Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

What Do You Want From Your Medical Director – Part I

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On FaceBook, Dr. Jeff Meyers asked a very important question.

If you had your way, what are the top 3 three things you expect from your medical director? Discuss, discuss!

A surprising (to me) number of people responded with a desire for some respect. I guess that I have been a bit spoiled, because I have not really had that problem. I have had over a dozen jobs in several states. Even when I have completely disagreed with the doctor, or the doctor has completely disagreed with what I have done, there has always been communication. The communication has been been in both directions, up to a point, but all conversations reach an end. Just because I would like to continue the conversation does not mean that the doctor should feel the same way.

I have occasionally been treated rudely by doctors, but usually that is just a misunderstanding. Occasionally, this is just a jerk doctor (we have jerk medics, too), or a topic on which the doctor is a jerk (as medics, we have some topics that we may be jerks about, too), so I do not see this so much as a problem coming from the doctors as much as we are not initiating communication.

My comment was –

I have only rarely had a medical director who would not spend time talking with me – as long as they were not busy. I have also spent a lot of time talking with doctors who are not my medical director. We need to stop being afraid to go up to a doctor and say, “If you have a minute, I would like to talk with you about this patient,” or something similar. Unless I have another call, I can stay with the patient until after the doctor has examined the patient, observe the examination, and ask the doctor what I should have found. Most doctors have taken the time to discuss the care of my patients with me. Is there any GOOD reason we need to leave the hospital immediately? If there is a reason, it is not the fault of the doctor.

In other words, I think that our biggest problem is often ourselves.

Yes, I have worked in Mother May I? systems and I gave more morphine in one Mother May I? system than any paramedic in the neighboring county that had standing orders for morphine.

I had to call to get permission to give even 1 mg of morphine to a 200 kg patient.

I also worked in the neighboring county that had standing orders for up to 0.2 mg/kg morphine for chest pain, burns, and for musculoskeletal pain. For the so called average adult patient of 70 kg (154 pounds), I would not have to call until I reached a dose of 14 mg of morphine. I don’t think that it is common to have adult patients as small as 70 kg, but . . . .

Is the problem that the doctors won’t talk to me?

Is the problem that we won’t talk to the doctors?

Doctors are people. We may chat with them about social topics, but we seem to shy away from discussing medical topics.

Before we start complaining that we do not get any respect from our medical directors, we need to show them that we know enough about patient care to have a conversation.

Maybe as a brand new medic there is a fear that we do not know enough to have a conversation with a doctor. We need to ask the doctors to teach us, so that we do have the knowledge to carry on conversations about medical care.

If doctors teach medics to assess patients better, we can do a better job of treating the patient according the the right protocol – or at least treating the patient in a way that is least likely to cause harm to the patient.

If we learn to just call command and follow orders, why would a doctor think that we know enough to be treated with respect?

I agree that a medical director should reach out to all of the medics that medical director authorizes to treat patients.

Those patients are the medical director’s patients.

But this does not mean that we cannot start a conversation with our medical directors or with any doctors.

When I call for orders for a controlled substance I always try to talk with the doctor afterwards to explain what I gave, what changed, and to thank the doctor for orders, if orders were necessary. With my current protocols, I do not need permission for a lot, but there is still plenty of room for improvement. EMS is continually improving and changing. Our protocols should be as well.

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Comments

  1. 1. Respect my knowledge, and know that I know what I am doing. Get involved with the medics at my service, and you will be pleasantly surprised at our abilities.
    2. Give me the tools, medications, and interventions that are required for me to take appropriate care of my patients. Don’t make me ask permission for a life-saving intervention.
    3. Understand that medicine is a changing field, and be prepared to adapt. Attend continuing education with us.

  2. Be an expert in prehospital medicine. Understand the controversies. Don’t be the last to adopt something good or useful. Talk to the ED physicians at the receiving hospital. Be an advocate and a liaison and a mentor. Screen new paramedics in the system. Sit them down and explain your expectations at the first opportunity. Make sure we are adequately medicating patients for pain. Don’t tolerate bad medics but always listen to both sides of the story.

  3. Provide appropriate and CONSISTENT education/training/supervision/remediation/discipline/whatever else to all providers and services in your systems. Don’t just single out one service, or one provider or one level, be it BLS, ALS, transport, non-transport, aeromedical. Hold everyone to the same standards and have the guts to not play the political games and do what’s right for the system, which will also what’s right for the patient. Do what’s right for the patient and don’t be afraid of being yelled at for stupid reasons. But again, I ask too much, maybe I should just drive the bus.

  4. I always run into problems when the docs and nurses don’t know me because I don’t go to that hospital very much. I have also ran into the occasional “I’m a doctor, and I am always right.” Type. Coming from being an army medic at a hospital to the prehospital still is an adjustment, but I am never afraid or think that I can not talk to a doctor. I actually enjoy talking over a pt that I brought in, and new things that are coming out. Honestly I am a kid in a candy store when it comes to my job. It would be nice to have monthly meetings for this. I think that if becoming a prehospital provider, no matter the level, was a bit more selective doctors would trust is with a lot more. It is the med directors pt when all is said and done. I think that bridging the gap between prehospital and hospital would go a long way for pt care. There is so much more that we can do for our pts on both ends with a little trust and training. I know there will always be politics, but in the end it is about the pts.

  5. Get involved with the organization your direct. Get to know your providers and their abilities. Garner their trust so they can garner yours. Don’t treat your medics as uneducated blue collar workers. Many are better educated and experienced than you realize.

    Medics, doctors are people too. Yes, there are some jerks out there, but as Rogue Medic states, there are plenty of jerk medics out there too. Don’t be a jerk. Be a professional. Don’t be afraid to talk to the doctor. Who knows, you may learn something, and so may s/he.

  6. Communication is the biggest issue. I’m lucky to have worked in a system where the medics know the medical director and vice versa. We’re comfortable enough with our medical director that most medics call him by his first name. I don’t, but only because I’m a traditionalist. I do call the other medical control docs by their first names, unless I’m angry with them. Then, like the parents, I call them by their full names.

    In all too many systems, the medical director is just a name to the medics and the medics aren’t even that to the medical director. It shows by the quality of care given.

  7. I work in a small Northwest Iowa town that due to the climate of the area has 10 transporting ambulance services in an area that only should have 3 proficient services. Due to this, we only get roughly 400 calls a year. (911+transfer) While this has an immense problem with skill fatigue, especially considering I only work part time, they were smart enough to realize they can get a lot of use out of us in the ED. Thus, we work in the ED in essentially the role of an ER nurse (There are somethings we can do that they can’t, and some things we can’t do but they can, so its a shared relationship). This allows us to maintain much of our skill level, maintain an active dialogue and regular communication with all the physicians, and gain the physicians trust. Due to this, we have all standing protocols and after a call, if we have any questions as to how we treated the patient, we always have a chance to talk to them. Due to this system, we have very few issues with our doctors and have generally trusting relationship.
    I like your encouragement of discussing cases with the doctor. If they see that you are willing to learn from your experiences and work to improve yourself, they are going to be much more receptive and much more trusting in your assessment/judgement when you call and ask for orders.
    It comes down to, you show an active respect for them, they will show an active respect for you.

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