact would be p o t e n t i a l l y d e t r i m e n t a l to p a t i e n t outcome and depend on the level of s o p h i s t i c a t i o n a n d t r a i n i n g of the EMTs. They probably should include procedures for i n i t i a l m a n a g e m e n t of a complete c a r d i o p u l m o n a r y arrest, use of an a p p r o p r i a t e a i r w a y - - o r a l , nasal, e n d o t r a c h e a l , or e s o p h a g e a l obturator -- when upper airway obstruction or a p n e a is present, est a b l i s h m e n t of a n i n t r a v e n o u s route for fluid or m e d i c a t i o n a d m i n i s t r a tion, and possibly use of lidocaine int r a v e n o u s l y for m u l t i p l e p r e m a t u r e v e n t r i c u l a r c o n t r a c t i o n s (PVCs). S t a n d i n g orders are to be followed strictly to the letter, w i t h no deviation, only in the specific conditions for w h i c h t h e y a r e w r i t t e n . The s t a n d i n g orders can be modified only by direct medical order. Immediate
PVCs or signs of ~ p.oor perfusion-x
"
~
PVCs 6/minute
@
@
multifocal
NO Rx -- KeepAtropine handy
Atropine .5-1 mg IV push I
R on T Greater than 2 in row
\
PVCs abolished No Rx
PVCs present
Lidocainebolus 50-100 mg IV and Drip*
Pulse?
60 Lidocaine bolus and drip
Fig. 1. Contained within one protocol is both a generalized and a "yes-no" approach to protocol development. 58/115
JACEP
I m m e d i a t e medical control is divided into two phases. 1) T h a t exercised by the physician who is giving the direct orders to the e m e r g e n c y m e d i c a l t e c h n i cian-paramedic (EMT-P). 2) T h a t exercised by the medical director of the s y s t e m in a s s u r i n g pat i e n t care is being delivered appropriately. Medical direction is the responsibility of the physician. In most systems, the i n i t i a l o r d e r s a n d direct medical supervision of the EMT-Ps will come from the 24-hour, hospitalb a s e d e m e r g e n c y p h y s i c i a n . However, in some c o m m u n i t i e s (particul a r l y in r u r a l c o m m u n i t i e s of less t h a n 20,000 population), the medical direc7:3 (M ar) 1978
for may well be the one giving orders, perhaps from his office or car, via portable radio if there is no 24hour emergency physician available. This p h y s i c i a n e v a l u a t e s the medical aspects of the case identifying treatment from the history and physical examination. It may be necessary to rely on the EMT-P's assessment of the situation. A physician derives a great deal of knowledge about a pat i e n t ' s c o n d i t i o n from his v i s u a l senses. At a distance fi'om the patient, he must rely upon the visual senses of the EMT-Ps in defining conditions or situations not easily assessed over the radio. Therefore, developing the anatomy and pharmacology expertise of the EMT-Ps is an absolute necessity. Without this knowledge, they cannot let the physician know when a pat't i c u l a r i n s t r u c t i o n m i g h t n o t be exactly appropriate. Reliance and confidence on each other m u s t be developed i n a n a d e q u a t e , w o r k i n g paramedic system. However, in any system there must be a captain and this role r e m a i n s with the physician. Responsibility of the medical director, then, is to monitor the call and have the power (given to him by the medical community), to intervene if he deems the care b e i n g rendered to the p a t i e n t is harmful. The medical director s h o u l d also i d e n t i f y those areas which may be radio errors to be discussed with the physician rendering the order or the EMT-P's in the field. In a well-run EMS system, however, immediate i n t e r v e n t i o n by the medical director should seldom, if ever, occur.
7:3 (Mar) 1978
RETROSPECTIVE Retrospective control is in reality another form of c o n t i n u i n g education. The i n f o r m a t i o n for r e t r o s p e c t i v e medical control and for improvements in the system can be derived from two sources. 1) The first is review of the radio c o m m u n i c a t i o n u s i n g a voiceactivated tape recorder and a n a l y s i s of the r u n reports, both immediately and retrospectively as in a medical audit procedure. Diagnosis and treatm e n t in t h e field as i n d i c a t e d i n the written r u n reports can be compared with the diagnosis and treatm e n t rendered in the emergency dep a r t m e n t as reported in the hospital record. Three questions are asked: a) Was the condition identified in the field the same as the emergency d e p a r t m e n t and final discharge diagnosis? b) Was any care given in the e m e r g e n c y d e p a r t m e n t which could have been better given in the prehospital period? c) Was the t r e a t m e n t rendered in the prehospital period or emergency d e p a r t m e n t inappropriate for the diagnosis obtained? 2) Consultations with the training officer can suggest appropriate c o n t i n u i n g education for EMT-Ps. The medical director can d o c u m e n t the specific deficiencies of the patient care on the r u n through a letter and include methods of remedial t r a i n i n g . Finally, the EMT-Ps can be called in for person-to-person consultation with the medical director.
