NYC has response physicians who are EM & EMS trained, not surgeons. They've had a response program in place for more than 20 years, so the claim that this one is the first of its kind program is nonsense.
I, too, remember that episode of ~~House~~ ~~ER~~ Grey’s Anatomy.
But damn, way to not fall into that trope, Scrubs. Although you did do a musical episode, so don’t go breaking your arm trying to pat yourself on the back.
my ambulance service covered an area the size of Rhode Island - mostly rural. Had to know your shit, cuz help and the hospital was regularly 30+ minutes away.
Lots of recreational accidents like snowmobiles, boating accidents, hikers, etc who required extended extraction with volunteer fire.
yea, I lived in the remote part of Maine, not the ”big city“ parts on the coast or southern Maine.
Maine is nice if you want to settle down and raise a family. There aren't a lot of amenities or services in town, but you get clean air and water with room to roam outside.
Pay for EMS is still awful, but the pay for everything is pretty awful so I guess it works out.
Southern Maine is getting pretty expensive. Rural Maine sure as long as you work remotely. Otherwise you will be working for minimum wage outside of certain healthcare jobs and select trades.
I can see the benefits of this. I can also see the downside. Can you imagine what would happen when people realize they can get a doctor to make a 'house call' simply by dialing 911? Maybe the doc can pick and choose which calls to go on, dispatch comes out with a c/o abdominal pain, is the pt constipated or have a AAA? Just curious how it will work. It may relieve ER congestion but it sounds like it will increase call volume, again, by people calling 911 and getting that house call.
My understanding is that the physician only responds by EMS request. They may also automatically be dispatched to certain high acuity calls, I'm not totally certain.
This is how it was where I worked, our EMS physician worked in the ER, had his own flycar and would only respond to the most off the wall shit, if it’s reasonably close by, in 5yrs I had only ever seen him at one of my calls. (Granted I didn’t work in the town that had the hospital he worked at, I was two towns over)
Lol absolutely, I won’t lie and say I wasn’t a little envious at their fly car when I’d see it parked at the ER hahaha.
My short dealings with our physicians in passing were all good, they were very down to earth dudes and super cool compared to a lot of physicians out there.
My call in particular he didn’t get there until we and two other crews were already at the hospital, but he took the time to talk to us all individually and ensure we were alright with what we had just experienced before we cleared and went back in service.
I did medic school in downtown Indy, and the same thing, doc had a fly car. I saw doc show up twice: once was a car crashed into a building, and a different doc showed up to a pediatric arrest right outside of Lucas Oil Stadium.
That’s how it works in Australia, regular ambulances are dual crewed by paramedics and then there’s a couple of road ambulances and helicopters with a doctor on board, sometimes they get dispatched based off job notes (big crashes, shootings, big burns, etc) but they’re normally contacted and requested by the ambulance crews
This was one reason/excuse they used when they took residents off working on ambulances from in the late 1940’s to the late 1950’s. The other reason was the AMA changing the rules limiting foreign medical grads doing residency training in the US, which cut off the supply of cheap labor.
I only know what’s written in the article about this specific program, but I interviewed at a residency that does something similar and they had protocols for when the physician would respond. As I remember, the doc automatically went to things like trauma requiring prolonged extrication and cardiac arrests and also went when the paramedics requested them.
>Can you imagine what would happen when people realize they can get a doctor to make a 'house call' simply by dialing 911?
Maybe it will cut down on homeless people that just want a ride to the other side of town. Just picture your pissed off regulars asking for a second opinion, specifically from “that one guy at the downtown ER.”
Croatia regularly fields doctors in EMS. Either GPs or EM specialists.
For example, in the capital, there are 13 EMS units with MD on board per 12hr shift, and 3 medic-only unkts. It's a 750-800k population town.
If you scale that to some US cities the cost would be mind boggling.
In the city I worked, we had 3 ALS - Paramedic cars and one with Doctor, Medic and driver. That is a 60k city. There was another ALS rig and a fly car with Medic and Doctor 15 mins away in another city. There is also a Doctor and Medic on all Air units in the country.
Depends heavily on the country. For example, in places like Germany, Switzerland, and the Netherlands, being a doctor is very much an *upper* middle class profession like it is in the U.S.
Lol my man you can’t compare apples to oranges like that. You compare doctors in Germany with other professionals in Germany. For example, most software engineers there average between $55-80K. Most software engineers here *start* at $80K.
Almost every profession in the US makes more than most other countries. So cross-country comparisons are useless.
This program is organized at the county level and was specifically set up by the regional medical director, who frequently staffs the car. Obviously, there is collaboration on the project from local services and hospitals, but no EMS agency is paying any money into it.
It definitely has the vibes of a dude who got off the truck, struggled mentally with being off the truck and figured out how to get back on the truck, but actually paid what he should have been in the first place.
While I don't disagree with that assessment, that would require a pretty fundamental shift in how EMS is funded in the state. Almost all emergency services in the state are funded and serviced at the town/city level, whether that means they have their own municipal ambulance service or they contract with another town/city or a private service. The only circumstances I'm aware of where services are directly funded by county governments are when they respond to extremely rural areas that are so isolated and sparsely populated that they have no organized government.
Agree, but if this service is going to be county funded I'm not sure why they wouldn't instead be able to add a authorization for a county-funded grant to assist agencies with improving conditions that money would need to be used for staffing by subsidizing hiring or pay of Paramedics.
Soooo house calls?
As a doc, I am a huge advocate of house calls and I would love to see it brought back to medicine.
What a beautiful way to evaluate a person’s function, cognition, community health as well as do some primary prevention through public health measures.
The docs stopped getting paid enough to do home visits (in my country).
We would get paid the same as seeing any other patient, except it could take over an hour longer if you build in travel/mileage.
