# procedures for motor vehicle accident



## AVPU (Mar 4, 2010)

A question in the practice section of my EMT-B book:

While u are starting CPR on the pt lying next to the vehicle a bystander runs up and states he is a doc and wants to help. What is your response?

two reasonable responses:

run it thru Med Con, stating he must follow your protocols (takes too long?)

let the doc take over

pretty basic I know, but my brain is stuck. Maybe I've been studying too long. Yikes!


----------



## JPINFV (Mar 4, 2010)

Run it through medical control, ask his specialty, and ask for his card. Additionally, find out if he wants to run the show or just provide an additional set of hands. There's a few pitfalls. First off, is he an MD or DO? If not, then sorry, he can provide an extra set of hands, but he's not taking over. Second, remember. Unlike EMT-Bs, EMT-Ps, RNs, and RTs, MDs and DOs have unrestricted licenses to practice medicine. Their scope of practice isn't confined to when they are just on the clock and under medical control unlike most other health care providers (like, say, podiatrists, DPTs, etc).


----------



## TransportJockey (Mar 4, 2010)

Here in ABQ you hand them a page from the protocol book that they read. It basically says that if you want to take over full care and violate protocols and standing orders you must ride in with the patient and complete all documentation. But I've never heard of it happening here. Most MDs here are like a lot of us when off duty and don't bother to stop


----------



## LondonMedic (Mar 4, 2010)

I think I, and most of my colleagues, would be happy just giving a hand - remembering that we recognise our limits and that we are out of our normal working environment. If I was first on scene, that might be a little different. Depends on the job and depends what crew turns up.

That said, I'm quite happy if I don't notice anyone who might need a hand.


----------



## AVPU (Mar 4, 2010)

So the first option sounds like it would be correct. But I wouldn't want to stop what I was doing to ctc med con. Assuming I have a partner who's available, have him do it ?


----------



## LondonMedic (Mar 4, 2010)

AVPU said:


> So the first option sounds like it would be correct. But I wouldn't want to stop what I was doing to ctc med con. Assuming I have a partner who's available, have him do it ?


So you'd interrupt 2-person CPR? Why not just tell the doc to :censored::censored::censored::censored: off?

What would you do if it was a paramedic or tech? Would you have to get grown-up permission for that?


----------



## dave3189 (Mar 4, 2010)

I have several friends that are Docs and I have tremendous respect for their education and talents.  That being said, in an out of hospital trauma situation, I'd take an experienced EMT working on me over an MD any day of the week.  The only exception to this would perhaps be an E.R. Doc.  Without the tools and resources of a hospital environment, an MD can't really do much more than an EMT can.  In the final analysis, EMTs are much more experienced and adept in treating patients in uncontrolled environments.


----------



## AVPU (Mar 4, 2010)

So, if I encounter this sort of question on the NR, what would the correct answer be??


----------



## TransportJockey (Mar 4, 2010)

AVPU said:


> So, if I encounter this sort of question on the NR, what would the correct answer be??



Somehow I doubt this question will come up on NR


----------



## CAOX3 (Mar 6, 2010)

I dont know where everyone worke but this rarely happens in my area.

And what exactly is an off duty MD going to do for the patient besides risk his medical lic.  If he was towing a trauma center behind his car then maybe .   Is his MD CPR going to be better then yours?  I doubt it.   If he wants to help out thats fine, but we are  probably going to have at least twenty people on scene at a fatality.  More hands isnt something we will need.

My answer would be unless he wants to ride into the hospital, give report and then sign mine.  Thank you but its best if he just move on.


----------



## 8jimi8 (Mar 6, 2010)

The most correct answer is the first answer.  

Contact medical control explain there is a Doctor (check his ID) who wants to take command of the scene.  The doctor will have to ride in and assume patient care until the patient can be transferred to definitive care of an equal or higher level.  

Somehow I doubt anyone is going to drop their plans to ride in on a random roadside medical / trauma.


----------



## VentMedic (Mar 6, 2010)

dave3189 said:


> I have several friends that are Docs and I have tremendous respect for their education and talents. That being said, in an out of hospital trauma situation, I'd take an experienced EMT working on me over an MD any day of the week. The only exception to this would perhaps be an E.R. Doc. Without the tools and resources of a hospital environment, an MD can't really do much more than an EMT can. In the final analysis, *EMTs are much more experienced and adept in treating patients in uncontrolled environments*.


