# Who's in charge of a scene?



## MedicDelta (Oct 23, 2014)

In training I was taught that you can't leave a patient with someone who has lower training than you. So I have 2 questions:

#1 Say an ALS unit responds to a call and there is someone there treating/monitoring the patient who identifies himself as a medical doctor. Does ALS have to now take the MD with them? Or is it their call? 

#2 If I was treating someone(off duty, I'm an EMR) and someone comes up and says they're a paramedic or anything higher than EMR does that now make it his patient because he has a higher level of scope of practice? 

I understand that some things taught in training are not what actually happens in the real world. I was curious if this is one of those things. Hopefully the questions make sense. Thanks in advance.


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## OnceAnEMT (Oct 23, 2014)

1. Depends on agency protocol. Where I'm at, it is the Paramedic's patient in that case. If the MD/DO insists on running the call, they have to jump through a few prompted hoops by discussing the matter with the medics and the OLMD. That MD will then have to commit in full, including riding to the hospital to a waiting medical director, or back off. A smart physician wouldn't keep a patient from 911 response. Short answer, it is the responder's patient.

2. This gets grey. You don't KNOW he is a Paramedic, and he doesn't know you are an EMR. Just like you don't know the MD above is an MD. Judgement call.

I'm not sure exactly where in the process of becoming a patient to being discharged abandonment is possible, but I would look at it as any good samaritans responding at the level of good samaritan, and nothing higher. So anyone who is not a designated responder by the system is considered a good samaritan.


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## Akulahawk (Oct 23, 2014)

My responses below, in a different color... hopefully. 


MedicDelta said:


> In training I was taught that you can't leave a patient with someone who has lower training than you. So I have 2 questions:
> 
> #1 Say an ALS unit responds to a call and there is someone there treating/monitoring the patient who identifies himself as a medical doctor. Does ALS have to now take the MD with them? Or is it their call?
> The "MD" has to be identified properly and has to choose whether to continue providing care. The on-duty 911 crew, if they can not identify the "MD", can choose to excuse the "MD" from the scene.
> ...


Abandonment can be a tricky thing... and when Good Sam get thrown in the mix, it just gets murkier. It's often just better if you can stay on scene until an on-duty crew arrives.


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## DesertMedic66 (Oct 23, 2014)

It may change with protocol. 

1) Since the doctor is not on duty then the EMT or Medic on scene who is on duty is incharge of patient care. If the doctor wants to maintain in control of patient care we have to call med control and make sure they are ok with it, check the doctors identification and make sure he is an emergency doctor, make sure the doctor understands what is going to happen now. 

2) off duty is off duty. So the first person who is on duty that arrives on scene EMT or Medic will be incharge of patient care. In most areas if you are off duty you can only act in basic first aid. Which means someone may be a medic but they can't use any of their medic skills.


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## MedicDelta (Oct 23, 2014)

Grimes said:


> 1. Depends on agency protocol. Where I'm at, it is the Paramedic's patient in that case. If the MD/DO insists on running the call, they have to jump through a few prompted hoops by discussing the matter with the medics and the OLMD. That MD will then have to commit in full, including riding to the hospital to a waiting medical director, or back off. A smart physician wouldn't keep a patient from 911 response. Short answer, it is the responder's patient.
> 
> 2. This gets grey. You don't KNOW he is a Paramedic, and he doesn't know you are an EMR. Just like you don't know the MD above is an MD. Judgement call.
> 
> I'm not sure exactly where in the process of becoming a patient to being discharged abandonment is possible, but I would look at it as any good samaritans responding at the level of good samaritan, and nothing higher. So anyone who is not a designated responder by the system is considered a good samaritan.


Very interesting. Thank you for the insight.


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## MedicDelta (Oct 23, 2014)

DesertEMT66 said:


> It may change with protocol.
> 
> 1) Since the doctor is not on duty then the EMT or Medic on scene who is on duty is incharge of patient care. If the doctor wants to maintain in control of patient care we have to call med control and make sure they are ok with it, check the doctors identification and make sure he is an emergency doctor, make sure the doctor understands what is going to happen now.
> 
> 2) off duty is off duty. So the first person who is on duty that arrives on scene EMT or Medic will be incharge of patient care. In most areas if you are off duty you can only act in basic first aid. Which means someone may be a medic but they can't use any of their medic skills.


