Question on medical directors and calling for orders

[PA-C Texas]

Hi, my name is James and I am a Licensed Paramedic and PA-C in Texas. I work in a small ER and also moonlight PRN for a 911 service and a helicopter service, usually about twice a month for each.

I sort of work in a dual capacity on these services and have both medical directors as supervising physicians to work as a PA. The only time I have to call for anything is for Morphine with the ground service because our pain management protocols are somewhat limited and I cannot prescribe Schedule II controlled substances. I don't have to call for things like exceeding the recommended dosage etc. on other drugs because I prescribe them under my own license since I have collaborative agreements with the supervising physicians.

When I do call for morphine on the truck, I call the hospital and speak directly with the the attending physician for orders, and I have even gotten in the habit of giving patient report directly to physicians over the radio when transporting a critical patient. I realize that this is partly because I work with physicians all the time, but IMO, Paramedics work as an extension of the physician much like PA's do. I was wondering what everyone else does. Do you talk to a nurse when requesting orders?

Paramedics are trained in the medical model just as I am or a doctor is, and we work under the direction of a licensed physician. Do you talk to the doc or to a nurse when you call for orders? I will give nurses report on stable patients, etc. but I believe we need to have better communication with our ER docs, so I try to get them involved. When I get to the hospital, however, I always give report to the nurse AND the physician or PA/NP and have them sign my documentation. I cannot transfer care to an RN because of abandonment issues.

I know when I am working ER and an ambulance calls me for orders, I try to get involved and be a resource for them. I get to play a little more than my fellow medics, but they get to play a little also when I am around (don't tell anyone ), and I always try to educate them just like they educate me. I am sort of on the divide here because I consider myself a Paramedic as well as a Physician Assistant, so I am trying to bring medicine and paramedicine together. What kind of involvement do you have with your medical directors or the ER docs you regularly see? How do they treat you? How do you treat them? I think if we as Paramedics start acting like a part of medicine then we will be treated like we are.

I am starting medical school this summer (starting to have second thoughts), so I think I will have to drop my EMS work, even though I want to continue to be involved with EMS. Hopefully being an MD will give me an even better advantage in advocating for us lowly paramedics, but I encourage each of you to try and foster a good relationship with MD's (AND PA's if you are around them), because I think it would enhance both professions. Don't be afraid to ask for a doc when you are getting on the horn asking for a drug order, or just asking for some good advice.

-JAMES

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[Apollyon]

In New York (upstate where I worked as an EMT-P, and City, where I went to med school), paramedics get orders from MD's only. Period. Ever. No mid-level providers or nurses ever answered the phone, except to answer it and say, "Wait for the attending". That was also an aspect of the EM residency - EM2's and higher would also answer the phone for direction.

As far as the report, if I was asking for orders, the doc would have the story (since I had to 'sell' the doc on it). Generally, though, we either 1. didn't call on the radio if it was basic or 2. called over 325 or 340 with the concise report ("70, SOB, rales, lasix, morphine, ntg, improved, 4 minutes", or "80F, cardiac arrest, asystole, tube, line, 3 minutes").

 

[PA-C Texas]

I was not trying to imply that nurses can give orders (they need to stick with minding their foley catheters and 1500 calorie diets). However, I am allowed to give orders on behalf of the medical control physicians where I work without consultation when no physician is present.

When someone calls in with an auto vs. pedestrian and state they have a pressure of 80/42, p126, thoracentesis for tension pneumo, bilateral 16's running wide open, and about to put them down to tube them, I want to be on the phone if they are coming to my ER because I need to get on the phone with a doc and get them in and until that happens, I am the one who is going to be working the patient and setting up transport to a tertiary facility.

I cannot order Schedule II narcotics by state law, so I will tell them to get the MD on the cell phone if they can or else give them nalbuphine or something of the like, but I know that in Texas it is common to have nurses relay the orders. Apparently it is not so common in NY, but I was wondering what everyone does.

