The EMS PhysicianThe EMS Physician Beyond Medical DirectionBeyond Medical Direction

Amy Gutman MDprehospitalmd@gmail.com

“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

OverviewOverview

• What / who are EM & EMS Physicians?

• Qualifications

• What does an EM / EMS physician do all day?

• What is a Medical Director?

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

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”

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

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

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

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

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

Taking “Don’t Panic” LiterallyTaking “Don’t Panic” Literally

Gutman’s Pornography Principal of “Sick”Gutman’s Pornography Principal of “Sick”

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

24 yo WM 24 yo WM Stab Wound ChestStab Wound Chest

19 yo WF 19 yo WF GSW to ChestGSW to Chest

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

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

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

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

What Does an EMS Physician Do All Day?What Does an EMS Physician Do All Day?

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

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

AdminstrativeAdminstrative

• Paperwork, Paperwork, Paperwork

• Protocol development

• Standard of care compliance (“CQI / QA”)

• Policy evaluation/modification

• Meetings

• Personnel “Issues”

EducationalEducational

• Mentoring• Medical / Allied Health /

Paramedical students• Residents

• Lectures• Grand Rounds• Prehospital Continuing

Education• Conferences

• Personal• Continuing Education

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

Ooops

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

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

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

Dignitary ProtectionDignitary Protection

• Medical back-up for “special-ops”• Presidential / Secret Service• FBI• SWAT• “Special People”

• Portable ED• Ibuprofen to cricothyrotomies

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

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

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

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

On-Scene Medical DirectionOn-Scene Medical Direction

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

SHREVEPORT LA FIRE DEPARTMENTSHREVEPORT LA FIRE DEPARTMENTHonorary Captain / Resident Medical DirectorHonorary Captain / Resident Medical Director

SFD SUPER 1

Cincinnati Fire DepartmentCincinnati Fire DepartmentEMS Fellow / Assistant Medical DirectorEMS Fellow / Assistant Medical Director

COOL CINCI FD PICSCOOL CINCI FD PICS

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!

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

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

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

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

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

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

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

Real Life

SummarySummary

• Definition & qualifications of an EM & EMS Physician

• Roles & experiences vary significantly between providers

• Personal background & preparation to become an EMS Physician & Medical Director

Questions?Questions?prehospitalmd@gmail.comprehospitalmd@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