I'm a part-time medical director (board-certified in EMS). I'm paid a total of $5,000/month for being the medical director of a large fire department, 2 very small fire departments, and a paramedic training program. They call my cell phone for all items above. If I'm not available, then they call the ER (which is handled by the EM-3 resident).
1. My state requires a physician order to stop CPR. We have aggressive protocols that allow for not initiating CPR, but once it's initiated, a physician order (direct, not protocol-based) is required to cease resuscitation.
2. I mitigate this by allowing 3 doses of fentanyl/Versed and up to 2 doses of ketamine under standing orders. We utilize a tightly controlled tracking system (that was recognized in Congress and has since become a standard many agencies have adopted -- this was recognized during voting on the Protecting Patient Access to Emergency Medications Act). When we receive a shipment of a controlled substance, 2 paramedics sign it in. Each vial is barcoded. I can track that vial from arrival at headquarters to the patient who receives it or the reverse distributor that destroys it (and every paramedic who had it in his/her possession). Any open top vial is sent to a reverse distributor where it is tested to make sure it contains the drug. When a paramedic administers a controlled substance, I receive an email the following morning that includes the attached PCR. I print, sign, scan, and email it back to the EMS Operations division. I then either mail the original or drop it off at our biweekly meeting.
3. I also do not take these calls while on-duty unless it is from my fire department. I cannot "authorize a refusal" like some paramedics ask. I can only say "hey, I think you should be seen." No physician can give permission for a patient to refuse. If the patient has capacity to make decisions, then it is his or her right to refuse. Sign on the dotted line. No prehospital provider has ever been successfully sued for a refusal when assessed properly and the patient has capacity to make decisions.
4. If they are asking whether to run lights or sirens, then that's absurd. For one, I do not believe in lights and siren returns to the hospital. The 90 seconds saved in running code to the hospital has no proven benefit to patient outcomes and has significant risk to the public and to the prehospital personnel in the ambulance. It took a while, but docs finally got on board with trauma patients with a BP of 80 being transported to the ER without lights and sirens. Recently we had a question whether a physician can order lights and siren for a transport for a testicular torsion. If one of my crews ran lights and siren for a testicular torsion transfer, I would be livid and they would be in my office being disciplined. A physician cannot order a crew to run lights and siren. They can order medical care within a scope of practice, but they cannot order a crew to run lights and siren as much as they can order a crew to only make right turns, to accelerate fully to the speed limit, or to slam on the brakes at any intersection. This is more of a policy and not protocol, and only a medical director can decide that.
5. All prehospital EKG's by my fire department come to my cell phone. They can text/call and I can pull it up immediately. However, all EKG's transmitted to my hospital are reviewed by the interventional cardiologist 24/7. They can activate/cancel the cath lab based on prehospital EKG.
6. If a crew called me to ask if a patient met trauma criteria, I would tell them to refer to their protocols. We have established trauma criteria that includes optimal destination decisions. There is published criteria for it.
