Curriculum

EMS Fellowship

Wayne State University School of Medicine

Department of Emergency Medicine

 

The focus of this program is to develop physicians who will actively participate in prehospital systems and become leaders at all levels of prehospital care. It utilizes the diversity of emergency medical services in the Southeastern Michigan region to afford the Fellow numerous opportunities to learn in both didactic and experiential forums, the essentials of physician oversight of prehospital systems. There is a strong emphasis on academic training, including research and advanced degree opportunities.

Specific goals for the fellow include:

• A thorough understanding of all aspects of prehospital medicine, including medical direction, administrative, and clinical responsibilities
• Becoming an excellent prehospital educator
• Understanding how to develop and execute prehospital research
• Developing skills to become a national and international leader in prehospital care

I.OPERATION AND CLINICAL EXPERIENCES

The fellow will interact with EMS faculty on a daily basis on weekdays either in lectures, during EMS meeting attendance or in the pre-hospital setting providing patient care. The EMS fellow can contact EMS faculty at any time through two-way or cellular communications to obtain advice or ask questions. Communication will also be virtually instantaneous with texting between fellow and faculty. EMS faculty are also available by these methods on weekend should questions or issues arise. When the fellow takes EMS call, an EMS faculty member will be on "back up" call and can be reached at any time by the fellow if needed.

A. Disaster Management

The Fellow will successfully complete required National Incident Management System Coursework. Further instruction covering mass casualty/disaster plan
components, implementations, drills and activities will be given, including oversight and integration of multiple mutual-aid agencies. Specialty situations such as hazardous materials, chemical and biological agents, and mass trauma will be addressed, as well as Federal efforts such as the National Disaster Medical System (NDMS).
The Fellow is expected to complete National Incident Management System Training within the first two months of their program to include ICS-100, 200, 700, 800, with the option to attend ICS-300 and 400 as available.

There are major disaster drills every year, the Fellow will participate in the planning and execution of these drills, including on scene triage and medical command as a field physician.

B. Mass Gathering Medicine

The Fellow will participate in local mass gathering planning and care.

C. Medical Direction

Medical Control System in Michigan

ESSENCE OF THE LAW MCL 333.209 (Commonly Referred to as PA 209)

The hospital's administrative leaders got together in each Medical Control Authority (MCA )and determined the structure based on their perception of state law, there is very little guidance from Michigan DHHS.  Since there is no physician required at agency level in Michigan the MCA is the final word on supervision of pre hospital care. Michigan is not a delegated practice state
   

ESSENCE OF THE LAW MCL 333.209 (Commonly Referred to as PA 209)

The hospital's administrative leaders got together in each Medical Control Authority (MCA )and determined the structure based on their perception of state law, there is very little guidance from Michigan DHHS.  Since there is no physician required at agency level in Michigan the MCA is the final word on supervision of pre hospital care. Michigan is not a delegated practice state

 What the hospitals are responsible for in the MCA legislation:

1. Creating a medical control board
2. Assigning/electing/appointing a medical director
3. Professional Standards Review (peer review and process improvement)
4. Signing the license application for every ambulance service in the designated geographic MCA
5. All life support agencies operating in the MCA are accountable to the MCA
6. The MCA establishes the protocols for patient care, and that care happens under the auspices of the selected medical director
7. The MCA must have protocols to remove privileges from an EMT immediately if there is life safety concern
8. Protocols to ensure appropriate dispatch. Many MCA's have response  time protocols and do not renew the licenses of non compliant agencies
9. Establishing qualifications for all EMS providers practicing in the MCA
10. Establishing qualifications for the life support agencies operating in the MCA

MCA's are prohibited from charging services for medical direction under the law.  Hospitals provide drugs at no charge to the services. In Michigan drugs have to be exchanged in the hospital, sealed for sealed, with accountability.  Many other states let agencies run their own pharmacies.  

MCA protocols have the force of state law per prior court ruling.  All protocols are approved at the local level and vetted by the state for legal compliance there is no physician with oversight responsibility at the state level. There is a part time state medical director with an advisory role.

MCA's are now required to supervise any community paramedicine program.

The primary MCA for the fellow is Detroit East MCA (covering the city, and all eastern Wayne County Communities (DEMCA.org).  Damon Gorelick, the director of operations will be the primary point of contact and can assist with all data requests.

