Exposure of Other Major Problems: Open right-side chest wound at site of surgery weeks ago. Surgeon has placed a chest tube and put an occlusive dressing on the wound. Patient has a port in the left chest wall for infusion of chemotherapy.
Secondary Assessment (appropriate to presenting condition)
Open chest wall, with no active bleeding. Patient in pain. Surgeon has inserted a chest tube and placed an occlusive dressing over the surgical site. He requests pain medication be withheld, and the patient transferred to the hospital where the surgery took place.
Allergies: Multiple allergies to antibiotics; "sensitive" to pain medicines.
Medications: Chemotherapy being injected in a port in the patient's chest wall. OxyContin pain medication.
Past Medical History: Lung cancer, right side.
Last Intake: Lunch at 1230.
Event: Patient with a significant open chest wound at the site of a recent surgery. The wound is closed with a dressing, and a chest tube placed. The patient will need to be transported to a hospital with the tube in place. The patient's physician is the surgeon who did the original surgery, and he has requested treatment that is not within EMS' medical protocols.
Attack One responds to a call for a sick person at a medical office building near one of the community's hospitals. It is unusual to have a response in this building, as most patients with acute medical problems there are simply moved by wheelchair to the nearby hospital. The crew enters the office of a chest surgeon and is greeted by a nurse, who asks that the crew remain in the back hallway for a minute to allow the physician to "complete a procedure" on the patient who is ill and needs transport. The nurse wants the crew to enter and exit through an interior corridor, away from the office waiting room, so they don't alarm the patients waiting to be seen.
The crew hears a patient yelling in pain in the procedure room. In a minute, the physician inside asks loudly if EMS has arrived. The nurse affirms they have, and the crew is allowed to enter the room. They find an elderly man lying on his left side on a procedure table, with a gaping hole in his right chest wall and a chest tube inserted above the hole. The surgeon has just placed the tube in the man's chest; he asks the crew to assist him in "holding the patient's chest wall together" while he covers it in a dressing. The patient looks fairly ill and is noticeably short of breath.
The surgeon is barking orders, and a paramedic who spends a lot of his off time around hospitals steps to the bedside to assist. "OK if we get the patient on some oxygen, doc? He looks a little blue there."
"Sure, but get some gloves on and help me push this chest wall together."
The oxygen mask goes on, and one of the other paramedics and the nurse move to the front of the patient to offer support. The nurse provides some history. This unfortunate patient had surgery on his right lung three weeks ago, and they found lung cancer. He is already undergoing chemotherapy and radiation therapy. The stitches in his chest wall were removed in the office by the surgeon today. When the patient went to leave, he slipped on the floor. He didn't strike anything, but his surgical wound split apart. The surgeon placed a big dressing over the chest, then placed a chest tube to remove the air.
The surgeon has shaped a plastic occlusive dressing just larger then the chest wound. He wants the paramedic to hold the chest wall edges together while he tapes the dressing in place. That is easily done, and the wound is held together. They fashion another piece of the plastic dressing to hold the chest tube in place. On oxygen, the patient is now breathing more easily, and his oxygen saturation improves.
The surgeon has placed the end of the chest tube into a suction device. He requests that the device be connected to the suction system in the transport medic, as he has seen used in the Mobile Intensive Care Unit at the hospital. He also requests that the patient receive a bolus of fluid through the intravenous port in his left chest, and that the patient be removed to the hospital about 10 miles away, where the original surgery was performed and where he has been getting radiation treatment and chemotherapy. The surgeon also warns that "The patient is really sensitive to pain medicines, so don't give him any!"
Those issues are all outside the scope of the Attack One crew's medical protocols and capabilities. The suction system in the transport will not deliver the sustained vacuum necessary for a chest tube. The physician is advised that MICUs are outfitted with those systems, but they're not available in everyday ambulances. The protocols do not allow the use of indwelling ports a patient may have in place. The crew offers to place a separate IV line and infuse a fluid bolus through that. The crew also wants to give a small dose of morphine for the patient's pain. Finally, a hospital is about 200 yards down the street, and ordinarily the patient would be removed to the closest hospital.
