1. #1
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    Default Over rideing "higher" medical care?

    I had my scanner in my truck on and I heard a call about a 1/4 mile down the rd. for a "Man down". I find a elderly gentleman on the ground turning blue with puke comeing out of his mouth. I see a Dr. doing the compressions,he is doing them "TV style" I get down to clean out the airway and a lady come running over and saying she is a nurse so I back out of the way and let her take over because she had "Higher medical training".

    Well I notice she hasnt even attempted to open the airway,and this doctor is useing a stehoscope to try to find a heart beat which makes no sense to me cause we dont got a defib and after this long with a blocked airway he aint gonna have heart beat. And this guy is just getting blue and bluer then the fd arrives and they take over and this guy gets some real care.

    So my question is, "Can a First Responder take over and do cpr at a scene like this where people with "Higher medical training" arnt rendering prudent care at all?" I dont want to knock them because they meant well but to be honest they didnt have a clue on what to do,im not a expert but I'd atleast give a try to clean out the airway and I do the compressions right.

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    When I was running on the bus, I had a very wise medic tell me that those who demand to help will provide none. Here's how I have handled this situation in the past.

    Simply, I ask if that physician or nurse is going to assume responsibility for the patient and stay with that patient until the patient is turned over to the hospital. At that point, they will normally say "no". I would politely tell them thank you and now please get the *&% out of my way. It worked.

    Remember this. The nurse might work in a plastic surgeon's office, or for an insurance company doing record reviews, or in a hospital doing recruiting (My wife is an ED nurse, these people exist) and may not even be certified in CPR. The doctor may be a total bonehead you wouldn't take your dog to.

    It seems to me that you have a moral. legal and ethical responsibility to ensure that the care provided to the patient is the best possible. If you refuse to let them provide substandard care, what is the worst that can happen to you? They get mad and write a nasty letter?

    Don't forget to chart the whole incident as it happened.

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    Cool Do podiatrist do compressions with their feet?

    George is exactly right. 99.9% of the time, if the Doctor hears that he has to assume patient care responsiblilty, and transport the patient to the ER, the doc is out of there faster then a Fleet Enema. When I first received my state paramedic certificate, I also received a wallet card that all the medics called the (bad word)-off card. It merely stated the rules of engagement for any of those good samaritan doctors out there.

    As for nurses.....love them like crazy, but in Washington State the medic in the field is considered the higher level for first on. If I call in an Airlift helicopter, I'm still responsible/in charge of patient care until I hand the patient over to flight nurses.

    What it comes down to is....don't let egos get in the way of good patient care. If the Doc and nurse are kickin' some butt, join in and find out how you can assist. If their losin' their butts, get them away from the patient and document, document, document.

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    Default I'll go with George on this one

    I have yet to see a Dr. in the field so I can't vow for the reaction but it does seem correct.

    Now the way that I see it is ask the MD and the RN if they have received any training in the field. Most likely the answer will be "No, but...." At that time I would be telling them to "kindly" step back and let me help this PT that you aren't helping. It seems like lots of Medical "Professionals"( MDs, RNs) get bad tunnel vision and honestly want to help but don't think about what might be wrong.

    But that's only my opinion, I could be wrong.

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    The Massachusetts Office of Emergency Medical Services ahs issued memos, and I believe a protocol, about this.

    If we, as a field provider, are instructed by an unknown physician who wishes to take over care we are to have that physician speak with our medical control MD who will then explain to them, in no uncertain terms I am sure, that we, the field providers, are in charge and responsible for the patient. If the MD still refuses to relinquish care, he must go with the patient to the receiving hospital and will have to write his own patient care report for documentation. I also believe that the Medical Review Board will become involved as well as a few other "interested parties."

    I also will tend to believe that a physicians malpractice insurance will not cover them outside of the "Controlled environment" either. I have never run into this situation either but I do know of a few cases locally where this has occurred. Fortunately, many of these inflated egos understand the situation and just back off as soon as we show up (This I have witnessed myself).

    Before disregarding the MD or nurse altogether I will ask what their specialty is and since it will most likely be irrelevant I will then kindly disregard them.
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    In my opinion, care can only be passed off to someone with higher care as long as they are with their responding agency (ie: medivac or ALS fly car). If they stop in their personal vehicle I won't say they can't help, if the help is needed, but they need to be supervised.

    My agency is a volunteer BLS transporting agency. There are members that are paramedics with other agencys. When these medics ride with us, under our certification, they know they can only provide care to a BLS level (aside from the fact that we don't carry the equiptment needed for medics).

