Conflict on Dual Medic Units

[Dustdevil]

NOTE: I am asking for input only from Paramedics on this question. No observations from Basics or Intermediates, please.

When discussing the pros and cons of dual Medic units, a theory that commonly comes forth is that having two Medics on a truck creates conflict when there are differing opinions on the assessment or plan. Interestingly enough, everytime I have heard this theory, it came from a Basic or Intermediate, and not from a Medic. And perhaps I am simply blessed with incredibly good luck and good partners, but I have to say that I have never once encountered this in thirty-something years of practice. However, my head explodes recalling all the times that I have had Basics (never an Intermediate) argue with me on scenes regarding patient care. This is not to say that there is no conflict between Medic partners about everything from when to eat to what street corner to hang out on. That is a constant, regardless of who your partner is. But I am speaking very strictly of medical issues.

My question to my fellow medics is, do you ever actually see this happening? If so, how often? Is it usually easily resolved, or does it indeed become a significant problem? Is there any common denominator you see, as far as when it is most likely to happen (i.e. experience levels, age of partner, gender of partner, type of patient, etc...) that we can attribute most of these incidents to?

And, as a follow-up question, do you experience this problem with Basic or Intermediate partners? Again, how often, and are there any common denominators? Is it more or less common than conflict with a Paramedic partner?

[flight-lp]

Dust, I frequently work with another medic. Sometimes that medic is an attendant, sometimes they are an in-charge, sometimes even a supervisor. I have NEVER had a situation where there has been a conflict. There certainly has been times when I would think to myself, "now I might have done that a little differently", but never to the level where the pt. was forced to suffer less than optimal care. Should there ever be a situation like that, an intervention is made, immediately, and the pt. provided the care needed.

I believe the difference lies in the fact that most medics see at an even level. Should another medic say "hey how about we do this for our pt.", most medics would be able to immediately interpret where their partner is coming from. And in my honest opinion, most will NOT react with defensiveness, or sulk and whine about it. I find that they are appreciative of the collaborative effort since there is a level of equality amongst them.

Where my problem lies is the all too often occurence when an EMT-B or I suddenly becomes a board certified ER physician and starts questioning why something wasn't done. Or worse, having a belief that something should be done that is in no way indicated...............

Case in point.............I work with an EMT-B on occasion who is the biggest "EMT's should be able to do xxx (insert ALS skill here) because we are a progressive 911 service". But he is also the first person to say that every 18 y/o female with menstrual cramps or a UTI needs an IV and is an ALS call.

The problem is that EMT-B's and I's rarely have the concept of autonomy or a thought process at a level that can allow critical thinking. Whether they know it or not, they definitely don't like hearing it.

Medics are equal co-workers and can understand another medic at the same level. Lower level EMT's are not and cannot always comprehend the "why's" to EMS. Instead of accepting this, defense mechanisms are shown. It is this involuntary and natural reaction to non-equal non-acceptance that I believe is the root of the problem.

But as has been stated before, we ourselves have developed the evil from within.

[Ridryder 911]

I agree, if Paramedics were all created equally. Right now, I have seen such a diverse in education in training, it no longer matters what title or patch they wear. There are many Basic EMT's that have hospital experience and even maybe have a B.S. degree that supersedes the Paramedic they are assigned to. Yes, it is shameful.

Now, if you were to asked me ten years ago, I would had stated that dual medics was the only way to go, now I have second thoughts. In returning to the field full time about 3 1/2 yrs ago, I have seen a different product of medics.

I have always worked with dual medic systems or be with those in school to be become one. I was taught to discuss patient care among each other (especially in those situations of the poop hitting the fan), realizing both of us were equal and if one was closer to the head, body, extremities, etc.. then to perform without prompting or permission from the other medic to treat at the Paramedic level. There was a lead medic on the call, however; I never heard .. "this is my call.. etc.. as I was taught it was a team approach. Now, I hear this is my call.. just do as I tell you. You can be the lead on the next call, then you tell me what to do. WTF? Why do I need to tell any peer what to do or be told what to do? If I or the other Paramedic does not know what to do, perform, then personally they need to be gone.

