Medical hierarchy vs Field savvy

RedBlanketRunner

Opheophagus Hannah Cuddler
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I'm out of the business now. On the sidelines. Re-retired after being a medical coordinator/facilitator for NGOs in third world countries. (Glutton for punishment)

And being out of the loop now I want to voice a gripe that has been gnawing at me for over 40 years. And hopefully, get some feedback if you would be so kind or bold.

Typical scenario. Just one example.
I was working at a hospital and my years of ambulance experience were well known to the ER staff. Out in the parking lot a woman took a dive out of a camper and was down. Husband sought assistance and I was first on scene.
Assess: Female sitting on the ground. 60+ yrs, somewhat overweight. Color good, panting, obvious pain. CAO 3. Her left arm was in an odd position, forearm fully posterior lateral. Shape of her shoulder was odd. Displacement indicated. I wanted her immobilized as is and on a stretcher as is, sitting. My gut told me supine was out.
Since the patient was otherwise stable and supported by a husky male I continued a full assessment for about 2 minutes.
A nurse was next responder. She immediately relocated the woman's forearm to the front and directed the other responders, 2 more nurses, to manhandle her up onto a gurney. The move not gentle and cautious but par with untrained bystander.
I handed off to the nurses. The next day an emergency trauma surgery was scheduled. Brac artery had been lacerated. Displaced FX at the ball.

Yes, I know. Bad calls happen all the time. If wishes were horses I'd have every ER nurse put in a few hours of field patient management and yada yada.

But the gripe: There is no venue to bring those screw ups to the attention of the medical hierarchy. Regardless of training, expertise, and experience, average field medic is a glorified package delivery service. In the above scenario, I attempted to suggest to the nurse to immobilize in place. And got my arse chewing by the ER sup and the DoN within hours.

What's your takes?
 
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NPO

Forum Deputy Chief
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It's a culture problem.

Everyone, regardless of rank, experience, tenure or training can always learn something. Rarely I am on any call where I don't poll all other responders about what they think should be done.

The best practitioners look to their peers who have outside or specific experience to lean on. Would it have been appropriate for them to ask you the best way? Sure. But if the culture of checking your ego at the door isn't established, it won't happen.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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Addendum. I reiterate, the above just one example. Another, possibly the worst, was a nurse in uniform at a TA, kneeling in a large pool and near hysterically demanding "GET AN AIRWAY." Carotid bleed out and three feet away from her a sitting silent person, labored breathing, dazed unfocused eyes, blood from one ear.
Tunnel vision. Triage, my darling. Big picture first if you will.

@NPO Nod and sigh. That nails it.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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So...I’m not getting the point... You are starting that you are better at medicine than all others?
You have an interesting slant to your postings. I'll certainly let you know when I staRt backyard neuro pathology seminars.

Ideally, a venue where an open discussion is possible. One ER had a certain PoD open round table discussions with all staff including EMTs after some scenarios.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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So...I’m not getting the point... You are starting that you are better at medicine than all others?
Checking old postings, firing off an internet search, looks like you have a twin brother. Same negativity, cynicism, critical caustic comments, borderline anti social. And at a glance it appears you and your twin spends a good portion of your life on the net crapping on people. I've had enough barf tossed in my face over the years. Please consider getting off of my cloud. I don't use the ignore feature, but maybe you could?
 

Carlos Danger

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Premium Member
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I'm out of the business now. On the sidelines. Re-retired after being a medical coordinator/facilitator for NGOs in third world countries. (Glutton for punishment)

And being out of the loop now I want to voice a gripe that has been gnawing at me for over 40 years. And hopefully, get some feedback if you would be so kind or bold.

Typical scenario. Just one example.
I was working at a hospital and my years of ambulance experience were well known to the ER staff. Out in the parking lot a woman took a dive out of a camper and was down. Husband sought assistance and I was first on scene.
Assess: Female sitting on the ground. 60+ yrs, somewhat overweight. Color good, panting, obvious pain. CAO 3. Her left arm was in an odd position, forearm fully posterior lateral. Shape of her shoulder was odd. Displacement indicated. I wanted her immobilized as is and on a stretcher as is, sitting. My gut told me supine was out.
Since the patient was otherwise stable and supported by a husky male I continued a full assessment for about 2 minutes.
A nurse was next responder. She immediately relocated the woman's forearm to the front and directed the other responders, 2 more nurses, to manhandle her up onto a gurney. The move not gentle and cautious but par with untrained bystander.
I handed off to the nurses. The next day an emergency trauma surgery was scheduled. Brac artery had been lacerated. Displaced FX at the ball.

