Medical director
Encyclopedia
As laboratory director,means that you are responsible for the overall operation and administration of the laboratory, including the employment of competent
qualified personnel. Even though you have the option to delegate some
of your responsibilities, you remain ultimately responsible and must
ensure that all the duties are properly performed and applicable CLIA
regulations are met. It is your responsibility to ensure that your
laboratory develops and uses a quality system approach to laboratory
testing that provides accurate and reliable patient test results.
Note: In the interest of clarity, medical directors exist in a variety of other settings in addition to EMS. It is largely a generic term used to describe a physician who has responsibility for the medical control and direction of various types of organizations, including hospital
departments, blood banks, clinical teaching services and others. This article focuses specifically on the role of the medical director with respect to the operation of EMS systems.
service, SAMU
, SMURD
, etc.) operate in various locales. There is little about what we call EMS that is universally applicable. Instead, communities and medical practitioners tend to develop systemic arrangements that are based on an assessment of local need. In the delivery of what we commonly refer to as EMS in various countries, there are two major service delivery models, with a number of minor models or variations from the main models. The first model, and arguably the oldest, is generally described as the Franco-German model. This model is physician-led, and places those operating ambulances into what are in many cases, minor, supporting roles. While this model is generally referred to as Franco-German, this may be something of a misnomer, since there is ample evidence and documentation indicating that at the turn of the 20th century, many North American
hospital-based ambulances in larger centres were actually staffed by ambulance surgeons; physicians who actually responded in the ambulance and provided care in a manner which very much resembles the current Franco-German model. In the French
version of the model, only physicians and nurses perform advanced care, and drivers have only minimal medical training.
In the German
version of the model, paramedics (called Rettungsassistents) do exist. Medical control is on-line, immediate, and direct. The training of the Rettungsassistent is comparable to that of many North American paramedics, but they are normally severely limited in their scope of practice. Paramedics may practice their advanced life support
skills at all times when the physician with whom they work is physically present, but are sharply restricted in what they may do in his absence. In most cases, under German law, unless an immediately life-threatening or potentially debilitating emergency is present, many such individuals are limited to basic life support
skills only, or to severely restricted ALS skills.
The fundamental philosophy of this model is to bring physician-centred definitive care to the patient, rather than bringing the patient to the care. As a result, in addition to conventional ambulances, most communities have physicians (called Notarzt) who respond directly to every life-threatening call to provide care. This system does not recognize emergency medicine
as a medical specialty, in the sense that North Americans understand it. In these cases, the 'emergency physician' is most commonly an anesthetist, or sometimes an internist or even a surgeon
. In most places, there appears to be little interest in the development of emergency medicine as a specialty
, although recent developments in Italy
suggest that this attitude may be changing. In this model, long 'at scene' times are common, with the physician attempting to provide some or all of the intervention that is necessary in place, with transportation to hospital occurring only for those with a legitimate need of a hospital bed, and urgent transportation to hospital being extremely rare. Many patients will never be transported to hospital. In the French version of this model, even the triage of incoming requests for service is physician-led, with a physician, assisted by others, interviewing the caller and determining what type of response resource, if any, will be sent. The German version of this model uses what we would recognize as 'conventional' dispatch processes, with the physician being sent to calls as requested by the EMS dispatcher
.
The Franco-German model operates in most places in Europe
and Russia
, but not in the United Kingdom
. In this model, the medical director is typically more of a leader of physicians, and an advisor on the training of, and quality control for, subordinate staff. In Germany, the term Ärztlicher Leiter Rettungsdienst is in use. This physician's role is to oversee EMS personnel
in a defined area, typically a bigger city
or county
, and corresponds to the position of medical director.
for emergency medicine, and indeed, prior to 1970, no real attempts to formally train physicians in its practice in the U.S., although it may be argued that in the U.K. formal consultancies in Emergency Medicine had existed for at least two decades before that time.
