# EMS Chain of Command??



## morales (Aug 17, 2009)

What is the ems/ first responder chain of command that includes hospital personnel, life guards, ems and so on.


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## WuLabsWuTecH (Aug 17, 2009)

Well, there is no set, but generally, in EMS, you have the Medical Director whose license you work under who has the final say in medical decisions.  Your operations director/EMS supervisor will write the standard operation procedures.  Between these you follow these guidelines and orders (offline medical control) and that is the holy grail.

To deviate, you ask for medical control who is a doctor who talks to you over the radio. (Online medical control)

Under the supervisor and medical control, you have sometimes a lead medic who is an EMT-P

Then the EMT-P ranks over the EMT-I ranks over the EMT-B who ranks over riders/provisional members.

As for at hospitals, it has nothing to do with EMS, and when you're they're you just hand over the patient to a nurse or doctor and each hospital has their own system for pecking order.

Some have a trauma triage nurse who looks at every patient and decides if the trauma unit wants them, if not, she sends them to the regular ED track.  Others just assign a room before/on arrival.

Lifeguards are on the scene and you "out rank" them so to speak.  Which is true for any scene.  They called YOU for help, so you take over.  If you don't want an MD on your scene, you have that say (in most states/areas).  The only exception is if your Medical Director shows up on scene.  There was a story on here sometime ago about a medic who didn;'t recognize his medical director and yelled at him to get off the scene!


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## JPINFV (Aug 17, 2009)

I'd say that the person in command on scene of a medical call is the highest provider on the transport team (anyone who is transporting, regardless of who that person works for). It makes no sense for someone who isn't going to be transporting to be making treatment decisions once the transport crew arrives. If a fly car paramedic hands off care to a basic and clears, then the basic is ultimately responsible for care after that point and should be able to refuse the hand off if uncomfortable with the patient. Similarly, a fire response paramedic shouldn't be dictating care to a transport paramedic if the first response paramedic isn't willing to see the call all the way to the hospital. 

Base hospital out ranks paramedic when base contact is warranted by either protocol or paramedic judgment. Medical director and the system administrators controls the system design, scope of practice, and protocols that guide treatment.


This said, being "in command" is no justification for ignoring members, not taking input, and operating as a team. Just because someone is "in charge" or "in command" doesn't make them infallible or omnipotent.


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## mycrofft (Aug 17, 2009)

*"Chain iof Command" doesn't mean "What's Best and Most Fair".*

Nothing (well, not much) sillier looking than a bunch of field EMS types, firefighters bystanders and so on quibbling over "who's in charge".


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## Akulahawk (Aug 18, 2009)

Some systems have specific protocols for when a Paramedic can transfer care to another provider. For instance, if a non-transport medic arrives and makes patient contact first, that medic is "in charge" until transport arrives and transfer of care occurs. If the patient is in-extremis, or meets/doesn't meet certain criteria, no hand-off may occur and the non-transport medic must accompany the patient to the hospital and is responsible for the care provided. The exception to this would be a transfer to a Flight Paramedic for the purposes of air transport. It's the non-transport vs. transport medic policy. A ground transport unit that doesn't transport and transfers care to an air unit would be the non-transport unit. 

 In my county, On-scene "Command" NORMALLY goes from MD -> EMT-P -> MICN/RN/EMT. Most of the time, there's no MD on scene... RN's, including MICN's function at the discretion of the Paramedic, and may provide BLS care only. MICN's may _assist _with ALS care and provide suggestions, but can not provide medical control on scene. Flight RN's are a higher level of Pre-Hospital care that's provided for under a separate policy. CCT RN's would be treated the same as an RN. They're not generally considered Pre-Hospital personnel. 

My county did this specifically so that there's no question about who is in charge of medical decisions while on scene.


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## Dominion (Aug 18, 2009)

It really depends, there is no 'set' chain of command other than company pecking order.  It all depends on the situation.  If you want to consider pecking order for MOST EMS companies then it's  Rider/student -> 3rd party service (fire, police, etc) -> Basic -> Whatever retarded advanced or intermediate certificates your state recognizes -> Paramedic -> supervisors -> Command staff -> Directors -> MD

Dispatch can either be after 3rd party or before command staff.  it depends on who staffs them.  For the most part around here dispatch goes after 3rd party services.  

Policy around here (and my personal policy) is no MD's, RN's, etc (unless flight coming to get patient) are in control.  The only exception to this policy is if it's a medical director for one of the services around here.  And they don't show up to take over they usually show up for an extra set of hands or to observe.


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## Mountain Res-Q (Aug 18, 2009)

I think the question is more of a, who "outranks" who on a scene:

EMT-B
EMT-I
EMT-P
RN
MICP
MICN
LVN
CNA
MFR/EMR
OEC
W-EMT
W-FR
Lifequard
ETC...

And i say it depends on the system and the circumstances, as some of these provider levels are not pre-hospital and some are specialized (wilderness, swimming pools, and beaches), although some are obvious.  Then again, a EMT working ambo would outrank an EMT working at a Water Park... but would they outrank an EMT in a ER?  Dunno...


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## hottrotter18 (Aug 18, 2009)

I agree with res-q.
It all really depends on the area you serve and whats already been established.
The person with the most training is going to be higher up typically


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## VentMedic (Aug 18, 2009)

Akulahawk said:


> In my county, On-scene "Command" NORMALLY goes from MD -> EMT-P -> MICN/RN/EMT. Most of the time, there's no MD on scene... RN's, including MICN's function at the discretion of the Paramedic, and may provide BLS care only. MICN's may _assist _with ALS care and provide suggestions, but can not provide medical control on scene. Flight RN's are a higher level of Pre-Hospital care that's provided for under a separate policy. CCT RN's would be treated the same as an RN. They're not generally considered Pre-Hospital personnel.


