Who's In Charge Of The Patient?

[x635 4,066]

While discussing this with a friend today, I though this might make for interesting discussion here.

Let's take TWO situations:

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?

[INIT915 1,119]

While discussing this with a friend today, I though this might make for interesting discussion here.

Let's take TWO situations:

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......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?

Situation #1 - You, the Medic, should be in charge of patient care.

Situation #2 - If you have ALS gear, considering accompanying the BLS unit to the ER. Without ALS gear, your not much better equipped than the BLS unit, so turning care over to BLS seems reasonable.

[OoO 24]

Situation #1 - You, the Medic, should be in charge of patient care.

Situation #2 - If you have ALS gear, considering accompanying the BLS unit to the ER. Without ALS gear, your not much better equipped than the BLS unit, so turning care over to BLS seems reasonable.

Agreed.

[Guest alsfirefighter]

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?

Situation #1: You perform patient care if your first line supervisor best thinks that you are better apt at handling a treatment that needs to be done.

Realistic answer #1: While we may wear Paramedic on our sleeves, we are only considered the level of provider that the agency you are operating under or performing a function for. So therefore in this case...you are nothing more then a CFR with a whole lot more training and probably experience. No different then when I am working on the BLS engine at work. I am only an EMT at that point. If the Lieutenant on the engine is a good manager he will know your skills and level of training and best use it. If not that is up to him and as stated according to NYS DOH you are only a level of provider equal to that of your agency.

Situation #2: Yet again you are only operating as a CFR. How can you perform ALS...if you aren't operating under an ALS credentialed agency, and do not have any ALS equipment. Again if its a situation where say you are bagging better then anyone around...or the BLS crew knows you and says we're gonna need help..that is still up to the OIC on your engine.

The other side of this equation is, if you are a Paramedic working as BLSFR, wether its EMT-B or CFR...you shouldn't be handling all patient care anyway. You should be that supportive, educator that all good Paramedics are to the rest of your crew so they gain the same comfort and experience you have at that BLS level.

[NWFDMedic 58]

Situation #2 is interesting because you should not be turning over a patient requiring a higher level of care to someone of a lower level of care, even if you don't have the equipment. Even if you are operating as a CFR, you are a still a paramedic in New York State and I imagine some abandonment issues come into play here. If that BLS provider did something even at the BLS level that was harmful to the patient that an ALS provider would have known better to do, you would be liable for that harmful care (ie. giving a treatment to a CHF patient).

[nycemt728 49]

NWFDMedic, I agree w/ the other posters, you cannot be considered ALS (despite your cert) w/o proper equipment and agency licensure to operate at the ALS level, and quite frankly if you try any ALS maneuvers (esp if it goes wrong), you could proably be cited for going above your scope b/c of it. Despite your cert, your agency is still not at the level you are at, and as you are on duty for that particular organization, you can legally only operate at that level of care. If you can't handle not playing medic when you shouldn't be, then you need to remove yourself from that situation. That being said, it is probaly very hard to work BLS as a regular ALS provider.

As for the first situation, I don't know how FD works it, but so long as the cert is valid and the skills kept up, the person certified to provide the highest level of care allowed to the agency should be in charge of the pt.

[ONEEYEDMIC 68]

Situation #2 is interesting because you should not be turning over a patient requiring a higher level of care to someone of a lower level of care, even if you don't have the equipment. Even if you are operating as a CFR, you are a still a paramedic in New York State and I imagine some abandonment issues come into play here. If that BLS provider did something even at the BLS level that was harmful to the patient that an ALS provider would have known better to do, you would be liable for that harmful care (ie. giving a treatment to a CHF patient).

I don't see any abandoment issues. As a matter of fact there probably are lots of FF/Medics that turn PT's over to BLS ambulances everyday right here in this COUNTY. What are you going to do as a MEDIC for a CHF PT with BLS equipment. O2. That is about it. So why put your FULL TIME JOB as a FF down on manpower when there is nothing for you too do? What if you are a COP but also hold the certification as a MEDIC and get sent on a call where no medic was available. The BLS crew shows up and it is indeed a BLS PT. Should I step in and say that I am a MEDIC and I need to ride this call in because I am going to be worried that the BLS crew doesn't know what they are doing. Of course not. Lets use some common sense here.

If you don't know what to do at a BLS level for a CHF PT then you shouldn't have passed your EMT course or be riding on and AMB. Just because somebody holds the title of PARAMEDIC doesn't mean what he/she says is GOSPEL.

