Who is the highest level of care?

[Freshmeat]

I'm an EMT in AZ, basically stationed in mining town 1/2 way from Phoenix to Vegas. As you can imagine, we fly ALOT of patients that are ALS, as ground transport to the nearest Hospital is about 2hrs. Anyhoo, What I'm wondering is who is the highest level of care on scene, when The chopper lands? Is it still my Medic partner, or the Flight RN??? Not really a turf issue, rather just something we were thinking about since occasionally we reach the scene about the same time :shock:

[Timmy]

Well the flight RN. Your giving them a hand over and their taking over care. Team work isnt such a bad thing

[ERDoc]

I agree with Timmy, teamwork is a wonderful thing. In the end it should be the RN calling the shots since he/she is the one that is going to be doing the transporting.

[Doczilla]

The Flight RN. EMS is ultimately not a democracy.

'zilla

[VentMedic]

Flight RN.

The Flight Team may also have more protocols if needed to stabilize the patient for flight. Safety for the patient and the flight crew must be considered for the duration of the flight.

[Freshmeat]

Again, it wasnt a turf post. My partner has never been one degree hot over a flight RN calling shots. Never had one single problem with a flight crew, of any kind whatsoever, we all work very well together. Certain situations just made us wonder who actually holds the reins when there is an RN on scene. A couple Medics I work with stated that the RN was never a higher level of care than a medic at an "outside of the hospital" setting. My partner actually believes that the RN is the highest level of care and has defered transport decisions to them in the past (ground/air when we both hit the scene same time and the patient isnt ALS) Much of the time, we try to do what is best for the patient financially on top of the obviouse medical considerations. A helicopter ride in our area is about $18,000.00 and who knows what an Ins co will do. So can anyone tell me definitively???? I really do appreciate the input!

[VentMedic]

Are both ground and air dispatched by the same service at the same time?

I can assure you that an RN who responds via Flight to a scene has advanced training including scene response and is not "just a hospital RN". He/she will probably have the same and more skills than the ground Paramedic as well as 3 - 5 years minimum in an ICU and ED. The skills include intubation including RSI, central lines, IOs and crics. These RNs also come with the whole alphabet soup and usually a BSN.

In my area, if the flight team is on scene they call the shots for transport or not and additional sevices. Safety is a concern and many factors must be taken into consideration that the ground crew are not aware of. Weather may detour the crew to another hospital or force them to defer the transport to the ground crew. If the hospital is two hours away by ground, the ground paramedic may not know the specifics of weather and can not make that call even if he/she did. If the patient is in cardiac arrest, the flight team will probably not transport. The exception might be for a cold water drowning of a child. Weight of the patient for smaller aircraft may also have to be considered. We also understand if the ground crew wants to start moving if our ETA is extended. They must try to get another landing zone for the helicopter if they want us to meet up.

Again, safety for everybody is a priorty. The Flight team is very aware of many safety factors that the ground crew may not be. (yes, I am repeating SAFETY again) The flight team also knows their advanced capabilities better.

Since this is even being questioned by members of the ground team indicates that they are not familiar with the services and abilities of the flight crew. If might be time your ground EMS had an inservice by the Flight team. This would also be the best way to get a handle on the specifics of scene management. Each area has a few different quirks in their policies. Not knowing the specifics of your ground EMS, Flight team, local and state policies, it is difficult to give you any more specific information.

Just starting the helicopter is expensive.

We do not allow money influence our decision. Delay in definitive care may be way more costly in the long run. One must also understand the limitations of on scene diagnostics and lack of specific diagnostic equipment.

Another interesting fact for many flight services; if a paramedic gets his/her RN license, he/she still can not apply for the Flight RN position until they have finished a minimum of 3-5 years in the ICU/ED. An RN in Florida can challenge the Paramedic exam.

[Freshmeat]

Most of the flight RN's I see are also CEP's, pretty much the same deal here as far as a test challenge goes; I'm currently a nursing school student & I'm pretty familiar with flight nurse qualifications, most of use are. Hell, our Critical Care Ambu nurses are pretty well loaded training wise as well. Think of my question in this context and perhaps it will be more clear. We (One medic/ One EMT) arrive on scene the same time as the Chopper (one medic/ One RN). My Medic asses's the patient and decides she/he is BLS & very stable and doesn't need an $18,000.00 chopper bill. This same ambulance medic is not concerned with flight weather, as he wants to ground the patient and believes there is no problem with this. The flight RN, wants to fly the patient, and disagrees with the assessment of the Medic. Who gets to make the final transport decision??? I believe its the RN, but I just don't know for sure. Can someone provide me with some valid basis as to whether I am right or wrong?