I have even had near physical confrontations dealing with newer Paramedics, whom suddenly think once they get the patch... the call is an "I" response, more than a "we" approach. I wish it was an isolated case or be able to blame it on one school, institution, or area, region, but this is not the case. I even have one explain to me, that if I had missed something upon examination, they would not inform me about it and allow the patient to suffer, "since it was not their call if they were not the lead". Apparently about the late 90's on.. it has been stressed that there should be only one in charge and others obey... Wow! what a different methodology

I always come back it would be much cheaper and easier to just have a basic or intermediate with me. If I am going to only be limited to perform only the direction of the "lead medic" and do the tasks and the only advantage is to switch or alternate calls, then place me with a basic. At the least I can teach and not have to argue with someone whom is supposed to be my peer and equal.

It is apparent most of the medics have now never worked in medicine. The most they have experienced is the few clinical hours or to drop off a patient in the ER. As well, have never experienced grand rounds, to consult and give suggestions, supplement each other.. again team approach. Definitely, never to be critiqued and reviewed.

I had thought maybe this was an isolated personal issue, but after talking to some "seasoned" medics, found it was a general occurrence. I even talk to administration to be told that "it is a "new generation" and "new work ethics".

Fortunately, I have had some of these "newer generations" describe that they felt less stress after agreeing to do it "my way" ... wow, working as a team is easier!

Part of the ignorance is they do not realize that in litigation that it will be an "us" in the courtroom, not just a single person.

I can no longer see advantages of dual medics, if this is the general consensus of how it is going to be performed.

R/r 911

[medic429]

I have to agree Dust, that more often than not, any questioning or conflict I get seems to come from Basics. When I am blessed to work with another Medic, I haven't had any issues regarding disagreements-none that I can remember, anyway. I can recall several instances where an EMT-B has questioned why I did something or didn't do something, because "so and so told them blah, blah, blah"!

We have Medic/Basic trucks here, so when I get to work with another Medic it's usually on a critical call. One of us assumes patient care and the other is usually there to lend ALS skills. In most cases, you are just thankful to have another Medic-no conflict necessary.

[akflightmedic]

Great topic Dust!

I have commented on this before in some other thread but here goes....

I was one of those EMTs that questioned everything. I would second guess my medic and critique him/her after the call. Most of the questioning was due in part to my natural desire to learn, however I was an ass on occassion.

Once I went to medic school and continued to learn after that as well, my eyes were opened to a whole new realm. I had absolutely no clue what the hell I was talking about as an EMT. The thought processes were entirely different and all this new knowledge taught me how little I knew.

I started out in a medic/emt system. I went from a cocky, save the world EMT to a more learned medic that was scared shitless. I now had to deal with other EMTs that used to be the same as me...ohhh the joys of karma. Regardless of what I would tell them or teach them, it just didnt get through for the most part. They always wanted to do more but not learn the hows and whys of the skill. They often questioned me on scene in front of patients, treatment modalities, etc. It was annoying as hell.

Then I moved to Florida...ahhhh, Florida. I went to work in an all medic system. Thats right, only hired medics for the entire county. At first, I was unsure of how I would react to this environment, but after orientation and getting my station and partner I quickly learned it was Val Halla. It was pure joy! There were no questioning looks, no smart comments. Everything was disucssed intelligently. For the most part, we were always on the same page treatment wise. There was no need to ask or tell anyone to do anything. It was already getting done.

On a few occassions, there would be a difference in the prioritization of what needed to be done. It was no big deal, quickly resolved and usually without words. After the call, we would ask each other, what were you thinking or why did you go this route with treatment, etc. I was blissfully happy there.

I have sat here thinking and thinking, and for the life of me right now, I can not come up with a time where there was such a huge variance in opinion that it created conflict (pt care wise). There were occassions when I debated between doing a RSI, surg cric, or decompression as opposed to any other alternative therapies or doublechecking my assessment. But this was usually resolved by looking at my partner, seeing they were in agreeance or handing me the equipment to do it without asking. It was so nice to have this double coverage.

I left that job to begin my flying career.

After Hurricaine Katrina, I went to LA to lend a hand. I worked for a service on a contract basis that paired me up with an EMT as that is how their system operates. I was excited as I had not been on a busy truck in a while and it had been many years since I was partnered with an EMT. It didn't take long before all the old shit started again. I worked with many different EMTs and they were all the same. Challenging procedures, wanting stuff done their way, basically trying to appear more knowledgeable in front of the patient than they actually were. It was so frustrating but I toughed it out. I went down there to help for a set amount of time and I was determined to complete my contract. But the entire time, I was wishing I were with a medic. There were a few rare shifts, I actually got partnered with a medic and it was great, not a single issue other than the medics telling me how my main EMT partner liked to tell everyone how incompetent I was and how she would of done things diffferently had she been the medic..lol.

