Highest Medical Training??

[DrParasite]

Ahhh! What? You or them might have to contact medical control or verify the M.D. somehow but if they are who they say they are your now there taxi driver or little assistant if they choose to go all the way to the ED to hand over patient care to another M.D.

if a doctor (even if he is approved by your medical director) wants to use all his equipment, and use my ambulance to transport the patient, then yes, I would be a taxi driver. You can't let him use equipment from your ambulance, because there is no verification that he knows what he is doing. not only that, but how can you bill for the equipment if you didn't apply it yourself? Not only that but I would be very hesitant to follow the direction of another doc (aside from my hospital ER attending or my medical control). The reason being, can you imagine the liability if the doc orders you to do something that your doc wouldn't approve of? Even worse, if you screwed up? or even better, if the on scene doc directed you to do something that is directly contrary to what your online doc would tell you? how do you defend that when the investigation occurs? "I am sorry sir, but this person who I don't know but says he is a doctor ordered me to do this, and because he is a doctor, I decided to ignore my given protocols by an emergency medicine expert and listen to him?" probably won't get you very far.

If the patient is really sick, are you going to wait on scene and wait for the MD to have his identity verified? or load and go and treat enroute?

We use to have a card our medical director gave us to give on scene doctors. It was written by him to explain things in extreme detail and very long. By the time the on scene doctor read it we where loading the patient up and leaving lol. but..... If he/she wanted to do they could tell me to wipe the patients butt and step on the gas.

I'm pretty sure wiping butts is outside of my scope of training

I would hope that all agencies have written policies and procedures that govern how to handle a physician on scene, so no one has make decisions on how to handle these types of situations on the fly during an emergency situation.

 

[JPINFV]

In my mind we are no longer pre-hospial field providers. We have made it to definitive care at the hospital and the ON DUTY nurse is a part of that and also working under a M.D. currently who is present.

Here's my point if I read this correctly (Socratic Method time), why are you specifying the nurse as being specifically on duty?

 

[ExpatMedic0]

Here's my point if I read this correctly (Socratic Method time), why are you specifying the nurse as being specifically on duty?

were getting pretty in depth here eh? You still haven't answered my question about delivering the pt. to the RN that I asked you? Cause I honestly do not know and gave you my thoughts.

The only reason I specified the nurse was on duty was that I was adding to the point of us being at a hospital, no longer being pre hospital providers. We reached our ultimate goal, definitive care. The nurse is a part of that when she is on duty in the hospital in the presence of an M.D. Also I know when many Paramedics are off duty we are not allowed to practice as paramedics depending on your system. I am unsure about nurses. (please note none of the above applies to pre-hostpial nurses on duty)

 

[ExpatMedic0]

if a doctor (even if he is approved by your medical director) wants to use all his equipment, and use my ambulance to transport the patient, then yes, I would be a taxi driver. You can't let him use equipment from your ambulance, because there is no verification that he knows what he is doing. not only that, but how can you bill for the equipment if you didn't apply it yourself?

So lets say an ED doc rolls up on your scene. He has a wild hair up his butt today and would like to take over care of your patient and transport them to the hospital. He either confirms himself with on line medical control or presents you with his medical licence..... What do you do? not just you but anyone who reads this....

 

[LondonMedic]

So lets say an ED doc rolls up on your scene. He has a wild hair up his butt today and would like to take over care of your patient and transport them to the hospital. He either confirms himself with on line medical control or presents you with his medical licence..... What do you do? not just you but anyone who reads this....

Work out in a calm way who takes charge and who takes responsibility and in what way. Anyone who can't do that has no place in medicine or emergency response.

Alternatively, we leave the patient, get on the phones, argue, flip a coin, call 'law enforcement' and play rock-scissors-stone to work out the 'chain of command'.

 

[ExpatMedic0]

Ok London,
Lets say its JP who has finished medical school and is now an emergency doctor. He introduces himself on scene as M.D. and would like to ride in to the hospital with the patient. He presents you with his medical licence and you can contact medical control if you like. He says he understands the liability and that he will have to ride into the hospital with the patient until he hands care over to the ED M.D. ?

I am thinking he is in charge now....

 

[bryncvp]

Not to open another can of worms, but what about interns and residents? In my athletic training practice, we don't let them do anything. They can sit and watch and ask questions, but they can't touch any athletes and in all cases we are usually teaching them about sports injury management. What about the EMS world? Can an intern or R1 give us orders or take over even though most of them don't know sh*# from shampoo?

And no one has really addressed the PA or NP question...where do they fall in? Say you call the ER for orders....can they give them to you?

 

[LondonMedic]

Ok London,
Lets say its JP who has finished medical school and is now an emergency doctor. He introduces himself on scene as M.D. and would like to ride in to the hospital with the patient. He presents you with his medical licence and you can contact medical control if you like. He says he understands the liability and that he will have to ride into the hospital with the patient until he hands care over to the ED M.D. ?

