# Duty to act, abandonment, etc.



## RedAirplane (Aug 19, 2015)

There was an incident that occurred recently that turned into a ethics discussion once a few hypotheticals got involved. I'll paint the same picture of what seems to be a thorny issue around duty to act and abandonment. 

It's a busy day for EMS with all the streets jammed, hospital computers disrupted, unexpected swarms of people visiting the city, and very hot weather. Response times are ranging from 20 minutes to 2 hours for 911 calls even with all ambulance companies dumped into the 911 system.

There is a first responder fire engine on scene of an unconscious trauma at a major interchange in the city. The engine has requested ALS ambulance code 3 (priority) but has been waiting there for about 40 minutes or so.

Another first responder unit is flagged down by PD on the other side of the interchange for a conscious but confused patient with an unclear history--possible syncope, possible head trauma, possibly none of the above. They also request an ambulance.

An ambulance responds to this interchange, sees the cop cars, and pulls up to the SECOND patient. They assume care, and only then realize that they were dispatched for the FIRST patient, the traumatic injury on the barely visible far on the other side of the traffic mess. There are dozens of calls holding, and only the most serious ones are getting units assigned right now.

Now, there was clearly a duty to act for the trauma patient across the way... and finding another ambulance will take some time. So if the ambulance didn't respond to the second patient, wouldn't that be a violation of duty?

On the other hand, the ambulance has now assumed care of a patient who is not fine and dandy, but also is conscious and has no clear complaint. They can't just leave him on scene (or can they?) because that would be abandonment. 

So to navigate the issue, what is supposed to be done?


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## WildlandEMT89 (Aug 19, 2015)

Just a point of clarification. Do you mean first responder engine as in no BLS or ALS personnel or first on scene?


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## WildlandEMT89 (Aug 19, 2015)

Just a point of clarification. Do you mean first responder engine as in no BLS or ALS personnel or first on scene? Either way I see my unit as having a duty to act for both patients being that we are on duty and on scene.

Assuming my unit is now the only unit on scene with BLS/ALS capabilities my priorities would be establish ics as there are now multiple patients on scene and triage of both patients and assess the needs of both and need for additional resources if any.
In this case I would assume that as the BLS provider I would take the conscious but confused pt for evaluation while my ALS partner would evaluate the trauma pt and we would remain in contact. Findings would be relayed to dispatch and we would get a trauma inventory as well as inventory of incoming units if any. 
Based on our findings my partner and I would come to a transport decision that is based on the needs of the more critical pt. 
If manpower was needed we would ask for assistance from the fire crews on scene for help during transport.


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## RedAirplane (Aug 19, 2015)

First responders are BLS fire engines or foot crews. 

The possible issue is that it's not a unified scene. Hypothetically, exit ramps on a highway where the ambulance came to the wrong ramp and found you.


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## cruiseforever (Aug 19, 2015)

Place #2 in the ambulance, drive over to pt. #1 and transport both to a trauma center.  Bring a firefighter with to help.


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## Jim37F (Aug 19, 2015)

I'm going to answer this based on my city's particular system. We are a fire based system (I'm a FD employee in a big red ambulance that says fire department on the side, though I am single role EMT-B). All 9 of our engine companies are dual paramedic units with full ALS scope and drug box and equipment. All 6 of our ambulances are BLS (if it's an ALS call the engine medics ride in with us) (the internal logic being with 60+% -probably on the low side- of our calls being BLS level we can take them without pulling the medics out of service, and now you have a full ALS first response unit typically the closest unit)


So..typically I'd be pulling up with the engine betweene and oncoming traffic so chances are I'd end up with them and move to package that patient for transport trusting the follow on unit(s) to handle the second patient with PD...

Now, it's quite possible things are every bit as hectic as the scenario, and we're coming up on scene from a direction that places us next to PD with their (the second) patient, and PD is flagging us in, and we go make contact with that patient without realizing that's not our dispatched patient. Well I'd immediately radio the Engine across the street and let them know the situation, give them a brief rundown of what we have. Basically in my mind the situation becomes similar to what happens when we have a TC with two spread out patients. I'd imagine the medics would want the first patient packaged and transported sooner rather than later since they are worse off, so then I'd imagine the Captain send the two non paramedic firefighters  (typically himself and the Engineer) over to care for the second patient wile we bring our equipment to package and transport the first patient, all while verifying a second engine and ambulance are being dispatched.

I'd say instead of a Paramedic Engine company it was either one of our ladder trucks without a medic, or a BLS engine from a neighboring cityon mutual aid, it would work out pretty much the same way. The Captain is in overall charge of the call and we have radio contact with them, and let him make the call. Both patients (unconscious/unresponsive and ALOC are ALS patients so either one I'd still have to wait for the medic unit unless the hospital is def closer than the ALS resource)


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## RedAirplane (Aug 19, 2015)

Very interesting thoughts. Thank you.


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## Tigger (Aug 20, 2015)

cruiseforever said:


> Place #2 in the ambulance, drive over to pt. #1 and transport both to a trauma center.  Bring a firefighter with to help.


Yup. If we are on modified dispatch and only high priority level calls get ambulances, just about anything goes. 

We've transported two rather urgent transfer patients out of the local hospital in the same ambulance more than a few times. We've also transported non-critical patients in the cab of the ambulance if they don't require monitoring if the back is full of patients who do (CO is usually when this happens). If there's no ambulances, there's no ambulances but they all need to go so we have to something. We don't bill them obviously. The current "record" with CO scenes is 7, four were transported in the ambulance and three in the fire department's light rescue with the ambulance EMT in back. There were no other available ambulances even on mutual aid. It's not ideal but...


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## RedAirplane (Aug 20, 2015)

What is a CO?


