I always love these pissing order threads
Ok..as prehosptial providers, we are suppose to defer to the person that has the highest medical training and that person is in charge....but what is the order of highest medical training that applies to the pre-hospital setting?
Physician
EMT-P
EMT-I, EMT-C or what Intermediate level you have in your state
EMT-B
EMR
But where do other medical professions fall? What about Emergency PA/NP's? What about non-emergency PA/NP's? Where do RN's rank since they give any sort of medications? Where would you rank physicians that arent Emergency or Family practice trained? Podiatrist? Dermatologist? Etc.
Has anyone had to tell a physician to back off because their speciality has nothing to do with the emergency pre-hospital setting?
Just curious.
There are so many rules governing this in various situations it makes it an impossible question to answer.
Medicine is not some paramilitary organization, there is not always a clear "chain of command" so to speak.
Even in the hospital, a team of physicians can treat patients either independantly or in collaboration. As an example I offer: a patient admitted to an IM floor who is on dialysis. Technically the admitting physician is in charge of care, however that physician will almost always defer to the plan of the nephrologist consulting. How does a surgeon operate if the anasthesiologist decides that the patient is too high risk and will not consent?
In any system I have ever heard of a physician who elects to take full care and responsibility for a patient can turn a paramedic into an angry taxi driver in a heartbeat.
Usually when a physician agrees to back off it is because they have chosen not to fight the battle, not because they would lose it.
You must always be very careful when judging a physician by specialty. Some physicians actually switch over time for many reasons. They may have experience outside of their specialty (like being part of the IRC or Doctors without boarders) which makes them quite formidable care providers out of the hospital. Additionally there are many physicians who operate in an "emergent" capacity who are not emergency medicine trained. (EM is rather new comparatively, and some of the old guys who have worked in the ED for decades even at large academic facilities are not EMs) The VA and many smaller hospitals also employ moonlighters.
A physician has an ability to take care of patients exponentially better than a paramedic. The protocol book is devised for "most patients" not all. The raw intellectual power of a dermatologist is considerable. It is one of the most competative specialties in US medicine, and they deal with diseases far more complex than acne. The same could be said for a psychiatrist, who must rule out all other causes of altered mental status before calling somebody "crazy" as well as knowing when crazy people are suffering from another disease that is altering them. Beware some doctors make their money in one specialty and fulfil their passion in a different medical arena.
A doctor is a formidable ally and any doctor brings a wealth of skills and knowledge unmatched by any other "mid level" or ancillary provider. You might be dealing with a patient who has an acute attack of disease or comorbity that a paramedic may never even have heard of or has only a rudimentary knowledge of.
Physicians in the office, until they transfer care, are ultimately in charge of their patient. Again, the patient may have a disease that requires emergent aid, not in your protocol. Even though you cannot take orders from them, you can supply equipment. Additionally, your med control may be more than willing to cede authority to a expert with a long history of caring for a particular patient.
As JP said, have one physician call another. They are playing at the same level, and there is an implied understanding and respect.
Food for thought, I will never be an emergency physician, If I offered advice or help on your scene, how fast would you discount it? Do you think that would be in the best interest of your ego or the best interest of the patient?
All the reputable healthcare providers I know will at least hear the argument of another (even lower level) before "pulling rank" just incase they over looked something or have limited exposure to it.
