# Chain of Command in Medical Field



## shadowstewie (Nov 10, 2010)

Im not completely sure if this has been said or not on this forum (though I've check everywhere.) I was trying to figure out who has higher authority. An EMT or CNA, then an EMT and LVN, then a Paramedic and RN. From what I remember, it goes CNA, EMT, LVN, Paramedic, RN, etc. Let me know and thanks in advance!


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## TransportJockey (Nov 10, 2010)

Heh, LVN is still a higher level of care than an EMT. There is no way they are the same level. RN is higher than a medic in all ways.
EDIT: I misread the original post. Ignore my snarkiness please.


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## 281mustang (Nov 10, 2010)

shadowstewie said:


> From what I remember, it goes CNA, EMT, LVN, Paramedic, RN, etc.


 Yep.


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## akflightmedic (Nov 10, 2010)

From what I recall, you are all wrong.

Seeing as how you are listing a chain of command yet merging/comparing only two from the actual dozens upon dozens of titles in the medical field, your info is inaccurate.

Nursing is CNA, LPN, RN with several more higher titles of those RNs.

EMS is EMT and Medic.

To merge the two and say this one is higher than that one is dishonest and has no relevance to the topic of chain of command.

Because on an EMS scene, a nurse does not trump me. In a hospital, I do not trump the nurse. We all work together as it is about the patient.

Who has more authority than the other is all location/job dependent. There is no one size fits all here.


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## CAOX3 (Nov 10, 2010)

shadowstewie said:


> Im not completely sure if this has been said or not on this forum (though I've check everywhere.) I was trying to figure out who has higher authority. An EMT or CNA, then an EMT and LVN, then a Paramedic and RN. From what I remember, it goes CNA, EMT, LVN, Paramedic, RN, etc. Let me know and thanks in advance!



We all answer to the doctor.


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## 46Young (Nov 10, 2010)

akflightmedic said:


> From what I recall, you are all wrong.
> 
> Seeing as how you are listing a chain of command yet merging/comparing only two from the actual dozens upon dozens of titles in the medical field, your info is inaccurate.
> 
> ...



+1. It's really an apples to oranges comparison. The CNA is trained differently than the EMT. The RN is trained differently than the paramedic, although the RN can be trained to fufill both ground and air emergent/IFT due to their level of education. With the paramedic, their education is focused to emergency medicine, and it's hit or miss whether they have even an Assosciate's. The vast majority only have 6-12 month tech school certifications. Their level of education, even with an EMS AAS or even a BA in EMS doesn't enable them to be trained to fufill certain roles in nursing. Like I said, apples and oranges.


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## usalsfyre (Nov 10, 2010)

CAOX3 said:


> We all answer to the doctor.



Yes and no. I answer to my medical direction. Which infuriates the local "doc in the box" hospital's physicians when we transport there. They would much rather we just scoop and run rather than actually intervene on behalf of the patient.


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## usalsfyre (Nov 10, 2010)

46Young said:


> +1. It's really an apples to oranges comparison. The CNA is trained differently than the EMT. The RN is trained differently than the paramedic, although the RN can be trained to fufill both ground and air emergent/IFT due to their level of education. With the paramedic, their education is focused to emergency medicine, and it's hit or miss whether they have even an Assosciate's. The vast majority only have 6-12 month tech school certifications. Their level of education, even with an EMS AAS or even a BA in EMS doesn't enable them to be trained to fufill certain roles in nursing. Like I said, apples and oranges.



Being unable to fufil certain nursing roles has FAR more to do with nurse practice acts and JACHO requirements than nurses being exceptionally better. I've seen many nurses flounder in the transport environment just as I've seen many medics flounder in the high-acuity IFT environment. It takes an exceptional individual to be able to do critical care transport. What license/cert they have becomes immaterial after a while.


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## adamjh3 (Nov 10, 2010)

The person in charge on-scene is the most level-headed one.


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## Akulahawk (Nov 10, 2010)

usalsfyre said:


> Being unable to fufil certain nursing roles has FAR more to do with nurse practice acts and JACHO requirements than nurses being exceptionally better. I've seen many nurses flounder in the transport environment just as I've seen many medics flounder in the high-acuity IFT environment. It takes an exceptional individual to be able to do critical care transport. What license/cert they have becomes immaterial after a while.


Ultimately, given good education, This.


