# Decison making on scene



## SeeNoMore (Jun 29, 2009)

If I am on scene with a providor with a higher level of cert, I assume I must follow their lead and medcial decisions? For example whether a PT gets a collar, 02 etc. 

I have ran into this a few times, and I am trying to decide how to handle it. I want to make sure I am fullfilling my duties as a providor, but also respecting the chain of command and not appearing arrogant.


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## Hastings (Jun 29, 2009)

SeeNoMore said:


> If I am on scene with a providor with a higher level of cert, I assume I must follow their lead and medcial decisions? For example whether a PT gets a collar, 02 etc.
> 
> I have ran into this a few times, and I am trying to decide how to handle it. I want to make sure I am fullfilling my duties as a providor, but also respecting the chain of command and not appearing arrogant.



Do those things.

If a higher level provider tells you to stop, or not to do it, then simply stop and don't do it.


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## lafmedic1 (Jun 29, 2009)

I have had a "Mds"show up on scene sometimes with an obscure non emergency related cert. If they direct you to do something harmful make sure you repeat it to them what they asked you to do and if you transport the patient have them attend the patient as they are a higher level than you and can not leave as it would constitue abandonment in some areas.Usually as soon as you mention that they WILL be riding to direct treatment all the way they back off. Drs can also be a big help so dont discount them right away .


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## SeeNoMore (Jun 29, 2009)

"Do those things.

If a higher level provider tells you to stop, or not to do it, then simply stop and don't do it."

That's what I have been doing. Thanks for the imput.


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## PapaBear434 (Jun 29, 2009)

There are certain things that need to be done at a BLS level despite the call.  Vitals, obviously.  Boarding someone or putting a collar on, possibly.  

You will get to the point, especially if you work with the same folks enough, that you will know what you're gonna do because you know what they are gonna do.  It's a rhythm you'll get.

But in answer, yeah, the highest level cert usually will run the call.  If it's a BLS patient, a lot of time higher level providers will let the Basic be the Attendant in Charge and run the call, but some won't as a matter of principal.  Just have to figure out who you're working with.


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## VentMedic (Jun 29, 2009)

PapaBear434 said:


> If it's a BLS patient, a lot of time higher level providers will let the Basic be the Attendant in Charge and run the call, but some won't as a matter of principal. Just have to figure out who you're working with.


 
Yes they may do that but with the knowledge that if anything happens they still will be held as the person with the higher license and the responsibility falls directly on their shoulders.


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## marineman (Jun 29, 2009)

It depends what you mean by higher level of cert. If the person has a duty to respond to that scene and has a duty to provide patient care then yes you go with their decision. If they don't have a duty to act then no they don't have a say (anyone that's not EMS like a doc or nurse regardless of their specialty unless they would like to take full responsibility for all patient care all the way in)


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## VentMedic (Jun 29, 2009)

marineman said:


> It depends what you mean by higher level of cert.


 
Unfortunately in EMS, a higher level of cert could mean any of the EMT-A-B-C-D-E-F-G alphabet.   

I have often wondered if in Washington state, does an EMT-Airway trump an EMT-IV?  Does the EMT-ILS trump an EMT-IV/Airway?


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## PapaBear434 (Jun 29, 2009)

VentMedic said:


> Yes they may do that but with the knowledge that if anything happens they still will be held as the person with the higher license and the responsibility falls directly on their shoulders.



Depends with us, actually.  If it's ruled a BLS patient, and the BLS attendant did something stupid, it's solely on him unless the ALS provider did nothing to correct it or stop him.  Whoever is ruled AIC for that case.


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## VFFforpeople (Jun 29, 2009)

I do y training, I know BLS and that is what I am going to do. Like stated if the Medic says hey you stop..I am going to keep doing my duty and call it a day.


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## Sasha (Jun 29, 2009)

VFFforpeople said:


> I do y training, I know BLS and that is what I am going to do. Like stated if the Medic says hey you stop..I am going to keep doing my duty and call it a day.



You're going to ignore a medic?


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## Shishkabob (Jun 29, 2009)

O what you know what to do, that is in your protocols, until told otherwise.


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## SeeNoMore (Jun 29, 2009)

Thanks for all the input folks. I probably am suffering from newbie enthusiasm but it seems better to me to be err on caution if time is not wasted. I guess all I can do is act as I have been trained and like said, stop or modify if directed.


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## reaper (Jun 29, 2009)

VFFforpeople said:


> I do y training, I know BLS and that is what I am going to do. Like stated if the Medic says hey you stop..I am going to keep doing my duty and call it a day.



Nice way to lose your cert!


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## WuLabsWuTecH (Jun 29, 2009)

Almost always listen to someone with a higher level of cert.  If you really feel uncomfortable doing it, ask them to help you with it or to do it for you.

