Pre-Hospital physicians

@Remi what's your spin on having them in fly cars similar to the UK with a paramedic assistant/ driver/ attendant?

VentMonkey said:

@Remi what's your spin on having them in fly cars similar to the UK with a paramedic assistant/ driver/ attendant?

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I don't know. On one hand it seems intuitively like it'd be a great thing, but OTOH, I can't think of too much that most EM docs are going to realistically be able to do in the field that a well-trained RN-EMTP crew can't do. Maybe if you are cracking chests and deploying ECMO on the street corners, but those things will always be really rare prehospital interventions, I think.

Edit: there has been some research in Europe showing improved outcomes when patients are intubated in the field by physicians vs non-physicians, but I don't think the differences were vast and I'm not sure how that translates to the bigger picture, especially across the pond in the US.

I think having a "go team" type resource for MCI's and unusual situations (field amputations) is probably a good thing. But beyond that I'm not too convinced that docs in the field are a necessity.

Remi said:

I don't know. On one hand it seems intuitively like it'd be a great thing, but OTOH, I can't think of too much that most EM docs are going to realistically be able to do in the field that a well-trained RN-EMTP crew can't do. Maybe if you are cracking chests and deploying ECMO on the street corners, but those things will always be really rare prehospital interventions, I think.

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My old CCT ground nurse is from across the pond, and is notorious for going on and on about European prehospital medicine, with examples such as the ones you've listed (e.g., "Princess Di").

I do find it fascinating how it does seem quite the opposite and wonder how these European models who embrace this approach fair in regards to patient outcomes. Maybe @EpiEMS has some stats he can dig up, or share.

Our medical director pops up from time to time and just helps out with simple stuff, but otherwise we don't do anything with docs on scene. The exception would be the previously mentioned field amputation. Or the one time a doc from an outpatient surgery center rode with us and her patient. Outside of that, I can't think of a reason I would call a doc to me when I could get them to a fully staffed hospital in less time. For really big stuff I could see it being nice to have something formally established though.

"cracking" chests is becoming more and more uncommon, because the risk is far out weighing the benefit, even for training purposes. Odds of survival having that done is next to zero and risk of provider injury and infectious disease transmission (sharp, broken ribs) is just too high.

E tank said:

"cracking" chests is becoming more and more uncommon, because the risk is far out weighing the benefit, even for training purposes. Odds of survival having that done is next to zero and risk of provider injury and infectious disease transmission (sharp, broken ribs) is just too high.

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I don't doubt this, and again, TMK, and the last time I got to talk with one of our trauma attendings, he all but summed it up to it being a very selective patient (single stab wound with the high index of tamponade suspicion) demographic being able to be successfully resuscitated from such a high-risk procedure.

@E tank feel free to elaborate further for us.

VentMonkey said:

I do find it fascinating how it does seem quite the opposite and wonder how these European models who embrace this approach fair in regards to patient outcomes. Maybe @EpiEMS has some stats he can dig up, or share.

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I love this question - I think it speaks to two major issues, one being cost, and the second being the efficacy of higher levels of field treatment. Cost, well, of course, if we could have an EM residency trained physician responding in every ambulance, I'm sure that'd be great. But we have no solid evidence that I am aware of that it would benefit survival for the bulk of patients.

I found several review articles (Bottinger, et al. 2016 which addresses physicians vs. non-physican treatment of out of hospital cardiac arrest, Botker et al., 2009, and a couple others like Ryyanen et al. 2010). The broad consensus is that physician response improves outcomes. But, of course, there are some caveats. I don't know what the (a) scope of practice differences between paramedics as I know them and paramedics in the studies are an issue (especially in older, European, and Japanese studies, (b) impact of differences between scope of physicians and paramedic personnel that could be bridged by expanding paramedic scope (e.g. RSI, as in Pakkanen et. al. 2016 - which, notably, describes very well the scope differences between paramedics and physicians in the Finnish EMS system), and (c) the incremental cost of physician response is. Obviously, physician responses are not cheaper than paramedic responses - so we should be very careful about studying costs and benefits as part of implementation/trials. Give me an RCT with a couple of thousands of patients, then I can give you something conclusive .