 
Do EMTs have the same knowledge and training a doctor has? Now before you bash doctors for not being able to work outside of their controlled envirionments, look at the many volunteers who have adapted to situations such as Haiti, Chile and Katrina. It sounds like you and a couple other members here have never worked with doctors or have any understanding of their knowledge and skills. 

If a doctor assumes the care for a patient outside of the hospital, especially if he/she has privileges at the hospital the patient is being taken to, you might be surprised at what they can do. For an example, their knowledge of assessment and diseases can get the patient to an OR or IR suite faster. We recently had a neuro doctor hop an ambulance with a patient who had AMS with stroke like symptoms and have that patient in IR within 20 minutes while only stopping for labs and a CT Scan. A good OB doctor can do many more manipulations than any EMT. If it happens to be their specialty and they have privileges at the hospital, they can also activate any team or equipment that might be required where an ED doctor would have to call for a consult first and then that team with specialized equipment might be activated. A doctor can also make use of the meds available since many protocols are very limiting for Paramedics as to the amount given for sedation or pain control in prehospital. Even those for RSI are very inadequate in many agencies. For cardiac arrest, a doctor might be able to identify and intervene with one of the Hs and Ts even with the limited meds and equipment. 

Of course, a doctor who is willing to get involved in prehospital will know his liability. And, it would be wise to contact medical control to advise them of the situation and/or allow that doctor to speak directly with them to give his/her credentials for identification. The real doctors that do get involved will probably know their strengths and weaknesses outside of a hospital which will become very evident when it is made known to them they assume responsibility and are to remain with the patient all the way to the hospital. The exception would be that they only do what any lay person can such as CPR or holding an IV bag. 

I also believe there was a discussion not too long ago where an EMS crew did not recognize their own medical director and rudely told him to :censored::censored::censored::censored: off when he just offered to help with CPR.  If you are going to decline assistance, at the very least don't scream curse words at them.


----------



## LucidResq (Mar 6, 2010)

VentMedic said:


> A good OB doctor can do many more manipulations than any EMT.



I work with two OB-GYNs and I would have them caring for me in a heartbeat before two experienced EMTs. 

They are surgeons, and they are really really good at handling emergencies. The number of cardiac arrests, significant hemorrhages and other "sick" patients they have worked on in one year is probably twice as many as you will work in your entire career. They may not be able to lead a heavy extrication, but this does not mean they would get all fumble-f***** if they came upon an emergency outside of the walls of the hospital. Nor do they need to have an OR, nurses, and a radiology department to be potentially valuable in assessment/treatment of a patient. 

We once had a patient seize on the exam table of our clinic. It shocked me how quickly the doctor recognized it, removed the speculum, and began assessment. The fact that she was seizing hadn't even registered in my head by the time the MD was at the head of the bed directing me to get more help and assessing the patient's airway, etc. 

Of course, not all MDs have this kind of experience. However, most who don't will recognize their limitations and capabilities and won't interfere at all.


----------



## LondonMedic (Mar 7, 2010)

LucidResq said:


> Of course, not all MDs have this kind of experience. However, most who don't will recognize their limitations and capabilities and won't interfere at all.


I think this is quite an interesting point.

Doctors work in an environment where they are surrounded by, and constantly referring to and discussing with colleagues who have other skills, knowledge and speciality. As such, most recognise where their qualities and flaws are and are used to recognising their limitations and capabilities and recognising them in others.

How often does this happen in EMS? Don't most people work with a single other person who has the exact same speciality and level of training? How much practice do they get in recognising others' contribution?


----------



## VentMedic (Mar 7, 2010)

LondonMedic said:


> How often does this happen in EMS? Don't most people work with a single other person who has the exact same speciality and level of training? How much practice do they get in recognising others' contribution?


 
Listening to physicians confer with each other among the different specialties is fascinating as each learns from the others.