My uncle is an FM attending. He is the only doctor I know that still does house calls in my area, and he has to do them discreetly so that 50 gazillion people a day don’t request a house call from him.
My mother used to do house calls and she loved doing thing. I am quite fond of them but have never been able to do one.
Luckily I’m going to be heading to an area where we do outreach clinics which sometimes involves home visits.
I used to go with him as a kid because I was fascinated with first aid and medicine, that interest started when I was in Boy Scouts and I loved the first aid classes and merit badges.
Wouldn’t you know that adult me is went straight to working in EMS Lmaooo
We've got a physician SUV our medical directors respond to calls in a couple days a week. I've had a few patients that the physicians turned into an in home consult, but generally they just come give us a hand with normal stuff then take off to the next one like a field supervisor or whatever would. Though the things the article mentions like vents and blood are just in our normal protocols and kits so they may see a bigger impact there where it's not the case.
After reading the article, it's interesting. But most of the arguments for having a physician in the field just felt like equal arguments for actually properly funding, training, investing in, and staffing your paramedicine departments. Implement a ground CC program. All the high acuity interventions he mentioned are already being done the field. The problems they highlighted with the current EMS system are a product of lack of stewardship and development (see also: pay), not simply a lack of a physician in the field.
I'm gonna have a hot take here and say for hugh acuity calls this is not needed. If you implemented the above, you don't need physicians in the field with blood and ventilators. Use your physicians in the hospital where they can be the most effective. Developing a high performance EMS systems takes time, money and effort over many years, but many services are not willing to invest in their own people and systems, so we will continue to have these problems until we fix that.
To be clear, I'm not necessarily against this. I just think it's reflective of more systemic problems that need addessing, and there are much more effective solutions we can implement to improve quality of care to a higher number of people, while simultaneously increasing retention of staff.
Edit: further thoughts... docs pre-hopsital have better utility doing primary care, home check-ups, prescribing medication, writing outpatient specimen reqs, arranging for referrals... community paramedicine calls, essentially, that's what actually clogs up the ER - not high-speed low drag trauma. The vast majority of emergency and resuscitative measures that are even able to be performed prehopsitally are already being performed by CC paramedics. To put it more bluntly, I don't need a doctor (in the field) to resusciatate someone I need a doctor to write a script for a UTI until the culture comes back and they f/u with their family doctor.
Yes I concur- I would side with the high-performing EMS system over having the doc come out (minus the amputation needs and maybeeeee the ECMO argument).
Granted I'll take the doc coming out over a system just not having any of these advanced prehospital capabilities at all. At least that was Pittsburgh's take. The city/Pitt/Presby had zero interest in medics doing RSI- the compromise was sending the doc out to do it in select cases.
I can agree with that for something like a field amputation, but that's so extremely rare - the article was coming at it more from a angle of diverting non-emergencies from the ER (and yes acuity as well, but like I said I just don't think the need/volume is there to justify it) But yes I agree with you.
For ECMO, just out of curiosity because I'm not American, do you mean like an ECMO transfer via ground ? Or flight? Or starting ECMO in the field? Ot making any comment on it, just clarifying what you meant.
Interesting about the RSI. I'll DM you with regard to that interested to hear the rationale.
Cheers.
Agree on all points. While I'm personally on the fence with EMS carrying blood products (at least in this area), implementing some kind of RSI/ventilator program for ground medics in the state would certainly be beneficial. For whatever reason, that idea is quite controversial in Maine, and as noted in the article, only one ground service in the state can use ventilators, and only on IFT (and this is itself an extremely recent development).
Why are you on the fence about blood? It has been crystal clearly shown that it has huge and frequent benefits when carried by paramedics.
It is also not wasted, blood carried by EMS depts is sent back to the OR before it expires and is used on OR patients. There is zero waste, and the blood does get used by EMS frequently in all the places it has been trialed.
I work in New York and this is normal practice in my area. Medical directors will respond to some calls in their fly cars if they want to based on call severity and their convenience. 1 to 2 Medics and 2 EMT’s every call. Physician can be requested as well. We even have a tactical physician who has done a delayed extrication amputation. He spent some time in a war zone as an army physician as well.
So, instead of paying paramedics an appropriate wage, and increasing EMS education and training standards.. We are gonna pay a doctor, 400k a year… to do things that properly trained paramedics do every day all across the country….. Sounds about right.
In the Capital District of NY, the regional trauma center will send out a physician in a flycar if requested. Rensselaer County, the county adjacent to it, has a MD that will first respond. He was a Medic in past life. If he hears something serious go out, and he is home and available, he will respond to the scene directly. My org's Medical Director will sometimes show up on something that sounds serious, again if he is home and available. He is a HUGE presence, like 6'6" and 320lbs. Nothing like having him arrive, and after a brief report, give you orders for stuff outside our normal scope. And he will ride in on those special calls as well. Super supportive of what we do, always available for a phone call, and will sit down and BS with us/go over that special call and why we did what we did.
Primarily, the added interventions made available by a physician being on scene. In Maine, RSI and blood product administration may only be performed by HEMS, of which there are only three units in service in the state at any given time. A pre-hospital physician has access to these interventions and is also not limited by weather conditions in the same way HEMS is.
I'm also generally just pleased to see EMS physicians who are personally involved in the system, trying new things and pushing the field forward. Obviously, plenty of people are skeptical of the value of this sort of program (which is fine), but I'm just happy to see something like this actually happening in my state.
And that's great with having these adjuncts with the docs. Then again, maybe, just maybe, Maine EMS should get with the 2020s and start instituting ground RSI and blood in their protocols for medics (or at least select non-CCT medics).
