Direct physician medical director involvement in pre-hospital care.

Pre-hospital care in the United States is provided by emergency medical technicians who work under supervision of a physician medical director. In Europe, pre-hospital care is provided by medical technicians who work side by side with physicians. In some parts of the US physicians (usually EMS fellows) have response vehicles and will respond to certain types of incident, like multiple vehicle motor vehicle accidents, mass casualty events, witnessed cardiac arrest, prolonged extrications, fires, tactical medical scenarios, large events, and certain pediatric calls.  In France and Germany they claim significantly better outcomes than here in the states by having physicians directly involved in pre-hospital care of trauma, cardiac arrest, infarction, and stroke patients.

To my surprise, I've found that many States-side medical agencies do not have medical directors trained in emergency medicine, and fewer yet have ones who are fellowship trained in EMS. Beyond this superficial observation there is a paucity of research into how involved medical directors are. Surveys seem to indicate that some agencies have medical direction in name only, at times by physicians with no familiarity with emergency medicine or EMS (e.g. radiologists). Most medical directors that are involved usually spend their time in retrospective quality assurance and paramedic education, but very few undertook on scene quality assurance or responded to calls that would have benefited for physician involvement.  Many medical directors reported working part time or on a volunteer basis, and as such were not always available for online medical direction when needed. The challenges add up further when you include medical direction of fire department based medical services and the issues relating to medical direction of technicians whose primary role is to fight fires rather than provide medical care.

Pre-hospital medicine has developed tremendously in the last 25 years, however it seems clear that certain areas are still in need of substantial improvement. Legislative efforts to standardize requirements for medical directors (minimum EM residency trained) and financial incentives for physician involvement would go a long ways towards improving the medical direction and oversight component of EMS systems.

Some links with further reading, if you're interested:
http://www.ncbi.nlm.nih.gov/pubmed/8370290
http://www.northjersey.com/news/70437017.html
http://www.ncbi.nlm.nih.gov/pubmed/19780921
http://www.shepscenter.unc.edu/rural/pubs/report/FR93.pdf
http://www.ncbi.nlm.nih.gov/pubmed/11727688
http://www.sponsorhospital.org/aspxpages/SharpTeam.aspx