[Guest alsfirefighter]

Situation #2 is interesting because you should not be turning over a patient requiring a higher level of care to someone of a lower level of care, even if you don't have the equipment

The point is...your not. You are turning over a patient to a higher level of care in the state's eyes if you are only a CFR level agency. If you are a BLS agency you are turning over the patient to the same level of care for transport if you are only BLSFR. Disposition 004...Treated by this unit...transported by another.

There is no abandonment issue, because you never abandoned the patient.

Think of it this way in situation #2. You are the Paramedic that intercepts with the ambulance or arrives on scene as the patient is being loaded...is it negligence if you only perform BLS skills while enroute because your best option is to get the patient to the hospital and that is all you got accomplished while enroute? No. BLS before ALS and sometimes the best treatements are BLS treatments while transporting.

[NWFDMedic 58]

I don't see any abandoment issues. As a matter of fact there probably are lots of FF/Medics that turn PT's over to BLS ambulances everyday right here in this COUNTY. What are you going to do as a MEDIC for a CHF PT with BLS equipment. O2. That is about it. So why put your FULL TIME JOB as a FF down on manpower when there is nothing for you too do? What if you are a COP but also hold the certification as a MEDIC and get sent on a call where no medic was available. The BLS crew shows up and it is indeed a BLS PT. Should I step in and say that I am a MEDIC and I need to ride this call in because I am going to be worried that the BLS crew doesn't know what they are doing. Of course not. Lets use some common sense here.

If you don't know what to do at a BLS level for a CHF PT then you shouldn't have passed your EMT course or be riding on and AMB. Just because somebody holds the title of PARAMEDIC doesn't mean what he/she says is GOSPEL.

If you have FF/Medics turning ALS patients over to BLS ambulances in your county, your system is severly flawed.

[NWFDMedic 58]

Think of it this way in situation #2. You are the Paramedic that intercepts with the ambulance or arrives on scene as the patient is being loaded...is it negligence if you only perform BLS skills while enroute because your best option is to get the patient to the hospital and that is all you got accomplished while enroute? No. BLS before ALS and sometimes the best treatements are BLS treatments while transporting.

That's a completely different situation. You didn't abandon the patient, you rode the patient to the hospital. If you are the highest trained responder on the scene, regardles of your affiliation you DO bear some responsibility for the patient, regardless of the equipment in your bag or the level of the agency you respond with.

[ONEEYEDMIC 68]

If you have FF/Medics turning ALS patients over to BLS ambulances in your county, your system is severly flawed.

Lets get on the same page here. For this situation, the FF is a MEDIC. He/She does not perform ALS skills at any other time other than when he/she works their 'B" job. The FD job only requires you to be a CFR. You just happened to be the highest LEVEL when you get hired. You go on and EMS call where only a BLS crew is AVAILABLE. IT happens to be a CHF PT what is that MEDIC to do? Ride in a ALS PT on a BLS AMB with BLS EQUIP?

I might be missing what you are saying. Does the FF/MEDIC have ALS gear? Then that is a DIFFERENT story. THen of course they shouldn't turn over the PT to the BLS crew.

Yeah the system is flawed. Have you not been reading other topics. BEING A MEDIC does not make you a GOD.

Have you ever been on scene when somebody walks up and says that they are DR. You ask what KIND. Lets say ER DOC. Are you going to let that PERSON who has a HIGHER LEVEL OF TRAINING THEN YOU work on your PT. HELL NO your NOT. How come? Because it is YOUR PT and what are they going to do that you can't.

[Guest alsfirefighter]

If you are the highest trained responder on the scene, regardles of your affiliation you DO bear some responsibility for the patient, regardless of the equipment in your bag or the level of the agency you respond with.

Of course you do...if something goes terribly wrong, or you do something inappropriately or you witness someone do something incorrectly and do not do anything about it. However, this doesn't include the transfer of a patient to a an agency that has the same level of care as I have at that point.

As far as bearing responsibility, you only bear the responsibility at the level in which the agency you are working operates at. You can't hold me responsible if a patient has an airway obstruction that cannot be cleared by BLS skills/equipment, if I only have BLS equipment and operating at work under an BLS agency. Does it suck when it happens...yes. But it is what it is.

If you have FF/Medics turning ALS patients over to BLS ambulances in your county, your system is severly flawed.

