For anyone who has ever had a "Doctor" show up on scene

[Shishkabob]

Critical Care Paramedic can do surgical cric and needle cric.

Heck, that's in my scope as a "normal" Paramedic... no need to be CC for that.

CCRN? Sure, they do. But it's common knowledge for a brand new Paramedic at how to do them.

 

[medicRob]

Heck, that's in my scope as a "normal" Paramedic... no need to be CC for that.

CCRN? Sure, they do. But it's common knowledge for a brand new Paramedic at how to do them.

Yep, I was unaware however if this was true in AtlantaEMT's area so on the side of caution I said, "Critical Care Paramedic" just to be sure.

 

[MSDeltaFlt]

My service specifically states that unless they are authorized DIRECTLY to take control by MY medical director they cannot take over my patient without me asking them to do so. Otherwise, they have to act as another pair of hands. If my medical director gives them permission to take over, they must accompany the patient. It is given unto me the authority by authorization of my medical director to ask an on scene physician to stand down.

"Thy Medical Director is a jealous director, thou shalt put none other before him"

Question. How would anyone be aware of that? Would communication be going on between said physician(s) while on scene with you caring for pt(s) or what?

 

[medicRob]

Question. How would anyone be aware of that? Would communication be between said physician(s) or what?

I'm not sure if I understood the question completely, but I assume you are asking how would I be aware that my medical director has given permission for the physician to take over.

Our medical director keeps us updated with his cell # in case we cannot reach him via radio. I would pick up my phone call him, explain the situation and would say something like, "Dr. Smith, I have so and so patient here in critical condition, we are x minutes away from the medical center, and I have a bystander physician with me wishing to take over, he is an interventional cardiologist with X medical center and I felt it appropriate for him to speak with you before I allow him to take over any treatments" I would then hand the phone to the bystander physician so he could explain to Dr. Smith, why he wants to take over, why he feels physician accompanied transport is warranted, and can ask permission to take control. He would then hand me back the phone and Dr. Smith would either advise me to use him as an extra pair of hands, let him take over and have him ride with us to the medical center, or to not allow him to take over.

This is one of the situations where Dr. Smith does not have any problem whatsoever with us contacting him on his personal cell.

 

[Akulahawk]

Veneficus does make some good points, (for instance: mag sulfate's other uses, using a scalpel for cutting into the body, diluting meds with IV fluid...) a lot of that happens to be stuff I already knew about. I have no doubt that a Physician has a MUCH broader knowledge base than I do. I do hope, however that Vene was stating that an ETT could be placed transversely into a wound within which a large artery was severed, inflate the cuff, and tamponade the hemorrhaging and not into the lumen of a large artery, and then to inflate the cuff sealing the lumen, thusly providing a nice, smooth pathway for blood to spurt forth from the adapter of the ETT in such a way that the spurting may be more easily directed... `

Then again, I'm probably a LOT more educated than your average knuckledragging Paramedic. Clearly though, I am not a Physician, and do not claim to be.

Now to answer the point of this thread, yes, I have had physicians approach me on scene. I tell them they have 3 options. Assist me and be an additional set of eyes and hands under my direction (suggestions welcomed, but no medical control), take total control of the patient and ride to the hospital, or talk to my medical director to provide on-scene medical direction/care. I have had only ONE Physician ride in. The others usually said "thanks" and went on their way. Oh, and if I (or my crew) don't know you and you can't prove to me you're a Physician, I'm going to bounce you from my scene.

My conversation with the Base Physician (in our case) would go a LOT like medicRob's. I won't stop working on my patient while the bystander Physician consults with the Base Physician. I would expect a similar answer from my Base Doc... In my case, I've never had to contact Base for that purpose.

 

[rescue99]

I don't know all the details but apparently we had someone show up to a bad MVA and asked if he could help. The medic allegedly whigged out with "who the &*)(^^&$%^ do you think you are??? get out of my scene!!" and the response was "I'm your medical director"

Guess he should have been a little more polite asking the question...big oops.
If the Medic got into any trouble it would only be for the way the asked, not that asked who the guy was.

