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Tue Apr 11 23:40:58 BST 2006

Hi, Mike:

How we've been trained (northern California, YMMV, etc) is that the
order from the on-scene physician is only valid if the physician has
/already/ consulted with medical control and formally taken full
medical responsibility for the patient.

The way you've described your situation is unsettling to me: it seems
to say that someone who simply identifies themselves as a physician
can override protocols and/or medical control simply by verbal order.
Is that the case?

Ashton

On 4/11/06, Mike MacKinnon <mmackinnon at cox.net> wrote:
> Hey Ben
>
> I did a little research about this issue in regards to my state. It is
> pretty clear that if a paramedic runs into a physician on a scene who gives
> an "order" the only way to reverse, ignore or modify that order it to
> contact medical control and have the two physicians speak. In this case
> (based on the articles presentation) it dosent appear that the Urgent care
> physician gave an order but more like a suggestion. Since we dont know how
> the actual exchange went, its very hard to tell.
>
> Mike M
> -------Original Message-------
>
> From: Ben Reynolds
> Date: 04/11/06 10:18:16
> To: Trauma &, Critical Care mailing list
> Subject: RE: In regards to EMS intubation issues
>
> He may not be able to order the paramedics to intubate
> (or do anything for that matter) but he certainly
> could have taken medical custody of her from the
> paramedics if he saw it fit.
>
> In most states, once a physician (no matter what
> flavor, whether emergency physician, dermatologist,
> psychiatrist, whatever) prescribes a course of care
> they are legally and ethically bound to see it to it's
> finality until they are relieved by another physician.
>   This requirement is not satisfied until the receiving
> physician has PHYSICALLY encountered the patient at
> his or her facility.  These are the tenets on which
> laws governing interhospital transfers (EMTALA) have
> been based.
>
> The same holds true for people needing medical
> attention outside of the hospital or on the street.  A
> physician is held to a higher standard of care than
> the average good samaritan; a common reason why civil
> suits against "good samaritan" physicians or nurses go
> forward with such success.
>
> Calling an ambulance to the physician's office or to
> an urgent care center and handing over a patient whose
> condition has unexpectedly changed to a paramedic
> doesn't absolve the transferring physician of medical
> responsibility if the patient's condition worsens
> enroute, even if the argument that it was the "right
> thing to do" holds true.  Conversely, the medical
> control physician approving a course of treatment for
> the paramedics on the patient being transferred does
> not make the receiving physician liable because the
> "physical contact" requirement hasn't been satisfied.
>
> This urgent care physician in this case was obviously
> pretty savvy:
>
> 1.  He did not take the patient into his facility to
> examine her and initiate a plan of care on her, thus
> it is debatable whether the patient was ever really
> "under his care".
>
> 2.  He only "offered" his assistance to the
> paramedics, which was refused without physically
> intervening himself.
>
> Thus the paramedics are up a creek without a paddle.
> If the facts of this particular case had been the same
> with different circumstances (ie patient with same
> problem but WASN'T picked up out the parking lot of an
> urgent care center and a physician HADN'T been
> involved) the outcome would probably have been
> different.
>
> Ben Reynolds, PA-C
> Pittsburgh, PA
>
>
>
>
>
> --- Robert Smith <rfsmithmd at comcast.net> wrote:
>
> > Great points. I'm confused about several of the
> > facts as stated also. For
> > one thing I'm acquainted with Frank and have always
> > considered him a strong
> > EMS advocate. Not only do I have doubts about the
> > Urgent Care doc being set
> > up to intubate, he certainly couldn't "give orders"
> > to the medics as he is
> > not part of their medical control.
> >
> > Rob Smith, MD
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> > [mailto:trauma-list-bounces at trauma.org]
> > On Behalf Of Jeffrey Leach
> > Sent: Tuesday, April 11, 2006 8:05 AM
> > To: trauma-list at trauma.org
> > Subject: In regards to EMS intubation issues
> >
> > According to the JEMS article, Etomidate is
> > described as a paralytic, when
> > in fact it is an induction agent. While etomidate
> > would be appropriate to
> > administer in this case, it may or may not relax the
> > Pt. enough to
> > accomplish intubation. A true paralytic would have
> > solved the problem of a "
> > clinched jaw ". If the Paramedics in this case did
> > not have a paralytic per
> > protocol, one must wonder if the Urgent Care
> > Facility Physician could have
> > facilitated intubation with a paralytic drug. In
> > regards to the
> > documentation issue, we should all remember that if
> > it is not documented,
> > then it was not done...
> >
> >                   Jeffrey P. Leach, EMT-P
> > --
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