Chain of Command in Medical Field

[iftmedic]

Paramedics have the highest level of training in the prehospital setting, and they answer to a base hospital physician. Nurses work in hospitals and carry out orders from docs

 

[Akulahawk]

Paramedics have the highest level of training in the prehospital setting, and they answer to a base hospital physician. Nurses work in hospitals and carry out orders from docs

:deadhorse:

Be careful of over generalizing things. Both Paramedics and RN's carry out orders from docs... both have a high level of training. A Paramedic is a specialist in pre-hospital care. An RN is a generalist that get specialized training for their area of care. Most RN's do not get any education in pre-hospital care. A Flight RN does and they might not spend the majority of their day working in a hospital...

 

[Veneficus]

Im not completely sure if this has been said or not on this forum (though I've check everywhere.) I was trying to figure out who has higher authority. An EMT or CNA, then an EMT and LVN, then a Paramedic and RN. From what I remember, it goes CNA, EMT, LVN, Paramedic, RN, etc. Let me know and thanks in advance!

This point has been argued for a long time, the real question is:

"Why does it matter?"

When taking care of a patient, the provider who is most capable is usually the person who judgement is deferred to.

Take for instance, a patient with an acute appendix. The management may fall to a senior resident even thogh the first physician the pt sees is an attending ED doc.

Likewise, a new ED doc may have expertise not covered by a senior orthopod.

In or out of the hospital that is generally the way it plays out, even without formal chain of command.

Aside from that, medicine is a team sport. If the GP wants to send a patient but doesn't want you to do anything, it might be because he knows what you will do will not help, or that it will interfere with what needs to be done to help the patient at the hospital in a more timely manner.

If somebody asks you to do something, it is better to ask why than to get into a pissing contest.

From the operational standpoint in an MCI, it is not always the most capable, most experienced, or highest qualified person that is in charge. Every MCI and even internal hosptial disaster I have ever been to, the outcome is decided by the first few people there. In a disaster or refugee condition the outcome is decided by logistics, not field providers.

One of the best things any provider can do in an operational standpoint is recognize what is needed and fill that role and do it as best they can without worrying about the rank or the cert of the person in charge overall.

For the most part nobody works is a bubble, you know you agency, who is in it, what their capabilities are. You know the people from surrounding agencies/ hospitals because we make up a small group even in the largest cities. Even if you don't know every detail abot them, when somebody knows what they are doing, or doesn't it becomes apparent very quickly.

Perhaps they may even have seen something in a moment that would make a difference? Perhaps they have a piece of information you don't?

If you are an EMT (or any type of provider) and somebody is giving you a hard time about being in charge, just ask them to sign the chart (run report) where it asks for provider in charge or primary provider responsible.Usually that is enough to get them to back down.

 

[MusicMedic]

Mr.Brown (future Dr.Brown) is the Highest and Final Authority in all Medical Situations

no questions asked


well that solves that question

 

[emtchick171]

Do you mean a medic in a hospital or out of?

Either way, both certs must have orders from a doctor... and many nurses have standing orders much like we do in the field.

Granted there's a bit more leeway for field providers (nurses included) due to the very nature that we can't always have a doctor there... but make no mistake, nurses can have standing orders too.

I mean in a hospital setting. At our hospital, a nurse cannot do a needle decompression, cannot do an IO, and other certain things. While a medic in the hospital setting is allowed to do such things without a doctor's orders.

 

[Veneficus]

I mean in a hospital setting. At our hospital, a nurse cannot do a needle decompression, cannot do an IO, and other certain things. While a medic in the hospital setting is allowed to do such things without a doctor's orders.

You have to be careful not to equate skills with knowledge, they are not equal.

I could teach you how to perform needle decompression and IO in about 15 minutes.

I could even discuss when to use them in about another 15 minutes.

But there is way more to know to use those skills appropriately and effectively. As it currently stands in the US, the RN is a far more educated provider than most EMS trained persons.

That doesn't mean they are more capable than somebody who has only a very narrow specialty, such as medics, when the need for that specialty arises.

Please also consider:

It takes far less effort to teach a nurse how to do medic skills than to teach a medic skills and the whys and wherefores.

The number of actual "emergencies" as we like to define them is decreasing, making the need for the "Emergency" specialist less. With advances in medicine we have found a vast majority of the patients who fall into emergent are not minute sensitive.

The Mcdonalds crew leader may be extremly capable of running a Mcdonalds shift, perhaps more so than a master chef, but the chef can make burgers anywhere. The McDs crew leader cannot run all eateries.

