To describe the efficiency of using on-line medical command (OLMC) to conduct a prospective, randomized clinical trial addressing safety and patient enrollment.

Prospective design using OLMC to randomize adult asthmatics into one of three treatment groups. After verifying inclusion and exclusion criteria, OLMC physicians removed a covering label on study sheets and ordered the treatment specified underneath the label that had been assigned in a random sequence.

A total of 204 patients were seen with dyspnea and wheezing during the three-month study. Of these, 68 (33%) were excluded from the study. Of the 136 (67%) patients who were eligible for study, 87 were enrolled (enrollment efficiency 64%), with 79 fully evaluable (evaluable efficiency 91%). The study safety was 100% because no enrolled patients met any exclusion criteria.

The design was random and prospective, with patient entry blinded, using paramedics to enroll patients and OLMC physicians as gatekeepers, thus ensuring appropriate patient eligibility and study-arm assignment. Use of OLMC physicians to perform prospective randomized studies is safe and efficient, and results in a high yield of evaluable patients.

Although general discussions of legal claims against emergency medical services (EMS) have been published, there is no literature that examines legal claims that specifically have involved base-station contact for direct medical control.

A review of case law through July 1994 was conducted to identify cases that involved radio communications between a prehospital provider and a physician or nurse under the direction of a physician.

Only eight cases could be identified. Each case is described in terms of the event, selected pertinent legal issues, and the opinions rendered by the court.

These few cases illustrate some important observations that indicate that there will occur an increase in the detail, role delineation, and clarification of the prehospital providers, medical directors, base-station physicians, and others who provide direct medical control to prehospital EMS providers. These findings have important implications for EMS medical directors.

The role of the base-hospital and on-line medical control in a disaster has not been investigated previously. This study assesses the roles of base-hospitals and the value and feasibility of on-line medical control during the 1989 Loma Prieta earthquake.

The researchers studied five Bay Area counties most affected by the earthquake: San Francisco, Alameda, San Mateo, Santa Clara, and Santa Cruz. Researchers sent questionnaires to all 1,498 registered EMTs and paramedics in these counties; 620 were returned (41.4%). Respondents answered questions about activities performed, contacts with base-hospitals and other agencies, and problems encountered the night of the earthquake. Researchers selected 63 paramedics for in-depth interviews based on their performance of significant advanced life support (ALS) activities performed during the disaster. The coordinators of the 13 base-hospitals (BHCs) in the region also received and returned questionnaires about medical control, base-hospital roles during the disaster, and problems encountered. Researchers interviewed all five county emergency medical services (EMS) agency directors.

The surveys of EMS directors, base-hospital coordinators, and paramedics indicate that confusion existed over the status of medical control after the earthquake. There was general agreement among base-hospital coordinators (BHCs) that suspension of medical control is appropriate in a major disaster.

Three bases had appropriate equipment to function as back-up dispatch centers. Eight bases had adequate personnel, but only one BHC felt his personnel had adequate training to function in a dispatch capacity. Nine paramedics did not start or continue resuscitation on patients whom they ordinarily would have begun resuscitation.

Emergency medical services should suspend medical control immediately following a major disaster and ensure that all prehospital and base personnel are notified. Disrupted communications protocols for prehospital personnel should reflect the skill and knowledge level of paramedics and the need for rapid, advanced practice in a disaster. Disaster planners should consider other roles for base hospitals in major disasters.