quickfeet

Smooth Operator
7+ Year Member
Dec 2, 2010
154
86
Status
Post Doc
If you were at your kids football game and there was a major trauma (say one of the kids suffers a major head injury).

You run out to attend the injured (because everyone there expects you to and/or you have a legal obligation). The paramedics are on the scene 3 minutes later.

Who is actually in charge? The off-duty EM physician or the paramedics?
 

emergentmd

10+ Year Member
Jul 6, 2008
1,467
1,608
Status
Attending Physician
If you were at your kids football game and there was a major trauma (say one of the kids suffers a major head injury).

You run out to attend the injured (because everyone there expects you to and/or you have a legal obligation). The paramedics are on the scene 3 minutes later.

Who is actually in charge? The off-duty EM physician or the paramedics?
I would say the paramedics. You can state your name/EM status and if they wish to relinquish then great. Otherwise, I would say that they are in charge.
 
  • Like
Reactions: cbrons

Daiphon

Semper Ubi Sub Ubi
15+ Year Member
Nov 6, 2003
989
259
The Windy City
Status
Attending Physician
I would say the paramedics. You can state your name/EM status and if they wish to relinquish then great. Otherwise, I would say that they are in charge.
Agree.

Prior to EMS arrival you should be covered by Good Samaritan laws (but be careful, oftentimes you can still get named).

Once EMS arrives, however, it's their SMOs & medical control who own the case & liability. You can supplant them, but then *you* own it fully & lose GoodSam protections.

Should note that, while seeming semantic, EMS doesn't relinquish their ownership of the scene in this situation; you forcibly take it... net result is the same, but if anything bad happens, you'll be hung out to dry.

Stabilize the kid until they get there to the best of your ability, then let them do their job.

-d
 
  • Like
Reactions: cbrons

medicsb

7+ Year Member
Jun 3, 2009
211
37
PA
Status
Resident [Any Field]
Most EMS' have protocols for "physician on scene". Keep in mind in the US, paramedics act under the medical direction of a physician and they are only to follow his/her protocols or someone delegated to give orders (e.g. an EM physician delegated to provide online medical command). Often it is required that you (the on-scene physician) contact medical command to discuss your credentials, etc. and only then they *may* pass on medical command authority to you (they are by no means required to pass command on to you). Almost all protocols require that you ride WITH the paramedics to the hospital; if you do not agree to ride, you have no authority to command the paramedics. Until you are "command", you have no authority to dictate care.

When I worked as a paramedic, I never had a physician try and dictate care. Some would make known their preference, but were not pushy. But, all were not EM, but usually FM, IM, surgery, pediatricians, etc. I was happy to listen to them and consider their recommendations, (other medics would care less) but ultimately I was bound by my protocols or my command doc. Most on-scene docs would walk out of the room as soon as we arrived, saying very very little.
 

Birdstrike

7+ Year Member
Dec 19, 2010
5,245
4,428
Status
Most of these incidents start with all the non-medical people around panicking, 100% certain there's been a decapitation/evisceration or devastating spinal cord injury all which can be fixed in a snap, "If only we can find a 'doctor,' like a dermatologist, psychiatrist podiatrist, PhD or anyone with a 'D' in their name and magic-healing-hands!" Then in the ED, after 14.5 X-ray series, pan-CT scans and trauma team activations, the diagnosis is clinched as: utterly survivable minor scratch/contusion/sprain +/-hurt-feelings.

Assist until EMS arrives, then let them do their job and get back to your life asap. They have life saving equipment and are on the clock. You're a dude or dudette in business casual with a hot dog and nacho cheese on your face, at a game. Get back to your seat asap and resume cheering, "Go Team."
 
Last edited:

WilcoWorld

Senior Member
10+ Year Member
Nov 2, 2004
3,018
1,778
Status
Apart from the legal issues mentioned above, I'd add that paramedics are probably better at delivering care in the field than most docs (including myself). Perhaps a doc who used to be a paramedic, or someone who is an expert in austere medicine are exceptions. But for the most part, I need to be in the ED, with all of its accuotrements, in order to of much use beyond BLS care.
 

