Medical control

[Veneficus]

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.

 

[JPINFV]

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?

 

[DrParasite]

...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.

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.

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.

 

[zmedic]

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.

 

[JPINFV]

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

 

[medicRob]

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.

 

[MrBrown]

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 ....

 

[Epi-do]

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.

 

[medicRob]

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.

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.

 

[Shishkabob]

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.

 

[JPINFV]

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.

 

[Shishkabob]

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.

 

[kbrodie694]

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