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

- Rogue Medic

Is Direct Medical Command Pointless?


In some places, OLMC (On Line Medical Command) permission requirements are still used.

Isn’t it dangerous to get rid of this physician oversight?

We can’t have a bunch of cowboy medics doing as they please – OLMC requirements are necessary to stop these dangerous medics.

Or is that the wrong way to look at physician oversight?

Physician oversight does not come from a phone call, a radio call, or any other pathetic substitute for real physician oversight.

Biophone Model 3502 – the Original Biophone from Emergency! – similar to the APCOR (Advanced Portable Coronary Observation Radio) I used to use.

The magic oversight phone call only encourages medical directors to approve dangerous paramedics on the assumption that they will have to call to do anything dangerous.

This is nonsense.

We can strap patients to a backboard and not manage the airway and arrive with a dead patient. How would a magic oversight phone call prevent that? What would prevent that is having higher standards and a medical director who is involved in observing the transfer of care, from medic to nurse, in the ED.

Then “there was a movement from on-line orders to offline protocols,” a slow but steadily increasing reliance on evidence-based procedures for specific situations, Dr. Bledsoe explained. And it made sense. “When you take the on-line component out of this, care is faster,” he said. In fact, he spoke directly with a paramedic in the field only a few times in the past few years, and most often it was regarding termination of resuscitation or a similar high-risk situation. “They are well-versed, and we are crazy-busy,” he explained.[1]


What if OLMC requirements do work in some systems?

Seattle has very high standards for their medics, but the medical directors still micromanage patient care.

This kind of medical control has paid off for a few systems, but very few, according to Michael Callaham, MD[1]


Has it worked, or have other aspects of the system made the problems harder to notice?

No evidence is provided that any OLMC requirements anywhere have made anything any better.


Why take the medic away from assessment and treatment to have him tell the doctor something designed to convince the doctor to give the orders the medic wants?

No good reason.

Why take the medic away from assessment and treatment of patients already in the ED (Emergency Department), to give the orders the medic wants?

No good reason.

Why encourage the medics to keep track of which doctor is working where, so that we can avoid calling the doctors who do not understand EMS and refuse basic treatment orders?

No good reason.

Do OLMC requirements improve patient care?


Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 “command” runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by chi 2 analysis). The on-scene time interval did not increase with the "standing orders" system.[2]


The autonomy of paramedics at his center would have been curtailed by now if they had seen adverse outcomes, “but that hasn’t been the case,” he stressed.[1]


The real dangerous people are the doctors who use excuses to not provide competent oversight.

OLMC requirements are incompetent oversight.


Go read the whole article.



[1] Special Report: Is Direct Medical Command Pointless?
Scheck, Anne
Emergency Medicine News:
April 2013 – Volume 35 – Issue 4 – p 8–9
doi: 10.1097/01.EEM.0000428924.57911.25
Special Report

[2] Decrease in medical command errors with use of a “standing orders” protocol system.
Holliman CJ, Wuerz RC, Meador SA.
Am J Emerg Med. 1994 May;12(3):279-83.
PMID: 8179730 [PubMed – indexed for MEDLINE]