Pre-Hospital physicians

[NysEms2117]

Just curious to see if you guys have any questions on the topic. I would also like to hear your input/critiques ect. new or experienced. This is something that has just lifted off where i work, I've used it 2 times and have a relatively in depth understanding of how it's supposed to work.
http://www.amc.edu/Academic/EMS/
http://www.timesunion.com/local/art...-partnership-will-put-doctors-at-10932310.php

 

[VentMonkey]

Cool beans, Pittsburgh EMS has been doing something similar for a bit as well, TMK:

http://pittsburghpa.gov/ems/ambulance_division.htm

 

[agregularguy]

Maryland has something similar as well, but goes further to include both the doc and a CRNA.
http://umm.edu/programs/shock-trauma/professionals/ems/go-team

 

[VentMonkey]

I'd be curious to know how frequently they're actually being utilized. It's kind of neat to see these programs. I kind of wish it was more the norm.

I wouldn't mind working in a system like London where the flight teams are composed of a physician, and a paramedic.

 

[NysEms2117]

I can tell you from my use, 1 time we used a physician(who i may be getting to join on this forum lol) was during a terrible terrible MVA. 5+ critical patients, our CC rig dispatched as well as the CCRN rig from the hospital. Physicians along with my CC-P partner took care of intubations/ highly advanced skills(as i call them). Since this was the opening month there really weren't any protocols set in stone, so he just acted as a ER doc, but outside the ER. It was super useful for a larger incident(not a MCI because we had enough resources at the city&county level) because the doctor can "oversee" multiple patients at once, opening up medics to focus on 1 patient.

The other time we used the physician from the hospital was on a series of unknown medical calls that came in from the same place. 5+ calls reporting same symptoms ect, so that was a large large call.

 

[VentMonkey]

Right, but aside from MCI-type events/ calls I would like to see a service roll them out in a manner similar to certain areas of the U.K.

 

[NysEms2117]

Right, but aside from MCI-type events/ calls I would like to see a service roll them out in a manner similar to certain areas of the U.K.

understood. no doctors on whirlybirds here

 

[Tigger]

My medical director responds to calls from home. He doesn't take any sort of lead position (though he could), he just comes and helps out as needed and will also provide on scene medical direction if appropriate (need many doses of ketamine? He's the guy). We can also call him 24/4 to respond but he doesn't really bring much with him. He will if he's at the hospital or arrange for another physician to respond if appropriate. We don't have a relationship with the trauma service though, so I am not sure if any pre-hospital surgical procedures are feasible.

I think it really comes down to our doc being a paramedic (he still keeps his NR) and wanting to occasionally be on some legit sounding calls.

 

[SpecialK]

Auckland HEMS has a Doc/ICP and can respond by road/air, and AFAIK all medical helos in AU have a Doc/ICP too.

The question is not if you should do it, but why shouldn't it be done, or if appropriate, why is it NOT being done?

Of course not for the majority, but a Doc can do a bunch of stuff over and above what an ICP can do; totally and completely discretionary general anaesthesia, blood, ultrasound, nerve blocks, wound closure/suturing, some do chest drains, a much-expanded range of drugs, and let's not forget even if they don't do anything particularly in terms of a skill, what skills they do have they are using lots in the hospital, and see many more patients who are quite sick a lot more frequently. The average ambulance officer sees about 1-2 major trauma patients a week; the average ED doc sees about 1 a week.

Love having a doc, wish we'd done it years ago.

 

[Carlos Danger]

In the late '90's ECMC in Buffalo had a physician field response program with their own QRV. At the time they weren't very active in terms of actually responding, and I have no idea what the status of that program is now. One of the HEMS programs I flew with had a medical director who would occasionally respond to scenes to help out if he happened to be in the area of the call

 

[E tank]

Maryland has something similar as well, but goes further to include both the doc and a CRNA.
http://umm.edu/programs/shock-trauma/professionals/ems/go-team

Pretty progressive....big diff between an anesthesiologist, a surgeon and a CC specialist. Wonder how they decide who goes. I'd think if only one doctor goes, the surgeon would bring the most to the table.

 

[NysEms2117]

Pretty progressive....big diff between an anesthesiologist, a surgeon and a CC specialist. Wonder how they decide who goes. I'd think if only one doctor goes, the surgeon would bring the most to the table.

Here in albany its only a ER physician going out. No surgeons or CRNA's.
@Remi this all started from one physician in albany getting his EMT cert for shts and giggles because he had a bunch of patients that came in wrong from the same service. So he decided to go and try and constructively fix the problem in a way that didn't involve people getting fired/ reamed in e-mail. Then he wen't on a really bad trauma call, knew what to do, but ended up being tied in a legal knot. So he asked if he can do EMS if needed as a Physician, a few others jumped on the train and now its a legit program

 

[NomadicMedic]

Great idea, but I don't see a service like this being very active. These services usually start with one guy who has a real interest in EMS. when he retires or goes on vacation, there's suddenly no Doc. The other big question, who funds it? What does the doc do when he's not jumping calls in his QRV? If he's seeing patients in the ED, who fills his spot when he goes out to a wreck?

