Docs on Ambulances

[Dukes]

I was just wondering if anyone out there knows anything about whether physicians can operate as medics on ambulances. I'm asking because I used to be a paramedic and am now in med school. I would definitely like to volunteer in the future somewhere on an ambulance. I don't know about the laws etc.. also, does the national registry or some state medical boards accept medical school as a recert class? My registry expired and was hoping that I wouldn't have to take a recert course in the future. Does anyone know what's up with this? Thanks.

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[southerndoc]

NREMT wouldn't even count my medical school for CME for recert, so I doubt you can use it for an expired license.

I'm sure laws vary by state as to whether you can work on an ambulance or not. However, one would think you can if you are a fully licensed physician. Mind you that paramedics are not licensed to practice medicine independently -- they must operate under a medical director. If a paramedic can operate under your license, I do not see why you cannot provide care yourself. The concerns of knowing how to immobilize patients, extricate, etc. will be moot points since you were a prior paramedic (most of that stuff has not changed).

There are several physicians and residents with my program who are EMS gurus. Some volunteer for local fire/rescue departments.

 

[flighterdoc]

NREMT wouldn't even count my medical school for CME for recert, so I doubt you can use it for an expired license.

I'm sure laws vary by state as to whether you can work on an ambulance or not. However, one would think you can if you are a fully licensed physician. Mind you that paramedics are not licensed to practice medicine independently -- they must operate under a medical director. If a paramedic can operate under your license, I do not see why you cannot provide care yourself. The concerns of knowing how to immobilize patients, extricate, etc. will be moot points since you were a prior paramedic (most of that stuff has not changed).

There are several physicians and residents with my program who are EMS gurus. Some volunteer for local fire/rescue departments.

Depending on the service, there may be physicians working on the rigs -as physicians. A physician CANT work as a medic, you can't get insurance to work below your level of competence. There is a bunch of case law that backs this up - for instance an NP working as an RN is held to the NP standard of care, period.

 

[docB]

Depending on the service, there may be physicians working on the rigs -as physicians. A physician CANT work as a medic, you can't get insurance to work below your level of competence. There is a bunch of case law that backs this up - for instance an NP working as an RN is held to the NP standard of care, period.

Hypothetically, if a doc were working on a rig and being held to the standard of a doc would they be liable if limited by the meds and equipment on the rig? It'd be hard to do a chest tube or a central line without the stuff (I know you could needle but just go with the hypothetical). I've often thought about this in terms of trying to assist at scenes.

 

[flighterdoc]

Hypothetically, if a doc were working on a rig and being held to the standard of a doc would they be liable if limited by the meds and equipment on the rig? It'd be hard to do a chest tube or a central line without the stuff (I know you could needle but just go with the hypothetical). I've often thought about this in terms of trying to assist at scenes.

If you're a doc at a scene (especially on a rig) you'll be held responsible for not having the right equipment. You're the doc on the scene, and the departments lack of equipment is something you'd be held accountable for. You and the department would both be liable, but it's YOUR license that would get nailed.

If you're not working and stop, you're most likely covered by whatever good samaritan laws the jurisdiction has. These are of varying degrees of good for the physician, since most require a defense that you weren't "grossly negligent".

 

[southerndoc]

Depending on the service, there may be physicians working on the rigs -as physicians. A physician CANT work as a medic, you can't get insurance to work below your level of competence. There is a bunch of case law that backs this up - for instance an NP working as an RN is held to the NP standard of care, period.

Sorry, didn't realize I stated that the physician would be working as a paramedic. (In rereading my post, I still don't see where that was stated or implied, but whatever.)

 

[southerndoc]

If you're a doc at a scene (especially on a rig) you'll be held responsible for not having the right equipment. You're the doc on the scene, and the departments lack of equipment is something you'd be held accountable for. You and the department would both be liable, but it's YOUR license that would get nailed.

If you're not working and stop, you're most likely covered by whatever good samaritan laws the jurisdiction has. These are of varying degrees of good for the physician, since most require a defense that you weren't "grossly negligent".

This is simply not true. You will be held accountable for the standard of care in the field. If the standard of care is pre-hospital chest tube insertions, then you should expect to do them in the field. The standard of care in the hospital does not apply in the field.

