# Question on scenario and who takes charge?



## RunnerD1987 (Sep 1, 2011)

Hypothetical situation: It is night a bad storm came in with wind and rain. Car B crashed into Car A, bad accident. Car C is a witness to the incident. Behind Car C is Car D. Car D is a Advanced EMT. Car C calls 912. Car B driver is walking around, but Car A is still trapped in the car. Car D driver checks on Car B driver. As the ambulance arrives it is from a town that only provides BLS service. The Medic is unavailable. The ambulance is 40 minutes away from the hospital and can intercept with a Medic 20 minutes enroute to the hospital.

Car A driver is a priority one patient. Car B driver is priority 3 and wants to go to the hospital. Can fit both patients on the rig.

Question is responders from the ambulance are one EMR, and two EMT-B's. Since the AEMT has a higher scope of practice what happens?

Appreciate the response.


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## MrBrown (Sep 1, 2011)

Speaking generically yes, the Advanced EMT would be in charge as he has the higher scope of practice.

That said: your jurisdictional, legislative or operational situation may differ.


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## BandageBrigade (Sep 1, 2011)

If it is not Car D's (the AEMT) responce area/service district, then he is nothing  more than a bystander and has no legitimate authority on this scene.


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## truetiger (Sep 1, 2011)

If the accident is in his district, he can take charge if district policy allows that.  If it's not, then its not his call. Because he's off duty, he's not required to do anything.


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## epipusher (Sep 1, 2011)

IMO, unless you know the AEMT on scene, I would thank him for his help and judge the patients for myself. Too much liability.


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## abckidsmom (Sep 1, 2011)

If I was the higher trained individual in this situation AND I chose to get involved, I would help a little, keeping it BLS unless it was CLEAR that what needed to be done would make a clear difference in the outcome of the patient.

The BLS provider who responded would certainly be in charge, and I would offer my help, explain who I was and where I belonged, and if they invited me to, and I could, I would step up and be the medic.

If I was outside of my area, not on duty, and involved in the accident, I have absolutely no duty to act, and I am free to go on about my day.  

There is too much room for chaos to ensue if this standard way of dealing is not followed.


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## BEorP (Sep 1, 2011)

As others have said, it will depend on your local policy for something like this. That being said, in the systems I have worked in, the AEMT would have no say in anything even if they worked in that area if they were not on duty at the time. Of course, in a rural area you may be inclined to accept their help if offered, but the ultimate decision making would go to the on-duty crew, regardless of their level.


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## Cup of Joe (Sep 1, 2011)

If the AEMT performed an intervention that would be above the BLS scope of practice, then he has to, by law, stay with the patient until they are transferred to someone with the same or more medical knowledge.

If he did anything that is still BLS (like splinting for example), I would get his name and ID number and write it clearly in my PCR (if he did ANYTHING I would do this as well).  

As far as abandonment, I'm not sure if its abandonment if he leaves the patient regardless of what he does or doesn't do, and leave the patient with a BLS provider.  What about if he did provide only BLS level service and leaves the patient with the ambulance crew, is that abandonment because he's leaving the patient with a provider with less medical knowledge and scope of practice?


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## HotelCo (Sep 1, 2011)

Unless the AEMT is on duty, and in their coverage area, then I'd say the BLS provider has control of the scene.

You mentioned EMR, is this a canadian scenario? In most places I've heard of in the United States, you're a BLS provider off duty, regardless of if you hold a higher level of licensure or not. (any folks on here who work in a system that allows them to be ALS off duty?)


Sent from my iPad using Tapatalk


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## mycrofft (Sep 1, 2011)

*Off duty means off duty*

Car D tells responder "Hi, I'm an off duty whatever, here's my ID, can I help".

On-duty responder says "Sure" or "No", but ought to try to utilize this resource (and getting name and license number).

Off-duty person has no duty to respond, so depends upon Good Samaritan to protect; one condition for Good Sam is to yield to medical authority. Since Car D is off duty, (s)he has no authority.


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## DESERTDOC (Sep 2, 2011)

Nothing should happen unless there is established policy that allows for intervention while not on duty.

The "priority one" patient is a priority one, why?  Hopefully not mechanism only.  If it is physiological then start an air ambulance if available.


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## jjesusfreak01 (Sep 2, 2011)

Generally speaking, any provider can act at a basic level while off duty on any scene. 

In some jurisdictions, advanced providers are permitted to carry equipment off duty either for use off duty or if they respond to scenes in their POVs. In either of these cases it would be permissible, if within their jurisdictions, for them to treat at an ALS level and take over care of the patient. 

Remember that there is very little that a paramedic can do clinically (not diagnostically) for a patient without advanced level equipment, so a paramedic onscene with a BLS ambulance can't really do anything past the basic scope.

Where I live, all ambulances are medic level, but all medics have the medical director on speed dial, so in the theoretical situation where the services of two medics on scene were needed but only one was on duty, a quick call before (and in rare circumstances, immediately after) administering ALS care will suffice.


