# Would a doc have scene control?



## Emt512 (Apr 28, 2011)

My question is in response to the last thread regarding the scenario with the emt- intermediate responding to a call and having choice words with a volunteer firefighter... 
First, wouldn't whoever has the highest level of education be in charge in that situation? I mean if you show up on scene and an a person is claiming to be an ER doc from a level 1 trauma center, and seems to be doing things that fit that skill level, can you as a paramedic, let alone an emt- basic volunteer firefighter take over the scene, when the patient could need his level of knowledge based care?? I thought that there were legal repercussions from that? And Don't we all carry identification?


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## Shishkabob (Apr 28, 2011)

The only person in the world that can tell me what to do is my medical control physician.  Not a single other person can.


It doesn't matter if they are a doctor or not, it's my scene/ my patient, and the only thing that can change that is if the doctor is willing to take FULL responsibility for the patient, and go in to the hospital with the patient.  If they aren't, they have no say.  If they DO take responsibility, it's up to me if I want to help or not.




Now, listening to experience is one thing (and you darn well better know for a fact they are a doctor before you listen to them), but if they aren't willing to take responsibility for the patient and go with them to the hospital, what they say means nothing.


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## Tommerag (Apr 28, 2011)

Emt512 said:


> My question is in response to the last thread regarding the scenario with the emt- intermediate responding to a call and having choice words with a volunteer firefighter...
> First, wouldn't whoever has the highest level of education be in charge in that situation? I mean if you show up on scene and an a person is claiming to be an ER doc from a level 1 trauma center, and seems to be doing things that fit that skill level, can you as a paramedic, let alone an emt- basic volunteer firefighter take over the scene, when the patient could need his level of knowledge based care?? I thought that there were legal repercussions from that? And Don't we all carry identification?



Yes, the responding crew would have control of the scene. If it were my scene and there was someone on scene saying that they are a doctor, I would call my medical director and see what he thought about it and if he was ok with said person providing care, I would make sure that said person would be riding with all the way to the hospital and letting him know he was responsible for the patient. If the medical director said not to let him do anything I would let the person know he was not to do any patient care and the patient was my responsibility.

I would probably ask for some type of identification before I even called the medical director. If he couldn't produce any I would politely ask him to leave since he would be unable to back up his claim. If he did produce some type of identification I would then call medical control.


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## NomadicMedic (Apr 28, 2011)

In a word, no. 

Here the paramedic controls the scene. If a doc shows up and wants to get in the mix, the doc must speak with my medical control, sign a form stating that they assume responsibility and they must accompany the patient to the ED. 

I had a doc offer his assistance at a minor MVA the other day. I was polite and explained what he would need to do if he wanted to treat a patient. He laughed and said, "looks like you've got it under control" and excused himself.


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## medicRob (Apr 28, 2011)

Emt512 said:


> My question is in response to the last thread regarding the scenario with the emt- intermediate responding to a call and having choice words with a volunteer firefighter...
> First, wouldn't whoever has the highest level of education be in charge in that situation? I mean if you show up on scene and an a person is claiming to be an ER doc from a level 1 trauma center, and seems to be doing things that fit that skill level, can you as a paramedic, let alone an emt- basic volunteer firefighter take over the scene, when the patient could need his level of knowledge based care?? I thought that there were legal repercussions from that? And Don't we all carry identification?



Paramedic is in charge of the scene. If a physician shows up and wants to take over, the decision is up to the paramedic, and if the paramedic chooses to allow the physician to intervene, the paramedic has to put the responding physician on the phone with medical control and that physician has to ride with the patient to the receiving medical center where he/she will explain any interventions to the receiving physician. It is pretty rare to have a situation in the field where a physician wants to take over.


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## abckidsmom (Apr 28, 2011)

I've had a doctor give his opinion, but I've never encountered one who remotely wanted responsibility for the scene.

Even the docs at the doctor's offices want us to magic the patient away from them as soon as they call.  It's weird, how little they desire responsibilty for the patients.


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## Veneficus (Apr 28, 2011)

Emt512 said:


> First, wouldn't whoever has the highest level of education be in charge in that situation?



No. 



Emt512 said:


> I mean if you show up on scene and an a person is claiming to be an ER doc from a level 1 trauma center, and seems to be doing things that fit that skill level, can you as a paramedic, let alone an emt- basic volunteer firefighter take over the scene, when the patient could need his level of knowledge based care?? I thought that there were legal repercussions from that? And Don't we all carry identification?



There must be a formal acceptance of care. Then a patient-provider relationship is created and the provider becomes responsible for treatment.

Physicians must be licensed in the state to function as such. They must also be able to produce such a credential.

In all the states I am familiar with, physicians have a wallet card.

I have had physicians of all sorts show up on scenes.  Never once did one agree to accept responsibility for the patient. None tried to issue orders, and one ER doc was more than content to carry the oxygen tank back to the truck as the only help I required.

During certain IFTs the sending physician in consult with the receiving physician initiated or asked for treatment not covered in protocol. My solution was to have the doc talk it over with med control, and if it was within my scope and approved, to carry it out. That is an extremely rare occurance especially now that CCT is more common.

But that is beyond field provider level. Those decisions need to be made by physicians with other physicians.


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## Veneficus (Apr 28, 2011)

abckidsmom said:


> Even the docs at the doctor's offices want us to magic the patient away from them as soon as they call.  It's weird, how little they desire responsibilty for the patients.



This is a byproduct of knowing what you don't know.

Who in their right head would start calling the shots over people specifically trained and credentialed for such patients without considerable knowledge and skill with what they were about to treat?


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## Shishkabob (Apr 28, 2011)

Veneficus said:


> Who in their right head would start calling the shots over people specifically trained and credentialed for such patients without considerable knowledge and skill with what they were about to treat?