In the Anglo-American model of care, the physician remains the leader of the care team, but paramedics function much more independently than in the Franco-German model. This has not always been the case. In the earliest days of paramedicine paramedics were required to contact a physician for formal orders for every single intervention that they performed. Indeed, it was argued in some systems that this was the only safe approach to providing care in this fashion. There were early examples of 'paramedics' who operated blindly, providing medications from numbered or colour-coded syringes as they were directed by the physician, with no real understanding of the interventions that they were performing. Control was absolute and immediate; there were examples of paramedics being trained, but not legally permitted to perform their skills, or in other cases, the performance of skills could only occur with a physician or nurse present, much like the existing Franco-German model. This was absolutely necessary in the earliest stages of paramedicine as, in the absence of formal licensing arrangements for paramedics, they often functioned as an extension of the physician's medical license
. This type of arrangement persists to this day in some locations, such as the Canadian
province
of Ontario
. As the training, knowledge and skill level of paramedics grew, as they developed licensing and certification
processes, and as physicians became more comfortable in working with this new profession, greater degrees of independent practice were permitted. This would ultimately evolve into a system in which most paramedics function almost purely on complex written protocols or standing orders committed to memory, often numerous pages in length, and contacting a physician only when standing orders have been exhausted.
In such systems, the medical director's role takes on several aspects. To begin with, the medical director is much more a leader of paramedics than of other physicians, although they generally perform a leadership role among the small group of physicians tasked with providing delegation
to paramedics in the field.
The medical director plays a key role in the professional development of paramedics as well. In almost all cases, the medical director will have, at a minimum, input into the curriculum of paramedic training at a local level. In actual practice, in a great many cases they will also teach some portions of the program, supervise clinical rotations of paramedics, and in some cases, even precept their initial field practice, prior to formal certification or licensing. In almost all cases, the medical director will be charged with the creation of all protocols and standing orders, and with any research that goes into their creation. The medical director will also, assisted by others, be responsible for the creation and development of the Standards of Practice for their EMS system. Throughout the paramedic's career, the medical director will provide the mechanism for medical quality control
, conducting chart
audits and reviewing medically-related service complaints, and may often have the ability to de-certify individual paramedics for cause. Medical directors will also act as advocates for their paramedics, advising elected officials and building support within the medical community for expanded scopes of practice when appropriate. Finally, medical directors will act as expert advisors to those in the EMS system administration and government administration, with respect to policies and legislation required by the EMS system, and in guiding its future direction. In this model, the paramedic is very much seen as an 'extender' of the emergency physician's reach. It is rare to see physicians in the field, unless they are precepting new paramedics or performing quality assurance activities, or are residents in emergency medicine training programs, gaining required field experience or conducting research. Medical directors and ED physicians will occasionally go into the field for large incidents, such as multi victim accidents and disasters to assume on site medical command
and South Africa
some paramedics have evolved into a role of autonomous practitioners in their own right. In such cases, individual paramedics may function in much the same manner as Physician assistants or Nurse Practitioners, assessing patients and making their own diagnoses, clinical judgments, and treatment decisions. In all such cases, a scope of practice
is predetermined for the role, and within that scope of practice all treatment decisions are made and care rendered at the discretion of the individual paramedic. In many cases, the scope of practice will focus more heavily on primary care
, although providing a more comprehensive level of care, such as suturing, or the management of long-term conditions, such as diabetes or hypertension
, than is normally permitted to the paramedic. In some jurisdictions, such practitioners even have the authority to both prescribe
and dispense a limited and defined set of medications.
In such circumstances, these Paramedic Practitioners or Emergency Care Practitioners are almost always very senior and experienced ALS providers, and retain their ability to practice these skills. In many cases, the practice of these individuals has gone well beyond what we normally consider to be the role of traditional EMS. There are locations in which these practitioners are providing E/R leadership after hours in small, rural hospitals (Australia and the U.K.), while in other locations these practitioners are actually taking night 'call' for group medical practices (U.K.). In some cases, the Practitioner retains the ability to summon a physician to the patient when the limits of the scope of practice are reached (U.K.) while in others, the finite limits of treatment are those within that scope of practice, and no physician 'back-up' is normally provided (South Africa).
In this type of model, the role of the medical director includes the teaching of the practitioners, in both the classroom and the clinical setting. Most such training programs tend to feature very large components of hands-on clinical experience, generally conducted in the emergency room or similar environment, and usually in a one to one ratio with the physician. The medical director will be responsible for examination of the candidate and certification of their ability to practice safely. The medical director will have a major role in determining the permitted scope of practice, and will investigate practice-related complaints. In some jurisdictions the medical director will be responsible for medical quality assurance, although there are some where this function is performed by the practitioners themselves. Finally, the medical director (or other emergency physicians) may be responsible for providing the required medical 'back up' when the practitioner reaches the limit of their scope of practice.
but other critical care training is also acceptable, who then complete an additional year of training in ambulance care. All such individuals are licensed by the Dutch Ambulance Institute(DIA), and are employed by one of approximately 45 private companies providing emergency ambulance service under government contract.
