Dr. Chrissy VanDillen: Online Medical Control (3/7/2023)

Is working very well. I can see you. Good.

So without any further ado, let me just let everyone know that the CME codes are now in the chat. And really honored to have Dr. Van Dilan present us today. This is another abstract, abstract number 10 from the NMSP National Conference. And it's specifically related to online medical direction and developing a curriculum around that for EM residents. And so I find that as a fascinating topic because everyone on this call takes calls. And so I wanted to Learn more from Dr. Vandillen. So without any further ado, Dr. Van Dillen, thanks for joining us and take it away.

Oh, great. Thank you. I was going to. Can I share screen?

Okay.

Yeah, absolutely, yeah. Please.

Okay, so I'm going to open share tray and screen share.

Hey, Peter, in the meantime, was it 17334 today?

Hey, Paul, it is 17334. And then for Eagles main, 17335. It's in the chat. Yeah.

Thank you.

Okay.

Philosophy. I like that philosophy. Very good.

Hey, one of the things we find, Christy, is that if you don't go to the exact PowerPoint view to your. Your overall. What's that called? Screen share. Yeah, Desktop. And then sometimes you'll get in that way. Okay, I'm going into a meeting. I'll see. I got to go with one of the commissioners right now in Dallas, so I gotta. I'll be. I'll be listening through my ear, but I will have to shut off. Okay, then I'll see it later. Thanks.

Bye. Thanks.

Awesome. So doing a screen share desktop, entire screen allow. Let's see if that works. Okay. Can you guys see my screen?

Not yet. Unless somebody else can see it first. It's not. It does. Not showing just yet.

Yeah, I don't see it either.

If it's easy, maybe you want to send it, forward it to me and I'll. And I can share it that way. You could do that.

Okay.

All right. Okay.

I'm so ready to spend the 600 bucks to buy the better Zoom.

Right, Right.

So we can get off teams.

I actually looked into it and I. I looked into it. Angus, I didn't. If you could forward me the link because I, trust me, I pay a lot for Zoom and I didn't see that option.

It's the.

It's a webinar add on.

Yeah, webinar add on doesn't allow us to talk to each other. It's just basically, you just have to be there in listening mode. Right.

You.

You promote people to panelists to be able to talk to Each other.

Oh, I may have that option. Let me look into it after the call today.

Yeah, give me a shout. I'll walk you through what I think you need.

Okay, well, I can get started and I can. Oh, here, here, here, here. Okay, I'm sending it to you.

Peter. Let's see.

I got my email open, right?

Is it Bell South?

That's fine. Yeah. Yep, yep.

All right. Okay, so I just sent it to you, but while you're. Well, while that's working out. Sorry, I should have sent that ahead of time. Thank you for doing that. Basically, what we wanted to do was we actually typically did not do our online med control through. Through Orlando Regional Medical center in Orange County. We did it through Health Central, and we wanted to bring that downtown to the residency program. And so before we did that, we wanted to make sure that both the faculty and the residents were clear on our protocols. I think that many of them knew them because they had been around for a long period of time, but we wanted to make sure that they were completely updated so they could best help the crews in any of their questions and concerns. So. So what we did is we did a series of lectures, and then we focused on what we felt like were some of the main topics that online med control utilizes the most. So if they need more sedation, more pain medications, but also refusals and termination of resuscitation, those were our focus points. And around some other additional protocols, and then again, focusing in. Around refusals, on the pediatric nuances and differences with family members and things like that. Doing a.

Oh, yeah, there we go. That's. That's our main abstract. And so once we kind of went through our.

The.

The different.