And frankly, based on the OPALS studies (trauma, respiratory, cardiac arrest) and several other large trials of ALS implementation (plus the very cool observational Sanghavi et al. 2015 - plus Sanghavi et al. 2015 on cardiac arrest), I am hesitant to suggest that there is evidence that ALS is beneficial (at the population level) for most categories of EMS patients* (and, indeed, most patients seen by EMS providers). However, I am unaware of evidence of the same quality for or against physician-provided ALS (as contrasted to paramedic-provided ALS). Given how the physical space of a scene call or an ambulance would restrict a physician's ability to provide physician-level care (i.e. there is a profound lack of diagnostic equipment, and there certainly isn't the number of staff that a resuscitation room has), I would be thoroughly surprised if - for most patients that need ALS treatment - a physician's presence really truly in an RCT would show better outcomes (assuming a reasonably competent and sufficiently-scope of practice enabled paramedic population).

*I believe that, based on the evidence I've seen, ALS is probably beneficial for chest pain and respiratory distress patients. Anecdotally, I love having ALS around for pain management, better assessments, etc., but there is no evidence that I am aware of that we can show *macro-level* better outcomes with ALS except for the two categories of patients I've mentioned. What we need, obviously, is more research.

Just to add: The Japanese studies (for example, this one) are particularly troubling to me because of the scope of practice of their non-physician EMS providers (I hesitate to call them paramedics, because the level of practice is somewhere around EMT-I '85 plus IV epinephrine) is so much lower than in the rest of the developed world, as far as I am aware.

Also, we really need to decide on what outcome we care most about. I can tell you this: I don't really care about ROSC. You could have 50% ROSC, but if you've got 5% neurologically intact survival, that's just not very good.

http://www.remo-ems.com/images/uploads/pdfs/FINAL_2017_Collaborative_Protocols_012717_(1).pdf
This set of protocols contains physician level for EMS.
this is aimed at Higher level practitioners like @VentMonkey @Remi @E tank. Would putting them on responses with a Critical Care rig on scene help at all. The doctors still have fly cars and what not, but the CCT rig is also on scene to get some additional benefits. **aiming at the fact that some CCU's/CCT rigs have things like ultrasound, cric sets, advanced vent's ect.** Granted the gear all depends if your a CCU CCT MICU ect.
I just haven't been in the "advanced" world of medicine long enough to know all the different scenario's those specialty pieces of equipment will actually successfully help.

@NysEms2117 thanks for the kind words bud, but Remi and Tank are CRNA's. That's a completely different level (see: upgrade) from just about any CCP that I am aware of. Their education, and clinical knowledge far supercedes mine. In other words, they're the guys on here, and in person, guys like me pester.

With that, I would absolutely love to staff a QRV with either another CCP, or even (preferably) solo, carry my advanced formulary, and scope/ tools with me such as my trusty vent. For me, unfortunately, that's more of a pipe dream than a reality.

Even if I'm not always strong on affability, I've always strived to be the voice of calm, or reason on scene. I pride myself on being able to emulate that medic and as such, lead more than monkey skills these days. Orchestrating a catastrophe is often hard to do without respect.

The person that other medics say "oh thank goodness it's so, and so" is the epitome of not only the highest level of paramedic in the field, but the ones others look to for professional advice be it by asking, or watching. Helicopter or not, that's my chosen profession.

E tank said:

"cracking" chests is becoming more and more uncommon, because the risk is far out weighing the benefit, even for training purposes. Odds of survival having that done is next to zero and risk of provider injury and infectious disease transmission (sharp, broken ribs) is just too high.

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Don't be such a #ResusWanker

Gurby said:

Don't be such a #ResusWanker

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Think that was a different kind of getting crucified ......RIP John Hinds

I think the biggest hurdle with pre-hospital physicians is that, even if they do show improved outcomes (which isn't terribly hard to believe, even given the limited equipment, though I only got to skim EpiEMS's studies), is that you can't realistically put enough docs on the street to have a real effect on outcomes without emptying the emergency department (and bankrupting your city's EMS budget). So its really about trying to find the sort of patients who would most benefit from a physician on scene AND making sure you could identify that patient and get a doc there in less time then it would take for EMS to just transport to the ED. I guess the semi-obvious answer is to put them in a helicopter, but as some people mentioned, the docs in helicopters tend to be residents doing a quick rotation, so by the time they get the hang of everything they end up rotating back to the ED.

