Taking/Relinquishing Scene Control

[EMTuKnowMe]

What is considered "proper etiquette" in terms of an EMT-b relinquishing scene control/command if a higher level EMT happens upon the scene? And what is the proper way for the higher level EMT to assume control?

I feel that in non-emergent situations, where the skill level required is at the BLS level, the higher level EMT should assume an observatory, supervisory position, hopefully to offer constructive criticism later.

However, what about in cases that are more urgent, such as, perhaps, respiratory arrest, cardiac arrest, or the like?

Thank you, in advance, for any thoughts.

[nsmedic393]

First off, you are talking about two different circumstances. Control of a scene, ie. a MVC could be a multi-agency deal. In my mind in control of a scene would be like a MCI, you have your incident commander that runs things such as triage, treatment, transport and rehab divisions. A incident commander could be relieved by a more experienced medic/supervisor.

The other thing is control of patient care. Around here, the highest level of medic is in charge of patient care, period. As a ACP on scene it is my responsability to assess the patient at the level to which I am trained and then make a decision weather I want to continue care or hand off care. Regardless, its my a$$ on the line. as an EMT you should never expect a ALS providor to just kick back because if something is wrong with the patient and its not picked up on, just because he showed up its his responsability.

For example, today we had a call for an elderly lady, altered LOC. From my assesment I was fairly certain she had had a stroke. While I was hooking up the defib, I asked the basic I was working with (not my normal, trustworthy partner) to listen for lung sounds. He replied that they were clear. We transported to the hospital which is literally the next building on the street.

once in the ER I listened to lung sounds myself and found her to have edema throughout all fields. I quickly recommended to the ERP that she be treated for pulmonary edema/CHF and we proceeded to do so.

Moral of the story; when its your a$$ on the line, check for yourself.

[Rescue0ne]

In my years as an EMS provider, it's been acceptable if the ALS provider allows the BLS provider to maintain scene control, as long as the ALS provider accompanies the BLS provider all the way to the ER, ready to assume control if the patient requires any type of ALS intervention. Usually, this takes place if the patient isn't in any real distress...simple O2 administration, monitoring of vitals, you know the drill.

If the patient, in any way, requires skills that the BLS provider can not provide, the ALS provider is required (by the laws in my state) to assume the primary role in patient care. There are some lines that become a bit hazy, in certain situations...but if the ALS provider makes his/her credentials known, and gives any type of care to the patient, or assistance to the BLS provider, then that ALS tech is responsible for patient care until relieved by someone of higher training...this usually being the doctor at the ER. If the ALS tech doesn't accompany the patient during transport, after rendering ANY type of assistance..then its the ALS tech's arse if something goes wrong, and the patient requires ALS care en route to the ER.

You get what I'm saying.

I know this to be true for the EMS Agencies under the purview of my OMD. It's true across the whole state of Virginia, if I'm not mistaken. Anyone else who responds to this thread will probably agree, to some extent, if not all.

As for the first part of the question...do it professionally...if for example, you're relieving someone at the scene of an MVA, in front of the FD, Police/Sheriff, the rubberneckers that you'd love to shoot, and God himself.

Proper way is for the "higher level EMT" to ask for/be given a thorough briefing of patient history & treatment. Make sure everything is documented, including both your names when you note xfer of pt. care.

Remember: IF IT'S NOT WRITTEN DOWN ON THE PATIENT CARE REPORT, IT DID NOT HAPPEN.

EDIT X MYSELF: What Medic393 states about it being your ass on the line is so dearly true. If your the ALS tech, and the junior tech isn't someone you'd trust with YOUR life, I'd definitely check behind them. Discreetly if possible, blatantly if necessary.

Also, in the event of an MVA/MVC...in my area, highest trained EMS provider of the agency with primary responsibility for the area that the accident took place in is Incident Commander. I don't know how it's set up in your neck o' the woods.

[christin]

[/font:8f065320a0] [/font:8f065320a0] It is in my opinion that as emergency medical professionals we should all hold the patient's best interest. I feel if it is a basic call, then the emt-b or iv can handle that call. Ultimately, that would be within their scope of practice. However, I feel if a medic is present or later arrives at the scene it is his/her responsability to make sure the scene is managed with in the realm of BLS or ALS care. Meaning if the emt-b has the scene managed then let them handle it. It is a good way for them to better their skills and become useful tools for their patients and future ems partners. I don't think as a medic myself I would try to relinquish scene control in a hostile fashion. I think it is extremely important to utilize your resources and this emt-b would be a resource.

