Controlling the Scene

[Bieber]

Hi everyone.

The topic of the day is scene control: seizing it and keeping it. Controlling the scene is one of those things I've struggled a lot with, for a variety of reasons. Before I begin, I'd like to share with you a story from today. I had loaned my car to a couple of friends last night so they could get home (I was unable to give them a ride due to having a bit of ETOH on board), and this morning I went to pick it up from them. However, on the way home, I happened upon a fresh accident (see, airbags still smoking) and got out to check everyone until EMS showed up. They were all fine, however when fire showed up (fire around here are all EMTs who generally arrive prior to EMS and are there to assist EMS), I attempted to give them a report and was summarily ignored by all of them. I'd identified myself as a paramedic with the county however the firefighter in charge cut me off in the middle of my report and instead went to speak with one of the other firefighters about the patient that I was trying to give the report on. Fine, whatever, you don't want my report? That's cool with me, I'll just wait till EMS shows up and give them the report instead. None of the firefighters had thought to ask the patient about their past medical history, and because she had a defibrillator/pacemaker I wanted to make sure EMS was aware of that before I left (also, I can't turn over patients to EMTs). And when EMS did show up I let them know about the patient and was on my merry way, however the incident left me fuming.

Around here, EMS has ultimate control over all medical scenes and fire is there to assist us. However, it seems like I very frequently encounter a lot of difficulty with the firefighters and tend to be "overlooked" or ignored even while I'm working on duty. Anytime we show up to a call, my partner is the one initially addressed even if I'm first in and obviously teching the call. It's embarrassing to admit it, but I must confess that I don't provide a strong enough presence on scene though I believe another part of the problem is the fact that I look very, very young for my age.

Anyway, the point of this is that I am sick of being treated like a junior firefighter on scene or otherwise being ignored and I recognize that I need to strengthen my presence on calls and I'm looking from advice from you guys on how to do that. I often find it hard to be confrontational with folks I'm not familiar with (being so new, I'm afraid I still have that overwhelming urge to "defer to the more experienced folks"), and I'm not looking to stir up any bad blood with fire folks but I'm getting ever more pissed with being talked down to by firefighters who don't have the same level of prehospital medical education as I do. To be honest, I really want to just pull a couple of those firefighters off to the side and say, "Hey, I really don't give a shit if you're twice my age because I'm the paramedic and you're the firefighter, so this is my scene and you guys are going to do what I say, got it?" Though I think that may be a little inappropriate or rude.

So, to all you more experienced folks out there, let me know: how can I be more dominating on scene? Paramedic represents the highest level of prehospital care, and I feel like I'm failing myself and my profession by being so god damn meek. I became a paramedic to be a leader, not to be a follower and letting firefighters walk all over me isn't doing that. In conclusion, I'd like to share a quote from my AMLS book: "If you don't take control of the scene, someone else will."

[crotchitymedic1986]

Be careful what you ask for or demand. Obviously you should stand up for yourself, but when you are off-duty you should defer to the on-duty folks when they arrive on scene. You can catch more flies with honey, and going into Clint Eastwood mode is probably not going to gain you any respect. Overtime you will gain respect and will learn when it is time to flex your muscle; at the scene of accident with no serious injuries is not the time to become "barney fife" and demand they respect your authoriti. Be more like Andy, the quiet expert who is there to save the day when needed.

[medicgirl05]

I understand your frustration. My first "bad" paramedic call was at a racetrack where there was already a private ambulance staged. They, however, didn't have a paramedic so it was "MY" call. The guy was entrapped due to no doors on racecars. Also he had no feeling below his collarbone. They had nothing on him. The racetrack is at least 15 miles from the station that I responded from....So I get there and fire crews won't let me access my patient. I just went with it for the most part. I did get in and start a line and talk to the patient though while they continued to cut. So I have 1000NS hanging on a 16g cath TKO. Some male nurse keeps opening my line up. I told him probably 5 times to cut it out. His response is that the patient is a trauma patient and trauma patients need fluid. I keep calmly telling him that if I could hear lung sounds or get a BP i may give fluid but since I dont know what shape his lungs are in I'm not giving fluid. Eventually, after the man was extricated and I had just had enough, I yelled "everyone hush!" That got there attention and from there on out I ran the call. As we left the racetrack some of the guys told me that they respected me for controlling the scene. If I had done it in the beginning, it wouldn't have gotten as out of control as it did.

I've since learned that if I walk into a call assertive I get much more respect from the bystanders. I work with a man who is an intermediate and is about 45y/o, so I have to assert myself so people know I'm running the show. The longer you let it go on, the harder it is to correct.

I think the biggest difference I made was just how I approached. Head up, confident, and talk assertively. If you act unsure of yourself they are going to be unsure of you also. If that is not enough I would tell the fire department This is my scene, things will be done my way. I have a similar fire department with similar thought process. If what they are doing could hurt my patient or myself I am sure to say something, otherwise I keep my mouth shut and do it my way. I have worked at my service long enough and we are small enough to know which fire guys are actually helpful and which ones are more of a hindrance. I give directions to the ones I trust and the other ones I send to do traffic control or something similar.

