Prehospital command hierarchy, fitting it in with the regular medical community

[Hotshot007]

Hi all, my partner and I were having a discussion about where in the chain of medical command certain elements fall in. We established that EMT-Bs are lower than any hospital people except CNAs, paramedics are under RNs and the ER doc is basically god. What we were unsure about was the role of LVN/LPNs in relation. I said that they were above paramedics because they could supervise CCT transports, but my partner insisted they were below paramedics because paramedics can stick IVs in while basic LVNs cannot unless they get IV certified. Who is right?

 

[Handsome Robb]

Paramedics can attend CCT transports. Ever heard of CCP-C or CCEMT-P?

 

[CAOX3]

Your comparing apples and oranges, on scene calls the EMT and medics are going to make the call unless the doctor wants to get involved.

I dont take orders from any nurse on scene, I consider their advice but sorry its my call, if you want to get on the phone with my medical director and argue about it, thats up to you.

In the hospital I dont really have any standing as I am a pre-hospital provider.

 

[Tigger]

Hi all, my partner and I were having a discussion about where in the chain of medical command certain elements fall in. We established that EMT-Bs are lower than any hospital people except CNAs, paramedics are under RNs and the ER doc is basically god. What we were unsure about was the role of LVN/LPNs in relation. I said that they were above paramedics because they could supervise CCT transports, but my partner insisted they were below paramedics because paramedics can stick IVs in while basic LVNs cannot unless they get IV certified. Who is right?

The more important question would be, "why does it matter?"

Also, where are LPNs supervising CCT transports? That has bad idea written all over it.

 

[MedicJon88]

Well- some Paramedics are employed as ER-Techs in parts of the country- They would definietly "out-rank" the LVN/LPNs in the ER.

But most of the time it is Apples and Oranges... however MICN technically out rank a paramedic they are Med control most of the time around my parts... and CCT-RN can do more than CCT-Ps... considering drips and all.. but thats a RN union things not a difference in skill level.

 

[MedicJon88]

Also, where are LPNs supervising CCT transports? That has bad idea written all over it.

That does sound scary... very scary.

 

[usafmedic45]

The more important question would be, "why does it matter?"

Also, where are LPNs supervising CCT transports? That has bad idea written all over it.

My thoughts exactly. Either you send an RN or an RT if they need more than a medic can offer. LPNs are the basic EMTs of the hospital world: The best of them have just enough knowledge to keep the patient alive until you get them someone with more education, the rest have just enough to be dangerous.

 

[firecoins]

where in the world can an LPN supervise a CCT?

 

[AlphaButch]

where in the world can an LPN supervise a CCT?

Not in Texas

 

[jjesusfreak01]

An LPN is closer in education to an Intermediate. Theyre nowhere near paramedic.

 

[LondonMedic]

What about the truly important questions? Does a lawyer outrank a shopkeeper? Is a swimmer below a footballer? And is a nurse going to get me fired if they catch me having a smoke in the ambulance bay?

 

[firecoins]

LPNs cant even accept care for our patients. They aren't recognized in NYC.

 

[Shishkabob]

Paramedics are 'under' RNs? Maybe in California, but nowhere else. Infact, if your average nurse tried to tell me what to do, I wouldn't be able to control my laughter.

The only person on Earth that can tell me what to do medically is my medical director.





You said 'prehospital' so I assume you mean on a call and not just 'in general'. The EMS crew is always in charge of patient care in such a situation, with the only exception being a physician that desires to take responsibility AND go with the patient to the hospital. CRNA, RT, RN, CNA, LVN on scene? Cool if I need them, as long as it's understood that I'm running the show, and if they step on my toes, the law is on my side, and they will be escorted off scene by PD. Straight up, the Paramedic is the utmost authority on pre-hospital medicine outisde of a physician fitting the above criteria. (Flight crews not-withstanding)

 

[systemet]

Hi all, my partner and I were having a discussion about where in the chain of medical command certain elements fall in. We established that EMT-Bs are lower than any hospital people except CNAs, paramedics are under RNs and the ER doc is basically god. What we were unsure about was the role of LVN/LPNs in relation. I said that they were above paramedics because they could supervise CCT transports, but my partner insisted they were below paramedics because paramedics can stick IVs in while basic LVNs cannot unless they get IV certified. Who is right?

A physician gives you orders. As long as you're comfortable that the orders they've given are in the patient's best interest, you do what they suggest. If you don't, either you (i) don't do it, or (ii) voice your concerns to another physician.

An RN, RT, NA, LPN, patient's family member, etc. All these people are sources of information with expertise in different areas. You use them as sources of information, evaluate their skill level and knowledge, compare it to your own, and make a decision.