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## Akulahawk (Nov 10, 2010)

usalsfyre said:


> Yes and no. I answer to my medical direction. Which infuriates the local "doc in the box" hospital's physicians when we transport there. *They would much rather we just scoop and run rather than actually intervene on behalf of the patient.*


I've seen that too. I had a physician tell me: "Don't do ANYTHING." This was an IFT transport from his office to the hospital. I asked him: Are you going to ride in with me? His answer: No.

I had to tell him that while his patient appears stable enough for transport now, I must follow the orders of the County EMS director if your patient deteriorates unless he rode in with me. He declined to ride in...


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## akflightmedic (Nov 10, 2010)

adamjh3 said:


> The person in charge on-scene is the most level-headed one.



Or they are the least knowledgeable or informed...it is easy to be calm when you don't know what you don't know.


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## Shishkabob (Nov 11, 2010)

Like akf said, no, an RN being an RN doesn't instantly trump me as a medic.

If the RN is part of my agency, and they are a CCRN, then yes, they are in charge of the patint.  

If its not a nurse from my agency, but say an RN at a nursing home that we were called to, sorry toots, I'm top dog.

Heck, I work with several RNs at standbys, and there's just an understanding that neither is "in charge", we work off each others skills and knowledge.  Cardiac or trauma?  The medic tends to lead.  Complex medical?  The nurse tends to lead.  But key word is "tends" as medicine, especially field medicine, is fluid.


Really, cert level is irrelevent after a point.  Do you really think people like vene are less capable than a newer nurse just because he's a "lowly medic"?  Base education is different, sure, as were a speciality whilst RNs are educated as generalist, but anyone who doesn't continue to learn after school shouldn't be in medicine anyway.  


Heck, having an MD after your name still doesn't give you ultimate authority over me.  The one and only doctor I'm required to listen to is the one that signs my protocol book.  Any and every other doctor I encounter, I can utilize for the benefit of the patient, but don't have to follow.


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## MrBrown (Nov 11, 2010)

The senior officer is always incharge, ie highest clinical skill level or most senior in the case of equal skill level

A Technician is under the direction of a Paramedic, a Paramedic under an Intensive Care Paramedic etc .... 

That said nobody presumes to be more important than anybody else however in a proper MCI then the Incident Commander is in charge operationally

It is the Officer treating the patient who decides how time critical they are, not the Officer driving.

The HEMS Doctor if he or she is on scene takes an overall medical leadership position however never discounts what everybody else has to say or suggest.

The Fire Service is guided by what the Ambulance staff want since they are mainly there in a technical role to cut people out of cars, get them out from squished places etc and its no good ripping doors off when the patient needs to be tended too first.


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## adamjh3 (Nov 11, 2010)

akflightmedic said:


> Or they are the least knowledgeable or informed...it is easy to be calm when you don't know what you don't know.



Touche`, good sir.


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## CAOX3 (Nov 11, 2010)

Funny only one person mentioned the team attitude.

More of a team effort then a chain of command, we all have a job to do, if at any level one of those team members fails then the patient suffers.


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## emtchick171 (Nov 11, 2010)

I am a CNA and an EMT.

EMT in every way is much higher cert. than a CNA. basically all CNAs can do is take vitals and tell a nurse what they see.
**this is in North Carolina, may vary from state to state.

In a hospital setting...technically an RN/BSN has more "power" than a medic.
However, a medic can do much more medically than an RN. A medic in a hospital setting does not have to have a doctor's orders to treat/medicate a patient. RN/BSN must have a doctors orders prior to doing anything to a pt...even starting an IV.


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## Shishkabob (Nov 11, 2010)

Do you mean a medic in a hospital or out of?

Either way, both certs must have orders from a doctor... and many nurses have standing orders much like we do in the field.

Granted there's a bit more leeway for field providers (nurses included) due to the very nature that we can't always have a doctor there... but make no mistake, nurses can have standing orders too.


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## firetender (Nov 11, 2010)

The more pertinent question might be "How would you determine who to release your patient to at the scene of an emergency? Would you adhere to a hierarchy?"


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## Akulahawk (Nov 11, 2010)

As Linuss has stated, both Paramedics and RN's can function under standing orders. Out of the gate, a Paramedic may have more leeway than an RN does, but the Paramedic is a niche provider of field emergency medicine. They're supposed to be trained to be "safe" out of the gate. They still suck. Give them a year or two and they're a better medic than when they started. RN's are generalists. They learn about the various parts of the medical system and a bit about how to function in each. Then when the RN gets hired, out of the gate, they suck. They get weeks and weeks of pre-service and in-service training to get them ready for their role in that area of medicine and THEN they're watched and mentored for about a year. In other words, they begin to specialize and have improved greatly from their beginning stages.