But...but... I thought doctors were ALWAYS the better choice over Paramedics in emergent situations?! h34r:


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## Veneficus (Apr 28, 2011)

Linuss said:


> But...but... I thought doctors were ALWAYS the better choice over Paramedics in emergent situations?! h34r:



I think that is an oversimplification.

A doctor will always have more medical knowledge and insight. (not to mention assessment ability)

They will not always have the comfort or practical skill to apply that knowledge in an efficient manner.

However, that is not dependant on the medical specialty, but the individual as well as their medical education.

If I am suffering an acute medical emergency of unknown cause. I definately want a doctor.

If I am suffering from the most common emergency based on epidemiology with uncomplicated history, the medic is probably more than sufficent.


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## Shishkabob (Apr 28, 2011)

Veneficus said:


> If I am suffering from ... emergency ... epidemiology... the medic is ... more than sufficent.



BAHAHAHAHAHAH!  Trapped!


I'm saving this one


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## Veneficus (Apr 28, 2011)

Linuss said:


> BAHAHAHAHAHAH!  Trapped!
> 
> 
> I'm saving this one



no worries, make sure "most common" is preserved


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## MrBrown (Apr 28, 2011)

It would be foolish to disregard the opinion of a Physician who presented themselves to you.  Said Physician has more education in basic and clinical science than the entire length of your entire Ambulance qualification.

Mind you, there are those GPs who hide in the corner when a sick person comes into their waiting room and are quick to hold the door open for you to take the patient away.  Brown is not an expert in primary care and that GP is probably not an expert in people who are acutely crook.


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## akflightmedic (Apr 28, 2011)

One significant point to be noted while discussing this topic...

Doctors do not routinely listen to scanners, pull over at MVCs, or wear any clothing or adorn their car with any device, sticker, plate, etc denoting themselves as a physician. 

Doctors do not routinely feel the need to "assist" outside of their scope. One might say they are smart in the regard that they DO know what they don't know as opposed to the people who don't know what they don't know.


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## MrBrown (Apr 28, 2011)

Its like Brown says, those who know the most have meaningful insight into the limits of their knowledge.

Now, is this London orange HEMS jumpsuit with "DOCTOR" written on the back a little too much?


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## JPINFV (Apr 28, 2011)

Basically as everyone has said here.

Yes, with the caveat that the physician can produce identification and is willing to assume care until the ED, provided the online medical control physician gives his blessings. However, the stars aligning so that all of that happens is going to be rare.


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## Bullets (Apr 28, 2011)

generally, unless its our medical control MD or one of the handful of EMS MD's from the area, which are ER Doctors but also are Paramedics and take on site medical control at large incidents, no. The first question when some identifies themselves as a doctor is MD or PhD? then if MD, whats your field. Ive had chiropractors and dentists on scenes, and most were content to just hold stuff and lend a hand, not offer actual treatment advice,


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## Veneficus (Apr 28, 2011)

Bullets said:


> whats your field.



I always suggest caution as a nonphysician when trying to judge the ability of a physician by specialty field.

It is in no way indicative or accurate of knowledge, ability, or potential contribution.


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## DesertMedic66 (Apr 28, 2011)

Veneficus said:


> I always suggest caution as a nonphysician when trying to judge the ability of a physician by specialty field.
> 
> It is in no way indicative or accurate of knowledge, ability, or potential contribution.



i think asking what their field is a good question to ask. 

Murphy's EMT Laws: "Always assume that any Physician found at the scene of an emergency is a Gynecologist, until proven otherwise."

http://www.murphys-laws.com/murphy/murphy-EMT.htm

some doctors are going to be a help at a scene.


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## samiam (Apr 28, 2011)

*Michigan*

In Michigan the suggested Michigan protocols state:

*Physician on Scene
Purpose: To provide a process for interaction between EMS personnel and physicians at the scene of a medical emergency.
1. Responsibility of Medical Control
A.
“When a life support agency is present at the scene of the emergency, authority for the management of an emergency patient in an emergency is vested in the physician responsible for medical control until that physician relinquishes management of the patient to a licensed physician at the scene of the emergency”. MCL 333.20967
B.
The EMS provider is responsible for management of the patient and acts as the agent of the medical control physician.
2. Patient Management in the Presence of an On Scene Physician
A.
The EMS provider may accept assistance and/or advice of the on-scene physician provided they are consistent with medical control protocols. The assistance of an on-scene physician may be provided without accepting full responsibility for patient care, as long as there is ongoing communications and approval by the medical control physician. The medical control physician may relinquish control of the patient to the on-scene physician provided the on-scene physician agrees to accept full responsibility for the patient. Full responsibility includes accompanying the patient to the hospital and completing a patient care record. The EMS personnel should encourage the on-scene physician to communicate with the on-line medical control physician.
B.
The medical control physician may reassume responsibility of the patient at their discretion at any time.*


The michigan health code as stated above says: 

“When a life support agency is present at the scene of the emergency, authority for the management of an emergency patient in an emergency is vested in the physician responsible for medical control until that physician relinquishes management of the patient to a licensed physician at the scene of the emergency”. MCL 333.20967


Source: MDCH Protocol PDF sorry don't have a link just a "hard copy" saved to my computer.


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## Veneficus (Apr 28, 2011)

firefite said:


> i think asking what their field is a good question to ask.
> 
> Murphy's EMT Laws: "Always assume that any Physician found at the scene of an emergency is a Gynecologist, until proven otherwise."
> 
> ...



You of course know enough about gynecology to know it is considered a surgical discipline and has a significant medical component particularly in endocrinology?

You realize they are tasked with diagnosing differentials in the female abdomen, which is a task far beyond that of a paramedic.

You know that they routinely operate on the bladder, rectum, appendix, and omentum while performing tasks associated with oncology?