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## Giant81 (Aug 20, 2015)

Carbon Monoxide


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## triemal04 (Aug 20, 2015)

RedAirplane, what are you?  Maybe you explained before and I missed it; your profile says "EMT" but most of the scenarios you come up with are...odd.  Are you an EMT?  Did you just get your cert and don't have any involvement whatsoever in EMS?  Are you just looking for other people's stories?  Asking about things that you heard about second or third hand?

Just curious is all.


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## Ewok Jerky (Aug 20, 2015)

Declare an MCI, request ETA of next transport unit, if not satisfactory, scoop up the Pt in front of you, go get the other patient +/- a firefighter, transport both Pts.


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## RedAirplane (Aug 20, 2015)

triemal04 said:


> RedAirplane, what are you?  Maybe you explained before and I missed it; your profile says "EMT" but most of the scenarios you come up with are...odd.  Are you an EMT?  Did you just get your cert and don't have any involvement whatsoever in EMS?  Are you just looking for other people's stories?  Asking about things that you heard about second or third hand?
> 
> Just curious is all.



I am a licensed EMT working as a volunteer in non-traditional settings. 

Monday to Friday I have a different job in a big office.

Weekends I'm on foot, an EMS bicycle, first aid station, sobering clinic, or possibly a golf cart ambulance, but not a road ambulance or fire engine.


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## EBMEMT (Aug 20, 2015)

This is just my personal take.

I don't consider this scenario to be very odd; at least not at its core.  In this particular scenario, there is a good chance that the two patients in close proximity are not a coincidence: the conscious but disoriented patient may have walked away from the scene where both were injured.   A reminder that you may have hidden patients at a scene who walked away or were thrown.   Also, it is not unusual for one accident (or the resulting backup or rubbernecking) to cause another.    Or you could simply have a pt with no air conditioning who overheated in the traffic backup.    And it isn't unusual for EMS systems to be overloaded, either.   The hospital being overloaded?  Not unusual.   The specific combination of details of the overload sound hypothetical.   I think OP and his buddies recognized a scenario that happened in his area as a teachable moment and modified it so you couldn't cop out by calling another ambulance and avoid the ethical questions.    And, yes, I think I could really have to face somewhat similar situations around here.

Patient two (conscious) gets a 30 second triage, a yellow triage tag, and the side bunk.  Steal the first responder, if possible.   Drive to Patient one (unconscious), red tag, stretcher.  Steal the first responder, if possible.    These two first responders continue to take care of their original patients, while you take care of both with attention primarily given to the red patient.     If one of the firemen was released to drive the ambulance, I would consider having that person drive freeing up the original driver/partner (who is probably an EMT or higher) for pt care.  I might also steal equipment off of the fire truck, such as jump bag, AED, or second pt monitor if the pt care justified it and it was available.  I might suggest that the two fire trucks coordinate with one another and swap people and or equipment so at least one could go back into service, though hopefully they can figure that out themselves.  One may or may not follow me to hospital to retrieve equipment and/or personnel.

In any event, the conscious pt is likely better off being second fiddle on board an ambulance, even with only one provider, than waiting an hour for an ambulance to arrive.

Because the system is overwhelmed at the scene (1 ambulance, 2 pts), system wide, and at the hospital, I can treat this is an MCI.   Actually, just being overwhelmed at the scene with very long times for additional ambulances would be sufficient.   Some areas need you to have a specific number of patients to consider it an MCI; that isn't really realistic.  We can deviate some from normal rules of duty of care and instead do the greatest good for the greatest number.    If the unconscious pt codes and the other pt condition appears to be serious and in need of immediate attention, I have to consider whether or not to spend time on the pt who coded.   I am going to pick and choose between normal procedures and MCI procedures as justified by the situation.   

I would not bother taking official incident command if I could avoid it as it would distract from patient care and very little incident command may be needed and could be done by a non-medical fireman.   And you could get into arguments about who should be IC.  If I did assume IC, I might immediately appoint a deputy and delegate.  I am not going to set up staging areas or designate a transport supervisor.

I would notify dispatch and medcom that we had two pts on board from two separate incident numbers.

Due to traffic, I might well request a helicopter for the unconscious pt; though they may be overwhelmed, as well.    Due to traffic and the fact that the normal hospital is not doing so well, I would also consider taking an alternate route to an alternate hospital.   But both of these options may be more viable here than in the original poster's more urban scenario.   I would notify dispatch that my patient would benefit from ALS (probably mutual aid enroute in our area) but chances are it isn't coming.

Afterwards, there might be an incident review.    I would expect plenty of suggestions about how I might have done things differently or how we might do things differently in the future, but I doubt I would get much guff there.

There was a thread recently on duty to act and flag downs while enroute to a call or maybe it was a subthread of one of the buffing threads.   That is more relevant to variations of this scenario than the original as the sheer proximity of the two scenes/extended scene makes travel time between scenes a non-issue.  IIRC, some systems expect providers to continue to the original call and others expect them to stop when flagged down and, at the very least, obtain information, tell them where you are going and why and notify dispatch, because it is very bad PR for ambulances to be ignoring flag downs.    In others, you may confer with dispatch and weight the needs of the patients and available resources.


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## EMT11KDL (Aug 25, 2015)

I would be transporting two patients and taking one of the guys from the engine to ride with me.  I have worked on days like this where literally anything and everything goes.  we have had engines transport patients to the hospitals.


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## Ensihoitaja (Aug 29, 2015)

cruiseforever said:


> Place #2 in the ambulance, drive over to pt. #1 and transport both to a trauma center.  Bring a firefighter with to help.



Yup, I'd do the same thing. In fact, I have done that.


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