Treating Patients While Off-duty

[Bernhard]

Personally I think the difference between a hero wannabe and a professional is that a professional calculates the risk before taking action.

I wouldn't consider (or degrade) people who simply want to help as "hero wannabes". A real hero wannabe would make sure a press photographer is near. But exactly your said difference makes a professional random first aider much more qualified to ensure scene safety even with non-standard equipment. BTW, it's much the same with arriving at a vehicle accident scene with an ambulance. We all know, that a full lighted ambulance doesn't make much more scene safety than any other car and there are much more reports of emergency professionals getting hurt in service. On my ambulance I have the same standard equipment every german commercial car driver has: a warning triangle, a safety vest and a blinking flashlight, plus some blue lights (BTW, all of them I have on my private car as well). Would you - considering extreme scene safety first - in your ambulance drive by then or wait a while until police/fire arrives and secures scene with all their fancy equipment? Or do you really have significant more warning equipment on ambulance than on your private car (except some flashlights)?

The first thing we learn is scene safety, and an MVC, especially at the side of a highway, especially when you are off duty without any way to put up appropriate warning signals, is a very unsafe scene. JEMS today had an article about an EMT killed in such a fashion.

And especially then a pro provider can sense the danger much more than a lay man. If too dangerous, I wouldn't stop, yes. But I may be much more creative in organize help otherwise...(and if it's just a very good sight report to dispatch).

The fact of the matter is that an off duty prehospital care provider, even if they had a full jump kit, can do very little that will improve patient outcome. The chances of them facing death or catastrophic injury versus the chance of them providing any sort of meaningful assistance is very slim.

I can't really prove otherwise since there is not enough scientific research in this despite very general aspects such as "early aid helps". But I can say, that some of my random interventions significantly reduced time-to-notifying, gave some people a safer feeling, enocuraged others to help as well under my lead and may help the one or another bleeding less or even getting into hospital soon enough instead beeing carried home by POV first. That's someone can do even without any equipment and "just" an educated brain (OK, gloves will help a lot).

There is a big difference between saying I am not going to render aid off duty under any circumstances and saying I have to stop at every single fender bender that occurs. You can find a medium someplace in there.

That's correct and I never doubt that or wrote otherwise.

[DwayneEMTP]

...And of course there is the EMT Oath and Code from National Registry:

http://www.naemt.org...us/emtoath.aspx

Brother, not a bad argument, but we really, really have to work on your reading comprehension. You're still seeming to believe that if you say a thing that that makes it true...

Dwayne

[Asysin2leads]

Bernhard, if I was dispatched to a scene with an ambulance, of course I wouldn't drive by. However, if the scene was not safe I would stage at an appropriate distance and call for appropriate resources. That's what we are supposed to do. The most obvious instance of this would be a possible Hazmat scene or downed power lines. An ambulance may not give you much more protection than a car, but the chances of me having my family in the ambulance and having to leave them in it while I rendered aid are much less.

I have a heart, but I also approach my job objectively. From a patient care standpoint, a person suffering from trauma secondary to a MVC needs the one thing an off-duty provider cannot supply: rapid transport to a surgical facility. The last time I stopped at an accident scene was when I was on a major highway, and there was car that had just gone down a steep embankment at high speed. There was no other professionals on scene and I was in uniform. I did enter the vehicle, assess the patient, and then made the decision to remove her from her seat when I noticed there was copious amount of gasoline leaking from the vehicle and entering the interior. I then used a pocket mask to assist her ventilations after discovering some fractured ribs and labored breathing from the seatbelt. I have done these things, and I like to believe my interventions made a difference. But it doesn't mean I have to stop and put up traffic flares every time there's a fender bender.

[Bernhard]

Bernhard, if I was dispatched to a scene with an ambulance, of course I wouldn't drive by. However, if the scene was not safe I would stage at an appropriate distance and call for appropriate resources. That's what we are supposed to do.

Asys, you're just telling me you're supposed to think. Nothing else I would expect from anyone with a professional background when encountering a random scene in private.

