Medical Direction of EMS

1. Medical Direction of EMS Franco Castro-Marín, MD, FACEP Prehospital Administrative Medical Director Scottsdale Emergency Associates | Scottsdale Healthcare Hospitals Public Safety Medical Director City of Scottsdale (AZ)

2. Disclosures • Salaried EMS Medical Director

3. Medical Director Doctrine • Commitment to High Quality Medical Care • Welfare of Patients, Community, and Workforce • EMS is a Practice of Medicine • Requires a strong “Relationship”

4. The Relationship • EMS Medical Director + EMS Agency • A mutual INVESTMENT of confidence focused on betterment of the human condition

5. Threats to the Relationship • Agency not aware of or not committed to Doctrine • Frequent turnover of EMS Leadership • Budgetary Challenges

6. EMS Medical Direction • Foundation and Philosophy • How we fulfill our DOCTRINE

7. Foundations and Philosophy • EMS is Emergency MEDICAL Services • EMS requires committed oversight • Culture, tone, STANDARD of how we provide medical care • Direction ≠ advice, supervision, control

8. Foundations and Philosophy • EMS is a delegated practice of medicine • 911 response is a "referral" to EMS medical director and credentialed agency personnel • Personnel will deliver same quality of care as designated EMS medical director

9. Foundations and Philosophy • Two-way obligation - The Relationship • Physician obligation to patient/agency • Agency obligation to patient/physician • A mutual INVESTMENT of confidence focused on betterment of the human condition

10. Apprenticeship

14. The Role of Apprenticeship • Seattle Medic One • CORE VALUE: Strict, meticulous physician leadership • Medic candidates vetted • 3x more patient contacts than national standard • 2x more instruction hours than national standard • Intensive apprenticeship and mentoring by physicians

15. The Role of Apprenticeship • Cardiac arrest survival rate • Witnessed VF/VT • 50% +

16. Sets and Reps • Sayre MR, et al. Cardiac Arrest Survival Depends On Paramedic Experience. Acad Emerg Med. May 2006:13(5) Suppl 1: S55-S56

17. Experience Matters • Every additional year of “procedure” medic experience adds 2% chance of survival • Additional experience of “command” medic not associated with increased survival • Gold LS, et al. The Effect Of Paramedic Experience On Survival From Cardiac Arrest. Prehosp Emerg Care. 2009 Jul-Sept;13(3):341-4.

20. Physician + Medic

21. Operational Medical Director

22. Operational Medical Director • “on-scene supervision and interaction”

23. Operational Medical Director • “no better place than… in the midst… of operations on a routine basis”

24. Operational Medical Director • “on-scene supervision and experience…obligatorycomponent”

25. Operational Medical Director • “respond to as many 911 calls as possible”

26. Operational Medical Director • “best form of QA…routine practice…on scene”

27. Operational Medical Director • “routine response…factual assessment…of service delivery”

28. Operational Medical Director • “rountinely participate in field responses, making contemporaneous patient care evaluations…”

29. Operational Medical Director • “field experience… one of the most valuable experiences for both medical directors and providers”

30. Operational Medical Director • “common knowledge…MDs can and will show up…”

33. EMS Medicine

36. Official authority • Well defined role • Combined prospective, concurrent, retrospective methods

37. EMS system has obligation to provide resources • Compensation for time • Materials and personnel • Liability insurance • Written agreements

39. Maintain a presence in the field • Maintain current knowledge and skills • Participate in CME

40. Obligations of the EMS System • Compensation for services • Materials and personnel • Liability insurance • Knowledge of the Incident Command System

41. Resources • Liability coverage • ePCR with robust QA/QI capability • Prehospital coordinator • PPE • Identification • Radio • Uniform • Response vehicle • Fireground training • Medical Equipment

43. “Medical directors, doctors hired by the cities to supervise emergency medical care, are often aware of these delays, but many told USA TODAY in the survey and interviews that they are viewed as outsiders by firefighters. The directors can make suggestions to improve care, but the fire chiefs have the final say about how money will be spent and how resources will be deployed. In Los Angeles, fire department commanders and a powerful firefighters union view fire suppression as the main focus of the department, with medical services ‘a very distant second,’ says medical director Marc Eckstein. He says many obstacles, including a ‘lack of attention to emergency medical systems issues, overwhelming priority in terms of training, and budget for fire-suppression activities instead,’ stand in the way of better performance. Still, he says, ‘our department is much further along in merging the two cultures than most.’

44. And operating within the system's structure requires cooperation: Today, Seattle paramedics work for the fire chief, but they deliver medical care as an extension of their hospital base. One of the fire stations is built into the ground floor of Harborview. The fact that fire department ambulances back into a station inside the hospital is more than just a matter of logistics. Cobb sees it as a sign of a healthy marriage of two systems — but a marriage that takes perhaps a certain amount of nagging to keep it on track. "The fire department itself is like most fire departments. It's not used to dealing with medical quality issues," he says. "If you left them alone, I don't think they would push this very far. I think most fire departments don't." Seattle's respected system could easily collapse without constant effort and close scrutiny of care. "It's a fragile system," Cobb says. "The quality of care is overseen by a handful of people. It wouldn't take much to disrupt that."

45. Fire Chief • Deputy Chief • Deputy Chief • Deputy Chief • Division Chief • Division Chief • Division Chief • Division Chief • Division Chief • ??? • “Consultant” • Medical Director

46. Agency

47. MD • “face-to-face training is a best practice” • -ICMA

48. Org Chart Example

49. Org Chart Example

50. Citizens • Mayor • City Manager • Fire Chief • Medical Director • Deputy Chief • Deputy Chief • Deputy Chief • Division Chief • Division Chief • Division Chief • Division Chief • Division Chief • Battalion Chief • Battalion Chief • Battalion Chief • Battalion Chief • Battalion Chief • Battalion Chief • Battalion Chief