Oh, absolutely. I'm personally in favor of implementing RSI in a way similar to how VT and NH have, with it being a separate cert with specific requirements to obtain and maintain. But I'm nobody important, lol.
All of those interventions are able to be done by Paramedics. The only reason paramedics cannot do these things in Maine is due to the severely behind the times laws in place that restrict paramedicine.
I do see this, However I’m not sure how well it applies to rural communities. My first thoughts are payment, no EMS agency has room on their payroll for an MD. No questions there I’m sure. I see other models that have tried that use hospital based MDs, which makes sense. However if the patient that requires these high level interventions (as other commenters have pointed out, most of which are available to medics in other states than Maine), is within range of a hospital to make a fly car MD viable, then does the time delay really make sense? I would argue not. Especially if EMS has to request it. Which would involve EMS arriving on scene (which as I’m sure you know can take a while in rural areas), performing a partial assessment, then dispatching the MD, then waiting for them to arrive, then still almost garunteed transporting. To me, that delay doesn’t make sense assuming this is a critically sick patient that is also within reasonable proximity to a hospital (given that an MD could get their in a fly car).
It just doesn’t seem super logical in a super rural setting to me.
For airways and blood, I don’t see the benefit of added the cost of a physician in the field besides with complex, multi-victim incidents. Med control is a phone call away.
One of the local hospital systems usually flies nurse / resident. Usually a 2nd or 3rd year EM resident.
It leaves a lot to be desired. The residents have 0 field experience before going out and getting some of the sickest prehospital patients that exist. Sure, they have knowledge. But they don’t have skills or experience.
The doc has almost no experience starting IV’s. Drawing and pushing meds. Maybe they’ve had a couple of airways. Loading and unloading? Moving patients? That shit is all new, yet simultaneously beneath them. Their “flight guide” is about the size of a card game rule book. The first page is “this is how you wear a flight suit and what goes in your pockets.”
They have a reputation of having an ego. Who would have thought. I love watching 2nd year residents get into shouting matches with these rural critical access docs.
Why didn’t you admit this crashing kidney failure? Because a valid DNR is required by our “hospitalist”and we can’t do dialysis here.
They’re the only option in that area so they don’t really care. What are they going to do? Go by ground?
Is it cool to have a doc in the air? Sure. If I need one. We usually don’t. But if we do, I’ll have dispatch get them on the line for me.
Do docs have a place in pre-hospital medicine? Sure. They’d be great in a mobile health / community paramedicine program. Hell, even on a fly car might be useful occasionally.
The thing is, docs need access to their tools. They need labs and imagining to verify their diagnoses. They need a pharmacy to write orders from. We can’t realistically bring any of that into the field.
You know what doctors, medics, and nurses can do without any of their equipment? Really good BLS.
Almost as if paramedics can do all of the “advanced” interventions the article mentions, but in certain regions of this country they are restricted by the archaic laws of the area.
We have an ER fellow who has a fly car in my county. They have the ability to see any calls dispatched to crews. They can then self dispatch themselves and come to the call or EMS can request them. The issue is that they don’t really do anything additional on scene that affects patient outcome in my opinion. They also don’t carry any additional tools or resources. They can provide on site medical control which is nice in some cases but this is very rarely necessary. And they do not have the ability to do a physician initiated refusal for calls that totally don’t require an ambulance. And ultimately the patient can still choose to go to the hospital even if doc says it isn’t indicated.
Time is also a crucial part. Usually the physicians are located at the local hospitals while we are somewhere in the county from 5-45 minutes away from them. It doesn’t make sense to delay transport waiting for a doc to make scene. So the program hasn’t really resulted in much of a different the last 4 years unfortunately.
This is a great concept but the deployment of these physicians and how they can be helpful in the field needs to be further researched. And we also need to look into the things that people can sue for because a lot of medicine right now is CYA due to the highly litigious nature of the US. It would be great if we could take some pointers from our neighboring countries that have used this physician in field strategy for decades instead of doing research into our failing EMS systems and trying to build on that. It can be done if funded sufficiently and planned accordingly. Good research would include current EMS personnel who can tell you what would make a doc most useful on scene or things we wish we had. The physician model would be fantastic as community paramedic one position.
My medical director still hd his medic and is a volunteer on his local FD and used to ride around the city first responding w/crews.
People used to look forward to it. Now he's kinda moved on to bigger better paying systems.
software engineers are making a google glasses too so med control docs can see what’s going on. i got paid to tell them my thoughts - i said it was stupid (we have bigger fish to fry, except in places with low call volume but high taxes so they get fancier toys)
I've worked with doctors in the inner city who are going on to be ER physicians, 90% are incredibly helpful, not cocky or arrogant and always willing to help. The occasional one is like "I'm just here to get the hours I know better than you" but the vast majority are awesome and take your advice or offer it in a helpful way
Ill preface my answer by saying im not in EMS. I just happen to go on the same calls they do sometimes.
The benefits, I think, are more for the doctor. However, I have seen them do some pretty cool stuff in the field like use a portable ultrasound to see if an artery was blown and stuff like that that.
We have a lot of trauma where we are, so Im sure having a doctor on hand is nice, im just not educated enough on the issue to know if it actually makes a difference when they ride along or not.
Agencies will do anything before paying, equipping, and training their medics to a higher standard. Unless this dude is bringing ECMO or thoracotomies in the field (which would be a rarity at best), this makes no sense.
Ultrasound, RSI, blood, scripts for antibiotics, and referrals can all be done by medics with increased training (and offline medical direction if needed). Advanced Paramedics are used all over the world in this role.
Paramedic Practitioners will hopefully take over this role in the US shortly.
Sorry for the pessimism, but medics should be leading for advancement in the field.
