1. EMS Medical Direction: “What does that doc do, anyway?”
Peter Taillac, MD, FACEP, FAEMS
Medical Director
Utah Bureau of EMS and Preparedness
Utah Department of Health

2. Utah State Requirements
(1) The Department may certify an off-line medical director for a four year period.
(2) An off-line medical director must be:
(a) a physician actively engaged in the provision of emergency medical care;
(b) familiar with the Utah EMS Systems Act, Title 26, Chapter 8a, and applicable state rules; and
(c) familiar with medical equipment and medications required under "R426 Equipment, Drugs and Supplies List." R

3. Utah State Requirements
(1) An individual who wishes to certify as an off-line medical director must: (a) have completed an American College of Emergency Physicians or National Association of Emergency Medical Services Physicians medical director training course or the Department's medical director training course within twelve months of becoming a medical director; (b) submit an application and; (c) pay all applicable fees. R

4. What he’s supposed to do: Know the system
(1) All licensees, designated dispatch centers, and quick response units must enter into a written agreement with a physician to serve as its off-line medical director to supervise the medical care or instructions provided by the field EMS personnel and dispatchers. The physician must be familiar with: (a) the design and operation of the local prehospital EMS system; and (b) local dispatch and communication systems and procedures. R

5. What she’s supposed to do: Protocols
(2) The off-line medical director shall develop and implement patient care standards which include written standing orders and triage, treatment, and transport protocols or pre-arrival instructions to be given by designated emergency medical dispatch centers.
AND:
(4)(b) annually review triage, treatment, and transport protocols and update them as necessary; R

6. What he’s supposed to do: Teach and evaluate medics
(3) The off-line medical director shall ensure the qualification of field EMS personnel involved in patient care and dispatch through the provision of ongoing continuing medical education programs and appropriate review and evaluation; R

7. What she’s supposed to do: QA/QI
(4) The off-line medical director shall: (a) develop and implement an effective quality improvement program, including medical audit, review, and critique of patient care; R

8. What he’s supposed to do: Discipline (??!!)
(c) suspend from patient care, pending Department review, a field EMS personnel or dispatcher who does not comply with local medical triage, treatment and transport protocols, pre-arrival instruction protocols, or who violates any of the EMS rules, or who the medical director determines is providing emergency medical service in a careless or unsafe manner. The medical director must notify the Department within one business day of the suspension. R

9. What she’s supposed to do: Participate
(d) attend meetings of the local EMS Council, if one exists, to participate in the coordination and operations of local EMS providers. R

10. What your medical director doesn’t (want to) do
Deal with labor issues
Deal with financial issues (unless medically related)
Deal with political issues (unless medically related)
Deal with turf battles

12. National survey of 1,425 local EMS directors Rural and urban
Asked about the role of their medical director
MD responsibilities based on 2004 Rural and Frontier Agenda for the Future
Slifkin, et al. J Rural Health 2009;25(4):392
McGinnis, K. National Rural Health Association 2004

13. Results of Survey Responses: Overall response rate 60%
Rural: 60% of agencies responded
Urban: 55% of agencies responded
Volunteer agencies: Defined as no employee receives a regular salary or hourly wage
Except on call pay and pay for EMS runs
Volunteer agencies:
Rural: 49%
Urban: 30%
98% of agencies overall had designated medical directors

14. What is the Specialty Certification of Your Medical Director?
???

15. Specialty Certification of Medical Directors
Emergency Medicine:
Rural: 42%
Urban: 82%
Family or General Medicine:
Rural: 44%
Urban: 9%
Does this matter to you?

16. Has Your Medical Director Undergone Training?
???

17. Medical Director Training
Has your medical director taken an EMS medical director course?
Overall: 55% of agency directors did not know
Of those who did know:
Rural: 32% said their docs have taken a course
Urban: 37% said their docs have taken a course
Does this matter to you?

18. Have you Had Trouble Recruiting Medical Directors?
???

19. Trouble Recruiting Medical Directors
“Yes”
Rural: 22%
Urban: 10%
Reasons for difficulty (similar for rural/urban):
Doctors not willing: 64%
Cannot pay a medical director: 40%
Local physicians not qualified: 18%

20. Off-Line Medical Direction
79%: from medical director
42% from state EMS office
15%: other (local EDs, other EMS agencies)
(could list more than one source)

21. Other Medical Director Functions
77%: Develop protocol and standing orders
Develop or implement quality improvement programs:
Rural: 47%
Urban: 53%
Regularly review run reports:
Rural: 43%
Urban: 39%
Review patient complaints:
Rural: 58%
Urban: 44%

22. Other Medical Director Functions
“Stay up-to-date on state, regional, or local information, changes in procedure, etc.”
Rural: 52%
Urban: 59%
Does this matter to you?

