Pediatric emergency medicine trisk 1152

different set of actions for basic, intermediate, and paramedic providers, and separate sections for adult and
pediatric patients. This protocol also clearly highlights when to contact online medical control for additional
guidance. This enables the providers in the field to have a pre-established, physician-evaluated course of action
for most patient care situations.
Online medical direction requires real-time communication between an EMS provider and a physician or
delegated surrogate (physician assistant, nurse practitioner, registered nurse). EMS systems should have protocols
for when online medical direction is required. Situations may include when additional doses of medication are
required, when patients are not responding to the steps outlined in offline protocols, or when patients or parents
are refusing EMS transport. Hospitals that provide online medical directions are commonly referred to as “base”
hospitals.
In some cases, a physician may serve in the role of a field responder. This may be a physician who is serving as
a service’s medical director, or a specialized provider or an EMS trainee/fellow in a larger system. Although the
field is not the typical practice environment for physicians in the United States (it is much more common in other
countries), there are distinct advantages to having a physician responder in certain situations. The first is that they
may provide direct medical control to the intermediate and paramedic providers on a scene. Second, they may
bring the ability to perform advanced interventions for patients with specialized needs, such as a field amputation
of an entrapped extremity. Third, they may play an important role in the management of complex incidents, such
as a mass casualty incident.
EMS fellowship training programs have been present since the early 1990s. The American Board of Medical
Specialties approved EMS medicine as a recognized subspecialty of emergency medicine in 2010, and
fellowships became accredited thereafter. The first board examination for recognition of EMS-specialized
physicians, administered by the American Board of Emergency Medicine, was offered in 2013. EMS fellowships
are open to physicians trained in multiple fields, including pediatrics. A list of available EMS fellowships can be
found at .

EMERGENCY MEDICAL DISPATCHERS AND DISPATCH PRINCIPLES
When an EMS system is activated, this places into motion a chain of events to efficiently deliver the most
appropriate personnel to the patient for safe transport to the most appropriate receiving hospital. There are many
steps to achieving this ideal goal. It is typically the parent, caregiver, or bystander who recognizes that a child
requires emergency medical help, and contacts EMS through the 9-1-1 emergency number. Ninety-nine percent
of the U.S. population has 9-1-1 services, with many having enhanced 9-1-1 (E-911) services that provide the

dispatcher with the address of the caller. Using a cell phone to contact 9-1-1 is increasingly common, and
improving technologies (wireless E-911 systems) can allow for the localization of the caller using the global
positioning satellite (GPS) technology built into many wireless phones.


TABLE 134.2
EMS MEDICAL DIRECTOR RESPONSIBILITIES


Clinical care

Communications

Field clinical
practice

Physician clinical
role

• On-scene medical direction
• Current knowledge and skills
• Knowledge of incident command system

Personnel
education

• Training for base station and out-of-hospital personnel
• Evaluation of medical competency of providers
• Collaborative relationships with academic institutions
• Continuous quality improvement

• Mechanism for data collection
• Ensure compliance with protocols
• Analyze system efficacy and cost-effectiveness
• Application of research methods
• Collaborative relationships with academic institutions
• Reliable methods of data collection
• Information flow from out-of-hospital to ED to inpatient care
• Standards for base station education and physician field
experience
• Qualifications and training for delegation of authority for online
medical direction to surrogates
• Resolution of disputes involving medical care within EMS
system
• Interactions with national, regional, state, and local EMS
authorities
• Coordination of emergency preparedness activities
• Educator and liaison to the media

System evaluation

EMS research

Administration

Liaison activities

Finance

Public access
Public health

• 9-1-1 system
• Training and continuing education of dispatchers
• Dispatch protocols
• Prearrival patient care instructions
• Dispatch criteria
• Continuous quality improvement
• Qualified online medical direction
• Training and credentialing of personnel
• Verification of skill proficiency for personnel
• Protocols for transport and nontransport
• Protocols for interaction with responders
• Protocol for online medical direction
• Transport and destination criteria
• Authority to limit activities of providers for cause
• Continuous quality improvement
• Equipment specifications

Public education

• Budgetary planning
• Grant application
• Establish funding priorities
• Collaborate with community to guarantee access to EMS
• Appropriate EMS utilization, prevention of emergencies
• Initial approach to common emergencies
• Community health assessment and surveillance


Illness and injury

prevention

Legislation and
regulation

• Injury and illness prevention for EMS personnel
• Assessment of community’s needs
• Collection of data-identifying factors contributing to illness and
injury
• Public education
• Participation in development of legislation
• Participation in local and national EMS organizations

Integration of
health services

• Integrate EMS interventions into health care
• Identify outcomes of patients accessing system
• Collaborate to community’s health surveillance

Information
systems

• Adoption of uniform data elements and definitions consistent
with national standards
• Integrated information system allowing exchange of vital
information
• Legal protection of all data related to continuous quality
improvement

Adapted from NAEMSP Position Paper.