The model looks very much Anglo-American on its surface, however, in most cases Dutch paramedics are for all practical purposes autonomous practitioners. The scope of practice and permissible procedures are determined at a national level by the Dutch Ambulance Institute, and all paramedics must function within this guidance. Within the scope of practice, however, all judgment and treatment decisions fall to the paramedic, as in the Autonomous Practitioner model. Each ambulance service is required to employ a medical manager whose role is oversight and quality assurance, and who may be contacted for directions by any paramedic who has reached the limits of their scope of practice, just as in the Anglo-American model. When necessary, however, the paramedic may request a rapid response by a physician, usually by either vehicle or helicopter. In these cases, a great deal of emergency intervention will occur on the scene, with the patient transported ultimately by land ambulance, as in the Franco-German model.
In this model, which is unique, the role of the Medical Director is substantially different. Scope of practice and all treatment protocols are developed by the Dutch Ambulance Institute on a national basis, and cannot be unilaterally changed at the local level by individual physicians. Scope and protocols are reviewed, revised, and announced every four years, and any physician who wishes a change to those protocols must provide sound reasons and present a successful argument before a committee of the DIA. The medical managers for each private carrier operate in a role approximating that of Medical Director, but only for that one company; their authority does not extend to other companies operating in the same community. These individuals do perform quality service functions such as chart audits and complaint investigation, but they cannot unilaterally change treatment protocols. They may provide guidance, advice and direction to paramedics by telephone or radio, or they may attend the scene in person to provide care. The Dutch system also operates a network of four helicopters staffed by physicians for rapid response to support paramedics in the field. While many of the individuals working in the Dutch system may be occasionally described as 'emergency physicians', the majority, as in the Franco-German model, are actually anesthetists.
qualified personnel. Even though you have the option to delegate some
of your responsibilities, you remain ultimately responsible and must
ensure that all the duties are properly performed and applicable CLIA
regulations are met. It is your responsibility to ensure that your
laboratory develops and uses a quality system approach to laboratory
testing that provides accurate and reliable patient test results.
Note: In the interest of clarity, medical directors exist in a variety of other settings in addition to EMS. It is largely a generic term used to describe a physician who has responsibility for the medical control and direction of various types of organizations, including hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
departments, blood banks, clinical teaching services and others. This article focuses specifically on the role of the medical director with respect to the operation of EMS systems.
Franco-German
To understand the role of the medical director in what North Americans call EMS, it is necessary to have a clear understanding of precisely how EMS systems (or ambulanceAmbulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
service, SAMU
Samu
Samu may refer to:* Samu, nickname for a Homo erectus man found in Vértesszőlős, Hungary* SAMU - Service d'Aide Médicale d'Urgence, an emergency medical service in France.* Servicio de Atencion Medica Urgente, also an emergency medical service...
, SMURD
SMURD
SMURD is an emergency rescue service based in Romania. SMURD is the Romanian acronym for "Serviciul Mobil de Urgenţǎ, Reanimare şi Descarcerare", that means Mobile Emergency Service for Resuscitation and Extrication....
, etc.) operate in various locales. There is little about what we call EMS that is universally applicable. Instead, communities and medical practitioners tend to develop systemic arrangements that are based on an assessment of local need. In the delivery of what we commonly refer to as EMS in various countries, there are two major service delivery models, with a number of minor models or variations from the main models. The first model, and arguably the oldest, is generally described as the Franco-German model. This model is physician-led, and places those operating ambulances into what are in many cases, minor, supporting roles. While this model is generally referred to as Franco-German, this may be something of a misnomer, since there is ample evidence and documentation indicating that at the turn of the 20th century, many North American
North American
North American generally refers to an entity, people, group, or attribute of North America, especially of the United States and Canada together.-Culture:*North American English, a collective term used to describe American English and Canadian English...
hospital-based ambulances in larger centres were actually staffed by ambulance surgeons; physicians who actually responded in the ambulance and provided care in a manner which very much resembles the current Franco-German model. In the French
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...
version of the model, only physicians and nurses perform advanced care, and drivers have only minimal medical training.
