NAEMSP: Pain Points and Some Solutions for Online Medical Control

Calling online medical control may not be your favorite thing in the world. Hearing from you may not be theirs, either. Breaking down that relationship in the aim of better understanding and communication was the topic of a session led by emergency physicians John Gallagher and John Lyng Friday at the NAEMSP’s annual meeting in San Diego.

Why do field crews consult online medical control? Common reasons include reaching the limits of their protocols, encountering a situation for which there is no protocol, or simply facing a complex patient where they’re not quite sure what to do.

But hospital docs aren’t always comfortable delivering OLMC, noted Gallagher, MD, FAEMS, FACEP, director and medical director for Sedgwick County EMS in Kansas. It can take them out of their element: They’re using to seeing and touching patients, and being suddenly questioned about random, maybe obscure medical and protocol intricacies can feel like “ABEM General.”

In fact, in systems where calls can go to emergency docs not directly affiliated with EMS, they may not even know EMS’ protocols. And then there’s an issue of time in busy departments; data suggests calls to medical control average around four minutes in length. A lot of those during a shift can add up.

Maybe you can consult a dedicated EMS medical director when you call, but in many systems you’ll talk to someone else—an ED physician, PA or nurse, maybe a senior medic or supervisor, perhaps even a specialty doc. Lyng, MD, FAEMS, FACEP, NRP, of North Memorial Health in Minnesota, cited a rural ALS service in his state with one full-time and three part-time medics, two hours from the closest STEMI, stroke, and trauma centers, for which it’s not uncommon for medics to provide care for 6–8 hours (from the scene to assisting in the ED and then interfacility transfer). That service’s online control comes from a local critical access hospital staffed by a traveling MD one week a month and nurse practitioners the other three.

Three Domains

There are three critical domains to understand for those providing OLMC:

• The care environment: hazards and threats, available equipment, other resource capabilities and limitations;
• Clinical care: pathophysiology, diagnostics, pharmacology, clinical judgment; and
• Operations: protocols, scopes of practice, available drugs and interventions, interagency interactions, matching patient needs and resources.

Different types of OLMC providers will have different strengths and weaknesses across these areas. An ED physician, for instance, should be strong in clinical care but likely weaker in the other domains. Conversely, a paramedic adviser will be much stronger than that doc in the operations and environment domains but not as strong in clinical care. An EMS physician will be the strongest across all three.

In conservative “Doctor, may I?” systems, restrictive protocols may require frequent consultation. For those providing control, an approach of collaborative consultation leads to the best care and resource management. OLMC that’s not comfortable with remote assessment and treatment may err in favor of overtreatment—the “do everything” model seen sometimes in cardiac arrest, where it can result in lots of drugs and lights-and-siren transport of dead patients—while those who don’t fully trust their medics or fear liability may tend toward a “do nothing, just transport” approach and thus undertreatment.

Field crews can help online medical control do its job in a few ways, primarily by delivering a succinct situation report, clear description of unmet needs, and specific requests. One study found important information omitted in more than two-thirds of such calls. The acronym MIST (for mechanism of injury/medical problem, injuries/illnesses identified, symptoms and vitals, and treatments given) can help communicate the essential information efficiently. Read back all orders for confirmation.

A level up, if OLMC’s answers are consistent, protocols can be adjusted. If the answer is consistently yes, can the question be incorporated? If it’s always no, can the option be removed?

Why does OLMC fail? Data from Texas suggests the most common reason is poor radio or cell reception, accounting for 55% of cases studied. No answer or no physician available represented another 35%, and other reasons the remaining 10%. Emerging technologies give us more options for redundancies and contingencies today, though; Internet-based services like RingCentral can provide voice, text, and video comms that are portable, recordable, and transferrable and can often be made HIPAA-compliant. FaceTime is definitely HIPAA-compliant, as calls (and thus protected health information) are not stored.

This may or may not amount to telemedicine that’s billable under Medicaid, which has a definition that seems to require interaction with actual patients, rather than just care providers.

An ideal online medical control system would have six points, the doctors concluded:

• Limited use of restrictive protocols;
• Succinct reports, clear and direct requests, and closed communications loops;
• Access to a consultant with strength in the necessary domains;
• It’s recorded and consistently QA’d by the medical director’s office;
• It’s flexible and transferrable, with built-in redundancies and contingencies; and
• It’s potentially reimbursable.

John Erich is the senior editor of EMS World.