In addition the fellow will attend as available the Western Wayne (HEMS), Macomb and other MCA's meetings

 

Medical Direction

The Fellow will understand the principles of both on-line and off-line command by direct participation in the local EMS system.

1. On-Line Medical Direction:

During clinical time, the Fellow will participate in the direct provision of medical command, as well as oversight and teaching of residents and students.

2. Off-Line Medical Direction
This will include the statutory authority and structure as outlined through DEMCA and state. Scope of practice issues will be covered for all EMS provider levels, and how this relates to the EMS Medical Director. Protocols and the issue of standing orders vs. medical command orders will be covered. Specialty situations, such as on scene medical control and authority and mass casualty, will be addressed. QA complaint handling and discipline both from a conceptual framework through development of policies and procedures will also be covered through both assigned readings and discussion with the Fellowship Director and faculty. The Fellow will also serve on the MCA Protocol and Quality Assurance (PSRO) Committees.

3. On Call Medical Direction

The Fellow is provided an EMS Radio.  This will allow the Fellow to respond to events where the possibility of on-scene medical direction will be useful or needed.  This to increase their ability to provide direct medical control.  In addition, the Fellow will be added to the City of Detroit's Smart Messaging system and will be notified as are the supervisors for multi-casualty incidents or high profile incidents that the Fellow can respond to and participate in direct medical control.

D. Quality Assurance

The Division of Prehospital Medicine serves as the central body for all EMS QA/QI activity in the region. QA reports, both from a general as well as specific perspective (complaint procedure, etc.) are generated and presented to the local as well as state EMS medical advisory committees. The Fellow will attend and participate in those meetings. The Fellow will also attend meetings to the Medical Dispatch Review Committee (MDRC) for EMD, and directly participate in the generation of individual and agency QA reports, and how these reports are used for CME, system change, protocol revision, remediation, and accreditation.

E. Specialty Care and Air Medical Transport

The fellow may be assigned 12 hour shifts with a MedStar air ambulance based on preference. Level of responsibility will progress with maturity of the fellow during the fellowship. For fellows with little or no previous air medical experience and those who do not wish to fly, we will use simulation to replicate common air medical pre-hospital and inter-facility clinical scenarios.

F. EMS Research

The Fellow will be exposed to the basics of research via a broad group of didactic articles and direct instruction by the program faculty and Research Director.

Research projects are developed through a set procedure. The first step is to develop and idea and hypothesis. The Fellow will then work with one or more Division personnel to create a brief written proposal. This is then presented to a Division research committee, consisting of the research director and academic faculty for the Division. Comments are then incorporated into the proposal and it is developed into a full document. Formal presentation is then performed in front of the Departmental Research Committee, and again necessary changes are made to the proposal. The study is then sent to the Institutional Review Board for formal approval. Upon completion, the study is presented to the faculty and residents of the Department of Emergency Medicine. Presentation at a national meeting is next. After the project is completed the Fellow is encouraged to submit the manuscript to a peer-reviewed journal.

Statistical support for both methodology development and data analysis is supplied by a contracted PhD at the Wayne State University.  Support for grant writing as well as research is available through Wayne State University.

The medical school library is a full service academic library, with personnel able to develop and complete literature searches.

There are numerous areas of ongoing investigation within the Wayne State University Medical Center, Department of Emergency Medicine and affiliates.  The general areas include cardiac arrest, traumatic brain injury, prehospital neuroscience, emergency preparedness and triage of trauma patients. With further questions regarding the Division's active research, please contact us directly.

G. EMS Leadership

Bimonthly the fellow will also accompany the fellowship director to the EMS Coordination Committee meeting for the EMS and Trauma Division for the Michigan Department of Community Health. This is a committee whose members are Governor-appointed and whose responsibilities include but are not limited to:

• Make recommendations to the department in the development of a comprehensive statewide emergency medical services program.
• Advise the legislature and the department on matters concerning emergency medical services throughout the state.
• Provide the department with advisory recommendations on appeals of local medical control decisions.
• Participate in educational activities, special studies, and the evaluation of emergency medical services as requested by the director.
• Represent the EM physicians in the state on the Michigan College of Emergency Physicians
• Advise the department concerning vehicle standards for ambulances.
• Advise the department concerning minimum patient care equipment lists. 