Thank you for the answer. So an ALS paramedic off duty couldn't perform something like a cric if he felt that he needed to perform the life saving technique? I honestly thought that you can perform any medical procedure and it's covered by the Good Samaritan Act as long as you have been trained to do so and its within your scope.


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## MedicDelta (Oct 23, 2014)

Akulahawk said:


> My responses below, in a different color... hopefully.
> 
> Abandonment can be a tricky thing... and when Good Sam get thrown in the mix, it just gets murkier. It's often just better if you can stay on scene until an on-duty crew arrives.


Thanks for the response.


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## Gurby (Oct 23, 2014)

MedicDelta said:


> Thank you for the answer. So an ALS paramedic off duty couldn't perform something like a cric if he felt that he needed to perform the life saving technique? I honestly thought that you can perform any medical procedure and it's covered by the Good Samaritan Act as long as you have been trained to do so and its within your scope.



Nooooo that is definitely not the case.  As an on-duty EMT you are operating under the license of a physician.  When you are off duty you're just an average Joe who maybe knows a little bit more about medicine than some people.  BLS skills are covered by good samaritan laws, but you couldn't legally do a needle decompression as an off-duty paramedic.



DesertEMT66 said:


> 1) Since the doctor is not on duty then the EMT or Medic on scene who is on duty is incharge of patient care. If the doctor wants to maintain in control of patient care we have to call med control and make sure they are ok with it, check the doctors identification and make sure he is an emergency doctor, make sure the doctor understands what is going to happen now.



I don't think there is really such thing as a doctor being on or off duty.  Assuming they are licensed in the given state (which may not necessarily be the case), they practice medicine under their own license and can do whatever, whenever.  That said, EMS is probably technically/legally in charge of the patient as soon as the 911 call comes in.


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## cprted (Oct 23, 2014)

In the real world it isn't so black and white.  There are many circumstances where a higher level can turn a patient over to a lower level of care.  In BC, we have a targeted ALS system, meaning we have cars that are staffed PCP-PCP and others that are ACP-ACP (as opposed to all cars being ACP-PCP staffed).  There are lots of cases where the ACP crew will assess a pt, even start a treatment and then pass over to the PCPs.  It all depends what is being done and what the lower level crew can maintain and manage.  Same thing happens with inter-hospital transfers all the time ... PCPs are a lower level of care than the hospital, but if the patient doesn't require interventions outside the PCP scope of practice, then it is fine.


MedicDelta said:


> Thank you for the answer. So an ALS paramedic off duty couldn't perform something like a cric if he felt that he needed to perform the life saving technique? I honestly thought that you can perform any medical procedure and it's covered by the Good Samaritan Act as long as you have been trained to do so and its within your scope.


Laws are different in different places.  In BC (and most provinces in Canada), the Good Samaritan Act would protect an ACP who performed a cric off-duty ... however, I don't know any ACPs who happen to have cric kits in their pockets, just in case ... lol.  But to carry on with this example, if the cric was put in and a PCP crew responded to the scene, maintaining a cric is outside the PCP scop, thus the ACP would be responsible for continuing care of the patient during transport to the hospital.


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## MedicDelta (Oct 23, 2014)

cprted said:


> In the real world it isn't so black and white.  There are many circumstances where a higher level can turn a patient over to a lower level of care.  In BC, we have a targeted ALS system, meaning we have cars that are staffed PCP-PCP and others that are ACP-ACP (as opposed to all cars being ACP-PCP staffed).  There are lots of cases where the ACP crew will assess a pt, even start a treatment and then pass over to the PCPs.  It all depends what is being done and what the lower level crew can maintain and manage.  Same thing happens with inter-hospital transfers all the time ... PCPs are a lower level of care than the hospital, but if the patient doesn't require interventions outside the PCP scope of practice, then it is fine.
> Laws are different in different places.  In Canada, the Good Samaritan Act would protect an ACP who performed a cric off-duty ... however, I don't know any ACPs who happen to have cric kits in their pockets, just in case ... lol.  But to carry on with this example, if the cric was put in and a PCP crew responded to the scene, maintaining a cric is outside the PCP scop, thus the ACP would be responsible for continuing care of the patient during transport to the hospital.


