scope of practice, just as in the Anglo-American model. When necessary, however, the paramedic may request a rapid response by a physician, usually by either vehicle or helicopter. In these cases, a great deal of emergency intervention will occur on the scene, with the patient transported ultimately by land ambulance, as in the Franco-German model. In this model, which is unique, the role of the medical director is substantially different. Scope of practice and all treatment protocols are developed by the Dutch Ambulance Institute on a national basis, and cannot be unilaterally changed at the local level by individual physicians. Scope and protocols are reviewed, revised, and announced every four years, and any physician who wishes a change to those protocols must provide sound reasons and present a successful argument before a committee of the DIA. The medical managers for each private carrier operate in a role approximating that of medical director, but only for that one company; their authority does not extend to other companies operating in the same community. These individuals do perform quality service functions such as chart audits and complaint investigation, but they cannot unilaterally change treatment protocols. They may provide guidance, advice and direction to paramedics by telephone or radio, or they may attend the scene in person to provide care. The Dutch system also operates a network of four helicopters staffed by physicians for rapid response to support paramedics in the field. While many of the individuals working in the Dutch system may be occasionally described as 'emergency physicians', the majority, as in the Franco-German model, are actually anesthetists. Other healthcare organizations Notable medical directors Daniel Amen of the Amen Clinics Nancy Caroline – co-founder of Freedom House, one of the first EMS medical directors in America, and first formal medical director of the Magen David Adom (Israeli EMS). Leonard Cobb – founding medical director, Seattle, Washington, 'Medic One' paramedic program. R Adams Cowley – founding medical director of America's first dedicated trauma centre (ShockTrauma — Baltimore) and of the first dedicated air ambulance operation in the U.S. (Maryland State Police). Creator of the concept of the Golden Hour for trauma care. Norman McSwain – founding medical director of the New Orleans paramedic training program and New Orleans Police EMS Detail (now New Orleans EMS), inventor of the McSwain Dart (for paramedic emergency management of tension pneumothorax). Eugene Nagel – founding medical director, Miami,