Shands Base Station Course

1. EMS Shands Base Station Course Christine Van Dillen MD 

2. EMS Base Station and On-line Medical ControlObjectives • Highlight the ACFR EMS system • Review the roles and responsibilities of a base station/on-line medical control physician • Discuss some medicolegal considerations of providing on-line medical control • Review the pertinent medical literature • Review prehospital scenarios, system protocols and on-line medical control interactions

3. Opening Comments • You are all great physicians and fully qualified to provide on-line medical control • I am not telling you how to practice medicine • I am merely sharing our knowledge, experience and understanding of the pertinent issues

4. Alachua County EMS System

5. Alachua County 5

6. Map of surrounding counties 6

7. Alachua County 7

8. ACFR • 30,704 calls in 2010 • 20,200 transports in 2010 • 243,574 population of Alachua county 8

9. Medical oversight Direct medical control Indirect medical control

10. 10

11. Direct Medical Control On-Scene On-Line

12. Associate hospital Base hospital Base hospital Base hospital Resource hospital EMS Boyd D et al: Medical Control and accountability of EMS systems, IEEE Transactions on Vehicular Technology VT-28(4):249-262, 1979 Satellite Control Model

13. Base Station Configurations Single EMS communication center (NYC)

14. Base Hospital Centralized Control Model ACFR System Model Boyd D et al: Medical Control and accountability of EMS systems, IEEE Transactions on Vehicular Technology VT-28(4):249-262, 1979

15. Key Communication Terms • PSAP - Public Safety Answering Point • EMD - Emergency Medical Dispatcher - A trained public safety telecommunication person with additional training and specific emergency medical knowledge essential for the efficient management of emergency medical communications

16. Medical Priority Dispatching

17. Key Communication Terms • Jargon • “Land line” = phone line communication • “ETA” = Estimated time of arrival • “Stand-by” = wait - do not transmit until recontacted • “Over” = statement finished ready for response • “Check” / “roger” / “copy” = acknowleged • Call sign = “Dr. Your Last Name” Local practice = standard english language

18. Communications Links • EMT / Paramedic to medical control • Patient report from field to hospital • Standard Hybrid 800 MHz system (ACFR) • Traditional UHF “Med” radio system • Other acceptable methods (via recorded line) • Cellular phones (we will be radio to nextel cell phone) • Phone lines • Sending Data via radio / cell phone • Medical Data Transmission (MDT) • Next wave of technology - visual medical data

19. Paramedic to PhysicianCommunications • No national standard exists for patient radio reports • No universal physician agreement on format • Key is to be brief and concise • Each system sets standards of: • Format • Methods (radio, cell phone, data transmission, bedside, etc.)

20. EMT-P to Physician Communications • Suggested format (tailored to patient) • Agency, unit designation, paramedic number • Call classification, “Calling for”: • Refusal, medical orders, consultation, code termination • Level of consciousness - Patient's age, sex, weight • Chief complaint and focused, brief HPI • Vital signs • Focused P.E. • Treatment provided, and treatment requested

21. Alachua County EMS Physician component Christine Van Dillen -Medical Director Amit Rawal and Evan Stern-Assistant Medical Directors

22. Responsibilities On-line Medical Control • Direct voice orders to EMS personnel in the field based on the EMT/paramedic’s assessment • Authorize MC options • System Medical Direction • Develop medically correct standing orders (protocols) • Regular protocol updates • QA/CQI • Education and training • EMS CME

23. Medical Practice Act • State legislation defines scope and role of EMS personnel • Local modifications authorized by medical oversight physician or board • Usually based on Department of Transportation (DOT) National Standard Curricula for each EMT level

24. On-Line Medical Control • Respondent superior- an individual supervising a borrowed servant is ultimately liable for the acts and omissions of the borrowed servant while that individual remains under his supervision

25. Medical Control Considerations • The EMT/paramedic may not perform medical interventions independently because of conflict with the Medical Practice Act • The EMT/paramedic must act under the medical license of a medical control physician to avoid this conflict

26. Physician Responsibility • The on-line medical control physician’s primary responsibility is the provision of direct voice orders to EMS personnel in the field based on the EMT/paramedic’s assessment

27. Physician Responsibility • Physician must have knowledge of • Certification / licensure level of EMS personnel requesting direction (if they are actively working they are licensed) • Interventions permitted by law and protocols, which the EMS provider may perform • Protocols will be provided in both paper and electronic form at all times in ED

28. Central Base Station • We will receive calls from over 15 different EMS agencies all with different medication lists and protocols • When asked to give pain medication to a child ask... “what narcotics do you have available?” This will help you to answer more quickly • Be prepared = ACFR will be calling Shands for medical direction for patients being transported NFR as well • As a courtesy, if you give orders on a pediatric patient going to Shands peds ED, please call the pediatric ED and let them know the patient is coming and the orders given 28

29. Authority • US Department of Transportation (National Highway Traffic Safety Admin. {NHTSA}) • Defines levels of prehospital providers • Certified First Responder (CFR) • Emergency Medical Technician - Basic (EMT-B) • Emergency Medical Technician - Intermediate (EMT-I) • Emergency Medical Technician - Paramedic (EMT-P) • Defines national curriculum for each level

