Imagine you or someone you know is badly injured, calls 9-1-1, and an ambulance arrives with EMTs and paramedics who begin to address your wounds, stabilize your life-threatening injuries and transport you to the nearest emergency department.
This scenario doesn't offer many surprises, but what if one of the responders is a physician? This is not a common finding in the United States, which follows the Anglo-American model, where patients are brought to the doctor, versus the Franco-German model, where the doctors are brought to the patient.1
Certainly, there are benefits to having a physician in the prehospital setting, whether actively involved in patient care, quality control, training purposes for other EMS healthcare professionals, or even to help deter the ever-more overcrowded emergency departments.2 If the issue was this simple, physicians responding to 9-1-1 calls on ambulances and treating patients in their homes would be a regular occurrence; however, it is far from simple.
The Prehospital Physician Concept
The concept of a prehospital physician could be similar to a triage liaison physician (TLP) employed in some overcrowded emergency departments to facilitate better care of patients. In a study published in Academic Emergency Medicine, the authors show the benefit of having a physician facilitate care, beginning in the waiting room.3 The study showed that using a TLP decreased the overall length of stay, as well as the number of patients who left without complete assessment. There was, however, no effect on ambulance wait times or diversions.
If a TLP can offer this benefit, it would not be a far leap to speculate that a prehospital physician could offer similar, if not greater, benefits to emergency departments. Some authors propose the possibility of emergency care becoming unreliable if the overcrowding continues with "poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff and violence."2
In Idaho, Julie Madsen, MD, serves as medical director of Canyon County's Ambulance District and rides on the ambulance approximately every two weeks.4 One of her supporters, Ambulance District Assistant Director Jeff Sceirine, says, "It is very exciting to have a doctor responding on calls and providing feedback during or following the call."
The New Jersey EMS Task Force's Physician Response Team, MD-1, also uses the services of a physician in the prehospital setting.5 The team began in 2005, based on models in New York City and Pittsburgh. In support of this endeavor, the local emergency department had its insurance policy rewritten to include prehospital coverage for attending physicians. In its first six months, the vehicle was requested 34 times. In 2006, the program was integrated into and funded by the New Jersey EMS Task Force. The program quickly grew to include MD-2 via St. Joseph's Regional Medical Center in Paterson.6
"The main goal of having the capability to dispatch physicians to a scene is to save more lives on the road," says Dr. Mark Rosenberg, chair of emergency medicine at St. Joseph's Healthcare System. "Paramedics and other first responders receive extensive training, but they just cannot provide the same type of care as doctors."
Docs vs. Paramedics
While the successes of prehospital physicians are evident and the benefits appear almost endless, it is important to note that there are also currently highly trained prehospital professionals skilled in emergency medicine treatment and management. In a study published in Resuscitation, a comparison was made in Oslo, Norway, between advanced life support provided by physician-manned ambulances (PMA) and nonphysician, paramedic-manned ambulances (non-PMA).7 The study revealed no difference in survival rates between the two groups, effectively showing that paramedic resuscitative efforts may be comparable to those of physicians. In a similar study published in Prehospital Emergency Care, authors demonstrated that out-of-hospital cardiac arrest patients treated by the physician group had a trend toward more frequent return of spontaneous circulation upon ED arrival and a higher rate of survival to hospital discharge. In addition, patients in the physician group received medications at nearly twice the rate of the paramedic-only group.8
While non-PMA represents the vast majority of U.S. response vehicles, why aren't more physicians riding ambulances? Three physicians who volunteer with local fire departments that provide ambulance service were asked their opinion on this issue.9 None currently ride the ambulance, stating that their concerns about doing so stem from mostly litigious reasons, since riding the ambulance leaves them legally vulnerable. All three have malpractice insurance provided through the hospitals where they are employed, which covers them in their scope of practice at their respective facilities but not in the prehospital setting.
"It's sad, but the truth is, it's just not worth the risk," says one physician.
While the skills of prehospital professionals are undeniable and irreplaceable, the added resources of a physician can be profound, including quality control, training, deterring overcrowding and facilitating care in the emergency department similar to the TLP, and "elevating the level of care available to the citizens."4 If physicians are currently concerned with legal retribution for riding an ambulance, perhaps we should follow New Jersey's example and adjust our local hospital or state insurance policies to protect those physicians willing to serve the greater good of the public.
1. Dick WF. Anglo-American vs. Franco-German emergency medical services system. Prehosp Disaster Med 18(1):29-35; discussion 35-37, Jan-Mar 2003.
2. Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: Complex causes and disturbing effects. Ann Emerg Med 35(1):63-68, 2000.
3. Holroyd BR. Impact of a triage liaison physician on emergency department overcrowding and throughput: A randomized controlled trial. Acad Emerg Med 35(1):63-68, Jan 2007.
4. Sillonis A. Is There a Doctor in the Ambulance? http://www.valli.com/webdesign/ccparamedics/doctor.html.
5. Merlin M, et al. Docs on demand. EMS 37(9):42-45, 2008.
6. Tyrka S. Doctors Are Now Ready to Hit The Road. http://www.northjersey.com/news/health/hospitals/70437017.html.
7. Olasveengen TM. Out-of-hospital advanced life support with or without a physician: Effects on quality of CPR and outcome. Resuscitation 80(11):1248-1252, 2008.
8. Dickinson E. The impact of prehospital physicians on out-of-hospital, nonasystolic cardiac arrest. Prehosp Emerg Care 1(3):132-135, 1997.
9. Keuhn B. Reports warn of primary care shortages. JAMA 300(16):1872-1875, 2008.
Glenn Skow, MD, MPH, is a clinical assistant instructor in the Department of Family Medicine at Stony Brook University Medical Center in New York.