The responses are interesting.
Some of us look at it as a "group survival" situation and some have turned it into an accident scene.
Both soliciting different "needs/demands" of the leader as well as liability and urgency in action/response.

No such thing as a black and white answer.

I strongly suggest he reads the story of HMS Bounty <img src="images/graemlins/smile.gif" alt="" />

Burak

Having just taken Integrated Crew Source Management, I can tell you “they” are stressing the use of all on-scene personnel, regardless of the number of years of experience one might have behind them. Although, like most things in the Fire Service/EMS, progress is often tempered/hampered by tradition, there is an effort (at least the theory is being promoted) to utilize crews to their fullest potential. So if an IC or chief line office is truly progressive, they will seek the advice (when and where appropriate) of the “newest” member of the team, who hopefully still has all those “new” techniques still in the short term memory banks and can recall them at will. However, the newest and greatest techniques must be balanced with real world experiences and the need to make rapid and decisive decisions. The fire/accident/rescue scene is not necessarily the place to start discussing them, which is why we take continuing education and conduct training drills, this is the place to explore and experiment with new ideas and techniques. Having been in both situations, both as the IC/Operations officer and as a lower man on the totem pole, I can tell you I prefer a leader who will make a decision right or wrong, but will seek the advice of others as the scene unfolds and make adjustments to accommodate either changing conditions or recognizes the original plan was not the best course of action. Personally, as a Paramedic, I or my partner are often the ones who are “in charge” of the patient or the EMS aspect of the scene, I prefer it, when the BLS crew takes the initiative to implement those aspects of patient care that they are responsible for, instead of waiting for me to tell them what to do. Often my mind is directed towards assimilating all of the information (nature of the call, patient condition, history, vital signs, resources, etc.) to decide upon a course of action and do so within the first few minutes of the call. Being in charge is not easy, often one must act upon experience and gut instinct, which hopefully is based upon extensive education and training. The bottom line – it is a TEAM effort that will lead to the best outcome. Pete

For example:

It was a simple BLS call for a slip and fall with possible head injury. Myself (EMT-B), the crew chief (EMT-I) arrived on scene in the ambulance, Extra un called EMT-P arrived in personal vehicle and Duty EMT-P arrived by personal vehicle. Pt was sitting and alert with visible brusing to forhead and thigh. Stated he had fallen when the top of a stair he was installing gave-way beneath him dropping him on a pile of lumber on concrete slab. Bystanders report brief moments of Loss of Consciousness. Pt wants to refuse service and starts walking around to "shake it off". With strong persuasion from Extra paramedic(pt's friend) Pt accepts transport. PROBLEM STARTS HERE. Extra paramedic starts to take control of scene and orders standing long board application. Pt is 6'11" tall. Duty chief is only EMT-I and Duty Paramedic has already triaged down. Luckily our duty chief is a strong personality and simply ignores the Extra and we get out the stretcher and have the Pt lie down on the long board. In this case the protocols state to avoid bending the spine if there is any chance of compromise so - standing long board application. Problem is that that works fine with a patient that is approximately the size of the long-board and not at all with a patient who is a full foot taller than the board. The chief didn't have the learn'in of the paramedic and hadn't been to school as recently but he knew what would be possible.

There seens to be two very different scenarios being discussed here. The accident scene with professionals on-site and the true ad hoc emergency. With regards to the accident scene, which upon further clarification was the main intent of your original message, the comments about addressing the issues during training makes sense. You may be relutant to do so during training to avoid "rockin' the boat," but that's the exact time in which to hammer out the process. Who knows, behaps the old hand will learn how to be a better leader in the process.

With regards to a true emergency situation, the question of leadership is much more fuzzy. Skater's Dad's philosophy, "It ain't gonna get done if we stand here looking at it, let's go!" rings tru with my experience. I tell the senior scouts in my troop that the first step in leadership is raising your hand when the need arises. Time and time again, I've been in situations where the leaders are the ones willing to step forward. A 'good' leader is one who knows his or her skills and limitation and is willing to seek help and delegate accordingly. In a true survival situation you have the added dynamic that the innocent bystanders are not just casual observers, but may actually be in danger themselves. Hence fear and panic become inflencers in the descision process. Add pain, hunger and cold into the mix and the leader has a handful. The STOP pricipal still applies. Except now the other members of the party become part of the mix. Part of Observe is to identify skill sets and assess or triage the mental state of the other members and to Plan accordingly, including them into the solution. That won't solve every problem, but it's a constructive start.

Interesting concept, group servival dynamics. we should perhaps reread Chris' account on the Channel islands. There the non-leaders were indifferent towards his leadership as they were not aware of the true peril of their situation. By quietly taking the steps he knew were correct, he eventual became the defacto leader without much question. What if they paniced and went off on their own regardless of his leadership. Well "you can lead a horse ..."

