Comments on proposed revisions to Pennsylvania EMS Regulations

Keith Conover, M.D., FACEP April 6, 1998

(member, Pennsylvania Emergency Health Services Council Medical Advisory Committee; Medical Director, Wilderness EMS Institute)

The new definition of medical command says:

Medical command -- An order given by a medical command physician to a prehospital practitioner in a prehospital, interfacility, or emergency care setting in a hospital, to provide immediate medical care to prevent loss of life or aggravation of physiological or psychological illness or injury.

For the first time, the EMS regulations specifically address the context within which EMS personnel can provide care – it now includes the interfacility and in-hospital settings as part of EMS, which have an impressive array of implications. Interestingly, I can find none of these settings is defined elsewhere in the proposed revisions. As the representative of the Wilderness EMS community on the Medical Advisory Committee, please let me address the first and seemingly least complicated setting: "prehospital."

This relates to conversations with Kenneth Brody, legal counsel for the Department of Health. WEMSI wants care of backcountry patients to be part of the Pennsylvania EMS system – particularly so, because the standard of care is different in the backcountry. For instance, national standards state that, in the backcountry, EMTs should routinely attempt reduction of a suspected shoulder dislocation, whereas in an ambulance, the standard is to splint and transport.

However, Mr. Brody told us that, given the wording of Act 45, "EMS" in Pennsylvania simply doesn’t extend to taking care of patients far from an ambulance, and that taking care of such patients isn’t within the scope of Pennsylvania EMS. He noted that EMTs and paramedics could occasionally provide care to backcountry patients under the good samaritan laws -- but, that EMTs and paramedics with search and rescue teams who train for and provide backcountry care weren’t doing so as part of the Pennsylvania EMS system.

Given this situation, let’s force the issue now – the new regulations should come down and say that Pennsylvania EMS either does or doesn’t include patients remote from an ambulance. Include a definition of the "prehospital" setting, for example, "the patient has to be in or near an ambulance," or "the patient can be anywhere other than in a hospital or in transit between hospitals," and this will be quite satisfactory.

[(1) P]provide medical command to prehospital [emergency health] personnel. This shall include providing online medical command to prehospital personnel whenever they seek direction.

As noted in the April 1 MAC meeting, this seems to imply that a medical command physician is expected to provide medical direction for anyone who calls in for medical direction, even if it’s a first responder from Kentucky who happened to dial the wrong number.

(i) That the physician satisfies the qualifications for a medical command physician in subsection (b).

(ii) That the physician has received certification as a medical command physician from the Department upon successfully completing the voluntary medical command physician certification program administered by the Department.

This seems to open the door for at least some of the skills required for Wilderness EMS – reducing shoulder dislocations, irrigating wounds, and the like. That is, if Pennsylvania EMS will recognize Wilderness EMT training as legitimate continuing education for EMTs and paramedics.

An individual whose medical command authorization has been denied [or restricted] by the ALS service medical director may appeal the decision within 14 days to the regional EMS medical director. The individual's appeal shall be in writing and shall specify the reasons the individual disagrees with the decision of the ALS service medical director. The regional EMS medical director shall conduct a hearing. If the regional EMS medical director is unable to conduct a fair hearing due to receiving prejudicial information prior to the hearing, or for any other reason, the regional EMS council shall arrange for the regional EMS medical director of another region to conduct the hearing. At the hearing, the ALS service medical director shall have the burden to proceed and offer testimony and other evidence in support of the ALS service medical director's decision. The individual shall also have an opportunity to present testimony and other evidence in support of the individual's position. Both parties have an opportunity to cross-examine opposing witnesses and to submit oral and written position statements. The regional EMS medical director may give the parties up to 5 additional days following the hearing to submit written position statements. The regional EMS medical director will issue a written decision affirming, reversing or modifying the ALS service medical director's decision within 14 days [of] after the hearing or within 14 days [of] after the submission of post hearing position statements, if they are filed. The regional EMS medical director's written decision shall contain the regional EMS medical director's findings and conclusions. If the ALS service medical director fails to appear at the hearing, the regional EMS medical director shall reverse the ALS service medical director's decision. If the individual fails to appear at the hearing, the regional EMS medical director shall make a determination upon the evidence presented and either affirm, reverse or modify the decision of the ALS service medical director. The burden of proof is a preponderance of the evidence.

This certainly is a change. My understanding of the privilege ("license") of an EMT or paramedic to practice a subset of the art of medicine was that the EMT or medic was operating under the license of a physician. If operating under protocols and standing orders, this was the license of the ALS medical director – and if operating under direct medical command, under the license of the physician providing the orders over the radio.

What if an ALS medical director says "I don’t want this medic operating under my license, and I refuse to authorize him to follow the protocols and standing orders I set up for this ALS service" but refuses to provide any documentation of that decision? If reversed by the Regional Medical Director, then I guess the medic will then operate under the license of the Regional Medical Director – but then doesn’t the Regional Medical Director have to give the medic a new set of protocols, signed by the Regional Medical Director instead of the ALS medical director? I suspect this would be a very interesting court case.

Is the plan simply to put this in the regulations and see how it comes out in court?

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