You drive by a bad car accident- what do you do?

[SXMMD]

First year FM resident here, in an unopposed rural program. Was driving through the boonies to meet a preceptor at clinic in a town 45 min away and came upon a bad car accident. EMS had just gotten on scene, police and firefighters had set up their perimeter. I pulled over to get out and help. Looked like a head on collision, truck vs car, guy in car looking worse for wear. Comatose, Cheyne-stokes like breathing, couldn't appreciate pupil reactivity (~4mm), EMS got to work on airway, I was able to pitch in. We ended up intubating the guy and sending him by heli to the major academic center 2-3 hours away. I let EMS/air evac team run the show and just tried to plug myself into places that I knew I could be helpful.

Still coming down from the rush, wanted to get some feedback from the experts in EM about handling that type of situation. What would you do? What are your expectations of a resident who comes on to that scene? Who should run the show?

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[RPedigo]

Honestly, the paramedics are going to be better at out of hospital care than you (not "you" specifically, but the general "you" as in people not trained in prehospital care). I would stop, stand at the sidelines, let them know my credentials, and probably not do anything to intervene unless asked to or there was obviously an emergent problem going on that I could handle better than they could (e.g., failed airway needing a more experienced provider or surgical airway, needing an EJ for access, etc.).

 

[theseeker4]

First year FM resident here, in an unopposed rural program. Was driving through the boonies to meet a preceptor at clinic in a town 45 min away and came upon a bad car accident. EMS had just gotten on scene, police and firefighters had set up their perimeter. I pulled over to get out and help. Looked like a head on collision, truck vs car, guy in car looking worse for wear. Comatose, Cheyne-stokes like breathing, couldn't appreciate pupil reactivity (~4mm), EMS got to work on airway, I was able to pitch in. We ended up intubating the guy and sending him by heli to the major academic center 2-3 hours away. I let EMS/air evac team run the show and just tried to plug myself into places that I knew I could be helpful.

Still coming down from the rush, wanted to get some feedback from the experts in EM about handling that type of situation. What would you do? What are your expectations of a resident who comes on to that scene? Who should run the show?

You, at least most jurisdictions, have no authority to be "in charge" on scene unless you are already involved in EMS coordination/supervision of that specific program. If you are present for an emergency, best bet is to let them run the show even when you are an attending. Stay out of the way, and if they need a hand pitch in, but don't press the issue if they refuse. Definitely don't try to give them orders or think that because you are a doctor, you are in charge. You are a bystander who happens to have medical training, while the EMS on the scene are officially, legally, and professionally responsible for the care of the patient. Approach it with that attitude and allow the EMS to do their job, help as needed, and otherwise just be a bystander and you will be fine.

 

[Rendar5]

Keep on driving...unless there is a mass casualty incident and they didn’t have enough manpower. In which case I would throw someone in my car and drive to my hospital

 

[NYEMMED]

Unless you are med control, or the director/asst director of that agency, just keep driving. We are not very helpful and are not trained for outside of the ED.

Also Good Samaritan laws don’t apply to physicians, unless they change that, I’m not stopping. It’s not worth a lawsuit or my liability

 

[emergentmd]

There is not enough information to answer this. Does he have insurance? J/K

If I am driving alone, I go right through unless something odd about the scene.
If my wife is in the car, I would stop b/c she would give me the guilt trip. Stop, get out, confirm I can't help, drive off.......

 

[KGflyboy]

Unless you are med control, or the director/asst director of that agency, just keep driving. We are not very helpful and are not trained for outside of the ED.

Also Good Samaritan laws don’t apply to physicians, unless they change that, I’m not stopping. It’s not worth a lawsuit or my liability

I agree, except for the liability issue. good samaritan laws often protect physicians. Perhaps your local laws differ. It's wise to always know one's local laws on this stuff.