Angry Birds

Angry Troll
7+ Year Member
Dec 4, 2011
1,275
1,553
Status
Attending Physician
I'm sure it varies from state to state, but what I've heard is that you could force yourself on them as the leader, in which case you need to accompany them all the way to the hospital.

But, this is *NOT* a good idea. EMS will think you are some yahoo and call their resource hospital to let them know that some yahoo is trying to take over. Plus, why on earth would you want to accept the medico-legal responsibility for this?

Like WilcoWorld said above, it's a totally different environment, one that you as an ER doc are not used to. Other than stabilizing c-spine (which I don't even know if this has proven to be useful), what else can you really do in such a setting? You could stabilize c-spine before EMS arrive, ask someone to call 911, and tell people to calm down. Those three steps would at least make people feel better.

Unless you are a transformer who can transform into an ambulance, then in that case that would be a game changer.
 

tkim

10 cc's cordrazine
15+ Year Member
Aug 2, 2002
7,638
364
New England
Status
Attending Physician
When I was a paramedic, I worked in physician-heavy towns, so there was always a dentist, internist, or hematologist around the corner trying to look like they could do stuff. We carried and handed out pre-printed "Medical Control cards" - i.e., the "Fxck off" cards, that basically said we were some ER docs biznitches and if they wanted to take over, it would be after they had a talk with our medical control, blah, blah, they would have to accompany the patient, blah, blah. By the time they finished reading the entire card, they'd either lose interest in being street hero, or we'd be loaded and drive away before they had a chance to jump on.

Even though I am EM trained, and a former medic, I would not get involved on a street call unless it looked like there was lots of work to go around, i.e. MCI, or a new medic was trying to put a tube in backwards. Or if it was my family member and they were screwing things up royally. Otherwise, I'd leave it alone.

Of course, there are some situations that medics can't handle and need a doc.
 
Last edited:
  • Like
Reactions: CraftyMed

engineeredout

10+ Year Member
May 11, 2008
3,434
601
Pennsylvania
Status
Fellow [Any Field]
Like WilcoWorld said above, it's a totally different environment, one that you as an ER doc are not used to. Other than stabilizing c-spine (which I don't even know if this has proven to be useful), what else can you really do in such a setting? You could stabilize c-spine before EMS arrive, ask someone to call 911, and tell people to calm down. Those three steps would at least make people feel better.

Unless you are a transformer who can transform into an ambulance, then in that case that would be a game changer.
Seriously. This applies to most public medical issues that come up. There is virtually nothing we can do aside from what was mentioned above. And with all respects to Hollywood, I'm not going to perform a cric with a pair of scissors and put in a straw for the patient's airway. 99/100 best thing that can be done is transport the patient to the ED rapidly, which I don't plan on doing in the back of my jeep on top of my ink stained white coat and countless amounts of papers and empty energy drink cans.
 

WilcoWorld

Senior Member
10+ Year Member
Nov 2, 2004
3,018
1,778
Status
I should clarify that BLS offers some very important interventions:

-Bystander CPR saved my dad's life (and brain).
-An effective jaw thrust can resolve many (most?) field-treatable airway emergencies.

But when EMS shows up, I'm more than ready to hand it over to them.
 

southerndoc

life is good
Moderator Emeritus
Lifetime Donor
15+ Year Member
Jun 6, 2002
12,110
1,115
Atlanta
Status
Attending Physician
If you were at your kids football game and there was a major trauma (say one of the kids suffers a major head injury).

You run out to attend the injured (because everyone there expects you to and/or you have a legal obligation). The paramedics are on the scene 3 minutes later.

Who is actually in charge? The off-duty EM physician or the paramedics?
The paramedics are in charge where I practice. I'm the medical director for a very large fire department and another county-based EMS agency. We have "medical professional intervener onscene" protocols that covers PA/NP and MD/DO.

Here is an excerpt from our protocol:


1. EMS should advise the healthcare provider on-scene that a patient-physician relationship has been established with the patient through offline medical direction by the EMS medical director and his physician advisors. EMS should notify the healthcare provider on-scene that they are operating under standard clinical operating guidelines that were developed and are closely supervised by the medical director and his designated physician advisors. Every effort should be made to work with the healthcare provider on-scene in a collegial environment so long as the care provided by the healthcare provider is not an invasive procedure, administration of medication, reduction of fractures/dislocations, or other medical care that is outside the normal care provided by a medical first responder (i.e., basic life support level care).