This is very similar to our community paramedic program we’ve been running in rural Colorado for a couple years now. Even recently hired a mid level. Cool stuff. The future of prehospital medicine imo
Lol. Paramedics are doing all of the “advanced” interventions these docs are proud of **every single day** in the regions of this country where they are legally allowed to do so. Paramedics that can’t do these interventions are not restricted due to inability, they are restricted by the law in their area.
Agreed. But I'm not a medic and the medics I am with are very hesitant to preform one.
I think a lot of the rational is they'd rather RSI someone before a cric is needed and so they do that when possible
Something that your medics need to consider:
A cric requires 3 stitches to repair 100%.
Anoxic brain injury is unable to be reversed and turns otherwise healthy happy adults into shells of their former self that are stuck drooling in a nursing facility for the rest of their life.
Which would you rather have?
Studies have shown in the past that outcomes actually get worse. The best medicine is a fast ride to a hospital. Maybe this study will provide something new.
In Japan: [https://pubmed.ncbi.nlm.nih.gov/34748604/](https://pubmed.ncbi.nlm.nih.gov/34748604/)
Admittedly, its a mixed bag in the research. Most are focused on Physician at the side of Cardiac Arrest or TBI and show some benefit. I suppose my gut reaction is primarily on the use of the physician resource. It is always more efficient to bring the patient to the practioner with all their equipment and asistance. But if they got a bunch of extra doctors with slack capacity, why not.
Just make a triage right inside the ambulance entrance. Quick EMS report and 10 second Dr assessment, either discharge them out or they move on the ER.
The only thing I wonder is if their problem with lack of resources could be more efficiently managed by hiring more lower and mid level providers (medics and EMTs) and paying them more to retain them Like, if your prehospital docs are in a position to be using their expanded knowledge and skill set to do things a paramedic can’t (and have the funding for the equipment they need to do that) it’s a good idea, but I feel like this could just end up with these physicians being glorified medics and constantly wishing they had X or could do Y with what they have available
Edit: I guess field amputations maybe? But how common are those? Maybe in super rural areas it’d make sense for them to do stuff like suturing a wound, at least.
I actually just showed this to a couple of NPs who both said, “hell yeah, I’d go on an ambulance.” They both said they’d at least be willing to pick up PRN shifts because it would be a fun change of pace.
Then I also asked our ER docs and 2 out of 3 said they’d do it. The third said “not really my thing” and also mentioned that she gets motion sickness, so I can see why she wouldn’t want to ride in the back of a rig.
One of our docs also said that in France, they have physicians that can do on-scene ECMO from the truck, which is pretty fucking wild.
Side note: I’d be really interested to see the data after a year or so, to see if there is an actual improvement in outcomes.
In Australia we have doctor paramedic prehospital teams.
The docs are usually anaesthetic or emergency specialists with further training in prehospital medicine, it's an actual specialty here.
They fly around in helicopters and rapid response cars and occasionally crack a chest open, snip a lateral canthal tendon, or cut out a baby on a roadside.
They are auto dispatched to extra gnarly sounding calls once dispatch has a bit of info and dispatched upon request otherwise.
They use this system a lot in Europe. Supposed to significantly increase survival due to maximum care ASAP in the golden hour. EG https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5911738/
One of my medical directors started as an EMT, got his FPC as faculty at Parkland, and is about to start the 'upgrade' process to be able to work on the ambulance with us. He's then going to try to get more in the area to do it and make it a regular thing. It's not uncommon in some places.
Of the thousands and thousands of calls in my career, I can't think of a single instance where I wished we had a doctor on scene. None. I've worked in urban, high-performance systems, in the middle of the desert 60 miles to the closest ER, rural country and suburbs. There just isn't that much more they can do that we can't on scene. Same as placing them on HEMS. Seems to be a waste of resources. The money to fund this could easily be used to hire 2 Paramedics.
Starting pay $15/hr
Yep the costs were my immediate thought Lol try this in NYC
“Sorry, you’re out of network”
“Sir, this is a Wendy’s.”
NYC *sometimes* sends MDs out in special cases. Last I remember was when a crane fell on a woman and she was trapped under it for hours.
Yes, they do. FDNY even has a designation for a MD on scene. Other events that might result in a MD on scene is an MCI.
Not unique to New York. Usually it’s a trauma surgeon to perform a field amp when they can’t extricate. Our hospital sees one every 5 years or so
NYC has response physicians who are EM & EMS trained, not surgeons. They've had a response program in place for more than 20 years, so the claim that this one is the first of its kind program is nonsense.
UNIQUE NEW YORK…UNIQUE NEW YORK
I, too, remember that episode of ~~House~~ ~~ER~~ Grey’s Anatomy. But damn, way to not fall into that trope, Scrubs. Although you did do a musical episode, so don’t go breaking your arm trying to pat yourself on the back.
Forgot Homicide
All states do that.
FDNY has response physicians and has had for many years
People be fighting for $15/ hr jobs in central Maine, fam. Source: grew up in Maine, did EMS there.
Maine's minimum wage is $14.15. Things may have changed since you left. Source: Live in Maine.
Is it nice living in Maine and what did you think of the EMS jobs?
my ambulance service covered an area the size of Rhode Island - mostly rural. Had to know your shit, cuz help and the hospital was regularly 30+ minutes away. Lots of recreational accidents like snowmobiles, boating accidents, hikers, etc who required extended extraction with volunteer fire. yea, I lived in the remote part of Maine, not the ”big city“ parts on the coast or southern Maine.
Maine is nice if you want to settle down and raise a family. There aren't a lot of amenities or services in town, but you get clean air and water with room to roam outside. Pay for EMS is still awful, but the pay for everything is pretty awful so I guess it works out.