Well I mean you could use a pen right? Lol. Thanks for clearing it all up. So it's one of those things that they teach you in training, but in the real world it just doesn't work that way. Thanks a bunch!


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## cprted (Oct 23, 2014)

MedicDelta said:


> Well I mean you could use a pen right? Lol. Thanks for clearing it all up. So it's one of those things that they teach you in training, but in the real world it just doesn't work that way. Thanks a bunch!


LOL, if I used a pocket knife and a pen I would expect to have my license revoked and go to jail.

It's not so much that it "doesn't work that way," but it is just more complicated.


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## Gurby (Oct 23, 2014)

cprted said:


> LOL, if I used a pocket knife and a pen I would expect to have my license revoked and go to jail.
> 
> It's not so much that it "doesn't work that way," but it is just more complicated.



I'm almost certain that an off-duty paramedic could not legally perform a cric in the US.  I don't see why knife and a pen is a problem, though, if it works.... Happened pretty recently here:
http://www.dailymail.co.uk/news/art...tracheotomy-knife-pen-choked-piece-steak.html


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## MonkeyArrow (Oct 23, 2014)

DesertEMT66 said:


> It may change with protocol.
> 
> 1) Since the doctor is not on duty then the EMT or Medic on scene who is on duty is incharge of patient care. If the doctor wants to maintain in control of patient care we have to call med control and make sure they are ok with it, check the doctors identification and make sure he is an *emergency doctor*, make sure the doctor understands what is going to happen now.
> 
> 2) off duty is off duty. So the first person who is on duty that arrives on scene EMT or Medic will be incharge of patient care. In most areas if you are off duty you can only act in basic first aid. Which means someone may be a medic but they can't use any of their medic skills.



What bearing does the specialty of the doctor have on...well...anything? An IFT paramedic is still a paramedic with the same level of training that the other 911 paramedics have. (Before you start trying to tell me that an emergency med doc has more training than a nephrologist, said nephrologist still has more training than any paramedic on the scene) Honestly, I don't see why I would NOT want to hand over care to a physician who wishes to assume it.


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## OnceAnEMT (Oct 23, 2014)

Gurby said:


> I'm almost certain that an off-duty paramedic could not legally perform a cric in the US.  I don't see why knife and a pen is a problem, though, if it works.... Happened pretty recently here:
> http://www.dailymail.co.uk/news/art...tracheotomy-knife-pen-choked-piece-steak.html



As long as a physician is above them in some way, sure they could; its in their scope. If a physician was on-scene and said do it, a medic totally could. Now, with a knife and pen, well that's another story. I'm going to bet that would definitely threaten a license, even if successful. Hence why a doctor can do it  Moral of the story? If you are on-scene and determine a cric is needed and there is a doc nearby, walk them through it!

Don't do that.


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## Akulahawk (Oct 23, 2014)

MedicDelta said:


> Well I mean you could use a pen right? Lol. Thanks for clearing it all up. So it's one of those things that they teach you in training, but in the real world it just doesn't work that way. Thanks a bunch!


It's not so black & white. If I had a patient that needed a cric and I, the off-duty medic did one, I would expect that two things would happen if it was done 100% correctly:

I would expect to not be prosecuted thanks to Good Sam laws. Depending upon the state involved, I might also expect to not be sued successfully for the same reason.

I would also expect to lose my local accreditation if I'm not explicitly authorized ALS skills off duty, and possibly my License as well, if I'm not authorized to do ALS "stuff" off duty. 
There are 3 different processes in play: Criminal, Civil, and Regulatory. Good Sam laws cover the first two... Knowing what you're authorized to do while off-duty will help keep you from having problems with the third.


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## DesertMedic66 (Oct 23, 2014)

MonkeyArrow said:


> What bearing does the specialty of the doctor have on...well...anything? An IFT paramedic is still a paramedic with the same level of training that the other 911 paramedics have. (Before you start trying to tell me that an emergency med doc has more training than a nephrologist, said nephrologist still has more training than any paramedic on the scene) Honestly, I don't see why I would NOT want to hand over care to a physician who wishes to assume it.


It used to be in protocols for us and when was the last time a nephrologist ran a full arrest? Hell the last full arrest I ran at a family medical facility was going horribly with the Doc in charge (they were dumping meds down the tube even though they had a good line).