[DwayneEMTP]

If the patient, in any way, requires skills that the BLS provider can not provide, the ALS provider is required (by the laws in my state) to assume the primary role in patient care. There are some lines that become a bit hazy, in certain situations...but if the ALS provider makes his/her credentials known, and gives any type of care to the patient, or assistance to the BLS provider, then that ALS tech is responsible for patient care until relieved by someone of higher training...this usually being the doctor at the ER. If the ALS tech doesn't accompany the patient during transport, after rendering ANY type of assistance..then its the ALS tech's arse if something goes wrong, and the patient requires ALS care en route to the ER.

Even if the patient doesn't have issues on the way to the hospital, wouldn't this be abandonment? Or in non-emergent situations, is this one of the lines you said sometimes gets blurred?

(It may seem like I'm being a smartass, but I truly don't know.... :oops: )

[1aCe3]

Yes... I believe that would be abandonment. As an ALS provider who has rendered any type of care as dwayne stated, the patient would be the ALS provider's responsibility. The Medic, as the higher certification level cannot transfer care to a lower level, thus they must maintain pt care. But hey, in my opinion, if there's a higher level of care on scene.. which rarely does happen around here quick enough... as an EMT I'd be happy to let the medic take over. If I were a paramedic and my medical director (MD)just happens to be around, by all means... etc. Sure, if you really want to continue care, and just have the higher lvl of care ready to jump in anytime, that works too, but why tie up two crews if it truly is a non-emergent situation?

[Rescue0ne]

In response to the abandonment issue...yes, you are correct. I was thinking along the lines of...if you left the rig, w/ the EMT in charge...and no one was the wiser...then you're guilty of abandonment, which is a really bad thing. you probably deserve to have your license or Certs pulled. Now, if you abandoned the patient to the BLS provider...and the patient coded, or seized...then you're REALLY screwed. Abandonment, plus lawsuits, possibly prison time, public humiliation, ridicule, everyone on this forum knowing that you're lower than whale@#$&. That's probably worst-case.

Yes, leaving the patient w/o being relieved by a provider trained higher than yourself IS abandonment. I apologize, I should have clarified what I meant.

As far as tying up 2 crews, often times, where I'm from (and I guess we're lucky in this aspect), the member driving the ambulance is sometimes not an EMT yet, or at all...allowing there to be two providers in the back w/ the patient. We're talking volunteer agency here, so it's really not uncommon. I'd agree with not tying up 2 crews, if that's indeed the case.

[nsmedic393]

All the US textbooks state that leaving the patient with a lower level of care is abandonment. Here we are allowed to defer patient care to a BLS provider if we have assesed the patient and we follow our policies.

Policie

[medic001918]

Here we have a protocol specifically for downgrading calls to BLS providers. As a medic, we are still supposed to write our own run form regarding our assessment of the patient in case the call ever comes into question. I'm always hesitant to hand off care of my patient to a BLS provider I'm not totally comfortable with because as has already been mentioned; it's me that someone is going to come to and start asking questions.

When it comes to BLS vs. ALS assessment, I'm all for a BLS provider doing some level of assessment. However, I have an obligation that an assessment is done thoroughly to my level of care. That means that I may interject questions into the assessment that I feel are pertinent. This will help to complete the assessment and also to steer the assessment in the direction I feel it needs to go. One thing that does drive me crazy though, is when I'm on a scene before a BLS provider and they come in and start stepping all over my assessment. If I've already started, please let me finish. I just might have an idea as to where I'm going with my assessment and I may have already asked them the question.

Shane

NREMT-P

[nsmedic393]

Here we have a protocol specifically for downgrading calls to BLS providers. As a medic, we are still supposed to write our own run form regarding our assessment of the patient in case the call ever comes into question. I'm always hesitant to hand off care of my patient to a BLS provider I'm not totally comfortable with because as has already been mentioned; it's me that someone is going to come to and start asking questions.

When it comes to BLS vs. ALS assessment, I'm all for a BLS provider doing some level of assessment. However, I have an obligation that an assessment is done thoroughly to my level of care. That means that I may interject questions into the assessment that I feel are pertinent. This will help to complete the assessment and also to steer the assessment in the direction I feel it needs to go. One thing that does drive me crazy though, is when I'm on a scene before a BLS provider and they come in and start stepping all over my assessment. If I've already started, please let me finish. I just might have an idea as to where I'm going with my assessment and I may have already asked them the question.

Shane

NREMT-P

I feel exactly the same way. If I don't at least supervise the assesment, I can't be sure it was done properly.

It also tickes me right off when you get a BLS provider asking irrevelant questions over your shoulder just to sound important.