# Medical control



## MrBrown (Feb 9, 2011)

As you know, down under have no requirement to contact "medical control" for anything.  Brown has been thinking more and more about the concept of having to ask permission and wonders how it works.

A good example Brown has found is asthma and anaphylaxis protocols often state you must obtain an order for adrenaline, and then it is often only IM and not IV adrenaline whereas we can start an adrenaline drip.

OK so lets say you have a critical asthmatic or anaphylactic patient who when you turn up is at the point of impending respiratory failure.  One of the first things we'd do here is give adrenaline.

So lets say you cannot and must obtain an order.

Who do you talk to? Do you just ring up the hospital and wait until they run round and find a Doctor? Does your medical director have a cellphone? What if nobody is avaliable? What do you do in the meantime, sit on your hands and go oh sorry patient, its not your fault you died, we had to ring up and ask the Doctor first!

Another good example is morphine.  Brown notices often you are allowed piddly little doses of morphine that Brown has maxed out in one go and its done nothing, eg we gave a NOF fracture 10mg one night and it did nothing, neither did the other 5 we gave her.  The ketamine worked a treat however.

Now, lets say you have maxed out your morphine dosage and want to do something novel like give the patient a bit of midazolam.  Are you likely to get approval? 

What if you think the order the Doctor has given you is not appropriate or inconsistent with good patient care, lets use Brown's previous example.  You have an old lady with a NOF facture who you cannot move because of irrectractable pain which is greatly impeding treatment and transport.  The 10mg of morph you gave her has done nothing but "medical control" won't allow you to give any additional morphone or some midaz and tells you to "bring patient to hospital".

In this circumstance can you challenge the order or ask to speak to somebody different, the Consultant Physician for example?

This concept seems rather odd to Brown and any clarity you folks who work it would be appreciated.

Thanks

Brown


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## rhan101277 (Feb 9, 2011)

Well you can always get a doctor, the number you call rings to their phones, there are several of them.  If you need an order for something, just paint them a good picture and if it makes since you get it.


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## medicRob (Feb 9, 2011)

We can radio in to the receiving facility for an attending physician, it doesn't necessarily have to be our medical director that we contact. Sometimes if radio contact isn't available, we will use our personal cell phones to call in to the ER and converse that way. In my specialty, a lot of my online medical direction is covered under, "Blanket orders" where I am allowed to use my discretion and medical judgement (within my scope of practice of course).


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## rhan101277 (Feb 9, 2011)

medicRob said:


> "Blanket orders" where I am allowed to use my discretion and medical judgement (within my scope of practice of course).



I can do the same, just gotta have a good reason.


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## abckidsmom (Feb 9, 2011)

In our area, the number we call to give report on the way to the hospital is also the medical control number.  I call, say "I need medical control for an adult patient" and get the 3rd year EM resident in about 20 seconds.

If I disagree with what he says, I can ask for the attending.  The nerve it takes to ask for the attending, if done properly, is usually enough to get them to say yes to whatever you want.

In your asthma example, or any other critical patient, I typically do the right thing, and call afterward with apologies that there wasn't time to contact them.  

In your hip fracture example, I would not get off the phone without my versed order.  I would use strong language about pain control, cruelty, elderly ladies screaming in agony if necessary.  

The key to this is that you get treated like a colleague if you communicate and act like one.  If you call medical control with a scattered, incomplete report and ask them if there's anything they'd like you to do (which really happens), they'll say "transport."  If you call with a concise, complete report (83 yof with a ground level fall, obvious hip fracture with a shortened, internally rotated right leg.  Pulses intact, she's awake and oriented in extreme pain, screams when you touch her and we haven't started moving her yet.  Vital signs are... PMH includes... I am calling for orders for more morphine and versed in 2 mg increments titrated to effect) I've never been turned down for a reasonable request.


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## Shishkabob (Feb 9, 2011)

MrBrown said:


> So lets say you cannot and must obtain an order.
> 
> Who do you talk to? Do you just ring up the hospital and wait until they run round and find a Doctor? Does your medical director have a cellphone? What if nobody is avaliable? What do you do in the meantime, sit on your hands and go oh sorry patient, its not your fault you died, we had to ring up and ask the Doctor first!



