MD-1: Inside New Jersey’s Physician Response Program
When EMS trailblazer Dr. Ronald Johnson of Pittsburgh started his physician field response unit in the 1980s, little did he know the impact he would have on the neighboring state of New Jersey. Mark Merlin was a volunteer EMT in that state (and later a paramedic in Pennsylvania) when he met Johnson and was influenced by his work. When Merlin became an emergency medicine physician years later, he drew from that experience to start New Jersey’s first physician response program, called MD-1.
Merlin started the program in 2002 as part of his EMS physician fellowship at Morristown Memorial Hospital. The first vehicle was donated by a local dealer, Warnock Ford, and equipment was acquired from various sources. Merlin later moved to Robert Wood Johnson University Hospital in New Brunswick and continued the MD-1 program in the central part of the state. In 2011 he began working with the St. Barnabas Health System through Newark Beth Israel Medical Center and became medical director for MONOC, a private company and the state’s largest provider of ALS care. The MD-1 program expanded as part of the New Jersey EMS Fellowship in Emergency Medicine there into its current form, an accredited program with six physician response vehicles staffed around the clock for response around the state. According to Merlin it is the largest such program in the country. The physician telemetry and medical control console for MONOC was also moved from southern New Jersey to Newark Beth Israel. This console provides online medical control for more than 170 ALS treatments a day.
According to Michael Carr, MD, one of the current EMS fellows, the goal of the program is not to take over a scene but to “supplement existing ALS response.” MD-1 physicians provide on-scene medical control to paramedics, advice for difficult calls, and specialized medicines or equipment the typical ALS unit doesn’t carry. The program can be accessed by ALS or BLS units where there is an extended entrapment or rescue call where a patient might require sutures, specific advanced airways, or a field amputation.
The MD-1 program is also the exclusive medical support for the New Jersey State Police TEAMS unit (its SWAT team). This team does not have its own tactical paramedic; instead, an MD-1 physician responds to its scenes with body armor and backs up the state troopers as needed. These physicians train extensively with the NJSP on procedures and tactics. The program also engages in extensive outreach to medical students, volunteer ambulance squads, and other physicians from around the country who take part in ride-alongs. Additionally, EMS fellows work as medical directors for local EMS agencies and oversee protocols.
Vehicles and Equipment
The MD-1 program fields six vehicles: five marked Ford Explorer Police Interceptor models and an unmarked Ford sedan used for State Police responses. These vehicles are issued to the EMS fellows for their entire fellowship period, often 1–2 years, and dispatched by the statewide MONOC control center. There is always a primary and backup truck on duty, plus a State Police tactical response vehicle. Physicians can either be requested by any unit (ALS or BLS) or choose to respond when they’re in proximity. Where distance is a factor, fellows can receive a state police escort or access MONOC Air-1, the system’s helicopter.
In terms of gear, each vehicle carries the same Lifepak monitor, drug box, airway bag, and jump kit found in a typical paramedic unit. Called by Carr an “ER on wheels,” each vehicle also includes video laryngoscopy, chest tube kits, surgical (thoracotomy) trays, ultrasound, and a more advanced drug selection that includes propofol, steroids, sedatives, antibiotics, hydroxocobalamin, and lidocaine. Other tools include amputation saws, suture kits, body armor, and Durabond. Physicians can also access whole blood if needed for field transfusions.
For their first 30 days on the truck, MD-1 physicians receive extensive training in scene safety and procedures. “Many of them have been EMTs or paramedics prior to medical school, but some have not,” says Merlin. “We start them with the basics of what all EMS providers know, including scene safety, lights-and-sirens driving, and MCI management.” EMS fellows are not permitted to respond solo to scenes unless law enforcement or another EMS provider has arrived first. All fellows receive additional training in ICS-100, ICS-200, ICS-300, and ICS-400, as well as difficult-airway and medical direction courses. They spend a great deal of time meeting and working with the paramedics in the field and developing those relationships.
Once a month fellows take part in a “journal club” where they review difficult cases and current EMS literature. “We pride ourselves on being cutting-edge with the research,” says Merlin. Findings are often shared through outreach to local EMS providers for training, medical direction, and protocols.
“I am repeatedly surprised by how much the paramedics like having the doctors in the field,” says Carr. “This was not my expectation going into the fellowship.”
The most beneficial part of prehospital physician response is the “face time” it provides with the paramedics and EMTs. Through this, both parties better understand each other’s capabilities, and as a result there’s comfort working together during difficult situations or when something goes wrong.
“I’m also surprised at how much I have learned from paramedics,” adds Carr. “While I may have a more advanced education, many paramedics surpass me with their clinical approach. Many medics who have been on the road for 20–30 years regularly teach me things about responding in the field. It’s very different than an ER. There are many levels of considerations when walking into a patient’s house that we do not experience in a hospital setting.”
“My goal,” says Merlin, “is to get doctors to think like EMS providers.”
Each physician generates about 30 charts a month through responses where they make patient contact. Many of these are cardiac arrest calls, where the doctors can be an invaluable resource. For example, a physician can perform an ultrasound of the heart and direct the EMT doing compressions to move to the left to maximize left ventricular compression. The physician can act as “airway backup” if the paramedics can’t get the intubation so the team can focus on compressions. They can offer alternative medications if there is a more complex situation. “Overall, we can enhance a patient’s experience,” says Carr, “not replace the excellent care EMTs and paramedics are already providing.”
Starting a Program
If you’re considering starting a physician response program, find someone who has done it. The key is setting up procedures and protocols around dispatch, field ALS and BLS care, law enforcement, the fire department, and scene safety. The program is not a revenue generator, nor is it ideal for billing, so you must realize it won’t be a money-maker to place physicians in the field. The goal should be to enhance patient care, and the role of the physician should be clearly defined within your system.
For example, some systems may have more mass-casualty events than others. You should prioritize physicians to those scenes to triage and control patient transports to the hospitals. The role of the EMS physician is not primarily supervisory—leave that up to the ICS commanders on scene. The goal of any EMS physician response program should be to act as a supplemental resource for the existing system with a goal of education for providers and improved patient outcomes.
Barry Bachenheimer, EdD, FF/EMT, is a career educator as well as a firefighter and member of the technical-rescue team with the Roseland (N.J.) Fire Department and an EMT with the South Orange (N.J.) Rescue Squad. With an emergency services career of more than 30 years, he frequently serves as an instructor for both departments. Reach him at firstname.lastname@example.org.
Mark Merlin, DO, is founder and program director of the New Jersey EMS fellowship. He is vice chair of emergency medicine at Newark Beth Israel Medical Center/RWJBarnabas Health, as well as chief medical officer and system medical director for MONOC, New Jersey’s largest EMS system. Reach him at Mark.Merlin@rwjbh.org.
Michael Carr, MD, is an EMS and disaster medicine fellow at Newark Beth Israel Medical Center in Newark, N.J., and deputy medical director for MONOC EMS.