Usually its not a big deal.  Just the other day the In charge medic told me to put a lady on 15 lpm by NRB.  The other medic told me not to and to keep it on 10.  What do I do?  Put it on 15 until they sorted it out between themselves.


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## PapaBear434 (Jun 29, 2009)

reaper said:


> Nice way to lose your cert!



I'd say that depends.  Obviously if the medic is doing something medic related, the basic probably shouldn't stop or correct him.  But if there is a fall victim that fell from six feet off a ladder and lost consciousness and the medic says "You don't have to worry about putting a collar on him or boarding him, let's just roll," I'd say you have every right to tell him no and do it anyway.

BLS level stuff is both basic's and medic's responsibilities, and the basic shouldn't be afraid to correct the medic if he's doing something stupid in that regard.


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## VentMedic (Jun 29, 2009)

PapaBear434 said:


> Depends with us, actually. If it's ruled a BLS patient, and the BLS attendant did something stupid, it's solely on him unless the ALS provider did nothing to correct it or stop him. Whoever is ruled AIC for that case.


 
That will not fly in any court room if that ALS provider is still present.


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## silver (Jun 30, 2009)

lafmedic1 said:


> I have had a "Mds"show up on scene sometimes with an obscure non emergency related cert. If they direct you to do something harmful make sure you repeat it to them what they asked you to do



Wait if you acknowledge that this is dangerous you would still follow his orders?

That does not seem right, and if you acknowledge it isn't right you will get your license pulled too.

If you dont feel comfortable with anything a higher credentialed person say, you can always say no. If a paramedic asks a basic to do something that is wrong you can always say I do not feel that is right and will not participate. I am going to report this instance when we get back.


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## PapaBear434 (Jun 30, 2009)

silver said:


> Wait if you acknowledge that this is dangerous you would still follow his orders?
> 
> That does not seem right, and if you acknowledge it isn't right you will get your license pulled too.
> 
> If you dont feel comfortable with anything a higher credentialed person say, you can always say no. If a paramedic asks a basic to do something that is wrong you can always say I do not feel that is right and will not participate. I am going to report this instance when we get back.



Also have to keep in mind that you practice under your Medical Director's medical license, not some random Doc that walks up.  You do what YOUR Doc says.


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## marineman (Jun 30, 2009)

PapaBear434 said:


> Also have to keep in mind that you practice under your Medical Director's medical license, not some random Doc that walks up.  You do what YOUR Doc says.



Exactly what I was trying to convey in my previous post. If the "higher trained" person giving you the order is your partner or another EMS provider that has a duty to act at that scene then yes follow the order. If it's a doctor, nurse, rrt, or god himself thank them and continue following your protocol. Nothing against those other professionals but just because they have a higher level of education doesn't mean that they're in charge of me or my scene.


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## reaper (Jun 30, 2009)

PapaBear434 said:


> Also have to keep in mind that you practice under your Medical Director's medical license, not some random Doc that walks up.  You do what YOUR Doc says.




Also remember that you work under that medics license, that is on scene. It is fine to say no or do something you believe to be right. You just better be right and be able to prove it! I have seen many EMT's lose their cert over this very thing.

I have no problem telling a Dr. no, if I know I can prove they were making a bad decision. This happens very rarely and you had better be right.


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## VentMedic (Jun 30, 2009)

VFFforpeople said:


> I do y training, I know BLS and that is what I am going to do. Like stated if the Medic says hey you stop..I am going to keep doing my duty and call it a day.


 
This thing is you only know BLS.   You do not know what someone at a higher level of training and education is seeing. So yes, if they tell you to stop, you had better, at the very least, listen to why.   Going blindly and bullheadedly forward with limited knowledge will do your patients no good and may possibly harm them.


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## Sasha (Jun 30, 2009)

VentMedic said:


> This thing is you only know BLS.   You do not know what someone at a higher level of training and education is seeing. So yes, if they tell you to stop, you had better, at the very least, listen to why.   Going blindly and bullheadedly forward with limited knowledge will do your patients no good and may possibly harm them.



And make for a really strained partnership for the rest of the shift, which is not good for patients.


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## Shishkabob (Jun 30, 2009)

reaper said:


> Also remember that you work under that medics license, that is on scene. It is fine to say no or do something you believe to be right. You just better be right and be able to prove it! I have seen many EMT's lose their cert over this very thing.
> 
> I have no problem telling a Dr. no, if I know I can prove they were making a bad decision. This happens very rarely and you had better be right.




I work under no medics license, as they are not licensed (Albeit there are "Licensed Medics" in Texas, but that's a different story)  They are responsibile for keeping their own cert, not me.