Depends on the company.  When I was at AMR, we were to contact the receiving hospital first, as that doc would be the one getting the patient.  If that didn't work, we'd call our own medical directors number.   At my new agency, we call our base hospital.



Now-- if you can't get in contact at all, or if it's a life saving thing that cannot wait, you do it and worry about the "order" later.  


But at the same time, there are agencies such as mine who have almost literally no requirement to contact med control except for such as we already started medical treatment (started an IV and gave medication) and the patient refuses transport... often diabetics who wake up after some D50.  It's more of a CYA than anything.





> Now, lets say you have maxed out your morphine dosage and want to do something novel like give the patient a bit of midazolam.  Are you likely to get approval?



Again, depends on how the agency is.  Mine allows us to give Benzos for agitation... someone in pain can get pretty agitated.  Ta-da, he's some Ativan/Versed.


Yesterday we were transporting a new-onset seizure patient who the sending facility gave her 1mg of Ativan because of painful tremors.  During transport, she started to have them again.  We technically don't have orders for "painful tremors" so we called up the doc, stated the sending facility gave 1mg ativan 2 hours prior and the tremors are back, and that we would like to give 1mg ativan.  Doctor allowed it, no questions asked.  




> What if you think the order the Doctor has given you is not appropriate or inconsistent with good patient care, lets use Brown's previous example.



Depends, again.  If the order is harmful for the patient (Give 1000 mg of Roc!) then it's your duty to speak up. 

If it's something that sucks, but not life-threatening, such as your lack of morphine scenario... well, it sucks, but if you give Morphine without an order for it (written or verbal) and the doc gets angry... watch out.

Luckily, I can give 200mcg Fentanyl without batting an eye ^_^




Now, I truly do wish Paramedics and RNs could have a "unlimited-within scope of practice-license" where we can do anything and everything within our scope without any actual doctors orders, written or otherwise, but the system in place, when done right, is not as bad as you make it seem.... unless you're in California where you have to ask a darn hospital RN to do anything.


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## EMS49393 (Feb 9, 2011)

We have a dedicated medical control phone number in PA.  In MD we have to go through syscom/EMRC to get a consulting physician.  I have just a couple more medications in PA then in MD.  I do not waste time calling when my patient is unstable unless I can't make a decision on the best course of treatment (that's never happened to me).  I have called when I do not want to proceed with a treatment when the protocol says I have to, just to cover my butt.  Example, I had an 70-some patient complaining of shortness of breath and chest discomfort with SBP in the one-teens, that was found to be in a-fib with RVR.  He was uncomfortable, but otherwise stable enough to get to the ER without intervention.  My cardioversion drug choices were Amiodarone and cardiazem.  I've never had luck with amiodarone, but that's another story.  He happened to be on beta-blockers.  I called medical control to ask permission to not convert the rhythm because I didn't feel the patient was unstable enough to cardiovert or mix anti-arrhythmics.  The physician agreed that it would be better to convert this patient in a more controlled environment.

I've now practiced in four states and have never been turned down for orders.  It's all in how much you know and how good you are at presenting your case.


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## mc400 (Feb 9, 2011)

I rarely have to call for anything. My anaphylaxis protocol is .3-.5 IM if not responsive begin a drip.

Asthma is duoneb, then epi IM, Solu-medrol and option for Mag if still non responsive. Can use SVN, In line SVN with BVM, inline with CPAP if needed, and of course in line with bvm via intubation.. We can also use nebulized EPI but I prefer the combo of Neb'd Duoneb with the EPI IM always seems to work much better in that combonation.


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## Aidey (Feb 9, 2011)

abckidsmom said:


> In your hip fracture example, I would not get off the phone without my versed order.  I would use strong language about pain control, cruelty, elderly ladies screaming in agony if necessary.



