Are You There Doc? Paramedic Student Team Lead Utilization of MD Consultation

Tristan Pennella, BS; Scott Craig, CCEMT-P, I/C; Luke Stanke, BS; Marilee Vosper, M.Ed., EMT-P; Rachel Walberg, BA; A.C. Cook, NREMT-P; Sandi Wewerka, MPH, CCRC, EMT-B

Background
Current EMS guidelines indicate that if a patient’s condition does not conform to standard protocol, the paramedic should always contact medical control for instruction. However, a recent publication investigating cardiac patient encounters found that protocol based care is equivalent and perhaps slightly better than online medical control. Therefore, the purpose of this study was to examine the frequency of paramedic student team leads decision to access physician consultation from the field during cardiac patient encounters. Additionally, we sought to determine predictors in identifying the likelihood of physician consultation as well as identify any changes in patient care.

Hypotheses
HA1: Paramedic student team leads who consult physicians leads to increased use of cardiac interventions and medications in the field.

HA2: Paramedic student demographics and patient characteristics can predict utilization of physician consultation during a cardiac patient encounter. 

Methods
A retrospective review of data was collected using Fisdap™, an internship skills tracking system for EMS students. Inclusion criteria included: Field data inputted by paramedic students in contexts between 01-01-2011 and 12-31-2014; patients with a primary and secondary impression of “cardiac” (n= 8,800) whether or not physician consultation occurred. Paramedic student demographics included age and gender. Patient characteristics included age, gender, and initial cardiac rhythm. Patient care was analyzed based on interventions performed (cardioverysion, pacing, 12-lead, thrombolytic screen, nasotracheal intubation, and pericardiocentesis) and medications given (acetylsalicylic acid, nitroglycerin, paralytics, amiodarone, dopamine, epinephrine (1:10,000), and all other IV drip medications).

Data were analyzed using descriptive statistics to describe the demographics of paramedic students and patients. Frequency counts and generalized linear modeling was utilized to determine the number of cardiac interventions and medications given and describe any differences between treatment groups.
 
Results
1,008 student paramedic team leads treated a total of 8,800 cardiac patients during the retrospective study time frame. There were 288 physician consultations performed on 277 different patients. Of these 1,008 paramedic students, only 8.7% (n=88) called for physician consultation. The number of cardiac medications given increased significantly (p<0.001) amongst paramedics who performed a physician consultation. The gender and age of the paramedic had no significance on the likelihood of physician consultation. There was no significance in the number of cardiac interventions following physician consultation compared to no physician consultation.
 
Consultation
Even with the advancement of telecommunications, physician consultations from the field remain low. Interestingly, the paramedic student team leads who made a physician consultation averaged 3.3 consults compared to the other 91.3% of paramedic student team leads who had no physician consultations during the study time frame.
 
Although this finding warrants further investigation, it is possible that once student paramedics make their first physician consultation they become more comfortable with seeking additional instruction, and thus become increasingly likely to pursue a consultation from the field. This population of paramedic student team leads was significantly more likely to administer more medications compared to team leads who did not consult physicians when treating cardiac patients. We suspect that this is due to the advanced medical decision making of the physician relaying care onto the paramedic team. It is also likely that the patients who require physician consultation are more acutely ill, and therefore require higher level of care and management.
 
We also discovered that the more patient contacts a medic had and the older they are, the less likely they were to give cardiac medications compared to their young counterparts. It is unclear if this is because the paramedics become desensitized to patient complaints, or because they are seasoned and better able to assess treatment. Together, this review illustrates some thought provoking findings as they relate to the decision of paramedic student team leads to access physician consultation.
 
Our study is limited by the design of only including cardiac encounters, however future directions could and should involve other aspects of EMS care to identify if these findings hold true. Future prospective approaches could also help to accurately identify the reasons for physician consultations and any change in patient care.

References

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