Both debunk the myth that patients can be kept safe if paramedics must request permission before doing something that might be dangerous. Unfortunately the highest risk/lowest frequency interventions are the ones that must be done most quickly. Instead of focusing on what the patient needs, paramedics in mother-may-I systems must pick up a phone and clearly articulate why a patient needs a surgical airway, cardioversion, chest decompression, or chemical restraint.
This puts everyone in a difficult position. If the paramedic does not sound like they know what they are doing over the phone (not an uncommon occurrence), but the patient needs an invasive procedure, what is the doctor supposed to do? Allow a paramedic to deliver potentially life-saving treatment and be on the hook if they screw up, or deny their request and hope the patient stays alive long enough to get to the hospital?
A paramedic, already in a stressful situation, must decide if they should follow the order, not follow it and risk getting in trouble, or “lose cell phone service.” Other interventions that require permission simply don’t get offered, such as pain management or steroids. None of the options are good for anyone, especially the patient.
Medical command should be available for advice in complicated situations, just as ED physicians have specialists available. It is useful to ask for advice when a number of treatment options are available, or which hospital is best equipped to handle a particular patient. If a patient refuses to be transported, having them talk to a physician on a taped line gives us some extra liability protection. Advice is good, permission is not.
If paramedics cannot be trusted to work independently in critical situations, their medical director needs to be involved way before they are actually in one. We need medical directors who knows what education we have, understand the environment we work in, and are familiar with the strengths and weaknesses of their particular service.
Give us direction before the next call, don’t make us ask for it when we’re on one.