No we have Firefighter/Medics who can only work as EMT's because their agency isn't an ALS agency to BLS ambulances for transport in each agency service area. Do I like it no. But this is the NYS system. Where I work we are fortunate that we have Paramedics available and assigned to a call 98 to 99% of the time. This doesn't happen often and even when it does we have a hospital 5 mins. maximum away drive time.

Home Rule State. Everything is AHJ and that is why its never a county issue its a local issue and local level government just never gets it.

[Guest alsfirefighter]

NYS Policy Statement

#06-04 BLS-FR Services Information

Personnel certified at Advanced EMT levels may NOT render care beyond the scope of practice of an EMT when providing care for a BLS-FR service. Defibrillation may only be provided by agencies with either PAD authority or BLS-Defibrillation authority as granted by a Regional Emergency Medical Advisory Committee

Footnote #1 at the bottom of page number 2.

Here is the link:

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

[firemoose827 324]

"What we have here is, failure to communicate..." lol sorry, had to get that in!!

Most of you fail to see the point that ALSFIrefighter is making, it all boils down to the LICENSURE LEVEL of the responding agency. This Engine is LICENSED as a CFR Unit, and therefore can only perform CFR duties, and the Paramedic can NOT perform ALS duties. SO he cant practise his skills...I believe its called "Practising above your scope", correct me if Im wrong. In order for the medic to be able to perform his ALS duties he would need to be assigned to a Paramedic Level Engine. Without the NYS DOH License on the rig, you cant perform the skills REGARDLESS if you have a medic card or not. Does this clarify for a lot of people?

Another thing for the first situation, with the firefighter/medic and the CFR Lieutenant...Had the engine have been an ALS unit, the Medic would be in charge of the patient, the Lieutenant would be in charge of the scene.

As far as situation 2, the licensure thing plays here also. The Engine is BLS ONLY, so they are performing BLS skills and the Medic can not ride on the bus in the capacity of Paramedic. Sucks, I know, but thats the rules NYS has in place to protect the responders' gluteous maximus'!! lol

[NWFDMedic 58]

Have you ever been on scene when somebody walks up and says that they are DR. You ask what KIND. Lets say ER DOC. Are you going to let that PERSON who has a HIGHER LEVEL OF TRAINING THEN YOU work on your PT. HELL NO your NOT. How come? Because it is YOUR PT and what are they going to do that you can't.

Actually, an appropriately trained doctor has every right to direct patient care at the scene if the medical control doctor you consult approves his assuming patient care. That doctor is then REQUIRED to accompany the patient to the hospital. Usually when you tell a doctor about this little protocol, they walk away and say good luck. If you are a paramedic on scene and you turn a critical patient over to a BLS agency for transport, you better hope your insurance is up to date.

[NWFDMedic 58]

"What we have here is, failure to communicate..." lol sorry, had to get that in!!

Most of you fail to see the point that ALSFIrefighter is making, it all boils down to the LICENSURE LEVEL of the responding agency. This Engine is LICENSED as a CFR Unit, and therefore can only perform CFR duties, and the Paramedic can NOT perform ALS duties. SO he cant practise his skills...I believe its called "Practising above your scope", correct me if Im wrong. In order for the medic to be able to perform his ALS duties he would need to be assigned to a Paramedic Level Engine. Without the NYS DOH License on the rig, you cant perform the skills REGARDLESS if you have a medic card or not. Does this clarify for a lot of people?

Actually, we all understand the scope of practice is based upon the agency. You obviously can't perform renegade ALS skills in New York State. However, you still have a higher level of training in the eyes of the state. You don't magically forget everything you learned about patient care when you ride for a lower level agency. It is your responsibility to make sure that patient receives the proper management and even at the BLS level, your patient management skills trump the provider from the BLS agency.

[ONEEYEDMIC 68]

Actually, an appropriately trained doctor has every right to direct patient care at the scene if the medical control doctor you consult approves his assuming patient care. That doctor is then REQUIRED to accompany the patient to the hospital. Usually when you tell a doctor about this little protocol, they walk away and say good luck. If you are a paramedic on scene and you turn a critical patient over to a BLS agency for transport, you better hope your insurance is up to date.

Your trying to argue with me a moot point. I know that if a DR walks up what to tell him/her. The question was is this an abandoment issue? Read above. No there wasn't. Maybe in BIZZARRO world it is. If the MEDIC can ONLY PERFORM CFR SKILLS WHILE WORKING AS A FF WHAT DO YOU WANT THEM TO DO?