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## chaz90 (Oct 23, 2014)

MonkeyArrow said:


> What bearing does the specialty of the doctor have on...well...anything? An IFT paramedic is still a paramedic with the same level of training that the other 911 paramedics have. (Before you start trying to tell me that an emergency med doc has more training than a nephrologist, said nephrologist still has more training than any paramedic on the scene) Honestly, I don't see why I would NOT want to hand over care to a physician who wishes to assume it.


I think this is largely an academic exercise we get ourselves caught up in. I have never actually heard of a situation where a physician who wasn't well qualified or used to caring for emergency patients attempted to take over an emergency scene. Even ED physicians recognize that, for the most part, their knowledge and skills can be most efficiently utilized in the ED with equipment, staff, and diagnostic tools available. 

That being said, I would make the argument that many practicing physicians who may be experts in their chosen fields are in no way qualified to provide general emergency care. Just because someone went to medical school 30 years ago with perhaps a one year internship doesn't mean they should be taking care of the status asthma patient crashing in front of them when paramedics are on scene as well. Fortunately, they seem to know this and stay far away most of the time.

I've found it's often true that the more education and experience one has the less interest they have in involving themselves in scenes that are none of their business.


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## Carlos Danger (Oct 24, 2014)

This topic comes up on the interwebz with surprising frequency, considering how uncommonly it actually happens.

In 15 years I've had two physicians on scene. The first, I was a new-ish paramedic responding to a call in a public place (I don't even remember what the call was for or where exactly it was), and when I got there, someone who happened to be a doctor was trying to make the patient comfortable while they waited for us. He identified himself and told us that if there was anything he could do to help, to please let him know, and then he stepped away. Second one was a serious multi-car MVC with numerous patients in a small, rural town that we responded to with 3 helicopters. When we landed on scene, an anesthesiologist from the nearby small hospital was wearing bloody scrubs just doing whatever he could to help EMS. The ED had sent him there to help when EMS called in telling OLMD that they had several patient who needed airway management. He intubated 2 patients, possibly saving their lives because they were pretty sick. He too, offered us any help he could before simply stepping away and letting us do our thing.

My point is not to rehash war stories, but just to illustrate how on-scene physicians usually work. In the real world, I've never even heard of an on-scene physician making things difficult and refusing to turn over care to EMS. I'm sure it happens occasionally, but it's a truly rare occurrence.


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## Kevinf (Oct 24, 2014)

You can see this sometimes in routine transport. My partner and I had taken a patient to a urology appointment and we were staged in the waiting room while the doctor was with the patient. After a little while a nurse came out and asks us to come back quickly... we get back to the room to find the patient unconscious. The doc wanted nothing to do with that and handed care back over to us as soon as we stepped in the room.


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## Chimpie (Oct 25, 2014)

I think you're more likely to have an green and anxious first responder or EMT show up on a scene vs an MD.


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## MedicDelta (Oct 25, 2014)

Akulahawk said:


> It's not so black & white. If I had a patient that needed a cric and I, the off-duty medic did one, I would expect that two things would happen if it was done 100% correctly:
> 
> I would expect to not be prosecuted thanks to Good Sam laws. Depending upon the state involved, I might also expect to not be sued successfully for the same reason.
> 
> ...


It must be different in Canada. I heard a story of an Advanced Care Paramedic who performed ET intubation on someone when he was working volunteer with St John Ambulance(volunteer first aid).


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## MedicDelta (Oct 25, 2014)

Remi said:


> This topic comes up on the interwebz with surprising frequency, considering how uncommonly it actually happens.
> 
> In 15 years I've had two physicians on scene. The first, I was a new-ish paramedic responding to a call in a public place (I don't even remember what the call was for or where exactly it was), and when I got there, someone who happened to be a doctor was trying to make the patient comfortable while they waited for us. He identified himself and told us that if there was anything he could do to help, to please let him know, and then he stepped away. Second one was a serious multi-car MVC with numerous patients in a small, rural town that we responded to with 3 helicopters. When we landed on scene, an anesthesiologist from the nearby small hospital was wearing bloody scrubs just doing whatever he could to help EMS. The ED had sent him there to help when EMS called in telling OLMD that they had several patient who needed airway management. He intubated 2 patients, possibly saving their lives because they were pretty sick. He too, offered us any help he could before simply stepping away and letting us do our thing.
> 
> My point is not to rehash war stories, but just to illustrate how on-scene physicians usually work. In the real world, I've never even heard of an on-scene physician making things difficult and refusing to turn over care to EMS. I'm sure it happens occasionally, but it's a truly rare occurrence.