The surgeon is not pleased with any of these answers, so the Attack One crew calls for online medical direction. The paramedic explains the patient's situation to the online emergency physician, then hands the phone to the surgeon. Several issues are easy to resolve: The chest tube can be "capped," meaning the end is closed off by the surgeon with a one-way valve, and suction later resumed in the emergency department. The paramedics will not touch the tube system en route. The surgeon is asked to connect the EMS intravenous lines to the port, as he is familiar with the device and can attach a line without compromising the system's sterility. The paramedics will give the requested fluid bolus and keep the line intact. The patient will be removed to the requested hospital farther away, because of his significant history there, and agrees to that. The control physician requests that the surgeon allow some pain medicine to be given, but the surgeon firmly disagrees, so the patient is placed in as comfortable a position as possible and transported.
The patient arrives at the emergency department. He's received a 500cc fluid bolus, and his oxygen saturation has been maintained with supplemental oxygen using a mask. His chest tube and drainage system are reconnected to suction, and inside the ED, pain medication can be given and the patient monitored closely. The patient's care is continued in the cancer unit at the hospital, his wound heals, and he is released four days later.
Physician interactions are an area of concern for prehospital care providers. Physicians who aren't familiar with EMS care may request evaluation, treatment and transportation beyond the scope of practice of crews on scene, or outside their departments' medical protocols. EMS organizations must have policies addressing the issue of "intervener" physicians and what such physicians can direct EMTs to do. There are situations where a patient's primary physician will have an important role in caring for a patient, and may need to direct an EMS crew to evaluate, treat and transport. That physician will need to accompany the patient to the hospital if his orders require the EMTs to work beyond their scope of practice (unless it is a disaster situation). In cases where an intervening physician has no established relationship with an emergency patient, the online physician identified by the organization's medical protocols has full responsibility for patient care.
Within an EMS organization's medical protocols is often a statement regarding authority for emergency patient management. The statement often addresses control of patient care at emergency scenes with statements such as:
The 9-1-1 EMS organization shall have responsibility for the 9-1-1 patient, and the individual in attendance designated as in charge will have the authority of the patient-physician interaction. When an EMS crew arrives at the scene of a 9-1-1 medical emergency and contact is made with medical control, the patient-physician relationship is established between the patient and the physician providing online medical control. That physician is responsible for management of the patient, and the lead EMT acts as an agent of medical control.
When the patient's primary physician is on scene, or the patient is in his/her medical office, EMS shall perform its duties per protocol. The primary physician may elect to supervise care provided by EMS. If the physician directs EMS providers to administer medication or perform procedures beyond their scope of practice or protocol, the EMTs will not administer the medicine or perform the procedure. The EMTs, if requested, may assist the physician in performing the procedures. The physician is then assuming responsibility for ongoing care and is expected to accompany the patient to the hospital.
There are many times when an intervening physician will interact with the patient and EMS crew, and the care provided will be within the normal scope of protocols and practice. The EMTs will only need to identify the physician and document the interaction. When a physician other than the patient's physician on the scene of a medical emergency properly identifies him-/herself and demonstrates willingness to assume responsibility for patient management outside the scope of EMS protocols, place that intervening physician in communication with medical control and document any intervention outside usual protocols. The intervener physician must confirm the orders for medications or procedures by signing the patient care report. If there is disagreement between the intervening physician and the medical control physician, or if the intervening physician refuses to speak with medical control, EMS should continue to take orders from the medical control physician.
Some agencies ask responders to carry a simple card for interactions with physicians that says something like:
This department welcomes the opportunity to work with physicians at emergency scenes who are willing to assist in improving care for emergency patients. This department has responsibilities to all patients where 9-1-1 services are requested. In legal terms, our EMTs act as agents for the medical control physicians to establish a patient-physician interaction.
An intervener physician is a physician on the scene who has no previous connection with the patient. For an intervener/Good Samaritan physician to assume control of the patient, he must:
Submit proof of licensure in this state.
Be willing to assume responsibility for the patient at the scene and during transportation to the hospital. This includes accompanying the patient during transportation (except disaster situations).
Perform procedures outside the scope of EMS protocols himself.
If a physician is unwilling to comply with these requirements, his/her assistance will be respectfully declined.
James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He serves as deputy chief-assistant medical director for Washington, DC Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at James.Augustine@dc.gov.