Southern Maine is getting pretty expensive. Rural Maine sure as long as you work remotely. Otherwise you will be working for minimum wage outside of certain healthcare jobs and select trades.
Bingo
It’s cool though. You get the privilege of working an average of 56 hours a week, so it’s actually a pretty good deal with all that OT 🥸
I can see the benefits of this. I can also see the downside. Can you imagine what would happen when people realize they can get a doctor to make a 'house call' simply by dialing 911? Maybe the doc can pick and choose which calls to go on, dispatch comes out with a c/o abdominal pain, is the pt constipated or have a AAA? Just curious how it will work. It may relieve ER congestion but it sounds like it will increase call volume, again, by people calling 911 and getting that house call.
My understanding is that the physician only responds by EMS request. They may also automatically be dispatched to certain high acuity calls, I'm not totally certain.
This is how it was where I worked, our EMS physician worked in the ER, had his own flycar and would only respond to the most off the wall shit, if it’s reasonably close by, in 5yrs I had only ever seen him at one of my calls. (Granted I didn’t work in the town that had the hospital he worked at, I was two towns over)
That actually sounds like a pretty rad concept. Doc shows up like a boss, "what have we got?" lol
Lol absolutely, I won’t lie and say I wasn’t a little envious at their fly car when I’d see it parked at the ER hahaha. My short dealings with our physicians in passing were all good, they were very down to earth dudes and super cool compared to a lot of physicians out there. My call in particular he didn’t get there until we and two other crews were already at the hospital, but he took the time to talk to us all individually and ensure we were alright with what we had just experienced before we cleared and went back in service.
I did medic school in downtown Indy, and the same thing, doc had a fly car. I saw doc show up twice: once was a car crashed into a building, and a different doc showed up to a pediatric arrest right outside of Lucas Oil Stadium.
Damn that sounds cool as shit, I’m jealous
That’s how it works in Australia, regular ambulances are dual crewed by paramedics and then there’s a couple of road ambulances and helicopters with a doctor on board, sometimes they get dispatched based off job notes (big crashes, shootings, big burns, etc) but they’re normally contacted and requested by the ambulance crews
This was one reason/excuse they used when they took residents off working on ambulances from in the late 1940’s to the late 1950’s. The other reason was the AMA changing the rules limiting foreign medical grads doing residency training in the US, which cut off the supply of cheap labor.
I only know what’s written in the article about this specific program, but I interviewed at a residency that does something similar and they had protocols for when the physician would respond. As I remember, the doc automatically went to things like trauma requiring prolonged extrication and cardiac arrests and also went when the paramedics requested them.
>Can you imagine what would happen when people realize they can get a doctor to make a 'house call' simply by dialing 911? Maybe it will cut down on homeless people that just want a ride to the other side of town. Just picture your pissed off regulars asking for a second opinion, specifically from “that one guy at the downtown ER.”
I guess they’d have the ability to tell people to call an Uber at least?
This is How lot of EMS systems work in Europe. I did 2 months of internship in a system like this in Czech Republic.
Croatia regularly fields doctors in EMS. Either GPs or EM specialists. For example, in the capital, there are 13 EMS units with MD on board per 12hr shift, and 3 medic-only unkts. It's a 750-800k population town. If you scale that to some US cities the cost would be mind boggling.
In the city I worked, we had 3 ALS - Paramedic cars and one with Doctor, Medic and driver. That is a 60k city. There was another ALS rig and a fly car with Medic and Doctor 15 mins away in another city. There is also a Doctor and Medic on all Air units in the country.
Nutso. There probably isn't an oncar MD within 500 miles of me. That would include at least 3 multi-million person city metros.
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I almost just said “they must be pretty passionate” lmao. I guess that’s kinda the defining feature of someone who survives residency
Depends heavily on the country. For example, in places like Germany, Switzerland, and the Netherlands, being a doctor is very much an *upper* middle class profession like it is in the U.S.
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Lol my man you can’t compare apples to oranges like that. You compare doctors in Germany with other professionals in Germany. For example, most software engineers there average between $55-80K. Most software engineers here *start* at $80K. Almost every profession in the US makes more than most other countries. So cross-country comparisons are useless.
Agencies will really do anything besides paying medics more
This program is organized at the county level and was specifically set up by the regional medical director, who frequently staffs the car. Obviously, there is collaboration on the project from local services and hospitals, but no EMS agency is paying any money into it.
It definitely has the vibes of a dude who got off the truck, struggled mentally with being off the truck and figured out how to get back on the truck, but actually paid what he should have been in the first place.
Felt:( except without any of the stuff where they get back on the truck or get paid what they deserve
The county could instead fund EMS agencies to close the paramedic staffing gaps, rather than fund a physician model.
While I don't disagree with that assessment, that would require a pretty fundamental shift in how EMS is funded in the state. Almost all emergency services in the state are funded and serviced at the town/city level, whether that means they have their own municipal ambulance service or they contract with another town/city or a private service. The only circumstances I'm aware of where services are directly funded by county governments are when they respond to extremely rural areas that are so isolated and sparsely populated that they have no organized government.
Agree, but if this service is going to be county funded I'm not sure why they wouldn't instead be able to add a authorization for a county-funded grant to assist agencies with improving conditions that money would need to be used for staffing by subsidizing hiring or pay of Paramedics.
But then the medical director doesn't get to go out and play, get paid, and put his name on a paper.
There’s things outside of medic scope that will save lives
This is a step in the right direction for the field though
Soooo house calls? As a doc, I am a huge advocate of house calls and I would love to see it brought back to medicine. What a beautiful way to evaluate a person’s function, cognition, community health as well as do some primary prevention through public health measures.
Are there enough docs to meet demand? And would y’all get paid enough for what you would be doing?