My last ditch option is to put the patient on the phone with the doctor. I will probably end up with a very pissed off doctor on my hands, but if they are not willing to negotiate I will let them explain to the patient why they are going to be in so much pain.


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## thegreypilgrim (Feb 9, 2011)

First of all I don't like it when Brown speaks of his system. It makes me jealous with angry...or angry with jealously...pah you know what I mean! Point is, knock it off!



MrBrown said:


> Who do you talk to? Do you just ring up the hospital and wait until they run round and find a Doctor? Does your medical director have a cellphone? What if nobody is avaliable? What do you do in the meantime, sit on your hands and go oh sorry patient, its not your fault you died, we had to ring up and ask the Doctor first!


Well, where I work no one trusts paramedics to do much of anything, so early and frequent medical control is considered of paramount importance here...seemingly more important than the concept of paramedic exercising "clinical judgment" or reasoning or whatever. We also rarely actually speak to the base hospital physicians themselves. In California, RNs have a specialized credential called a Mobile Intensive Care Nurse (MICN) certification which permits them to "issue instructions to prehospital emergency medical care personnel...according to standardized procedures". MICNs, therefore, handle most of our call-ins. If you need to go off the reservation or do something not in the protocols...well...you just have to sell it well...like _really_ well. MICNs guard their role as "medical control" as though it's the manna of life and are rather resistant towards getting the doc on the line for you.

The delays and the sort of posturing pissing match that calling base (medical control) can result in is a royal pain in the ***. It really is. The report you must give is essentially the same report you'd give bedside, so even though we have VHF radios on board our rigs are also equipped with cell phones. The latter of which are used by almost everyone primarily because of how detailed and involved the base report ends up being.



> Now, lets say you have maxed out your morphine dosage and want to do something novel like give the patient a bit of midazolam.  Are you likely to get approval?


Depends on several factors beyond your ability to sell such as: what MICN picks up the line, whether or not you're wearing yellow pants (i.e. fire-based rescue ambulance) or blue pants (i.e. private ambulance scrub medic), your ETA, etc. In all likelihood, however, you'll just be told to transport.



> What if you think the order the Doctor has given you is not appropriate or inconsistent with good patient care...In this circumstance can you challenge the order or ask to speak to somebody different, the Consultant Physician for example?


Oddly we're not under any _obligation_ to follow the orders of the base hospital - even after all the blustering and posturing about it. If they order something we disagree with we can elect to not do it, and if we're right nothing will come of it. If we're wrong, however, we're just going to be hung out to dry. The real way to get in trouble, however, is acting on your own. To take your anaphylaxis example, if we weren't permitted to give adrenaline prior to contact (which, thankfully, we are) and we had a critical patient where there wasn't time to call it in and just went ahead and did it we would not be praised at all for our critical thinking and will to act at all. You've gone off the grid son, you carried out a procedure you're not authorized to perform without a base order, this is the penultimate offense. Ye are to be taken to the gates outside the city and stones cast upon thee until thou art demised.


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## NomadicMedic (Feb 9, 2011)

I'm lucky that I work in a system that is a happy medium between Brown's and Grey Pilgrim's. 

Where I work, the medics are trusted and respected and have rather agressive protocol/standing orders. I've mentioned this before, but in both of the systems that work in, I don't have to make base station contact with a Doc unless I'm bringing in a STEMI with long transport times and want to start thrombolytics, or if I want to go _far_ off the page in terms of treatment.

Otherwise I just call as a courtsey to let 'em know I'm coming.

To take Brown's example of the little old lady with the hip FX that is screaming in pain; My pain management protocols allow for up to 40mg of Morphine and 500ug of Fentanyl before I have to call and ask for (and recieve) orders for more,or for a benzo like Versed. That's certainly not a piddiling little amount of Morphine.







In the case of the critical asthmatic or anaphylactic patient who is at the point of impending respiratory failure... That PT will get IM Epi, SoluMedrol, Albuterol SVN, Benadryl and IV Epi, followed by an Epi drip, if indicated. No base station contact is needed. 

They trust us to use critical thinking skills and our clinical judgement. 