[Guest alsfirefighter]

Well said Moose and thank you for putting what I was trying to say in a different light and that makes more sense then my words apparantly.

NWFD...you are correct..there is also that form that no one carries that you are suppose to have them fill out and off of memory I think they have to use their own stuff.

Is everyone clear now, especially with the post and link off DOH site?

[helicopper 1,050]

Situation #1 - The medic can and should be in charge of patient care decisions. That may mean directing the CFR's to provide care appropriate to their level of training or actually doing it him/herself. The officer can and should be in charge of the scene - making sure transportation is coming, coordinating with other agencies, etc.

Situation #2 - Given the original scenario, there is no ALS available. So the FF (who is working as a BLSFR) is perfectly within his/her scope to allow BLS to transport. If he/she has ALS equipment, they have to be within the ALS system for which they are given medical control. They can't just "have ALS equipment". The certification does not confer authority to them, operating within an ALS SYSTEM is what gives a medic their authority to perform ALS.

Yes, the medic should absolutely make sure that candidates for ALS receive it within the constraints of the system they're working in. There absolutely is a distinction between being a medic and being a medic within their ALS system and I imagine that you'd be hard pressed to tell the XYZ fire department that one of their employees who is coincidentally a paramedic must accompany every candidate for ALS within their operating area. What about cops/medics? You going to tell PD Chief's the same thing - of course not.

Have you ever been on scene when somebody walks up and says that they are DR. You ask what KIND. Lets say ER DOC. Are you going to let that PERSON who has a HIGHER LEVEL OF TRAINING THEN YOU work on your PT. HELL NO your NOT. How come? Because it is YOUR PT and what are they going to do that you can't.

I wouldn't say that. I've had physicians and nurses assist me more times than I can count. I even remember an anesthesiologist riding with us to the hospital with a crappy arrest. He took care of the airway - soup to nuts. Couldn't have worked out better. So, I wouldn't make blanket statements yay or nay. Not to say I would have done the same thing with a podiatrist, it was a unique situation. He also never gave medical control - that was vested in the ER doc.

[helicopper 1,050]

Actually, we all understand the scope of practice is based upon the agency. You obviously can't perform renegade ALS skills in New York State. However, you still have a higher level of training in the eyes of the state. You don't magically forget everything you learned about patient care when you ride for a lower level agency. It is your responsibility to make sure that patient receives the proper management and even at the BLS level, your patient management skills trump the provider from the BLS agency.

We are not the EMS police just because we're paramedics. There has to be an assumption that a certified ambulance arrives with certified personnel who are competent to perform skills required of their level of service.

You have a higher level of training and knowledge/experience but that does not change the fact that in a BLS system you're a BLS provider.

I would challenge your assertion that we trump the BLS agency having jurisdiction. To do what exactly? We're not an ALS provider in this scenario so what are we going to do?

[NWFDMedic 58]

Well said Moose and thank you for putting what I was trying to say in a different light and that makes more sense then my words apparantly.

NWFD...you are correct..there is also that form that no one carries that you are suppose to have them fill out and off of memory I think they have to use their own stuff.

Is everyone clear now, especially with the post and link off DOH site?

That form nobody carries is actually part of every patient information/billing packet at my agency but that's beside the point.

Maybe you are correct in your opinion but I can tell you for a fact that my former fire department addressed this identical situation with their lawyer. The conclusion that they came to after reading state regulations was that our medics, even in a non-EMS providing agency, had a duty to make sure the patient was receiving appropriate care and it was not appropriate to turn an ALS level patient over to a BLS agency. Of course my department interpreted what the lawyer was saying as "We're not sending our guys on that ambulance unless the EMT's are completely clueless and will kill the patient."

P.S. This very legal opinion led that FD to stop responding to all EMS assist calls because they didn't want to incur the liability.

Edited January 3, 2008 by NWFDMedic

[ONEEYEDMIC 68]

That form nobody carries is actually part of every patient information/billing packet at my agency but that's beside the point.

Maybe you are correct in your opinion but I can tell you for a fact that my former fire department addressed this identical situation with their lawyer. The conclusion that they came to after reading state regulations was that our medics, even in a non-EMS providing agency, had a duty to make sure the patient was receiving appropriate care and it was not appropriate to turn an ALS level patient over to a BLS agency. Of course my department interpreted what the lawyer was saying as "We're not sending our guys on that ambulance unless the EMT's are completely clueless and will kill the patient."