JACEP
In a service with such a system, one t r a i n i n g officer will be necessary for each five paramedic u n i t s on the street. One hour per week of medical director time is required for each 1,000 r u n s per year. If there are in excess of 5,000 r u n s per year, one full-time individual m u s t be responsible for retrospective audit and review of all the charts, much like a medical records l i b r a r i a n in a n y h o s p i t a l m e d i c a l audit system. This person reviews r u n reports, compares t r e a t m e n t and d i a g n o s i s b e t w e e n the r u n report, e m e r g e n c y d e p a r t m e n t record a n d final discharge s u m m a r y according to the protocols developed for the system. Any r u n s that fall outside the protocol are t h e n reviewed by the medical di= rector and appropriate action is taken. The methodology for such a retrospective audit was presented at a n a t i o n a l EMS m e e t i n g in New Orleans, J a n u a r y 11-13, 1977 a n d has been reported. 1
CONCLUSION As in any other field of medicine, if we, as physicians, do not assume these responsibilities ourselves, the void will be rapidly filled by some bureaucratic system t h a t neither understands q u a l i t y medical care nor has the flexibility to identify when deviations from s t a n d a r d protocols are important.
REFERENCE 1. McSwain NE Jr: Methodology for evaluating prehospital training programs. The E M T J o u r n a l 1:49-53, 1977.
116/59
Medical C o n t r o l - - W h a t Is It? Norman E. McSwain, Jr, MD, FACS New Orleans, Louisiana
Medical control is essentially divided into three phases: prospective, immediate and retrospective. Adequate medical supervision of any paramedic system is necessary to guarantee quality of medical care. Anything short of physician control of prehospital medical care would be to abdicate our responsibilities to our patients. McSwain NE Jr: Medical control - - w h a t is it?JACEP 7:114-116, March, 1978. medical control; emergency medical technician, standing orders.
INTRODUCTION While i n i t i a l t r a i n i n g of emergency medical technicians (EMTs), and, to a lesser extent, the necessity for their c o n t i n u i n g education is understood and accepted, the concept of medical control has been in limbo. Either medical control actually exists but u n d e r other names and so is n o t h i n g really new or medical personnel (particularly physicians) and the directors of emergency medical services (EMS) stick their heads in the sand and say, "We don't need it. Our system can work without it." The medical c o m m u n i t y m u s t accept the responsibility to see t h a t medical control is accomplished properly a n d that the guidelines are understood. Otherwise, medical care will be given in the prehospital period with no quality assurance. This can m e a n poor care rendered while the patients suffer. Medical control can be divided into three phases: prospective, immediate and retrospective.