The fellow will accompany a faculty member to the MDHHS EMS QA Task Force meeting, which is responsible for development of and modification of the statewide treatment protocols.

The fellow will attend the NAEMSP Medical Directors course during their year of fellowship along with the NAEMSP Meeting.

The fellow will also rotate with faculty members from other MCAs to gain exposure to EMS systems with different structures.

The fellow will be involved with the Michigan College of Emergency Physicians EMS/Preparedness committee.

Fellows are encouraged to take full advantage of various federally sponsored educational programs that offer residential courses that may supplement the fellow's core educational experience (e.g., National Fire Academy, FEMA Center for Domestic Preparedness, CONTOMS Medical Director Course). These courses are typically 1-week courses. They will, however, be voluntary to minimize any potential negative impact on fellows or their families.

H. Clinical Responsibilities

The fellow will be required to become credentialed as an attending emergency physician at the primary site. This will serve as a foundational means to allow the fellow to not only function as an independent clinician in the hospital but will also to provide basic clinical care in the field consistent with that of a residency-trained emergency physician. This additionally serves as the minimal requirement to provide autonomous direct medical control in the EMS system. The primary site Sinai-Grace Hospital, serves as medical control for Detroit East Medical Control Authority. Since this is a one-year fellowship program, the faculty will expect the fellow to progress during the training year from an initial observational only role to hands on provision of medical care in the pre-hospital setting. Likewise, medical direction duties will initially be learned through lecture and observation with progression to specific assignments. At each stage of development, the program director and EMS faculty will discuss the fellow responsibilities before allowing greater independence in activities as consistent with the Next Accreditation System.

 

II. EVALUATION AND DIDACTICS

A. Evaluation

The core faculty of the EMS fellowship will meet quarterly to evaluate the fellow's performance. The six competencies will be discussed at each meeting as they pertain to the fellow's performance and the fellowship program. DMC residency and fellowship program faculty also receive training and education in systematic methods via the DMC GME Faculty Development Brown Bag Series (available online and in person with certificates of completion and evaluation via New Innovations) and through the DMC.

The Fellow will also be part of the Department's 360-degree evaluation process as part of his/her clinical practice in the emergency department.

Semi-annual review will be held with the Fellowship Director and will include review of the results of a multi-source evaluation and other assessments of the fellow performance. Following areas will be identified for continued growth of the fellow during the second half of the year. This meeting will be followed up with a written summary that must be signed by the fellow and the Program Director.

B. Didactics

Director and core/key faculty are responsible for assigning the fellows to various didactic experiences throughout the fellowship. For every didactic topic assigned, a collaborating faculty member will be identified to assist the fellow in the planning of the didactic session. The EMS Program Director will monitor the fellows' schedule on a monthly basis to assure that they are involved in sufficient teaching activities. All fellow presentations will be evaluated by EMS Faculty and constructive feedback provided to the fellow.

Each of the fellowship faculty members will provide assigned planned didactic experiences, either individually or jointly with other program faculty. As such, there will be no didactic presentation that has not been developed or screened by faculty and/or program director. On-line computer assisted instruction modules will be reviewed and approved for use by the program director prior to the fellow engaging in the activity. When state or national courses are incorporated into the experiences, the program director will have previously taken these courses and/or screened the content of the current course to ensure it remains relevant.

Fellows will be scheduled to ride one day a week on average with the various ground services whose medical direction is provided by fellowship faculty. In this capacity the fellow will be both providing direct patient care in the pre-hospital setting and direct medical oversight of the care provided by the responding EMS personnel. Early on the fellow will be paired directly with fellowship faculty or the EMS supervisor and later in the fellowship year may respond independently to EMS calls. Fellow will progress to staffing the fellow response vehicle.

 

III. CURRICULUM AND SCHEDULE

A. Fellowship Curriculum

The Prehospital Medicine Fellowship follows a set curriculum and is primarily self-directed with readings chosen by the faculty which are then followed by discussion with the respective faculty content expert. Whenever possible, an experiential component augment's the Fellow's training and education. The following are the main curricular areas that the Fellow is expected to complete during their program.