Lectures that we did for general information, we then went through a course with them for specific cases. And we actually used radios, and we used an off channel, and we went out of the room and had one of us in the room and one of them outside the room. And we did it five different groups so that actually the. Both the faculty and the residents could actually do a call. And we were like the medics. And so that was a sort of simulation that we actually probably enjoyed it a little too much. You know, I think a lot of us, probably including many of you, have some pretty outstanding med control calls. And so we use some of our best historical resources for that. And we went back and forth. Well, we did a. Before and after studying our survey, doing a pre and post. And as you can see here, there is. We broke it up into termination, refusal, as well as the medical medical necessity and the non transport, non protocol meds and with the, with the pre and post protocols there is a significant difference in their comfort level and being able to answer these calls. And we were actually very serious even with the faculty that they had to do this course or they couldn't work a shift. So when we, when we put the stakes very high like that, we actually got near 100% compliance. And the before and after survey showed P values of less than.0001. So very significant increase in comfortability. And it's actually been, been going very, very well. And I actually get phone calls on a regular basis asking me if they did a good job. And typically they're right on track. You know, I think that everyone is very, you know, they're feeling very responsible and I, and I think that it actually gives the utmost respect to medical directors as well, seeing kind of some of the questions and concerns that the medics go through. So I think it's a great experience for the faculty and the residents to kind of appreciate pre hospital medicine not only for the medics but also for the medical directors and the EMS is, you know, is a special.

Separate sort of knowledge. And I think this worked very well. If anybody would like to kind of have any details on exactly how we did the course, we probably asked them to spend, I think it was a total of two hours in lecture time and then another two and a half hours we put them through the groups. So it was course of about five hours that they went through. And if you, I don't know if you're able to go to the next slide on the PowerPoint. So that's. And then one more. Sorry, this is actually looking at the PGY1 PGY2 PGY3 at attending level. We actually make sure that all of our med control calls are answered with an attending available if the third year answers it. But usually it's only the third years in attending that actually speak on the radio because we wanted a graduated, graduated sense of responsibility and autonomy with that. And we also didn't want them to give med control answers and then have someone else come on after and say wait a minute, we were not going to do that. So we asked that the attendings are there during the, the conversation so that they can talk about it before it's communicated to the paramedic. And it's been going very, very well.

So, so this is, this is fascinating. So you, you. I just want to learn more about the course itself. So you said two hour didactic and you focused on these Four topics in general?

Yeah, I mean we, we covered a, a host of different scope of practice as well as our medications that we, that we carry. But this was, this was the, the big focus points because in, in our history of doing med control, these were most of the reasons that people get called.

Right. And then, so then after the two hour didactic, then it was basically this radio. You're outside the room and they're inside the room and you're basically going through. And then is there like a feedback session after, after each case? Is that how you did that?

Yes, yes. And actually there were five groups and the one that's left off here is peds. Like, like. So we also did a fifth topic which was pediatrics because that makes everybody nervous right.

Now. The question I have also is, has this ever been done in reverse where paramedics are given this type of training? And I'm curious as to that because I have a sense that the reason they don't call as often as I'd like them to call. And again, like many of you, I'm not like the mother, may I? At all. Like, it's the exact opposite. But I still want them to call for the high risk refusals, et cetera, the DNRs, etcetera. And I just have a sense that they don't call because they've never been trained on like how to execute a good medical director call the right way. What's your thought on that aspect of it?

So I actually, when I clear my medics to work in my system, I actually run them through a set of scenarios just sitting down with me or Dr. Walker. And when, as I run them through those scenarios, I have them call for medcontrol to allow for a, I don't, I want them to get assistance and a pediatric refusal. I want them, you know, to get the medical director to talk to the parent to get them to go to the hospital. And it's like a mean dad and a grandma. The grandma wants to take the kid to the hospital. There was a brew and all this stuff and the dad refuses, refuses, refuses. And, and, and you know, the, the medical director, the online med control is, is busy. What do you want? And I have them walk through the process of, you know, you have to say, I am calling because, you know, I have a child who I think needs to go to the hospital and the parents are refusing. I need your assistance in helping me with this so that they ask for what they want at the beginning and then give the, then give the scenario. And so I Talk them, I let them talk through it and then I kind of give them feedback on the best way to do that. But I, but I, I have not studied that and I don't know that there is a study or, or any data on that. But that's something that I do because I think that they get frustrated and the online med control gets frustrated if they don't know that. That I feel like that works with consultants but also with online med control well too.

Yeah. Is anyone doing that or is anyone recording their med control calls for CQI afterwards? Anyone want to comment on that? Angus, go ahead. What are you doing?