They may also know something about pregnancy, labor, and its complications both before and after birth as well. 

Whoever wrote that was stupid.


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## DesertMedic66 (Apr 28, 2011)

Veneficus said:


> You of course know enough about gynecology to know it is considered a surgical discipline and has a significant medical component particularly in endocrinology?
> 
> You realize they are tasked with diagnosing differentials in the female abdomen, which is a task far beyond that of a paramedic.
> 
> ...



I know they do alot but I would still ask. But I have never met a dentist that can do a full trauma assessment (there may be some out there). Is a dentist going to know what meds to push? Nothing against dentists just showing my opinion. It's like having a smog technician do a full rebuild on your motor. Yes they know alot about the exhaust system but I would rather have a general technician rebuild it.


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## nwhitney (Apr 28, 2011)

I know I'm still new to all of this but I would say no.  Scenes are dynamic and I don't know if that Dr. has any training or experience in scene management.  Is there anything a level 1 trauma doctor can do that a paramedic can't that would be vital for a positive pt outcome in the field? I don't know but I wouldn't wait around or call medical control to find out.  Not worth it to me.  The person with the highest cert or training is not necessarily the one who is managing the scene.  This is really only based on the limited education I've had and my brief interactions with the medics and fire dept. in my city.

Love this...
Murphy's EMT Laws: "Always assume that any Physician found at the scene of an emergency is a Gynecologist, until proven otherwise."


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## Scott33 (Apr 28, 2011)

firefite said:


> I have never met a dentist that can do a full trauma assessment



To be honest, you will be hard pushed to find a paramedic who could do a *full* trauma assessment. What we learn in EMS land is watered down.


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## DesertMedic66 (Apr 28, 2011)

nwhitney said:


> I know I'm still new to all of this but I would say no.  Scenes are dynamic and I don't know if that Dr. has any training or experience in scene management.  Is there anything a level 1 trauma doctor can do that a paramedic can't that would be vital for a positive pt outcome in the field? I don't know but I wouldn't wait around or call medical control to find out.  Not worth it to me.  The person with the highest cert or training is not necessarily the one who is managing the scene.  This is really only based on the limited education I've had and my brief interactions with the medics and fire dept. in my city.
> 
> Love this...
> Murphy's EMT Laws: "Always assume that any Physician found at the scene of an emergency is a Gynecologist, until proven otherwise."



Same. If a doctor comes on scene and states that he is a doctor I would ask for some kind of ID and also figure out what field he is in. Then make contact with my medical director and see what he wants.


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## nwhitney (Apr 28, 2011)

firefite said:


> Same. If a doctor comes on scene and states that he is a doctor I would ask for some kind of ID and also figure out what field he is in. Then make contact with my medical director and see what he wants.



Personally I wouldn't even bother calling medical direction, I would reply with a no thank you doctor we have it under control.  This isn't a slight to doctors at all and I appreciate the willingness to help but I doubt how much help they really could provide on scene that a paramedic couldn't.  The doctor might be able to diagnose but would that change the treatment given?  Maybe and maybe not.

I should add that I understand there may be extenuating circumstances where I would gladly except help but I wouldn't give up scene management to a doctor.


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## bigbaldguy (Apr 28, 2011)

On the aircraft I generally have 6 to 10 Medicals a year that require us to make the "are there any medically trained professionals on board" announcement. On those occasions when a doctor has volunteered to help (they generally don't) they don't generally add much to the situation. However the doctors who have helped out on my planes are always non-emergency/critical care people. On the other hand on those occasions when a medic has volunteered they have always been a huge help. When I've had nurses assist during Medicals they tend to fall somewhere in the middle. On my last medical a doctor did come forward watched over my shoulder for a few minutes said "you don't need me on this one, if he gets worse come get me" then went and sat back down. I spoke with him later and he was nice enough to give me his card. He was the medical director of a major hospital on the east coast that specialized in OB/gyn. The medical I had 11 days before this one was a woman in labor, figures.


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## ffemt8978 (Apr 28, 2011)

I've had one doctor and five nurses show up on various scenes in my career.  Interestingly enough, the doctor was more than willing to turn over care to the ambulance crew and get out of the area before he was identified. h34r: 

The majority of the nurses, on the other hand, wanted to continue directing care after the ambulance arrived and weren't real happy when we asked them to leave the scene after giving a report.


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## JPINFV (Apr 28, 2011)

firefite said:


> I know they do alot but I would still ask. But I have never met a dentist that can do a full trauma assessment (there may be some out there). Is a dentist going to know what meds to push? Nothing against dentists just showing my opinion. It's like having a smog technician do a full rebuild on your motor. Yes they know alot about the exhaust system but I would rather have a general technician rebuild it.



Dentist!=physician?


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## JPINFV (Apr 28, 2011)

nwhitney said:


> Personally I wouldn't even bother calling medical direction, I would reply with a no thank you doctor we have it under control.  This isn't a slight to doctors at all and I appreciate the willingness to help but I doubt how much help they really could provide on scene that a paramedic couldn't.  The doctor might be able to diagnose but would that change the treatment given?  *Maybe and maybe not.*
> 
> I should add that I understand there may be extenuating circumstances where I would gladly except help but I wouldn't give up scene management to a doctor.


Emphasis added.

1. Do you really want to make someone mad that could very easily become an acquaintance with your medical director? Medicine, as a whole, is a small profession.

2. You won't know what he can or can't do until the physician is able to assess and know what tools s/he has available. The last thing defense you want to use when issue 1 is invokes is, "Well, it probably wouldn't have helped anyways."