In the German
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
version of the model, paramedics (called Rettungsassistents) do exist. Medical control is on-line, immediate, and direct. The training of the Rettungsassistent is comparable to that of many North American paramedics, but they are normally severely limited in their scope of practice. Paramedics may practice their advanced life support
Advanced Life Support
Advanced Life Support is a set of life-saving protocols and skills that extend Basic Life Support to further support the circulation and provide an open airway and adequate ventilation .-Components of ALS:These include:...
skills at all times when the physician with whom they work is physically present, but are sharply restricted in what they may do in his absence. In most cases, under German law, unless an immediately life-threatening or potentially debilitating emergency is present, many such individuals are limited to basic life support
Basic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
skills only, or to severely restricted ALS skills.
The fundamental philosophy of this model is to bring physician-centred definitive care to the patient, rather than bringing the patient to the care. As a result, in addition to conventional ambulances, most communities have physicians (called Notarzt) who respond directly to every life-threatening call to provide care. This system does not recognize emergency medicine
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
as a medical specialty, in the sense that North Americans understand it. In these cases, the 'emergency physician' is most commonly an anesthetist, or sometimes an internist or even a surgeon
Surgeon
In medicine, a surgeon is a specialist in surgery. Surgery is a broad category of invasive medical treatment that involves the cutting of a body, whether human or animal, for a specific reason such as the removal of diseased tissue or to repair a tear or breakage...
. In most places, there appears to be little interest in the development of emergency medicine as a specialty
Specialty (medicine)
A specialty in medicine is a branch of medical science. After completing medical school, physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple year residency to become a medical specialist.-History of medical specialization:To...
, although recent developments in Italy
Italy
Italy , officially the Italian Republic languages]] under the European Charter for Regional or Minority Languages. In each of these, Italy's official name is as follows:;;;;;;;;), is a unitary parliamentary republic in South-Central Europe. To the north it borders France, Switzerland, Austria and...
suggest that this attitude may be changing. In this model, long 'at scene' times are common, with the physician attempting to provide some or all of the intervention that is necessary in place, with transportation to hospital occurring only for those with a legitimate need of a hospital bed, and urgent transportation to hospital being extremely rare. Many patients will never be transported to hospital. In the French version of this model, even the triage of incoming requests for service is physician-led, with a physician, assisted by others, interviewing the caller and determining what type of response resource, if any, will be sent. The German version of this model uses what we would recognize as 'conventional' dispatch processes, with the physician being sent to calls as requested by the EMS dispatcher
Emergency medical dispatcher
An Emergency medical dispatcher is a professional telecommunicator, tasked with the gathering of information related to medical emergencies, the provision of assistance and instructions by voice, prior to the arrival of Emergency Medical Services, and the dispatching and support of EMS resources...
.
The Franco-German model operates in most places in Europe
Europe
Europe is, by convention, one of the world's seven continents. Comprising the westernmost peninsula of Eurasia, Europe is generally 'divided' from Asia to its east by the watershed divides of the Ural and Caucasus Mountains, the Ural River, the Caspian and Black Seas, and the waterways connecting...
and Russia
Russia
Russia or , officially known as both Russia and the Russian Federation , is a country in northern Eurasia. It is a federal semi-presidential republic, comprising 83 federal subjects...
, but not in the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
. In this model, the medical director is typically more of a leader of physicians, and an advisor on the training of, and quality control for, subordinate staff. In Germany, the term Ärztlicher Leiter Rettungsdienst is in use. This physician's role is to oversee EMS personnel
Emergency medical services in Germany
Emergency Medical Service in Germany is a service of public pre-hospital emergency healthcare, including ambulance service, provided by individual German cities and counties...
in a defined area, typically a bigger city
City
A city is a relatively large and permanent settlement. Although there is no agreement on how a city is distinguished from a town within general English language meanings, many cities have a particular administrative, legal, or historical status based on local law.For example, in the U.S...
or county
County
A county is a jurisdiction of local government in certain modern nations. Historically in mainland Europe, the original French term, comté, and its equivalents in other languages denoted a jurisdiction under the sovereignty of a count A county is a jurisdiction of local government in certain...
