Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

OLMC (On Line Medical Command) Requirements Delenda Est

Carthago delenda est.

The secret to appropriate drug dosing is titration. Should a medic who cannot be trusted to titrate opioids, sedatives, and other drugs be trusted to provide ALS care?

“Wait. To the OLMC Batphone, Robin. My Batcompetence will grow 3 sizes on the phone, just as the Grinch’s heart did on Christmas Day.”

Curiously, as the Batmedic completes this OLMC order, his competence disappears like Brigadoon, until he is on the Batphone with OLMC, again – maybe still with the same patient.

When someone is talking on the phone while driving a car, we consider this a dangerous distraction, yet when the same interruption is made in the assessment and treatment of a patient the interruption is expected to have the opposite effect.

Perhaps we should hang up and drive.

Perhaps we should hang up and assess the patient.

Perhaps we should hang up and treat the patient.

Some people learn and develop their abilities. Why is EMS designed to prevent medics from using that improvement in ability to help the patient?

You learn what you do. If you do not learn from this repetition, you are defective and need to be replaced with someone not prone to continually repeating the same mistakes.

The change from OLMC requirements to standing orders has been progressing, like the frog climbing out of the well in the notorious math problem. A little bit of progress, then some recidivism, followed by many repetitions. The progress does exceed the backsliding, but not by a lot.

Medics used to have to call OLMC to get permission to start IVs, then medical directors realized that medics could be taught to make these decisions and we had some early standing orders.

Medics used to have to call OLMC to get permission to give any drug, e.g. “push one amp of the silver box.” Then medics were introduced to pharmacology. After a while, medical directors realized that medics could be taught to make some of these decisions and standing orders were expanded.

There is no demon in opioids or benzodiazepines and these will eventually be administered almost universally on standing orders; administered in doses that would make some of the physicians today blush; administered with few limitations on the conditions to be treated. This is just a predictable continuation of what is already happening. Some choose not to see it.

There will always be places that do not go along, but overwhelmingly the move will be toward more medic autonomy. Not complete autonomy, but changing the physician oversight from the mysticism of OLMC requirements to genuine oversight. Playing whisper-down-the-line with an OLMC physician is oversight in name only. It’s result is an arbitrary denial of care to some patients, a denial of appropriate care to other patients, and permission for only some patients to receive appropriate care. Probably not exactly what Hippocrates had in mind.

There are already places that have the aggressive standing orders that I describe.

It may take ten or twenty years for the rest of the country to catch up.

What is different about those places?

Are the medics with aggressive standing orders killing a greater percentage of their patients than those with OLMC requirements?

More and more medics are becoming doctors and they understand that much can be done for the patient before the patient arrives at the hospital. They understand that making the patient wait until the patient arrives at the hospital may not be consistent with good patient care. Changes in protocols probably do not require any change in the medic scope of practice. This will require a change in the amount and type of standing orders and will require a change to a method of physician oversight that really works.

As increasing numbers of medics become doctors there will be more of a realization that little, if anything, that a medic does is improved by abbreviating the patient assessment and abbreviating the patient treatment to give a hasty report of this interrupted assessment to the OLMC physician.

EMS education needs to be improved significantly, but much of this can be done through remediation. Those who cannot be remediated can be demoted, terminated, or transferred to systems that just don’t get it. Or they could work for the sanitation department – it seems to pay better, has lower quality standards, yet is more important for public health.

The systems that have a bunch of medics showing up on every call will have much winnowing to do. Maintaining skills under those circumstances is impractical. We have been acting as if quantity solves everything. Increasing the quantity of medics makes maintaining the same quality much more difficult. OLMC requirements do not change that.

If the medical directors do not take the lead in directing change in EMS the politicians will. If you want to see that future, just look for the city with the highest concentration of politicians and see if it’s EMS system sets a good example.

The politicians are focused on mainly response times.

If you believe that EMS is primarily a public safety business, then response times may be critically important to you.

If you believe that EMS is primarily a medical business, then taking a little bit longer to get good care to the patient may be critically important to you.

The more we understand about EMS the more we realize that rapid response times are not anywhere near as important as good patient care. Faster response times and scoop and run medical care are not the way to maintain the quality of care or to improve the quality of care.

EMS is presented with many problems.

On Monday, Peter Canning wrote a post about the problems in EMS. Men’s Health: Does EMS Need to Call 911? His comments give you a perspective on many of the problems EMS faces that I do not intend to address.

My other posts on OLMC requirements and Medic X are:

OLMC for President!

OLMC = The Used Car Dealers of EMS?

OLMC For Good Medics

Fun with explosives – NTG.


  1. It’s about time we got some Latin up in here! I also see you are becoming adept at the linky-thingy.A few more observations:1)enough with the hyperbole already. As a fellow Irishman, we both know that our competence can only swell to a maximum of 2 sizes; 2 1/2 tops!2)Thanks to the Cohen brothers and their hijacking of “recidivism” I still think of Raising Arizona whenever I hear that word. Thanks for making me giggle just now.3) As a paramedic who is about to become a doctor (having just passed my step 1 board exam– shameless plug I know)I will be sure to fight the good fight for my brothers. Hopefully we will see progression toward more standing orders in the name of patient care. Good post.


  1. […] medic or the medical director. This is another example of the dangerous Medic X that I wrote about here, here, here, here, and here. Not that I have an opinion on this mistreatment of patients by medical […]

  2. […] do appear to be afraid of upsetting the OLMC (On Line Medical Command) requirements […]

  3. […] OLMC (On Line Medical Command) Requirements Delenda Est […]

  4. […] for President! Thu, 27 Mar 2008 17:23:00 +0000 By Rogue Medic 3 Comments The justification for OLMC (On Line Medical Command) requirements is usually “Well you wouldn’t want Medic X treating your mother (or daughter, or […]