After a few years of seasoning, ideally, both providers (say a Paramedic and an ED RN) will end up being very competent in their jobs. It's at that point that I don't care who takes care of me... Get the job done, and competently so.


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## iftmedic (Nov 11, 2010)

Paramedics have the highest level of training in the prehospital setting, and they answer to a base hospital physician. Nurses work in hospitals and carry out orders from docs


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## Akulahawk (Nov 11, 2010)

iftmedic said:


> Paramedics have the highest level of training in the prehospital setting, and they answer to a base hospital physician. Nurses work in hospitals and carry out orders from docs


:deadhorse:

Be careful of over generalizing things. Both Paramedics and RN's carry out orders from docs... both have a high level of training. A Paramedic is a specialist in pre-hospital care. An RN is a generalist that get specialized training for their area of care. Most RN's do not get any education in pre-hospital care. A Flight RN does and they might not spend the majority of their day working in a hospital...


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## Veneficus (Nov 11, 2010)

shadowstewie said:


> Im not completely sure if this has been said or not on this forum (though I've check everywhere.) I was trying to figure out who has higher authority. An EMT or CNA, then an EMT and LVN, then a Paramedic and RN. From what I remember, it goes CNA, EMT, LVN, Paramedic, RN, etc. Let me know and thanks in advance!



This point has been argued for a long time, the real question is:

"Why does it matter?"

When taking care of a patient, the provider who is most capable is usually the person who judgement is deferred to. 

Take for instance, a patient with an acute appendix. The management may fall to a senior resident even thogh the first physician the pt sees is an attending ED doc. 

Likewise, a new ED doc may have expertise not covered by a senior orthopod.  

In or out of the hospital that is generally the way it plays out, even without formal chain of command.

Aside from that, medicine is a team sport. If the GP wants to send a patient but doesn't want you to do anything, it might be because he knows what you will do will not help, or that it will interfere with what needs to be done to help the patient at the hospital in a more timely manner. 

If somebody asks you to do something, it is better to ask why than to get into a pissing contest. 

From the operational standpoint in an MCI, it is not always the most capable, most experienced, or highest qualified person that is in charge. Every MCI and even internal hosptial disaster I have ever been to, the outcome is decided by the first few people there. In a disaster or refugee condition the outcome is decided by logistics, not field providers. 

One of the best things any provider can do in an operational standpoint is recognize what is needed and fill that role and do it as best they can without worrying about the rank or the cert of the person in charge overall. 

For the most part nobody works is a bubble, you know you agency, who is in it, what their capabilities are. You know the people from surrounding agencies/ hospitals because we make up a small group even in the largest cities. Even if you don't know every detail abot them, when somebody knows what they are doing, or doesn't it becomes apparent very quickly. 

Perhaps they may even have seen something in a moment that would make a difference? Perhaps they have a piece of information you don't?

If you are an EMT (or any type of provider) and somebody is giving you a hard time about being in charge, just ask them to sign the chart (run report) where it asks for provider in charge or primary provider responsible.Usually that is enough to get them to back down.


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## MusicMedic (Nov 11, 2010)

Mr.Brown (future Dr.Brown) is the Highest and Final Authority in all Medical Situations

no questions asked


well that solves that question


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## emtchick171 (Nov 11, 2010)

Linuss said:


> Do you mean a medic in a hospital or out of?
> 
> Either way, both certs must have orders from a doctor... and many nurses have standing orders much like we do in the field.
> 
> Granted there's a bit more leeway for field providers (nurses included) due to the very nature that we can't always have a doctor there... but make no mistake, nurses can have standing orders too.



I mean in a hospital setting. At our hospital, a nurse cannot do a needle decompression, cannot do an IO, and other certain things. While a medic in the hospital setting is allowed to do such things without a doctor's orders.


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## Veneficus (Nov 11, 2010)

emtchick171 said:


> I mean in a hospital setting. At our hospital, a nurse cannot do a needle decompression, cannot do an IO, and other certain things. While a medic in the hospital setting is allowed to do such things without a doctor's orders.



You have to be careful not to equate skills with knowledge, they are not equal.

I could teach you how to perform needle decompression and IO in about 15 minutes.

I could even discuss when to use them in about another 15 minutes. 

But there is way more to know to use those skills appropriately and effectively. As it currently stands in the US, the RN is a far more educated provider than _most_ EMS trained persons. 

That doesn't mean they are more capable than somebody who has only a very narrow specialty, such as medics, when the need for that specialty arises.