 

[southerndoc]

Originally posted by PA-C Texas
I was not trying to imply that nurses can give orders (they need to stick with minding their foley catheters and 1500 calorie diets). However, I am allowed to give orders on behalf of the medical control physicians where I work without consultation when no physician is present.

That's not a very nice thing to say.

Anyhow, in some states, there are designated nurses that do give orders. I think they call them Mobile Intensive Care Nurses or something similar.

 

[deleted6669]

MICN'S actually can't give orders, they can only read standing/protocol orders written by an md/do. at my job as a pa I also act as base station liasion and give field orders to medics. when I was a medic I always found it helpful to ask for meds by name and dose rather than ask if the doc had any orders. you tend to never get turned down that way because they know you are on the ball.good luck with med school. don't forget the pa's and medics when you hit the big time.

 

[EMT036]

In Upstate NY (east), where I worked in EMS and the ED, only ED physicians who completed a certification course (i.e. how to use the radio) could give orders to field EMS providers (Basics on up). However, RN's who completed the course could "relay" orders from the physicians if they could not physically come to the radio. I also have been known to relay (PCT). Also their were some PA's who would "borrow" an MD's regionally assigned radio ID and give orders without the physician being present. Unfortunately, the telemetry dispatchers often needed to attempt various hospitals, since MD's were often with patients and not sitting by the radio, so I guess someone is better than noone.

As far as BLS radio reports, (i.e. we're coming in with a shuck)... RN's, ED techs and in some hospitals even secretaries took them.

 

[oudoc08]

At our local hospital. we have a separate medical control line that rings directly into the doctors office for medical consult (I like that term better than medical control, as it is a better description of the role that an ER physician should hold as an online resource from the field.)

Enroute to the hospital, I make a radio report which is answered by a triage nurse or paramedic. That way, the doctor isn't ever responsible for deciding where to put the patient, etc..

If necessary to use the radio for med. control, I always ask for a physician (or pa). You never know who would be relaying orders otherwise. Besides the potential for confusion, there is also the possbility of getting turned down due to the relayer making you look like an idiot.

 

[12R34Y]

at my service we would ask to speak directly to the doc on duty for specific orders for ex. on a chest pain, bad CHFer, or trauma etc....

however, 99% of the time we just told the nurse the story and the doctor was "listening" and the nurse would relay anything that the doctor said.

a lot of the time the doc was busy suturing or running another code or whatever and couldn't come to the phone.

in that instance we would just "tell" the nurse what we have been doing and what we're bringing in and continue with standing orders from our protocols.

"we'll be continuing with ACLS until arrival"

or something to that effect.

later

 

[trauma_junky]

Our Medical Director intrust our Superviors. We Consult them for below the line stuff. makes life easier to have a field experience person granting orders.

 

[southerndoc]

Originally posted by emedpa
MICN'S actually can't give orders, they can only read standing/protocol orders written by an md/do. at my job as a pa I also act as base station liasion and give field orders to medics. when I was a medic I always found it helpful to ask for meds by name and dose rather than ask if the doc had any orders. you tend to never get turned down that way because they know you are on the ball.good luck with med school. don't forget the pa's and medics when you hit the big time.

Oh, I was under the impression that some states allowed MICN's to give orders independent of physicians. Maybe they were following protocols, which brings up the question of why paramedics couldn't just follow the same protocols.

Oh well, in my years as an EMT and paramedic, I never called for an order for anything, including conscious sedation and morphine. We had some really aggressive standing orders for every medication. They were pretty neat -- protocols for major conditions (e.g., cardiac arrest algorithms, MI, etc.), and then "medication-based protocols" that allowed you to administer medications outside of a traditional protocol.

 

[12R34Y]

When i first got hired at my service (years ago) we had to call for a second nitro on chest pains!!

couldn't give ASA standing order, morphine. nothing.

now we have standing orders for just about everything and rarely need permission to anything.

a good medical director can make ALL the difference in the world!