To answer another part of your question, the contributing factors that potentially influence the behavior that I have observed are the EMTs are usually very young, short on life experience. I have worked with some older EMTs new to the field and did not encounter such issues. They tend to be more reserved and observant, not feeling the need to establish themselves as a hero, mostly due in part to them already knowing their place in life. Male or female was not a huge factor.

OK, I have lost track due to outside influence. I will submit now and come back later...lol.

[paramedicmike]

I have had the unfortunate occasion to work with a couple burned out medics who attempt to BLS every call for which they were up. This has lead to some interesting discussions after the fact. I'm not sure this plays into the current discussion, though. It wasn't a matter of not knowing what needed to be done. It was just a matter of being lazy.

In at least one case that I know, it did lead to the medic being terminated.

The larger situation has been handled more than once by me asking, "Do you just want me to 'doc' and you can drive?" I've not been turned down yet. And that takes care of the issue.

Overall, though, I've been fortunate in the sense that even the burned out medics know and do what needs to be done. It's a rare thing for me when they're so burned they just don't care.

Now, for medics who care about what they're doing and aren't lazy and/or burned out, I've not once run into a problem where I've had to disagree with either their assessment or treatment plan. If a question has come up we have discussed the issue, reached a consensus and moved on from there. No conflict existed nor was there disagreement.

Unfortunately, I've not had the same productive experience with basics and/or intermediates. I've had more "B" and "I" crew members try to argue assessment and treatment options than I care to think about. The way it usually ends is with me asking, "Why?" and their reply, "Because I saw so and so do it that way once."

I could go on, too, but I'm late for a goodbye summer blow out. I'll follow up later. :thumbup:

[Scaramedic]

I mostly agree with everyone else, my experience with 'drama' tends to be with newer Medics and Basics. Though I do have to disagree with one point AK brought, the best partner (Basic) I ever had was about as experienced as anyone out there, 18 yrs. We had a few rather intense discussions, though not related to treatment but rather transport. She really did not like dealing with the intoxicated open air living crowd.

Only one dual system person has ever crossed the line of suggestion to a full blown blow-our and she was a brand new Medic who worked as a Basic for about 2 years. Her attitude really changed after she got that ''P" behind her name.

I agree that the dual Medic seems to work better, at least for me. I think it is because you can both take a path on interventions, "I'll tube em you get the line and catch the monitor" kind of thing. Where as a Basic tends to want to be involved and might seem pushy and over think the situation and their training. Also it might come down to feelings of being inadequate as a new Medic or as a Basic.

[Asysin2leads]

I've yet to hear or see a full blown arguement among two medics over treatment. However, sometimes there is disagreement between the medics working, and that is a GOOD thing. Many times if one of the medics is in err in judgement, simply the act of being forced to explain his or her reasoning will allow him or her to make the right decision. In addition, as both medics usually realize, there's really no reason to argue, because of the luxury of phoning a friend at telemetry. If Medic 1 wants X and Medic 2 wants Y, both of them will agree that calling the doc to find out the right answer is far better than a pissing match.

Part of it is I think the unwritten rule of professional courteousy that extends to not questioning the medic who is teching's decision unless absolutely necessary, and even then, its usually discussed rather than outright argued. I think the fact that the situation can arise where one medic can question the other during a call is a key benefit of a dual medic truck. As my old instructor used to say "We all have bad days. We all have brain farts and such. That's why its good to have partner there to catch it and vice versa."

Possibility of medic making mistake: Hopefully fairly low. Possibility of both medics being mistaken: Expotentially lower. I think if an arguement does actually break out its because someone's ego has gotten in the way, and usually ego issues are ironed out by the 3rd or fourth year or whenever the medic works out his or her underlying mother/father/inferiority/picked-last-for-dodgeball issues.

I also have to concur that my experience has been its usually the EMT-B/first responder whacker pack that will start an arguement on scene, and personally, I say its society's fault. We are a country built on democracy, where everyone gets a vote, but today's society has taken it one step further, where not only does your opinion count, YOU are the MOST IMPORTANT person, and what you say matters. If you're an EMT and you're used to watching any talk show, where anyone in the audience can stand up and challenge the expert and the arena of television gives them equal weight, why should you think any different when you get on a call? It doesn't matter if the person in the audience speaks in some regional subdialect of English and the expert has a PhD, the host will remind us that "everyone has a say," and this is what people learn. Sometimes you just have to say "Listen, this isn't American Idol, and your vote doesn't count as much as the judges."

