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EMS medical direction: Why physicians should ‘get out there’

There’s nothing like hopping a ride in the back of an ambulance and observing or providing care at the scene

Out-of-hospital medical care means care provided outside a medical facility and examples include terminal care, home health care and, a long time ago, the “house call.”

When out-of-hospital is used for acute care or critical care, it means care provided in the prehospital environment or during an interfacility transport. Prehospital care is provided to a patient prior to delivery to a medical facility and is generally provided by ambulance personnel and scene first responders.

Prehospital care is commonly referred to as EMS or Emergency Medical Services, although that term also applies to a broader system of emergency care. You would think that most physicians who practice emergency medicine would be EMS experts but that’s not necessarily true.

Many emergency physicians were trained at a time where EMS was not a part of their curriculum; or were trained in a different medical specialty before starting a career in emergency medicine; or just haven’t been actively involved with EMS.

Today, most or all emergency medicine residencies include EMS in their educational program and some offer EMS fellowships. And that’s great for those services that have a medical director who is board certified in emergency medicine and active in EMS or has practiced emergency medicine for a long time and has made EMS a part of their practice.

But the reality is that many, if not the majority of EMS medical directors across the United States are not residency trained emergency medicine physicians and/or do not have a background in EMS. They are mostly volunteers or minimally compensated physicians who agree to be the medical director for the local EMS service.

It is important for these physicians to recognize the medical director’s responsibility for the quality of out-of-hospital medical care provided by their EMS organization — even if they were told when they signed on that their involvement would be minimal and not take much of their time.

It is also important that the medical director is aware of any statutes, rules or regulations under his or her state licensing authority that may delineate the physician’s responsibility as the EMS medical director.

The volunteer or semi-volunteer EMS physician is an essential element in maintaining the quality of care provided by the EMS system regardless of size. This is accomplished primarily through developing and maintaining a process to monitor and sustain the accepted standard of care.

That doesn’t mean the medical director does all the work but it does require that the medical director understand EMS and EMS systems, and the process of quality improvement as it applies to out-of-hospital medicine.

For those physicians without an EMS background but a desire to be an active EMS medical director, help is available. Your state may offer or even require EMS medical director training. There are online resources for medical director training such as the Guide for Preparing Medical Directors available at

The National Association of EMS Physicians ( ) offers face-to-face medical director courses every year. And by the way, every EMS physician should be a member of the NAEMSP, an organization that is dedicated to EMS and the EMS physician.

NAEMSP provides educational opportunities, position papers, resources and reports on EMS topics, plus opportunities to serve on EMS related committees and the publication of the only peer-reviewed journal for out-of-hospital medical care: Prehospital Emergency Care.

Another resource for the EMS medical director is the American College of Emergency Physicians ( ), offering various EMS publications and policy statements, plus a prehospital section in their journal, The Annals of Emergency Medicine.

To maximize the educational opportunities noted above, there’s nothing like hopping a ride in the back of an ambulance and observing or providing care at the scene along with those who look to you for medical direction.

And it’s OK if you’re unsure what to do once you get there — just ask. Initially you may be assigned a job like holding c-spine, which gets you out of the way of the field providers but to your advantage gives you the best view of what occurs on scene.

Prehospital providers will tell you “it’s different out there” and you need to become familiar with that difference, which means you need to go out there if you have never done so.

Not only do those experiences familiarize you with how things actually operate in the field, you gain credibility as their medical director; you’re a “field doc”.

The downside of being an active, involved medical director is that you may find it so rewarding that it begins to consume time that was once devoted to other activities. On occasion, EMS medical direction may feel more like a hobby as it takes up your free time and costs you money.

But if you get over extended and find yourself spending too much time in the back of a rig or figuring out how you can expand or improve the services provided, you may be able to find a local chapter of EMS Anonymous for excessively active medical directors or perhaps start one of your own to help contain your increasing ambulance addiction. Good luck.

Jim Upchurch, MD, MA, NREMT, has focused on emergency medicine and EMS while providing the full spectrum of care required in a rural/frontier environment. He provides medical direction for BLS and ALS EMS systems, including critical care interfacility transport.