Third, notify online medical control of the presence of the on-scene physician and express his desire to actively participate in the direction of patient care. Medical control must be convinced of this physician’s qualifications and be comfortable authorizing the EMS providers to act under his direction.
Finally, have the physician sign a statement accepting control of patient care.3 This affirmation can be captured on either the standard patient care report or on a form specially created for this purpose. Only after these conditions have been met should the EMS provider feel secure in sharing patient-care responsibilities with the bystander physician.
Online medical control may revoke the authority it has given to the on-scene physician at any time. And at no time are you, the EMS provider, relieved of your duties to act in this situation; the bystander physician cannot direct you to practice outside of your scope of practice or your system’s protocols. EMS providers must promptly report orders from these doctors that deviate from accepted prehospital care procedures and give medical control the ability to reestablish its oversight if needed.
As always, documentation is crucial, and your run report needs to contain all pertinent details of this encounter. At a minimum, this includes the doctor’s name, medical license number and signature. If policy dictates, you may want to complete a supplemental incident report to fully capture what occurred on scene. These types of events could be deemed as unusual occurrences and may be subject to further clinical or administrative review. You need to accurately document the facts relating to such incidents while they’re fresh in your mind.
Systems around the country have developed various strategies to help EMS providers successfully handle intervening physicians. A common tool used is a business-size card outlining the alternatives open to the doctor seeking to assist in prehospital patient care. One such card has been created by the California EMS Authority and the California Medical Association (Figure 1). This card is easily carried by EMS providers and can assist in quickly educating a bystander physician that the EMS providers are acting under the guidance of medical control, thanking him for his offer to assist and listing multiple possibilities for his involvement. This is most helpful where there is an online physician to whom the intervening doctor can speak.
Often used in lieu of or in conjunction with a card notification is a form for a bystander physician to read and complete after he approaches an EMS crew on a scene. This form makes it clear that should the physician wish to deliver medical care, and online medical control agrees to relinquish authority, he will need to sign for acceptance of the patient. This method is not as easy to implement as the card method, but presents roughly the same sort of information and gives the crew the ability to gain a legally binding signature. Also, making the doctor responsible via a sworn, signed statement tends to impress upon him the enormity of the liability being assumed, especially if online communications with medical control are unavailable.
A less-often-utilized yet highly effective strategy is education, both of EMTs and physicians. The topic of bystander physicians is only briefly dealt with in most EMT and paramedic course curricula. ALS providers receive additional exposure to procedures for handling doctors presenting on scene in area protocols, but this material may not be revisited after initial credentialing, and BLS providers are usually not as informed. Also, despite the documents promulgated by ACEP, NAEMSP and AMA, the vast majority of physicians are unfamiliar with these requirements. The capabilities of modern EMS systems and the various levels of providers found practicing in them (CFR, EMT-B, EMT-I, EMT-P) are a mystery to most general practitioners, and even some emergency medicine specialists. There are few fully integrated prehospital/hospital systems where medical students are allowed to do ride-alongs with their local EMS agencies. Even more rare are physician-education programs that have incorporated the completion of this prehospital time into their clinical requirements.