I am thinking he is in charge now....

It depends. Between the three of you, you should be able to work out who's got the most suitable training and experience.

Most doctors are, in my experience, sensible enough to realise when they're out of their area of expertise and defer to someone with more suitable training - they do this every day (wheras EMTs and Paramedics don't).

Bear in mind though, that doctors are not 'off duty' and have a professional duty to offer to help and must be satisfied that the patient is in suitable care before leaving (wording may vary by licensing board).

 

[medic417]

Ok London,
Lets say its JP who has finished medical school and is now an emergency doctor. He introduces himself on scene as M.D. and would like to ride in to the hospital with the patient. He presents you with his medical licence and you can contact medical control if you like. He says he understands the liability and that he will have to ride into the hospital with the patient until he hands care over to the ED M.D. ?

I am thinking he is in charge now....

In my system I still decide whether to let him be in charge or not. So as I don't like JP as I have seen him kill more than his share of the stub toes I have brought in to his ER no way I will let him take charge. In fact I will ask the cops to arrest him.

But seriously unless I am confident that patient will benefit I stay in charge. I have actually allowed a couple of doctors to be my assistant, doing what I told them. I have also ran many a doctor off my scene. And I have when it was best for my patient let the doctor take charge and I just gave them what help I could. So ultimately it is a system policy that will determine what to do. I know many services that if the doctor wants to take over they are required to let them.

 

[LondonMedic]

Not to open another can of worms, but what about interns and residents? In my athletic training practice, we don't let them do anything. They can sit and watch and ask questions, but they can't touch any athletes and in all cases we are usually teaching them about sports injury management.

Which is an entirely different scenario. Similarly, if a doctor is attached to an ambulance as an observer, they are an observed. This is about situations where they are not there as observers.

What about the EMS world? Can an intern or R1 give us orders or take over even though most of them don't know sh*# from shampoo?

:glare: Is multi-disciplinary working just a UK thing?

No-one can make you do anything without your consent, they can, however, make you wish you had.

 

[Shishkabob]

So if my flight nurse and I were to show up on your scene, you are saying she isn't "above you" on the hierchy of care? Even though she is a more educated and experienced pre-hospital provider than you? Even though she is part of a higher level of care that has been requested because you for whatever reason did not have the most appropriate capability to care for your patient? Am I perceiving what you are writing incorrectly?

Are we going off of official titles here, or off of experience/education? Two different monsters.


Because official titles, no, an RN is not "above" a Paramedic. However it would only benefit the lesser experienced provider in the current situation, be it RN or medic, to work with the one of higher experience and utilize that experience.

 

[JPINFV]

Regarding the nurse at the hospital, another good point. I dunno you tell me why or how its ok for us to turn over care to the RN at the ED or if that should even happen?

The hospital nurse represents the next person in the chain of care and has immediate access to hospital resources, including attending physicians. While prehospital, it depends on why the nurse is present, at the receiving hospital, the nurse is a higher level of care. Similarly, I'd argue that, in general, a paramedic is a higher level of care than a nurse on scene (provided that the nurse is on duty either at a medical facility (including nursing homes) or a home health nurse) since the paramedic has access to more resources to effect an appropriate transport and, in most cases, mitigate emergencies.

 

[JPINFV]

Not to open another can of worms, but what about interns and residents? In my athletic training practice, we don't let them do anything. They can sit and watch and ask questions, but they can't touch any athletes and in all cases we are usually teaching them about sports injury management. What about the EMS world? Can an intern or R1 give us orders or take over even though most of them don't know sh*# from shampoo?

Simple. R1 (more commonly referred to as a PGY (post graduate year) 1) holds a restricted license to practice medicine and is restricted to the residency program. A PGY 2s and beyond have completed USMLE or COMLEX step 3 and have an unrestricted license to practice medicine, so the only way you know that they are still a resident is if you know them or they tell you. So a physician showing up with a medical license could basically fall into 3 categories. He could be a true general practitioner (completed intern year, did not complete residency. Very rare in the US as most primary care physicians are specialized in either family medicine or internal medicine), "board eligible" (time between end of residency and finally completing the board certification process), or a board certified specialist.

Similarly, it's not rare for PGY 2, 3, and 4s to moonlight in EDs outside of their residency, generally provided that there's at least one board certified physician also present ("double coverage").

And no one has really addressed the PA or NP question...where do they fall in? Say you call the ER for orders....can they give them to you?

That's system depended. In most (if not all) of California, the primary person giving orders at the base hospital is a "mobile intensive care nurse" who is an RN.

 

[ExpatMedic0]

I know many services that if the doctor wants to take over they are required to let them.

Yes that is the way it is in my area. Although from what I have seen it normally go's as London stated. Everyone is pretty polite we talk about things real quick and the doc normally bails. Not always though, I had an off duty doctor on scene just last month who took over care.