P.S. This very legal opinion led that FD to stop responding to all EMS assist calls because they didn't want to incur the liability.

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.

[Remember585 815]

Situatuon #1 - The FF with the highest level of training should assume care of the patient. If you're all equals, then draw straws. The Officer should be In Charge of the overall scene, which means he holds a radio and not the IV bag, and making sure appropriate resources show up, etc.

Situatuon #2 - I would think the transporting agency is, in essence, a higher level of care then a non-transporting agency, no?

Edited January 3, 2008 by Remember585

[Guest alsfirefighter]

That form nobody carries is actually part of every patient information/billing packet at my agency but that's beside the point.

Maybe you are correct in your opinion but I can tell you for a fact that my former fire department addressed this identical situation with their lawyer. The conclusion that they came to after reading state regulations was that our medics, even in a non-EMS providing agency, had a duty to make sure the patient was receiving appropriate care and it was not appropriate to turn an ALS level patient over to a BLS agency. Of course my department interpreted what the lawyer was saying as "We're not sending our guys on that ambulance unless the EMT's are completely clueless and will kill the patient."

First, that's great that your agency does have those on hand. I've never had a doctor or nurse for that matter that isn't more then willing to hand over patient care. Even in doctors offices I have had cardiologists that have loved that I've given medications off standing orders that they didn't.

Second:

I want to clarify that I'm not getting personal with you in any way and I have valued your conversation and input. With that being said....I think its pretty clear that this isn't "my opinion", its in black and white in a DOH policy statement which I posted the link and a direct quote from.

Not appropriate to turn over an ALS patient over to a BLS agency? So what is the answer...sit and wait for one? And that is better? Your final quote says exactly what I said 2 posts ago. If you see soemthing that is inappropriate then you better step up to the plate and correct it or you could be found at a higher percentage of fault then some other that are there. Lawyers are wonderful and can come up with whatever they want to interpret. All I know is I haven't heard of one lawsuit stemming from the issue at hand. Another thing that just came to mind...if you are not a "EMS providing agency" you have no obligation, nor do you have any medical control on a scene to worry about what is appropriate medical care. You have a personal and professional obligation. If there was anything else, there would be Firefighters, police officers, doctors and nurses who are volunteer firefighers in non EMS providing agencies that would be getting jammed up all over.

[P.S. This very legal opinion led that FD to stop responding to all EMS assist calls because they didn't want to incur the liability./quote]

Well if that's what your department opted to do great for them...but I as a manager never look at a reduction in service as a positive thing and we certainly don't operate under the realm of "liability." I don't know what that lawyer was looking at, and of course I'm not one...but perhaps he might want to look at the policy statement from the link I posted. Seems pretty cut and dry to me...and several other colleagues on here. If you are operate as a BLSFR system and opt to get out of it, you might want your attorney's to look into that end of the deal also, being you are now stopping what you created as a standard of care in your area. According to NYS DOH, my department is a BLSFR agency, if I'm working on the BLS engine...I am nothing more then an EMT operating under a BLS agency. Therefore when the ambulance arrives and no ALS is available I am turning them over to an equal level of agency/provider. Period. They will do nothing more then what I've already done, except I might be able to explain it a little more and tell them they might want to go code 3 to the hospital. I cannot transport as a medic, because 1 I can't leave my engine, 2 I am not operating under the license of an ALS agency with a medical control director. That is a bigger liability and again it changes nothing in the scope of care.

[16fire5 693]

In the City of New York these are the rules.

Firefighters working on the engine companies operate at the CFR-D level regardless of certification. If you know what your doing and take charge of patient care no one will stop you.

At any scene the ranking operations officer is the IC and the highest level of care is responsible for patient care e.g. EMS deputy chief and FD Lieutenant on scene FD Lieutenant is the IC.

It may seem odd to some but it works very well.

[Goose 188]

Seth, nice discussion!

As was said before, if your on a first response engine and you happen to be a medic but your agency is CFR-D, then you can only operate as a CFR-D. The uniform your wearing and not the card in your pocket really delineates what you can and cannot do.

Now, that's not to say you can't have your Lt. call for ALS or if a BLS bus shows up, let them know of your assessment and make a recommendation.

So, who's in charge of the patient? The highest medical authority (IE: the first response engine and then it's transfered to EMS) I haven't had any issue with transfer of care when working with first response engine companies.

