Who's In Charge Of The Patient?

[Guest alsfirefighter]

Thanks Chris...I was waiting for your back up on this one.

Depending on the pt.'s condition the medic should have better training to spot impending events that could lead to needing defib or changing oxygen levels, etc.

Antique, with all due respect because I always thoroughly enjoy your posts, this isn't directed towards you...just the comment in the post.

Can I and should I be able to spot impending events...yes, but so should BLS providers. Will I be able to as a BLS provider, with BLS equipment or on a BLS ambulance....NO. I won't be able to see any impending event that would need defibrillation because BLS only carries AED's and many carry the LP-500 that has no monitoring capabilities. Which in turn would be a NYS protocol violation because by protocol AED's are to be attached to unresponsive patients in either cardiac arrest or imminent cardiac arrest anyway. So even if I could see it. I couldn't do anything anyway until the AED let me. As far as changing oxygen levels, on a BLS level if you don't know how to deal with this...you should pack it in. Not to mention that while its not a bad tool to use, pulse oximetry really means nothing in the scope of care being protocols and treatments are symptom based. Proper O2 admin, with proper positioning and proper airway management are what matters. Not what the little probe on the finger is. THERE IS NOTHING I CAN DO WITH BLS EQUIPMENT THAT ANOTHER BLS PROVIDER SHOULDN'T BE ABLE TO DO! And if they can't...I still shouldn't rush in to do it or they will never be able to graps it or to do it in the future or correctly. We should be educators as well!

No one isn't saying the patient comes first. What we are discussing is the fact that you can't be held responsible for patient conditions that are above the agency you are working for regardless of what level you are certified at. If anything as a medic when working as BLSFR the best patient care I can give them is solid BLS care with no delay getting them into the ambulance so they can get to definitive care.

Could you imagine how many agencies would dump providing BLSFR if they had to worry about or be liable for an ALS trained member on the unit everytime the scenario mentioned would happen?

Exactly what a lawyer would tell you

LOL. Actually no that's not what they would tell you. They do not care about patient care. They only care about the legal aspects of EMS and issues pertaining to patient care. They could care less about patient care and more whether you didn't do something or did too much that could give reasons for a lawsuit, then if you did it right or not. And following what is clearly in the protocol means a lawyer tells me nothing.

In fact I don't worry about what lawyers will tell me, I don't give them any reason to have to tell me anything in the first place. I'm not one of those overly lawsuit conscious providers today where every other word out of the their mouths has soemthing to do with lawyers, and lawsuit, and liability and the famous "well if the right lawyer gets something in their hands."

Do your job, follow the protocols as a great guide, but be a clinical provider! After all if you want to read a book and follow exact steps on how to do something....become a chef and use a cookbook. When you do your job right, to the best of your ability and you document it all well...there is nothing that can beat that period.

[Guest]

Situation #1: Let's say your a career Firefighter, with extensive roots in EMS. You are trained to Paramedic level.

Your Engine company does EMS first response. You have a Lt. on the Engine. Except for you (you're a medic), everyone else is a CFR.

Who is in charge of the patient, AND the scene......the officer with only CFR training, or the FF, with Paramedic training?

I would say the Paramedic would be in charge in that situation.

Situation #2: NOW, let's say a BLS transporting agency shows up, they are only BLS. The patient needs ALS care, but none is available. Who is in charge of the patient then, and what do you do?

Sit. 1 - the patient is yours as the medic - the scene is the Lt's as the officer on the scene. The only issue that should come up is who is in charge of the scene when the transporting unit shows up.?? The transporting unit - EMS is in charge of EMS calls. As an ALS provider you have a duty to act if you deem it needed and thus the pt remains yours. The way I see it the only reason why the FD is on scene is because of First Response. When the ambulance shows up first response isn't needed any more. If the first responders decided to be BLS or ALS then they also have a duty to act regardless.

Situation #2: You have already started ALS on the this - hopefully - and since you can't downgrade the pt. to BLS then you have to go with the unit.

[Guest alsfirefighter]

Sit. 1 - the patient is yours as the medic - the scene is the Lt's as the officer on the scene. The only issue that should come up is who is in charge of the scene when the transporting unit shows up.?? The transporting unit - EMS is in charge of EMS calls. As an ALS provider you have a duty to act if you deem it needed and thus the pt remains yours. The way I see it the only reason why the FD is on scene is because of First Response. When the ambulance shows up first response isn't needed any more. If the first responders decided to be BLS or ALS then they also have a duty to act regardless.

Dude...first check your font because it is nearly impossible to read. Also..I have to ask..are you reading the same posts as we are?

