During transport, who is in charge if L&S should be used. Also can you refuse treatment/transport?

[RomeViking09]

I am embarrassed to say this, but this is one of the problems with volly squads, that there is no real rules and guidelines.

The other night my (volly)BLS squad (in New Jersey) got into a heated debate of who is in charge during the patient transport. In particular - lights and sirens.

I am of the belief that the EMT treating is in charge, and that if he/she based on the patients status, tells the driver (usually not even an EMT), NOT to go with lights and sirens. Then the driver can NOT use them. And if the driver does, they are opening themselves up to sever liability issues. The problem is, that a lot of drivers love going with lights and sirens.

Other members claim, that the driver is in charge, and it is his decision whether to use lights or sirens. That "if we are transporting then it must be an emergency".

This led to a different discussion whether or not a EMS squad dispatched to a call can refuse treatment/transport if they feel that it is not a "real emergency".

I am of the belief that refusing transport would be considered abandonment, (thus being the reason why we need RMA's). They claimed that even though you arrive on scene and do a quick assessment, it is not considered abandonment until you actually start treating the patient.

So basically, the two questions are:

1) Who is in charge in regards to using lights and sirens during a transport.

2) Can you refuse treatment/transport of a patient if you feel it is not an emergecny.

Remember, we are dealing with BLS here.

It could be that I am wrong regarding both of these. I would love to hear what anyone has to say about this. Also if anyone has links to any legal documents, etc... We are dealing with New Jersey here, but any input would be appreciated.

Thanks

1- The attending Medic/EMT is in charge of the call, My paramedic partner and I (I'm an EMT-I) swap every other call who is in the back unless the patient needs ALS care beyond that of an EMT-I, when I am in the back on the call I decide how we transport, when he is in the back he decides. The only time it does not work that way is if the driver feels it is unsafe (due to weather, road condition, etc.) to drive emergency.

2-If they call you haul (unless they refuse to go), you do not have the "right" to refuse to transport anyone who wants to go (except maybe someone in police custody depending on your state and/or service policy)

non-EMT drivers often have problems understanding that the medical needs are the reason for what we do. I have seen non-EMT drivers who want to run L&S to go get lunch b/c it is "cool"

My personal view is if your on the truck you should at least be an EMT-Basic. I think the idea of an emergency driver does not make since and you should invest the time in becoming an EMT if you want to work or even volunteer in EMS.

[HERBIE1]

Are you kiding me? Threating somebody elses job/posistion over lights and siren useage? That's totally over the top! You have two people working as partners, working together on a shift/call/etc and they should be doing so as a team. But in the end it comes down to the highest trained provider. But really its lights and sirens, and not work a drag down fight.

When it comes to "provider initated refusal" you would need to have protocals with ALS and medical command support before ever doing something like that. I can't imagine that a BLS provider who hasn't even had basic anatomy could be expected to know everything necessary to tell someone they shouldn't go to the hospital.

Since this is a volunteer group, I don't know what specific rules are in place but the person on the scene with the highest level of training should make all decisions made on scene and pertaining to patient care- including the use of lights and sirens. If everyone is at the same provider level, then someone who holds the highest rank may be in charge, or barring that, the most experienced provider on the scene. There needs to be some type of organizational chart (formal or not) that delineates chain of command and job responsibilities and everyone needs to be on the same page with that.

Whether or not to provide transport is a separate issue and that is a system policy, not an internal problem to be debated.

If you do not have protocols that govern this, I suggest this would be a perfect time to develop them in order to avoid these situations. Paid or not, there needs to be some guidelines to protect everyone- including the patient. Contacting the state is a good idea, and getting suggestions from other systems would also be prudent.

Yes, in a perfect world, partners should not be having ego clashes- it should be about the patient, and in most cases, that is the case. Occasionally you get conflicts and someone puts their own issues ahead of the patient's needs and the crew's safety, so back up guidelines need to be in place.

[Lone Star]

It has always been my understanding that the highest medical license is the one 'in charge' of a scene. This includes transport priorities. If a lower license level or non-medically trained driver thinks they can 'trump' the attendant's decision, they really need to rethink their position before it gets them into some serious trouble!

Just as 'scene size up' doesn't end until you return to the station, the transport priority of the patient is still part of the scene. This continues until you transfer the care of the patient to the recieving facility. By our protocols, this includes a verbal and written report.

As far as refusing to transport a patient, once you arrive on scene and start talking with your patient, you've made 'patient contact'. If you decide that you don't want to transport this patient, and you leave; you've just committed the sin of abandonment.

RMA is a completely different duck. With this, the patient has decided that they don't want to be transported, after we've explained the possible ramifications of their decision.

Do I think that losing one's job because they want to push for the 'cool factor' and endanger MY life, the life of my patient and put the general public at risk for unnecessarily using lights and sirens? Absolutely not.

Lights and sirens are generally overused, and if they cause detriment to the patient's condition, losing your job should be the least of your concerns!