Medics can only practice medicine under a doctors license, the same license I work under.  



If you can articulate why you did something, and it's in your protocols, that's all that matters.


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## Sasha (Jun 30, 2009)

Linuss said:


> I work under no medics license, as they are not licensed (Albeit there are "Licensed Medics" in Texas, but that's a different story)  They are responsibile for keeping their own cert, not me.
> 
> Medics can only practice medicine under a doctors license, the same license I work under.
> 
> ...



Sorry but when a medic is on scene, he or she is in charge and is responsible for the patient and what happens and it's their license on the line when you screw up. You had better listen to what they say.


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## EMTinNEPA (Jun 30, 2009)

As stated, the medic knows best.  If he tells you to do something (as long as it falls within your scope of practice) or not to do something, you'd better listen.


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## redcrossemt (Jun 30, 2009)

Linuss said:


> If you can articulate why you did something, and it's in your protocols, that's all that matters.



EMT-B: "I did 'it' because protocol said to."

EMT-P: "I told the EMT not to do 'it' because I understand why this patient is in distress and the underlying pathophysiology."


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## Shishkabob (Jun 30, 2009)

Sasha said:


> Sorry but when a medic is on scene, he or she is in charge and is responsible for the patient and what happens and it's their license on the line when you screw up. You had better listen to what they say.



Doesn't change a thing I said, does it?  I don't work under their license.  Period.  End of question.

But you also missed the point I was saying, which is do what you know what to do, as long as you're supposed to do it.



redcrossemt said:


> EMT-B: "I did 'it' because protocol said to."
> 
> EMT-P: "I told the EMT not to do 'it' because I understand why this patient is in distress and the underlying pathophysiology."



You obviously need to look up the word "articulate"


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## redcrossemt (Jun 30, 2009)

Linuss said:


> Doesn't change a thing I said, does it?  I don't work under their license.  Period.  End of question.
> 
> But you also missed the point I was saying, which is do what you know what to do, as long as you're supposed to do it.
> 
> You obviously need to look up the word "articulate"



In my state, the medical provider with a duty to act, and the highest medical licensure, is in charge of the patient's care.

If I (as a paramedic) believe something is not in the patient's best interest, and I tell you (as a basic) not to do it, you had better not do it. 

That's not saying that I don't value input as to what should be done for the patient, or if an EMT starts obvious treatments such as holding c-spine, applying a nasal cannula, etc. If an EMT, for instance, starts holding c-spine and I determine that c-spine immobilization is not called for, I will thank the EMT for maintaining c-spine and tell them that it's okay to let go now.

You as an EMT can always say/document, "the medic told me not to". As a paramedic, I take full responsibility for the patient's care, and can lose my license if you do something inappropriate and I don't intervene.


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## Shishkabob (Jun 30, 2009)

I'm not debating the on scene CoC at all, red, as most of the time, the higher credentialed person is in charge.   Common sense and common knowledge dictate as such.




I was just stating the fact that I do not work under a medics license, period. 

Medics, in the state of Texas and quite sure many other states, do NOT have a 'real' medical license to where they can practice, and delegate practice, outside of an MD's  orders.  That is ALL that my post was stating.


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## redcrossemt (Jun 30, 2009)

Linuss said:


> I'm not debating the on scene CoC at all, red, as most of the time, the higher credentialed person is in charge.   Common sense and common knowledge dictate as such.
> 
> I was just stating the fact that I do not work under a medics license, period.
> 
> Medics, in the state of Texas and quite sure many other states, do NOT have a 'real' medical license to where they can practice, and delegate practice, outside of an MD's  orders.  That is ALL that my post was stating.



Fair enough.

In Michigan, we are licensed providers, but required to work under an MD's orders. That being said, I am allowed to delegate supervised practice to others as allowed in their scope of practice.


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## Shishkabob (Jun 30, 2009)

redcrossemt said:


> Fair enough.
> 
> In Michigan, we are licensed providers, but required to work under an MD's orders. That being said, I am allowed to delegate supervised practice to others as allowed in their scope of practice.



Same as with Texas.



Texas is weird though... we have "Paramedics" and "Licensed Paramedics".  But LP's don't have a 'real' license, they just have an AAS in paramedcine, or a BS in any other area.




I always nitpick statements and argue them... tis how I role and why some on here despise me


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## HotelCo (Jun 30, 2009)

lafmedic1 said:


> I have had a "Mds"show up on scene sometimes with an obscure non emergency related cert. If they direct you to do something harmful make sure you repeat it to them what they asked you to do and if you transport the patient have them attend the patient as they are a higher level than you and can not leave as it would constitue abandonment in some areas.Usually as soon as you mention that they WILL be riding to direct treatment all the way they back off. Drs can also be a big help so dont discount them right away .