So a couple things. One, Christy, this reminds me very much of the Pennsylvania medical command physician class that anybody who's going to do online medical control in the state of Pennsylvania is required to do. We do that as residents. Before we were allowed to do radio calls for the medics. So in other states they have formal procedures for doctors to actually get an actual several hour class like this. I think having the medics practice and be trained in and signed off on how to do an appropriate consultation as part of their initial certification process is definitely a good idea. And some we certainly do. Here we also have.

We actually don't use residents to answer our calls. We have our own group of online docs, most of whom are board certified in ems. But we do, as part of our monthly QA work, we pull five random consults from each doc and have them reviewed by a medical director. Not so much for the medics performance, but for the doc's performance.

How are you doing that? How are you navigating? Is that like through Google Voice or is it just recorded on the recorded line that they have to call you on? How are you doing that?

No, actually the county over here prefers that we do our consults over the radio. So everything is radio based here. We only go to cell phones for our critical care team and some other sort of more complicated stuff.

Awesome. Our colleague from Canada, Mike Austin. Go ahead with your question.

Mike.

Thanks for being here.

Thanks Peter. And thanks for the chat, Kristi. It's great. It's very interesting. I was just going to say that we have developed sort of a new program. We used to have online sort of medical control in our emergency department. We moved it out of the emergency department and now call it online medical consultation. We're really sort of taking the top down approach away from that sort of component and making it more like a consult. But one of the parts that we've built into our system is sort of what Angus was talking about is we built in a peer to peer peer sort of process. So we record all of our calls by phone. So it comes in through a system that records the calls and we link them to the paramedic record and each physician while they're on duty reviews each other's calls. So we're providing feedback between each other to improve the system that the physicians are operating. But in addition, we have the ability to send emails to the paramedics, post the call, so we can follow up both in the call in the discussion and mentor and help and educate throughout that process. So it seems to be working well. We've done some interviewing surveys of the medics and it's quite well received in the context of sort of just bolstering and expanding on their ability and their role in the prehospital setting.

Are you planning on publishing that, Mike?

Yeah, we presented at the Cape last year and we're just about in the process of publishing some of our work. We've sort of expanded a lot on pre hospital discharge. Right. So stepping away from this concept of refusal and moving towards, you know, appropriate dispositioning patients and alternate pathways. So figuring out better ways that we can manage patients who call 911, maybe they don't need to go to an emergency department. But also having them refuse and having not a plan isn't ideal either. So we're really working at developing a. I'll call it, and we've got the three or four different directives, palliative being the easiest one. Right. That most people are sort of jumping on. But you know, I think we're looking at alternative pathways of care to build in processes for patients who engage right. In 911 systems.

I love your idea to make a positive spin on that. That's really great and appropriate because I think that there's a lot of negativity with refusals but pre hospital discharge and the appropriate plan around it. That's nice.

Now we do have a lot of great EMS leaders here and I'm wondering, and I'm going to pick on someone like Chief Coyle to say that, you know, we have Chief, we have what's 16, 1700 medics.

They call. But let's say more infrequently, let's say us as medical directors want to hear them. What do you think needs to be done or can be done to promote more of that in times when they truly need us? What are your thoughts on that? CHIEF coyle, Palm beach county.

And maybe he's not there.

Oh, see that he left. He left me. Anybody else from the EMS side, EMS admin side? What are your thoughts about or any, any heartache about these types of things being done on the EMS side? Just unmute your microphone. We'd love to hear your, your opinion there.

I love, I love the Caribbean music in the background. That's really good.

Let's see. All right, I don't see my. Let me bring in Dr. Landry. Kim, you are someone who, you're in the field. You seem to be on every call. You really have the pulse of your department. What are your thoughts on medical director phone calls? And what do you do with your system?

Yeah, so anytime our medics need to contact med control for either a medication order, a refusal, or anything related to patient care, they go through a central dispatch center that we have and then it's patched through to me on a recorded line. And the main purpose of that is kind of to protect the medics whenever there's a particularly a refusal where it's a pretty high risk refusal. And, you know, the patient may be having subternal chest pain, diaphoretic, and, you know, flat out doesn't want to go to the hospital, he's got the capacity to refuse. I'll have a discussion with the patient. It is recorded and on occasion there will be a bad outcome. And now the family wants to challenge our refusing to take the patient to the hospital. And so, boy, this gives us a whole lot of protection from some of the challenges of the families with respect to, well, we didn't do, you know, they called 911 and we didn't take the patient to the hospital. And that's their bottom line when in reality, we've offered the patient every opportunity to be transported. We provided the risk, they accepted the risk. They had the capacity to take that risk. And it pretty much stops the challenge right there. So that's one of the prime reasons we use it. But then we augmented it with the ET3 and tele911 system so that even, even, you know, if we can get the physician to actually present himself or herself to the patient and the family, with the paramedic at the patient's side, that is even more.