However, if you screw up more than once, you'll be remediated, every critical call reviewed and then find yourself on a pretty short leash. The medics that practice subpar medicine here don't last more than a few months. The other medics and the Doc make sure they are gone before they hurt someone.


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## rhan101277 (Feb 9, 2011)

Aidey said:


> My last ditch option is to put the patient on the phone with the doctor. I will probably end up with a very pissed off doctor on my hands, but if they are not willing to negotiate I will let them explain to the patient why they are going to be in so much pain.



I got the dr. on the line with a pt. who was refusing but really needed to go, to try to explain the importance of going.  Pt still refused, lol.


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## abckidsmom (Feb 9, 2011)

rhan101277 said:


> I got the dr. on the line with a pt. who was refusing but really needed to go, to try to explain the importance of going.  Pt still refused, lol.




The protocol I am least compliant with is the one that requires me to have guardians of refusing minors and people with ALS complaints to speak with the physician before we leave the scene.  Oh, the agony. 

"Ma'am, my protocols require that I call the physician before you are free to leave the scene with your toddler who fell and scraped his knee.  The doctor is going to ask you if you are *certain* the baby did not hit his head, and he is going to tell you that the baby may die of a head injury or his leg might fall off if you don't take him to the hospital immediately."

Mom to dr:  "Hello?  Yes, he just fell and scraped his knee.  No, I'm sure he didn't hit his head.  No, really!  He just scraped his knee.  Well, I don't think he is going to have any issues since he didn't hit his head.  OK, I'll be sure to keep the scrape clean.  Yes, I know he can die from infection.  OK.  No, we're definitely not going to the hospital.  KthanksBYE!"

I just want to die whenever I am not transporting a kid.  Of embarassment.  Because obviously whoever's in charge of me does not think me capable of doing my job.


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## JPINFV (Feb 9, 2011)

In terms of LA med control politics, ambulance service medical directors who also work at base hospitals can provide direct medical control in the field. What I'd love to see is one of the medical directors doing a ride along and immediately countermand a base hospital refusal of an appropriate request followed by a complaint of negligent base hospital oversight. 


For reference, service medical director policy page from LA LEMSA:
http://ems.dhs.lacounty.gov/policies/Ref400/411.pdf


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## thegreypilgrim (Feb 9, 2011)

JPINFV said:


> In terms of LA med control politics, ambulance service medical directors who also work at base hospitals can provide direct medical control in the field. What I'd love to see is one of the medical directors doing a ride along and immediately countermand a base hospital refusal of an appropriate request followed by a complaint of negligent base hospital oversight.


That would be nice. It would probably elicit a rather strong response from the ANA\C and CNA though.


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## JPINFV (Feb 9, 2011)

thegreypilgrim said:


> That would be nice. It would probably elicit a rather strong response from the ANA\C and CNA though.



...and hopefully the LACMA tells them to go pound sand.


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## thegreypilgrim (Feb 9, 2011)

JPINFV said:


> ...and hopefully the LACMA tells them to go pound sand.


You mean the Museum of Art? 

I sincerely hope they would though.


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## DrParasite (Feb 9, 2011)

medicRob said:


> Sometimes if radio contact isn't available, we will use our personal cell phones to call in to the ER and converse that way.


very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very bad idea if you are just calling the ER and asking to speak to the doctor.  the biggest reason to go through dispatch or whomever handles your medical control connections is all your discussions are RECORDED, so when you get sued or have charges filed against you for whatever reason, you have documentation that the doctor said you could or could not do something.  whether it be through cell phone patches or radio patches to the doc, somebody is recording everything you both say.

in NJ (right wrong or indifferent) every ALS patient gets a chat with medical control.  this is done after your initial interventions are completed, all your first line drugs, and usually happens after you are out of the house and on your way to the hospital.  often it's just M+T order since you already gave all your meds, but occasionally the doc will want something else given.  

and paramedics ALWAYS speak to a doctor, an MD, typically an attending or a resident year with an attending looking over their shoulder. 

oh and if the doctor can't be reached, than radio failure protocols are put into place, which let you do a lot more, but typically come with an incident report to medical director as to why you couldn't reach the med control doc.  and your chart WILL get QAed because of it.


