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

- Rogue Medic

OLMC For Good Medics


You claim that
requiring OLMC (On Line Medical Command) permission to treat patients does not work and actually lowers the quality of medic in a system. You state that Medic X, the example of the dangerous medic, is made worse by OLMC requirements. But, at least, OLMC requirements help the good medics. Let’s call this one Medic A.

Even better, let’s call this example of a good medic – Medic AD – everybody should be able to trust that Medic AD provides excellent care.

OK. Then why wouldn’t OLMC requirements help Medic AD?

You’re asking the wrong question.

The question should be How would OLMC requirements help Medic AD?

Consider it asked.

First – the goal of Quality Control, Quality Improvement, and all other CYA stuff is to improve the quality of the care the patients receive, or to create the appearance of controlling, or improving, or assessing the quality of the care the patients receive.

Focusing QC/QI/CYA on the medic is missing the point – it is about the patient.

How the medic does the job is not the important thing compared to the effect on the patient.

So, how does the need to get permission from OLMC to treat the patient benefit the patient?

The medic, even Medic AD, is not a doctor. He doesn’t know as much as a doctor.

Yes and No.

There are plenty of physicians who just do not understand all areas of emergency medicine.

What ? ! ?

The most obvious example is pain management, such as aggressive fentanyl administration on standing orders.

But these are powerful drugs!

Are there any drugs that a medic carries that are not powerful?

Maybe, but I think I see your point – if all, or almost all, of the drugs a medic uses are powerful, why treat these differently?

That is a good question.

So, what is the answer?

Gosh, I would have to be a psychiatrist – like Dr. Deborah Peel – to be able to diagnose a bunch of physicians without ever having met most of them.

So, you think the problem is psychological?

Not entirely, but there is more than a bit of paranoia about pain medication.

I believe that a lot of this is paranoia and due to a lack of understanding of the medications.

Let me give an example that is typical of what I hear from physicians defending OLMC requirements. The following comments are not at all unusual for conversations I have with medical directors. This written communication just did a wonderful job of bringing so many of them together.

It seems you DO have an opinion, and a sarcastic one at that. But that is beside the point.

Yes, I have an opinion.

Yes, I express it with more than a hint of sarcasm.

You see, you feel comfortable bashing the med control doctors out there because its not YOUR license on the line, and the med control MD hasn’t even seen the patient yet.

So, if I make a mistake the doctor’s license is on the line?

Please, somebody comment about any case where a doctor lost their license because of bad care by a medic. Anyone.

You see what I mean about paranoia?

So, if I make a mistake my license is not on the line?

Why does the doctor need a phone call for permission when it is pain management, but not arrhythmia, or cardiac arrest, or anaphylaxis, or respiratory distress, . . . ?

Paranoia.

Its not YOUR so-called “deep pocket” that the lawyer for the patient who, in so much pain that EMS felt the need to give repeated boluses and later respiratory arrested, are going to go after. While I’m sure in your jurisdiction this doesn’t happen, even in the best of EMS systems there are those few EMS personnel that are either new, inexperienced, or just plain too ignorant to know the dangers of too much analgesia.

Sounds as if I found one of those physicians who is comfortable authorizing medics to treat patients, while knowing that these medics are not safe to treat patients.

OLMC to the rescue!

That will fix everything.

After all, just because they are too stupid to deal with pain management without a magical phone call doesn’t mean they can’t handle life threatening emergencies safely.

If they can’t handle something as simple as pain management – relatively simple if you are well trained – how will they handle a difficult airway?

But, maybe he isn’t the medical director for all of the medics in the system and he just doesn’t trust medics from other organizations.

How many of you out there can truthfully say that you haven’t had at least one case in which a big tough guy had apnea after only a minimum of versed or MSO4?

Again, comments please! Has anyone ever had this happen?

I adjust the dose to match the patient’s weight, underlying health, age, and current condition – then I reassess and determine if more is needed. I keep doing this until side effects discourage further treatment, or I run out of medication (or orders), or the patient is tolerating the pain well. I am always limiting the rate of administration, since most side effects are rate related.

I have never seen this miracle apnea, the doctor describes.

Or one of my most “treasured” memories, the call from EMS who had an unconscious victim and after administering the impaired protocol, called med control for morphine orders because the patient had just “come around and he was screaming in pain”.

Hmm. Unconscious “victim?”

I have addressed appropriate use of naloxone elsewhere.

Maybe a cancer patient treated inappropriately with naloxone?

Point is we are only a voice on the other end of the line sometimes. We cannot see what you see, only hear what you have to tell us.

For a moment, just for a moment, there is reality.

Sometimes we know exactly who you are and what you are all about and we can trust your judgement.

Right here, the doctor states that he does not have a problem with Medic AD using his judgment.

He doesn’t go as far as to say that Medic AD would not benefit from OLMC requirements, but he does suggest that he would automatically give Medic AD the orders being requested.

So, what would be the point of having Medic AD call OLMC before allowing the patient to receive treatment?

OLMC can then hear a familiar, trusted voice and relax.

It is all about the paranoia.

But other times you are simply “that voice over the radio”, the volunteer EMS system from “BFE”, the requested order from an RN who runs into the trauma room asking for morphine for EMS while you are trying to intubate someone,

Doesn’t that sound like a system that works well?

Would you like to be a patient there?

and sometimes, albeit rarely, you are simply another EMS provider who likes to give morphine to everyone, regardless of chief complaint.

This isn’t even using the lowest common denominator to justify OLMC requirements.

This is a medic who makes Medic X look good.

So, why is this medic still working?

OLMC requirements allow medical directors to justify keeping this worse-than-Medic X on the street and pushing drugs.

OLMC requirements endanger patients.

Requiring Medic AD to call OLMC to ask for permission to do what he knows how to do is only interrupting assessment and treatment, delaying patient care, and creating the possibility that an OLMC physician does not give orders that are appropriate for the patient.

The objections from most doctors, who are supportive of OLMC requirements, seem to be most focused on the physician’s ability to control things.

The problem with OLMC requirements is that they are barriers to patient care.

This is about patient care, not physicians’ need for control.

My other posts on OLMC requirements and Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

Fun with explosives – NTG.

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  1. […] 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 […]

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