PROSPECTIVE Protocols and s t a n d i n g orders u n d e r which the EMS system f u n c t i o n s should be developed prior to system initiation. The protocols are standards for p a t i e n t care in the usual, accepted circumstance, yet standards t h a t should be deviated from if the patient's medical condition dictates. This deviation, accomplished in the '~immediate" phase of medical control, should occur only on the direct order of a physician based on information delivered via radio from the EMT and w i t h i n guidelines established by the medical community. Protocols are guidelines to coordinate p a t i e n t care for both the emergency physician and the EMT in the field and m u s t be carried out u n d e r direct voice communication with the physician. The protocols as i n - d e p t h p a t i e n t care m a n a g e m e n t schemes based on t r e a t m e n t conditions such as coma, shock or cardiopulmonary arrest are not necessarily based on specific disease diagnoses. They are used in the identification, diagnosis, and t r e a t m e n t of the existing condition even when a specific diagnosis has been established. Protocols should be developed as a step-wise system for patient condition, not diagnoses, such as t r a u m a , cardiac arrest, p u l m o n a r y edema, hemorrhagic blood loss, angina, pneumothorax, to encompass the 20 or 30 most common condit i o n s seen in the field. Protocols can be w r i t t e n specifically with each step in mana g e m e n t of the p a t i e n t outlined in detail or as a '~yes-no" cascade (Figure 1). From the Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas. Dr. McSwain is now at the Department of Surgery, Tulane University School of Medicine, New Orleans. Address for reprints: Norman E. McSwain, Jr, MD, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112 7:3 (Mar) 1978
JACEP
114/57
PROTOCOL EMT WILL: 1. Administer O2/nasal cannula or mask 6-8 liters/min. - - if no pre-existing pulmonary disorder exists. If so, 2 liters/min and position patient in upright position or position of comfort. 2. Start IV of D5W to K.O. 3. Apply monitor electrodes and transmit telemetry if available. 4. Administer lidocaine 50 mg bolus in the event of pulse greater than 50 and more than 6 PVCs/min, or multifocal PVCs, or ventricular tachycardia. 5. Do brief physical exam general appearance vital signs high or low neck vein distention, rales, peripheral edema
Standing Orders
6. Obtain brief history onset, nature, location, duration, radiation, aggravating and alleviating and associated symptoms of the pain dyspnea, nausea, vomiting, sweating, dizziness, palpations 7. Radio physician as rapidly as possible with: age, sex, chief complaint, history as above physical exam, and field treatment Physician's Orders 1. Start IV with D5W to K.O. if not initiated. 2. Transmit EKG by telemetry - confirm rhythm on scope in field 3. M o r p h i n e S u l p h a t e (tubex) 4-6mg IV titrated:
Indications severe chest pain rales
The flow of p a t i e n t care should proceed in o r d e r l y fashion from initial identification to the final treatm e n t and should include m o n i t o r i n g a n d i d e n t i f i c a t i o n of t h e p o i n t at which hospital contact is established. Protocols c a n be d e v e l o p e d by one or two i n d i v i d u a l s knowledgeable in the provision of prehospital care or by a c o m m i t t e e . However, t h e y s h o u l d be s u b m i t t e d to t h e c o m m u n i t y m e d i c a l society fbr approval prior to initiation. Revisions will probably be required as deficiencies of these protocols are identified by actual use.
Contraindications Hypotension Patient has taken alcohol or other depressants Patient known or suspected to have pulmonary disease Asthmatic patient
Other Medications Pulse
S t a n d i n g orders, a p a r t of protocols, are those specific, step-by-step t e c h n i q u e s of p a t i e n t c a r e accomplished before e s t a b l i s h i n g radio contact with the hospital. They are usually used only w h e n a t i m e delay in e s t a b l i s h i n g radio contact would be p o t e n t i a l l y d e t r i m e n t a l to p a t i e n t outcome and depend on the level of s o p h i s t i c a t i o n a n d t r a i n i n g of the EMTs. They probably should include procedures for i n i t i a l m a n a g e m e n t of a complete c a r d i o p u l m o n a r y arrest, use of an a p p r o p r i a t e a i r w a y - - o r a l , nasal, e n d o t r a c h e a l , or e s o p h a g e a l obturator -- when upper airway obstruction or a p n e a is present, est a b l i s h m e n t of a n i n t r a v e n o u s route for fluid or m e d i c a t i o n a d m i n i s t r a tion, and possibly use of lidocaine int r a v e n o u s l y for m u l t i p l e p r e m a t u r e v e n t r i c u l a r c o n t r a c t i o n s (PVCs). S t a n d i n g orders are to be followed strictly to the letter, w i t h no deviation, only in the specific conditions for w h i c h t h e y a r e w r i t t e n . The s t a n d i n g orders can be modified only by direct medical order. Immediate
PVCs or signs of ~ p.oor perfusion-x
"
~
PVCs 6/minute
@
@
multifocal
NO Rx -- KeepAtropine handy
Atropine .5-1 mg IV push I
R on T Greater than 2 in row
\
PVCs abolished No Rx
PVCs present
Lidocainebolus 50-100 mg IV and Drip*
Pulse?