It's clearly not (always) the unsafe scene some here seem to imagine. It's clearly not (always) the "too much if I stop at any person laying down". Just think, and don't make up lame excuses but professional based decisions (generally speaking not addressing anyone in special).

On the other hand I may be a bit over-allergic to the ones calling off-duty first aiders "wannabe heroes". I had several strange incidents sometimes no other seems to step into. I didn't felt heroic, neither was but did it anyway, just because I was there, felt I could handle this and did. Hazmat including (teaching me something about the reality before some random first aider calls emergency).

The most obvious instance of this would be a possible Hazmat scene or downed power lines.

I see no difference when responding to such a thing within an ambulance or within private car. If I can detect the danger, I wouldn't go near until scene is safe. As educated professional I even may be better in detecting dangers (or clearing them).

And a road itself isn't that dangerous some seem to state here. I didn't read the JEMS article about the unlucky EMT (is it online?) but if I have to stop with my family in the car on the Autobahn, my family will get behind the guard rails as soon as the car stops. Simply because I know how dangerous it is - other persons may not.

From a patient care standpoint, a person suffering from trauma secondary to a MVC needs the one thing an off-duty provider cannot supply: rapid transport to a surgical facility.

What's with bleeding control, airway control, thermal control, c-spine control, comfort and general care? Fact based update for dispatch? Scene assessment (other participants, fluids etc.)? A lot to do until ambulance arrives, saving them and the patient time. No, i don't want to explain basic first aid to someone who surely knows it. But I know, a lot of EMS pro's literally fear beeing alone without partner, equipment, radio and the adrenaline rush stemming from a sudden experience without 10 or more minutes preparation time en route. That's what I argue against.

But it doesn't mean I have to stop and put up traffic flares every time there's a fender bender.

No, sure. Never said that and never expected it from anyone.

To close my rant (yes, I'm kinda in it, I confess), I encourage any professional but random passer-by to think, to ensure scene safety with help of his professional sense much more than any lay person can and act appropriate. And I clearly think, that noone shouldn't help because he "hasn't the right equipment". At least, don't make the same lame excuses as the random non-medical passer-by. Basic first aid is possible including a fact based emergency call, and that could be expected even from Mr./Mrs. Super-Medic. Should be...

Again, having gloves with you will help.

[Asysin2leads]

I didn't mean that an off-duty medical personnel shouldn't render medical aid if they aren't dispatched to it and don't have their entire tool kit. I personally believe it is the ethical thing to do, when necessary, to see if you can render assistance. What I don't appreciate is the small, yet very vocal contingent of our profession that insists their is some sort of obligation for any person who ever learned CPR to stop and render aid whenever something occurs. It isn't an obligation. It's a personal choice. If any provider ever said "No, I am not going to stop for this..." for whatever reason, I would respect their decision. I may not agree with it always, but I would respect it. Given the amount this line of work takes out of your personal life, those few moments you get off-duty might be the only chance you have to spend time with your family or friends. You shouldn't have to give that up whenever someone else needs something.

[azemt2007]

_{Having read through the entire thread, thought I would add from my few years of experience. I worked in a rural area of CA, rare to find that now but I digress. Often times when off duty, I was closer by 10-15 min. than the fastest responding ambulance. As such when I would visit family (I was one of those weird people that would commute 500 miles one way to work for a friend's ambulance company in my hometown), I would be on call and be paid for any call i was dispatched to. My boss made sure I had a full ALS jump bag and monitor and I would respond POV, stabilize the patient if necessary and ride in with the ambo. I would get $50 per call. Aside from that, I never used that jump bag for anything off duty. I'm not sure how it works back east or in the midwest, but where I am licensed/certified (Arizona, California, Nevada), Paramedics cannot freelance (meaning cannot operate at an ALS level if not on duty) unless specifically directed to in advance by the medical director for that region/area. That being said, I would stop at serious MVA's to make sure everyone was ok and offer BLS care only if necessary. If people were up and walking around and the damage to the vehicles was not significant, I would keep driving, notify the highway patrol dispatch and continue on my trip. One of the contentious arguments in Paramedic school was if you stopped, someone obviously needed ALS treatment and you had the supplies/equipment, would you do it? My answer is NO. I would like to but I wouldn't since the Good Samaritan Law does not cover you in that sense. And in most cases, especially trauma, there isn't much ALS procedures can do to change the outcome of the patient. I respect anyone that has the conviction to try and save the world. Most of the people like that are very good hearted and caring people. Now if you have multiple scanners, decorate your car like an ambulance, and stop at every accident scene and put on your EMS jacket, you might be a whacker and a bit creepy.}

