EMS is a medical care system that includes medical practice as delegated by physicians to non-physician providers who manage patient care outside the tradition confines of office or hospital. As befits this delegation of authority, it is the physician's obligation to be involved in all aspects of the patient care system.
Specific areas of involvement include the following: * planning and protocols * on-line medical direction and consultation * audit and evaluation of patient care.
Regulation 61-7 (pdf), Section 302, under Statutory Authority Section 44-61-150 of Act 1118 of 1974, amended in 1981, 1988 and 1995, requires that "Each licensed provider that provides patient care shall retain a medical control physician to maintain quality control of the care provided...."
The most recent amendments in 1995 updated the requirement of medical control for all services, even those who are licensed only as basic life support, to allow for medical control for the advanced skills now performed by basic EMTs.
Another important amendment grants authority to the medical control physicians to "oversee the quality of patient care for all EMS personnel and retain other responsibilities as may be negotiated by agreement with the service."
The first state medical director was appointed in 1981. His first tasks were to develop a quality assurance program for EMS services that would assist them in maintaining the competency levels of their personnel through in-service training programs and reviews of skills. Later, in 1985, the state medical director and the four regional medical directors formed the Medical Control Committee. The state medical director serves as the chairman of the Medical Control Committee, as well as chief medical advisor to the Division of EMS.
Regulation 61-7 (pdf) lists the functions of the off-line medical control physicians as:
Quality assurance of patient care including the development of protocols, standing orders, training, policies and procedures; and approval of medications and techniques permitted for field use by direct observation, field instruction, in-service training or other means including, but not limited to:
Off-line medical control physicians must establish standing orders and/or protocols. Requests for pilot projects or additions to the state drug list must be forwarded through the medical control physician, with the EMS director's agreement.
The medical control physician is responsible for recommending certifications and re-certifications, as well as de-certifications to the Division of EMS & Trauma. He or she may withdraw medical direction from any EMT under his authority so that the EMT will not be able to perform advanced life support procedures while working for that service. He or she must establish educational programs and continuing education programs for the service's EMTs, dispatchers, educational coordinators and on-line medical control physicians.
Off-line medical control physicians are required to attend a half-day medical control physician workshop within one year of accepting a position as a service's off-line medical control physician. This workshop briefs the physicians on the history of EMS in South Carolina, laws and regulations affecting EMS, their responsibilities as medical control physicians and certification and in-service training requirements.
Beginning in January 2000, off-line medical control physicians will be required to re-certify annually. This recertification can be accomplished in several ways, including attending the annual medical control physician's workshop, reading and commenting on the minutes of two Medical Control Committee meetings (minutes available for review on the SC EMS Educators Association website), attending one of the four regional informational meetings or other EMS committee meetings such as the Trauma System Committee, Training Committee or EMS Advisory Council or watching a video which will be available which contains summary information on the Medical Control Committee meetings for the past year.
Each of the four regional EMS offices is advised by a regional medical control physician, and each of these physicians also serves on the Medical Control Committee. The regional medical control physicians oversee regional advanced training courses and are responsible for the actions of advanced training candidates during class and clinical. They assist the local medical control physicians in developing training and quality assurance programs and they coordinate all regional requests for additions or changes to the state drug lists. Regional medical control physicians provided leadership during the recent regional trauma planning meetings.
The on-line medical control physician's primary responsibility is the provision of direct radio or telephone orders to advanced life support personnel in the field. However, many of the on-line medical control physician's duties overlap those of the off-line physician. The on-line physician assists the off-line physician in development of standards and protocols, accepts responsibility for orders issued over the radio, assumes a lead role in development of training programs for EMS personnel, assists the off-line physician in the design and implementation of EMS system audits and may assist in certification and recertification training of EMS personnel.
As mentioned above, the Medical Control Committee was formed in 1985 by the first state medical control physician. Its membership includes chairmanship by the state medical control physician (currently Dr. Ed DesChamps, who is also one of the Committee's original members), each of the four regional medical control physicians, a representative of the state Committee on Trauma, an ACEP representative, a representative of the Medical Association, and representatives from each of South Carolina's two Schools of Medicine, one of which is a pediatric specialist.
The purpose of the Committee is "to delineate medical practice standards for Emergency Medical Services in S.C. and to provide regular review, advice and revision regarding those standards and to make recommendations to the state EMS Advisory Council and its subcommittees."
The goals of the Committee were determined to be:
The Medical Control Committee established the now required medical control physician's workshop, developed the state approved drug list document with the cooperation of staff, adopted the Champion Trauma Score system in 1987 and later adopted the Revised Trauma Score system for prehospital evaluation of traumatic injuries, drafted a subcommittee to develop a Do Not Resuscitate law.
The Medical Control Committee provided leadership in the development of S. C.'s trauma system. In the early stages of trauma system development the Medical Control Committee adopted ACS criteria for trauma center designations and reviewed recommendations for designations. Then, with the approval of federal trauma grant funding to develop a state trauma plan, the Medical Control Committee appointed a multidisciplinary Trauma System Committee, which serves as a subcommittee. The Medical Control Committee remains heavily involved in all issues surrounding trauma system development.
Of all the elements of S.C.'s EMS system development, the Medical Control Committee and the medical control system itself are one of our greatest success stories.
A history of dynamic leadership in medical control has kept physicians on the front line in the development of the EMS system. With its direction, the development of a comprehensive drug list enables our EMTs to have the necessary medication tools to provide the best patient care. The Committee has also addressed the changing roles of paramedics in the workplace and continues to provide recommendations as new roles emerge. In the span of only about five years, the Committee has coordinated the growth of a few designated Level I trauma centers using adapted ACS criteria to a full-fledged, regionally based voluntary trauma system with 24 designated trauma centers, a comprehensive written state trauma plan and four regional trauma plans.
In recent years, the Medical Control Committee has revised and put into algorithm format a set of state approved protocols for use and adaptation by local medical control physicians. The Committee has revised the State Drug Formulary to include separate lists of standard prehospital drugs and special purpose, or local option, drugs, as well as a separate list of interfacility drugs. Additionally, they have encouraged the development of pilot projects by local EMS services and have recently approved Lancaster County's Rapid Sequence Induction project as a local option skill (with state approval).
The medical control system of off- and on-line physicians flows smoothly, especially with the recent changes in regulation to allow the physicians more authority in their roles.
Medical Control related documents available from the Division of EMS & Trauma
DHEC Form Number 3462 (Do Not Resuscitate) (pdf) is a document made to prevent EMS personnel from employing resuscitative measures or any other medical process that would only extend the patient's suffering with no viable medical reason to perform the procedure.
When called to render emergency medical services, EMS personnel must not use any resuscitative treatment if the patient has a "do not resuscitate order for emergency services" and the document is presented to the EMS personnel upon their arrival. EMS personnel must provide that degree of palliative care called for under the circumstances which exist at the time treatment is rendered.
Under the South Carolina Code of Laws Sections 44-78-20 and 44-78-50 a patient in receipt of an EMS DNR must be diagnosed with a terminal condition AND be at least eighteen (18) years of age.
Please call the DHEC EMS Office if you need assistance with this form.
Arnold Alier, Division Director
For additional information, call (803) 545-4204