 

[thatJeffguy]

http://www.dsf.health.state.pa.us/health/lib/health/ems/pa_bls_protocols_effective_11-01-08.pdf

904

ON-SCENE PHYSICIAN / RN
STATEWIDE BLS PROTOCOL
Criteria:
A. At the scene of illness or injury, a bystander identifies himself or herself as a licensed physician or registered nurse and this healthcare practitioner wants to direct the care of the patient.
OR
B. At the scene of an incident, a medical command physician wants to provide on-scene medical command.
Exclusion Criteria:
A. None
Procedure
A. When a bystander at an emergency scene identifies himself/herself as a physician:
1. Ask to see the physician’s identification and credentials as a physician, unless the EMS practitioner knows them.
2. Inform the physician of the regulatory responsibility to medical command.
3. Immediately contact medical command facility and speak to the medical command physician.
4. Instruct the physician on scene in radio/phone operation and have the on scene physician speak directly with the medical command physician.
5. The medical command physician can:
a. Request that the physician on scene function in an observer capacity only.
b. Retain medical command but consider suggestions offered by the physician on scene.
c. Permit the physician on scene to take responsibility for patient care. NOTE: If the on-scene physician agrees to assume this responsibility, they are required to accompany the patient to the receiving facility in the ambulance if the physician performs skills that are beyond the scope of practice of the EMS personnel or if the EMS personnel are uncomfortable following the orders given by the physician. Under these circumstances, EMS practitioners will:
1) Make equipment and supplies available to the physician and offer assistance.
2) Ensure that the physician accompanies the patient to the receiving facility in the ambulance.
3) Ensure that the physician signs for all instructions and medical care given on the patient care report. Document the physician’s name on the PaPCR.
4) Keep the receiving facility advised of the patient and transport status. Follow directions from the on-scene physician unless the physician orders treatment that is beyond the scope of practice of the EMS practitioner.

B. When a bystander at an emergency scene identifies himself/herself as a registered nurse:
1. Ask to see evidence of the nurse’s license and prehospital credentials, unless the EMS practitioner knows them.
2. Inform the nurse of the regulatory responsibility to medical command.
3. An RN may provide assistance within their scope of practice or certification level at the discretion of the EMS crew when approved by the medical command physician.
C. When a medical command physician arrives on-scene as a member of the ambulance service’s routine response:
1. The medical command physician may provide on-scene medical command orders to practitioners of the ambulance service if all of the following occur:
a. The ambulance service has a prearranged agreement for the medical command physician to respond and participate in on-scene medical command, and the ambulance service medical director is aware of this arrangement.
b. The medical command physician is an active medical command physician with a medical command facility that has an arrangement with the ambulance service to provide on-scene medical command.
c. All orders given by the on-scene medical command physician must be documented either on the PaPCR for the incident or on the medical command facilities usual medical command form. This documentation must be kept in the usual manner of the medical command facility and must be available for QI at the facility.
d. The EMS personnel must be able to identify the on-scene medical command physician as an individual who is associated with the service to provide on-scene medical command

2. If a medical command physician who is not associated with the ambulance service arrives on-scene and offers assistance, follow the procedure related to bystander physician on scene (Procedure section A).

 

[MrBrown]

Our Ambulance Officers have a good working relationship with physician collegues and it's not often you find a Doctor on scene and much less often one volunteers to help out; not because they don't want to but because they respect AOs as being very good at extricating, doing a little stabilisation and transporting the patient to the hospital.

We do not have a specific guideline for Doctor-on-scene because we do not operate under such a horrendously restrictive and outdated legal framework like in the US. A Doctor may request that an Officer administer a drug, fluid or treatment not contained in our Clinical Guidelines and the Officer may choose to follow such a request if they believe it is in good faith.

Should a Doctor approach me and ask "can I help?" it would be pig ignorant and foolish of me to say "no" even if its just another person to bounce ideas off. It might take longer to become an Intensive Care Paramedic here than to get your MBChB (I ain't kidding) but you can't compare the education that's for sure!

