Medical Direction

Common Errors

Critical errors in prehospital application of medical direction:

• Failing to reassess after intervention. Vital signs must be rechecked every 5 minutes for unstable patients
• Incorrect medication dosing. Always use length-based estimation (Broselow tape) for pediatric patients
• Tunnel vision on one finding while missing the complete clinical picture
• Not communicating changes to receiving facility during transport

Overview

Physician oversight: online (real-time) and offline (standing orders/protocols) direction. Tested on EMT and Paramedic exams.

In prehospital assessment, ETCO2 reference range: adult 35-45 mmHg, pediatric 35-45 mmHg. Deviations from these norms guide treatment decisions in the field.

Assessment Techniques

Assessment techniques for medical direction:

Cincinnati Stroke Scale

Components: Facial droop, Arm drift, Speech abnormality. Scoring: Any 1 positive = 72% probability of stroke

OPQRST

Components: Onset, Provocation, Quality, Radiation, Severity, Time. Scoring: Pain assessment mnemonic

Calculation Methods

Dosage calculations related to medical direction in EMS:

• atropine: 0.5mg IV q3-5min, max 3mg (IV/IO)
• midazolam: 2-5mg IV/IM, 0.2mg/kg IN (IV, IM, IN)
• epinephrine: 1:10,000 1mg IV/IO q3-5min (cardiac arrest), 1:1,000 0.3mg IM (anaphylaxis) (IV/IO, IM, ET)

Pediatric dosing: always calculate by weight (mg/kg). Use Broselow tape if weight is unknown.

Exam Focus Areas

On the Nremt Emt, Nremt Paramedic exam(s), questions about medical direction typically test:

1. Correct medication selection, dosing, and route of administration
2. Assessment findings that differentiate between similar presentations
3. Appropriate transport decisions and hospital notification criteria
4. Recognition of signs and symptoms requiring immediate intervention

Regulatory Context

Regulatory context for medical direction includes federal and state requirements. Healthcare facilities must comply with CMS Conditions of Participation, state licensure requirements, and accreditation standards (Joint Commission or AAAHC). Non-compliance can result in citations, fines, or loss of Medicare/Medicaid reimbursement.