60 Lidocaine bolus and drip
Fig. 1. Contained within one protocol is both a generalized and a "yes-no" approach to protocol development. 58/115
JACEP
I m m e d i a t e medical control is divided into two phases. 1) T h a t exercised by the physician who is giving the direct orders to the e m e r g e n c y m e d i c a l t e c h n i cian-paramedic (EMT-P). 2) T h a t exercised by the medical director of the s y s t e m in a s s u r i n g pat i e n t care is being delivered appropriately. Medical direction is the responsibility of the physician. In most systems, the i n i t i a l o r d e r s a n d direct medical supervision of the EMT-Ps will come from the 24-hour, hospitalb a s e d e m e r g e n c y p h y s i c i a n . However, in some c o m m u n i t i e s (particul a r l y in r u r a l c o m m u n i t i e s of less t h a n 20,000 population), the medical direc7:3 (M ar) 1978
for may well be the one giving orders, perhaps from his office or car, via portable radio if there is no 24hour emergency physician available. This p h y s i c i a n e v a l u a t e s the medical aspects of the case identifying treatment from the history and physical examination. It may be necessary to rely on the EMT-P's assessment of the situation. A physician derives a great deal of knowledge about a pat i e n t ' s c o n d i t i o n from his v i s u a l senses. At a distance fi'om the patient, he must rely upon the visual senses of the EMT-Ps in defining conditions or situations not easily assessed over the radio. Therefore, developing the anatomy and pharmacology expertise of the EMT-Ps is an absolute necessity. Without this knowledge, they cannot let the physician know when a pat't i c u l a r i n s t r u c t i o n m i g h t n o t be exactly appropriate. Reliance and confidence on each other m u s t be developed i n a n a d e q u a t e , w o r k i n g paramedic system. However, in any system there must be a captain and this role r e m a i n s with the physician. Responsibility of the medical director, then, is to monitor the call and have the power (given to him by the medical community), to intervene if he deems the care b e i n g rendered to the p a t i e n t is harmful. The medical director s h o u l d also i d e n t i f y those areas which may be radio errors to be discussed with the physician rendering the order or the EMT-P's in the field. In a well-run EMS system, however, immediate i n t e r v e n t i o n by the medical director should seldom, if ever, occur.
7:3 (Mar) 1978
RETROSPECTIVE Retrospective control is in reality another form of c o n t i n u i n g education. The i n f o r m a t i o n for r e t r o s p e c t i v e medical control and for improvements in the system can be derived from two sources. 1) The first is review of the radio c o m m u n i c a t i o n u s i n g a voiceactivated tape recorder and a n a l y s i s of the r u n reports, both immediately and retrospectively as in a medical audit procedure. Diagnosis and treatm e n t in t h e field as i n d i c a t e d i n the written r u n reports can be compared with the diagnosis and treatm e n t rendered in the emergency dep a r t m e n t as reported in the hospital record. Three questions are asked: a) Was the condition identified in the field the same as the emergency d e p a r t m e n t and final discharge diagnosis? b) Was any care given in the e m e r g e n c y d e p a r t m e n t which could have been better given in the prehospital period? c) Was the t r e a t m e n t rendered in the prehospital period or emergency d e p a r t m e n t inappropriate for the diagnosis obtained? 2) Consultations with the training officer can suggest appropriate c o n t i n u i n g education for EMT-Ps. The medical director can d o c u m e n t the specific deficiencies of the patient care on the r u n through a letter and include methods of remedial t r a i n i n g . Finally, the EMT-Ps can be called in for person-to-person consultation with the medical director.
JACEP
In a service with such a system, one t r a i n i n g officer will be necessary for each five paramedic u n i t s on the street. One hour per week of medical director time is required for each 1,000 r u n s per year. If there are in excess of 5,000 r u n s per year, one full-time individual m u s t be responsible for retrospective audit and review of all the charts, much like a medical records l i b r a r i a n in a n y h o s p i t a l m e d i c a l audit system. This person reviews r u n reports, compares t r e a t m e n t and d i a g n o s i s b e t w e e n the r u n report, e m e r g e n c y d e p a r t m e n t record a n d final discharge s u m m a r y according to the protocols developed for the system. Any r u n s that fall outside the protocol are t h e n reviewed by the medical di= rector and appropriate action is taken. The methodology for such a retrospective audit was presented at a n a t i o n a l EMS m e e t i n g in New Orleans, J a n u a r y 11-13, 1977 a n d has been reported. 1
CONCLUSION As in any other field of medicine, if we, as physicians, do not assume these responsibilities ourselves, the void will be rapidly filled by some bureaucratic system t h a t neither understands q u a l i t y medical care nor has the flexibility to identify when deviations from s t a n d a r d protocols are important.
REFERENCE 1. McSwain NE Jr: Methodology for evaluating prehospital training programs. The E M T J o u r n a l 1:49-53, 1977.
116/59
