Medical control for 1st Responders? Basics?

[DHerrington]

I don't mean on-line medcon for orders to give Charcoal or something, either.
Let me sketch out what we're dealing with in rural Connecticut.

Recently a Respiratory Therapist took the position of Medical Director at the sponsor hospital for my EMT-Intermediate level ambulance service.
At first he (rightly) made sure everyone was doing CMEs. The last Director, who was a PA, was somewhat lax and simply signed renewal forms.

SCENARIO 1
Once all Intermediates were taking CMEs, this medical director said that in order to have medical control, all Intermediates would have to take classes with only instructors approved by him. No one said much because there were several instructors giving several classes a month.

After a few months, the instructors, who were certified Paramedics and EMS-Instructors by the state, got tired of his micromanaging (telling them to reschedule classes, canceling their own classes, reviewing their syllabi with extreme scrutiny and telling them they could not offer certain subjects, etc). So he allowed CMEs from other sources, but required all Intermediates to attend four classes, yearly, taught by him. This got people talking, but still, no one called the state to see if he could require X number of CMEs from a particular source, since there was one class scheduled per month at our ambulance garage. Then the cancellations started... all in all, he canceled 6 of those courses. People who could not make 4 had their medical control suspended. (Including a student working on their degree who has college courses Mon and Wed nights).

The Medical Director insists that since the state requires CMEs and empowers him to sign off on those same CMEs before he submits the renewal paperwork, he also, according to him, has the power to require WHATEVER he wants insofar as CMEs go. In other words, if that means requiring a one hour class every night for a month, he can do it. If that means a certain instructor, or (more recently) a specific list of pre-approved topics, so be it (no Cardiology, for example -- you can go, but you won't get CME credit since it's beyond the EMT-I scope here).

I am at the point where I -have- to clarify this with the state since this has started to impact our staffing levels. Anyone had experience in this area? Is any of what he says even remotely true?

SCENARIO 2
Oh, it gets better. After all of the above happened, he has now said that he will be requiring medical control for the First Responders (MRT’s) and EMT-Basics in the form of a written test.

In CT, MRTs and Basics are required to take a refresher and test afterward, and if they fail, they must remediate and restest. MRTs and Basics perform no invasive skills, not even finger pricking for a Glucose check.

There are no differences in protocol for Basics from region to region. No invasive skills can be performed. They have required testing every 22 months after their refreshers. And yet they have to have medical control?

Well, came the reply from the Medical Director, it’s “required by state regulation.” It is? Funny, 'cuz I couldn't find it in the CT General Statutes. **DIRECT** Medical control IS in fact required if we want to (for example) give Charcoal, and I believe he is confusing direct medical control with the concept of medical control at the ALS level required for the I and P to practice.

Is any of this in fact true? I have calls in to the state but no word back.

BTW, yes, CT still has the concept of medical control in the "working under a Physician's license" sense. Please don't point and laugh. 20 miles over the line in Massachusetts, First Responders give Epi-Pens on standing orders. It's also 20 miles away to New York, where Intermediates Intubate with ET tubes and perform needle chest decompressions. Here, EMT-I's can start IVs in 8 or 9 very narrow circumstances (not including dehydration) and can use a CombiTube, but only in cardiac arrests:blush:

 

[Ridryder911]

How in the h*ll, does a respiratory therapist become a medical director or even a P.A. ? WOW!

I did not even read all your posts after that statement. I would contact your state EMS Regulatory Division and check the requirements. I have NEVER EVER heard, that NO ONE other than a LICENSED MEDICAL PHYSICIAN has the authority or ability, to ever be a Medical Director!

If this is the case, I would be protesting legislation changes. Personally, I will contact some ambulance chasing attorneys, because we will have a field day.

R/r 911

 

[DHerrington]

How in the h*ll, does a respiratory therapist become a medical director or even a P.A. ? WOW!

Another misread of regs, I suspect. I came to CT in 2004 and a bunch of things seemed "not quite right." Technically, the doc is Medical Director, but he hands everything down to someone less busy. When I asked around, I got mostly funny looks with "well, nothing says a doc can't do that! He's busy, you know!"

If this is the case, I would be protesting legislation changes.

That has it's own wonderful dead end. Here is one problem as an example. EMT-Basics used to do finger sticks, but in 2004 that ended. It seems a legislator noticed that the regs -- get this -- didn't specifically allow EMT-B's to do this. So after this legislator called around to some hospitals, the practice stopped. It spread like wildfire. So regional committees were formed to deal with this because it was only a matter of time before everything got taken away (wait, these regs don't say anything about Amiodarone!) Suffice to say that the Basic finger stick thing got added, but was given as a medical control option (and you guessed right! No Medical Director allows it.)

If it can benefit a patient here, it's probably a happy accident that EMS can do it here. They are so profoundly insular here that they don't know or care that EMS is done in other states. They want very little done, by gosh, and it better be done like it was in '75.

If it's not in the regs, then nothing says you can do it. So forget it! The attitude is so pervasive among providers that it's a bit like fish not noticing the water. Many that I work with have always thought this way and arguing against these things gets me these vacant stares and blank looks.