Thank you for your personal stories I appreciate it. I'm learning a lot already.


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## MedicDelta (Oct 25, 2014)

Hey guys, just an update I actually ran into this article on Facebook from EMS1.com about who's in charge of a scene a MD or an EMT. 
http://www.ems1.com/emt/articles/20...eater-authority-on-a-medical-emergency-scene/


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## JPINFV (Oct 26, 2014)

Chimpie said:


> I think you're more likely to have an green and anxious first responder or EMT show up on a scene vs an MD.



Pretty much this. I've been on scene once since starting medical school... and that was a roll over incident in the middle of nowhere (about an hour from anyplace) on the freeway that runs between LA and Vegas. There ended up being 1 person with no training, an off duty paramedic, an EMR, and myself (2nd year medical student at the time) there for a good 15 minutes before EMS arrived. 

Anyone want to guess which of the 4 of us was freaking out and trying to call for a helicopter?


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## DesertMedic66 (Oct 26, 2014)

JPINFV said:


> Pretty much this. I've been on scene once since starting medical school... and that was a roll over incident in the middle of nowhere (about an hour from anyplace) on the freeway that runs between LA and Vegas. There ended up being 1 person with no training, an off duty paramedic, an EMR, and myself (2nd year medical student at the time) there for a good 15 minutes before EMS arrived.
> 
> Anyone want to guess which of the 4 of us was freaking out and trying to call for a helicopter?


Gonna make a wild guess and say it wasn't you or the off duty medic


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## JPINFV (Oct 26, 2014)

DesertEMT66 said:


> Gonna make a wild guess and say it wasn't you or the off duty medic


It wasn't the person with no training either...


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## MedicDelta (Oct 26, 2014)

JPINFV said:


> Pretty much this. I've been on scene once since starting medical school... and that was a roll over incident in the middle of nowhere (about an hour from anyplace) on the freeway that runs between LA and Vegas. There ended up being 1 person with no training, an off duty paramedic, an EMR, and myself (2nd year medical student at the time) there for a good 15 minutes before EMS arrived.
> 
> Anyone want to guess which of the 4 of us was freaking out and trying to call for a helicopter?


I'm one of the athletic trainers for my high school football team and a couple weeks ago we had an opposing player go flying in the air and was complaining of severe pain in his lumbar spine and my first thought was "holy crap I gotta hold c spine on this guy and get a collar on". The other AT(who is less qualified than me with emergency care, but with plenty of experience as an AT) assured me that there was no need to do any of that but in my gut I still felt that we needed to. I've come to realize that things taught in training are not the way it works in real life. I am a newly certified EMR though and I'm sure I felt the same was as that EMR in your story. We're nervous and want to take every precaution possible because that's the way we're trained. If I was there alone on that day I probably would have been holding c spine waiting for the ambulance. I'm learning everyday though, from you guys, from the other AT on the team and from my dad who was a Canadian Forces Search And Rescue Technician and paramedic for 12 or so years. I don't know if I'd be calling for a helicopter though lol, on the football team it's a team effort and we make decisions together because we compliment each other with our certifications. We also had a paramedic sitting right there in the crowd who I knew and asked to help us out.


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## JPINFV (Oct 26, 2014)

Nothing wrong with holding c-spine. It was the entire, "OMG, WE NEED A HELICOPTER AND FLY THE PATIENT BACK TO VEGAS!"

I think one of the hardest lessons to learn in medical care is that when dealing with emergencies, either you control the scene or the scene will control you. Regardless of how much poop is hitting the fan, you can never let the scene control you.


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## MedicDelta (Oct 26, 2014)

JPINFV said:


> Nothing wrong with holding c-spine. It was the entire, "OMG, WE NEED A HELICOPTER AND FLY THE PATIENT BACK TO VEGAS!"
> 
> I think one of the hardest lessons to learn in medical care is that when dealing with emergencies, either you control the scene or the scene will control you. Regardless of how much poop is hitting the fan, you can never let the scene control you.


I like that, thanks. I will keep that in mind.


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