Secondly, "the only reason the FD is on scene is because of first response"??? Well why else would the FD unit be there if it wasn't providing BLSFR...besides other intriquate trauma related cases where specialized equipment and training might be needed, CO calls ans cush. The transporting unit is in charge of nothing until they receive a proper face to face change of patient care. When the ambulance shows up first response isn't needed anymore? LOL. Awesome gang...memo to all of us who provide BLSFR...no more lifting and assisting the transport crews!! wooohooo! The patient isn't yours as a medic if you agency is only a BLS provider. period. If you are who I think you are I know you know this.

Situation #2: You have already started ALS on the this - hopefully - and since you can't downgrade the pt. to BLS then you have to go with the unit.

Who as started ALS care? and on what in this scenario? You can't start ALS care with BLS equipment...so therefore there is no ALS care started.

This really isn't that difficult...go to the DOH link I posted and read it off the policy statement for yourselves if you have not yet done so.

[Goose 188]

If the FD in question is CFR or EMT and your a Paramedic, you CANNOT operate as a medic. IE: you have no more or less authority than your fellow EMTs or CFRs (i'm 99.9% sure on this, someone correct me if i'm wrong)

[ny10570 745]

This is a common scenario in NYC. ALS nailed it off the bat. If you respond as a CFR you are a CFR under the direction of your officer. If you are a NYC remac certified Medic working BLS while waiting for your paramedic upgrade, you are an EMT. You are only as well trained as the title under which you are operating. Since you are only operating as a CFR there is no patient abandonment issue when care is handed off to the BLS. You get to know the guys working the CFR companies in your area and sometimes their outside training can be very useful. In these cases however they are operating outside their scope of training and the risks associated with that.

There is also a whole procedure for accepting direction from a doctor or nurse on scene. Remember, you are practicing under your medical directors license. If this on scene doc wants to take over, then let them ahve at it. If they want you to operate then they need to let you do your thing. There is an option where the on scene doc can be responsible for your medical control options and discretionary decisions. If everything is kosher and telemetry is ok with it you are now operating under the on scene doc's license.

sorry, 16fire5 I had missed your post before.

Edited January 4, 2008 by ny10570

[Guest alsfirefighter]

If the FD in question is CFR or EMT and your a Paramedic, you CANNOT operate as a medic. IE: you have no more or less authority than your fellow EMTs or CFRs (i'm 99.9% sure on this, someone correct me if i'm wrong)

\

Come on Goose..brother...if you read the rest of the posts you would know you're 100% right. But there are a few whom still seem to still have a problem with that or aren't getting it.

For everyone's viewing pleasure yet again.....read the bottom of page #2.

http://www.health.state.ny.us/nysdoh/ems/pdf/06-04.pdf

[ems-buff 81]

So you have to do what your DEPT wants you to do. Doesn't mean that it works all over the STATE. If the LEVEL of care you can give as a FF/MEDIC is CFR then that is what you give. You turn the PT over to the BLS CREW if that is all that is available. I don't see the liablility. Especially if there is nothing that the FF/MEDIC can do to improve the PT's condition.

In the eyes of the state. You may HAVE BEEN a Paramedic while working an EMS Agency, but in the fire department you are an FF/CFR, Nothing more... Does that mean just because of that you should forget everything you learned, NO! Should you be able to know the signs of CHF/ Cardiac Asthma/ SOB/ PE/ Asthma, whatever the case may be. NO! Should you give O2 sit them up right, and get an ETA on the ambulance. YES! Why you ask? because thats all you can do.

Sit 1. ALS is right, as your OIC, if he is a good officer, and knows what he is doing, then he will let you take charge of PT. care due to your experience only (the reason why i say experience only is because you WERE a medic, now your a CFR like the rest of your crew)

Sit 2. I personally think you shouldn't ride with the ambulance crew, To many people in the back for one. Secondly, The crew might get intimidated by you being back there.

Edited January 5, 2008 by ems-buff

[ckroll 101]

It's a slippery slope. Quality of care is often in the eye of the AEMT, who may be overestimating what he/she has to add. Best benefit to the majority of patients is getting the patient off scene with solid BLS skills being performed. Unless one is on duty in an EMS capacity, and this applies to A and B EMTs, one has no standing to practice. My experience is that 85% of good ALS is good BLS. Helping a BLS crew set up to run a successful call and coaching, if necessary, probably has as much or more benefit to the patient, especially in the short transport environment.

The ALS role in educating/assisting BLS is undervalued. Good assessment is the same BLS or ALS. BLS is just as capable at recognizing and addressing basic respiratory and circulatory issues. If a BLS provider needs an assist, use the opportunity to teach. The EMTs we ride with today we will ride with tomorrow. Make them better at what they do and they will be there for you [and the patient] when the going gets tough.

[antiquefirelt 994]

Antique, with all due respect because I always thoroughly enjoy your posts, this isn't directed towards you...just the comment in the post.

Can I and should I be able to spot impending events...yes, but so should BLS providers. Will I be able to as a BLS provider, with BLS equipment or on a BLS ambulance....NO.