As far as legal support for this position, I would check with state and local protocols. If there is nothing 'in statute', then it's time to talk to the state representative that covers your district for state inspections, etc

[Kiwiology]

If a lower license level or non-medically trained driver thinks they can 'trump' the attendant's decision, they really need to rethink their position before it gets them into some serious trouble!

Should it not be the AO treating the patient who should make that decision? A lot of our trucks run Technician/Paramedic or Paramedic/Intensive Care Paramedic - if you are the officer treating the patient (even tho you have a lower qualification) you can decide what status to transport the patient.

Lights and/or sirens are only to be used here in known or suspected "life threatning situations" ... I've seen lights used twice during transport and the siren once in 5 years.

Going to a job it is the decision of the EMD as to what priority to assign the job, going to hospital it's who is treating the patient.

[FireMedic65]

I agree Ben. These sort of situations happen all the time when you run an EMT/Medic ambulance. A lot of the time, the patient will not require ALS care, and the EMT will attend to them. At that point, the EMT is in charge. The Medic is just there to help at that point, and drive to the hospital. Usually you are dispatched, and given a type of incident, and severity. Most 911 are ALS just by the nature of the call, but some are dispatched 911, but turn out they are not. When you get on scene, the assessment it made and it's determined what care is needed. We do this because EMT's are not just ambulance drivers, and they need to keep their skills of taking blood pressures up to snuff or something.

This happens a lot also, in volunteer services. Medics do volunteer at ambulance squads, but when they do, they are only allowed to give care up to the level that the ambulance is licensed for, BLS. Even though they are a paramedic responding to a 911 with an EMT, their level of care is still only that of an EMT. So, technically, no one is of a higher "license" regardless of their training and education.

[Kiwiology]

I agree Ben.

That reinforces my theory that most people agree with me ... eventually

Most 911 are ALS just by the nature of the call, but some are dispatched 911, but turn out they are not.

When you get on scene, the assessment it made and it's determined what care is needed.

That's like 99% of all calls is it not? I think something like 70-80% of our jobs are dispatched "priority 1" and turn out to be a stable patient. That said just because a job is p1 doesn't mean we *have* to run lights and/or siren, in a small town at 11pm for example you might just run the lights or decide not to because there is zero traffic.

We do this because EMT's are not just ambulance drivers, and they need to keep their skills of taking blood pressures up to snuff or something.

Yeah ... hard skill that one (I almsot wet my pants when I read that, it was good mate)

[FireMedic65]

That reinforces my theory that most people agree with me ... eventually

That's like 99% of all calls is it not? I think something like 70-80% of our jobs are dispatched "priority 1" and turn out to be a stable patient. That said just because a job is p1 doesn't mean we *have* to run lights and/or siren, in a small town at 11pm for example you might just run the lights or decide not to because there is zero traffic.

Stable does not necessarily mean they aren't in need of ALS care. Most of the time they are having difficulty breathing, but they are still "alright". Put them on the monitor, put in an IV or heplock, breathing treatment. That's ALS care being provided, but the patient is still "stable". Now, if you were to be dispatched for a "fall victim" and it turns out to just be a twisted ankle, heck even a broken ankle, this patient is most likely stable and does not require ALS care. Yes, there are circumstances that would make them ALS, like if they fell down stairs and smashed their head and are altered or the reason they fell was hypoglycemia or had a syncopal episode, etc etc. I am just referring to normal situations without other contributing factors.

You make a good point though

[spenac]

There is no law that says you can not deny transport to a person. If after an exam they are not in need of emergency services if your protocols allow it you can say no. But in saying that basics and even most Paramedics do not have enough education to do a proper assessment, so they should not be denying.

As to the L&S the person giving patient care determines L&S for the most part. If the driver deems it not safe to use L&S he has the right not to. But if the driver decides on his own to use L&S he is in the wrong.

[FireMedic65]

There is no law that says you can not deny transport to a person. If after an exam they are not in need of emergency services if your protocols allow it you can say no. But in saying that basics and even most Paramedics do not have enough education to do a proper assessment, so they should not be denying.

As to the L&S the person giving patient care determines L&S for the most part. If the driver deems it not safe to use L&S he has the right not to. But if the driver decides on his own to use L&S he is in the wrong.

Good point! There will always be circumstances outside of patient care where you need L&S. For example, a rain storm, snow storm, nuclear blast...

[Richard B the EMT]

OK, probably not based in laws and statewide regulations here in New York, but, on my now defunct VAS, the EMT designated "Crew Chief" was the "de facto" squad Sergent, and in overall command of the ambulance. The driver, who, under squad rules back in the day, didn't necessarily have to be an EMT (this was before Certified First Responder-Defibrillation was requested/required by the NYS DoH, and we didn't have any Paramedics in the organization), but was under the understanding that (s)he was to get the vehicle and crew where needed, and do so safely.