Traditional roles for the physician in EMS have involved quality improvement, protocol development, and provider education. In general, physicians do not typically provide routine EMS care in the field setting; however, the role of the EMS physician has been evolving. The National Association of EMS Physicians (NAEMSP) has issued a position statement affirming the role of EMS physicians in the field.¹ The role of the EMS physician is myriad and not well standardized as described in a 2000 field survey of the 125 largest cities in the United States.² Many EMS systems now provide mechanisms by which EMS-trained physicians can be called into the field to directly provide and/or coordinate patient care for unusual circumstances. These same EMS physicians can also provide real-time education, quality assurance, and online medical direction on routine calls.³ In addition, direct exposure to the challenging field environment can help the EMS physician with protocol development and provider education programs. In this chapter, we will provide an overview of the roles and responsibilities of EMS physicians in the field.

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  Describe the responsibilities of an EMS physician on the scene of a patient care call.

  
  
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  Describe the some specific responsibilities of an EMS physician on the scene of an MCI (details covered in Chapter 75), the scene of a fire (details covered in Chapter 65), and on the scene of a tactical operation (details covered in Chapter 66).

  
  
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  Discuss situations in which the EMS physician should act as a direct, on-scene, provider of patient care.

  
  
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  Discuss how the EMS physician’s on-scene roles and responsibilities affect EMS provider education, CQI, and protocol development.

UNDERSTANDING THE CHALLENGES OF THE PREHOSPITAL ENVIRONMENT

Yet another benefit of EMS medical director field response is for the physician to gain a better understanding of the highly unique challenges of prehospital patient care. This level of understanding is crucial in protocol development, planning, and resource allocation. Although many EMS medical directors have had direct EMS experience as an EMS provider prior to becoming a physician, this is not universally the case. As EMS systems advance in complexity, the increased need for EMS medical directors has resulted in many non–EMS-trained physicians being asked to oversee EMS programs. This diversity of experience has proven to be a benefit to the science of EMS medical oversight as increased involvement also brings new energies and ideas to the table.

Moreover, each EMS system poses its own unique set of geographic, political, technical, and financial challenges. It is important for the EMS medical director to be intimately familiar with the challenges of the prehospital system that he or she is tasked to oversee. This degree of technical understanding is necessary to operate effectively as a medical director and can only be gained through the regular interactions with EMS personnel and patients in the field.

ENHANCING PATIENT CARE

Field response of EMS medical directors and EMS physicians may directly enhance patient care through the direct application of advanced skills and procedures that are out of the scope of practice for nonphysician EMS providers.⁴ Some examples may include:

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  Central-line placement

  
  
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  Tube thoracostomy

  
  
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  Field amputation of entangled extremities

  
  
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  Prehospital ultrasound

  
  
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  Awake, fiber-optic intubation

  
  
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  Blood product transfusion

  
  
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  Procedural sedation

  
  
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  Prolonged treatment of patients who are unable to be transported in a timely fashion to receiving hospitals (Figure 29-1)

However, the presence of an EMS medical director in the field can enhance patient care in situations even without the need to perform these advanced procedures.⁵ For example, physicians may be more adept at providing death notifications to family members in cases of field termination of resuscitation. In addition, additional clinical experience may also allow EMS medical directors to counsel EMS providers in making decisions about high risk but infrequently used procedures such as the decision to control an airway in a spontaneously breathing patient via RSI and surgical cricothyrotomy.

REAL-TIME EMS EDUCATION

Traditional medical education is built around an apprenticeship model which provides graduated degrees of responsibility and training as experience progresses. In the physician-education model with which physicians are most familiar, medical students progress from the preclinical didactic years to clerkship rotations, internships, and residencies. As medical students and residents progress through these education phases, learner-contact time with physician mentors increases in duration and intensity. In particular, during emergency department residency training, experienced attending physicians are generally required to be present “at the bedside” and/or immediately available to resident physicians.

EMS education programs are modeled in a similar fashion with did­actic sessions followed by structured clinical rotations in various settings. Learners are given increased autonomy as their training progres­ses. Unfortunately, this is where the similarity ends. Unlike the physician education model, EMS students are often supervised by preceptors that are generally seasoned EMS personnel rather than physicians. Although these preceptors are expert field providers, as a generalization, they may lack the depth of clinical knowledge and experience that comes with the thousands of educational hours spent by physicians during medical school and residency. Moreover, because of the relative scarcity of EMS-trained physicians, when EMS students are exposed to physician-led educational experiences (such as emergency department, anesthesia, and ob/gyn rotations), the physician mentors in these settings are rarely EMS-trained physicians. Although non–EMS-trained physicians are unquestionably experts at their particular application(s) of clinical medicine, they may not be as familiar with the practical applications of their clinical knowledge to the myriad of technically challenging environments faced by EMS personnel on a daily basis. Lastly, upon completion of their training program, EMS personnel interaction with physicians may become limited to a few brief moments during ED handoffs, continuing-education refresher lectures, and regularly scheduled skill verification sessions.

Placing EMS physicians in the field can very effectively bring the strengths of the physician education model to the realm of EMS. An experienced, EMS-trained medical director who responds in the field can provide expert real-time guidance to a paramedic student who is preparing to perform their first field intubation. In addition, the direct “bedside” presence of the EMS physician can help guide learners and even seasoned paramedics through critical thinking scenarios such as whether or not a patient requires medication facilitated intubation. Moreover, the EMS physician can assist the EMS provider with high-risk, infrequently performed procedures such as needle thoracostomy, cricothyrotomy, and rapid-sequence induction. At the completion of a call the EMS physician can discuss the call with the provider and answer clinical management questions that will benefit the provider in future encounters (Figure 29-2).