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## medicRob (Feb 9, 2011)

DrParasite said:


> very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very very bad idea if you are just calling the ER and asking to speak to the doctor.  the biggest reason to go through dispatch or whomever handles your medical control connections is all your discussions are RECORDED, so when you get sued or have charges filed against you for whatever reason, you have documentation that the doctor said you could or could not do something.  whether it be through cell phone patches or radio patches to the doc, somebody is recording everything you both say.
> 
> in NJ (right wrong or indifferent) every ALS patient gets a chat with medical control.  this is done after your initial interventions are completed, all your first line drugs, and usually happens after you are out of the house and on your way to the hospital.  often it's just M+T order since you already gave all your meds, but occasionally the doc will want something else given.
> 
> ...



We call a personal line established specifically for EMS communications. Also, if my narrative says that I obtained permission from medical control and the physician's narrative states that he gave me permission, there wouldn't be an issue with me calling on his private line regardless.


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## DrParasite (Feb 9, 2011)

medicRob said:


> Also, if my narrative says that I obtained permission from medical control and the physician's narrative states that he gave me permission, there wouldn't be an issue with me calling on his private line regardless.


and what happens when you say you obtained permission to (insert random medication) and the patient has a massive reaction and dies, and the physician says he never said you could?

When everything goes right, no one cares, but A lot of these rules and technologies are for when stuff doesn't go right and now you are making sure your *** is still covered.  or rather, making sure your *** stays both licensed, certified and employed, especially when a lawsuit is filed and you are hoping that you have some way to spread the blame instead of having it all fall on your shoulders.

But again, I'm overly paranoid, and always want to make sure I have my *** covered, especially considering I know people will screw you in order to save their own asses


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## Veneficus (Feb 9, 2011)

I have never been denied any request I have made to medical control. 

In the few times I was not able to reach a doctor in a timely manner, I simply did what I had to do and followed up as per the commnication failure protocols and procedures.

Some states permit the use of a nurse to answer or relay orders during med control communication. I have never worked in such a system and I do not like the idea. 

No matter how much experience or education a nurse has, there is a discrepency between that knowledge and that of a physician. That means that the comfort level and limitations of the middleman comes into play in patient care. 

I am aware of no system where you cannot demand to speak with a physician. Remeber though that the physician's time is very valuable and there are many demands on it, so an EMS provider should have their ducks in order before they call, not use it as a crutch.


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## JPINFV (Feb 9, 2011)

DrParasite said:


> and what happens when you say you obtained permission to (insert random medication) and the patient has a massive reaction and dies, and the physician says he never said you could?
> 
> When everything goes right, no one cares, but A lot of these rules and technologies are for when stuff doesn't go right and now you are making sure your *** is still covered.  or rather, making sure your *** stays both licensed, certified and employed, especially when a lawsuit is filed and you are hoping that you have some way to spread the blame instead of having it all fall on your shoulders.
> 
> But again, I'm overly paranoid, and always want to make sure I have my *** covered, especially considering I know people will screw you in order to save their own asses



...and what happens if the recording system fails or, in some older systems, the RN forgets to put a tape into the machine?

What's stopping the physician from saying, "Well, 123 sign/symptom/component of the history was obvious and should have been relayed, but wasn't. 

What about the fact that many places offer medical control physicians immunity short of gross negligence?


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## DrParasite (Feb 9, 2011)

JPINFV said:


> ...and what happens if the recording system fails or, in some older systems, the RN forgets to put a tape into the machine?


if it happens frequently, fire the RN.  if the system fails, get a new system.  either way, the intent was there, and the system failed.  or put bluntly, it was there, and it was a rarity that the system failed.


