EMS World

AUG 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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EMSWORLD.com | AUGUST 2018 23 needed hard skills. They should also have familiarity with modern EMS, and hopefully certification in that ABEM subspecialty. For every major system with a well-known rock- star doc, there are multiple others whose medical direction comes from a contracted physician at a local hospital who may not have experience with field medicine. "You don't want someone you have to explain push-dose epinephrine to, or whom you have to fight to use ketamine," says Bouthillet. "You'd hope it's someone who's kind of dialed in to modern EMS practice." Most systems don't get medical control from the type of high-profile PubMed- heavyweight EMS physicians who speak at the Gathering of Eagles or get quoted in magazine articles. Many can't pay for full- time medical control docs to be involved in the day-to-day and focused on improv- ing care. Instead they pay for intermittent guidance from a doc who may be willing but have multiple other priorities. Beyond the hard skills lie some key per- sonal qualities. First is open-mindedness. There will be other smart people at that decision table. A doc should know what he/she doesn't know and when to defer to those with grounding in other areas. Medical control also requires leadership. Leaders can pursue change but understand poor performance usually has more roots in bad systems and structures than bad people. They wield the same soft skills at the meeting table as they do at the bedside. Finally, there's little substitute for cred- ibility when promoting a vision. A medical control doc can carry that from having an EMS background and having served in the trenches or earn it through fierce advo- cacy for their crews. One example: After he initiated a spinal-clearance protocol at North Carolina's Wake County EMS, then- director/medical director Brent Myers once reportedly got up at 3 a.m. to set straight a new attending who'd chastised a medic crew for not backboarding. "You don't see that every day," says Bouthillet. "One thing I can tell you about [fire and EMS providers] is, if you're cred- ible and they know you're going to go to bat for them, and you show them respect and understanding, they'll jump over the moon for you—they'll do anything. But if you come at them the wrong way, you're chum in the water, and you won't get a second chance." Bringing Them Together There's not a simple answer to minimizing problems between the clinical and opera- tional interests of modern EMS—both sides are complex and not getting easier. But here are some ideas to consider. • Fit—Before you ever swipe right, make sure the chief, doc, and top personnel are philosophically in tune. If you're a more con- servative department, great, but avoid a cutting-edge doc who wants to try a lot of new things. If you're a progressive depart- ment used to pushing care envelopes, a late-adopting skeptic isn't your best MD fit. "They have to be somewhat aligned," says Frank Babinec, chief of Florida's Coral Springs-Parkland Fire Department. "If you have a chief who's trying to move things along and a medical director who's not willing, or a medical director who wants to move things forward but a chief who doesn't, that's not going to work." • Qualification—A medical control phy- sician or medical director in EMS should be familiar with prehospital medicine, not just the ED. Ideally they should hold an EMS subspecialty certification. • Data—Collect as much outcomes and other data as possible about the care you provide and the effect of changes. "We're fortunate to have a data analyst working for the department," says Babinec. "This helps us evaluate everything we do." • Buy-in—Successful change requires the support of line personnel. Involve them as much as possible, through mechanisms like protocol and equipment committees, in weighing and making changes. No one likes imperial edicts handed down. Also, training all members as a team can help build unity and underscore and reinforce the value of all aspects of the mission. • Collegiality—This boils down to soft skills like communication and holding each other in basic respect. Docs talking down to field crews shouldn't be tolerated. Similarly, ops chiefs may not realize their decisions can affect the delivery of quality care. • The org chart—Think carefully about the role of your medical control physician and where he/she should reside on your org chart. "One of the things the grand jury called out here in San Diego was that my replacement was appointed to report to a deputy fire chief," says Dunford. "When I was EMS medical director when the system was created in 1997, I didn't report to the fire chief at all—I was accountable to the community, as their physician." Deep Divides Generalizing about medical/operational conflicts is almost impossible. Systems are different, personalities unique, anecdotes aren't data. But clearly problems can occur across resources, culture, and more. Clashes are often blamed on differences in personality. Really they often go deeper. "I think personality really has little to do with [conflicts]," says Richmond. "It has to do with profound philosophical differences about what the roles of these services are, as well as the different skill sets, training and experience these individuals bring to their positions. "In most systems I believe it's the oper- ations that drives the medicine, not the other way around. We talk about financial sustainability, but even from the opera- tional end—staffing, scheduling, retaining tenured providers, discipline, all of that, in addition to basic quality of care and safety of patients—I think we would do so much better if the medicine drove the operations. But that's not really how most services are constructed. If we don't provide personnel with the tools to ensure appropriate clinical decision-making on the front end and don't have the necessary resources to quality- assure that decision-making on the back end, then the emphasis will continue to be on process." "Ever y EMS system is at a starting point, and you go through certain eras as a department," says Bouthillet. "I need a doctor who can help me get from where I am to where I want to be. To me what we're talking about is improvement culture. But to make that happen I think 100% requires those soft skills. Otherwise, it's like a mar- riage: A lot can go wrong." ABOUT THE AUTHOR John Erich is senior editor of EMS World. Reach him at john. erich@emsworld.com

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