1. History of EMS

Basic historical points will be covered through reading and discussion including: the military origin of EMS including historical perspective through modern warfare and principles; birth of national/public EMS including a review of the 1966 white paper, demonstration projects and subsequent findings; the impact of television the public psyche of emergency medicine and EMS; the 1973 EMS act and subsequent amendments; the birth of cardiac care units and Pantridge's role in modern EMS; the birth of trauma care and the "golden hour" concept; current development of EMS and provider training levels; the genesis of the Emergency Medical Treatment and Active Labor Act (EMTALA) and its impact on EMS; the impact of 9/11 and bioterrorism response; the 2006 IOM subcommittee report on EMS; and the 2013 FICEMS Strategic Plan.

2. Legislation/Legal Issues

Basic legislative points will be covered by reading, lectures, and discussion. Participation in local and regional meetings will afford the Fellow additional experience particularly through participation in state committees. Other content areas that will be specifically addressed include: COBRA/EMTALA and its effects on EMS transport and delivery; Good Samaritan laws and the linking of Public Access Defibrillation provisions; patient competency/refusal of care issues; DNR/Termination of Care in the field; physician care on scene; the impact and legal aspects of overcrowding and diversion; and various aspects of negligence, malpractice, and risk management as it pertains to prehospital care.

3. EMS System Design

The Southeastern Michigan area has a tremendous diversity of EMS provider models allowing the Fellow a broad range of experience. The didactic curriculum specifically includes the following content areas: The historical aspects of EMS system design including the 15 points as outlined by the 1973 EMS act and seven clinical system models; current models including fire based, third service, and proprietary; ambulance placement, including fixed base deployment versus use of systems status management; new concepts in alternative destination and triage will also be covered, including expanded scope of care. The Fellow is strongly encouraged to visit other EMS systems outside the Southeastern Michigan Region during their fellowship to gain greater exposure to the wide variety of systems and medical oversight.

4. Personnel/Human Resources

The Fellow will become familiar with the training requirements and scope of practice of all levels of EMS providers, from PAD/First Responder through EMT-P and Critical Care Transport Paramedic. Human resource issues such as communicable diseases, stress, occupational injury and medical concerns, certification, labor relations, unions, contracts, and discipline will be covered. The Fellow will also become familiar with expanding scope of practice initiatives including statutory regulations from both a state and national perspective.

5. EMS Equipment

The Fellow will spend time with specific ambulance personnel and manufacturers to learn ambulance design and specifications including Michigan requirements. Communications equipment and familiarity with different communication systems, including radio frequencies and regulations, will be obtained. This will include system status management, the use of GPS and automatic vehicle locators, and system status boards. Medication use, benefit, and proper storage including satisfying security requirements will be discussed with DEMCA pharmacy committee members. Special equipment and training in such areas as water rescue, high angle rescue, and farm medic programs are available through enrollment in the specific programs.

6. Education/Training

The Fellow will also provide didactic instruction and assist in coordinating the emergency medicine resident education in prehospital medicine at affiliated programs. This will include reviewing lectures given by residents to field providers, and providing didactic instruction to residents during their core lecture series in EMS. Participation in prehospital training is during fellowship at multiple sites.

The fellows will develop skills to locate, appraise, and assimilate evidence from scientific studies related to treatment modalities for specific illness from multiple mechanisms. As part of the planned education experience, the fellow will discuss interesting or challenging cases and a literature review regarding current diagnostic work up and treatment recommendations. The fellow will also be encouraged to look up information when possible and pertinent at the time of point of care for patients being treated during transport. Annual review, modification or creation of new state model EMS medical treatment protocols as part of the medical direction will also include a literature review, review of national standard and assimilation of this information into current updates offered as a rotating fellow with the a SE Michigan Protocol Committee or EMS task force for the EMS Division of Michigan Department of Health and Human Services.

All program faculty participate in the Wayne State University development lecture series that includes topics such as curriculum development, creative use of innovative learning methods, bedside mentoring techniques, and assessing learner performance. Specific topics are occasionally addressed in monthly faculty meetings. In addition, all faculty must review a recent presentation describing best practice techniques for bedside teaching from SME's in the field followed by a 1:1 meeting with the education

7. Field Operations

The Fellow is expected to become intimately familiar with the provision of prehospital care in the field through direct field experience.

