Okay, I admit it. I grew up watching Johnny Gage (Randolph Mantooth) and Roy DeSoto (Kevin Tighe) on the television series “Emergency!” I loved that show! I spent my formative early teenage years plopped down in front of the tube, as Johnny and Roy responded to yet another rollover on Canyon Road, or a “man down” behind the medical centre. I can still picture Roy kneeling on his left knee opening up that steel box with the “biophone” inside calling Rampart. Who could ever forget those magical words: “Rampart, this is Squad 51. Do you read me?” He was so calm and said it with such confidence and self-assuredness! I wanted to be just like him.
And then equally magical was the vision of Nurse Dixie McCall (played by Julie London) – with her false eyelashes, blonde hair and nursing cap – answering the phone at Rampart General Hospital in her semi-sweet, sultry voice, “This is Rampart. Read you loud and clear, 51.” Then, Dr. Brackett with a permanent scowl on his face would come online and say something like, “Squad 51, this patient may have a subdural hematoma. Start an IV of Ringer’s Lactate TKVO and transport to Rampart Emergency, stat!” Oh, it still gives me shivers down my spine!

The concept of the emergency department coming to the patient in the form of the paramedic Rescue Squad was a new one introduced to America in the early 1970s. History buffs among you will no doubt have a better understanding than me of timelines and waypoints of this magical journey from ambulance driver to ambulance attendant to paramedic here in Canada. We have come so far. Yet, in some ways, we aren’t as far ahead as we might think.

Take, for example, online medical control. The Patch. I recently posted a question on the paramedicine list server about the practice of physician patching and whether or not there was still a perceived need for it. Of course, in hindsight that was remarkably naïve of me. The first response I received set the tone that this discussion thread would take from that point on. Gary Saffer, a paramedic from Boston, Massachusetts, replied in part, “I generally only patch them if they’re leaking. Other than that, a little hissing and venting is normal and no cause for concern.” That was an excellent answer on so many levels, wasn’t it? Actually, it cut right to the heart of my question.

We are trained to a certain level of skill and perform a certain list of procedures and can administer certain types of medications in specific dosages. The bible we work from to provide advanced care to our patients is our medical directives. Nevertheless, not every medical treatment that we can perform is covered by these directives. In other words, our training exceeds or standing orders. Sometimes we need to contact online medical control for authorization of a specific course of treatment. For instance, while synchronized cardioversion is part of my skill set and I had better know when and when not to use it, where I work I still must contact online medical control in order to get the order to do it. Same goes for exceeding a particular dose of medication, such as morphine, in the interest of patient care. But why?
What is the point of playing dial-a-doc in the year twenty-oh-five? Wouldn’t it make more sense to have good, sound, aggressive medical directives with a high-level quality assurance and monitoring program, coupled with peer-to-peer mentoring? Surely medical directors can see and acknowledge the need to go beyond the current medical directives. They must, or why would they constantly be rewriting them? The very existence of the radio patch or phone patch system to establish contact with a base hospital physician acknowledges that the medical directives are not sufficient to cover all eventualities. Or even all normal eventualities. Synchronized or chemical cardioversion are simple procedures. In fact, many EMS jurisdictions in Canada allow their paramedics to perform these procedures without first initiating a patch, trusting the assessment and sound clinical judgment of their paramedics. There are several procedures that can be performed by medics competently without medical control over here, but not over there. I don’t get it.

One other weakness in the online medical control model is the disparity of orders from one physician to the next. It can be frustrating knowing what course of treatment outside of the medical directives your patient may require, only to be met on the patch line by a doctor that is reluctant to give that order. Especially if you are certain that, had you gotten Dr. X instead of Dr. Y, you would likely have been given the order. This leads, in some cases, to paramedics being reluctant to initiate a patch, fearing that by doing so, they are just wasting valuable time and energy. Or, arguably worse, it may lead to the practice of “massaging the orders,” whereby one extracts the most from the medical directives using, for example, compressed time lines, in order to boost loading doses of medications to achieve a more desired result.

Does this mean that I think that medics are better able to determine the care for their patients than a physician? Not necessarily so. However, the paramedic is on the scene with the patient. The paramedic has gone through a rigorous training program to ensure that they understand good, sound medical treatment protocols and algorithms. The paramedic has performed rounds in the clinical environment and has been tested to death. So, while the level of training of the paramedic is not as great as the physician, it is nonetheless sound and reliable. Like Lassie in a blue shirt. Again, good, sound, aggressive medical directives with a high-level quality assurance and monitoring program, coupled with peer-to-peer mentoring would go a long way in offsetting the need for online medical control.

I am not advocating the complete elimination of the patch, though. I don’t want to lose that nostalgic feeling I get every time I push the buttons on my portable radio to contact Sunnybrook. After all, there may still be times even with a comprehensive set of medical directives when a paramedic needs to consult with a physician. That’s the way I see the patch best utilised. As a consulting tool.

A doctor in the ER has the opportunity to consult with a colleague or a textbook when confronted with a confounding condition or diabolical medical mystery. Not so for the paramedic. So, even when in the future the medical directives will provide an avenue to treat almost any given patient, it would be nice to maintain a route by which the newer or confused paramedic can call up the physician and say, “Hey, doc, I’m kinda stymied here. Can you tell me what you think?”
Johnny and Roy, I suspect, would appreciate the severing of the electronic tether for those things done routinely and frequently now. It might not make for exciting television drama, but it would make for better prehospital medicine.

“Station 51, 10-4, KMG 365.”