This is a brief rant about a thing that totally annoys the crap out of me about my job. One word. Telemetry. No, not the telemetry beds that patients go to when they have cardiac issues, I am talking about the telemetry where paramedics have to call the ER and we as docs have to provide “control”. So, the deal is this. A paramedic unit is called to a patient and is now transporting him or her either to us or to another ED. They then HAVE to (by law in my state) call “Med control” – ie me, and present the case and then have me authorise (or deny) various treatments they propose for the patient. I consider this an EPIC waste of time – both theirs and mine. I have to basically drop whatever I am doing and answer them. I then have to listen to a whole long spiel (that is often rambling and full of things I really don’t need to know but they have to tell me anyway) before I say something like “yes, that is fine, go ahead and give 70 of Lasix, see you in 10″. 99% of the time I agree with what their assessment and plans are, so in my mind, it is a complete waste of time. Unfortunately, I often display this annoyance in my tone of voice – but it is not annoyance with the medics themselves, but the stupid system we are forced to work with. In my mind, an MD should only be called to give narcotics, pronounce death, or sign a patient out AMA (RMA or refusal of medical assistance in the prehospital setting). That’s it. Otherwise, the medics should just call the ER itself and leave a brief notification of what is coming in with vitals and that is that. They are allowed to provide ALS care in the event of “radio failure” where they cannot reach the doc anyway so my recommendations are redundant. Done. Faster and more efficient. And I don’t have to leave a patient’s room to answer that damn console!
Oh yeah, Happy Thanksgiving everyone!
Medics (and EMTs) feel the same way. Unfortunately, in some hospitals or some systems its the only way. I have been chastised for not calling in orders or an Entry note at some hospitals and the opposite elsewhere.
This comes back to mommy-may-I medicine– back to the days of Johnny and Roy on Rescue 51.
Its good to hear the frustration from the other end… some medics interpret it as docs that hate them or b*itchy nurses, where I assume that isnt always the case.
personally if i the poor smuck being transported I only want my care providers stopping treatment WHEN they feel they are in a situation they need the consult or the stuff ERP mentioned about. I too find stupidity in the workplace to be highly irritating.
I am an ER nurse, and we answer the radio for report, and to give “some orders” that are above and beyond the ones in their paramedic protocols. Pretty much everything has a protocol and a treatment, and we rarely have to bother a doctor for an order for any of this.
The state is pretty messed up in preventing doctors from making decisions about patient care.
As I see it, these requirements for on line medical command permission are a way for EMS medical directors to feel comfortable putting bad medics on the street. What we need in EMS is much more aggressive physician oversight. Physicians who understand the differences between treatments that are effective in the hospital and treatments that are effective out of the hospital. Physicians who pay attention to the research on things paramedics can consistently do safely that also benefits patients.
There are not enough medical directors who meet these criteria. One of the reasons is that they do not get paid well enough for being excellent medical directors. It is considered a side job, or even a volunteer job. How does having the responsibility for the oversight of EMS providers, protocol development (as much as the state allows), and reviewing actual patient care, not have value? Why do so many places try to do this on the cheap?
In many places with aggressive medical oversight, the protocols have moved to permitting more paramedic discretion, including high dose nitrates, fentanyl, versed, and paralytics on standing orders. These kinds of protocols require accountability and enough familiarity that the medical director knows which medics are capable of working at this level and which are not.
We have too many paramedics, but some systems are still trying to make it so that everyone responding is a medic. A quality system cannot exist without the ability to obtain/maintain a lot of experience (unless there is a lot of time spent on training/continuing education/simulation, but many every-responder-a-medic systems do not seem to be so inclined).
Standing protocols – you need them! When I started as a medic, we had to call and get permission to give epi in a full arrest. Half the time we were way further along in the ACLS algorithm and just got the orders retroactively. Also, the medic is going to lead you down the garden path – if they think it is CHF, they will describe CHF. I guarantee you, you will not be able to pick out the pneumonia patient by their report. Nowadays, medics in our area do EVERYTHING by protocol. I think they can even give fentanyl. Much better all around.
I think it is time for EMS to step up to the plate and get the job done without the hassles of geting orders for things that should already have a protocol in place my department is in the process of updating our protocols and adding more so we don’t have to call for every problem
I know that if I worked in this system, my radio would be quite susceptible to failure.
the WHO for the year 2007 said that the frequency of the mortality by patients with acute myocard infarct is 52% in prehospital phase. So telemtry can be useful in the control of giving prehospital fibrinloytic therapy by the EMS. So providing “control” by the docs from the ED seems very reasonable …
p.s. i am reading your blog awhile and I find very interesting texts about medicine. I work in the EMS as a physician in southeast Europa…
No one really gives fibrinolytics in my area since there are so many cardiac cath centres. EMS could just tell us a STEMI is coming in in about 5-10 minutes and we would activate the cath team. It is different in very rural areas I am sure.
Dr. Marija,
Where I am there are also plenty of cath labs, so fibrinolytics are not even a consideration for EMS.
I am not claiming that there is never a reason use medical command, but that research can show us what EMS can treat competently without calling for permission each time.
the way on line medical command permission is used is to delay treatment. We had to call for permission to give aspirin for cardiac chest pain in a patient without contraindications for receiving aspirin. Aspirin is still the only drug that I carry, that can improve outcomes from a heart attack.
Too many protocols are set up the wrong way. They are not looking at what treatments will make a difference when given before the patient gets to the hospital. they look at what will be done in the hospital, then that is extended to the prehospital providers.
Some of what is done in the hospital does not work well outside of the hospital. Some of what is done in the hospital actually is safer outside of the hospital for the typical patient.
Pain management and sedation are two that fall into that category. In the hospital, staff will not be assigned to stay with the patient continually, unless there is a problem or procedural sedation is being used. Outside of the hospital, I am within an arm’s length of the patient at all times. While it is possible to ignore the patient in spite of being that close to the patient, no competent provider should. When giving opioids or benzodiazepines (my only options for sedation and pain management), I need to be continually reassessing response. Even with standard doses. Although standard doses tend not to work for a patient with severe pain, when placed on a poorly padded stretcher on top of the rear axle and driven down some poorly paved roads.
This is one of the reasons short acting drugs are much more appropriate for EMS, such as fentanyl and midazolam. By the time we are transferring care at the ED, the medications are already beginning to wear off. The patient is no longer receiving as much painful stimulus. This could be a problem if things become busy in the ED. If the medication is wearing off that provides an extra layer of safety. Repeat dosing can be performed in the ED according to the comfort level of the physician.
One way of making sure that EMS has the ability to assess adequately and has the understanding to be able to choose appropriate doses and choose when NOT to give more medication, is to rotate them through a burn center, or other setting where very high doses of opioids are used. A phone call/radio call to someone who cannot see the patient and has to rely on my assessment, is not a good way to determine dosing that is appropriate for the patient.
the patient is the reason we are all there. The goal is to provide treatment that is appropriate for the patient. The goal is not to make all of the doses fit into a very narrow range, or anything else, that is not individual to that patient.