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You’re on your way to a midnight call for chest pain with an engine company in the farthest reach of your district. You’re hoping you'll be canceled—maybe via POV, or even a miracle. There’s a young paramedic lieutenant on the engine who’s sure he’s the God of EMS. He runs maybe a call a week, but he likes to dictate the flow of your medicine, right there in front of patients and their families. And the sum total of his medical knowledge would fit in the hub of a TB syringe. Easily.

Sure enough, as you pull up there’s a firefighter waiting at the curb. You’re still putting the rig in park when he pulls open the driver’s door and gives you the instructions from on high: Bring in the bed. No scene size-up, no complaint, no patient status, no findings, no answers to questions. God says bring in the bed.

You offload the cot and spend two seconds adding your normal complement of carry-in gear. That seems to make the first responder nervous, although he doesn’t mention it, and soon you’re all in the bedroom of a 70-year-old man. Kneeling on the bed behind the patient, the lieutenant is holding him in an upright position. A woman stands meekly in the corner of the room, fingering her rosary beads.

You note the patient’s apathy and pasty skin from across the room, while the first responder searches doggedly with a $6 stethoscope for a peripheral pressure not even a Doppler would detect. The lieutenant’s communication is painfully terse: "What took you so long? Let’s get this gentleman on his way." They’ve been on scene for 15 minutes, but there’s no history, no vitals, no meds, no nuthin’.

When you suggest an immediate change in the patient’s body position, a vertical index finger in front of the lieutenant’s mouth shushes you. Ambulance driver, remember thou art diddly. Wow, that generates some blood pressure: yours.

Q. Damn straight, it does. I’ve had it right up to here with medical neophytes routinely dictating and obstructing our medicine. We seldom see these guys, but they do this every time. We’re the transport medics. The medicine, the consequences and the documentation are always on us. We get all the responsibility and no authority. I’ve brought this to the attention of my agency’s leadership, but nothing happens. What can we do?

A.  “Always” and “never” are two words that seldom apply to field medicine, but the three trustiest exceptions for “always” are about interpersonal relations. Always, always and always talk directly to people before you involve their supervisors.

Also, do a little diagnosis. Does this only happen on your shift and with this one lieutenant? If so, the problem sounds like a personal one. Does it happen with the company officers at other stations? If so, maybe it’s an agency issue. But either way, it’s clearly jeopardizing the people to whom you and your first responders have dedicated your lives. However it makes you feel, you share some common ground. You’re all responsible for making things work better than this.

Q.  Easy for you to say, but I get the point. It only happens with this engine company, and specifically with this lieutenant. Problem is, our coverage plan doesn’t allow for face-time with this crew unless we’re on a call with them.

A. This really seems important enough to get a supervisor’s permission to deviate from the plan—or possibly meet the engine halfway. This is a people problem, and a huge majority of people problems yield to simple communication.

Q. Maybe, but we’re nervous about walking up to these guys and telling them what we really think. Got any specific suggestions?

A. Steve, a friend of mine, used an outstanding analogy to resolve a very similar issue. He described a single-role medic approaching an engineer operating the pump panel on an engine at a working fire, and directing the engineer to make specific hydraulic settings. They all agreed, the engineer would probably offer a suggestion of his own.

Steve continued that good ALS depends on good BLS. You spread the peanut butter on one side and the jelly on the other. (Ego is not part of the recipe. Humility and a single-minded focus on the end result are essential.) Put them together and you get PB&J every time. Put the peanut butter on top of the jelly (or vice-versa), and you get something else.

Whatever that is, you’ll waste lot of time cleaning it up.

Thom Dick has been involved in EMS for 41 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service in Brighton, CO. Thom is also a member of EMS World Magazine’s editorial advisory board. E-mail


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