[fallout]

Most of my conflicts when on a dual medic truck result from a lack of professionalism on the part of my partner.

I will preface this by saying that most of the time I have professional paramedic partners and we have some minor discussion on patient care, but is oriented toward whether we are providing the best care and making sure we aren't missing something glaringly obvious about the patient.

Occasionally, I get the partner who has no interest in anything but dumping the patient as quickly as possible. I've had that nearly turn into an argument on scene, as he was wanting to start toward the hospital before I had even assessed and done any stabilizing treatment on the patient. For that matter, even knew if any stabilizing treatment was necessary. I got quite a bit of attitude from him when I told him to slow down, give me a few minutes and let me know what exactly is happening with this patient. We discussed it after the call and he told me that he believes we should be moving toward the hospital anytime the patient is sitting in the ambulance, for liability reasons. I felt there was greater liability in not thoroughly assessing and treating the patient where they are. We reached a state of detente where basically, if it was his turn to write the report, he made the call and if it was my turn, I made the call of when we left scene.

I am a new paramedic and generally try and listen and learn from experienced paramedics, but some experienced paramedics are also burnt out paramedics, so I have stand up for my what I believe is correct patient care, at times.

[mediccjh]

Where do I start?

While I respectfully disagree with Dust's belief that all ambulances should be ALS, I believe all ALS trucks should be dual-medic.

I have worked in both EMT-Medic and Dual-medic systems; the latter being where I am currently employed full-time. There are pros and cons for both.

EMT-Medic:

Pros:

-If you have a strong EMT partner, or a medic student, it is almost like working with another medic. Yes, they may not be able to perform the skills; however, if they are good, they will be thinking one step ahead of you and have your equipment ready. My partner at my last full-time job was a medic student, and it was like having another medic with me. We were a great team.

-If you are with an EMT, you are not doing paperwork on any BLS job. When an EMT argues the point with me, I ask them if they can write an ALS chart. That ends the conversation there.

Cons:

-If you have a rookie EMT with a shitty job, chances are you will be working by yourself. You're trying to get 20 things done at the same time with someone who is clueless. It sucks.

-You have an EMT who thinks they know-it-all. They will question you in front of the family or patient, or bad-mouth you behind your back. They are the ones who get put in their place in front of the family or the patient. Yes, it sucks, but be a diplomat to the family or patient, and all will be OK.

-If you have a shitty EMT partner, or one who is anti-medic, the lazy factor can come out. They will claim, "Well, it's ALS equipment, so I don't have to do anything." Or, the attitude is, "You're the medic and get paid more, so all I have to do is drive." These are the ones who are usually crying when they work with me.

Dual-medic system:

Pros:

-You have someone to lean back on. If you miss a skill, they can try, and probably get it. My personal rule is 2 strikes. If I am unsuccessful twice on an IV or an ETT (HA!), I will turf it to my partner.

-You have someone to bounce back ideas and treatment modalities on. Yes, everyone has their bad day, or their day when they are off. It helps to have someone who holds the same knowledge (I use that term loosely) with you on the job in case you get stuck.

Cons:

-You have the Paramedics who have the Napoleon complex. It's their way or the highway. Fortunately, I've never have come to fist-o-cuffs. That would be bad, and make us all look really bad.

-You have lazy paramedics. Unfortunately, I have some of them where I work, and when they piss me off, they get relegated to driving duties. I will NOT tolerate lazy paramedicine on da Herbie Bus.

To answer your question Dust, it usually isn't a problem when I'm with another medic. The rule I have on my bus is if one medic wants to treat, it gets done. Discussion after the job. A 12-Lead, Saline Lock, and Blood Sugar check NEVER killed anyone. EMTs on the other hand, yes. I even had a hoople bucket-fairy file a State QA charge against me on a job, which occured during the November 2006 Week From Hell. Needless to say, nothing ever came from it.

I've been a medic for 6 years, which is a twinkle in the eye of most who have posted in this thread so far. However, in those 6 years, I have been working in busy systems, so I think I can hack it with most of youz, and would enjoy a tour with yaz.