    As far as the unknown "good samaritan" nurse is concerned, ask for their certification. See if they have PRE-HOSPITAL training. In my experiance the ones that don't are "lost" in the field. One or two have told me that. Being in the field where everything isn't "layed out" for you is much more difficult than in a hospital setting.

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    Default Higher Medical Care?

    I am not sure, in the situation that is described, that we need to worry about medical certification levels and who has a higher level of training. What we are talking about, as I understand it, is BLS CPR without any equipment/adjuncts. If this is the case, then the EMT with a CPR card and no equipment is just as "certified" as the doctor with a CPR card and no equipment. dfdex1 - I understand your question, but I would ask of you, did they have any special skills, training, or equipment in that scenario that you did not possess? If the answer is no, then as I see it, there is no case for turning over care to a "higher authority".

    Now, about thier apparent lack of ability to perform BLS CPR. It has been my experience that given proper direction, even a layperson with no training can help. Could you have told the nurse, "I'll take over the airway, can you (give an assignment) - get a history from the family OR call 911 and verify that an ambulance is enroute and tell them we are doing CPR OR talk with and comfort the family. Maybe we should recognize poor performance and direct those to a task that is more suited for their background. As far as the poor chest compression, a little coaching should have taken care of that problem.

    I commend you for your willingness to step in and take action, especially of a puke filled airway without equipment! My first time doing CPR as a first arriving person (without equipment), I was offered "help" by Dr. Soandso. I quickly realized that this doctor was not trained in CPR. And in 1980, most DENTIST were not! I learned a lesson about people who are introduced as doctor, nurse, even EMT or paramedic.

    John

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    check with your state department of health. every state is different. here in texas we ask what specialty the doctor is and if they accept full responsbility of the patient. they must also ride in with the patient to the hospital. obviously we are not going to allow a foot doctor treat a chest pain patient. most of the time if the patient is not one of the doctor's own then they will relinquish responsbility of the patient to anyone else.

    but i would check with your health department and medical control to see what they recommend.
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    A couple of weeks ago, my Engine Co responded to a report of a possible heart attack at a local church. Since it was my parish, I knew it was the annual festival. We arrived to 10 people waving us into the parking lot. We walked into the gymn to find a wall of nuns blocking the crowd from the 87 y/o male patient. CPR was in progress by 3 people, who claimed to be an RN, a nurse anesthitist(?), and an MD. The N/A was screaming at me for a tube-I offered a combitube (we're BLS), but she didn't know what it was. When I went to use the BVM, she yanked it out of my hand. I thought fine, I'll start compressions, but the AED showed a pulse. The private medics arrived, and I expected them to tell our "helpers" to beat it. They didn't, and the N/A and the doctor kept messing with the tube and getting in our way. We had two more MDs walk up and offer to help, the medic told them we already had too many doctors. We rode with the ambulance to the hospital to help work the guy. The drugs got him into v-fib, and we defibbed him 4 times enroute. He died anyway.

    My wife was in the gymn when the guy went down and saw it happen. She said the nurse and the MD were right there, and spent 5 minutes doing the Heimlich before sending someone to call 911. He was eating when he dropped, so they assumed he was only choking.

    Our crew had a talk with the ambulance crew and we agreed to never let anyone push us around like that again. Even if they hadn't been so pushy, they completely destroyed our rhythem and teamwork. If you would have asked me before the run, I would have said we would run them off right away. But when you have 500 people watching, and the MD is using his "I'm in charge" voice, it's harder to do.

    BTW, Michigan law requires an MD to go to the hospital and be responsible for the patient or get out of the way. Our helpers disappeared as soon as we got the guy on the stretcher.