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## nwhitney (Apr 28, 2011)

JPINFV said:


> Emphasis added.
> 
> 1. Do you really want to make someone mad that could very easily become an acquaintance with your medical director? Medicine, as a whole, is a small profession.
> 
> 2. You won't know what he can or can't do until the physician is able to assess and know what tools s/he has available. The last thing defense you want to use when issue 1 is invokes is, "Well, it probably wouldn't have helped anyways."



Well the original question was about giving up scene control and I will still say no I would not give over scene management to a doctor.  Scenes are dynamic and they may or may not have training to deal with it.  I wouldn't risk my safety, safety of my partner, or safety of the pt because someone is a doctor.  I also see this as a liability issue. 

I understand that the world of medicine is small that is why (I think I said this earlier) I would say no thank you in a polite and professional manner.  

So the question I still have is what could a medical doctor do in the field that a paramedic can't?  Again I don't know I'm not even done with my basic but I find it hard to believe that a doctor could perform some skill in the field beyond a paramedic that would ensure a successful pt outcome.  I'm open to the idea I'm wrong.


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## DesertMedic66 (Apr 28, 2011)

JPINFV said:


> Dentist!=physician?



Dentist=Dr. 
Physician=Dr. 

Just pointing out that just because someone can say "hey I'm a doctor" doesn't mean they are going to be the best help.


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## abckidsmom (Apr 28, 2011)

Veneficus said:


> You of course know enough about gynecology to know it is considered a surgical discipline and has a significant medical component particularly in endocrinology?
> 
> You realize they are tasked with diagnosing differentials in the female abdomen, which is a task far beyond that of a paramedic.
> 
> ...



Why miss an opportunity to combine EMT ego inflation with misogyny?  Sheesh...gynocologists are all just cooch-checkers, anyway.  Who needs 'em?


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## Veneficus (Apr 28, 2011)

nwhitney said:


> Is there anything a level 1 trauma doctor can do that a paramedic can't that would be vital for a positive pt outcome in the field?



I have written extensively on this on this forum, more than I care to rehash, but let me just ask a few quick questions to make my point.

Can you use epi or vasopression to control hemorrhage?

Can you use IV tubing to reroute blood around a break in the artery?

A foley catheter to stop carotid artery bleeding?

Cross clamp anything? 

Reduce a fracture?

I really could probably write a book on this. Along with the situational benefits that any specialty physician or even dentist could offer in a situation that warrented it.

As was pointed out, the very assessment that any level of EMS provider provides is a long way off from a physician level one. 

Be careful not to confuse what you don't know about physicians as there not being anything to know.




nwhitney said:


> I don't know but I wouldn't wait around or call medical control to find out.  Not worth it to me.  The person with the highest cert or training is not necessarily the one who is managing the scene.  This is really only based on the limited education I've had and my brief interactions with the medics and fire dept. in my city.



I think you should spend some clinical time with a physician.


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## Shishkabob (Apr 28, 2011)

Veneficus said:


> Can you use epi or vasopression to control hemorrhage?
> Can you use IV tubing to reroute blood around a break in the artery?
> A foley catheter to stop carotid artery bleeding?
> Cross clamp anything?
> Reduce a fracture?



Yes, yes, yes, yes, and yes.


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## Veneficus (Apr 28, 2011)

Linuss said:


> Yes, yes, yes, yes, and yes.



ok, tell me how


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## Shishkabob (Apr 28, 2011)

Very, very carefully.


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## Veneficus (Apr 28, 2011)

Linuss said:


> Very, very carefully.



how about the technique or doses for the epi and vaso?


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## Shishkabob (Apr 28, 2011)

Hey, you just asked if I could, not if I knew how to.


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## Veneficus (Apr 28, 2011)

Linuss said:


> Hey, you just asked if I could, not if I knew how to.



If you don't know how, then you can't.


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## bigbaldguy (Apr 28, 2011)

Veneficus said:


> I have written extensively on this on this forum, more than I care to rehash, but let me just ask a few quick questions to make my point.
> 
> Can you use epi or vasopression to control hemorrhage?
> 
> ...



Isn't there an app for that?


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## Shishkabob (Apr 28, 2011)

Actually, reducing a fracture I can, and is not a physician exclusive skill.





And you yourself, countless times in countless threads (primarily nurse vs medic), have said "skills can be done by monkeys", therefor as far as your skill list goes:  "Who cares about some monkey skills?"  Anyone, given adequate practice, can do any of those things you listed, regardless of level of medical education.




Don't play both sides of the fence, it makes my job harder


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## Veneficus (Apr 28, 2011)

Linuss said:


> Actually, reducing a fracture I can, and is not a physician exclusive skill.
> 
> 
> 
> ...



Nice try.

sorry, a paramedic in texas is not as good as a doctor.


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## Shishkabob (Apr 28, 2011)

And who ever claimed that?



Fact still stands, you have said skills don't matter, therefor skills don't matter.




(PS-- Depends on what kind of doctor you're speaking of, and what task you're speaking of, as well)


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## Veneficus (Apr 28, 2011)

Linuss said:


> And who ever claimed that?



Seems to be your argument.





Linuss said:


> Fact still stands, you have said skills don't matter, therefor skills don't matter.



In the future I will be sure to qualify that skills taught to EMS are the ones I am refering to.

Actually I probably won't. 

good luck


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## HotelCo (Apr 28, 2011)

In my area, I'm within 10 minutes of a hospital almost anywhere I go. 15 minutes at the max. Luckily, my protocols leave the choice to give control over to a physician on scene up to the paramedic on scene. The exception to this being if we contact medical control "once the patient's immediate needs are met."

I've never had a physician ask to help, but have had plenty of nurses come out of the woodwork on scenes. 

Before letting a doc near a patient of mine, they better have their drivers license, and state MD/DO license out for me to look at. (if I have time to look at their license, and make sure they're really a doctor, then the patient probably doesn't need a doc on scene). My question would be is their some way to tell if a doc has complete, unrestricted practice (not an intern), by looking at their license.