, and corresponds to the position of medical director.
Anglo-American
The Anglo-American model of care is largely led by the medical director. This model has evolved significantly since its origins in the late 1960s. It is interesting to note that the development of this role, the professionalization of emergency medical services, the profession of paramedic, and the medical specialty of emergency medicine, have all developed in a symbiotic relationship since they were first created. Prior to 1979, there was no formal specialty training certificationCertification
Certification refers to the confirmation of certain characteristics of an object, person, or organization. This confirmation is often, but not always, provided by some form of external review, education, assessment, or audit...
for emergency medicine, and indeed, prior to 1970, no real attempts to formally train physicians in its practice in the U.S., although it may be argued that in the U.K. formal consultancies in Emergency Medicine had existed for at least two decades before that time.
In the Anglo-American model of care, the physician remains the leader of the care team, but paramedics function much more independently than in the Franco-German model. This has not always been the case. In the earliest days of paramedicine paramedics were required to contact a physician for formal orders for every single intervention that they performed. Indeed, it was argued in some systems that this was the only safe approach to providing care in this fashion. There were early examples of 'paramedics' who operated blindly, providing medications from numbered or colour-coded syringes as they were directed by the physician, with no real understanding of the interventions that they were performing. Control was absolute and immediate; there were examples of paramedics being trained, but not legally permitted to perform their skills, or in other cases, the performance of skills could only occur with a physician or nurse present, much like the existing Franco-German model. This was absolutely necessary in the earliest stages of paramedicine as, in the absence of formal licensing arrangements for paramedics, they often functioned as an extension of the physician's medical license
Medical license
In most countries, only persons with a medical license bestowed either by a specified government-approved professional association or a government agency are authorized to practice medicine. Licenses are not granted automatically to all people with medical degrees...
. This type of arrangement persists to this day in some locations, such as the Canadian
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
province
Province
A province is a territorial unit, almost always an administrative division, within a country or state.-Etymology:The English word "province" is attested since about 1330 and derives from the 13th-century Old French "province," which itself comes from the Latin word "provincia," which referred to...
of Ontario
Ontario
Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....
. As the training, knowledge and skill level of paramedics grew, as they developed licensing and certification
Certification
Certification refers to the confirmation of certain characteristics of an object, person, or organization. This confirmation is often, but not always, provided by some form of external review, education, assessment, or audit...
processes, and as physicians became more comfortable in working with this new profession, greater degrees of independent practice were permitted. This would ultimately evolve into a system in which most paramedics function almost purely on complex written protocols or standing orders committed to memory, often numerous pages in length, and contacting a physician only when standing orders have been exhausted.
In such systems, the medical director's role takes on several aspects. To begin with, the medical director is much more a leader of paramedics than of other physicians, although they generally perform a leadership role among the small group of physicians tasked with providing delegation
Delegation
Delegation is the assignment of authority and responsibility to another person to carry out specific activities. However the person who delegated the work remains accountable for the outcome of the delegated work. Delegation empowers a subordinate to make decisions, i.e...
to paramedics in the field.
The medical director plays a key role in the professional development of paramedics as well. In almost all cases, the medical director will have, at a minimum, input into the curriculum of paramedic training at a local level. In actual practice, in a great many cases they will also teach some portions of the program, supervise clinical rotations of paramedics, and in some cases, even precept their initial field practice, prior to formal certification or licensing. In almost all cases, the medical director will be charged with the creation of all protocols and standing orders, and with any research that goes into their creation. The medical director will also, assisted by others, be responsible for the creation and development of the Standards of Practice for their EMS system. Throughout the paramedic's career, the medical director will provide the mechanism for medical quality control
Quality control
Quality control, or QC for short, is a process by which entities review the quality of all factors involved in production. This approach places an emphasis on three aspects:...
