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Introduction: From their inception, advanced life support (ALS) programs have had oversight by emergency medical services (EMS) medical directors. Position statements about medical direction have been published in the medical literature, initially by the American College of Emergency Physicians (ACEP). Most recently, the National Association of EMS Physicians (NAEMSP) published a position paper to serve as a guideline for the medical directors' tasks, describing qualifications and areas of involvement., Objective: To study the baseline status of EMS oversight in Maryland as the position paper was disseminated, to view how local directors meet the published guidelines., Methods: Twenty-two of the 23 (96%) jurisdictional EMS medical directors (JMDs) in Maryland were interviewed in face-to-face meetings. Information was collected about their qualifications and their regular involvement in activities within various EMS subsystems., Results: Sixteen (73%) JMDs are members of ACEP and four (18%) are members of NAEMSP. Six (27%) received EMS medical director training. Three (14%) went through a formal application process for their positions. Activities of relatively high involvement were investigations of variance from protocols (100% of JMDs involved), runsheet review (15 [68%]), liaison duties (20 [91%]), and disaster drills (15 [68%]). Most other subsystems, including dispatch, public health, administration, system evaluation, and quality programs, showed relatively low regular involvement (0-59%)., Conclusion: In Maryland, significant increases in active physician involvement in EMS are necessary to meet the national job description. These data provide supportive evidence of the need for further commitment by state and local agencies, as well as trained EMS physicians in national societies, to enable all JMDs to reach the goals set forth for their important roles in EMS systems.

The authors examined a portion of the complex issue of the scope of practice of paramedics in light of the epidemiologic profile of emergency patients seen at two Baltimore hospitals. They suggest that the same approach could and should be used to help decide on the scope of work of prehospital personnel in any jurisdiction. The findings lead the authors to urge caution toward any potential changes to the work done by medics, because of the enormous breadth of presenting patient conditions. The authors suggest that the epidemiologic profile witnessed in Baltimore would require increased direct physician input on patient destination decisions for all medics who would be working under an expanded scope of functions, and the paper suggests a mechanism for accomplishing this goal. Finally, while there may be compelling economic reasons to change what medics do in the field, this article cautions health care managers to design changes, based on solid evidence, that will have a positive public health impact, and then work to evaluate the character of the impact after changes are implemented.

Objective: To analyze the potential for expanding the scope of practice of paramedics from public health, health planning, and health policy perspectives, utilizing data covering more than 42,000 emergency patients., Methods: The authors conducted a retrospective study of 42,918 patients seen in two Baltimore emergency departments over a six-month period, 5,259 of whom were transported by emergency ambulance. The authors constructed epidemiologic profiles of in-hospital and prehospital patients, and merged ambulance data with discharge diagnoses., Results: The 42,918 patients had a total of 2,118 different discharge diagnoses. The ten most frequent diagnoses of ambulance-transported patients were convulsions, injuries, asthma, congestive heart failure, chest pain, syncope and collapse, otitis media, abdominal pain, cardiac arrest, and respiratory abnormality. The ten most frequent diagnoses for all ED patients were otitis media, asthma, finger and nonspecific injuries, upper respiratory infections, chest pain, bronchitis, pharyngitis, gastroenteritis, nonspecific viral infections, and urinary tract infections. Infections accounted for 31.6% of the top 50% of diagnoses by volume, followed by injuries (24%) and cardiovascular cases (16.5%). However, 26.9% of ED patients received an assessment and diagnosis of general symptoms (no procedure)., Conclusions: The high number of diagnoses and the frequency of infections as a primary complaint in this patient sample reconfirm the primacy of the physician in prioritizing patients and assigning treatment pathways. The authors suggest a methodology that may allow properly trained medics to alter some of their role as physician extenders, but suggest that system planners must first ensure that any changes not reduce the public health benefits that each EMS system already provides.