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## Veneficus (Apr 28, 2011)

HotelCo said:


> In my area, I'm within 10 minutes of a hospital almost anywhere I go. 15 minutes at the max. Luckily, my protocols leave the choice to give control over to a physician on scene up to the paramedic on scene. The exception to this being if we contact medical control "once the patient's immediate needs are met."
> 
> I've never had a physician ask to help, but have had plenty of nurses come out of the woodwork on scenes.
> 
> Before letting a doc near a patient of mine, they better have their drivers license, and state MD/DO license out for me to look at. (if I have time to look at their license, and make sure they're really a doctor, then the patient probably doesn't need a doc on scene). My question would be is their some way to tell if a doc has complete, unrestricted practice (not an intern), by looking at their license.



A doc gets the unrestricted license at the end of the intern year.


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## HotelCo (Apr 28, 2011)

Veneficus said:


> A doc gets the unrestricted license at the end of the intern year.



Yes, but I'm wondering if my state issues a license stating they don't have unrestricted practice, and then another showing they do.


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## Veneficus (Apr 28, 2011)

HotelCo said:


> Yes, but I'm wondering if my state issues a license stating they don't have unrestricted practice, and then another showing they do.



no idea, but i am thinking it probably says so on the license.


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## usalsfyre (Apr 28, 2011)

Veneficus said:


> how about the technique or doses for the epi and vaso?



Epi is 1:100,000, either injected in 2-3ml amounts around the wound or soaked onto gauze and applied as a dressing.

Doesn't mean I'd ever try it though, I very much lack the requisite anatomy knowledge to pull this off.


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## Veneficus (Apr 28, 2011)

usalsfyre said:


> Epi is 1:100,000, either injected in 2-3ml amounts around the wound or soaked onto gauze and applied as a dressing.
> 
> Doesn't mean I'd ever try it though, I very much lack the requisite anatomy knowledge to pull this off.



or 1:50,000 depending.


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## JPINFV (Apr 28, 2011)

usalsfyre said:


> Epi is 1:100,000, either injected in 2-3ml amounts around the wound or soaked onto gauze and applied as a dressing.
> 
> Doesn't mean I'd ever try it though, I very much lack the requisite anatomy knowledge to pull this off.



You mean you don't know what alpha-1 receptors do?


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## usalsfyre (Apr 28, 2011)

usalsfyre said:


> Epi is 1:100,000, either injected in 2-3ml amounts around the wound or soaked onto gauze and applied as a dressing.
> 
> Doesn't mean I'd ever try it though, I very much lack the requisite anatomy knowledge to pull this off.



Probably should have added a disclaimer to this, I have visions of a certain group of paramedics making patients nose's look like Michael Jacksons...


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## usalsfyre (Apr 28, 2011)

JPINFV said:


> You mean you don't know what alpha-1 receptors do?



Nope, physiology's not the problem. My luck is I'd stick the needle directly in a major plexus and make their leg twitch for 96 hours straight .


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## mycrofft (Apr 28, 2011)

*I had a podiatrist on scene screw things up before we got there.*

Once law enforcement or fire get there, Incident Control System (ICS) takes over.

Unless you are a deputy or such, any "scene control" will be decided unofficially, with the capper "Ok, if you are assuming control, I need your name, credential/professional license, I will give you report and you will then be in control". No threats, just advise what you are about to do. If they want to stick and kibbitz, ignore them.

Nothing like watching bystanders argue over who is in charge. I used to hate bystanders.


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## nwhitney (Apr 29, 2011)

Veneficus said:


> I have written extensively on this on this forum, more than I care to rehash, but let me just ask a few quick questions to make my point.
> 
> Can you use epi or vasopression to control hemorrhage?
> 
> ...



I get that there is a wealth of knowledge that a physician has and no one at any EMT level does.  I appreciate the list you put up of things that doctors could do.  Nothing I can do.  The original question was about scene control.  Who would you want managing a scene a firefighter or a doctor?  I'll go firefighter 100% of the time. I wouldn't waste my time finding out what kind of doctor is offering to help and then contacting medical control to find out if the doctor can take over scene control.  Treatment for the pt? Maybe but as I said earlier I don't know enough but would probably say no thanks.


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## ffemt8978 (Apr 29, 2011)

nwhitney said:


> I get that there is a wealth of knowledge that a physician has and no one at any EMT level does.  I appreciate the list you put up of things that doctors could do.  Nothing I can do.  *The original question was about scene control.  Who would you want managing a scene a firefighter or a doctor?*  I'll go firefighter 100% of the time. I wouldn't waste my time finding out what kind of doctor is offering to help and then contacting medical control to find out if the doctor can take over scene control.  Treatment for the pt? Maybe but as I said earlier I don't know enough but would probably say no thanks.


Excellent distinction.


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## DrParasite (Apr 29, 2011)

Veneficus said:


> You of course know enough about gynecology to know it is considered a surgical discipline and has a significant medical component particularly in endocrinology?
> 
> You realize they are tasked with diagnosing differentials in the female abdomen, which is a task far beyond that of a paramedic.
> 
> ...


dude, can't you take a joke?  and he is missing part of it:

Always assume that any Physician found at the scene of an emergency is a Gynecologist, until proven otherwise.
Corollary 1:
Never turn your back on a Proctologist.

it's a joke, not a slam on gynecologists (or Proctologists for that matter), lighten up, geeez


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## abckidsmom (Apr 29, 2011)

DrParasite said:


> dude, can't you take a joke?  and he is missing part of it:
> 
> Always assume that any Physician found at the scene of an emergency is a Gynecologist, until proven otherwise.
> Corollary 1:
> ...