31. Authority • State-specific laws define scope of practice • Regional and local modifications of specific treatment protocols is common • Little commonality between states as to scope of practice or other regulations • i.e. All EMT-Intermediates are not created equal • Intubation and IV fluids only in one state and full ACLS drugs and skills in another state • As stated earlier EMT- I does not exist in florida, therefore EMT-Basic (BLS) and EMT-P (ACLS) are what you are dealing with, ability to RSI is agency dependent (ACFR does not use RSI)

32. Authority • No standardized process for reciprocity of certification between states • National Registry of EMTs • Provides national standard examination and certification for CFRs and EMT-B/I/P • Defacto “National Board” for prehospital providers • Still not recognized by all states

33. Provider Specifications • Emergency Medical Technician- Basic • Primary level of staffing of ambulances nationally • 110 hours of training (per DOT) + CPR • Optional training within curriculum for: • Intubation • Pediatric NGT insertion • Assisting patients with Rx medications

34. Provider Specifications • Paramedic (EMT-P) • ALS provider providing secondary level of EMS staffing • 1200 hours of training (per 1998 DOT) • Clinical, didactic and field intern training • Advanced patient assessment skills • Often greater scope of practice for aviation-based paramedics • Advanced procedural skills such as surgical airways (based on local scope of practice)

35. Medical Control • Exact procedures/medications/protocols specified by: • State • Region • Service medical director • “A base station physician must know level(s) of training of local providers and their specific treatment protocols.”

36. Most Common OLMC Contacts • Request for consultation • Calling for medication orders • Calling for refusal of care &/or transport • Calling for terminating a code

37. Considerations • Treat the on-line patient as you would a patient you are evaluating in the ED • Make the best medical decision for the patient you are contacted about • System issues are already factored into the protocols

38. Orders which Require Attending Supervision • Termination of resuscitation • Refusal of care • Any procedure (cricothyrotomy, amputation, post mortem C section, etc) • Any order which you are unsure of giving over the phone to a medic in the field by himself 38

39. Case Scenarios • No national OLMC standards • Standard of care is dictated by your EM practice • Base Station Course content represents our best practice recommendations

40. Case Scenarios • You are an emergency physician, on duty at the EMS Base Station Hospital • Your on-line medical control physician call sign is “MD 911” • You are receiving patient information from BLS and ALS units in the field • Two way communication is available

41. Case #1 • Rescue One-to-MD 911 • I have a 52 y/o WM c/o SSCP rad to his neck and jaw x past 1 hr • PMH: negative, he’s on no meds, and he has no allergies • V/S: BP=130/84, HR=80, RR=16, O2 sat=98% • On P.E., pt’s pale and diaphoretic, there’s no JVD, lungs are clear, heart sounds are normal, and no neuro findings • Cardiac monitor is showing NSR, rate of 80, ŝ ectopy • Pt’s been placed on O2 via NRBM @ 12LPM, he has an IV NS established and running KVO, he’s received 2 baby Asa, and 3 NTG sprays • His C/P has gone from a 10/10-to-8/10, V/S unchanged • I’m requesting morphine for continued C/P

42. How Would You Respond?

43. On-line Medical Control Guidelines • Request clarification or additional information of any item to assist your decision • When giving on-line orders: • State your order • Paramedic must repeat your order • Restate your order • If you modify your order, the cycle repeats

44. Case #1 Response • “Give 2 mg morphine, slow IV bolus” • “Repeat 2 mg morphine q 5 min prn/pain to a maximum dose of 6 mg Medic repeats: “2 mg morphine, slow IV bolus, repeat q 5 min prn/pain, to a maximum dose of 6 mg” • “ Affirmative, re-contact if you need any further orders”

45. Case #2 • “Rescue Two-to-MD 911” (time=0300 hrs) • “We have a 10 y/o boy with flu-like symptoms, father states he will take the child to the PCP in the morning, we’re requesting approval of refusal” • V/S: BP=105/65, HR=120, RR=normal • P.E.: patient is appropriately tired for 3am

46. Think About Your Response?

47. Case #2 Considerations • Approach the patient as if you are evaluating him in the ED • Obtain as detailed information as needed to be comfortable that you have a good picture of the clinical condition • If this is a patient you would prefer to obtain labs, radiological films or observe then this patient obviously needs transport to an ED

48. Case #2 Additional Info • Patient had several days of excessive thirst and excessive fluid intake, followed by progressive weakness • Patient is now lethargic • ECG=sinus tach, rate 122 • ETCO2 = 8

49. Patient Outcome • 10 hours later, presented to the ED in critical condition: • pH=6.7 • CO2 = 5 • Glucose = 1380 • O2 sat = 82% • Dx: Severe DKA (new onset diabetes) • Admitted to PICU

50. On-line Medical ControlPitfalls • Prehospital provider can influence your patient impression • By inclusion or omission of information • By the voice urgency during communication • Prematurely breaking communication because of ED volume • Inadequate knowledge of provider protocols • Provider can dictate the treatment • Inappropriate orders may be given