Questions From a Reader, Part Three

Howdy, all. I'm sorry that I've been gone so long. Here's another great question from our querulous reader. This one in particular, I invite everyone to chime in.

"3. When you describe deciding to administer certain procedures or even
medications, it seems you are able to decide these on your own. Are there
some procedures which require "authorization" from an M.D. over the radio?"

What an excellent question! The answer is "Yes." If you remember back to my previous entry about the different "levels" that EMS providers achieve, there are associated levels of care that each one can provide. In short, all EMS providers in the pre-hospital environment operate under the license of a physician. We are extensions of his legal and medical authority. Each jurisdiction has a medical director who is responsible for all that is done in the pre-hospital setting and, ultimately, is the one responsible for the care provided by EMS personnel. We call this Medical Control.

There are two types of Medical Control. On-line medical control is when the EMS provider is speaking directly to the medical director or, more commonly, an authorized doctor at the hospital that will receive the patient or a specialty hospital depending on the needs of the patient. We do this consultation in order to get permission and guidance in the treatment of our patients. More on that in a bit...

Off-line medical control usually appears in the form of written standing orders or medical protocols. These protocols differ from state to state in the U.S. and even from jurisdiction to jurisdiction. These written instructions are how the medical director gives instruction to us EMS providers without having to talk to us all the time on the radio.

These instructions detail how and what we can do with patients as their conditions present. They also tell what interventions each level of EMS provider can give under our own judgment and what we need to consult with medical direction to do. For example: I can, as an EMT-Basic, administer an epinephrine auto-injector to someone who is in anaphylaxis, or severe allergic reaction. If I am presented with a patient who is having a severe asthma attack, using the Epinephrine injector may help them very much but I am required to consult with medical direction before administering it.

This is all written out in a book that is readily available. The protocols also direct me as to what drugs, their dosages I can administer and goes into what equipment to use with patients and when. The protocols contain a lot of algorithms that are basically patient care flow charts. There is no shame in consulting with one's pocket version of the protocols when treating a patient.

Any procedure that is outside the scope of what I am authorized to do in the protocols requires me to consult with medical direction. As mentioned before, this consultation is usually in the form of me speaking with a doctor at the receiving hospital via radio. This is also done to notify the hospital of what we have and our expected arrival time so they can be ready for us. This helps to provide continuity of patient care and reduce the wait time at the hospital for the patient.

When an EMT does call for consultation, we give the consulting doctor a ton of information but in a well organized format. According to Essentials of Paramedic Care, Bledsoe, et. al., Pearson Education (2003), a good format for the consultation report is SOAPIE: Subjective information, Objective information, Assessment, Plan of treatment, Interventions taken, Effect of interventions.

Subjective information: This is what the patient tells the medic. "My chest hurts. it feels like an 800lb gorilla is sitting on my chest!" That sort of thing. Often what the patient is complaining of is not the actual problem. These are also called symptoms.

Objective information: This is what the paramedic observes about the patient, the vital signs, patient condition, evidence of trauma, etc.. These are also called signs.

Assessment: The paramedic puts the above all together and, by process of ruling out other possible causes of the patient's condition, comes up with a diagnosis.

Plan: Here the paramedic details what he plans on doing to treat the patient all the way to the hospital. If the paramedic is asking to perform a procedure or intervention that requires approval from the consulting doctor, here's where it is detailed.

Interventions: The paramedic tells the consulting doctor what he/she's done already to treat the patient's condition.

Effect: This is a description of how the patient responds to the treatments and interventions given.

All of this information helps to give the consulting doctor a clear picture of the patient's condition so he or she can give a good consultation to the paramedic and so that the receiving hospital can be ready for them. As with any communication system, there are breakdowns and miscommunications. I have heard tons of stories about bad consultation, poor communications and frustrating doctors.

Do any of you more experienced readers out there have any "war stories?" If they're too big for a comment, post it in your blog and I'll link to it.

I hope that answers your question, Dear Reader. I'll continue to answer more!

Thanks for reading


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