Misogynistic jokes were hillarious back before women operated chain saws.  

I once took care of a 74 yo guy who turned his back on a blow torch.  We cited that corollary in its amended form often while turning him for wound care.

Still, to highlight a practitioner of women's health care as especially useless on the scene of an emergency is, well, not cool.


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## JPINFV (Apr 29, 2011)

nwhitney said:


> Who would you want managing a scene a firefighter or a doctor?


Depends on the scene... I don't want a fire fighter running a police scene or a medical scene, and I think a physician is more than capable of managing the scene at the vast majority of medical calls. Similarly, in a case with a single patient not involving a road way, scene management and patient management is one and the same.


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## DrParasite (Apr 29, 2011)

abckidsmom said:


> Misogynistic jokes were hillarious back before women operated chain saws.
> 
> I once took care of a 74 yo guy who turned his back on a blow torch.  We cited that corollary in its amended form often while turning him for wound care.
> 
> Still, to highlight a practitioner of women's health care as especially useless on the scene of an emergency is, well, not cool.


serious?  ok, if the joke is changed from Gynecologist to Podiatrist, would you not take offense to it?  After all, both men and women both have feet.  or maybe Dermatologists? 

Any moderator, please change my joke from Gyn to Podiatrist or Dermatologist, whatever abckidsmom finds less offensive.

I'll even make the effort to contact the murphy's site, and request the change be made, so women don't take offense to it.


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## systemet (Apr 29, 2011)

I've got to ask a few questions about some of this stuff, because I'm really interested.  Obviously I wouldn't try doing any of these things in the ambulance without having been adequately trained:




Veneficus said:


> Can you use epi or vasopression to control hemorrhage?



Does this work well, in potentially life threatening hemorrhage?  I can see this being useful with superficial wounds, when suturing -- but if I have a major vessel transected, surely this isn't going to be enough, right?



> Can you use IV tubing to reroute blood around a break in the artery?



How do you do this?  Do you have any suggestions for reading?  I assume you have to actually be able to visualise the severed ends of the artery, and most of these retract into the surrounding tissue, right, a la "Blackhawk down"?



> A foley catheter to stop carotid artery bleeding?



Same thing here -- does it work?  How long does it take to do?  Do you have any good suggestions for textbooks or papers to read?



> Cross clamp anything?



Isn't this going to require cutting down to the site of the vessel needing clamping as well?



> Reduce a fracture?



Are we counting traction splints?  



> I really could probably write a book on this. Along with the situational benefits that any specialty physician or even dentist could offer in a situation that warrented it.



If you feel like doing this, it sounds like it would at least make a great thread.



> As was pointed out, the very assessment that any level of EMS provider provides is a long way off from a physician level one.



I agree with this to a point.

Overwhelmingly my interactions with physicians in the field have been entirely positive.  

I remember two instances where a physician assumed care in my truck.  Once was a family MD in a rural setting who jumped on my BLS truck, gave around 300ug of fentanyl and some midazolam to a multi-trauma patient with a compound femur fracture with (hopefully adequately) controlled arterial hemorrhage, and then jumped back in his own vehicle and followed the ambulance to the hospital.  This was hardly optimal.

A second instance occurred some time later, when I was a paramedic, and picked up a dehydrated endurance athlete at a major sporting event.  The national team physician wanted to direct care, read IV hydration and anti-emetic in the ambulance.  I told him he was welcome to do so, but that I was quite capable of doing that independently if he wanted to travel by other means.  He chose to assume care.  I was fine with that.

We used to get called to various family physician clinics to transport patients in SVT / VT, with MIs, etc.  The key to these situations was to show the physician respect, and invoke the spectre of the invisible physician from which all paramedics draw great power, e.g. "In this situation, our physicians like us to contact a local cardiologist, fax an ECG, and give thrombolytics -- is it possible for us to use your room for half an hour?".  Almost all these situations have gone well.  It's about appearing professional, and acting professional.  If the physician has an issue (which never happened to me), then they get put in touch with another physician to talk it out.  Being a half decent paramedic means managing the egos of people from other agencies.  

There are of course, many similar situations when flying, especially in rural areas.  Or being a paramedic in a really rural setting.  Perhaps the family physician taking care of the patient today is originally a South African anesthetist who's worked on trauma all day in Johannesburg for years.  Or perhaps he/she's got no real trauma experience, but has awesome skills in another area that we don't need today.  Either situation the physician is deserving of respect.  But in some cases, they're going to need the paramedic to manage the patient until flight arrives.  That doesn't mean they're inadequate as a physician, just that their skills lie in a different area.

The tricky situation, of course, occurs when you disagree with the physician's treatment, and you feel it may be harmful to the patient.  Case in point, I (hypothetically) responded once to a local clinic for a patient who had recently started on stemetil for some vague nausea/anxiety syndrome.  He presents to the clinic with torticollis, tardive dyskinesia, etc. and the MD wants us to give 100mg of meperidine IV for pain control, and transport to the stroke center, where he's already notified the stroke team.  Not a terrible plan if this was a stroke -- but not the correct treatment plan for this patient.

The physician is always more educated, and always deserving of great respect, and often (more often), but not always right.  Just my opinion.


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## Veneficus (Apr 29, 2011)

systemet said:


> _"Can you use epi or vasopression to control hemorrhage?
> 
> Does this work well, in potentially life threatening hemorrhage? I can see this being useful with superficial wounds, when suturing -- but if I have a major vessel transected, surely this isn't going to be enough, right?"_.



Using locally injected epi is a treatment for certain levels of upper GI bleeding originating in the esophagus. 

Yes. It is used endoscopically as a temporizing measure by GI and general surgery. The theory and practicality of it is demonstrated. Normally it is not used in other parts of the body, but demonstrating what can be done with the materials available on the average ALS unit was my point. Not suggesting it should be a regular practice.

