# King County and Medical Direction



## Ginger Medic (Jul 28, 2015)

I've been scouring the internet for a few weeks looking up all the information I can find about King County Medic 1. It looks like a great place to work, however one thing that came up was the topic of Medical Direction. In their recruitment video (I can't post a link as this is my first post on this forum), one of the medics mentions that they "talk directly with the doc" and "make their case" then perform their treatment. I've seen several people post that the Seattle Medic One group must OK all treatment with a physician before performing it, including IV's unless the patient is unstable and delaying care would cause death. I have not been able to find any information on their site, nor have I found definitive information from any of the numerous forum boards I looked at in regards to medical direction throughout the rest of King County. 

I decided to post this in the hopes that someone here actually works for Medic One and can give me more information. Are you required to contact online medical control on every patient prior to treatment? 

Thank-you for any information!


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## NomadicMedic (Jul 28, 2015)

I don't work there, but am very familiar with the system. 

Yes, the medics make a med control contact with a doc for everything, present a treatment plan, the doc on the radio or phone confirms what the medic said and approves or denies the treatment. 

At Harborview, there is a designated "medic One doc" and a designated "trauma doc" (two separate talk groups on the radio) for consults and orders. 

Most of what the medics do is simple, basic ALS (diabetics, Chest pain, etc) and the med control contact is just pro forma. I've seen many instances where the treatment was complete before the medic called to "ask".


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## RocketMedic (Jul 28, 2015)

I find this to be extra-funny- they don't even have autonomy within standing orders? ROFL @ KCM1.


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## NomadicMedic (Jul 28, 2015)

RocketMedic said:


> I find this to be extra-funny- they don't even have autonomy within standing orders? ROFL @ KCM1.



Well, they do have some standing orders, they use "Plans" to serve as standing orders for immediate life threatinging conditions, but no real protocols, just a standard of care. If you want to treat a patient with chest pain with ASA, NTG and Morphine, you call and present and say, 'hey, this is what I want to do. " The doc usually agrees  ... but they still have to consult with a doc.

Here's a good example of how it works, from the Harborview perspective.
https://depts.washington.edu/pmedic/sites/default/files/ATLS-SFD Talk.ppt


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## Ginger Medic (Jul 28, 2015)

Helpful presentation, thanks! While I'd love the seemingly extra knowledge they have, I don't know that I can get past having to call a doc for permission to do what I'm trained to do.


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## Summit (Jul 28, 2015)

Why do some here perceive it as a lower levelofautonomy to come up with a plan and present it versus following a script?


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## Ginger Medic (Jul 28, 2015)

Summit said:


> Why do some here perceive it as a lower levelofautonomy to come up with a plan and present it versus following a script?



In my system I don't follow a script. I have a tool box, and it's at my discretion how I use my tools. The few things that I have to make base contact for are reasonable as they are extremely rare occurrence (Ca++ for hyperkalemia). On nearly every patient, I assess, plan and treat without any outside input until I call the hospital to tell them what I've done, and I'm held accountable for how I've treated my patient.


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## RocketMedic (Jul 28, 2015)

Ginger Medic said:


> In my system I don't follow a script. I have a tool box, and it's at my discretion how I use my tools. The few things that I have to make base contact for are reasonable as they are extremely rare occurrence (Ca++ for hyperkalemia). On nearly every patient, I assess, plan and treat without any outside input until I call the hospital to tell them what I've done, and I'm held accountable for how I've treated my patient.



This^. Yes, I have protocols, but it is my responsibility and perrogative to implement them.


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## NomadicMedic (Jul 28, 2015)

Not saying its bad or good... it's how they do it, and it works for them. If you want to work in King County, you call the doc. 

You get used to it.


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## Tigger (Jul 28, 2015)

Somewhat related: Do all the Medic One programs operate the same way as KCM1? I didn't realize there was more than the one until today, and that Seattle runs its own.


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## Carlos Danger (Jul 28, 2015)

I wouldn't want to have to call an MD for every patient contact. That just seems like a silly, unnecessary PITA and waste of time. I am actually surprised that any large, busy urban system does that. 

But that issue really has nothing to do with autonomy. The existence or absence of autonomy is not dependent on the number of times "call for medical direction" appears in your protocol book.


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## NomadicMedic (Jul 28, 2015)

Tigger said:


> Somewhat related: Do all the Medic One programs operate the same way as KCM1? I didn't realize there was more than the one until today, and that Seattle runs its own.



"Medic One" is the brand name for paramedics in Weatern Washington. Not all the Medic One services are affiliated with the Medic One foundation or with Harborview, but every paramedic in King County works for a Medic One service and MUST attend Harborview. King County Medic One is NOT Seattle, it's the service that provides ALS to south King County and is the only M1 service in KC thats not fire based. (Although the medics are IAFF members and are based in fire stations)


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## Tigger (Jul 28, 2015)

DEmedic said:


> "medic One" is the brand name for paramedics in Weatern Washibgton.


And all of them go through Harborview's program and have that "interesting" scope of practice this oft-talked about here? I see they are all fire-based but are any also firefighters?


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## NomadicMedic (Jul 28, 2015)

See the reply above.


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## NomadicMedic (Jul 28, 2015)

For instance, Mason County Medic One isn't a county agency, it's a private, operated by Olympic Ambulance and the medics can be educated anywhere.