_{I don't work for that small service anymore and have been primarily in the big city working. Not much reason to stop unless someone is under a car or it's on fire. Response times are usually less than 6 min. and transport times are usually even less. If I stop, I'm usually just in the way since each crew has a process by which they run a call. Besides, who am I to piss in their pool?}

[portland medic]

In general I don't stop at incidents. I've been a medic long enough that I know that bystanders usually just end up getting in the way, prolonging scene time, and occasionally even hindering care. If I do happen to stumble upon something where a person is in obvious need of help, and no medical personnel have arrived, of course I'll help, but usually with very little results. I made sure an unconscious guy stayed still who got ran over by a semi in front of me once until the amblance arrived, helped a lady who vagaled down in a 747 bathroom on a flight, and not much else. In the era of cellphone saves, rescue is usually at the scene very quickly in my area. Also, when I am off duty, I have no kits, no lifepak, no airway kit, no meds, no IV's, and no PPE. If I do render help, it's just to try to do minimal scene management until the properly equipped professionals that are on duty arrive. When I'm off duty I am just unprepared like most people.

[Bernhard]

Some interesting thoughts! In addition to my approach I already made clear, I may have to explain my background over here.

What I don't appreciate is the small, yet very vocal contingent of our profession that insists their is some sort of obligation for any person who ever learned CPR to stop and render aid whenever something occurs. It isn't an obligation. It's a personal choice.

Here in Germany by law everyone is obliged to help (in his scope of practise, as long as he is able to detect the emergency and as long as he doesn't harm himself or other more important duties). This implies that NO professional provider is more obliged to help, just since he's professionally educated. He simply has the same obligation as any civil lay man.

Here, too, some EMS people think, they are more obliged to help than the general public, just because they are educated or have a sticker on their car. That is not the case (it would be when on-duty). They just have the same duty to act, including all restrictions ("...if it doesn't harm other duties...", this could be having to care for kids or else).

Given the amount this line of work takes out of your personal life, those few moments you get off-duty might be the only chance you have to spend time with your family or friends. You shouldn't have to give that up whenever someone else needs something.

Come on, how often does it occur that you come by a strangely laying person on the sidewalk or a traffic accident with suspected injured victims? It occurs to me 1-2 times a year, and that's what my friends say is extraordinarly often. I see no problem with my time-management, then. Since law obliges me to render aid (as everyone else) it's a valid excuse for getting late to work anyway here.

where I am licensed/certified (Arizona, California, Nevada), Paramedics cannot freelance (meaning cannot operate at an ALS level if not on duty) unless specifically directed to in advance by the medical director for that region/area. That being said, I would stop at serious MVA's to make sure everyone was ok and offer BLS care only if necessary.

Without equipment you can't do much more anyway. At the moment there is no ALS thing coming in mind without the need of advanced equipment. OK, legal situation here: (just as on duty) there is all possible what you can do, including accepting restrictions by situation. So if you would be fully equipped, you can do almost all what you want (can). If not, then not and it would be fully acceptable to step back to BLS or even basic first aid. You don't need to be officially on-duty here to operate in your full scope of knowledge.

One of the contentious arguments in Paramedic school was if you stopped, someone obviously needed ALS treatment and you had the supplies/equipment, would you do it? My answer is NO. I would like to but I wouldn't since the Good Samaritan Law does not cover you in that sense.

