EMS physicians: We still make house calls
A specially trained group of emergency physicians responds with EMS providers to assist with care, build relationships and improve patient outcomes
By Jay MacNeal
Mercy Health MD-1 is a 24/7/365 physician staffed response vehicle available to respond with EMS in the field and assist with patients for 15 counties in southern Wisconsin and northern Illinois. Mercy Health has a long interest in vertically integrated health care and views EMS as a significant part of that integration. The MD-1 program launched in 2013 has grown to four response vehicles staffed by an EMS medical director, Jay MacNeal, MD and seven associate medical directors.
Paramedic Chief asked MacNeal about the history of the program and its components, how MD-1 physicians are selected and trained, the response to MD-1 and how the program has improved patient care.
Paramedic Chief: What is the purpose of a field EMS physician?
Jay MacNeal, MD-1: Football teams would not go to the Super Bowl without their coach nearby. One of the key components of a high-functioning EMS system is an involved coach. That coach is the EMS medical director.
The rationale to have a physician on critical scenes seems obvious to EMS physicians. We knew we could better support our EMS providers with further training, bedside teaching and physician response to critical patients.
There is no better place to see in real time what an EMS system is doing than in the field working directly with EMS providers. Many EMS medical directors participate in field care with EMS providers when they are able. This experience can be obtained by riding with crew members on an ambulance, riding with a field supervisor or by using a physician response vehicle.
Paramedic Chief: What qualifications are needed for the physicians?
MD-1: The MD-1 vehicle is staffed by residency-trained emergency medicine physicians who have an interest in prehospital activities. All EMS physicians who staff MD-1 have served in fire, EMS or law enforcement at some point during their careers. The physicians also staff our emergency departments to retain that skill set and work on the receiving end of our EMS system.
We set our goal to be the kind of physicians who people look up to in their communities as leaders and trustworthy colleagues. We see our EMS providers as every bit as important as any other part of the health care system.
Keep in mind the first 10, 20, 30 or even 60 minutes of critical patient care does not occur in the hospital. The most critical time period of patient care occurs in the field.
Paramedic Chief: What training do the physicians receive?
MD-1: EMS physicians staffing the MD-1 trucks complete extensive training and an orientation program before they are allowed to take independent call on the truck. Emergency vehicle driver training, incident command, hazmat and TEMS training are required. They are mentored by a seasoned EMS physician and approved by the system medical director prior to ever working a shift on the truck.
Paramedic Chief: What equipment is stocked on MD-1?
MD-1: In addition to physician knowledge, the MD-1 vehicle arrives with equipment and medications not routinely carried or even allowed on paramedic ambulances. Ultrasound, chest tubes, central lines, an amputation kit and junctional tourniquets are just some of the extra equipment carried.
The fleet has two Chevy Tahoes and two Chevy Suburbans equipped with lights and sirens for emergency response. All are equipped with local and statewide radio networks for both Illinois and Wisconsin, since we cover 15 in both states.
Paramedic Chief: How have EMS providers reacted to MD-1?
MD-1: Before launching the program, we made extensive efforts to educate EMS providers about what the program was here to do. Despite our best efforts, the program has not been without some road bumps. Some EMS providers were concerned early on that the EMS physicians would interfere, write them up or just be another mouth to feed at the dinner table.
We also needed to work through regulatory issues with Illinois and Wisconsin since this was a new concept. Both state EMS offices sat down with us and worked through a solid process and plan to ensure the program was compliant and served as intended to improve EMS care.
Paramedic Chief: What about opposition from competing hospital systems?
MD-1: We educated competing health systems that the program would benefit them as well, since the skills learned by the EMS providers would also benefit their patients.
MD-1 does not bill the patient or EMS agency. It transports with EMS to the nearest appropriate destination, and when requested to respond, works with all EMS providers regardless of their medical direction.
Paramedic Chief: How did you gain the trust of EMS providers?
MD-1: Building relationships with EMS providers was critical. We knew the MD-1 was a new concept. We did not want EMS providers to think we were taking over their skills or coming into the field to punish them.
MD-1 stands for Medical Director-1, not Mobile Discipline-1. We have physicians do ride time on the ambulance and give extensive training lectures.
Physicians value EMS providers’ efforts and their importance to the overall patient care. Physicians are there when EMS has a concern. Basically, physicians are doing all the things a physician should do in the eyes of their EMS providers and patients.
Paramedic Chief: How has MD-1 improved patient outcomes?
MD-1: Once EMS providers became comfortable with the EMS physicians and the EMS physicians became comfortable with the EMS providers we knew we were on to something. The amount of bedside teaching, critical procedures and integration of the EMS system into the overall health care system was incredible. Clear indicators the program was working were:
- Decreasing door to CT times for trauma and stroke patients
- Increasing cardiac and traumatic arrest survival
- Improving communications between EMS and the receiving hospital
EMS physicians have considerable protected time for field response and really become immersed in it. MD-1 EMS physicians handled on-scene rehab during major events and served as a linkage between EMS and public health during a recent outbreak. They also improved patient stabilization, thus allowing transport to the specialty center initially which reduced time to definitive care.
Paramedic Chief: How has the program grown since it was founded?
MD-1: As the program developed, we continued to grow. In four years, we had three 24/7 trucks with a backup truck available as needed. We have grown from one EMS physician to eight and we are actively recruiting for several more.
The program has been a benefit to both EMS and the doctors. EMS providers can call their EMS medical directors 24/7 for real-time consultation. The EMS physicians feel they are part of the system, see true value to their work and the physicians have suffered less burnout than they had prior to the program.
Paramedic Chief: What are some other MD-1 successes?
MD-1: We have published papers on issues we have seen and improved upon as EMS physicians. Those papers include:
- Effect of station-specific alerting and ramp-up tones on firefighters' alarm time heart rates. MacNeal JJ, et al. J Occup Environ Hyg. 2016.
- Use of haloperidol in PCP-intoxicated individuals. MacNeal JJ, et al. Clin Toxicol (Phila). 2012.
We created Casualty Care Kits for mass wounding events. We helped with ramp-up alarm tones for better firefighter health. We offer community based tactical training. The classroom casualty care program has been presented to EMS providers and physicians at EMS World Expo, the Exemplar Innovation Trauma Center, the Iowa EMS Association conference and the American Association for the Surgery of Trauma) Conference.
We are working on methods to validate physician field response and looking at our European counterparts’ life and cost savings to the system. EMS physicians in the field have incredible value in integration of health care for routine and emergency situations when appropriately trained, equipped, and motivated.
The success of this program is the direct result of EMS providers learning to work in tandem with unconventional responders. Having a physician in the back of an ambulance can make some EMS providers nervous. At the end of the day, we are all here to save and improve lives.
My associate EMS medical directors — Drs. Chris Wistrom, Todd Daniello, Sean Marquis, John Pakiela, Matt Smetana, Ken Hanson and Mitch Li — and I are blessed to be part of the most critical time period in emergency medical care. We are incredibly proud of our EMS providers and their willingness to teach us, work with us and give their best to our patients every day.