At any rate, Brown has just sprinted all the way from the helicopter in his very hot orange jumpsuit with "DOCTOR" written on it and is sweaty and icky and lugging a bloody great Thomas Pack ... you wouldn't have made him do that for nothing would you?

 

[firecoins]

Without proper ID, there is not an MD on scene.

 

[Akulahawk]

Hey, if a Physician walked up and had his/her medical license displayed so that I KNEW the person is actually a Physician, and asked if I could use some help... You'd better believe I'd say "Thanks!!! Please do! Here's what I need...and are you willing to ride in with me?"

 

[MrBrown]

Aw now now what are you saying, you wouldn't trust Brown if he showed up at a job, whipped a Thomas Pack out of his back pocket and said "yes hello I am Dr Brown, here, let me help, get me 200mg of ketamine to start...." :unsure:

 

[Akulahawk]

LOL! Here Doctor... 200mg Ketamine should make you feel right at home.... Now where did I put that patient of mine...


ooh. Squirrel!

 

[MrBrown]

Oh that is too funny, Brown deserved that

 

[Veneficus]

.

I do hope, however that Vene was stating that an ETT could be placed transversely into a wound within which a large artery was severed, inflate the cuff, and tamponade the hemorrhaging and not into the lumen of a large artery, and then to inflate the cuff sealing the lumen, thusly providing a nice, smooth pathway for blood to spurt forth from the adapter of the ETT in such a way that the spurting may be more easily directed...

Actually I was thinking along the lines of cutting it down and placing it into the lumen of the large artery to keep the blood flowing. It is most often accomplished in a trauma bay with IV tubing, but it requires some stiches to work and that is usually not available on the average ambulance. Another good stand by is a clamped foley catheter, but you can clamp an ET tube all the same if you so desire.

I have also met an Israeli physician who will open a chest in the field.

Unless I am very much mistaken, paramedics are not authorized to do a tracheotomy, but rather a cricothyrotomy, which is a preferred emergency airway or the 2.

I have had physicians on scene a few times, there was never any issue, and they were always glad to help in any way they could. Even if all they did was carry some equipment back to the truck.

Then again, I'm probably a LOT more educated than your average knuckledragging Paramedic. Clearly though, I am not a Physician, and do not claim to be.

It has nothing to do with being a "knuckledragging" paramedic actually. It has to do with a lot more schooling and an unlimited license to practice medicine. It permits more improvising without wasting time contacting online medical control as well as being able to perform a host of treatments not available to a paramedic.

Years ago we had a couple of medics here lose their certifications for performing an episiotomy under online medical direction. The medical director was simply told it was an inappropriate order and to please not do it again. Had it been an onscene physician that performed it, I doubt it would have made the news. If it did it would have been a more "heroic" outcome.

One of the most frustrating things I found being a paramedic was knowing what to do but not being permitted to do it.

 

[Akulahawk]

.

Actually I was thinking along the lines of cutting it down and placing it into the lumen of the large artery to keep the blood flowing. It is most often accomplished in a trauma bay with IV tubing, but it requires some stiches to work and that is usually not available on the average ambulance. Another good stand by is a clamped foley catheter, but you can clamp an ET tube all the same if you so desire.

I have also met an Israeli physician who will open a chest in the field.

Unless I am very much mistaken, paramedics are not authorized to do a tracheotomy, but rather a cricothyrotomy, which is a preferred emergency airway or the 2.

I have had physicians on scene a few times, there was never any issue, and they were always glad to help in any way they could. Even if all they did was carry some equipment back to the truck.



It has nothing to do with being a "knuckledragging" paramedic actually. It has to do with a lot more schooling and an unlimited license to practice medicine. It permits more improvising without wasting time contacting online medical control as well as being able to perform a host of treatments not available to a paramedic.