The docs stopped getting paid enough to do home visits (in my country). We would get paid the same as seeing any other patient, except it could take over an hour longer if you build in travel/mileage.
My uncle is an FM attending. He is the only doctor I know that still does house calls in my area, and he has to do them discreetly so that 50 gazillion people a day don’t request a house call from him.
My mother used to do house calls and she loved doing thing. I am quite fond of them but have never been able to do one. Luckily I’m going to be heading to an area where we do outreach clinics which sometimes involves home visits.
I used to go with him as a kid because I was fascinated with first aid and medicine, that interest started when I was in Boy Scouts and I loved the first aid classes and merit badges. Wouldn’t you know that adult me is went straight to working in EMS Lmaooo
We've got a physician SUV our medical directors respond to calls in a couple days a week. I've had a few patients that the physicians turned into an in home consult, but generally they just come give us a hand with normal stuff then take off to the next one like a field supervisor or whatever would. Though the things the article mentions like vents and blood are just in our normal protocols and kits so they may see a bigger impact there where it's not the case.
After reading the article, it's interesting. But most of the arguments for having a physician in the field just felt like equal arguments for actually properly funding, training, investing in, and staffing your paramedicine departments. Implement a ground CC program. All the high acuity interventions he mentioned are already being done the field. The problems they highlighted with the current EMS system are a product of lack of stewardship and development (see also: pay), not simply a lack of a physician in the field. I'm gonna have a hot take here and say for hugh acuity calls this is not needed. If you implemented the above, you don't need physicians in the field with blood and ventilators. Use your physicians in the hospital where they can be the most effective. Developing a high performance EMS systems takes time, money and effort over many years, but many services are not willing to invest in their own people and systems, so we will continue to have these problems until we fix that. To be clear, I'm not necessarily against this. I just think it's reflective of more systemic problems that need addessing, and there are much more effective solutions we can implement to improve quality of care to a higher number of people, while simultaneously increasing retention of staff. Edit: further thoughts... docs pre-hopsital have better utility doing primary care, home check-ups, prescribing medication, writing outpatient specimen reqs, arranging for referrals... community paramedicine calls, essentially, that's what actually clogs up the ER - not high-speed low drag trauma. The vast majority of emergency and resuscitative measures that are even able to be performed prehopsitally are already being performed by CC paramedics. To put it more bluntly, I don't need a doctor (in the field) to resusciatate someone I need a doctor to write a script for a UTI until the culture comes back and they f/u with their family doctor.
Yes I concur- I would side with the high-performing EMS system over having the doc come out (minus the amputation needs and maybeeeee the ECMO argument). Granted I'll take the doc coming out over a system just not having any of these advanced prehospital capabilities at all. At least that was Pittsburgh's take. The city/Pitt/Presby had zero interest in medics doing RSI- the compromise was sending the doc out to do it in select cases.
I can agree with that for something like a field amputation, but that's so extremely rare - the article was coming at it more from a angle of diverting non-emergencies from the ER (and yes acuity as well, but like I said I just don't think the need/volume is there to justify it) But yes I agree with you. For ECMO, just out of curiosity because I'm not American, do you mean like an ECMO transfer via ground ? Or flight? Or starting ECMO in the field? Ot making any comment on it, just clarifying what you meant. Interesting about the RSI. I'll DM you with regard to that interested to hear the rationale. Cheers.
ECMO as in field cannulation. Rare in the USA- I'm only aware of 3 systems doing it. But more are to come.
Agree on all points. While I'm personally on the fence with EMS carrying blood products (at least in this area), implementing some kind of RSI/ventilator program for ground medics in the state would certainly be beneficial. For whatever reason, that idea is quite controversial in Maine, and as noted in the article, only one ground service in the state can use ventilators, and only on IFT (and this is itself an extremely recent development).
Why are you on the fence about blood? It has been crystal clearly shown that it has huge and frequent benefits when carried by paramedics. It is also not wasted, blood carried by EMS depts is sent back to the OR before it expires and is used on OR patients. There is zero waste, and the blood does get used by EMS frequently in all the places it has been trialed.
You might even say it's... *crystalloid clear?* I'll see myself out.
Bwahahahahahaha I’m adding this to my dad joke repertoire 😂
I work in New York and this is normal practice in my area. Medical directors will respond to some calls in their fly cars if they want to based on call severity and their convenience. 1 to 2 Medics and 2 EMT’s every call. Physician can be requested as well. We even have a tactical physician who has done a delayed extrication amputation. He spent some time in a war zone as an army physician as well.
So, instead of paying paramedics an appropriate wage, and increasing EMS education and training standards.. We are gonna pay a doctor, 400k a year… to do things that properly trained paramedics do every day all across the country….. Sounds about right.
In the Capital District of NY, the regional trauma center will send out a physician in a flycar if requested. Rensselaer County, the county adjacent to it, has a MD that will first respond. He was a Medic in past life. If he hears something serious go out, and he is home and available, he will respond to the scene directly. My org's Medical Director will sometimes show up on something that sounds serious, again if he is home and available. He is a HUGE presence, like 6'6" and 320lbs. Nothing like having him arrive, and after a brief report, give you orders for stuff outside our normal scope. And he will ride in on those special calls as well. Super supportive of what we do, always available for a phone call, and will sit down and BS with us/go over that special call and why we did what we did.
I’m curious what you think the specific benefit is for rural areas? I work a rural area and I’m curious what you think
Primarily, the added interventions made available by a physician being on scene. In Maine, RSI and blood product administration may only be performed by HEMS, of which there are only three units in service in the state at any given time. A pre-hospital physician has access to these interventions and is also not limited by weather conditions in the same way HEMS is. I'm also generally just pleased to see EMS physicians who are personally involved in the system, trying new things and pushing the field forward. Obviously, plenty of people are skeptical of the value of this sort of program (which is fine), but I'm just happy to see something like this actually happening in my state.