Yes, I know. Bad calls happen all the time. If wishes were horses I'd have every ER nurse put in a few hours of field patient management and yada yada.

But the gripe: There is no venue to bring those screw ups to the attention of the medical hierarchy. Regardless of training, expertise, and experience, average field medic is a glorified package delivery service. In the above scenario, I attempted to suggest to the nurse to immobilize in place. And got my arse chewing by the ER sup and the DoN within hours.

What's your takes?
I am a bit unclear on the first scenario. If you were first on scene and your years of experience were well known to hospital staff, why didn't you do a better job taking charge? The nurses did what they did because they didn't know any better. Why didn't you stop them from moving the patient if you felt it was inappropriate? Why was "emergency trauma surgery" not "scheduled" until the next day for a devastating orthopedic injury with an bleed? Sounds highly unusual. If you really did get your arse chewed by the director of nursing simply for suggesting that the arm be immobilized, then that makes me wonder what else was going on.

Second example, again you have a layperson outside their element, trying to put their training to work in order to help. Not really sure what to say about it.

I'm not convinced that a medical hierarchy exists that automatically places nurses above paramedics in the field, or that your examples support that. Maybe its different where you are from, but it isn't really like that anywhere I've worked. In fact I've responded in an ambulance to hospital parking lots several times because policies existed that disallowed clinicians from going outside to retrieve patients for these exact reasons. And there is always an avenue to report a legitimate concern about quality of care.

Is the intention here just want to tell stories about times we've seen nurses screw up?
 

joshrunkle35

EMT-P/RN
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Where I work:

In the field, our hierarchy is: paramedic over nurse (Assuming nurse is not Surface Transport or Pre-Hospital). At the hospital, nurse over paramedic. Both over EMT, medically speaking, although EMTs may have jurisdiction in an area over a nurse due to laws.

In my experience, conflicts seem to exist in higher numbers the lower in education a provider is. Meaning: I frequently hear gripes from EMTs about physicians, nurses or paramedics, but, the more training the provider has, the less I hear them complain about other roles.
 

DrParasite

The fire extinguisher is not just for show
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And got my arse chewing by the ER sup and the DoN within hours.
why?? for suggesting they immobilize the arm? there has to be more to that story.

better question, isn't a lacerated brac artery a life threatening emergency? why did they wait until the next day to do the surgery?

In my experience, if staff know you, know of your experience, and are familiar with your knowledge, they will listen to you, and let you call the shots, provided you have a command presence. idk what role you held at the hospital, but i've had nurses that won't even leave the ER doors, and any falls in the parking lot are attended by security and the 911 EMS agency

More truth be told: many medical professionals are useless outside of their area of expertise. So if you take a floor nurse and put her on a 911 ambulance, she will fail. if you take an ER nurse, and put her on a ortho floor, they will go insane. if you take a proctologist, and put them in the middle of a multi system trauma patient, they will look like an *******.

a paramedic is really good in the field, in an emergency, because that is what they do day in and day out. In the field, they are the top of the medical food chain, put them in the ER, and they become a tech, and fall to the bottom of the food chain. Historically, EMS providers have one job: to stabilize the patient, and to transport them to definitive care, which is why we are really good at that, but beyond that, we are at the lowest level of the medical hierarchy.

Nurses do make mistakes. paramedics make mistakes. EMTs make mistakes. firefighters never make mistakes. and even muppets make mistakes, once in a while. I wouldn't stress over the actions of others.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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Thanks MUCH for the responses!

To clarify: Woman down in parking lot. I was a fish out of water. No equipment, no ability to request anything. I knew staff were summoned. So it was assess and reassure while trying to keep the patient as immobile as possible.
Honestly, the reverse of a nurse showing up at a field scene. If I had a unit there, no prob. Instruct the bystander, grab the gear and wrap her.

I am a bit unclear on the first scenario. If you were first on scene and your years of experience were well known to hospital staff, why didn't you do a better job taking charge? The nurses did what they did because they didn't know any better. Why didn't you stop them from moving the patient if you felt it was inappropriate?
Hierarchy. I could easily cuss a couple of paragraphs here. My first job on an ambulance, our units were retired hearses, the ambulance company ran a funeral home. No standing orders, physician directives by radio and the radios sucked. Grab and run. Red blankets.

Then when I went back to ambulance, we were just forming an EMS. We had a hefty load of old school pedant docs on the advisory board. I can't even guess how many times I heard "practicing medicine without a license". Getting the EMS off the ground took 7 years. The hierarchy was set in stone. Nurse always supersedes ALL EMTs inc. parameds. And thus, ER nurse took her beetch straight to the Sup. A lowly paramed dared tell ME what I should do!