, conducting chart
Chart
A chart is a graphical representation of data, in which "the data is represented by symbols, such as bars in a bar chart, lines in a line chart, or slices in a pie chart"...
audits and reviewing medically-related service complaints, and may often have the ability to de-certify individual paramedics for cause. Medical directors will also act as advocates for their paramedics, advising elected officials and building support within the medical community for expanded scopes of practice when appropriate. Finally, medical directors will act as expert advisors to those in the EMS system administration and government administration, with respect to policies and legislation required by the EMS system, and in guiding its future direction. In this model, the paramedic is very much seen as an 'extender' of the emergency physician's reach. It is rare to see physicians in the field, unless they are precepting new paramedics or performing quality assurance activities, or are residents in emergency medicine training programs, gaining required field experience or conducting research. Medical directors and ED physicians will occasionally go into the field for large incidents, such as multi victim accidents and disasters to assume on site medical command
Autonomous practice
In some parts of the world, most notably the U.K., AustraliaAustralia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
and South Africa
South Africa
The Republic of South Africa is a country in southern Africa. Located at the southern tip of Africa, it is divided into nine provinces, with of coastline on the Atlantic and Indian oceans...
some paramedics have evolved into a role of autonomous practitioners in their own right. In such cases, individual paramedics may function in much the same manner as Physician assistants or Nurse Practitioners, assessing patients and making their own diagnoses, clinical judgments, and treatment decisions. In all such cases, a scope of practice
Scope of Practice
Scope of Practice is a terminology used by national and state/provincial licensing boards for various professions that defines the procedures, actions, and processes that are permitted for the licensed individual. The scope of practice is limited to that which the law allows for specific education...
is predetermined for the role, and within that scope of practice all treatment decisions are made and care rendered at the discretion of the individual paramedic. In many cases, the scope of practice will focus more heavily on primary care
Primary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...
, although providing a more comprehensive level of care, such as suturing, or the management of long-term conditions, such as diabetes or hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, than is normally permitted to the paramedic. In some jurisdictions, such practitioners even have the authority to both prescribe
Medical prescription
A prescription is a health-care program implemented by a physician or other medical practitioner in the form of instructions that govern the plan of care for an individual patient. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist or other therapist....
and dispense a limited and defined set of medications.
In such circumstances, these Paramedic Practitioners or Emergency Care Practitioners are almost always very senior and experienced ALS providers, and retain their ability to practice these skills. In many cases, the practice of these individuals has gone well beyond what we normally consider to be the role of traditional EMS. There are locations in which these practitioners are providing E/R leadership after hours in small, rural hospitals (Australia and the U.K.), while in other locations these practitioners are actually taking night 'call' for group medical practices (U.K.). In some cases, the Practitioner retains the ability to summon a physician to the patient when the limits of the scope of practice are reached (U.K.) while in others, the finite limits of treatment are those within that scope of practice, and no physician 'back-up' is normally provided (South Africa).
In this type of model, the role of the medical director includes the teaching of the practitioners, in both the classroom and the clinical setting. Most such training programs tend to feature very large components of hands-on clinical experience, generally conducted in the emergency room or similar environment, and usually in a one to one ratio with the physician. The medical director will be responsible for examination of the candidate and certification of their ability to practice safely. The medical director will have a major role in determining the permitted scope of practice, and will investigate practice-related complaints. In some jurisdictions the medical director will be responsible for medical quality assurance, although there are some where this function is performed by the practitioners themselves. Finally, the medical director (or other emergency physicians) may be responsible for providing the required medical 'back up' when the practitioner reaches the limit of their scope of practice.
Crossover models
There are some models, most notably Holland, which use a blend of a number of these models, including the Franco-German, Anglo-American, and Autonomous Practice models. In Holland, for example, all paramedics are in fact registered nurses with one year of additional training, usually in anesthesiaAnesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
but other critical care training is also acceptable, who then complete an additional year of training in ambulance care. All such individuals are licensed by the Dutch Ambulance Institute(DIA), and are employed by one of approximately 45 private companies providing emergency ambulance service under government contract.
The model looks very much Anglo-American on its surface, however, in most cases Dutch paramedics are for all practical purposes autonomous practitioners. The scope of practice and permissible procedures are determined at a national level by the Dutch Ambulance Institute, and all paramedics must function within this guidance. Within the scope of practice, however, all judgment and treatment decisions fall to the paramedic, as in the Autonomous Practitioner model. Each ambulance service is required to employ a medical manager whose role is oversight and quality assurance, and who may be contacted for directions by any paramedic who has reached the limits of their scope of practice, just as in the Anglo-American model. When necessary, however, the paramedic may request a rapid response by a physician, usually by either vehicle or helicopter. In these cases, a great deal of emergency intervention will occur on the scene, with the patient transported ultimately by land ambulance, as in the Franco-German model.