For an EMT, it might seem like you have to do whatever the medic says. But you don't. That a medic tells you to do something that's wrong isn't going to help you "get out of jail free", if you violate something within your own scope. For example: You respond to a 60 year old woman with nausea and epigastric pain. Your partner spends 30 seconds on scene yelling at her, telling her she shouldn't have called 911 for an obvious gastroenteritis and should go to her family doctor. You leave 20 seconds later, and as you're doing your paperwork she arrests. You're going to be just as fired, and almost as liable. Because you should have known better.

It's not the army.

 

[Melclin]

Hierarchy? As long as we can all agree that I'm above Linuss, then all will be right in the world.

What about the truly important questions? Does a lawyer outrank a shopkeeper? Is a swimmer below a footballer? And is a nurse going to get me fired if they catch me having a smoke in the ambulance bay?

Ohhh no no no. Look here, lets get one thing strait...


...soccer isn't a sport, mate.

 

[Shishkabob]

Hierarchy? As long as we can all agree that I'm above Linuss, then all will be right in the world.

But if I don't agree to it, then we aren't all in agreement, are we? ^_^



Authoritative Opposition Defiant Disorder. Oh yes, I have legit medical reason why I hate being told what to do.

 

[Melclin]

But if I don't agree to it, then we aren't all in agreement, are we? ^_^

DAMMIT! Foiled again.

This won't be the last you hear from Professor Melclin! *flies away on rocket boots*.

 

[Shishkabob]

*flies away on rocket boots*.

Guess you WOULD be "above" me then, wouldn't you? :unsure:

 

[ZootownMedic]

This is a interesting topic and as a current Medic student I will throw in my 2 cents for whatever they are worth. Paramedics are a strange breed in the world of medicine for several reasons and these reasons also factor into where we 'sit' in the heirarchy and also why certain other healthcare levels(ahem....RN's) dislike us. I recently just did a 12hr rotation in the ER and as a Paramedic student I was shadowing the Charge RN's. These are the top RN's in the ER and tell the other nurses what to do. I was very impressed with their knowledge of pathophysiology as well as their demeanor and expertise in the skills that I saw them do. That being said here we go with the main point......

CNA's can barely take a blood pressure so lets just leave it at that.

LPN's scope of practice varies greatly by state and additional training but for the most part they cannot do much more than a IV certified EMT can and a EMT-B here in the great state of Colorado can do quite a bit. Here a EMT-B can push any drug on the rig as long as the Paramedic TELLS them to do so. Kinda like how a LPN or RN needs a doc to tell them what to do. So I would put EMT-B's on the same level as LPN's but I think EMT-B's have alot more freedom.

Now the hard part...the classic RN vs Medic argument...haha....its funny because on one of my third rides last week for P school we did a transfer of a patient from this hospital up north to the central one with a RN. The protocols had just changed where Medics are allowed to transfer patients with chest tubes WITHOUT a RN on board...one of the RN's made a comment about this and how medics are 'growing up'. We just laughed at her overweight worthless self and let her think that she was a real healthcare provider(she just sits at a desk in a slow, deadpan ER). So we then got the REAL ER RN(who was quite good BTW) and took the patient. A friendly argument started in the back between my preceptor medic, the RN, and myself. Her argument was that she can push ANY drug and that we can push only the ones on our 'short' list of like 40-50. We retorted that we can give drugs on standing orders at our discretion and that she had to have verbal ordered permission. The argument also arose about abandonment. Since technically Paramedics often take critical patients from one ER to another without a RN on board she tried to argue that it wasn't the same and that we aren't the same level of provider. The bottom line is RN's are in there own little world in the hospital and report directly to a Physician. While Paramedics report to a physician as well it is much less DIRECTLY(some go weeks without talking to their MD) and have WAY more freedom to perform both good and bad medicine.

In my opinion RN's are just pissed that Paramedics are getting more respect everyday and soon it won't even be a debate about who is the higher level of care and it will just be universally known that they are equal. As a side note as well I am talking in general about CRN's and ER RN's. RN's that are not really part of emergency medicine or a similar discipline aren't even close to Medics in their freedom, medical skills, or judgement making abilities. On the streets, Paramedics are the gods 96% of the time. Again, just a medic student who's in the thick of it's 2 cents.

 

[JPINFV]

While Paramedics report to a physician as well it is much less DIRECTLY(some go weeks without talking to their MD) and have WAY more freedom to perform both good and bad medicine.

Which is, of course, what makes the educational standards and general mentality of EMS so sad and dangerous.