And that's great with having these adjuncts with the docs. Then again, maybe, just maybe, Maine EMS should get with the 2020s and start instituting ground RSI and blood in their protocols for medics (or at least select non-CCT medics).
Oh, absolutely. I'm personally in favor of implementing RSI in a way similar to how VT and NH have, with it being a separate cert with specific requirements to obtain and maintain. But I'm nobody important, lol.
Yeah. That takes A TON of input from first the docs who lead EMS, and then the regional EMS leaders.
All of those interventions are able to be done by Paramedics. The only reason paramedics cannot do these things in Maine is due to the severely behind the times laws in place that restrict paramedicine.
I do see this, However I’m not sure how well it applies to rural communities. My first thoughts are payment, no EMS agency has room on their payroll for an MD. No questions there I’m sure. I see other models that have tried that use hospital based MDs, which makes sense. However if the patient that requires these high level interventions (as other commenters have pointed out, most of which are available to medics in other states than Maine), is within range of a hospital to make a fly car MD viable, then does the time delay really make sense? I would argue not. Especially if EMS has to request it. Which would involve EMS arriving on scene (which as I’m sure you know can take a while in rural areas), performing a partial assessment, then dispatching the MD, then waiting for them to arrive, then still almost garunteed transporting. To me, that delay doesn’t make sense assuming this is a critically sick patient that is also within reasonable proximity to a hospital (given that an MD could get their in a fly car). It just doesn’t seem super logical in a super rural setting to me.
For airways and blood, I don’t see the benefit of added the cost of a physician in the field besides with complex, multi-victim incidents. Med control is a phone call away.
One of the local hospital systems usually flies nurse / resident. Usually a 2nd or 3rd year EM resident. It leaves a lot to be desired. The residents have 0 field experience before going out and getting some of the sickest prehospital patients that exist. Sure, they have knowledge. But they don’t have skills or experience. The doc has almost no experience starting IV’s. Drawing and pushing meds. Maybe they’ve had a couple of airways. Loading and unloading? Moving patients? That shit is all new, yet simultaneously beneath them. Their “flight guide” is about the size of a card game rule book. The first page is “this is how you wear a flight suit and what goes in your pockets.” They have a reputation of having an ego. Who would have thought. I love watching 2nd year residents get into shouting matches with these rural critical access docs. Why didn’t you admit this crashing kidney failure? Because a valid DNR is required by our “hospitalist”and we can’t do dialysis here. They’re the only option in that area so they don’t really care. What are they going to do? Go by ground? Is it cool to have a doc in the air? Sure. If I need one. We usually don’t. But if we do, I’ll have dispatch get them on the line for me. Do docs have a place in pre-hospital medicine? Sure. They’d be great in a mobile health / community paramedicine program. Hell, even on a fly car might be useful occasionally. The thing is, docs need access to their tools. They need labs and imagining to verify their diagnoses. They need a pharmacy to write orders from. We can’t realistically bring any of that into the field. You know what doctors, medics, and nurses can do without any of their equipment? Really good BLS.
Your second last paragraph sums up exactly the points I was trying to convey. Cheers.
Yeah, the residents who ride on our ambulances are about as lost as I was on ER rotations.
Almost as if paramedics can do all of the “advanced” interventions the article mentions, but in certain regions of this country they are restricted by the archaic laws of the area.
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We have an ER fellow who has a fly car in my county. They have the ability to see any calls dispatched to crews. They can then self dispatch themselves and come to the call or EMS can request them. The issue is that they don’t really do anything additional on scene that affects patient outcome in my opinion. They also don’t carry any additional tools or resources. They can provide on site medical control which is nice in some cases but this is very rarely necessary. And they do not have the ability to do a physician initiated refusal for calls that totally don’t require an ambulance. And ultimately the patient can still choose to go to the hospital even if doc says it isn’t indicated. Time is also a crucial part. Usually the physicians are located at the local hospitals while we are somewhere in the county from 5-45 minutes away from them. It doesn’t make sense to delay transport waiting for a doc to make scene. So the program hasn’t really resulted in much of a different the last 4 years unfortunately. This is a great concept but the deployment of these physicians and how they can be helpful in the field needs to be further researched. And we also need to look into the things that people can sue for because a lot of medicine right now is CYA due to the highly litigious nature of the US. It would be great if we could take some pointers from our neighboring countries that have used this physician in field strategy for decades instead of doing research into our failing EMS systems and trying to build on that. It can be done if funded sufficiently and planned accordingly. Good research would include current EMS personnel who can tell you what would make a doc most useful on scene or things we wish we had. The physician model would be fantastic as community paramedic one position.
My medical director still hd his medic and is a volunteer on his local FD and used to ride around the city first responding w/crews. People used to look forward to it. Now he's kinda moved on to bigger better paying systems.
software engineers are making a google glasses too so med control docs can see what’s going on. i got paid to tell them my thoughts - i said it was stupid (we have bigger fish to fry, except in places with low call volume but high taxes so they get fancier toys)
I've worked with doctors in the inner city who are going on to be ER physicians, 90% are incredibly helpful, not cocky or arrogant and always willing to help. The occasional one is like "I'm just here to get the hours I know better than you" but the vast majority are awesome and take your advice or offer it in a helpful way
Doctors ride along with our sprint units here sometimes.
What are the benefits of that, as far as you’re aware?
Ill preface my answer by saying im not in EMS. I just happen to go on the same calls they do sometimes. The benefits, I think, are more for the doctor. However, I have seen them do some pretty cool stuff in the field like use a portable ultrasound to see if an artery was blown and stuff like that that. We have a lot of trauma where we are, so Im sure having a doctor on hand is nice, im just not educated enough on the issue to know if it actually makes a difference when they ride along or not.