 

[ExpatMedic0]

Are we going off of official titles here, or off of experience/education? Two different monsters.
Because official titles, no, an RN is not "above" a Paramedic.

Linuss I do not know for sure, but I think a flight nurse is a completely different monster as I stated before. I am guessing she is working under a medical director somewhere and she is probably is also a certified Paramedic. If shes not, I can bet you that she(or he) is written into your protocols or something somewhere to able to take over care from the Paramedic in the field. I think it would have to be this way from a legal standpoint. She is an on duty pre-hospital care provider and directly involved in pre-hospital patient care, along with rapid transport to definitive care.

 

[Veneficus]

Linuss I do not know for sure, but I think a flight nurse is a completely different monster as I stated before. I am guessing she is working under a medical director somewhere and she is probably is also a certified Paramedic. If shes not, I can bet you that she(or he) is written into your protocols or something somewhere to able to take over care from the Paramedic in the field. I think it would have to be this way from a legal standpoint. She is an on duty pre-hospital care provider and directly involved in pre-hospital patient care, along with rapid transport to definitive care.

Could I just offer the perspective that once a patient is rescued that the medical care is directed by the most educated/qualified medical provider.

I don't understand the specifics of nursing always, but it would seem that the nurse is acting as the emisarry of the physican controlling her.

Once a critical care team is on scene, it constitutes a more definitive level of care than standard EMS. As such, when patient contact is made and care accepted by the nurse (a paramedic or not) a primary response EMS agency may have relinquished any furhter authority over patient care.

Just a though.

 

[jjesusfreak01]

Yes that is the way it is in my area. Although from what I have seen it normally go's as London stated. Everyone is pretty polite we talk about things real quick and the doc normally bails. Not always though, I had an off duty doctor on scene just last month who took over care.

Kind of a scary thought unless you knew the doctor. I know a few doctors and one is an emergency physician. Sure I would let him take over, but do you really want some office confined GP trying to treat a cardiac patient if you are a paramedic?

Ignoring my protocols (for the sake of this discussion), I would want a few things from any doctor that wanted to jump in:

1. Seeing their license

2. They profess that they have recent experience treating emergency patients of whatever type I am treating (see above paragraph)

3. They appear to be treating correctly once I let them (if I start seeing something stupid, like the doctor that wants to do chest compressions on a conscious patient, then I have them removed from the scene)

Thats just my uninformed thoughts on the issue.

 

[DrankTheKoolaid]

Simple. R1 (more commonly referred to as a PGY (post graduate year) 1) holds a restricted license to practice medicine and is restricted to the residency program. A PGY 2s and beyond have completed USMLE or COMLEX step 3 and have an unrestricted license to practice medicine, so the only way you know that they are still a resident is if you know them or they tell you. So a physician showing up with a medical license could basically fall into 3 categories. He could be a true general practitioner (completed intern year, did not complete residency. Very rare in the US as most primary care physicians are specialized in either family medicine or internal medicine), "board eligible" (time between end of residency and finally completing the board certification process), or a board certified specialist.

Similarly, it's not rare for PGY 2, 3, and 4s to moonlight in EDs outside of their residency, generally provided that there's at least one board certified physician also present ("double coverage").



That's system depended. In most (if not all) of California, the primary person giving orders at the base hospital is a "mobile intensive care nurse" who is an RN.

Not to nip pick but to keep this as informative as possible. Majority of MICN's answering radios in a ED are a Base MICN and not a Field MICN and yes there is a difference. Here in Northern California where I practice as a FT 911 Paramedic it goes without questions that the FIELD MICN is a notch above us on the food chain. That said, I would also be the first to argue that i would not want 90% of the RN's that i have encountered in hospitals to take care of me, a loved one or even a few people i dont care for. The longer i have been in this field the more i realized how little some nurses really know when it comes to emergency management of patients.

 

[MrBrown]

Can an intern or R1 give us orders or take over even though most of them don't know sh*# from shampoo?

It depends if they are in an orange jumpsuit carrying a Thomas Pack or not

Seriously, I will value any medical input as you never know that dude in tennies nad jeans might just be a Consultant in the particular speciality you require!

And even if he is a House Officer with no acute experience, he has more education than me so who am I to tell him that I know better than he?

 

[ExpatMedic0]

bryncvp here is an example picture of how we are doing things. The trainer is in red, I have the hat and white shirt on with the orange bag. I just go out for show mainly and watch the trainer do his assessment. This makes the crowd, bystanders, and team mates feel better. If I feel its a 911 emergency Ill speak up, if not I just sit there by the patient and observe.
Sometimes after words we talk about the injury and exchange ideas. Neither of us have the "pulling rank" or I am in charge attitude. Although I know from a legal standpoint if I do make patient contact I am. We both know that because now I have to either release the patient or transfer care to another Paramedic for transport.
As you can see I am walking a thin line being on the scene... just not making verbal or physical contact with the patient.