2. If the healthcare provider on-scene is a mid-level provider (physician assistant, nurse practitioner, etc.), then EMS may NOT release care to that provider under no circumstances. Doctors of chiropractor (DC), doctors of ophthalmology (OD), doctors of medical dentistry (DMD), doctors of dental surgery (DDS), doctors of naturopathic medicine (ND), or other healthcare providers who are not duly licensed doctors of medicine (MD) or doctors of osteopathy (DO) specifically by the Georgia Composite Board of Medical Examiners do not have the authority to take command of patient care on-scene in the pre-hospital environment.

3. EMS personnel may release patient care responsibility to an on-scene physician only after:

A. The physician has been identified as a Georgia licensed physician and has offered an active non-expired physician license by the Georgia Composite Medical Board along with a valid government-issued photo identification; AND,

B. Obtaining from the physician a commitment to accompany the patient to the hospital in the vehicle transporting the patient; AND,

C. Having the physician speak directly to the medical director, his designated physician advisors, or the physician responsible for online medical direction (the online medical control physician in the receiving emergency department) and receiving authority to release the patient to physician care to operate outside standard operating protocols/clinical guidelines.

D. In the absence of any of the above factors, the patient may not be released and care will continue as if no physician were on the scene. Law enforcement officers should be contacted in any conflict situation. If the healthcare provider on-scene is desiring to operate outside clinical guidelines, and in the best judgement of the highest trained EMS professional on-scene appears to be not following standard of care, or if the EMS provider on-scene is not comfortable with the care suggested by the healthcare provider on-scene, then law enforcement should be notified immediately and the healthcare provider on-scene should be advised they will be arrested if they do not discontinue their behavior.

E. In the situation where a patient encounter occurs at a private physician’s office who is already under the care of a private physician, reassure him/her that paramedics operate under protocols and standing orders, and the paramedic in charge will be in contact with the emergency department for treatment orders and consultation if outside standard operating guidelines. Only after A through C have been met shall the primary care physician provide treatment, including medication orders, that are outside protocol. This does not exclude the ability of the physician or his/her designated healthcare providers (nurse, medical office assistant, etc.) to have the ability to personally administer medications to the patient from medications supplied by the physician's practice.

3. On-scene medical oversight may be provided by the EMS medical director and/or an EMS physician advisors without securing permission from the direct medical control physician in the emergency department. These individuals are identified by the service director of operations and medical director in advance.
 
  • Like
Reactions: Daiphon and cbrons

Apollyon

Screw the GST
Lifetime Donor
15+ Year Member
Nov 24, 2002
20,322
5,108
SCREW IT!
2. If the healthcare provider on-scene is a mid-level provider (physician assistant, nurse practitioner, etc.), then EMS may NOT release care to that provider under no circumstances. Doctors of chiropractor (DC), doctors of ophthalmology (OD), doctors of medical dentistry (DMD), doctors of dental surgery (DDS), doctors of naturopathic medicine (ND), or other healthcare providers who are not duly licensed doctors of medicine (MD) or doctors of osteopathy (DO) specifically by the Georgia Composite Board of Medical Examiners do not have the authority to take command of patient care on-scene in the pre-hospital environment.
OD's are optometrists, and "doctors of optometry". It's jargon, but they're not "doctors of ophthalmology".

I don't know if you have any juice to update this, but, as the regs name-check NDs, DMDs, DCs, and DDSs, I would guess (uneducatedly) that that would be an easy fix.
 

Vandalia

5+ Year Member
Feb 21, 2014
561
768
Status
Attending Physician
I think the whole thing boils down to something very simple: how do you know that someone is what they say they are when you are - perhaps quite literally - in the field?

In my state, the wallet id-card is about as secure a document as a 1970's social security card - and most of the other physicians I know don't even carry it, they put it in the picture frame in the office that holds their license. (I have a very strong suspicion that this is not a coincidence. It resolves a lot of potential issues for them as well. I am also willing to bet that the likelihood of someone carrying the wallet card is inversely proportional to their value in an actual emergency.)

As an aside, someone just mentioned to me that there can be significant problems if a physician loses any part of his physical license documents - including the wallet card. Hence the picture frame.
 