Throughout the fellowship, in a longitudinal fashion, fellows will be assigned to run with various EMS agencies which have fellowship faculty as their medical directors. They will respond to pre-hospital calls, providing direct patient care and on scene supervision of the care provided by EMS personnel. In addition, the fellow will be provided a hand-held hand prep radio to provide radio medical command and oversight to EMS personnel. S/he also will spend time in the 911 communication center. Later in the fellowship year, the fellow will be periodically scheduled to provide backup administrative call for selected ground EMS agencies should administrative or treatment questions arise. In addition, the fellow will be afforded the opportunity to provide medical direction to a number of special events that occur in this area.

The fellow will rotate through various models of EMS services supplying pre-hospital care in the local region. These service types will include third party county-funded EMS services, fire-based, hospital-based, critical care ground and air, blended career and volunteer and neonatal transport services. Program faculty will provide medical direction to many of these services in all service models as well. The fellow will be responding with a supervisor or a response car to pre-hospital medical calls or with the agency itself in all of the above types of agencies.

When the fellow is providing pre-hospital medical care of patients, s/he will accompany the patient to the receiving destination and give a verbal report to the accepting physician followed by leaving an electronic and hard copy hand off form for the medical record. If the fellow is unable to accompany the patient to the receiving destination due to other patient care commitments, s/he will call and provide a verbal report to the receiving physician.

EMS supervisory personnel are available 24/7 and assigned to each agency. If clinical care needs exceeds the fellow's ability, they will always be present to assist and take over the patient's care as needed. In addition, either the program director or co- associate program directors will also be available by radio or phone consultation on patient care matters on a rotation basis.
Courses in Firefighting, Search and Rescue, Tactical Medicine, Hazardous

Materials, and other specialties of interest to the special are available and can be arranged dependent upon the Fellow's interest.

8. Communications

The Fellow, through both readings and didactic sessions with communications personnel at both the 911 center and individual agencies will understand the various communication systems in use and available, including radio, cell phone and mobile data terminals (MDT's) for EMS providers. Strengths and weaknesses of each type will be covered; this will include VHF, UHF, and trunked systems. An understanding of the 911 system, including enhanced 911 from both traditional and cellular phones will be reviewed, along with the fundamentals of EMD including classification and pre-arrival instructions. The basic tenets of medical command, including process, medical direction, documentation, triage, and QA will also be addressed. Communication in disasters/MCI/HAZMAT settings will be covered through field experience.

B. Sample Weekly Schedule

 

Sunday	Activity	Hours
	OFF	24
Monday	Activity	Hours
	Ride shift with EMS agency  either ground or air medical	12
Tuesday	Activity	Hours
	EMS fellowship  didactic lectures, computer based training	4
	Medical communications center (observation and provide medical command)	2
	EMS Admin meetings	2
Wednesday	Activity	Hours
	Attend quality improvement meeting of EMS agency or review/prepare QI cases and data	2
	Participate in competency check offs of EMS personnel	4
	Ongoing research project activities	2
Thursday	Activity	Hours
	Attend EMS administrative meetings	6
	Provide or prepare for didactic lectures to EM residency, or EMS agency personnel in training programs	2
Friday	Activity	Hours
	Attend regional or a state  meetings for healthcare preparedness activities/or ED or Ambulance Shift	8
Saturday	Activity	Hours
	Emergency Department shift	8

 

APPENDIX C: EMS Fellowship Book List

Emergency Medical Services - Clinical Practice and Systems Oversight - two-volume set
Edited by David Cone
Co-Edited by Jane H. Brice, Theodore R. Delbridge and J. Brent Myers
February 2021 | ISBN: 978-1-118-86530-9

 

An Introduction to EMS Research

Lawrence H. Brown et al.

Brady Publishers, 2002

 

Emergency Care in the Streets, Current editions

Nancy Caroline

AAOS / Jones and Bartlett

Note: This is the standard EMT-Paramedic text

 

Emergency Care and Transportation of the Sick and Injured Current editions

Andrew N. Pollak

Jones and Bartlett / AAOS

Note: This is the standard EMT-Basic text

MDHHS MCA Handbook