Is the intention here just want to tell stories about times we've seen nurses screw up?
Absolutely not. If I gave that impression I owe all an abject apology. Admittedly, I take nurses for granted. But I will be the first to admit I wouldn't want their jobs at triple the going pay rate. High pressure with no let up every minute of the shift and get each and every detail right first time every time.
The highest accolade I could offer nurses was when I was working bio-med tech. In their way constantly, equipment malfunctions, administration cutting every corner to save a buck (20 year old patient monitors in the ICU, one defib had vacuum tubes) and the nurses constantly put out effort to be civil and calm around me when it was obvious most would have loved to yell GET THE F OUT OF MY WAY!
(An aside, one AM, 12 work orders handed to me of the nurse call system on the floor nutting up. A little added bonus to the nursing staff workload. Antique nurse call system. When it was on the fritz they had to do door checks every 5-10 minutes.)

better question, isn't a lacerated brac artery a life threatening emergency? why did they wait until the next day to do the surgery?
I never heard. Mushroom. Kept in dark and fed... There was a serious crackdown on talking about patients at that hospital. On numerous occasions I wasn't even able to get updates on patients I brought in. This was during the malpractice lawsuits heyday of the early 80's which would explain some of it.

firefighters never make mistakes
Put the wet stuff on the red stuff. ;)


Here's a more recent war story. After years of towing the line, standing orders, P&Ps I went to Thailand. Volunteer teaching hygiene and disease prevention. That ballooned into doing some field medical work. One day I had a female in acute pain. (Turned out to be an ecotopic preg). Well, I didn't know the procedures at the local hospitals. Was an ambulance available? Which hospital and yada yada. So I called a hospital and got an ER doc. More like 10 calls. Lousy phone connection plus I wanted the protocols: call the shots, doc.
Finally got her transported, checked her into the ER, then the doc grabbed me by the sleeve and dragged me to an office. Door closed and up in my face. "You're a paramedic, right? Well welcome to the third world. JUST SHUT THE **** UP AND DO THE DAMNED JOB!"
And all those years of rigidly followed rules and regulations and towing the line and not one toe out of place got tossed out the window.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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More truth be told: many medical professionals are useless outside of their area of expertise. So if you take a floor nurse and put her on a 911 ambulance, she will fail. if you take an ER nurse, and put her on a ortho floor, they will go insane. if you take a proctologist, and put them in the middle of a multi system trauma patient, they will look like an *******.
Or a bio-med tech babysitting a piece of **** C arm smack in the middle of an open heart surgery. It was like watching this incredible intricate choreographed dance. Everyone knew precisely what to do and when to do it. Mind blowing.
 

CCCSD

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Just three monkey wrenches gumming up the works. Fed will/may/can defer to state. Some states allow the courts to have a say in holds, and the ever popular financial aspect and socialized medicine.
I know of one fantastical mess that is ongoing where a hold was utilized with other evidence to place a man in a conservatorship. Then other family members intervened and this has been dragging through the civil court system for at least three years. A law enforcement agency and a hospital along with several individuals are being sued.
Checking old postings, firing off an internet search, looks like you have a twin brother. Same negativity, cynicism, critical caustic comments, borderline anti social. And at a glance it appears you and your twin spends a good portion of your life on the net crapping on people. I've had enough barf tossed in my face over the years. Please consider getting off of my cloud. I don't use the ignore feature, but maybe you could?

Good! Then you can see that I call out BS quickly and don’t pull punches.
Since you’ve misinterpreted my other posts on other forums, because you don’t work or have experience in those areas, you have no say about them.

You seem upset that some are questioning your tales. We should. They sound like an EMT that has a huge ego and is determined to force people to recognize how “ great” he (thinks) he is.
 

KingCountyMedic

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I think if you made it out of the business after 40 years and are in retirement this is the last place I'd hang out! If you have survived this job physically and mentally get off the EMS forum and go get a hobby! On a serious note, 40 years in the field has probably had an effect on you. If you're still worrying about stuff you experienced you might want to talk to a pro about it. ENJOY a well earned retirement!
 

Chimpie

Site Administrator
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From our rules page:
We take the "Be Polite" rule VERY seriously! We consider it our "First Rule". We do not tolerate ANY rudeness, profane or offensive language whatsoever. Any member who is intentionally unpleasant or disruptive may be suspended or banned.
 

DrParasite

The fire extinguisher is not just for show
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So your bringing up something that happened in the 80s? Were you that traumatized by it that it has bugged you ever since?

If I had a nickel for every time I was talked down to by a doctor, nurse, firefighter, cop, CNA, RT, or supervisor, I would be loooooong retired, living in a beachhouse, and spending my days destroying my liver. But alas....