People that work in hospitals do have the advantage of knowing the credentials, abilities and contributions of others. I also believe this knowledge has been a contributing factor for increasing education levels of all the healthcare professions within the walls of the hospital. Our name tags list our highest education level, license title pertinent to the job and maybe one or two professional specialty certs like CCRN (RN) or NPS (RT). When we are gathered together during rounds or multidisciplinary meetings, each professional may get a chance to share their area of expertise. When we get new medical residents or visiting professionals from other facilities especially from other countries, they take note of our credentials as we speak. They also know we will be their teachers in our areas of specialty. 

Several years ago we had a group of physicians visiting from other countries who stated "why so little education for such responsibility?" when they noticed the RNs and RRTs in the ICUs only had a 2 year degree. Apparently the RNs in their country had much more education and after seeing the posts about Spain and a few other countries, I can see why that comment was made. Since that time we have strived to have all RNs and RRTs in our ICUs and on the Specialty teams have no less than a Bachelors degree. We have also required the get the time and additional education in to get their specialty certs which may take another 18 months to 2 years. We also have the PTs with their doctorates making impressive contributions along with OT, SLP and Dietary with their Masters. They are also part of rounds in all areas of the hospital. And, let's not forget the PAs and NPs especially those in various specialty areas who may have done extensive internships and residencies in their specialties beyond their "basic" education. 

EMS has stayed very alienated and have judged other health care professionals by a 5 minute interaction. It is generally their "judgments" of others that have kept them alienated and not their work environment. EMS personnel have been invited to join in continuing education opportunities for issues in cardiac, stroke and various equipment such as various venous access devices, ventricular assist devices, homecare or LTC equipment and new meds even if EMS doesn't carry them. But, many have declined because "we're different" or "don't want to do it the nursing way" or "that stuff is boring". Even for education where degrees are available, EMS will often choose to have its own abbreviated and separate version of A&P and pharmacology rather than taking the same prerequisites as nursing and all the other allied health professions to know what base knowledge each has as well as interacting with other future professionals.


----------



## reaper (Mar 7, 2010)

This is very true.

Our level 1 puts on at least 2-3 seminars a month on different specialties. Cardiac,Stroke,Equipment,Cath lab, Disease processes. These are put on for the Dr's and Rn's. The Medics are always invited to attend and it never costs a dime. You receive full CEU's.

The sad part that pisses me off the most. Out of 200 medics, it is always the same 4-5 that show up for all of them. We let the hospital know how much it is appreciated, hoping they don't stop including us for lack of response.

How can anyone in the medical field not want to increase their education? Especially when it's free and you receive CEU's for it? Most of the time, the hospital even caters full lunch and snacks!

If your local hospital systems provide this and are nice enough to include the local EMS, take full advantage of it!


----------



## dave3189 (Mar 7, 2010)

I think the definitive point here is "trauma".  Someone mentioned an OB situation earlier.  Cleary an MD experienced in emergency OB is going to be a better asset in this type of emergency just as a neuro Doc would be with an AMS patient.  What we are talking about here is a trauma patient and the reality that in an out of hospital environment there is really nothing an MD can do that an EMT can't.  As a matter of fact, I would suggest that most MDs have horrible CPR skills.  (The Medics that taught my Basic course admitted that even their CPR paled in comparison to the Basics).  Most MDs are not accustomed to palping a pulse or BP on the freeway with road noise and vibrations.  They are not used to working in emergency conditions where there is a lack of resources.  This is not a turf war of EMTs and MDs.  It is clear that MDs have a much greater wealth of education and knowledge.  However, medicine is a very broad discipline.  Just because you have MD at the end of your name does not mean you are going to be the most effective practitioner in every situation.


----------



## VentMedic (Mar 7, 2010)

dave3189 said:


> I think the definitive point here is "trauma". Someone mentioned an OB situation earlier. Cleary an MD experienced in emergency OB is going to be a better asset in this type of emergency just as a neuro Doc would be with an AMS patient. What we are talking about here is a trauma patient and the reality that in an out of hospital environment there is really nothing an MD can do that an EMT can't. As a matter of fact, I would suggest that most MDs have horrible CPR skills. (The Medics that taught my Basic course admitted that even their CPR paled in comparison to the Basics). *Most MDs are not accustomed to palping a pulse or BP on the freeway with road noise and vibrations.* They are not used to working in emergency conditions where there is a lack of resources. This is not a turf war of EMTs and MDs. It is clear that MDs have a much greater wealth of education and knowledge. However, medicine is a very broad discipline. Just because you have MD at the end of your name does not mean you are going to be the most effective practitioner in every situation.


