Ch 2. Resident Roles & Responsibilities
EMS training experiences vary between programs. In fact, many programs don’t even require ambulance ride-alongs, let alone flight time. With the advent of ACGME accreditation of EMS fellowship programs, a more generalized educational ex- perience across residencies is likely to develop in order to meet standardized expectations of fellowship directors. For the time being, residents should become familiar with their individual program requirements. However, a model curriculum created in 1996 offers some expectation of resident EMS education. The ‘Experiential Components’ section the curriculum offers a reasonable focus.
Your level of involvement may vary – you might just help here and there with any of the following tasks, or you may wish to become a resident/assistant medical director, working with an attending physician to provide medical oversight for a particular
EMS agency in your area. Regardless of the particular opportu- nities of individual residency programs, it is critical for EM resi- dents to understand the nuances of EMS medicine and how they differ from emergency medicine.
Direct observation allows evaluation of subtleties not captured in written EMS run reports. You will also gain a greater appreciation for what the EMS providers deal with on scene, and their protocols prior to ED arrival. You will also have the opportunity to experience prehospital specific procedures, like backboarding/spinal immobilization, vehicle extrication, and various airway rescue devices. Depending on your residency program you may be in an observer-only role or, as a junior resident, you might operate only under EMS protocols. As a senior resident, you may be allowed to assume on-scene med- ical oversight, allowing the use of your own clinical judgment, procedures, and skills to perform interventions outside the EMS scope of practice.
Opportunities abound to give a lecture at your lo- cal EMS agency, facilitate hands-on training, or lead an interactive review of some recent runs. This can be provided on a set schedule, or in response to specific concerns. For example, if the department has been having trouble with pediatric airway management, you may choose to review those run reports and discuss appropriate intubation and non-invasive airway manage- ment options and techniques specific to the pediatric airway.
You may also consider other lecturing opportunities to develop public speaking skills. Check with your local EMS coordinator, training program instructor, or EMS official at your organization to find out about local classes, EMS conferences, and provider courses for potential opportunities.
This aspect of training involves online medical direction via phone or radio or offline via protocol development and case review. Each residency program and EMS group will have its own protocols or guidelines for medical direction, so be sure to become familiar with them prior to par- ticipating in this capacity. Another means of gaining experience with medical direction lies in quality assurance and improve- ment activities. The Medical Director, along with the Quality Improvement team, regularly review EMS runs. A robust QA/QI program can recognize systematic as well as individual trends, which may allow for focused training, individual action plans, or a system-wide change. Many regions have a set schedule for this (eg, review of chest pain runs in January, shortness of breath in February, etc.). Others use random chart sampling for a fixed interval, review of sentinel events, or trend analysis. Another op- portunity in medical direction experience is the review, creation of, or implementation of protocols. Most EMS providers operate under protocols, which may be designed and revised by groups (a regional physician advisory board or a standing orders com- mittee) or by an individual, like the system or state medical director. Protocols specify prehospital provider scope of practice: what medications/doses they may use, whether they may per- form rapid sequence intubation, or if they may call ahead to activate the cardiac cath lab. Involvement in developing and drafting protocols is a great way to learn more about EMS systems at the local, state, or national level, and also is an opportunity to ensure that best medical practices, new and emerging technology, and up-to-date evidence-based medicine is reflected in these proto- cols.
Most hospitals run disaster drills that in- clude patient evacuation, haz-mat, and limited-resource training, and participating at this level is often required. However, as an emergency medicine resident you will need a working knowledge of prehospital disaster management. Mass gatherings like concerts, sporting events, and political rallies often require EMS presence. This is a valuable exposure to disaster planning and to the many aspects of mass casualty medicine. Involvement may include preplanning, evacuation plans, and providing direct pa- tient care at on-scene aid stations. If you are interested in disas- ter medicine, join your local DMAT (Disaster Medical Assistance Team), or US&R (Urban Search & Rescue) Task Force. Their med- ical directors help provide training, but their main purpose is to ensure the health and well-being of their crews preparing for and during a deployment. Some states have their own disaster re- sponse teams that provide services similar to the DMAT or US&R
Task Force, which can be deployed at the state level without fed- eral approval. Depending on where you live, there also may be opportunities to work with more specialized teams like wilder- ness or air and sea search and rescue.
Beyond the typical EMS and fire department model
NREMT test item writing: Several times a year, physicians and EMS providers and educators gather at the National Registry of Emergency Medical Technicians headquarters in Columbus,
OH, to write test questions for the national certifying exams for EMTs and paramedics. This is another good way to become more familiar with the EMS curriculum, develop your test-writing skills, and contribute at the national level to education and certification of EMS providers.
Advocacy on behalf of EMS, and liaison between EMS and other groups: This is a role that every medical director must fill to some extent. For some, it may be the simple day-to-day com- munication on behalf of EMS – explaining to hospital-based physicians/nurses why EMS did things a certain way, how they
operate, or what their protocols do or do not allow them to do. Others may take this role much further – working with leaders in the community to build a strong local EMS system, or speaking to government officials up to the national (or even international) levels to advocate on behalf of EMS.
SWAT/Tactical law enforcement: These teams are increasingly looking for active EM physician involvement. This includes pro- viding training for their own medics and working alongside the tactical team as a primary medical asset. Opportunities abound in this exciting and expanding area of emergency medicine. EM residents across the country are actively supporting tactical teams at the city, county, regional, state, and even federal levels, including FBI SWAT.
Medical director for EMD (emergency medical dispatch) centers: EMS are the first people to physically see and touch the patient, but dispatchers are the earliest link in the emergency response system, as they answer the phone call and provide verbal in- struction for things like CPR and bleeding control, or even walk the caller through delivering a baby.
Flight medicine: There is likely a helicopter transport service of some type in your area. In many ways, flight medicine is similar to ground EMS in that they have specific protocols and require regular training. There are, of course, many nuances specific to the flight service that make this another good opportunity to be involved.
Metropolitan Medical Response System: The MMRS is a federal grant program designed to promote and improve disaster re- sponse involving multiple agencies, jurisdictions, and roles. An MMRS may have several smaller committees, focusing on anything from preparation for a mass casualty, to preparing for EMS’s response to an active shooter, to planning resources and response for an epidemic disease outbreak. Even if there is not an MMRS active in your region, there is probably some person or agency working on these types of domestic preparedness activities.
- Katzer R, Cabanas JG, Martin-Gill C. Emergency medical services education in emergency medicine residency programs: a national survey. Acad Emerg Med. 2012;19(2):174-179.
- Verdile VP, Krohmer JR, Swor RA, Spaite DW. Model curriculum in emergency medical services for emergency medicine residency programs. SAEM Emergency Medical Services Committee. Acad Emerg Med. 1996;3(7):716-722.