Medical control

[MrBrown]

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

 

[rhan101277]

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.

 

[medicRob]

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).

 

[rhan101277]

"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.

 

[abckidsmom]

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.

 

[Shishkabob]

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.

 

[EMS49393]

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.

 

[mc400]

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.

 

[Aidey]

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.

 

[thegreypilgrim]

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!

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.

 

[NomadicMedic]

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.

 

[rhan101277]

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.

 

[abckidsmom]

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.

 

[JPINFV]

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

 

[thegreypilgrim]

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.

 

[JPINFV]

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.

 

[thegreypilgrim]

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

You mean the Museum of Art?

I sincerely hope they would though.

 

[DrParasite]

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.

 

[medicRob]

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.

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.

 

[DrParasite]

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