 

[SXMMD]

My first thought going into this was "EMS is here and I'm late to clinic"

Saw how bad it was and decided to at least offer help, but it was clear that this was their environment, not mine, so I just acted as an extra pair of hands, reading these responses makes me glad I did. Always respected first responders, but man I am way more appreciative than ever for what they do lol

 

[theKingLT]

Not a doctor, but have spent a few years in EMS and EMS management. Only thing I would add to this conversation is if in a rural setting like OP stated, I would recommend always at least check out a bad accident, even if EMS is already on scene. Many rural services respond with only EMT-Basics, not paramedics, and even then they are sometimes volunteers who haven't worked on a truck in 30 years. In a situation like that they will also sometimes carry advanced life support equipment with the goal of an "on-call" physician or paramedic intercepting serious calls. The chances of coming across a call like that are pretty slim, but if you're looking at 20+ minutes to any hospital or paramedic intercept, any physician like yourself who feels comfortable placing an advanced airway could end up saving a life.

 

[deleted109597]

EMS medical director here.
If you are there as extra trained hands and aren't interfering, then feel free to help out. If you think you get to run the show, then feel free to present credentials AND accompany the patient to the ER. Otherwise, toss off.
Good Sam will cover you in all 50 states and in the air above as a federal law. Just don't act outside your scope or what you peers would do in the same. That means no roadside thoracotomies or REBOA. That means no craniotomies. But as long as you aren't acting crazy you'll be fairly protected. Doesn't mean you can't get sued, but you won't lose.

 

[InternistDO]

When I was still working full time in EMS I'd stop occasionally off duty if the medics weren't there yet. 99% of the time when you stop at an accident you exist purely to calm down the bystanders and stop them from doing anything stupid until the professionals arrive.

If EMS is already on scene I usually keep driving/walking. However, I live in New York where you can have multiple ALS rigs on scene in 5 minutes. In rural areas you may be the most highly trained person on scene (or in the whole county), and the ambulance service may be two ancient volunteer EMTs who see one serious call a year. When I lived in a place like that I usually stopped more often, though usually it just meant I said hi to the crew and went on my way.

As for who runs the show, we had a protocol for physicians who wanted to direct patient care. They would contact our medical command physician and if they agreed, would take over and ride in to the hospital with us. I've never seen it happen except with our actual medical directors though.

 

[WilcoWorld]

I was sitting in the passenger seat as my wife drove us home from the airport. We'd had a long day of traveling.

When we stopped at a red light a homeless man that looked familiar motioned for me to roll down my window. I tried to pretend that I didn't see it, but he was quite insistent. When I rolled down the window he yelled "call 911".

I asked what to tell them was the matter. "Alcoholism and COPD" he said, clearly annoyed by my question. While talking to 911 I realized where I recognized him from & we got the left hand turn arrow. I pointed, indicating to my wife that we should go.

My 5 yo asked why I didn't stop to help him, I said that my friends at work would do that.

I saw him the next day as a return visit. His chief complaint was "it's raining".

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For me it's highly context dependent. If EMS is on scene, I drive on by 99% of the time. If I'm the first upon scene I'll stop & call 911. The most I've ever done out of a hospital was stabilize a tib/fib fracture and check a pulse. If you do stop, and you're a doc, remember that scene safety comes before the ABC's.

 

[theseeker4]

Unless you are med control, or the director/asst director of that agency, just keep driving. We are not very helpful and are not trained for outside of the ED.

Also Good Samaritan laws don’t apply to physicians, unless they change that, I’m not stopping. It’s not worth a lawsuit or my liability

Why do you think Good Samaritan laws don't apply to physicians? Everything I have read is that they do, at least most places in the US.

 

[alpinism]

Not a doctor, but have spent a few years in EMS and EMS management. Only thing I would add to this conversation is if in a rural setting like OP stated, I would recommend always at least check out a bad accident, even if EMS is already on scene. Many rural services respond with only EMT-Basics, not paramedics, and even then they are sometimes volunteers who haven't worked on a truck in 30 years. In a situation like that they will also sometimes carry advanced life support equipment with the goal of an "on-call" physician or paramedic intercepting serious calls. The chances of coming across a call like that are pretty slim, but if you're looking at 20+ minutes to any hospital or paramedic intercept, any physician like yourself who feels comfortable placing an advanced airway could end up saving a life.