Now this doesn't mean that some scum won't try to sue you, but it's highly unlikely that it will be successful. Additionally, if you are volunteering, then a state's Good Samaritan law might prevent any lawsuits brought against you so long as you aren't grossly negligent.

For clarification, I can run this by our EMS section chief if you want. He's probably considered one of the top 5 EMS guys in the country.

 

[docB]

If you're a doc at a scene (especially on a rig) you'll be held responsible for not having the right equipment. You're the doc on the scene, and the departments lack of equipment is something you'd be held accountable for. You and the department would both be liable, but it's YOUR license that would get nailed.

If you're not working and stop, you're most likely covered by whatever good samaritan laws the jurisdiction has. These are of varying degrees of good for the physician, since most require a defense that you weren't "grossly negligent".

How far does this go? If you had a doc on the rig or in a helo and a penetrating trauma pt crashed would get dinged for not doing a thoracotomy? Does this apply to rescue as well? A volly dept I worked on once had bake sales for a year to buy a jaws. If you don't have a jaws and can't extricate someone is the dept liable?

 

[flighterdoc]

How far does this go? If you had a doc on the rig or in a helo and a penetrating trauma pt crashed would get dinged for not doing a thoracotomy? Does this apply to rescue as well? A volly dept I worked on once had bake sales for a year to buy a jaws. If you don't have a jaws and can't extricate someone is the dept liable?

Government agencies typically have statutory immunity from such claims. For example the police have no duty to act to show up within any particular time frame if you call 9-1-1, because they can't staff sufficiently to make certain that under all circumstances a certain response time will happen.

But, a doc working for an agency can still be sued individually - and the department has to defend you. But, the agency doesn't have the license action, the doc does.

There have been at least a few cases in the last few years where volunteer rescuers (I do wildernes SAR so I keep up with the literature) have been sued for gross negligence in a tort, based on not having the "appropriate" equipment, personnel, or standards of training/performance. Some a-hole lawyer convinces a jury that they were negligent (not meeting the reasonable standard of care) and thats all she wrote.

 

[Dukes]

Thanks to everyone who responded. I appreciate the input. It seems as though this issue falls into a rather grey area. What I was told was that a doctor could get certified as a paramedic and if you're working on a rig you would could only practice to the level of an EMT-P. Anything done beyond the scope of a paramedic you would have to call in and get approval. This is just what I heard from a someone I know. I wasn't sure what to think about that. Speaking of practicing below your level, someone on my rescue squad when I was in college graduated from PA school didn't like being a PA and is now in nursing school. Strange.

 

[flighterdoc]

Thanks to everyone who responded. I appreciate the input. It seems as though this issue falls into a rather grey area. What I was told was that a doctor could get certified as a paramedic and if you're working on a rig you would could only practice to the level of an EMT-P. Anything done beyond the scope of a paramedic you would have to call in and get approval. This is just what I heard from a someone I know. I wasn't sure what to think about that. Speaking of practicing below your level, someone on my rescue squad when I was in college graduated from PA school didn't like being a PA and is now in nursing school. Strange.

Thats a bit of a different case - the PA has to be licensed separately from the Nurse. All a PA has to do is not become licensed. Doctors will always be held to the highest standard, because we're doctors.

 

[OSUdoc08]

If you are certified as a paramedic and are also a medical student or resident, you are only permitted to work as a paramedic. This is because of ambulance licensure-----the ambulance level designation allows for only a certain level of care. If you are working as an agent of the hospital to accompany the patient, then full physician powers are allowed, as opposed to working as an employee of the ambulance service, where only regulated procedures are allowed.

This is per a physician who worked a couple of shifts after he started his residency.

 

[southerndoc]

If you are certified as a paramedic and are also a medical student or resident, you are only permitted to work as a paramedic. This is because of ambulance licensure-----the ambulance level designation allows for only a certain level of care. If you are working as an agent of the hospital to accompany the patient, then full physician powers are allowed, as opposed to working as an employee of the ambulance service, where only regulated procedures are allowed.

This is per a physician who worked a couple of shifts after he started his residency.