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## Rcoddington (Feb 20, 2013)

mycrofft said:


> Car D tells responder "Hi, I'm an off duty whatever, here's my ID, can I help".
> 
> On-duty responder says "Sure" or "No", but ought to try to utilize this resource (and getting name and license number).
> 
> Off-duty person has no duty to respond, so depends upon Good Samaritan to protect; one condition for Good Sam is to yield to medical authority. Since Car D is off duty, (s)he has no authority.



Good Samaritan laws only protect very basic procedures, such as CPR, the AEMT would be personally liable for any ALS procedures conducted. It would be reckless for the AEMT todo anything else, and because he is off-duty he has absolutely no authority on scene.


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## MrJones (Feb 20, 2013)

jjesusfreak01 said:


> Generally speaking, any provider can act at a basic level while off duty on any scene.



Really? On what do you base that?


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## PaddyWagon (Feb 20, 2013)

Good sam laws have nothing to say about what scope you're allowed to use, that would depend on your local protocols for off duty responding.  God sam protects you unless you're grossly negligent, operate outside your scope, do something phenomenally stupid or abandon the patient once you've undertaken care.


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## Milla3P (Feb 23, 2013)

WCSU1987 said:


> Car D is a Advanced EMT. Car C calls 912. Car B driver is walking around, but Car A is still trapped in the car.



Car C is apparently a Stonecutter and knows that 911 is for suckers.


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## Medic Tim (Feb 23, 2013)

Milla3P said:


> Car C is apparently a Stonecutter and knows that 911 is for suckers.
> 
> View attachment 1459



Awesome


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## Milla3P (Feb 23, 2013)

Is it sad that I couldn't finish the "Car D" part before I looked for this picture.


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## cruiseforever (Feb 23, 2013)

WCSU1987 said:


> Hypothetical situation: It is night a bad storm came in with wind and rain. Car B crashed into Car A, bad accident. Car C is a witness to the incident. Behind Car C is Car D. Car D is a Advanced EMT. Car C calls 912. Car B driver is walking around, but Car A is still trapped in the car. Car D driver checks on Car B driver. As the ambulance arrives it is from a town that only provides BLS service. The Medic is unavailable. The ambulance is 40 minutes away from the hospital and can intercept with a Medic 20 minutes enroute to the hospital.
> 
> Car A driver is a priority one patient. Car B driver is priority 3 and wants to go to the hospital. Can fit both patients on the rig.
> 
> ...



Sound like the BLS ambulance is on the scene.  Place both pts. in the rig and start transport.  As others have said AEMT is a first responder doing BLS unless it is in his area.

Call for a meet with the ALS rig.  No air to night it's storming out.

Just wondering when crews meet with an ALS ambulance do you keep the pt. in your ambulance or does ALS want them in their ambulance?


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## Akulahawk (Feb 23, 2013)

While the AEMT has the higher scope of practice, because the AEMT isn't on duty, the on-duty EMT crew has scene authority. That means that the EMT crew can accept or reject the offer of assistance. In my local area, if I am "affiliated" with an ALS provider, I'm explicitly authorized to provide full ALS scope while off-duty. Here's where things get interesting: should an on-duty BLS 911 rig show up, I can legally turn the patient over to the BLS crew without an issue as long as I am not turning the patient over to them with something that they're not allowed to monitor. Can a BLS crew monitor a patient that's intubated? Yes. A patient that's got a line of NS going? Yes. A chest tube that I placed? Yep. 

The reality is that I'm going to provide BLS-only care, turn the patient over to the on-duty crew, and beat feet. I have other things to do with my time than be stuck in an ambulance providing care when the on-duty crew is capable of handling things and (more importantly) arranging for further care... even if they're BLS-only.


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## CodeBru1984 (Feb 24, 2013)

Akulahawk said:


> While the AEMT has the higher scope of practice, because the AEMT isn't on duty, the on-duty EMT crew has scene authority. That means that the EMT crew can accept or reject the offer of assistance. In my local area, if I am "affiliated" with an ALS provider, I'm explicitly authorized to provide full ALS scope while off-duty. Here's where things get interesting: should an on-duty BLS 911 rig show up, I can legally turn the patient over to the BLS crew without an issue as long as I am not turning the patient over to them with something that they're not allowed to monitor. Can a BLS crew monitor a patient that's intubated? Yes. A patient that's got a line of NS going? Yes. A chest tube that I placed? Yep.
> 
> The reality is that I'm going to provide BLS-only care, turn the patient over to the on-duty crew, and beat feet. I have other things to do with my time than be stuck in an ambulance providing care when the on-duty crew is capable of handling things and (more importantly) arranging for further care... even if they're BLS-only.



I wasn't aware that in Ca if your are "affiliated" with an ALS provider that one has an explicit authority to provide full ALS scope of practice off duty. Is this a new policy? From my understanding, Ca EMS providers (EMT/Paramedic) have no duty to act off duty.