It would be cool to try and do some research on the subject, though I don't know if any of the emergency medicine residencies with affiliated flight programs have ever done studies on it.

rescue1 said:

So its really about trying to find the sort of patients who would most benefit from a physician on scene AND making sure you could identify that patient and get a doc there in less time then it would take for EMS to just transport to the ED. I guess the semi-obvious answer is to put them in a helicopter,

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i agree for the most part, but im curious as to how putting them on a helicopter would have any effect on a city. I know where I am (albany NY) helicopters don't fly in the cities because it's utterly useless. I get if your flying 300 miles to the middle of the woods sure, but not the city. I personally think the answer is what albany is doing right now. Have the physicians have their own fly cars if need be. Get all ER doctors to agree that: hey this is something we can try, so that way if their time to shine does come out and one doc has to leave the other ones aren't annoyed and what not at the other for leaving. The doctors also have discretion as to going out into the field or not. It's not like a paramedic being dispatched where it's an obligation to go. The paramedic calls the hospital says we need a doc and here is why. In the time that we needed to use a doctor I actually called. I got the nurse, said i need a doctor now, she put one on. I said "we have this giant MVA out here tons of critical patients, we need you for xyz reason", within 2 minutes he was en-route. I think the parts that really makes this whole program is 1: all the docs agreed to do it. 2: It's discretionary on their end, the physician i talked to could have very well said "your on a critical care rig, your CC-P could handle it", given on line MO's and that was that. Could we have.... probably. Same end result, i'd be willing to bet the barn no.

@ERDoc I'd love to hear you weigh in!!!
---For the record i am not bashing you, just stating an opposing statement, i fully understand and agree mostly where you are coming from

I guess I don't really see how a physician helps in MCIs besides being able to "treat and release" large numbers of non-critical patients without burdening the system. The ability to perform advanced skills during an MCI is not really what matters and I can't imagine an MCI in which non-paramedic skills were somehow beneficial. Now if there's a tech rescue incident within an incident that requires surgical extrication, that might be different.

Gurby said:

Don't be such a #ResusWanker

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Short video on a similar subject. Some impressive stuff surrounding this.

So for big MCIs like you describe I agree, there are lots of patients and you can't transport them all rapidly, so it makes sense to bring the doc to you. Those happen pretty rarely though, and while its good to practice for them and be prepared when they happen (both on EMS and on the physician's end), I don't think setting up a whole pre-hospital physician system just for the handful of MCIs that are run a year is a good use of resources. But giving them access to a fly car in the ED (or having a city rig pick them up)? Yeah, absolutely. Where I worked in PA, you could get a doctor from somewhere (whether a county medical director or someone who'd get picked up at the ED by another ambulance) if you really needed it for a field amputation or a big MCI, but there was no official system in place for it.

But if you're going to go whole hog into having pre-hospital physicians integrated into your system, that is, emergency physicians who spend a reasonable amount of time outside the ED, I think you need to have a way of deploying them where they're best needed for "routine" emergencies as well, not just the holy **** MCI/amputation/emergency c-section ones. Because by the time you get on scene, and say "wow, this patient is way over my head", call a doc, get the doc there, and have him or her do their thing, you probably could have just met the physician at the hospital. So you need a way to rapidly get a doctor there too, if needed. London uses both helicopters and fly cars to make it work, over here I imagine it would really depend on the area. Here in NYC helicopters would be useless, but I used to date a girl who lived in Albany, and it can get rural pretty quickly once you leave Albany/Troy, especially on the east side of the Hudson. But yeah, helos would be pretty useless in the city itself.

All of this is also assuming that having a doctor on scene is worth the hassle of setting all this up. I think there are patients who would benefit, but its about identifying who those patients are.

I should add the disclaimer that I really want pre-hospital physicians to be a thing that works out, since I left EMS to go to medical school and to do emergency medicine and medical direction/EMS education. But if I do pre-hospital stuff I want it to be because it benefits patients, not because prehospital doctors are cool. But either way, selfishly I'm glad to see the push to put physicians in the field.

Houston Fire has a medical director who responds to calls when he feels like it. Dude carries a belt-pouch crike kit and such. Really cool, but overall, I think that it is a fairly inefficient use of a very rare resource. IMO, if you need that degree of field oversight, it is better to have a telecommunications link to a physician and paramedics you trust as opposed to burning precious time in traffic.

There are several EMS physicians the routinely respond to calls in NJ. They serve as medical directors of the ALS agencies, and sometimes want to get out of the office and play.

Those places I know who have a doc all have the following:

- They are all Sr Reg or Consultant from ED, ICU or anaesthesia
- They all do it routinely (either permanently regular part-time, or full-time)
- They work with dedicated ICPs who are full time with the team (usually a helo)
- They only go to specific types of jobs and have an experienced ICP from their team in Control screening jobs to decide it
- They do it lots
- They practice lots when not doing it for real

Sure, you can put a doc in a car but that doesn't mean you're doing it properly.