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## Madclown (Jul 29, 2015)

Not trying to take over this thread, but I was hoping someone here could tell me what the starting pay is for an EMT-B at Tri-Med?

I have an interview with them and I can't get an answer. I know it will be a lower pay, but I was told Tri-Med was an excellent service to start out as an EMT.


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## Scott33 (Jul 29, 2015)

DEmedic said:


> If you want to treat a patient with chest pain with ASA, NTG and Morphine, you call and present and say, 'hey, this is what I want to do. " The doc usually agrees  ... but they still have to consult with a doc.



So in all actuality, KCM1 is probably one of the least progressive systems out there.


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## Aprz (Jul 29, 2015)

How is online medical direction any less progressive than offline medical direction? It is just a different way for the doctor to communicate their orders. The doctor will actually be involved in the call. The paramedics probably have an excellent rapport with the doctors. Looks like an implementation of crew resource management to make sure the paramedic's plan is sane.


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## epipusher (Jul 29, 2015)

Aprz said:


> How is online medical direction any less progressive than offline medical direction? It is just a different way for the doctor to communicate their orders. The doctor will actually be involved in the call. The paramedics probably have an excellent rapport with the doctors. Looks like an implementation of crew resource management to make sure the paramedic's plan is sane.



Tl;dr, they need permission


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## Aprz (Jul 29, 2015)

epipusher said:


> Tl;dr, they need permission


You need permission either way. One is just prewritten and the other is not.


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## Carlos Danger (Jul 29, 2015)

Scott33 said:


> So in all actuality, KCM1 is probably one of the least progressive systems out there.



I guess it depends on how you define "progressive".

If by "progressive", you mean a system with protocols that allow the paramedics to do "lots of cool stuff" and never requires OLMC, then yeah, I guess KCM1 isn't progressive.  But, if by "progressive", you mean a system that is focused on implementing evidence-based protocols in order to actually improve patient outcomes, then it sounds like KCM1 is probably one of the better ones out there.

Some systems are actually experimenting with tele-consultation with iPads and such. I suppose by your metric, those would be the _least_ progressive systems?

Protocols should be patient-centered, not paramedic-centered. They exist to help the patient, not the paramedic's ego.



Aprz said:


> You need permission either way. One is just prewritten and the other is not.



Exactly.

Not having to ever call for orders is not the same thing as having autonomy. It simply means you've been _given permission_ to not have to call for orders. That permission can be revoked at any time, and you are still have to stay inside the box that someone else draws for you.


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## Aprz (Jul 29, 2015)

Thris thread somewhat reminds me of this article.

Culture of Silence

The article was more about negative feedback, but it is really true for getting any type of feedback I feel like.

We talked about this article in another thread here.


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## Scott33 (Jul 29, 2015)

Remi said:


> If by "progressive", you mean a system with protocols that allow the paramedics to do "lots of cool stuff" and never requires OLMC, then yeah, I guess KCM1 isn't progressive.



At what point did I say that? I am in my mid 40's, and left the "lots of cool stuff" behind years ago when I became an RN.



> Some systems are actually experimenting with tele-consultation with iPads and such. I suppose by your metric, those would be the _least_ progressive systems?



You are probably going to be disheartened when I tell you that my own system's community paramedics have been using teleconferencing for about 2 years now. Treat and release / treat and refer teleconferencing is a world away from asking a doctor's permission to take a BGL or drop a line in the field. Do KCM1 happen to have a CP component?



> Protocols should be patient-centered, not paramedic-centered. They exist to help the patient, not the paramedic's ego.



How about catching up with the rest of the world and binning protocols in favor of clinical guidelines with a reasonable amount of wiggle room?These 'mother may I' systems (and I am not specifically talking about KCM1) suggest one of two things to me - lack of trust in the provider, or lack of ability of the provider.


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## Carlos Danger (Jul 29, 2015)

Scott33 said:


> At what point did I say that? I am in my mid 40's, and left the "lots of cool stuff" behind years ago when I became an RN.



You implied it when you equated calling for OLMC with being "the least progressive".

I agree that calling OLMC on every call sounds onerous and unnecessary. But it has little to do with how progressive a system is.


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## RocketMedic (Jul 30, 2015)

I disagree- it is an outstanding measure of how progressive a system is. How many of those contacts result in treatments exceeding what is conventionally found in standing orders, as opposed to how many treatments that would be appropriate and authorized under standing orders are deferred by physician preference?

I think the best place to evaluate progression in any system is pain management and field treatment of sentinel findings- ie ABX in the context of suspected sepsis, dysrhythMia correction, etc.


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## waaaemt (Aug 1, 2015)

Tigger said:


> And all of them go through Harborview's program and have that "interesting" scope of practice this oft-talked about here? I see they are all fire-based but are any also firefighters?



Many non King County fire dept medic units have MEDIC ONE  branded on them.  I believe they buy into/receive grants from  the foundation or something. Or just uae it cause it sounds cool? Idk.  But you do not need to be King County/UW/Harborview trained.  There are multiple Pierce County FDs,  Thurston County Medic One (hard core ALS dumpers I've been told ) 
Central Skagit Medic One (sounds like an amazing place to work) etc. For Thurston the medics i think are provided  by city and  county fire depts,  are FFs,  and just work on a medic one rig. 

Also Seattle Fire Medic One medics are FFs promoted internally after at least 3 years on the job.


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