Patterns of Online Medical Direction Utilization in an Urban EMS System: A Retrospective Analysis of 9,944 Consultations

OBJECTIVES: Emergency medical services (EMS) clinicians primarily rely on standing protocols for prehospital care but may seek real-time physician guidance through online medical direction (OLMD) when situations fall outside established protocols. This study aimed to characterize patterns of OLMD consultation, including indications, timing, and physician decision-making within an urban EMS system and identify potential opportunities for protocol refinement. METHODS: We used an observational study design and retrospective descriptive analysis of 9,944 OLMD consultation records from July 2016 to December 2024. Data included patient demographics, consultation timing, reasons for contact, physician type, refusal factors, specific requests, hospital destinations, and the training level of the EMS clinician initiating the consultation. Records were captured in real time using Research Electronic Data Capture (REDCap) software by physicians at the University Medical Center of El Paso. Descriptive statistics were used to summarize OLMD utilization and consultation characteristics. RESULTS: In line with required clinical protocols, the common OLMD consultations included refusals, termination of resuscitation, and transport decisions. Patient refusals accounted for 65% (n = 5,175) of OLMD consultations, with physician approval documented in 97% of these cases. Requests for termination of resuscitation and transport destination changes demonstrated approval rates of 98% and 90%, respectively. Most consultations involved adult patients with a balanced sex distribution. Call volume was highest during late morning hours. Approval rates were similar between attending physicians and resident physicians (approximately 93%). CONCLUSIONS: Within this urban border EMS system, OLMD consultations are most frequently requested for patient refusals and are associated with high levels of physician agreement. These findings suggest strong alignment between paramedic clinical judgment and physician decision-making and may support expansion of standing protocols for selected clinical scenarios. Continued physician involvement remains important for complex clinical and ethical situations.