As an aside, The Maryland Go Team isn't particularly active, but they have enough staff at Shock Trauma that they can scramble up a crew and put them in an MSP airship pretty quickly. That's probably a better model than a doc in an SUV going to calls when he happens to be close it it sounds good.

I can't say I'm in love with this unless you need a surgical intervention in the field, like an amputation to free an entrapped patient.

 

[E tank]

Here in albany its only a ER physician going out. No surgeons or CRNA's.
@Remi this all started from one physician in albany getting his EMT cert for shts and giggles because he had a bunch of patients that came in wrong from the same service. So he decided to go and try and constructively fix the problem in a way that didn't involve people getting fired/ reamed in e-mail. Then he wen't on a really bad trauma call, knew what to do, but ended up being tied in a legal knot. So he asked if he can do EMS if needed as a Physician, a few others jumped on the train and now its a legit program

Yeah...I think that makes more sense, considering the practical realities of what can and can't actually be done on scene. Shock/Trauma has always been sort of "larger than life" in the scope they take on and their (hubris) stated mission. A lines and CVP in the field? Whatever...

If it sounds like I'm criticizing, I'm not. That sounds like a really cool idea, but a little overkill, maybe? ER doc ought to be plenty with on scene hands. My opinion only...

 

[NysEms2117]

Yeah...I think that makes more sense, considering the practical realities of what can and can't actually be done on scene. Shock/Trauma has always been sort of "larger than life" in the scope they take on and their (hubris) stated mission. A lines and CVP in the field? Whatever...

If it sounds like I'm criticizing, I'm not. That sounds like a really cool idea, but a little overkill, maybe? ER doc ought to be plenty with on scene hands. My opinion only...

True the part that is super useful is the "monitoring part" because CC-p's can leave with critical patients while the doctor monitors multiple others.
And nomadic they volunteer their time I believe. It's very useful in certain rare situations. Otherwise it's not necessarily the most useful thing.

And an aside at Albany med they have multiple doctors in the er, since all doctors are on board with the program they agreed to pick up the slack, while they are gone. It's not the fact that medics can't do the skills it's just doctors have more practice/ are more experienced for the most part. I would also argue more efficient too.


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[VentMonkey]

Great idea, but I don't see a service like this being very active. These services usually start with one guy who has a real interest in EMS. when he retires or goes on vacation, there's suddenly no Doc. The other big question, who funds it? What does the doc do when he's not jumping calls in his QRV? If he's seeing patients in the ED, who fills his spot when he goes out to a wreck?

All valid points. I still think it would be a decent learning opportunity for EM residents as such, perhaps 3rd and 4th years tied to their university and/ or level 1 or 2.

Is it realistic? I doubt it, but it would be a bit more of an involved and encompassing approach to learning prehospital EM for any EM physician to be.

Doing ride-a-longs here and there is one thing, being a bit more acclimated to the challenges we face could (potentially) be a bridge in a gap to the frequent "misunderstandings" between prehospital folks and ED folks. It may even perhaps encourage the future generations of EM physicians of deficiencies we face in this country, which in turn, may give us both backing power by way of first-hand physician accounts, and solidify our legitimacy at the healthcare table.

As far as what they do in between calls, perhaps just deploy as needed within a certain radius of the hospital depending on acuity of the call(s).

...just think out loud here.

 

[Carlos Danger]

We also had EM residents with us on the helicopter every Thurs. Some were good and helpful; most were not.

 

[NysEms2117]

We also had EM residents with us on the helicopter every Thurs. Some were good and helpful; most were not.

As somebody that doesn't know.. whats the difference between a resident and a doctor? i know doctors have to do residencies and what not. Is that equivalent to an FTO period, but longer? my google-fu gave me a ridiculous timeframe "residencies range from 2-9 years".

 

[VentMonkey]

As somebody that doesn't know.. whats the difference between a resident and a doctor? i know doctors have to do residencies and what not. Is that equivalent to an FTO period, but longer? my google-fu gave me a ridiculous timeframe "residencies range from 2-9 years".

Essentially yes, the length of their residencey typically depends on their chosen specialty.

We also had EM residents with us on the helicopter every Thurs. Some were good and helpful; most were not.

So for the sake of dialogue, what exactly was it that made them a nuisance? Was it their ego, their lack of fundamental understanding of the out-of-hospital environment? Was it both? Were these 3rd and 4th year residents?

I'm not disputing, I'm genuinely curious.

 

[Carlos Danger]

So for the sake of dialogue, what exactly was it that made them a nuisance? Was it their ego, their lack of fundamental understanding of the out-of-hospital environment? Was it both? Were these 3rd and 4th year residents?

I'm not disputing, I'm genuinely curious.

IIRC they were all 3rd years and it was an elective rotation for them.

I've always enjoyed teaching, especially people who I knew I could also learn a lot from. So I usually enjoyed having them.

Bu you know how it is having riders on the helicopter; it's a PITA. Very different than having a rider on an ambulance, because you really have to babysit them. There were plenty of days I just didn't want to deal with it.