Right now I have some people bothered that I oppose medical control for MRTs and Basics since "[Director] is trying to do some quality control, so why are you fighting him? [Doctor above him] is putting his license on the line!" To which I reply that the whole "working under the license" concept applies to the performance of ALS skills. After all, a layperson can do a sling and swath, use a defib, or give Orange Juice to a diabetic without medcon. And at that point, it goes right back to "[Director] is trying to do some quality control, so why are you fighting him?" :wacko: :wacko:

 

[akflightmedic]

I too was shocked at his statements regarding medical direction.

However, after perusing the DOH website for CT, I have found two clarified definitions in the regs.

To paraphrase:

1. Medical Control is the direct oversight by a licensed physician.

2. Medical Direction (which could be loosely translated to mean a medical director) is "the provision of medical advice, consultation, instruction, and authorization to appropriately trained or certified personnel by DESIGNATED STAFF MEMBERS AT SPONSOR HOSPITALS".

The bold part was done by me, so basically if the hospital decides the janitor can give medical advice, they and he can legally do so as there is no requirement on the medical director to be any certain level, only that he be designated by the hospital.

http://www.ct.gov/dph/cwp/view.asp?a=3127&q=387368&dphNav_GID=1827&dphNav=|


As for your specific questions, I have read and reread the statues. For CME, all you need is your 15 hours in a 2 year period to maintain current status and the retesting at the end of 2 years which you are aware of already.

I found nothing relating to a medical director dictating who and when a CME can be given as long as the class or instructor is authorized by the state and submits their syllabus per the state's requirement.

Sorry but your Medical Director sounds like a micro managing screwball. Having said that, he IS your service's medical director and as long as his superiors support him, he can probably dictate whatever he wants as far as training goes as long as HE MEETS OR EXCEEDS THE STATE REQUIREMENT.

Since his overbearing style possibly does meet/exceed the minimum, he can probably get away with it.

Oh well, good luck ! !

 

[skyemt]

so basically....

the medical director wants increased CME for emt's...

wants only basic skills for EMT-B's (many areas like mine don't allow finger sticks... wouldn't change the treatment on the basic level anyway...)

and... they don't want anything done that is not in the regs...

what am i missing here, other than basic's wanting to do more, which is the case everywhere?

 

[DHerrington]

so basically....
the medical director wants increased CME for emt's...

No, not the issue. No one balks at that. The problem is saying "you can only take CMEs from ME." The problem is his telling us he is giving ample opportunities to take classes, then canceling same.

wants only basic skills for EMT-B's

No one disagrees with that, either. We disagree with the philosophy of "we didn't find it in state law, so we're taking away what you once used to do based not on complaints or misuse or lack of training but on the basis of not finding it in state law." I see you're from NY. I used to practise there too as an AEMT-I. Imagine if some legislators got together and said 'hey, you know, the EMT-CC scope of practice doesn't appear in New York state law. Sure, it's set by DHS, and protocols are written by [whatever, for me it was REMO], but it's not in state law. We've got to take away their drug boxes until we can add that to the statutes!"

Pretty ridiculous, right? I mean, you're in EMS because you want to help people, and you have to have the diagnostic tools to do it. I am not up in arms about glucose monitoring being yanked from B's because the medic is there on scene too 90% of the time. But it does bother some people when the medic's not available or late coming to the scene, and you have to just give juice to the diabetic to be on the safe side (and later find out they were at 999... maybe higher because the Glucose monitor doesn't go up any higher. Yeah, it's happened. I was on such a call.)

what am i missing here, other than basic's wanting to do more, which is the case everywhere?

No, Basics aren't saying they want to do more. You took away the wrong central message, which is a Medical Director that in some of our opinions has started to go haywire.

I am only interested in EMS levels doing more if it's necessary, and in my system here, we have a medic co-response. I am not terribly worried about that. When it comes to scope of practice, as long as the medical director is focused on patient care rather than restricting EMS providers, I'm fairly fine with it.

One of the best things I've read about scope of practice is from Wisconsin:
"...if skills, medications or procedures contained in the National Standard Curriculum for EMT-Intermediates are to be omitted for use in Wisconsin, they shall only be omitted based on their safety and efficacy for this level of provider and not based in whole or in part because of the effects these interventions may have on other levels of EMS providers."

Our focus should be patient care and improving the standard of care as it is revised. When the focus is continually on scope of practice, something's profoundly wrong.

My problem is with someone who is keeping Basics from staffing our rigs because he wants them to take HIS classes, HIS tests (because state-sponsored tests at refreshers presumably aren't good enough) and generally ride herd on them when he lacks authorization.

BTW thanks for the info akflightmedic. The attitude unfortunately is:
Save lives? The law doesn't say you can!
Create bureaucracy? The law doesn't say I can't!

 

[mdtaylor]

Is there anything that says you cannot take whatever form of CE you desire to renew your state certification, AND THEN jump through whatever hoops this medical director has laid out as refresher training for your organization?

 

[akflightmedic]

This is an operational issue more than a state issue.

The concerns need to be addressed within his organization.