Please also consider: 

It takes far less effort to teach a nurse how to do medic skills than to teach a medic skills and the whys and wherefores.

The number of actual "emergencies" as we like to define them is decreasing, making the need for the "Emergency" specialist less. With advances in medicine we have found a vast majority of the patients who fall into emergent are not minute sensitive.

The Mcdonalds crew leader may be extremly capable of running a Mcdonalds shift, perhaps more so than a master chef, but the chef can make burgers anywhere. The McDs crew leader cannot run all eateries.


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## emtchick171 (Nov 13, 2010)

Veneficus said:


> You have to be careful not to equate skills with knowledge, they are not equal.
> 
> I could teach you how to perform needle decompression and IO in about 15 minutes.
> 
> ...




I wasn't trying to say that all medics are more knowledgeable than RNs...I was just simply saying how things went in our local hospital.


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## Rescue0ne (Dec 8, 2010)

*Apples & Oranges*

In places where Paramedics are employed in the ER in a role that is comparable to an RN, both are pretty much the same, depending on how that particular program is set up by the Docs and Administrators.  Granted, a Medic (in the field) might normally be able to decompress a pleural space, cardiovert, or pace transdermally under standing orders, but that same Medic might not have that role in the emergency dept.

I don't feel that an RN is superior to a Paramedic in any fashion, and the same is true vice-versa. Like it was stated previously, RNs are cross-educated to work in pre-hospital settings in some cases, just like Medics are cross-trained to work in ER & clinical settings, in some cases.

Sometimes apples and oranges might begin to look the same after a while, but you can't make an apple pie with oranges, just like you can't make orange juice with apples.


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## HappyParamedicRN (Dec 8, 2010)

Having worked as an RN, I can tell you on scene that an RN SHOULD NOT BE the person in command if your talking about a scene and even in an ER.

RNs, from my experience, unless they are also medics are afraid to function without a doctor present!!!


Happy


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## Journey (Dec 8, 2010)

HappyParamedicRN said:


> Having worked as an RN, I can tell you on scene that an RN SHOULD NOT BE the person in command if your talking about a scene and even in an ER.
> 
> RNs, from my experience, unless they are also medics are afraid to function without a doctor present!!!
> 
> ...



You sound like a very, very new RN and you may not be qualified to work in an ED, CCT or Flight.  Maybe you were not given the respect you felt you deserved as an RN with a Paramedic patch in the hospital.  An RN most definitely can be in command of a scene with Flight and PHRNs proving this everyday. They can also be in charge of complex cross country transports without a physician with no problem.   I suggest you work in a progressive hospital ED or ICU to see how RNs really function. You have no idea.


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## fortsmithman (Dec 8, 2010)

HappyParamedicRN said:


> Having worked as an RN, I can tell you on scene that an RN SHOULD NOT BE the person in command if your talking about a scene and even in an ER.
> 
> RNs, from my experience, unless they are also medics are afraid to function without a doctor present!!!
> 
> ...



In my neck of the woods the RNs do function quite well without a physician present.  Here in the NWT most communities have RNs and LPNs.  Most communities here in the NWT have no EMS available at all just the guy with either a van or pick up truck.  In some european countries RNs are the prehospital providers.


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## jjesusfreak01 (Dec 8, 2010)

firetender said:


> The more pertinent question might be "How would you determine who to release your patient to at the scene of an emergency? Would you adhere to a hierarchy?"



I think you are getting closer to a good answer to the original question. My answer is this:

The chain of command is quite simple for an EMS officer. The person in charge is always the person who is ultimately responsible for the patient. 

A nurse in the field who doesn't work in EMS cannot trump a medic or even an EMT because they have little authority to work outside the hospital and are not responsible for the patient. Likewise, within a hospital the nurses, and ultimately, the doctors are at the top of the chain once they take a report and possession of the patient. In the field, a doctor doesn't automatically trump an EMT or Medic, but if the crew is authorized to do so by medical control (a DOCTOR), they may be able to hand off partial responsibility for the patient to the attending doc. 

Unfortunately for the CNAs, they aren't really in the chain of command, as they work under the control of nurses who are directly responsible for the patients. This is different from EMTs, who are often directly responsible for patients even though they operate under another provider's license. 

There should never be a time when you have to hash out who trumps who in a medical situation, because ultimately, unless you bring NPs into the mix, the doctors and administrators of every organization control the hierarchy, so all anyone really needs to know is what hierarchy has been set up at your organization? While you are responsible for the patient, you follow that, and after you hand them off, it isn't your problem anymore.


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