I'll echo what @KingCountyMedic said: enjoy your retirement. don't worry about issues that happened back in the day. things change, things have changed, and things will continue to change. And since your retired, you shouldn't be even letting it bother you.
 

Summit

Critical Crazy
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The hierarchy is supposed to be the patient over everyone else. If you see something, speak up. If you see imminent harm, intervene.

Primum non nocere.

The focus of healthcare culture these days is on patient empowerment instead of paternalistic care. Research, awareness, activism, regulators, accrediting agencies and reimbursement models have put hospitals on a focus of reducing harm, improving reliability, and increasing quality of care. Protected reporting, non-retaliation, systematic incident processes like RCA, and value supportive models like Just Culture are meant to be transformative.

There are places with sick cultures. There are places than haven't come to modernity in care. But in many places, a lot has changed since OP was in the game.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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It's good to hear things have changed for the better. I would note the two examples I gave were just selected because they gave clear cut examples of the problem. A problem which many of us bucked year after year.
Another one comes to mind. A bus load of FFs. A tree came down on it. Ambulances (2) arrived and a physician showed. The driver of the bus was pinned under the caved in roof and tree. The doc detected a femoral pulse and directed all rescue efforts on him. Reportedly, over the course of an hour 2 other cases went from serious to critical, the FFs attending to each other. The driver turned out to be brain dead.
It was a pretty common scenario back then. Physicians interpretation of the Hippocratic oath vs Triage.

And I would add, some docs. Banging head against the wall here. Knowing they were on duty made you pause and chew nails when you keyed the mic.

(I was chatting with a really good trauma doc once and I mentioned one certain doc. The doc paused a moment then cautiously remarked, "I understand he's a very good carpenter."
 
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DrParasite

The fire extinguisher is not just for show
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define "a physician." are you talking about your medical director? an on duty ER doc who was requested to the scene? an EMS physician, part of a recognized pre hospital physician program?

or just the proctologist who was driving by on his way home from work?

if my medical director tells me to treat the driver, than that's what I'm going to do. I'm also going to be calling for more help to treat everyone else.

most fire firefighters, esp for a bus crash with multiple injuries, are going to call for a second rescue unit and more resources to aid in the disentanglement. Especially after the first hour and no progress. However, most FDs won't take directions from a random doctor.

I will reiterate what I said before: everyone makes mistakes, especially when you take them out of their regular environment. if you take that trauma doctor out of the ER/OR, where they are dealing with one patient at at time, and place him in the center of bus accident, they might tunnel vision on that sick patient (because that is what they are used to dealing with, one train wreck at a time). Doesn't mean they aren't who you want to treat you after you get hit by a bus, only that the are better in an ER vs out in the field.

And there are some amazingly helpful and useful doctors who will help EMS beyond the hospital doors.
 

NomadicMedic

I know a guy who knows a guy.
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Interesting stories, but worth nothing except a historical viewpoint. EMS doesn't function this way any longer, and hasn't in a very long time. At every agency I've been involved with in the last 25 years has made available a clear channel for incident reporting, whether the clinical manager, quality improvement officer,compliance or CEO, I've not had an instance where I wasn't able to make a valid concern heard.
 
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RedBlanketRunner

RedBlanketRunner

Opheophagus Hannah Cuddler
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or just the proctologist who was driving by on his way home from work?
About this
@DrParasite "most fire firefighters, esp for a bus crash with multiple injuries, are going to call for a second rescue unit and more resources to aid in the disentanglement. Especially after the first hour and no progress. However, most FDs won't take directions from a random doctor. "
The Lassen fire incident. Complete mayhem. Roads cut. All available personnel were spread over a fire line stretching for miles.

I'm giving you modern younguns a window into the past. Reading your comments now it's hard to believe how much authority the medical chain of command wielded. Not just ambulance but extended to the FFs. Today the front line responders are reaping the rewards of a groundswell that apparently has managed to come into it's own right.

I remember the horror stories from before the EMS. Funeral homes running ambulance services, grabbing the dead bodies first as there was more money in it. No standing orders. No SOPs. All directed by physicians. First fights sometimes broke out among conflicting ambulance crews as to who got which patient.
And this still goes on in other countries.

It's nice to know that things have changed.

@NomadicMedic "At every agency I've been involved with in the last 25 years has made available a clear channel for incident reporting, whether the clinical manager, quality improvement officer,compliance or CEO, I've not had an instance where I wasn't able to make a valid concern heard."
This is universal now?

I spent the past 20 years in the third world where it hasn't progressed from those dark times. I ask a little understanding here.
 
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