 
But then, for some scenes, the command does not necessarily need a medical title. It all depends on the scene. For clarification (or for confusion) to the OP, most of the statements in this thread are only about the medical personnel and the actual scene command may be very different. 

As broke as CA is, are they using RNs (or MICNs) for 911 response especially with it being largely fire based EMS and 6 Paramedics showing up at each scene? 

I also thought that Sacremento still had an MICN at the base hospital that could give an order to the Paramedic? Aren't there also MICNs or liason RNs that assist the Medical Director and supervise  the Paramedics in that area? 

Even the CCTs in many parts of CA just use one CCT RN and 2 EMT-Bs. Then there is the thing with Paramedics not being able to work in some counties unless they are with a 911 EMS. Of course the very limited scope of practice for Paramedics in CA is the reason RNs have been on the CCT trucks for so long. It is also a good reason as to why most of the flight programs in CA use RN teams. And let us not forget the reason the ED RN (or CCT RN) must ride with the ALS truck to get a patient a few more blocks with a patient that needs a cath lab when the Paramedics drop at the nearest facility. Once almost any medicated drip is hanging and/or an ETT is established, the RN must go. If a second RN or RRT goes, the Paramedic may ride up front and not in the patient compartment. 

And, in CA as in some other states, all the RN has to do is challenge the Paramedic test and that can solve some issues about who is what. Or it can muddy the waters even more.


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## Akulahawk (Aug 18, 2009)

Lots of stuff here. I'll respond in RED for clarity as to what I'm responding to.


VentMedic said:


> But then, for some scenes, the command does not necessarily need a medical title. It all depends on the scene. For clarification (or for confusion) to the OP, most of the statements in this thread are only about the medical personnel and the actual scene command may be very different.
> Yes, for large incidents, the actual scene command structure might the ICS system and as such, overall command may be fairly high ranking LEO or FD person.
> As broke as CA is, are they using RNs (or MICNs) for 911 response especially with it being largely fire based EMS and 6 Paramedics showing up at each scene?
> No. There's protocols for "Physician/RN at scene". Most of the time, these personnel know to NOT get in the way of the field specialists.
> ...


Yes, there's a lot. Some states allow a wider scope of practice for Paramedics than California does. Politics and fear of liability plays a large part in this. A lot of that restriction comes from Medical Directors that are afraid of too much liability on their part if a Medic screws up. A lot of that comes from the RN lobby that doesn't want Paramedics to gain more skills and scope of practice. That would just kill the CCT-RN programs out there if Paramedics could provide most of those services...  As it turns out, CCT-P programs actually make it easier for CCT-RN programs to do well because their time isn't wasted on transporting someone on a NTG drip or a K+ drip that's out of scope for a local medic. 

Flight programs that use RN/RN teams use them because their RN's only have to follow company protocols and not those protocols for each and every different EMS system. The Paramedics on flight teams have to follow the county protocols that they're based in and they provide that level of care out in the field under a mutual aid agreement if they respond out of their home county. They also use them because some of the meds and procedures that they can provide are out of scope for California Paramedics. Escharotomy and Surgical Cric come to mind... as does use of Sux, Roc, Vec...


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## VentMedic (Aug 18, 2009)

Akulahawk said:


> Yes, in California, an RN can challenge the Paramedic test, but they MUST complete the 480 hour internship. The only thing that the challenge gets them out of is the didactic portion of the training. Some of them fail because they can't figure out how to be an EMT... No pass the internship, no get EMT-P.


 
Not quite accurate. They only need 40 ALS patient contacts which any Flight RN can get while working on the job. An MICN or RN that also rides on an ALS truck can do the same thing. 

I can't remember hearing of many CCT-P transports in Alameda county without an RN. RNs can titrate drips and troubleshoot IV pumps whereas the CCT-P can not. Those that did have a CCT-P required only a cardiac monitor and a couple liters of O2. 

http://www.acgov.org/PublicHealth/o...urce_policy_manual/CCTP/CCTP_Field_Manual.pdf

Also, if a patient is on a ventilator for IFT, they usually require more of a ventilator than an ATV which I believe is all the state of CA allows at the Paramedic or even CCT-P level. 



> They also use them because some of the meds and procedures that they can provide are out of scope for California Paramedics. Escharotomy and Surgical Cric come to mind... as does use of Sux, Roc, Vec...


VADs, IABPs, ventilator beyond the ATV (most ICU patients), Diprivan (Propofol), transvenous pacemakers...to name a few more.



> A lot of that comes from the RN lobby that doesn't want Paramedics to gain more skills and scope of practice.


Blaming RNs for the state of California's EMS is a cheap shot. 
However, the RNs that may lobby know the EMS agencies and education are not ready to step up to the plate.
 Only a small percentage of all the CA RNs are on CCTs. Many ED RNs have been very supportive of the Paramedics getting 12-lead EKGs and transporting to the most appropriate facility. 
It has been the EMS agencies that have been slow to advance. I have yet to see 12-leads done in some of the major cities and many Paramedics must transport a chest pain to the nearest facility. This is why I am familiar with RNs from the ED (or CCT) transporting to the more appropriate facility within a few minutes of arrival.


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## morales (Aug 19, 2009)

I like to thank everyone for there responses.


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## downunderwunda (Aug 19, 2009)

As a follow on to this post, when should the chain of command be broken.

If the person designated is incompetent, should you follow their direction?


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