JPINFV said:


> What's stopping the physician from saying, "Well, 123 sign/symptom/component of the history was obvious and should have been relayed, but wasn't.


did the physician ask?  if he is unclear, he has a responsibility to ask the paramedic for clarification. and if he doesn't, the tape proves that the physician never asked. Not only that, but it also shows that the paramedic painted a good pictures (if he or she actually did), and the physician wasn't able to get it.  and if the picture was painted incorrectly and important information was not related, then the paramedic is held accountable for his or her error, and the doctor is proven to be not responsible.


JPINFV said:


> What about the fact that many places offer medical control physicians immunity short of gross negligence?


really? what places?  is that a legal precedent, or a hospital policy?  and if a legal standing, can you cite the state and citation, because I would be very interested to see that in writing.


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## zmedic (Feb 9, 2011)

Someone mentioned if you are supposed to call for something and you don't feel like you have time, doing it and asking forgiveness later. I don't know if I agree with that. If it is in the protocols as a call in it means they don't trust the medics enough to use their judgement for that, and you have to call. I have seen people get suspended for that, not calling in when they are supposed to.  

I have mixed feelings about it all, while I want to trust my providers, I get really worried about having someone out there who says "yeah I knew what they rules said, but I am smarter than the person who wrote the rules and don't need to follow them." People come up with all kind of hypotheticals but in practice it is very very rare that there is something that needs to be done that:

1: Is crucial to saving the patient's life
2: Can not wait the 3 minutes it takes to call in and
3: Is not in the standing protocols. 

Knowingly violate my rules when I'm a medical director, and expect to be suspended.


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## JPINFV (Feb 9, 2011)

DrParasite said:


> if it happens frequently, fire the RN.  if the system fails, get a new system.  either way, the intent was there, and the system failed.  or put bluntly, it was there, and it was a rarity that the system failed.


Even if it just happens from time to time, the risk exists that the one time is the time that you need the recording. 



> did the physician ask?  if he is unclear, he has a responsibility to ask the paramedic for clarification. and if he doesn't, the tape proves that the physician never asked. Not only that, but it also shows that the paramedic painted a good pictures (if he or she actually did), and the physician wasn't able to get it.  and if the picture was painted incorrectly and important information was not related, then the paramedic is held accountable for his or her error, and the doctor is proven to be not responsible.


There's a difference between a clarification and believing that you are being provided all relevant information available. Emergency medicine exists in an environment where life altering decisions are made, by necessity, with limited information. The potential is very real that what the physician considers pertinent information the paramedic doesn't. 




> really? what places?  is that a legal precedent, or a hospital policy?  and if a legal standing, can you cite the state and citation, because I would be very interested to see that in writing.


Massachusetts for one...

“…nor shall any physician be liable in a suit for damages as a result of acts or omissions relating to the discharge of duties under [Chapter 111C], including, without limitation, duties as a medical director at the state or regional level, if such acts or omissions were made in good faith.”
http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/physician_liability.pdf

California
"1799.104. (a) No physician or nurse, who in good faith gives emergency instructions to an EMT-II or mobile intensive care paramedic at the scene of an emergency, shall be liable for any civil damages as a result of issuing the instructions. 
(b) No EMT-II or mobile intensive care paramedic rendering care within the scope of his duties who, in good faith and in a nonnegligent manner, follows the instructions of a physician or nurse shall be liable for any civil damages as a result of following such instructions."

http://www.emsa.ca.gov/laws/files/division25.pdf


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## medicRob (Feb 9, 2011)

zmedic said:


> Someone mentioned if you are supposed to call for something and you don't feel like you have time, doing it and asking forgiveness later.



While this is true in *some situations*, this is one of those things that your textbook says to do one thing and EMS providers are doing something else. I urge you to exercise CAUTION doing this. 

Most of the individuals who have spoken of doing this have built a professional rapport with the receiving staff (mainly the receiving physician), and have developed trust in the eyes of those individuals to utilize their critical judgements in the heat of a moment. 

For instance, I could come into a company as a new BSN/Paramedic with all my shiny titles, etc, try this, and get written up or worse fired.. while a medic who has been with the company for 10 years might get a pat on the back and a "Good Job" for doing the exact same thing. The reason being, I haven't shown them that I have sound clinical judgement to make those decisions yet and as such, I could end up in some really bad ju ju even though I have the appropriate training and formal education. 