23. What more would you like from your medical director?
29%: nothing more
71%: “I want more!”
What else would you like?
Support for expanding scope of practice
Regular and timely run reviews / more QA/QI
More involvement in continuing medic education

24. Views from Utah Rural Medical Directors
Comments solicited from four rural Utah EMS Medical Directors
All discussed agency challenges
None discussed medical director pay or EMS malpractice issues

25. Views from Utah Rural Medical Directors
Challenges
Training: time/money
Funding:
Is the “volunteer” model really the right answer?
Police/Fire: usually have more fixed/reliable funding
Statewide tax/fees
Local “special service districts”
“Surge”: managing rural mass gathering events
Staffing: finding enough medics locally
Employer constraints: losing staff for 3-4 hours at a time

26. Views from Utah Rural Medical Directors
Opportunities
Partner with urban agencies
Part-time staffing
Training/”ride-along” opportunities for rural medics
Webinar-type training
Alternate funding sources
Leverage State EMS and Office of Rural Health
Grants
Educational resources/support
Consolidation of local resources
Community paramedicine/EMT hospital staffing
Full-time local EMS employment?

27. Types of EMS Medical Directors
Bad: Doesn’t do Anything
Good:
Goes along with whatever we want to do
Bad: Interferes in our operational functioning
Guides us in what we SHOULD do
Inactive:
Active:

28. Why do docs play with EMS?
They get paid (sort of…sometimes)
They didn’t show up to that meeting…
They’re the newest doc in town (“Tag, you’re it!”)
They really care about the care of their patients
They really care about their community

29. EMS Nationally FICEMS: Federal Interagency Committee on EMS
Strategic national policies and agendas for EMS
NEMSAC: National EMS Advisory Council
Advises Federal Government on EMS-related issues
Sets national priorities for EMS systems development
NASEMSO: National Association of State EMS Officials
Association of all state EMS offices
Medical Directors Council: all of the state EMS medical directors
NAEMSP: National Association of EMS Physicians
Association of EMS medical directors
ACEP: EMS Committee
NREMT, NAEMSE, AAA, NAEMT, CoAEMSP, IAFF/IAFC, etc…

30. EMS Scope of Practice

31. EMS Scope of Practice EMR: Emergency Medical Responder
hr training
Basic first aid, immobilization, dressings, splinting
EMT: Emergency Medical Technician
hr training
Limited medication use: oxygen, oral glucose, epinephrine, narcan, NTG
AEMT: Advanced Emergency Medical Technician
hr training
IV skills, supraglottic airways, more extensive meds
Foundation of rural EMS
Paramedic
hr training
Advanced airway management
Extensive medication use

32. EMS-C: EMS for Children
Goal: to ensure excellence in emergency care for kids
HRSA: Health Resources and Services Administration
Congressional funding source
Recommended ambulance equipment
Recommended ED equipment
Pediatric performance measures
Funding for prehospital pediatric EBG development
Utah EMS-C Medical Director: Dr. Hilary Hewes

33. Prehospital Evidence-Based Guidelines
2006 IOM Report: “Emergency Medical Services at the Crossroads”
Advised the development of Evidence-based treatment protocols for prehospital Care
National Model Process for EBG Development

35. Current Prehospital Evidence-Based Guidelines
Cardiac arrest (AHA)
Pain management
Helicopter activation
Hemorrhage control
Seizures (peds)
Respiratory distress (peds)
Spinal Care (peds)*
Shock (peds)*
Allergic reactions (peds)*
Airway management (peds)*
* Submitted for publication this year

36. NASEMSO Model EMS Clinical Guidelines
Created/maintained by NHTSA/OEMS grant funding
Collection of evidence- and consensus-based guidelines for prehospital care
States/agencies use them to develop prehospital treatment protocols

37. NEMSIS: National EMS Information System
Collects and aggregates EMS data from states
Publically accessible for PI, analysis, research
Based at the University of Utah

38. EMS Compass NHTSA/OEMS supported project
Standardized, evidence-based performance measures for EMS

39. EMS Compass Performance Measures
Seizure
Hypoglycemia
Cardiac arrest
STEMI
Stroke
Trauma
Pediatrics
Operational/Safety

40. Questions?
Discussion?