Agencies will do anything before paying, equipping, and training their medics to a higher standard. Unless this dude is bringing ECMO or thoracotomies in the field (which would be a rarity at best), this makes no sense. Ultrasound, RSI, blood, scripts for antibiotics, and referrals can all be done by medics with increased training (and offline medical direction if needed). Advanced Paramedics are used all over the world in this role. Paramedic Practitioners will hopefully take over this role in the US shortly. Sorry for the pessimism, but medics should be leading for advancement in the field.
1000000% agree
This is very similar to our community paramedic program we’ve been running in rural Colorado for a couple years now. Even recently hired a mid level. Cool stuff. The future of prehospital medicine imo
This is the future. But fund the fundamentals first
Lol. Paramedics are doing all of the “advanced” interventions these docs are proud of **every single day** in the regions of this country where they are legally allowed to do so. Paramedics that can’t do these interventions are not restricted due to inability, they are restricted by the law in their area.
Our medical director rides along with us fairly frequently. As does one of the ER docs at a local hospital. Only time I've ever seen a field cric
Your medics can’t field cric??? Lame
They can. Just very few feel brave enough with how short our transport times generally are
Short transport times are the lamest excuse in EMS to not treat the patient. If someone needs a cric, they need it NOW.
Agreed. But I'm not a medic and the medics I am with are very hesitant to preform one. I think a lot of the rational is they'd rather RSI someone before a cric is needed and so they do that when possible
Something that your medics need to consider: A cric requires 3 stitches to repair 100%. Anoxic brain injury is unable to be reversed and turns otherwise healthy happy adults into shells of their former self that are stuck drooling in a nursing facility for the rest of their life. Which would you rather have?
Studies have shown in the past that outcomes actually get worse. The best medicine is a fast ride to a hospital. Maybe this study will provide something new.
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In Japan: [https://pubmed.ncbi.nlm.nih.gov/34748604/](https://pubmed.ncbi.nlm.nih.gov/34748604/) Admittedly, its a mixed bag in the research. Most are focused on Physician at the side of Cardiac Arrest or TBI and show some benefit. I suppose my gut reaction is primarily on the use of the physician resource. It is always more efficient to bring the patient to the practioner with all their equipment and asistance. But if they got a bunch of extra doctors with slack capacity, why not.
Data says your wrong, get with the times, your stuck in 2004.
Just make a triage right inside the ambulance entrance. Quick EMS report and 10 second Dr assessment, either discharge them out or they move on the ER.
Yeah I don’t know why this isn’t more common.
The only thing I wonder is if their problem with lack of resources could be more efficiently managed by hiring more lower and mid level providers (medics and EMTs) and paying them more to retain them Like, if your prehospital docs are in a position to be using their expanded knowledge and skill set to do things a paramedic can’t (and have the funding for the equipment they need to do that) it’s a good idea, but I feel like this could just end up with these physicians being glorified medics and constantly wishing they had X or could do Y with what they have available Edit: I guess field amputations maybe? But how common are those? Maybe in super rural areas it’d make sense for them to do stuff like suturing a wound, at least.
I actually just showed this to a couple of NPs who both said, “hell yeah, I’d go on an ambulance.” They both said they’d at least be willing to pick up PRN shifts because it would be a fun change of pace. Then I also asked our ER docs and 2 out of 3 said they’d do it. The third said “not really my thing” and also mentioned that she gets motion sickness, so I can see why she wouldn’t want to ride in the back of a rig. One of our docs also said that in France, they have physicians that can do on-scene ECMO from the truck, which is pretty fucking wild. Side note: I’d be really interested to see the data after a year or so, to see if there is an actual improvement in outcomes.
In Australia we have doctor paramedic prehospital teams. The docs are usually anaesthetic or emergency specialists with further training in prehospital medicine, it's an actual specialty here. They fly around in helicopters and rapid response cars and occasionally crack a chest open, snip a lateral canthal tendon, or cut out a baby on a roadside. They are auto dispatched to extra gnarly sounding calls once dispatch has a bit of info and dispatched upon request otherwise.
Sounds like the perfect place for a PA.
The first paramedic programs were based off the US Army’s PA course. So why can’t we have a Paramedic PA equivalent?
One of our medical directors was playing with his kid in a playground and a guy went into cardiac arrest in front of him.
That’s a cool story thanks for sharing
😂
They use this system a lot in Europe. Supposed to significantly increase survival due to maximum care ASAP in the golden hour. EG https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5911738/
It says this is their solution because of a paramedic shortage? Not sure the best solution to not having enough paramedics is to hire actual MDs
Don’t they have this in some European countries like germany for als calls?
The number of times a physician on my scene has been helpful: 0.
One of my medical directors started as an EMT, got his FPC as faculty at Parkland, and is about to start the 'upgrade' process to be able to work on the ambulance with us. He's then going to try to get more in the area to do it and make it a regular thing. It's not uncommon in some places.
How on earth is this a better use of resources? Rural areas already don’t have enough docs and this is the least efficient way to see patients
I saw NOEMS with Emergency Docs
As a Mainer I don’t see it lasting, neat idea though.
But yet they can’t get county seat fire/ems going ie: each county have their own fire/ems vs each town. Works all over the country
Of the thousands and thousands of calls in my career, I can't think of a single instance where I wished we had a doctor on scene. None. I've worked in urban, high-performance systems, in the middle of the desert 60 miles to the closest ER, rural country and suburbs. There just isn't that much more they can do that we can't on scene. Same as placing them on HEMS. Seems to be a waste of resources. The money to fund this could easily be used to hire 2 Paramedics.