[VentMedic]

I'm an EMT in AZ, basically stationed in mining town 1/2 way from Phoenix to Vegas. As you can imagine, we fly ALOT of patients that are ALS, as ground transport to the nearest Hospital is about 2hrs.

Who dispatches the helicopter?

What are your policies for canceling the helicopter before it lands?

What is the cost of a two hour ground transport?

How many back up ambulances do you have to allow far a truck to be out of service for 4 hours minimum?

How many calls per month over x years has your paramedic done? This sounds like a very rural area with a low call volume.

Can your paramedic be absolutely positive the patient won't deteriorate in enroute? Remember, if the patient does deteriorate enroute via ground, the RN will make a great witness.

Will this be a "speedy" L/S trip for two hours?

What about patient comfort? An ambulance ride is not a lot of fun especially if you are the patient.

Does your paramedic have the ability to provide adequate pain management for a two hour trip if necessary?

What is your "plan B" if the patient becomes unstable from an unseen internal bleeder in transit with another hour to go? Drive faster?

While I agree, helicopters are over used in some areas, but when there is a 2 hour transport involved, some justification can usually be found to fly especially if both services were dispatched simultaneously or by another authority at scene. Granted there are cases like you stated that might be just BLS. Many EMS systems consider the transport time as a criteria for using the helicopter. Some systems stipulate transport times over 30 minutes or 1 hour for calls that were initiated by 911 and require transport may need flight. I would take it that your traveling time to get to each scene is probably fairly long also.

You would have to consult with your county and State policies. Many times flights to rural regions are also funded by other means and there is a contractual agreement with the county and state.

You can also venture over to www.flightweb.com if you want a whole forum of flight people.

[captainstandup]

Under ICS the incident commander has operational command of the scene. The safety officer has delegated authority to cease all scene operations and even order scene evacuation including abandoning the patient(s) in interest of safety. Under unified command there should be an easily understood flow and transfer of care.

The RN's presence on scene doesn’t necessarily mean that care has been transferred to them by default. The paramedic in charge of care (prior to arrival of the flight team) retains care until they have reached a point where care can be appropriately transferred.

With this said, only a fool would squander the additional knowledge, tools, equipment, supplies and therapies the flight crew can offer. One of the reasons this sometimes occurs is that a history of arrogance and criticism of EMS and Fire by the flight crews. This is especially true in our area where virtually without fail they are arrogant, ungrateful and exude an omnipotent persona that offends pretty much all of the "less lofty" terra firma bound providers. These folks are hated and every attempt is made to call other flight services when possible. Problem is they are virtually the only game in town.

In our area the advantages of flight crews are few and include:

A relatively faster ride to the hospital.

The ability to bring to the scene and initiate blood infusion.

The ability to initiate a central line.

Beyond this we carry the same critical care medications, same therapies, and have the same critical care training as the flight crews. In this situation the CCEMTP on scene retains patient care authority until transferred to the flight crew.

I mentioned relatively faster transport times because if calling for the chopper is delayed until the EMS unit reaches the scene there are many instances where ground transport is faster if the patient is treated as a "load and go" We must also remember the risk of helicopter evacuation. Unfamiliar terrain, overhead obstructions, scene debris that may become airborne and threaten the aircraft and bystanders are but a few considerations. These risks must be weighed against the actual benefit of minutes saved. In very rural area such as where spenac works helicopter evac of even mildly serious medical emergency patients may be warranted.

Turf battles are inherent in highly emotional situations such as EMS. These are worsened by people of poor character who have been lucky enough to be selected for highly honored flight positions. Hopefully the old guard of the hateful, arrogant fools will “die out” or leave these services sooner rather than later.

Finally, I would caution providers against the assumption that just because someone flew into your scene on a helicopter and has RN or CCEMTP on their name badge doesn’t make them uniquely qualified to deliver better care. I have witnessed egregious errors on the part of flight nurses, potentially life ending errors for the patient that was never pursued by the powers that be. We are all human, in spite of the flightsuit and arrogant attitude, they are too.