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## Medic496 (Feb 27, 2013)

CA Paramedics while off duty may not practice ALS.  A paramedic must be accredited, work for an approved ALS provider, and be on duty.  Even if the medic is going to go help with disaster relief, the paramedic must be being sent by the employer with the full compliment of equipment.  No running around starting lines on everyone just because we can.


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## Akulahawk (Feb 28, 2013)

OCEMThopeful said:


> *CA Paramedics while off duty may not practice ALS*.  A paramedic must be accredited, work for an approved ALS provider, and be on duty.  Even if the medic is going to go help with disaster relief, the paramedic must be being sent by the employer with the full compliment of equipment.  No running around starting lines on everyone just because we can.


Generally this is true. Sacramento County explicitly authorizes off-duty ALS. However, each Paramedic _must_ be affiliated with a Paramedic Provider and have a current accreditation. Here's the catch: Off-duty possession of ALS equipment is controlled. Paramedics can't just assemble a full-bore kit with meds "just because." They must have county EMS permission to do that.

That being said, should said Paramedic stumble upon all the equipment necessary, he or she could use all that equipment in providing care. One of the reasons why Sacramento County has the provision for ALS off-duty is because it's entirely possible that an event occurs somewhere and an off-duty paramedic just happens to be there and offers to assist. This way more ALS hands are available early on while on-duty paramedics are still en-route to the scene. One odd wrinkle is that off-duty paramedics aren't required to ride-in with unstable patients that they cared for as the primary paramedic. They can just turn the patient over to an on-duty paramedic and leave the scene. 

Yes, this is very odd and unusual, but it's how Sacramento built it's system. Most of the time, a Paramedic can only provide ALS services while on-duty... otherwise they're only allowed to provide BLS only care. Of course, any Paramedic can provide that level care at any time, even if no longer working, because it's essentially first-aid.


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## Akulahawk (Feb 28, 2013)

CodeBru1984 said:


> I wasn't aware that in Ca if your are "affiliated" with an ALS provider that one has an explicit authority to provide full ALS scope of practice off duty. Is this a new policy? From my understanding, Ca EMS providers (EMT/Paramedic) have no duty to act off duty.


Off-duty ALS is pretty unique to Sacramento County. It's been this way for at least 12 years.

Paramedics must be affiliated with a Paramedic Provider to provide any ALS services, even if on-duty. So, if you're a paramedic but you work for a BLS provider, you may only provide BLS care. Off-duty, paramedics are generally authorized to provide BLS care only.


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## CodeBru1984 (Feb 28, 2013)

Akulahawk said:


> Off-duty ALS is pretty unique to Sacramento County. It's been this way for at least 12 years.
> 
> Paramedics must be affiliated with a Paramedic Provider to provide any ALS services, even if on-duty. So, if you're a paramedic but you work for a BLS provider, you may only provide BLS care. Off-duty, paramedics are generally authorized to provide BLS care only.



I got my start in EMS in Sacramento County back in 2002 and even I wasn't aware of that... Learn something new everyday.


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## Akulahawk (Mar 1, 2013)

CodeBru1984 said:


> I got my start in EMS in Sacramento County back in 2002 and even I wasn't aware of that... Learn something new everyday.


That's something that's very specific to paramedic providers, so BLS providers wouldn't have to know about that provision because it doesn't apply to them, and it's not something they'd ever have to deal with as a Basic.

We do have some large areas that are covered by volunteers, so that off-duty provision of ALS and possession of ALS equipment (outside of advanced airways) is something that won't go away for quite some time.


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## CodeBru1984 (Mar 1, 2013)

Akulahawk said:


> That's something that's very specific to paramedic providers, so BLS providers wouldn't have to know about that provision because it doesn't apply to them, and it's not something they'd ever have to deal with as a Basic.
> 
> We do have some large areas that are covered by volunteers, so that off-duty provision of ALS and possession of ALS equipment (outside of advanced airways) is something that won't go away for quite some time.



They can't posses advanced airway equipment off duty?


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## medic17 (Mar 9, 2013)

I don't know the law in your state but by us all medically trained personnel must give assistance if required (duty to act). I asked the instructor (an EMT-A) in one of the EMT-B courses I helped out in and he said that here it's his decision if he wants to take over or not but he wulde not if he can so as not to confuse the team.


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## Akulahawk (Mar 10, 2013)

CodeBru1984 said:


> They can't posses advanced airway equipment off duty?


_All _Sacramento County Paramedics canpossess advanced airway equipment off duty. That equipment may be personally owned, or it could be issued to them. It's all the other stuff (like code meds, IV catheters, Defib that's not an AED for own use, and the like) that they prohibit. Think of it like this: Airway kit? Good to go. ALS jump kit? Not so much, unless _specifically _authorized by the county to possess that stuff. No off-duty Paramedic is authorized to possess controlled substances (think "narcotics") as part of an "off-duty" kit, if authorized to possess an ALS kit while off-duty.

What do I mean by the ALS jump kit? Simple: think of it as an ambulance in a bag. You put that kit on a BLS truck and hop on board and suddenly you've emergently created an ALS ambulance minus the controlled "narcs." Yes, that "kit" could include monitors and the like too.


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