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Medical Direction and Medicolegal Issues
Questions and Answers
1
What is direct medical oversight?
While state specific, emergency medical services (EMS) agencies have providers (typically physicians or advanced practice providers) on standby to provide direct medical oversight. Direct medical oversight, also referred to as online medical control, medical command, or online medical direction, refers to orders given by a physician or designee to the prehospital provider either in person or via telephone or radio. Direct medical oversight is utilized when interventions required are outside the scope of protocols as well as for high-risk refusals, termination of resuscitation, and other complex situations.
2
What is indirect medical oversight?
Indirect medical oversight, also known as offline medical control, refers to treatment protocols, policies, procedures, and standing orders that have been preapproved by a medical director. These interventions may be utilized by a prehospital provider without the need for a direct order from a physician.
3
Do physicians receive training in direct medical oversight?
States differ in their requirements; however, all emergency medicine residency trained physicians receive some form of EMS education. Oftentimes, these physicians-in-training do ride-alongs with EMS providers to gain a basic understanding of the circumstances faced by first responders. They may also take a base station course and provide direct medical oversight under the supervision of a trained physician.
4
Do physicians ever go to the scene?
Some medical centers have physician teams that can be dispatched to the scene. This is more common in European EMS models. In-person physician oversight is seen most often in cases of severe trauma, cardiac arrest, or mass casualty incidents to aid in complex, unusual patient care or scene logistics. It is more common for physicians to have a role in EMS education, quality assurance, and protocol development. However, on-scene presence allows for on-scene quality management, bedside teaching approving paramedic training, and occasionally facilitating patient care.
5
When should you call for direct medical oversight?
State and local protocols differ in their guidelines. In general, direct medical oversight should be utilized for consultation on complex or critically ill patients or for approval of medication administration or procedures outside the scope of protocols. Direct medical oversight can also be a useful resource for high-risk refusals. Additionally, specialized resources, such as cardiac catheterization, stroke, and trauma evaluations, can be activated or requested after EMS consultation with the designated provider. In some systems, prehospital providers are required to contact medical oversight to request aeromedical dispatch. Be mindful that depending on your agency, the provider giving medical oversight may not be at the receiving hospital or may not have experience in EMS.
6
How should you present the information on the phone?
When contacting direct medical oversight, identify yourself and unit number. Provide a brief description of the patient’s condition, including vital signs, pertinent patient history and exam findings, and treatments administered. Clearly state your request and reasoning for this request. Document the physician name and recommendation or approved intervention. If given orders, use closed-loop communication by repeating back the orders to the physician for confirmation.
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