I appreciate your candor and your post explains the contrast between EMS rules/laws in NY and here in Maine. In ME it is rare for any bus to be only BLS. In fact most are licensed at the EMT-B level and permitted to a higher level (Intermediate or Paramedic)This allows the truck to carry ALS equipment while not having ALS providers. Your service must provide personnel at the level of licensure 100% of the time and but may never actually respond with a medic though permitted to the Paramedic level. To permit above your license level you need only an affiliated paramedic whom will be responsible for the ALS equipment and drugs.

Our FD runs three ambo's licensed at the Intermediate level and we're permitted to the paramedic level. We provide a medic on about 80% of our calls. While none of the services around us are licensed above EMT-B they all are permitted to the medic level and carry full ALS gear and drug boxes. We also carry an Out of Town ALS kit so our medics have "their" equipment rather thatn rely on the other services gear which may not be checked as frequently. So it its hard to imagine stepping into a bus that doesn't have a Lifepack 11 and IV equipment. We of course are a far less populated state and therefore have far fewer EMS units so the cost of equipping every ambulance to the ALS level is not ridiculous. I'm sure there are some BLS only transfer trucks in the metro Portland area, but up my way there are none.

As for being able to spot impending life threatening events? I think it depends on how much time you have on the emergency bus. I'm certain that our medics who have far more training than our EMT-I's have done more "sh*tting the bed" calls than any others around us and therefore are much more apt to be able to see and hear more with their eyes and a stethascope than a lesser trained or experienced provider. Our medics frequently argue that they are better eyes and ears than other providers due to their experience and training and therefore command more money. In fact without this knowledge we could hire only EMT-I's as we can (I'm an EMT-I) do many of the things a medic can with online medical control. Our EMT-I level allows for defib, 12 leads, IV's, ET tubes, administration of nitro, epi, Narcan, and some others so that the majority of the normal runs can be covered by EMT-I's. But regardless of this, there is nothing like having a quality trained medic with decent experience.

Also in ME, we cannot transfer care to a lower license level regardless of the transport unit. We frequently provide first response to another services area, and if we send a medic and the call is for chest pain my medic must transport in their unit unless they have a medic of their own. Here your EMS license is a stand alone license not assigned to the dept. but to you specifically.

[ny10570 745]

Antique, how does the inability to down triage patients to BLS affect a scenario where there are more patients than medics? MVA with two seriously injured patients both assessed by the medic and the second bus is just BLS. Are you sending them off to the ER and hoping it works out or are you protected if the "more stable" patient decides not to cooperate and crap out.

[antiquefirelt 994]

Antique, how does the inability to down triage patients to BLS affect a scenario where there are more patients than medics? MVA with two seriously injured patients both assessed by the medic and the second bus is just BLS. Are you sending them off to the ER and hoping it works out or are you protected if the "more stable" patient decides not to cooperate and crap out.

Paramedics are specifically allowed to triage pts down to lesser licensed personnel when there are multiple patients. In all it's kind of the best of all worlds scenario because it ensures the highest level of care to the victim or in a mass casualty scenario the most severely injured viable victim. And yes, you'd be fully protected so long as you could justify your actions as to who was triaged. We have a specific triage system that basically allows anyone with an EMS license to complete the triage thus allowing the medic to see the most critically injured first and not be directly involved in triaging 5 or more vicitims.

Again, rarely are any buses BLS only, we have three real license levels: EMT-B who can administer O2 and use the AED, EMT-I's which can give IV's, ET tubes, use a cardiac monitor and give many drugs with on line med control, lastly are the medics who can do it all. So while Paramedics are the only official ALS, the EMT-I's can perform many ALS functions.

Edited January 7, 2008 by antiquefirelt

[ny10570 745]

So that protection only applies to multiple patient incidents or can you hand off the FDGB (fall down go boom) w/ a broken wrist to BLS just so you don't unnecessarily strip the area of a medic?

[antiquefirelt 994]

So that protection only applies to multiple patient incidents or can you hand off the FDGB (fall down go boom) w/ a broken wrist to BLS just so you don't unnecessarily strip the area of a medic?

Yes, you may triage care to a lesser licensed person in the FDGB scenario or similar. The problem is that this can be and is abused, say the medic says the chest pain is non-cardiac in nature... This has led to many services such as ours have more hard fast rules when it comes to turfing care.

Now the State has mandated that dispatch centers be "licensed" through EMS to perform EMD. This will force (as well it should) the dispatcher to send the closest ALS if the 911 call sounds like its necessary. Currently, each service determines how long between tones and how to call out paramedics. Sometimes a chest pain call will not have a medic started until the first due ambulance arrives and actually concludes the dispatcher was correct that it was a chest pain/cardiac call. Soon, if you do not have a medic on a duty roster the closest one will be simultaneously dispatched.