  • Like
Reactions: emememem

southerndoc

life is good
Moderator Emeritus
Lifetime Donor
15+ Year Member
Jun 6, 2002
12,110
1,115
Atlanta
Status
Attending Physician
OD's are optometrists, and "doctors of optometry". It's jargon, but they're not "doctors of ophthalmology".

I don't know if you have any juice to update this, but, as the regs name-check NDs, DMDs, DCs, and DDSs, I would guess (uneducatedly) that that would be an easy fix.
You are correct. It's a typo.

I do have the means to update it. I'm the one who wrote it.
 
  • Like
Reactions: cbrons and Apollyon

dchristismi

Gin and Tonic
15+ Year Member
Dec 4, 2003
1,035
451
Central Florida
Visit site
Status
Attending Physician
I happened to have the wallet card on me when AirFrance asked to see it, after paging 3 times overhead if there was a doctor on board. (And yes, I stalled until the 3rd page. It was a freaking 747 after all.) I absentmindedly stuck it behind my DL and voter reg card once, and was glad it was there. Thankfully, all we needed was some paracetamol and ice that day.
 

WilcoWorld

Senior Member
10+ Year Member
Nov 2, 2004
3,018
1,778
Status
I happened to have the wallet card on me when AirFrance asked to see it, after paging 3 times overhead if there was a doctor on board. (And yes, I stalled until the 3rd page. It was a freaking 747 after all.) I absentmindedly stuck it behind my DL and voter reg card once, and was glad it was there. Thankfully, all we needed was some paracetamol and ice that day.
Good thing you could speak French.
 
  • Like
Reactions: emememem

dozitgetchahi

10+ Year Member
Oct 21, 2008
1,583
611
Status
Fellow [Any Field]
"Every effort should be made to work with the healthcare provider on-scene in a collegial environment so long as the care provided by the healthcare provider is not an invasive procedure, administration of medication, reduction of fractures/dislocations, or other medical care that is outside the normal care provided by a medical first responder (i.e., basic life support level care).'

So if some dude appears to be having an MI and somebody else in the crowd has aspirin, there's going to be a problem if I tell the dude to chew 325?

(This would be before the EMTs show up, presumably.)
 

Perrin

sittin in the morning sun
15+ Year Member
Apr 6, 2004
3,370
1,556
40
The Porch
Visit site
Status
Attending Physician
I doubt giving an aspirin to someone with chest pain would land you in hot water. Aspirin is OTC and if you're worried, just offer the person an aspirin and let them accept or refuse. I may be wrong, but it doesn't sound like you are offering care outside of what a Good Samaritan would do.
 

CajunMedic

10+ Year Member
Mar 24, 2009
778
517
Officially in West By God Virginia
Status
Resident [Any Field]
I doubt giving an aspirin to someone with chest pain would land you in hot water. Aspirin is OTC and if you're worried, just offer the person an aspirin and let them accept or refuse. I may be wrong, but it doesn't sound like you are offering care outside of what a Good Samaritan would do.
Sounds right. That's also the same thing the Emergency Medical Dispatcher will instruct someone to do if that agency has those type of pre-arrival protocols.

Usually around here, on-scene physician is in charge until we get there. The parish I worked in, we had the usual policies concerning bystander physicians-we could only take orders from them if they agreed to ride in to the ED and sign off on the run report as medical control. The only exception was if it was a known to us EM physician, that worked in one of our designated online med control facilities.

Smoothest cardiac arrest scene I ever worked was in a front yard, next door to one of the local family practice docs. Neighbor collapsed during his office Christmas party. Him and 2 of his RN's did CPR until we got there. We got on scene and he went "Ok guys, the medics are here, let's let them take over." and they all backed out and took care of the family.
 

Birdstrike

7+ Year Member
Dec 19, 2010
5,245
4,428
Status
At medical catastrophe situations, I jump right in, loudly and boldly announce I'm a physician and that I'm here to bring calm, control the chaos and do what my training has taught me is most important. At that point I hand out Press-Ganey surveys, then peace out.

 

Doctor Bob

EM/CC
10+ Year Member
Feb 12, 2009
1,834
2,249
Orlando
Status
Attending Physician