Profound with respect to influencing the patient or the family to do the right thing and get the patient to the hospital or change their mind about an actual, actual refusal. But it also offers, you know, protection for the medics when, you know, we're giving them orders for.

Medication dosages via the hand tevi system. And basically, you know, they made Me come back. Hey, you told me to give this dose and it's like, no, that's not. Let's go back and listen to the recording. You know, it's actually 5 milligrams less that I told you to use. And so there's a whole bunch of reasons why, but it's mostly for that patient family dynamics when it comes to a high risk refusal.

So that begs the question then, should, should all of us be recording the high risk refusals? Even if it's not a medical director phone call, just record the interaction of determination of capacity, etc, you know, understanding the risks of not. Of not being treated. And then secondly, should we all be recording the medical director interaction for. For legal liability? So Chrissy, you first. And I'd love to hear Angus as well.

Yeah.

Okay. I think Chrissy's from. Go ahead, Chrissy. There you are.

So, I mean, I think.

Chrissy, you're breaking up. Is that just me or is that.

No, I can't hear either.

Yeah, Chrissy, you're. You're a little choppy. Maybe if you turn off your video, maybe we can hear your audio better.

Does that work better?

Yes, go ahead. Perfect. Yeah.

Okay.

So I mean, I have always felt that, I think that if they call for med control, I would give us a 60% chance that even just via our voice and them taking the extra step and calling online med control, that the person tends to agree that they need to go to the hospital.

So I think that. So one of the things that I did in my protocols in Osceola county was I made a high risk category of patients that I prefer that they call on patients with chest pain, shortness of breath, patients over the age of 65, less than 1 years of age, just so that they could call in those circumstances and have kind of a sense of what would be high risk. Again, I do think that it would be a good idea to record these conversations, but my concern would be always in legal liability. Does that lead us to more risk based on some of the interactions? I mean, that, that would always be my concern, but I think it would be definitely documenting them but recording them. That would make me a little bit nervous, but I think with the right training, it could be a good thing.

Awesome. Let's go to Angus and then Michael.

So interesting discussion. I actually think we should get Tom James or somebody to come on and talk to us about risk with these things because I have a very different opinion on this. I teach that all refusals are high risk refusals and the concept of a High medical legal risk to the system is probably not where we should be focusing. We should be focusing on making the right thing happen for the patient. So I actively have gotten rid of putting people on the radio or on the phone, the patient, I mean, on the radio or on the phone, to record that interaction. I try to have the medic who's at the patient side do the decisional capacity determination, and if they want to have the doc try to convince the person as well, sure, we'll do that. But.

I found that that actually doesn't work very often. You know, when I did my fellowship at fdny, we did them all on the phone and we recorded these long conversations between the. What we call up there called the telemetry doc and the patient. And it didn't seem like it was that impactful. So for me, I think the value of the recording is much more for quality work rather than legal work. I really am not sure that it gets you much above a good, well documented chart. I'd be interested to hear from Tom or other experts if they have a different opinion of that. And then the second thing, just because I know Michael put it in the chat there is. We used to actually have them talk to a paramedic first before the doctor. And I have worked as an EMT in systems like that, and I always kind of resented that. And I heard from a lot of medics here that they resented that as well, that they didn't want to ask another medic for permission to do their job. And so I have advocated very strongly that if the medic is calling for medical backup, they deserve to be talking directly to a doc.

Great insight. All right, Michael, go ahead.

Yeah, that's interesting, Angus, because I think, you know, some of the aspects of what B.C. does with regards to using medics is more on the operational side. So, you know, in that context, not about the medicine as much. And they do. They have a linked or a dual system. But that's a. It's an interesting feedback component, and I agree with you 100%. I think from a standpoint of legalities, we don't even consider it. It's a requirement to record. But we look at it more from a quality improvement side of things. And I think it's such robust information to be able to go back and review and to be honest, even give it to the medics if they've not provided a great succinct sort of patch into the system that they can learn from it in addition to the physician side learning from it. So Quite, you know, really, really important.