A physician who knows the theory and practice is capable of applying that theory as needed in exceptional circumstances. Most EMS providers are grossly under informed about medical theory.

ADH is given systemically, its effects are more profound on lower pressure arteries that still may present life threatening hemorrhage, it is an intensivise therapy and also used in OB/GYN for specific types of uterine bleeding post delivery.



systemet said:


> _Can you use IV tubing to reroute blood around a break in the artery?
> 
> How do you do this? Do you have any suggestions for reading? I assume you have to actually be able to visualise the severed ends of the artery, and most of these retract into the surrounding tissue, right, a la "Blackhawk down"?_



I have seen it done on the carotid, brachial, and popliteal arteries as a temporizing measure by trauma surgery in the ED prior to surgery, as well as in the OR.

You do need access to the severed ends, but the level of retraction is largely based on the specific artery. Some like the uterine artery to retract far and deep. Not all do. 

Obviously this is used for open wounds. It does leak a bit unless it is sutured in place, but it still keeps the blood in the circuit, rather than on the ground. 

In my opinion of the use, this is potentially useful prehospital in the rare instance of coming upon life threatening hemorrhage that is time critical. 



systemet said:


> _A foley catheter to stop carotid artery bleeding?
> 
> Same thing here -- does it work? How long does it take to do? Do you have any good suggestions for textbooks or papers to read_?



I think there was an article about it on trauma.org some time ago, I don't recall seeing it in the surgical text, but i don't recall it not being there either.

Again, I watched it in use with my own eyes. It took merely seconds and only 1 hand. The patient was slashed in the neck with a knife partially severing one of the carotid arteries, the surgeon (whose name i will never forget) stopped the bleeding by holding the artery with 1 hand, and inserting the catheter with the other. A nurse inflated the baloon on direction enough to slow the bleeding to a trickle. After that the free end of the catheter was tied in a knot to stop the flow of blood through the lumen. The patient was taken to OR for definitive repair and draining of the hematoma.   

The event went far too smoothly to have been made up on the spot. So I am of the mind it was taught or listed somewhere.



systemet said:


> Cross clamp anything?
> 
> _Isn't this going to require cutting down to the site of the vessel needing clamping as well?_



If it is not exposed. However, sometimes you have to cut to stop bleeding. (sounds sort of counter productive doesn't it?)

Using the Blackhawk Down example, if the femoral artery is severed and bleeding cannot be controlled, it was taught to us in vascular surgery we should dissect to and clamp the supplying artery. In this case the External Illiac.

In OB/GYN this theory is also put to practical use, and we recite for the daily oral quiz, that uncontrolable bleeding from the Uterine artery should be clamped at the internal illiac.

Again the theory is applicable anywhere. But my point being, not only do you have to know what to do, you must be taught, as well as authorized, demostrating again, with just the equipment found on an ambulance, a physician brings considerably more resource than what a paramedic is limited to as this was taught to all medical students, not certain ones with specific interests.   



systemet said:


> _Are we counting traction splints? _



Sure, because I overlooked that example while thinking of another. 




systemet said:


> _I really could probably write a book on this. Along with the situational benefits that any specialty physician or even dentist could offer in a situation that warrented it.
> 
> If you feel like doing this, it sounds like it would at least make a great thread._



Perhaps I will, but I will just give you a quick teaser.

A Pharengeal abcess, in various locations, can cause airway obstruction, a dentist is capable of incising and draining them. 

Not the only capability of an onscene dentist, but certainly not a paramedic skill. (and in a pinch all he would need is a needle and syringe, but the scapel found in most cric or OB kits would be better)  




systemet said:


> _The physician is always more educated, and always deserving of great respect, and often (more often), but not always right. Just my opinion_.



Physicans are not always right. Sometimes they have no idea at all. 

But a number of replies on this thread seem to fail to appreciate the capabilities that education brings with it. 

In this thread and in others like it here, there seems to be an almost contemptuous attitude towards physicians in the vain effort to show they are no better than EMS providers prehospital. 

Not only is it disrespectful to physicians, it is not true either. 

I have no doubt that not every physician is going to be useful in every case. But a confrontational or arrogant approach is not warrented. 

As I pointed out, but apparently there seems to be some disbelief, physicians are complex and smart people, they all have interests beyond the medical specialty that defines them. They also come from different backgrounds including EMS, or countries where every doctor is expected to understand emergency care to at least the level of a paramedic. World wide recognition of doctors allows them to volunteer and work in austere environments most medics will never appreciate. 

Advocating that a particular specialst or any doctor is useless on out of the hospital because they are not thought of as acute care because of profound ignorance as to what doctors are capable of is something that should not be propagated.


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## systemet (Apr 29, 2011)

Awesome post.  Thanks for answering my many questions.  I agree wholeheartedly with the spirit of what you wrote.  
.


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## HotelCo (Apr 29, 2011)

abckidsmom said:


> Still, to highlight a practitioner of women's health care as especially useless on the scene of an emergency is, well, not cool.



What use are they on the scene of a penetrating chest trauma/neuro trauma/Anything unrelated to a vagina?

I understand they've been trained to a higher level than I have, but don't forget that old saying: "If you don't use it, you lose it."


Side note: Where was it ever said the gynecologist was female?


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## systemet (Apr 29, 2011)

Veneficus said:


> Again, I watched it in use with my own eyes. It took merely seconds and only 1 hand. The patient was slashed in the neck with a knife partially severing one of the carotid arteries, the surgeon (whose name i will never forget) stopped the bleeding by holding the artery with 1 hand, and inserting the catheter with the other. A nurse inflated the baloon on direction enough to slow the bleeding to a trickle. After that the free end of the catheter was tied in a knot to stop the flow of blood through the lumen. The patient was taken to OR for definitive repair and draining of the hematoma.



