the ems physician beyond medical direction
DESCRIPTION
The EMS Physician Beyond Medical Direction. Amy Gutman MD [email protected]. 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? - PowerPoint PPT PresentationTRANSCRIPT
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The EMS PhysicianThe EMS Physician Beyond Medical DirectionBeyond Medical Direction
Amy Gutman [email protected]
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“I’d say you’re suffering from an arrow through your head, but to play it safe I am ordering a bunch of tests”
The Difference Between EMTs & MDsThe Difference Between EMTs & MDs
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OverviewOverview
• What / who are EM & EMS Physicians?
• Qualifications
• What does an EM / EMS physician do all day?
• What is a Medical Director?
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What is an EM Physician?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
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Residents, Fellows & AttendingsResidents, 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”
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What Kind of Patients Do We See?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
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Patient TrendsPatient 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
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What Are the Shifts?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
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Why Do I Have to Wait So Long To Be Seen?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
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Important EM MD QualitiesImportant EM MD Qualities
• Ability to multi-task
• Tolerate indescribably horrific smells & sights
• Never panic
• Multi-tasking
• Short attention span
• Multi-tasking?
• Attention to Details
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Taking “Don’t Panic” LiterallyTaking “Don’t Panic” Literally
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Gutman’s Pornography Principal of “Sick”Gutman’s Pornography Principal of “Sick”
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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
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24 yo WM 24 yo WM Stab Wound ChestStab Wound Chest
19 yo WF 19 yo WF GSW to ChestGSW to Chest
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What is an EMS Physician?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
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QualificationsQualifications
• 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
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EMS FellowshipsEMS 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
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2 Decades of Job Prep2 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
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What Does an EMS Physician Do All Day?What Does an EMS Physician Do All Day?
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45% Deal with assholes, drug-seekers, drunks
& whiners25% Care of actual
sick & injured patients
10% Personal
Time
10% EMS Administration
10% EMS Education
How I Spend My Days
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Educational
Research
EDClinical
Political
Sub-Specialty
Administrative
MedicalDirection
•CQI/QA•Protocol Development•Policy Review•National / Regional Committees
•Tactical•Aeromedical•USAR•Toxicology•Wilderness•MCI
•Political Lobbying•Fire vs. EMS•Government
•Prehospital•Hospital
•Governmental
•Prospective•Retrospective
•Texts / Journals
•Direct•Indirect
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AdminstrativeAdminstrative
• Paperwork, Paperwork, Paperwork
• Protocol development
• Standard of care compliance (“CQI / QA”)
• Policy evaluation/modification
• Meetings
• Personnel “Issues”
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EducationalEducational
• Mentoring• Medical / Allied Health /
Paramedical students• Residents
• Lectures• Grand Rounds• Prehospital Continuing
Education• Conferences
• Personal• Continuing Education
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Flight PhysicianFlight Physician
• 10% of medical directorships focus solely on flight transport
• Fixed wing or helicopter EMS
• “Transport EMS” includes coordination of flight, water & ground transport
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Ooops
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O2 Tank (wall & portable)
TraumaBlanket
Stretcher
Restraints
Space Heater
Fan
2 Monitors / DefibrillatorsPacer Pads / Leads
Ventilator / CPAP
Teddy Bear
Wall Suction
Drugs:4 ACLS4 Narcs
4 RSI4 Benzos
4 TBI4 Antiemesis
4 DM
2 Radios2 Helmets2 Headsets
2 Units PRBC500cc Mannitol2 (3) Channel Pumps1 (4) Channel Pump
4 Survival Kits
S/M/L Gloves
Tape &Carabeeners (everywhere)
Emergency Airway Kit (Adult & Pediatric)BVMs / ETCO2 continuous waveformKing LT / BougieCricothyrotomyPericardiocentesis
PortableSuction
16 IV Start Kits4 IVF LitersFAST IOSternal IO
BP CuffsStethoscopes
Glucometer
2 Sharps Containers
Vomit Bags
Syringes19 g Needles
TowelsGauzeABD Pads
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Special OperationsSpecial 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
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Worst Case Scenario TabletopsWorst 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
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Dignitary ProtectionDignitary Protection
• Medical back-up for “special-ops”• Presidential / Secret Service• FBI• SWAT• “Special People”
• Portable ED• Ibuprofen to cricothyrotomies
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Mass Gathering Mass Gathering MedicineMedicine
• 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
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Medical DirectionMedical 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
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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
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Medical DirectionMedical 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
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On-Scene Medical DirectionOn-Scene Medical Direction
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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
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SHREVEPORT LA FIRE DEPARTMENTSHREVEPORT LA FIRE DEPARTMENTHonorary Captain / Resident Medical DirectorHonorary Captain / Resident Medical Director
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SFD SUPER 1
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Cincinnati Fire DepartmentCincinnati Fire DepartmentEMS Fellow / Assistant Medical DirectorEMS Fellow / Assistant Medical Director
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COOL CINCI FD PICSCOOL CINCI FD PICS
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ResearchResearch• 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!
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5 EMS Studies you Need to Know5 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
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5 EMS Studies You Need to Know: 5 EMS Studies You Need to Know: Intubation Associated with Decreased Intubation Associated with Decreased Survival in Pediatric Cardiac ArrestSurvival 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
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5 EMS Studies You Need to Know5 EMS Studies You Need to KnowTiered Staffing vs All ALSTiered 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
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5 EMS Studies You Need to Know5 EMS Studies You Need to KnowEarly Stroke Identification Saves LivesEarly 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
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5 EMS Studies You Need To Know: 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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EM MD Truisms
• We talk & move fast• Average PPH = 1.8• Attending may oversee >40 pts• I average 18-26 pts / 8 hr shift
• We have short attention spans
• Our handwriting sucks
• We sometimes hate patients
• We order too many tests
• Stuff grosses us out
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How Real Are Medical How Real Are Medical Shows?Shows?
• Sex in the ED? Bacteria, feces, vomitus & body parts does not romance make
• You can’t smell patients on TV
• Plot lines are far-fetched
• Most doctors aren’t “experts” at “everything”
• Most EMS MDs have no social lives or social skills
• Medical conditions are sometimes close, but real life is far, far stranger
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Real Life
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SummarySummary
• Definition & qualifications of an EM & EMS Physician
• Roles & experiences vary significantly between providers
• Personal background & preparation to become an EMS Physician & Medical Director
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[email protected]@gmail.com
“The most exciting phrase to hear in science, that heralds new discoveries, is not “Eureka, I found it!”, but
rather, “Hmm...that's funny...” ~ Isaac Asimov
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