That's only if your residency program will not sign off on you going beyond the care provided by your paramedic training. Most residency programs will not allow you to do this, unless it's part of an EMS rotation sponsored by that hospital. Working (i.e., moonlighting) means that you'd have to work as a paramedic unless you have an independent physician license and malpractice coverage. Likewise, the EMS service medical director will need to approve you to work beyond the scope of a paramedic.

So, having said that, it's very state dependent, EMS dependent, and also dependent on whether you have a license or are still in training.

 

[trauma_junky]

I was just wondering if anyone out there knows anything about whether physicians can operate as medics on ambulances. I'm asking because I used to be a paramedic and am now in med school. I would definitely like to volunteer in the future somewhere on an ambulance. I don't know about the laws etc.. also, does the national registry or some state medical boards accept medical school as a recert class? My registry expired and was hoping that I wouldn't have to take a recert course in the future. Does anyone know what's up with this? Thanks.

You are no longer protected under the good samaritian laws as an MD so that is why very few MD's get on an Ambulance.

 

[hakksar]

Well, it depends on your state . . . in some states volunteers are covered under good samaritan acts even if they are volunteering with a service (in which case you would be fine). In other states they are not covered if they are volunteering with a service (so you could be held liable for any malpractice in court even if it was just negligence and not gross negligence). However, either way your license will not be in any more danger than if you were practicing in the hospital. Your license is completely separate from the good samaritan act which only protects you from litigation except in cases of gross negligence (in other words it has nothing to do with your license, just the ability of others to bring a lawsuit against you). Most likely if you volunteer with a service it will be under your own license (so you will not need to worry about a medical director). Also, you will only be held to the standard of care for treatment in the field (which is pretty much the same as a Paramedics standard of care). I know of several Physicians in Colorado that volunteer as ski patrollers, search and rescue members, and volunteer fire/ems personnel so it can definitely be done. You will not be considered a "medic" though . . . you will be a Physician and will most likely be the "highest level" of training on the scene.

Also it is a fallacy to say that Physicians are not covered under the good samaritan act. This might be true in some states but most states it is not. The purpose of the good samaritan act was to encourage Physicians to offer their assistance in emergencies if they were not "on duty" (or in other words being paid to perform the service or treating an established client) because the risk of a lawsuit dropped significantly. The good samaritan act was then expanded to cover all healthcare providers.

 

[southerndoc]

You are no longer protected under the good samaritian laws as an MD so that is why very few MD's get on an Ambulance.

In most states physicians are covered under Good Samaritan laws. Which state are you in that does not cover physicians?

 

[medic170]

I am going to keep my paramedic license active for this very reason. then, there will be no question. My ems medical director told me to do this if I ever wanted to volunteer on an ambulance and his credentials are also DO, EMT-P. He said you can still function as a physician on the rig, but things are a lot easier if you just keep your medic license. Also, you would still have to consult with the online med control physician per protocol, but you could sign off on your drugs. If you were certified as a basic, the same would hold true.

 

[flighterdoc]

In most states physicians are covered under Good Samaritan laws. Which state are you in that does not cover physicians?

\
Good samaritan laws don't apply to people employed to render aid. If you're getting paid they don't cover you ANYWHERE that I know of in the US. Residency stipends count as getting paid.

 

[medic170]

\
Good samaritan laws don't apply to people employed to render aid. If you're getting paid they don't cover you ANYWHERE that I know of in the US. Residency stipends count as getting paid.

But they would apply if you were a resident at say Hospital A and volunteered without pay with ems service B.

 

[flighterdoc]

But they would apply if you were a resident at say Hospital A and volunteered without pay with ems service B.

I wouldn't try it (personally) unless it was in a totally different area - i.e. no chance of going to your teaching hospital at all, even on a transport. Actually, I wouldn't risk it under any circumstances.

Lawyers suck, don't they?

 

[medic170]

I wouldn't try it (personally) unless it was in a totally different area - i.e. no chance of going to your teaching hospital at all, even on a transport. Actually, I wouldn't risk it under any circumstances.