Just exercise caution with this one, that's all I ask.


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## MrBrown (Feb 9, 2011)

Its interesting that the things restricted to sometimes requiring medical control physician contact include adrenaline and cardioversion .... which Brown goes to thinking hmmm ok we could wait the three to five minutes required to ring up the Doctor, or the patient could die.

Perhaps its not as bad as Brown envisages ....


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## Epi-do (Feb 9, 2011)

We are lucky that our protocols are fairly liberal when I hear what some of you have to call in for.  

I can give up to 150 mcg loading dose of fentanyl and additional doses of 50 mcg every 5 minutes up to a total of 300 mcg.  I am in an urban area with short transports, so that is typically more than enough to get me to the ER, however, I have only been denied additional pain meds once, and that was due to the fact that I got the most conservative doc in the ER when I called in.

We can cardiovert, cric, decompress, start IOs, access PICC lines/Broviacs/Hickmans, externally pace without calling in for orders.  We can also give IM epi for anaphylaxis.  I am sure there are other things I am forgetting about that I have seen mentioned on here as needing to call in & get verbal orders before being able to do it.

We have been told that our protocols are in place for "the dumbest medic you know, at 3:00 am, while half asleep & unable to form a complete thought."  One of the county medical directors states that if it was up to him, our protocols would be a single page stating "do the right thing."  Granted, he is the most liberal of the medical directors in the county, but even the one that I currently work under is certainly one of the more liberal ones in the county.  

If I think my patient will benefit from something outside of my protocols, as long as I paint a good picture, know what I want, and why I want it, I am not typically going to be refused anything I ask for.

When we do call in, most of the time the voice we hear on the other end is that of a nurse, but a lot of times there is still a doc standing by as well.  All we have to do is say we want a doc for XXX and one is on the other end of the radio.  That being said, outside of requesting orders, the only other time we would call in is to alert the receiving facility of a STEMI, CVA, or some other type of critical patient.


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## medicRob (Feb 9, 2011)

Epi-do said:


> We are lucky that our protocols are fairly liberal when I hear what some of you have to call in for.
> 
> I can give up to 150 mcg loading dose of fentanyl and additional doses of 50 mcg every 5 minutes up to a total of 300 mcg.  I am in an urban area with short transports, so that is typically more than enough to get me to the ER, however, I have only been denied additional pain meds once, and that was due to the fact that I got the most conservative doc in the ER when I called in.
> 
> ...



One of the reasons that I am thankful for my title being transport RN as opposed to transport medic when I am on the ground unit is the autonomy afforded me with regard to specific pharmacological interventions.


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## Shishkabob (Feb 9, 2011)

DrParasite said:


> if it happens frequently, fire the RN.  if the system fails, get a new system.  either way, the intent was there, and the system failed.  or put bluntly, it was there, and it was a rarity that the system failed.



The very fact that RNs are giving orders to Paramedics in the field is proof enough that A LOT has failed.



A nurse tries to tell me to do something and I'll laugh... oh wait, that happened just this week, and I did laugh... and the Doc and RT backed me up.


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## JPINFV (Feb 9, 2011)

Yea, but when med control is required to give psych patients versed or morphine to patients with non-traumatic abdominal pain, I'd rather be wasting the RNs time than the physician's time.


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## Shishkabob (Feb 9, 2011)

JPINFV said:


> Yea, but when med control is required to give psych patients versed or morphine to patients with non-traumatic abdominal pain, I'd rather be wasting the RNs time than the physician's time.



Or get rid of the damn system that requires PRN verbal orders for those two in the first place....


I'll waste whoevers time I must in archaic system like that, which harms providers and patients, until they they get so fed up they change it.


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## kbrodie694 (Feb 13, 2011)

Here in Maine we have to call for almost everything and if we are lucky the ER doc knows our protocols and gives us the orders we want.  Other wise we are SOL


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