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    DFD,
    The question you pose has answers that can depend on your state protocols and/or procedures. For me it falls under the EMS region I am working in, in regards to ALS protocol. But there is another important answer that jumps out at me that I didn't see anyone else come up with. You were in your POV, when you arrived you were just as good as private citizen, you weren't acting as being "on duty." Now I am speaking from NY which you would then be protected under good samaratin law, so no you wouldn't have to pass care. If you were on duty, you have to make the call, and I would have took some direction from the Doc. I would also have explained to him that if he continued he would have to take responsibility for the patient and accompany me to the ER, and we carry forms so they know we aren't B.S.ing!!
    There are a couple of other things I noticed in your post that I'd like to point out. #1..The doctor wasn't wrong for checking for a heartbeat, just as you should check for a pulse. Don't ever assume. There is nothing wrong with listening for a heartbeat, in fact on pediatric patients I find it much easier. And not having an AED has nothing to do with doing a pulse check and/or listening for heart sounds. Just as the level of cyanosis a patient displays doesn't indicate whether or not they have cardiac function...they could have been hypoxic and converted with CPR, you don't do a pulse check or whatever and start compressions again and you can cause more problems.
    Also could you tell me what "TV Style" compressions are?
    Also George made a great point about nurses, you never know what kind they are. Not to mention that there aren't too many nurses who do their job on a street corner. If they ask, I'll always tell them nicely "I got it." Then comes the nastiness if need be. Finally, I also wanted to just add that you may want to post this in the EMS General section, you may get more replies being that some of them don't venture into the fire portion. And there is tons of experience and insight with my gang in there.

    GunnyV, with all due respect to a fellow Marine, a AED cannot tell you a patient has a pulse. It only shows the electrical rhythem which doesn't mean the mechanical is operating.
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    I was just a civilian with training who diecided to stop,I knew 911 had been called cause I heard it on the fire channel.

    The TV style compressions is what the instructor calls compressions that dont compress the chest the person just bends there arms---as seen on tv!

    As far as the checking for a heartbeat-yes I agree ,but not the way he did it he would stop in the middle of his "TV" style compressions at about 8 and check.

    I follwed my training found out what happend and it sounded like a heart attack so I was prepared to treat for heart attack,if it was something else it was something else im not dr.

    Thanks for the advice though I know what ill do next time.

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    DFD I understand more know about the compressions, and yes obviously he wasn't all that effective or correct. But then again, I haven't seen all that many doctors do CPR.

    Just keep in mind that while you may think he had a heart attack, he was pulseless and apneic, and with a obstructed airway. So it was clear the airway and CPR, there was no treatment for an MI being he was dead. Plus you were even farther behind the 8 ball being you were in your POV.

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    One more thing...50% of all doctors graduated in the bottom half of their class.

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    Like others have said on here before, and from what I have heard, ask the MD/RN/whoever if they are willing to assume full responsibility for the pt until they arrive at the ER AND if they are also willing to do the documentation.
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    I have waited till I knew the scene was safe to post......

    I have read a bunch of posts and I see the same thing being brought up...does the MD or Nurse want to assume pt care and take responsibility for the pt. But didnt he say in his first post that he had just stopped by after hearing for a call on his scanner (which I will refrain from talking about).
    How many times have you as EMS providers been called to a scene where people are doing CPR....even if they are trained they do not have to assume responsibility for the pt, so I dont see why a MD or Nurse would have to assume responsibility for a pt if all they had done was stopped to assist in CPR until EMS arrives. Now if he had arrived with the ambulance and the MD or Nurse wanted to inject,then yes they would have to talk to my recieving MD and assume responsibility for the pt.
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    Originally posted by hagerff/emti

    ... so I dont see why a MD or Nurse would have to assume responsibility for a pt if all they had done was stopped to assist in CPR until EMS arrives.
    That is what i was trying to get to in my response. In the scenario provided, I see all parties as equals. That is, if each is trained to BLS CPR and nobody has any specialty equipment, then the playing field is level. There is no higher medical authority. If anything, I would bet that physician or nurse didn't have a current CPR card.

    Again, in this situation, don't push any help away. Try to give them directions that would better suit their ability.

    John

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    ..........
    Last edited by MedEvac; 02-12-2010 at 02:02 AM.

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    MD's and RN's have a wide educational base to pass licensure in their respective fields, then advance into a clinical specialty. Many don't know the first thing about prehospital care and have never performed CPR outside of the classroom setting. Yes, MD/RN's have a 'higher level of education' but the question you need to ask is - In what? Possibly Emergency Care or maybe Psychiatry.
    My wife (busy ED nurse) once sent a new resident in to check on a patient who was obviously dead. Lo and behold, after a twenty minute assessment, the doctor came out of the room with a list of tests he wanted done and orders he wanted filled. Keep in mind, this patient was cold.

    Somewhere out there is the worst doctor in the world. My luck, he finds his way into my EMS run.

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    For my fellow Devildog ALS Firefighter,
    You are of course correct. I guess what I meant was that we hadn't found a good pulse yet. The fact that he had a decent rhythem showing on the AED just prompted us to try a little harder to find a pulse, which we did at the carotid. Again, we had two RNs and an MD telling us he had no pulse, you expect them to know what they are talking about.

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