[FFLieu 70]

While discussing this with a friend today, I though this might make for interesting discussion here.

Let's take TWO situations:

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?

Situation 1: The Lieutenant. Even though you're a medic, you're only as good as the supplies you have on your rig. Let's just say you go to an asthmatic call and the patient needs a breathing treatment. I'm willing to bet that you don't have a nebulizer and the associated drugs that go with it. Medic or no, you're with the FD, so you're nothing more than a CFR. That also goes for paid medics who also volunteer for VACs in their spare time. It's nice to have ALS skills, but if you're with a VAC, then you're strictly BLS.

Situation 2: BLS is in charge. BLS is the higher medical authority and you must relinquish care to them. It doesn't matter if the patient needs ALS care; BLS is there, they assume care, and then transport to the hospital. It's easier for everyone involved if the patient gets to the ER quickly; if you wait for an ALS unit to arrive, you're wasting time since you could be at the ER faster.

[antiquefirelt 994]

Good topic.

As a fire officer/EMT-I in a ALS providing FD this issue happens weekly. Our ambulances are all sttaffed with EMT-I at the minimum. The engine rolls on all unconscious, MVA's, Code 99's, industrial/commercial accidents and whenever requested for assistance. As the fire officer I am in charge on the scene and the pt. care medic (daily rotation per ambo) is in charge of pt. care. Rarely do the scene and pt. care issues conflict.

Twice in the last 12 years I have had to "overrule" the medic and order them to transport when transport was not indicated (pt. dead no chance or revival). This was done to calm the scene, and in no way compromised patient care, but did benefit the crew and the bystanders at both scenes. I cannot imagine some how compromising pt. care by instructing a medic not to do his/her job 110%. But, then I do start IV's and do whatever is needed at the scene, regardless of my rank (when it doesn't compromise the scene).

On #2: I have no basis by which to judge by NY law, but I'd send the medic in the BLS truck to the hospital and let him/her do whatever was possible. 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. In my dept. our principle is that the pt. comes first, all decisions are based on what is best for the patient and that includes undermanning fire apparatus when there are no other calls pending. We always favor the emergency at hand vs. the potential emergency.

[NWFDMedic 58]

On #2: I have no basis by which to judge by NY law, but I'd send the medic in the BLS truck to the hospital and let him/her do whatever was possible. 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. In my dept. our principle is that the pt. comes first, all decisions are based on what is best for the patient and that includes undermanning fire apparatus when there are no other calls pending. We always favor the emergency at hand vs. the potential emergency.

Exactly what a lawyer would tell you. Maybe I should move to Maine. Of course, the bottom line in all of these situations is that you need to work together to get the job done.

[helicopper 1,050]

On #2: I have no basis by which to judge by NY law, but I'd send the medic in the BLS truck to the hospital and let him/her do whatever was possible. 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. In my dept. our principle is that the pt. comes first, all decisions are based on what is best for the patient and that includes undermanning fire apparatus when there are no other calls pending. We always favor the emergency at hand vs. the potential emergency.

What exactly is accomplished by putting the medic in the very uncomfortable position of knowing that more should be done and not being able to do anything about it? Conceptually, I appreciate that the "medic has more knowledge" but that doesn't translate into performing advanced skills in a BLS setting. All the medic is going to be is another set of BLS hands - maybe THAT is warranted but it could be any BLSFR it wouldn't have to be the medic.

The patient you've got should always come before the call that might be coming but if you have to take first due apparatus out of service because personnel are being used to augment BLS transport units, there will eventually be a problem.

In NYS, a medic in the BLS setting can only defibrillate when an EMT can and oxygen is going to be administered the same way whether you're a PD CFR/EMT/medic, FD CFR/EMT/medic or on the ambulance crew. I don't understand the benefit to the patient or the agency involved by using a medic in this capacity.

I remember when Putnam County had NO ALS - at all - unless you want to count the occasional medevac (they were based in NYC at the time) or the intercept when going to a Dutchess County hospital. I was a medic in Westchester and a volly in Putnam. Are you saying that I should have ridden with every candidate for ALS instead of letting the other EMT's in my agency be EMT's? Frankly, I think EMT's were as intuitive as I would have been and recognized that a patient was circling the drain. They didn't need the extra "P" on my card to tell them that. It also would not have changed the patient outcome because they could do BLS skills as well as I could.