In this model, which is unique, the role of the Medical Director is substantially different. Scope of practice and all treatment protocols are developed by the Dutch Ambulance Institute on a national basis, and cannot be unilaterally changed at the local level by individual physicians. Scope and protocols are reviewed, revised, and announced every four years, and any physician who wishes a change to those protocols must provide sound reasons and present a successful argument before a committee of the DIA. The medical managers for each private carrier operate in a role approximating that of Medical Director, but only for that one company; their authority does not extend to other companies operating in the same community. These individuals do perform quality service functions such as chart audits and complaint investigation, but they cannot unilaterally change treatment protocols. They may provide guidance, advice and direction to paramedics by telephone or radio, or they may attend the scene in person to provide care. The Dutch system also operates a network of four helicopters staffed by physicians for rapid response to support paramedics in the field. While many of the individuals working in the Dutch system may be occasionally described as 'emergency physicians', the majority, as in the Franco-German model, are actually anesthetists.
Notable medical directors
- Dr. Peter Safar - credited as the inventor of CPR and the Intensive Care UnitIntensive Care Unitthumb|220px|ICU roomAn intensive-care unit , critical-care unit , intensive-therapy unit/intensive-treatment unit is a specialized department in a hospital that provides intensive-care medicine...
, and founding medical director of the Freedom House Ambulance Service (America's first paramedic ambulance service). - Dr. Nancy Caroline - Co-founder of Freedom House, one of the first EMS medical directors in America, and first formal medical director of the Magen David AdomMagen David AdomThe Magen David Adom is Israel's national emergency medical, disaster, ambulance and blood bank service. The name means "Red Star of David"...
(Israeli EMS). - Dr. R Adams Cowley - Founding medical director of America's first dedicated trauma centre (ShockTrauma — Baltimore) and of the first dedicated air ambulanceAir ambulanceAn air ambulance is an aircraft used for emergency medical assistance in situations where either a traditional ambulance cannot reach the scene easily or quickly enough, or the patient needs to be transported over a distance or terrain that makes air transportation the most practical transport....
operation in the U.S. (Maryland State Police). Creator of the concept of the Golden HourGolden hour (medicine)In emergency medicine, the golden hour refers to a time period lasting from a few minutes to several hours following traumatic injury being sustained by a casualty, during which there is the highest likelihood that prompt medical treatment will prevent death...
for trauma care. - Dr. Norman McSwain - Founding medical director of the New Orleans paramedic training program and New Orleans Police EMS Detail (now New Orleans EMS), inventor of the McSwain Dart (for paramedic emergency management of tension pneumothorax).
- Dr. Ronald Stewart - Founding medical director, Los Angeles County paramedic program, Pittsburgh EMS, substantial role in the founding of TorontoTorontoToronto is the provincial capital of Ontario and the largest city in Canada. It is located in Southern Ontario on the northwestern shore of Lake Ontario. A relatively modern city, Toronto's history dates back to the late-18th century, when its land was first purchased by the British monarchy from...
, CanadaCanadaCanada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
, paramedic program, and Nova ScotiaNova ScotiaNova Scotia is one of Canada's three Maritime provinces and is the most populous province in Atlantic Canada. The name of the province is Latin for "New Scotland," but "Nova Scotia" is the recognized, English-language name of the province. The provincial capital is Halifax. Nova Scotia is the...
, Canada, paramedic program. - Dr. Leonard Cobb - Founding medical director, Seattle, Washington, 'Medic One' paramedic program.
- Dr. Eugene Nagel - Founding medical director, Miami, FloridaFloridaFlorida is a state in the southeastern United States, located on the nation's Atlantic and Gulf coasts. It is bordered to the west by the Gulf of Mexico, to the north by Alabama and Georgia and to the east by the Atlantic Ocean. With a population of 18,801,310 as measured by the 2010 census, it...
paramedic program. - Dr. Jullette Saussy - Medical director of New Orleans Emergency Medical ServicesNew Orleans Emergency Medical ServicesNew Orleans Emergency Medical Services provides basic life support and advanced life support ambulance units throughout the city of New Orleans, Louisiana, USA....
and a nationally recognized female leader in emergency medical services.