 
Look at the many threads we have on this forum started by EMT(P)s who are having difficulty palpating pulses and taking a BP. Some of the difficulties expressed are even without being in a moving truck or on a scene. 

And, with all the studies published about CPR fatigue amongst prehospital providers, why would you refuse assistance from another health care professional who has a CPR card? Of course this might not be an issue where there are 6 - 8 FF/Paramedics on scene but then that would depend on how many of those are willing to do any part of patient care.

As I already mentioned, a physician on scene of a TBI or some trauma that does require RSI or pain management where the medication protocols are very limiting as to the dose, that doctor can assume responsibility with med control's knowledge for additional medication. But then it is not about the "skills" at the scene of a trauma but about the knowledge of knowing when to do the skills and when not to. Also, while the assessment may look similar, the processing of the data obtained from that assessment will be different. That is the true difference between a basic and advanced level provider be it a Paramedic or an MD. OPALS did prove this very well and there is no way to use that study as a comparison in the U.S. since the base education for their "Basic" was more than most U.S. Paramedics. 

And, as already stated by several forum members, doctors generally know their own limitations. An OB physician probably won't attempt a cric but may be good at a pericardiocentesis. The unfortunate thing is that some in EMS may assume they know more because of environment but forget the basic principles of patient care are still there regardless of where the scene is.


----------



## Veneficus (Mar 7, 2010)

Could I just point out that OB/GYN is a surgical discipline. In fact I think they fight with ENT as to who was the original doctoral level surgeons not simply barbers.

Somewhere I also heard that trauma was a surgical disease.

It would stand to reason that a surgeon would be a lot of help at the scene of a trauma. It is also quite fasionable in many medical circles to work in more austere environments. I would be careful discounting any doctor. Not only do they bring considerable education to any encounter, but they may have experience with groups like doctors without boarders, missionary work, as well as other austere experiences.

You also cannot discount doctors based on specialty anyway. I know one doctor who now practices as a GP after 30+ years as an ED doc. As well, I know a few ED docs who are internal medicine specialists because EM didn't exist when they did residency. One of my former professors was an OB/GYN attached to an embassy to provide care for the staff and volunteered quite frequently with the indigenous population. Yet another one of my former professors spent years in EM before becomming a histopathologist. 

Most doctors I have met who feel uncomfortable in an emergency or out of the hospital quietly walk on without attracting any attention. The handful of times I had a physician show up on scene when I worked as a medic, they made no effort to call the shots. In every case they sked me what they could do to help me, and one was even happy to do no more than help carry the gear back to the rig. 

In one of my favorite scenarios I saw published to help students practice the national registry oral station. The scenario starts when a bystander tells you the patient likely has an epidural bleed from a fracture of the middle meningeal artery. I definately wouldn't be quick to dismiss a bystander who volunteered something as specific as that. While it is possible they watch too much House, or stayed at a holiday inn last night; they could also be a very knowledgable provider trying to help you but not interfere.


----------



## Jon (Mar 7, 2010)

AVPU said:


> A question in the practice section of my EMT-B book:
> 
> While u are starting CPR on the pt lying next to the vehicle a bystander runs up and states he is a doc and wants to help. What is your response?
> 
> ...




Better question - CPR at a MVA?
Only patient?
Witnessed arrest?
Traumatic arrest?

an unwitnessed  traumatic arrest has a VERY low chance of survial. Additionally, if there are other patients, you should really drop a black tag on this one and worry about the rest.


As for a doc wanting to help - Depends on what he wants to do, especially at the ALS level. If he wants to help, I'm going to ask if he is requesting to assume responsibility for my patient, accompany me to the hospital, and document what interventions he preforms. If yes to all of the above, then I'll call OLMC, and they will talk Doc-to-Doc... if all is OK, then I'll assist the doc to my scope of practice.


----------