Lawyers suck, don't they?

just don't screw up and you'll be fine

 

[flighterdoc]

just don't screw up and you'll be fine

That doesn't matter. You can do everything exactly right, documented up the wazzoo, and if the pt has a bad outcome you get sued. It's happened to me - ******* kid who dove into a river from a cliff, without checking the water depth. Became a quad, and everyone got sued, including his high school (it was "senior ditch day" and he was a junior), the water district (if they had released more water from a dam upstream the river would have been higher), the highway patrol (for not having a better helicopter to fly him out with), the California Division of Forestry (us, for gross negligence in saving him), the University of California Regents (individually) and the UC Davis Hospital (where he got flown to), every doctor that was on duty that day (including the pathology and ob/gyn services, to name a few), the nurses (ditto), the state of California. The only people who didn't get sued were the kids parents (they did the suing, of course) and the two kids who grabbed the victim by the head and pulled him out of the water. Now, who do you think caused his paralysis?

Fortunately for me, while we were rigging for a river rescue I was checking the pt out with binoculars, and I could see (and documented) that he was using accessory muscles for breathing, so the damage had already been done. I spend at least 30 minutes in the witness box JUST saying that I had documented that little fact BEFORE I got wet.

 

[hakksar]

But they would apply if you were a resident at say Hospital A and volunteered without pay with ems service B.

It depends on the states Good Samaritan law. A Physician is covered regardless if they "Do not have a duty to act" which would mean that they are not working/volunteering for a service (for instance rendering aid at a witnessed accident, cardiac arrest, etc when not at the hospital). In some states this also applies to people who are volunteering with an ems or rescue service as well (it all depends on how the state defines "a duty to act"). Just check with your state or the EMS service's legal advisor . . . regardless I do not know why you would be willing to practice as a Physician in the hospital if you are so afraid to practice out of the hospital. In the hospital Good Samaritan never applies and you are at the most legal risk possible. Out of the hospital the worst you could do is have the same risk you have in the hospital . . . in many cases you would have less due to good samaritan coverage. I guess if the only reason you became a Physician is for the money than volunteering of any type (whether it be for an EMS agency, a free clinic, or helping at a witnessed cardiac arrest while on the street) would be foolish. However, if you became a Physician for other reasons than if volunteering is something you would like to do there is no reason not to.

As for lawsuits it is possible for people to sue you regardless. However, these suits will often be eliminated in Preliminary Judgement due to lack of merit if you did everything right (no guarantees but often the case). It is just as possible for this to happen in the hospital as it is in the field.

However, your license is just as safe in the field as it is in the hospital. If you do everything right you will not lose or even be penalized regardless if you were practicing in the hospital or the field. Just meet the standard of care (which is different even for Physicians in the field) and do not go over your scope of practice and you will be fine as far as your license goes.

If you have any doubts consult a Lawyer . . . juddson might be a good person to ask.

 

[southerndoc]

But they would apply if you were a resident at say Hospital A and volunteered without pay with ems service B.

Exactly!

They also apply if you stop to render aid at a car accident. Even though you are salaried, you aren't "on duty" except when you are at the hospital or functioning on official education activities that your program requires (e.g., a dedicated EMS rotation).

Volunteering for an ambulance service will mean that you're still covered in most states.

 

[mikegoal]

all of you have been talking about being a paramedic im curious about working as a basic. My ambulance corps is all BLS with ALS fly cars from another agency. After i gradutate would i be able to volunteer just as a basic.

 

[medic170]

all of you have been talking about being a paramedic im curious about working as a basic. My ambulance corps is all BLS with ALS fly cars from another agency. After i gradutate would i be able to volunteer just as a basic.

Paramedics save lives. basics save Paramedics

 

[MedicCCTRN]

It varies state by state. In Pennsylvania they have an EMS certification called Health Professional which is divided into PHRN and PHMD. This allows Docs and Nurses to operate on ALS units. The PHRN's follow the paramedic standing orders and protocols but have an extended scope of practice for vents, meds, etc. The PHMD is a physician and is only limited by the equipment and drugs found on an ALS ambulance. Which effectively limits him to paramedic practice. But unlike the EMTP or PHRN. He doesn't necessarily have to follow the Standing Protocols. He can use the medications as he sees fit for the patients problem. At least I beleive that's the way it works. I know one PHMD in the entire county I operate in. Have to ask him next time I see him. I also think the Health Professional status can include NPs or PA's but I haven't seen anything in writing from state EMS office.