Unless they have a cert in something related to the patients problem, then I'll wait until my medical director gives me the OK that they can run the scene.

I don't see much point in letting a dermatologist run my scene unless the patient has broken out in a trauma rash.


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## Shishkabob (Jun 30, 2009)

HotelCo said:


> I don't see much point in letting a dermatologist run my scene unless the patient has broken out in a trauma rash.



Necrotizing fasciitis?


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## VentMedic (Jun 30, 2009)

Linuss said:


> Necrotizing fasciitis?


 
That requires an Infectious Disease doctor and a wound care specialist or maybe even an Intensivist depending on the extent. As well, reconstructive physicians may be called in during the healing process. This also can consist of a variety of other doctors depending on the location. Ex. ENT may be on the case if it is in that region.

A dermatologist will usually not be part of the team.


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## Sasha (Jun 30, 2009)

Linuss said:


> Necrotizing fasciitis?




And what do you expect the dermatologist to do in the field?? The treatment for that includes antibiotics, possible grafts, possible amputations, maybe a hyperbaric chamber none of which are field treatment. Treatment would be fully supportive, perhaps I'm naive, but I don't see how a dermatologist would have anytinhg to add. It doesn't really "eat the skin" it's an infection that causes destruction of the tissue, not so much a skin disease.


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## Shishkabob (Jun 30, 2009)

Sasha said:


> And what do you expect the dermatologist to do in the field?? The treatment for that includes antibiotics, possible grafts, possible amputations, maybe a hyperbaric chamber none of which are field treatment. Treatment would be fully supportive, perhaps I'm naive, but I don't see how a dermatologist would have anytinhg to add.



You're such a fan of my wit, aren't you?


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## Sasha (Jun 30, 2009)

Linuss said:


> You're such a fan of my wit, aren't you?



I haven't seen any wit.


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## VentMedic (Jun 30, 2009)

It is difficult to tell what it is on a forum since we cannot see facial expressions.

It could be one of wit or of cluelessness.


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## Shishkabob (Jun 30, 2009)

*Uses wit to make a cute comeback*


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## daedalus (Jun 30, 2009)

PapaBear434 said:


> Depends with us, actually.  If it's ruled a BLS patient, and the BLS attendant did something stupid, it's solely on him unless the ALS provider did nothing to correct it or stop him.  Whoever is ruled AIC for that case.



Not really. The paramedic can still be sued.


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## wyoskibum (Jun 30, 2009)

SeeNoMore said:


> If I am on scene with a providor with a higher level of cert, I assume I must follow their lead and medcial decisions? For example whether a PT gets a collar, 02 etc.
> 
> I have ran into this a few times, and I am trying to decide how to handle it. I want to make sure I am fullfilling my duties as a providor, but also respecting the chain of command and not appearing arrogant.



Are you a first responder assisting on scene and someone else will be transporting or are you part of the transport team?

It can be challenging in those situations, everyone will do something different.  I always try to make calls a "team effort" and encourage all provider's input.  The key is to make a suggestion in way that it make it a good "teachable moment".   IE:

"Do you think the mechanism was sufficient to warrant spinal stabilization?"
"Would you like me to put the pt on a cannula since his RR is 26?"

If you are riding the pt to the hospital and writing the PCR, then you should have final say.


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## SeeNoMore (Jul 1, 2009)

"The key is to make a suggestion in way that it make it a good "teachable moment". IE:"


This is a great suggestion.  This is what I have been doing to make sure I am doing my best, but not making an *** of myself.

To all the medics here, please don't take my comments as evidene that I think I know better!  Believe me I have a ton to learn and am more than happy to folllow lead. 

I will say I have seen times in the field where some corners were cut that I am pretty sure did not have much to do with greater experience and knowledge. I could be mistaken, and this has been a minority of the time. 

But certainly having me second guess an I or medic would only disrupt patient care.


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## wyoskibum (Jul 1, 2009)

SeeNoMore said:


> To all the medics here, please don't take my comments as evidene that I think I know better!  Believe me I have a ton to learn and am more than happy to folllow lead.



At the end of the day, it is all about what is best for the patients.  We are all human and even the most experience medic can get tunnel vision or make a mistake.   I would rather work with an EMT who make suggestions and is active in the patient care instead of an EMT that I have to tell to get a set of vitals or put the pt on O2.



SeeNoMore said:


> certainly having me second guess an I or medic would only disrupt patient care.



If you have a medic who is approachable, after the run I would encourage you to ask the medic why they did what they did.  At the very least you will learn the different schools of thought on the treatment of whatever is wrong with the patient.


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