03 April 2008

Incident command

At every level of EMT training, you learn about incident command. Specifically, the fire department senior officer is in charge. Emphasis on period, regardless of the type of "incident". Most departments use the National Incident Management System because the government has decided that is the training required to get a hold of the all important $$$. This system is really intended for large incidents where you need a staging area, different operational groups and levels of command. But, working with fire departments I encounter officers with varying interpretations of their responsibility.

The vast majority of the fire officers are EMT-Basics and are happy to be involved in coordinating their firefighters with the ambulance folk, telling us where to park, how we're going to extricate the patient and helping carry them, performing the complicated and technical extrications that can be required, breaking whatever necessary to get us to the patient's side, even providing patient condition updates en route since they arrive before us, and generally being reasonably helpful and not too obtrusive. As far as actual medical care, most defer to the paramedic on scene, recognizing that the additional education and training usually allow them to make good patient care decisions. All is happy smiles in the world of intra-agency cooperation.

Then there are the other officers, and sometimes firefighters, who want to be in "command" of everything on scene. One particular officer in the city has been an on-going problem for me. Now, he is a paramedic himself, with a number of years of patient care experience prior to the FD becoming a non-transport agency and no longer working elsewhere as a transporting medic, so the issue is not one of education and training. He is in charge when he is on scene unless there is a captain or chief of some rank there, which is rare for EMS calls. He likes to directly "command" every aspect of a scene, including all decisions on patient care, to the point of actively interfering when something is not being done per his assumed course (even if he hasn't told anybody what that is). Where the difficulty lies is that he is not the medic whose ass gets chewed by the doctors if something is not to their satisfaction.

Just one quick example: The Asian and I arrive on scene for an overdose patient, unresponsive in a parking lot at night, maybe 40-45 degrees outside. When we get to the patient, the firefighters are searching the man's pockets for ID to give the police, the officer is talking to PD with the friend who found the patient trying to get noticed. I don't know what to make of this at first, is he dead? is he fine? why isn't anybody treating the patient?

I start assessing the patient, who has a pulse, is breathing adequately and protecting his airway, but is distinctly unresponsive. He is laying next to a car which is blocking all ambient light. I've got baseline vitals and tell The Asian I'm heading for the stretcher so we can move the patient into the truck where it is 1. warm, 2. safe, 3. light. As we get the patient onto the stretcher, the officer decides that we are not allowed to move the patient until we drop an OPA (oropharyngeal airway) to protect his airway. The Asian and I both pretty much ignore him and continue to the ambulance because, since we actually assessed the patient, we're not that immediately worried. When we are nearly ready to leave, The Asian asks if I can go find the pt's friend to try and get some additional information on the overdosed drug. The officer blocks my path and refuses to help locate the friend, instead demanding repeatedly, "What do you want to know?" He never offers any information, and I'm not sure what exactly the question was. Finally, I find the friend the question gets answered and off we go.

This officer follows us to the hospital and demands all sorts of attention and action, eventually keeping his crew out of service at the hospital for over an hour waiting for our supervisor to come address the issue. Which boiled down to respect. He felt we did not respect his command of the scene. Well, I couldn't really argue with that point. The problem is that you lost your opportunity for respect when the crew that you really should be in command of was not caring for the patient and you did NOTHING.

I followed up with some of the management folks on this and was told that I am to do whatever this officer says, when he says it, regardless of what I think about it. He is in charge of the scene and paramedic, or basic, or first-grade nosepicker is irrelevant because the officer on scene will always be the first one on the legal hook. I find this both ridiculous and unbelievable and struggle with it every time we encounter said officer. I don't even want to go on calls with that engine because I always wonder if he's going to be there.


Ellie said...

I had several run-ins with the FD too, even in my short time with the Rock. Him being "commander" on a medical scene is just crap. He's not acting as a paramedic at that point (esp. considering he didn't bother with patient care) and does that type of scene even require a "commander"?
I think it boils down to him being an ass, myself.

manchmedic said...

I know who you're talking about, and I had a run-in not too long ago with him myself. He tried to give me similar crap, and I asked him which of us would end up going to court if something ended up going rather wrong. Considering that he didn't get anywhere near the patient, that question was moot, wouldn't you say?

AlexD said...


It is amazing what a little power can do. I see that the officer has a control issue and your leaders are probably handcuffed by a local ordinance which places fire in charge(which is the case down here in Alabama.) Best choice is not to be made an example of...plastic smiles and then do your job out of eye shot. This officer is the living embodiment of City Hall and we all know you can't fight those guys. Good read. Keep up the good work.

Alex ~D~