Exactly.

Rural vs urban is an entirely different ballgame. In many rural settings the first responding EMS crews are volunteer BLS units and ALS response times often exceed 20 to 30 min. In those situations with severe trauma you can make a huge difference with airway management and hemorrhage control. There's no harm in quickly stopping to check on the patient and if everything is fine you keep on driving. But if the patient is truly sick most first responders are grateful for an extra set of hands with medical training.

 

[drmwvr]

Fire/EMS on scene, keep driving. No one, just police, stop.

 

[BAM!]

Normally keep driving. However I did stop once at 2am on a lonesome road. I realized when calling 911 I had no idea what the cross street was. Reception was bad and there weren't any nearby houses to give an address. They weren't excited about taking my non-specific directions. So if you stop, make sure you know where you are.

Also, there was a ton of broken glass and shrapnel on the ground. not good for sneakers.

Tip -- keep a few gloves in your car. This was useful for me when I checked the drunk guy's pulse.

but as other people showed up, it was mostly keeping everyone calm when waiting for EMS.

 

[NYEMMED]

Why do you think Good Samaritan laws don't apply to physicians? Everything I have read is that they do, at least most places in the US.

It really depends on your local state laws. I live/work in NY, the Good Samaritan laws here are weak for “professionals”. Unfortunately in NY and NJ lawsuits are employment for many

 

[Tiger26]

One of my patient's daughters last night last felt the need to inform us all that she was an RN . . .

Think of this as the equivalent to a physician showing up at an accident scene and trying to direct well-trained paramedics already working.

 

[InternistDO]

It really depends on your local state laws. I live/work in NY, the Good Samaritan laws here are weak for “professionals”. Unfortunately in NY and NJ lawsuits are employment for many

I thought in New York the standard for Good Samaritan as a professional was gross negligence. I mean, that's not complete immunity but that's a pretty high bar.

 

[deleted547339]

Agree with above. If no one is on scene, you need to at least slow down enough to make sure no one is bleeding. If EMS is there and it’s relatively contained, keep driving. If EMS is there and it looks like a cluster, slow down and shout to EMS that you’re an ER doc - they will tell you that they’re cool and to keep moving.

 

[NYEMMED]

I thought in New York the standard for Good Samaritan as a professional was gross negligence. I mean, that's not complete immunity but that's a pretty high bar.

It’s a weird law, it says gross negligence, however at the very end of the law it says the law will not convey any reduction of liability.

Regardless I don’t want to waste my time and money in a court room and defense. Until they change that, I won’t stop.

 

[deleted547339]

It’s a weird law, it says gross negligence, however at the very end of the law it says the law will not convey any reduction of liability.

Regardless I don’t want to waste my time and money in a court room and defense. Until they change that, I won’t stop.

Wow.

 

[InternistDO]

That's reduction of liability in the normal course of practice, not reduction of liability when rendering good samaritan care. So you can't use the law to get out of liability if you're treating an emergency that happens in your primary care office, or if you're a physician with an EMS service.

"Nothing in this subdivision shall be deemed or construed to relieve a licensed physician from liability for damages for injuries or death caused by an act or omission on the part of a physician while rendering professional services in the normal and ordinary course of his practice."

New York Education Section 6527 - Special Provisions. - New York Attorney Resources - New York Laws

Obviously its still New York and you might get sued anyway, even if it will get tossed, so I don't blame anyone for not stopping.

 

[Apollyon]

Normally keep driving. However I did stop once at 2am on a lonesome road. I realized when calling 911 I had no idea what the cross street was. Reception was bad and there weren't any nearby houses to give an address. They weren't excited about taking my non-specific directions. So if you stop, make sure you know where you are.

Also, there was a ton of broken glass and shrapnel on the ground. not good for sneakers.

Tip -- keep a few gloves in your car. This was useful for me when I checked the drunk guy's pulse.

but as other people showed up, it was mostly keeping everyone calm when waiting for EMS.

How lonesome could that road be, if, at 2am, there were that many people that stopped before EMS got there?

