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different set of actions for basic, intermediate, and paramedic providers, and separate sections for adult and pediatric patients This protocol also clearly highlights when to contact online medical control for additional guidance This enables the providers in the field to have a pre-established, physician-evaluated course of action for most patient care situations Online medical direction requires real-time communication between an EMS provider and a physician or delegated surrogate (physician assistant, nurse practitioner, registered nurse) EMS systems should have protocols for when online medical direction is required Situations may include when additional doses of medication are required, when patients are not responding to the steps outlined in offline protocols, or when patients or parents are refusing EMS transport Hospitals that provide online medical directions are commonly referred to as “base” hospitals In some cases, a physician may serve in the role of a field responder This may be a physician who is serving as a service’s medical director, or a specialized provider or an EMS trainee/fellow in a larger system Although the field is not the typical practice environment for physicians in the United States (it is much more common in other countries), there are distinct advantages to having a physician responder in certain situations The first is that they may provide direct medical control to the intermediate and paramedic providers on a scene Second, they may bring the ability to perform advanced interventions for patients with specialized needs, such as a field amputation of an entrapped extremity Third, they may play an important role in the management of complex incidents, such as a mass casualty incident EMS fellowship training programs have been present since the early 1990s The American Board of Medical Specialties approved EMS medicine as a recognized subspecialty of emergency medicine in 2010, and fellowships became accredited thereafter The first board examination for recognition of EMS-specialized physicians, administered by the American Board of Emergency Medicine, was offered in 2013 EMS fellowships are open to physicians trained in multiple fields, including pediatrics A list of available EMS fellowships can be found at https://naemsp.org/career-development/fellowship-programs/ EMERGENCY MEDICAL DISPATCHERS AND DISPATCH PRINCIPLES When an EMS system is activated, this places into motion a chain of events to efficiently deliver the most appropriate personnel to the patient for safe transport to the most appropriate receiving hospital There are many steps to achieving this ideal goal It is typically the parent, caregiver, or bystander who recognizes that a child requires emergency medical help, and contacts EMS through the 9-1-1 emergency number Ninety-nine percent of the U.S population has 9-1-1 services, with many having enhanced 9-1-1 (E-911) services that provide the dispatcher with the address of the caller Using a cell phone to contact 9-1-1 is increasingly common, and improving technologies (wireless E-911 systems) can allow for the localization of the caller using the global positioning satellite (GPS) technology built into many wireless phones TABLE 134.2 EMS MEDICAL DIRECTOR RESPONSIBILITIES Clinical care Communications Field clinical practice Physician clinical role • On-scene medical direction • Current knowledge and skills • Knowledge of incident command system Personnel education • Training for base station and out-of-hospital personnel • Evaluation of medical competency of providers • Collaborative relationships with academic institutions • Continuous quality improvement • Mechanism for data collection • Ensure compliance with protocols • Analyze system efficacy and cost-effectiveness • Application of research methods • Collaborative relationships with academic institutions • Reliable methods of data collection • Information flow from out-of-hospital to ED to inpatient care • Standards for base station education and physician field experience • Qualifications and training for delegation of authority for online medical direction to surrogates • Resolution of disputes involving medical care within EMS system • Interactions with national, regional, state, and local EMS authorities • Coordination of emergency preparedness activities • Educator and liaison to the media System evaluation EMS research Administration Liaison activities Finance Public access Public health • 9-1-1 system • Training and continuing education of dispatchers • Dispatch protocols • Prearrival patient care instructions • Dispatch criteria • Continuous quality improvement • Qualified online medical direction • Training and credentialing of personnel • Verification of skill proficiency for personnel • Protocols for transport and nontransport • Protocols for interaction with responders • Protocol for online medical direction • Transport and destination criteria • Authority to limit activities of providers for cause • Continuous quality improvement • Equipment specifications Public education • Budgetary planning • Grant application • Establish funding priorities • Collaborate with community to guarantee access to EMS • Appropriate EMS utilization, prevention of emergencies • Initial approach to common emergencies • Community health assessment and surveillance Illness and injury prevention Legislation and regulation • Injury and illness prevention for EMS personnel • Assessment of community’s needs • Collection of data-identifying factors contributing to illness and injury • Public education • Participation in development of legislation • Participation in local and national EMS organizations Integration of health services • Integrate EMS interventions into health care • Identify outcomes of patients accessing system • Collaborate to community’s health surveillance Information systems • Adoption of uniform data elements and definitions consistent with national standards • Integrated information system allowing exchange of vital information • Legal protection of all data related to continuous quality improvement Adapted from NAEMSP Position Paper  ... system • Interactions with national, regional, state, and local EMS authorities • Coordination of emergency preparedness activities • Educator and liaison to the media System evaluation EMS research