I hope this helps and god luck to you!

[HERBIE1]

Tough call. Lots of factors here. First, we all project a certain aura or personality. Most folks in the public safety business are Type A- act first, ask questions later, and if someone senses a person is tentative or weak they will seize control of the scene. Worse case, if the person stepping up is not in charge, or not in a position of authority, they can create havoc on a scene.

The only way to change someone's opinion of you is to step up and take control of the scene. Be confident in your abilities, PROVE that you are capable of controlling a scene. Be firm, authoritative, and aggressive with your care. If you are the senior medical person, then you need to act like it.

Next time you are in an ER and there is a code or critical patient, WATCH the person running the code. See how they handle things. Look at their demeanor, the tone of their voice, their mannerisms.how they react when things go bad. You also need to know what everyone's job and responsibilities are. No, you don't have to know all the details, but at least be familiar with them and know how the various pieces fit together. Example- on the scene of an accident, LEO's are collecting information, directing traffic, making reports, etc. The fire company is securing the car, maybe disconnecting the battery, extrication, assisting EMS, etc. EMS of course is caring for the patient. Someone is triage, another may be telemetry officer, another may be arranging transport, another may be collecting information from victims, etc. You need to be aware of all these things and more, keep that data in the back of your mind, and use it- and the resources as needed. THAT will give you control of the scene.

[DwayneEMTP]

Fire often gets all puffed up with their macho bullshit. Some day when you're in the fire house ask if anyone has ever saved a pt from a medic and you'll hear on idiotic story after another about how intubation is idiotic, medics are idiots, how they've taken medics drugs from them and pushed them all themselves saving the day, yadda, yadda, yadda...whatever. When you spend your entire training being told what a hero you are, how balls are what save patients, not brains, listening to how the college educated medics may be smart but they just run around scared on scene!! it tends to queer your perspective a bit.

You don't know how to get their respect? You treat them with professional courtesy. They earn YOUR respect. Know how you do that? The ones that work well, that are team players..involve them in everything. Let them bag, do compression, start IVs if they're allowed. Take the same ones over and over and soon you'll see that others want to be able to play too.

Ok..bonehead stunt number one....almost certainly, when you stopped while off duty you weren't the highest level of care there. That may not be true if you're in a state that has a duty to act when off duty. And if your state does have a duty to act, it's possible that you are now guilty of abandonment. Do you know what they call a paramedic on scene without a jumpbag? A spectator. If no one was seriously hurt you should have been on your way as soon as the hosemonkeys showed up. They're going to be running around with collars and board and doing their thing...how can you really help them when most of what they are going to do is pointless anyway? Was it your intention to help them board and apply oxygen? You put yourself into a situation where you were destined to fail brother.

I had a new medic on my current project that was upset because he had to wear his own shirts when they ran out of EMS shirts. He wanted to know how anyone could tell if he was a medic or not if something went wrong? I gave him my shirts and explained, "If there is an emergency and anyone there has trouble figuring out what role I play, then I'm not really being a paramedic, am I?" And I believe that. When I show up on scene everything concerning any sick or injured human beings is on me and I will not allow anyone to stand in my way. I have no ax to grind, but if you have some agenda that is apart from helping out team care for pts as well and efficiently as possibly, I'm simply going to run your dumb ass over. I'll ask for help, give kind instructions, and if you want to play then the call should be really fun and/or interesting. If you want to fuck with me I will have you removed. My believing that seems to be enough to allow others to see it as I've never had to do it.

You need to decide that you are the highest level of care on scene. Are you under the belief that your medic cert was some kind of a gift? Did you not work for it? Did you not sweat blood to be worthy of it?

People call you because you are the most well trained and dedicated person available. When you show up and defer to Sparky the Knuckle Dragger you've shown those people that they are fools, that you didn't come to be THE medic, but came to play at being a medic. I believe that you're one of the most inspiring new medics we've had here in a while...but until you decide to be THE medic, then I'd rather have a really good basic care for my family.

You need to decide what you're role is my young friend. I'm sorry you've found this part of your moral/ethical obligation to be uncomfortable and hard. Wait until you need to protect your patient from the LEOs, or when the physicians kid is hit by a car in front of their house. You are there to protect your patients against EVERYTHING. There are some firemen that you will truly be inspired by on scene.. I have learned a lot from the good ones..but when they're not? Walk your ass through them, around them, and/or over them and do your job, OK? And then create paper and burn their dumb asses down so that MY family doesn't have to suffer while they play their stupid macho games.

Dwayne

[Mateo_1387]

Bieber, I must say, it is a pleasure watching your progression as a paramedic. Almost like reading my story…

In regards to the topic though, you pose an interesting question…

(I’m just going to ignore all the parts of you stopping at a crash scene for something other than distressed models involved in a fender-bender on the Playboy Bus and focus on the part about scene presence)

This may sound cliché, but being in charge is not about acting the part, so much as knowing you are in charge. In a way, it is about having the right mindset to guide your actions and not just being able to bark the loudest.