So, yeah, I'll often play back the consult during case reviews with, with them and have a discussion about, you know, how I was understanding what was happening versus how they were understanding what was happening. And that's often a very valuable tool in the case reviews.

Angus, you had mentioned before though, that in a well documented chart, how often if they're determining capacity and you're helping them and going through, let's say it's a five minute consultant. What I have found is that a lot of that information, the important information, determination of capacity is not in there, but it is in a recording. So doesn't that recording give you that buffer to say we did determine capacity, your honor?

Well, I guess my protocol says they have to document how they determined whether or not the patient had decisional capacity. Like they actually have to. If they don't write the words decisional capacity in their narrative, the chart will flag for review. So they have to actually go through. And that's first pass for you, by the way. So, no, they have to. It's not checking a box. They have to describe to me in the narrative how they determine that the patient had decisional capacity.

That's, you know, to have first pass would be great to do that. It just said from a medical leader.

They also, by the way, have to have a narrative that's at least 500 characters long, two complete sets of vital signs and a few other things.

All right.

You know, the other thing, Peter, that's really, really good to have recordings is when we do onboarding of new physicians or fellows or somebody coming on board, we can take a handful, like 30 recordings and give them to these people who are onboarding and say, listen to these. These are the best that we've picked out of our pot. So you can learn before you jump on and start taking calls. So it's a really, I think, empower a powerful thing in the context of learning and quality.

They make for great lectures at Wednesday rounds for the residents too.

I was going to say, have you guys put together a talk or should the NMSP have some kind of database where people can just go in and. Because I think that these are really where the real learning happens with the real calls that are real. It really happened and you can really learn from them. Is there anything like that out there?

Hey, Peter, just real quick, I've got to go. But say, to answer the address, the issue that Angus brought up is that they could just use the eagles because that's like 500 characters, right? You are One of the leading characters, I think, in the group, as a matter of fact.

Okay, so I. You know what? I vote, I vote that Angus talks about this this year in Eagles because it's fascinating topic and it's done so disparately. Right. Everyone does their own little mom and pop thing that I think it's very important.

So. So I actually offer my medics orientation. Yeah, I offer them $100 on the spot if they can find the words high risk refusal in my protocol book. Because I so, like, vehemently disagree with that defensive kind of concept.

Interesting.

You're crazy. You're crazy. Angus.

Jane. Jane.

Not the first time somebody saw me.

Chrissy.

Jane Bedford. Hey, Jane. From the state, do you handle out of county EMS differently? For example, 30% of rural counties don't even have a hospital.

So, I mean, I guess none of us can really answer that because we don't. That's not what we deal with. But that's another interesting question.

All right, well, thank you, everybody.

Not everybody thinks I'm crazy. Mike does.

We know that patients can make bad decisions, right? Better to make them follow up for them, so.

Exactly.

That's the reason legality doesn't know why up here.

Listen, you can make bad decisions here in America. In fact, that's what a lot of our work is predicated on. But they just have to be informed. Bad decisions.

Many people do.

Down here in Florida, we get plenty of business.

Yes, we have both chronic and acute poor decision making down here.

Yeah, we do. We do. Well, Chrissy, thank you so much. Please give us your last word. Where do you think we should go with this? And just thanks for bringing this topic up and for your presentation today. We'll give you the last word and then we'll pop over to Pepe's lecture.

I. I would just say that I. I like to continue to expand the idea that EMS is. Is a subspecialty and continue to motivate and inspire residents in, in, in and around EMS. And so I appreciate everything you guys are doing. Dr. Antebe. You know, Angus, you guys are doing a great job, so I appreciate everything you're doing. Thank you.

Awesome. Thank you so much. And Angus, welcome back, man. You're on vacation, man. We missed you. So welcome back. You look very relaxed.

Thanks. Very relaxed and very tan.

Yeah.

Yeah.

Let me get this stream going.

Let's do it.

All right, I'll see you guys on the other side.