Definitions

Offline Medical Control

Standing orders authored by the EMS medical director — applies without contacting a physician in real time.

Online Medical Control

Real-time direction from a physician for patient care decisions outside standing orders.

Online Medical Direction Physician (OMD)

Designated physician available to provide online medical control. Typically the EMS medical director, an emergency physician at the receiving facility, or a regional medical control authority.

Purpose

To establish when providers must consult the OMD, how the consultation is conducted, and how the resulting orders are documented and executed.

Scope

Applies to all patient care encounters where the situation exceeds the scope of standing orders or where the standing orders specifically require OMD consultation.

When OMD Consultation Is Required

• Any standing-order protocol that says 'Contact OMD.'
• Refusal of care in any high-acuity scenario (chest pain, suspected stroke, altered mental status, pediatric trauma, suicidal ideation, pregnancy complications).
• Field termination of resuscitation per protocol.
• Restraint of a patient.
• Treatment beyond standing orders that the provider believes is in the patient's best interest.
• Destination outside the closest appropriate facility.
• Any scope-of-practice ambiguity.

Before Calling

1. Complete the assessment to the extent possible.
2. Formulate the specific question or request.
3. Have vital signs, monitor strip findings, allergies, and medications ready.
4. Identify what has been tried and the patient's response.

Calling the OMD

Read-Back

Every order is read back to the OMD verbatim. The OMD confirms. The order is then documented and executed. Misheard or unclear orders are clarified before execution — no execution on assumption.

Disagreement

If the provider believes an order is unsafe or contraindicated, the provider states the concern directly to the OMD: 'I'm concerned that [order] may [risk]. Can we discuss?' If the disagreement cannot be resolved, the provider does not execute the order, requests the OMD's name and badge, documents the conversation in detail, and notifies the EMS chief and medical director after the call.

Documentation

• OMD physician name and facility.
• Time of contact and time of order.
• Specific request and specific order received.
• Read-back confirmation.
• Execution of the order with time, dose if applicable, route, response.
• Any disagreement and resolution.
• Subsequent contacts and orders.

Communication Failure

• Try the primary OMD channel.
• Try the secondary OMD channel.
• Try the receiving facility's emergency department directly.
• If communication cannot be established, document the attempts and proceed per standing orders or, if outside standing orders, with the best available judgment, transporting urgently.
• Notify the medical director after the call.

Quality Improvement

All OMD calls are reviewed monthly by the medical director or designee. Trends are used for education, protocol revision, and OMD physician education. Issues identified during OMD calls do not by themselves indicate provider failure; they are an opportunity for system improvement.

Training

• Initial training in OMD communication at onboarding.
• Annual case-based refresher.
• Officer-level training on disagreement management.
• Joint training with OMD physicians annually where possible.

References

• NAEMSP Position Statement on Medical Directionnaemsp.org
• ACEP Medical Direction of EMSacep.org
• State EMS Medical Direction Rules[INSERT STATE]

Adapt this template

Before this template becomes your department's policy, review the following items and adjust accordingly. Anything else that does not match your operation should be updated as well.

• Name the OMD primary and secondary contact channels.
• Identify the medical director.
• Adjust required-consultation triggers to match your standing orders.
• Cross-reference Patient Refusal SOP, Controlled Substance Handling SOP, and Behavioral / Mental Health Response SOG.