Years ago we had a couple of medics here lose their certifications for performing an episiotomy under online medical direction. The medical director was simply told it was an inappropriate order and to please not do it again. Had it been an onscene physician that performed it, I doubt it would have made the news. If it did it would have been a more "heroic" outcome.

One of the most frustrating things I found being a paramedic was knowing what to do but not being permitted to do it.

Vene: I understand the frustration. I really do. While I do NOT have the same level of education that a Physician has, in the field I originally trained in, what I can do goes way beyond what any non-Physician EMS provider can do that I am aware of.

And with your somewhat improved description of what you were thinking of with the ETT, that'll work, if the vessel lumen is big enough. That will contain the blood long enough to keep the patient alive long enough for a proper surgical repair. Given a relatively short duration that the device would be in place... problems with clotting shouldn't be a factor. Same with any other device you mentioned...

I am aware of a couple medics that did an emergency cesarean on a deceased female, with Base Physician Orders to do so, and the Paramedics lost their licenses and the BHP got a "you shouldn't have done that, don't do it again." IIRC, that was in Virginia a few years ago. That might be what you were thinking of. Made National News, that event did...

And while I agree that a Physician has an unlimited license to practice medicine, I don't necessarily think that it would be advisable for a GP to perform a lung transplant, or crash cesarean, Total Knee... or any number of other things right out of his or her Primary Care Residency. As you and I are both aware, the field of medicine is EXTREMELY broad even once you become a Physician, and the specialties and sub-specialties can require YEARS to master.

My previous education was very specialized and took years to master. It's a shame that I can NOT use that education to it's full capacity... For what I do know, I'd be extremely useful in certain venues.

 

[MrBrown]

I have seen some Doctors hiding in the corner having a panic attack while Paramedics work on the cardiac arrest in his waiting room or politely asking "now, you did give this asthmatic some salbutamol with his oxygen right?".

Not all physicians are confident in dealing with whacky situations like what Vene has described and I bet some would run away. My GP (who is a bloody fantastic GP) wanted to be an emerg consultant but never did because the highly pressurised environment of an acute medical emergency is not one in which they felt most confident and of most value.

Brown on the other hand enjoys a good challenge and has no interest in being anything other than an intensevist or critical care anaesthetist. Sitting in the Office going here is your prescription, ten bucks please, next ... ick!

Perhaps that is why I want to become a helicopter doctor? You don't see them doing house calls for the sniffles now do you

 

[JPINFV]

Perhaps that is why I want to become a helicopter doctor? You don't see them doing house calls for the sniffles now do you

They did on Trauma...

 

[Veneficus]

I am aware of a couple medics that did an emergency cesarean on a deceased female, with Base Physician Orders to do so, and the Paramedics lost their licenses and the BHP got a "you shouldn't have done that, don't do it again." IIRC, that was in Virginia a few years ago. That might be what you were thinking of. Made National News, that event did....

They were seperate incidences, the one I spoke of touched off a change in our state which allowed a paramedic to perform any procedure the local medical director authorized to much more rigid statewide scope of practice. The latest state protocols are extremely conservative and now universal to all state services. It was definately a step backward in my opinion.

And while I agree that a Physician has an unlimited license to practice medicine, I don't necessarily think that it would be advisable for a GP to perform a lung transplant, or crash cesarean, Total Knee... or any number of other things right out of his or her Primary Care Residency. As you and I are both aware, the field of medicine is EXTREMELY broad even once you become a Physician, and the specialties and sub-specialties can require YEARS to master.

Something I am all too familiar with However I was thinking more along the lines of emergent procedures like the crash c section. Usually when doing that, there is already significant fetal distress which is not responsive to treating the mother. (if she is even still alive)

 

[MrBrown]

They did on Trauma...

Yes true but Brown would like to keep his license to practice medicine and not be branded a rogue and unethical practitioner

 

[Aidey]

We have some of those Thanks but no thanks cards we can hand out. I've never had an enough of an issue to use it. The biggest problem I run into when a family member is a MD (Or PA, ANP etc) is they are too helpful. Its like "please, sir, I need the patient to answer the question".