Being young, you will have to get used to the fact that other responders, patients, and their families will commonly address the older looking crewmember. The same kinds of things happen to other providers who happen to be ugly, non-white skinned, are rude, have physical defects, or whatever. Just one of those things man…

Being confrontational with others on a scene, unless it is necessary, is ill advised. Confrontation will mostly create uneasiness between the different providers and the patient’s perception of said providers rendering care to them. Plus, honestly man, being confrontational, rude, or the like is just what all the old heads are going to expect from you. Please do not play into that trap.

Honestly, I find the best ways to have scene control is to do a few simple things: Be calm, cool, and collected. Speaking up a little always seems to help, but not so loud people don’t want to hear your voice. During a ‘bad call’ giving directions to others helps establish your control. On the not so bad calls, how you explain things or ask questions can help establish your scene control. For example, saying to a patient “is it ok for my coworker Amy to take your blood pressure?” Indirectly, it lets others know what they are to do and it is a nicer way to take scene control.

I think you will find on most ‘bad calls’ taking scene control is quite easy. Most people are scared on the bad calls to begin with. Being calm and guiding others’ actions usually does the trick, as most people don’t want to be the one in charge of a bad call.

Your scene presence will develop over time along with feeling comfortable in the new paramedic skin. Being in charge can be quite an eye opener, especially when you may be responsible for leading folks with more age/life experience than yourself. Definitely learn from what anyone with that experience has to teach but work on being the adult you’re expected to be and not so much the kid you were trained to be for the past majority of your life.

[Bieber]

Hey guys, sorry I was a little slow responding to this. I've had a little bit of time to cool down and think about things. It seemed like I had finally plateaued by the end of internship, and now that I'm on the streets "for real" I'm back to square one. I guess this is what they meant when they said you're never done learning. It's harder to remain assertive when I don't have my preceptors' cattle prod egging me onward.

Thanks to everyone who replied. Herbie, you're right, I am the senior medical officer on scene and I do need to show it. It's hard to really step up to the plate when most of my coworkers could be my parents, but it's something I'm going to be working really hard on. Thankfully (I think) I'm working Sunday through Thursday straight so I'll get a chance to really get a good amount of experience as opposed to the here and there shifts I've been dealing with lately.

Dwayne, as always, you are like a mentor to me and I can't thank you enough for your advice. I always look forward to it and it never fails to inspire me or make me reflect on how I act on every call. To be honest sometimes it does feel like I just lucked into becoming a paramedic, and that lack of confidence in myself is something I've struggled with for a long time--even before I ever got into EMS. Undoing the "failure" mentality is an ongoing process for me, but you're right, I did sweat and struggle and fight every day for over a year to become a paramedic, and I really do need to step into those shoes and recognize that I have proven myself and trust that I really DO know what I'm doing.

Mateo and Medicgirl, thanks for the words of encouragement and the advice. I need to get going to bed but I want you guys (and everyone who's replied to this thread) to know that I have read all of your words carefully and I'll surely reread them again and remember them when I'm working this coming week. I'll try to follow your guys' advice the best I can, and try to "find myself" as a paramedic and really live up to the title.

It's hard to share my weaknesses with others, and to admit my flaws, but you guys hopefully know me by now and know my intentions are good. I told my preceptors at the end of my internship, I'm not a good paramedic yet, but I'm going to continue to try every day to become one. It's the foundation that they and my college built for me, with the guidance of my colleagues like you all, and my own determination that will eventually make me a good paramedic. Until then, I'm just a paramedic, but I look forward to the day I can join the ranks of you all, and with your continued help I'll surely see that day.

[akflightmedic]

Dwayne, as always, you are like a mentor to me and I can't thank you enough for your advice.

Wow...who knew this day would come eh?

[DwayneEMTP]

Wow...who knew this day would come eh?

Yeah, man. 'Specially when I still say the same things to you!!

Fortunately Mr. Bieber is smart enough that he will soon see the error of his ways and be more careful about choosing mentors in the future.

Glad you're busy Yeti, but miss your posts here. Be safe man...

Dwayne

[fiznat]

I agree with just about everything others have posted. If I might just add a few small things:

-Make sure you get the initial report and any critical info. If your partner is taking the initial report then that is a problem. Politely ask him/her to refer first responders to you when they have (important/relevant) information to pass on. I've noticed that it helps if you are the first person who walks through the door. Grab the FRONT of the stretcher and make eye contact when you step into a scene.

-Focus first on your patient, not the first responders. When you are working, "being in charge" means being responsible for the patient. Make sure you get the information and the help you need, and use those opportunities to start directing people on scene. People will get the point when they see it is you who is doing what needs to get done.

-Don't stop at random car crashes. Especially routine ones. You just cannot expect people who are at work to take direction from some plainclothes witness who claims to be a paramedic. You don't have your equipment, you're not at work, and - frankly - you're not really helping. If you absolutely must stop, your report to first responders should be SUPER short with only the bare essentials, and then you should GTFO.

-Realize that this stuff comes with time. Don't try to rush it by puffing your chest and making a big deal out of small things to save your ego. Just treat your patients well, make sure you get everything you need, and people will start to recognize you as a leader. It takes more than a patch to get respect-- remember that you still have to earn it.