 

[emtchick171]

You have to be careful not to equate skills with knowledge, they are not equal.

I could teach you how to perform needle decompression and IO in about 15 minutes.

I could even discuss when to use them in about another 15 minutes.

But there is way more to know to use those skills appropriately and effectively. As it currently stands in the US, the RN is a far more educated provider than most EMS trained persons.

That doesn't mean they are more capable than somebody who has only a very narrow specialty, such as medics, when the need for that specialty arises.

Please also consider:

It takes far less effort to teach a nurse how to do medic skills than to teach a medic skills and the whys and wherefores.

The number of actual "emergencies" as we like to define them is decreasing, making the need for the "Emergency" specialist less. With advances in medicine we have found a vast majority of the patients who fall into emergent are not minute sensitive.

The Mcdonalds crew leader may be extremly capable of running a Mcdonalds shift, perhaps more so than a master chef, but the chef can make burgers anywhere. The McDs crew leader cannot run all eateries.

I wasn't trying to say that all medics are more knowledgeable than RNs...I was just simply saying how things went in our local hospital.

 

[Rescue0ne]

Apples & Oranges

In places where Paramedics are employed in the ER in a role that is comparable to an RN, both are pretty much the same, depending on how that particular program is set up by the Docs and Administrators. Granted, a Medic (in the field) might normally be able to decompress a pleural space, cardiovert, or pace transdermally under standing orders, but that same Medic might not have that role in the emergency dept.

I don't feel that an RN is superior to a Paramedic in any fashion, and the same is true vice-versa. Like it was stated previously, RNs are cross-educated to work in pre-hospital settings in some cases, just like Medics are cross-trained to work in ER & clinical settings, in some cases.

Sometimes apples and oranges might begin to look the same after a while, but you can't make an apple pie with oranges, just like you can't make orange juice with apples.

 

[HappyParamedicRN]

Having worked as an RN, I can tell you on scene that an RN SHOULD NOT BE the person in command if your talking about a scene and even in an ER.

RNs, from my experience, unless they are also medics are afraid to function without a doctor present!!!


Happy

 

[Journey]

Having worked as an RN, I can tell you on scene that an RN SHOULD NOT BE the person in command if your talking about a scene and even in an ER.

RNs, from my experience, unless they are also medics are afraid to function without a doctor present!!!


Happy

You sound like a very, very new RN and you may not be qualified to work in an ED, CCT or Flight. Maybe you were not given the respect you felt you deserved as an RN with a Paramedic patch in the hospital. An RN most definitely can be in command of a scene with Flight and PHRNs proving this everyday. They can also be in charge of complex cross country transports without a physician with no problem. I suggest you work in a progressive hospital ED or ICU to see how RNs really function. You have no idea.

 

[fortsmithman]

Having worked as an RN, I can tell you on scene that an RN SHOULD NOT BE the person in command if your talking about a scene and even in an ER.

RNs, from my experience, unless they are also medics are afraid to function without a doctor present!!!


Happy

In my neck of the woods the RNs do function quite well without a physician present. Here in the NWT most communities have RNs and LPNs. Most communities here in the NWT have no EMS available at all just the guy with either a van or pick up truck. In some european countries RNs are the prehospital providers.

 

[jjesusfreak01]

The more pertinent question might be "How would you determine who to release your patient to at the scene of an emergency? Would you adhere to a hierarchy?"

I think you are getting closer to a good answer to the original question. My answer is this:

The chain of command is quite simple for an EMS officer. The person in charge is always the person who is ultimately responsible for the patient.

A nurse in the field who doesn't work in EMS cannot trump a medic or even an EMT because they have little authority to work outside the hospital and are not responsible for the patient. Likewise, within a hospital the nurses, and ultimately, the doctors are at the top of the chain once they take a report and possession of the patient. In the field, a doctor doesn't automatically trump an EMT or Medic, but if the crew is authorized to do so by medical control (a DOCTOR), they may be able to hand off partial responsibility for the patient to the attending doc.

Unfortunately for the CNAs, they aren't really in the chain of command, as they work under the control of nurses who are directly responsible for the patients. This is different from EMTs, who are often directly responsible for patients even though they operate under another provider's license.

There should never be a time when you have to hash out who trumps who in a medical situation, because ultimately, unless you bring NPs into the mix, the doctors and administrators of every organization control the hierarchy, so all anyone really needs to know is what hierarchy has been set up at your organization? While you are responsible for the patient, you follow that, and after you hand them off, it isn't your problem anymore.