For what it's worth, I found a review article that looks like it has some interesting references:

Ball CG, Wyrzykowski AD, Nicholas JM, Rozycki GS, Feliciano DV.A decade's experience with balloon catheter tamponade for the emergency control of hemorrhage.J Trauma. 2011 Feb;70(2):330-3.  PMID:21307730


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## DesertMedic66 (Apr 29, 2011)

HotelCo said:


> What use are they on the scene of a penetrating chest trauma/neuro trauma/Anything unrelated to a vagina?
> 
> I understand they've been trained to a higher level than I have, but don't forget that old saying: "If you don't lose it, you lose it."
> 
> ...



thats the point i was trying to make. yes they are doctors...... but it doesnt mean they will be helpful and someone you want to give scene control to. if the patient is having a cardiac problem and there is a cardiologist on scene then yes he/she will most likely be tons of help. if the doctor area of study is something unrelated to the heart then he/she probably wont be much help and probably not someone you want to put in charge of the scene.

if any of you guys/girls have taken the FEMA courses it says that the highest ranking person on scene doesnt have to be the IC.


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## HotelCo (Apr 29, 2011)

firefite said:


> thats the point i was trying to make. yes they are doctors...... but it doesnt mean they will be helpful and someone you want to give scene control to. if the patient is having a cardiac problem and there is a cardiologist on scene then yes he/she will most likely be tons of help. if the doctor area of study is something unrelated to the heart then he/she probably wont be much help and probably not someone you want to put in charge of the scene.
> 
> if any of you guys/girls have taken the FEMA courses it says that the highest ranking person on scene doesnt have to be the IC.



Gah... really screwed up that saying. Should have been: If you don't USE it, you lose it. :wacko:


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## DesertMedic66 (Apr 29, 2011)

HotelCo said:


> Gah... really screwed up that saying. Should have been: If you don't USE it, you lose it. :wacko:



I didn't even notice you messed that up lol


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## LucidResq (Apr 29, 2011)

HotelCo said:


> What use are they on the scene of a penetrating chest trauma/neuro trauma/Anything unrelated to a vagina?



Don't forget that OB-GYNs are not just doctors they're surgeons- surgeons that are really damn good and experienced with internal hemorrhage too. 

The OB-GYN I used to work for got held at a hospital in NY to treat victims of the 9/11 attacks and I guarantee you she wasn't doing pap smears.


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## abckidsmom (Apr 29, 2011)

HotelCo said:


> What use are they on the scene of a penetrating chest trauma/neuro trauma/Anything unrelated to a vagina?
> 
> I understand they've been trained to a higher level than I have, but don't forget that old saying: "If you don't use it, you lose it."
> 
> ...



Surgeons are pretty useful.  People who have experience dealing with people who are emotionally out of control are useful.  I could go on but I won't.

The gynecologist wasn't female.  My sentence structure  above indicates that the gynecologist practices medicine on female patients.

Seriously, people...the point here isn't some kind of women unite to overtake the world, but to challenge the status quo that you can make fun of and belittle medical professionals because they work primarily with women.

Like there's something wrong or less than valuable about that.  

Honestly, the most useless kind of physician I've encountered on a standard car accident scene has to be a family practice doc or a cardiologist.  Those are the ones who can't usually see the forest for the zebras, in my experience.


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## mycrofft (Apr 30, 2011)

*Let's re-rail it somewhat.*

I'd rather have a calm GYN* show up than a hyper newbie EMT-B with his own yellow roof lights and Portapower to extricate me onto his homemade long board.

*or podiatrist, psychiatrist, dermatologist, whatever, someone I could trust to be conservative and call in the big guns.
Who** I'd really like to see would be Johhny and Roy on Squad 51...



**"sorry, "whom"


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## jjesusfreak01 (May 3, 2011)

Man, i'm loving this thread...my take...

If a physician shows up and they (and their specialty) are known to me personally and it would seem to be something useful, I would let them assist my efforts and give helpful advice as they saw fit. If I knew I had an ER doc on scene and I had a critical patient, I would straight up ask if they wanted to take control of the patient, and then they would get my full cooperation. If I don't know the doc its unlikely i'm going to let them do more than simply assist. 

PS: Johhny and Roy would be perfect helpers on scene, as they are primarily just trained in skills. In a cardiac arrest, they could do CPR, get a line, push drugs, defibrillate, all sorts of things.


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## medicstudent101 (May 3, 2011)

Just call Chuck Norris.


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## usalsfyre (May 3, 2011)

medicstudent101 said:


> Just call Chuck Norris.



You don't call Chuck Norris, Chuck Norris shows up at your emergency.


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## medicstudent101 (May 3, 2011)

usalsfyre said:


> You don't call Chuck Norris, Chuck Norris shows up at your emergency.



Touche.


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## Shishkabob (May 3, 2011)

usalsfyre said:


> You don't call Chuck Norris, Chuck Norris shows up at your emergency.



More than likely, he actually caused it.


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## medicstudent101 (May 3, 2011)

Linuss said:


> More than likely, he actually caused it.



All the while he was in China saving millions from a tsunami on the costal front.


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## usalsfyre (May 3, 2011)

Linuss said:


> More than likely, he actually caused it.



You forget, you don't call 911 for a Chuck Norris emergency, you call the coroner.


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## medicstudent101 (May 3, 2011)

usalsfyre said:


> You forget, you don't call 911 for a Chuck Norris emergency, you call the coroner.



There's one issue with that. Chuck Norris is dully elected as the entire world's coroner.


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## JPINFV (May 3, 2011)

Oh, let's not forget any emergency CCTs, pickups at doctor's offices, or other clinics.


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