Ultimately, if you prepare and practice, and are willing to step forward in time of need, I beleive most folks will see your confidence and success (provided you've practiced) and will follow with out question.

My rule is never to second-guess the decision making of another provider if I was not on the scene and involved directly with the call, so I will not comment on whom is right or wrong. Each jurisdiction may have a different mechanism for implementing “who is to be in charge”, I can only tell you how, in general things are handled around here. All of our ambulances are BLS and are associated with a Volunteer Fire and/or Rescue Company, staffed either by volunteers or a combination of volunteers and career staff. We do not have a county fire department but do have a Department of Fire/Rescue Services (DFRS), mainly for the direction of career staff. Officers under DFRS do not have any official operational authority, but may serve in that capacity until a line/duty office of one of the first-due companies is on the scene. The Line/Duty Officer may allow the DFRS officer to continue to be IC if they deem the individual has things well in control and the call is proceeding smoothly. However, due to the way the laws are written for the fire service in our area, the Line/Duty Officer actually has the legal authority and responsibly for the call. All of our ALS units are chase vehicles, scattered around the county and are under the direction of the Department of Fire/Rescues Services, we have gone from a 100% volunteer staff of about 20-30 CRT/EMT-I and EMT-Ps to 95 % career staffing. There are many reasons for the shift, which I will not go into here. If the call is dispatched ALS or upgraded to ALS, the on scene 1st due ALS unit medic (can be an CRT/EMT-I or EMT-P) has the authority for patient care directing requests for additional resources through the Line/Duty Officer who has IC. If the incident requires additional medic units, generally an ALS Duty Officer will also respond to direct the call. If I were to show up to a call “off duty”, I would be expected to handle the call until a medic unit arrived on scene, the on duty ALS provider can elect to take over the call or if they feel the call is proceeding smoothly and I have the time and can transport with the patient, allow me to handle the call.

Without second guessing how your call proceeded and they was still some concern of not boarding the patient while standing, due to his size, could you have used a collar with a K.E.D.s device to initially stabilize the neck and back, until the patient was to place onto the stretcher?

Pete

I think you struck the nail on the head here. Diplomacy goes hand in hand with both leadership and being in a subordinate position. If you are in a situation where you see an error being made, a simple nudge or quiet, constructive comment will go farther than an outright slam. If the intended audience is alert and receptive you will get your point across and not step on their toes.

As an example, I once worked with a paramedic who was fresh out of school and had no previous ALS experience. Out of confusion (or stress) he would mix up the leads on the heart monitor and then try and figure out the odd looking rythm on the screen. The way I would correct him would be to say something like "Why don't we try switching the black and white leads to see if that gives a better picture". This would clue him into the error and he would be thankful for my input. It was a lot better than saying "What are you, a moron? You can't even get your wires straight?"

Another thing to consider is that you may have bystanders and family members about who are expecting professionalism. Seeing crewmembers squabbling doesn't promote a good public image or boost confidence.


Chris

One thing I did fail to mention is that if the on-duty ALS provider is a CRT/EMT-I, and I as an EMT-P turn patient care over to that individual, I can be held legally responsible (both civilly and criminally) for patient abandonment, if the call were to head south. The same thing would be true if I were to down grade the call to BLS and turned patient care over to the BLS crew and the patient took a turn for the worse or I failed to recognize a life-threatening condition. Pete

It is not only the "fresh"/new providers who can make a mistake, even seasoned individuals, who for many reasons can overlook the obvious. The way you handled the “correction” is to be applauded. Unfortunately many ALS providers are afflicted with the “I am GOD” syndrome and “never” make mistakes. The same method you used to “correct” an oversight would be well employed by many ALS providers who treat BLS personnel like idiots. A gentle reminder or whisper can do a lot to foster relationships between varying levels of EMS providers. Although, I must admit, I have gotten somewhat verbal when I have to constantly remind the BLS provider to continue with ventilations instead of watching me. Pete

All good points. And yes we did collar the pt before having them lay on the long board. The Ked + lb presents some packaging problems and removing the ked after boarding is all around a bad thing.

In our jurisdiction the ALS is also a chase vehicle and at their discretion will ride along or not. Practice here is for the ALS to always arrive on-scene in consultative capacity. If the Paramedic takes pt care at all they must ride along. Commonly they will stand back as the call is assessed by the B or I. At first indication of shock or other serious situation they will step in and commit to the call. I am not versed on the protocols from med control on the guidelines for "triaging the call down to the BLS team" There must be something in the Standing Orders for that.