Good Smaritan law here covers all help from random bystanders, even fully ALS equipped and educated people off-duty (in theoretical extreme, not that this happens often). This includes beeing insured in case of own injury and having rights to be compensated for damaged things (i.e. bloody trousers, used first aid kit).

Now if you have multiple scanners, decorate your car like an ambulance, and stop at every accident scene and put on your EMS jacket, you might be a whacker and a bit creepy.

Yes. But what's disturbing me, that at any time I state that I would stop to help in almost any cases one of the next arguments is this "whacker" argument. I'm proud to have my brain with me even if naked (once I had to do first aid on the beach with nothing else with me than my bathing trousers - even no gloves!).

And for the scanner thingy - if you really need to have a fancy car, beeing called to save the world - make it organized, open up a first responder unit, get it professionally equipped, get members high-leveled educated, let it register with dispatch and make a significant change in your community. BTDT *

Response times are usually less than 6 min. and transport times are usually even less. If I stop, I'm usually just in the way since each crew has a process by which they run a call. Besides, who am I to piss in their pool?

You're sure someone already has called them? 6 minutes in a CPR situation would be way to long for survival. First aid is no pissing in the pool, hauling the patient away and bill them would be.

I've been a medic long enough that I know that bystanders usually just end up getting in the way, prolonging scene time, and occasionally even hindering care.

Whow, never saw it this way. Do they really? But that doesn't make you the same kind if you render first aid, professionally hand the scene over to ambulance and step back. Beside that I never had significant problems with random bystanders (except the occasional drunk friend), wonder why this could be.

If I do happen to stumble upon something where a person is in obvious need of help, and no medical personnel have arrived, of course I'll help, but usually with very little results.

Depends what you count as results. It may not make an impression on you, because you are familiar with much more advanced treatment, but it sure will make a difference for the patient and others to have a calm, ensuring person there who really knows what to do. Even if he doesn't do much.

If I do render help, it's just to try to do minimal scene management until the properly equipped professionals that are on duty arrive. When I'm off duty I am just unprepared like most people.

You have an educated brain with you. Don't forget it.

Having said this, I already have encountered professional EMS providers in private first aid situations, who were severely drunk. THAT sometimes could be a real problem - they simply don't have a working brain with them...

So I should add to my expectations for first aiders: as soon as ambulance arrives, hand over and step back unless specifically asked to assist further on.

* I know this topic is a weak point for me after >20 year discussion and a very personal commitment to reducing responding times in my area, resulting in the now common volunteer first responder system here (and eventually two additional ambulance stations = even more career jobs in EMS). Maybe that's why I'm a bit allergic to unreflected and insulting terms like "wannabe saving the world", heard it often enough. I sure should try to stop discussing this on EMTcity further on. If interested, PM me. Thank you for listening.

Edited November 1, 2011 by Bernhard

[DFIB]

Here in Germany by law everyone is obliged to help (in his scope of practise, as long as he is able to detect the emergency and as long as he doesn't harm himself or other more important duties). This implies that NO professional provider is more obliged to help, just since he's professionally educated. He simply has the same obligation as any civil lay man.

I agree with every point you made in this post but the quote was pretty long.

In Mexico it is similar. We don't have a Good Samaritan law but EMS personnel are required to stop and render aid. We cannot transport in personal vehicles but are expected to stop. Untrained bystanders will always stop and benefit from trained leadership so they do not mishandle the patients.

I will even stop when the ambulance is already on the scene, just to see if I can be of help. Sometimes this only involves slowing down and asking if they could use some help through an open car window. Our resources are limited and frequently overcome. Sometimes I will stay on the scene with patients while the second ambulance arrives or while it delivers a load of patients and returns for more.

A trained professional can almost always be of some service.

Edited November 1, 2011 by DFIB

[tcripp]

So I should add to my expectations for first aiders: as soon as ambulance arrives, hand over and step back unless specifically asked to assist further on.

Instead of asking them to become passive in their care (stepping back and waiting), have them ask "What can I do to help you?" You know, a friendly reminder of "I'm here and can provide you another set of hands..."

Toni