 

[Tenk]

I stopped at a motorcycle vs car once on a rural highway just because nobody was at scene and I almost hit one of the bystanders so I figured someone might get hurt. Got out of my truck and told everyone to get the hell out of the road. Good thing I did because shortly after that a big truck went barreling by and probably would have killed anyone on the road. They also wanted to do stupid stuff like move the guy (gcs3, breathing) on his stomach which I told them not to. EMS got there I helped them lift and then said good luck.

You can make a difference even without equipment just because people without any knowledge of EMS and medicine don’t even understand things as basic as scene safety. I agree though, when EMS is on scene: gtfo.

 

[Perrotfish]

Normally keep driving. However I did stop once at 2am on a lonesome road.

Did there shine a shiny demon?

 

[SXMMD]

Did there shine a shiny demon?

I'll bet it threatened to eat his soul if he didn't play the best song in the world

 

[Birdstrike]

First year FM resident here, in an unopposed rural program. Was driving through the boonies to meet a preceptor at clinic in a town 45 min away and came upon a bad car accident. EMS had just gotten on scene, police and firefighters had set up their perimeter. I pulled over to get out and help. Looked like a head on collision, truck vs car, guy in car looking worse for wear. Comatose, Cheyne-stokes like breathing, couldn't appreciate pupil reactivity (~4mm), EMS got to work on airway, I was able to pitch in. We ended up intubating the guy and sending him by heli to the major academic center 2-3 hours away. I let EMS/air evac team run the show and just tried to plug myself into places that I knew I could be helpful.

Still coming down from the rush, wanted to get some feedback from the experts in EM about handling that type of situation. What would you do? What are your expectations of a resident who comes on to that scene? Who should run the show?

When I come up on an accident with EMS working, I generally drive on by, let EMS work, and go about my business. I'm not saying what you did was wrong. I wasn't wrong. But just imagine how many accidents you're going to drive by, with EMS already on scene, in your life. Are you going to stop at every one? If not why not? If not all of them, why any of them? What's your criteria for stopping? You see lot's of blood? The scene "looks cool"? Cars "look bad"? Are you going to decide whether or not to stop, based on whether or not you have somewhere to be, or not? I don't know.

EMS is EMS.

Physicians are physicians.

We all kind of have our own lane. Yes, there's some overlap, and it's not that you can't stop and help. But are you really helping people who need help? Or are you interrupting people skilled at their craft who don't need help, throwing them off their game? Are you simply doing exactly what they would have done, except for the fact that you delayed whatever they were going to do by stopping them, introducing yourself, identifying your credentials, trying to gain their confidence super fast simply based on your word that you, for some reason, are going to do better what they were about to do perfectly fine?

I don't know. I think if I was an EMS guy, and I was confident in what I do, and was doing it without difficulty at some moment in time, and some random dude/dudette popped out of a BMW 325 in shorts and a t-shirt, and said what is essentially the equivalent of, "I have a more advanced degree than you, I can do your job better than you, because I'm a doctor and you're not," that I'd likely be kind of irritated. On the other hand, if you roll up on scene, take a peak and you recognize all the EMS guys and gals, they recognize you such that you already have an established trust and rapport, you read that they're distressed, struggling with an airway or something, and they're kind of peaking up at you with please-bail-me-out-of-this-jam eyes, then that might be different.

But honestly, 99.9% of the time, unless there's no one on scene yet, or there's some heinous mass casualty thing where the more hands present the better, then I'm usually content to roll on by and let EMS earn their paycheck, on their time, on their turf.

 

[Redrox]

Feel like the further we are in our training, the more we realize just how kinda less than helpful we are outside of the hospital.

Was first on the scene to an obviously bad unconscious motorcyclist. Just held C-spine till paramedics came, had honest to god like 8 good samaritans try and take over with their nursing student or even one medical assistant student credentials, frustrated I wasn't doing anything more than that.

"Helped out" with a seizure on a plane that didn't stock any ativan or any other antiseizure drugs. (Aka did diddly squat) Wife of the man fairly disappointed I couldn't do more.

Same with friends on a skiing trip wondering why I wasn't pushing ski patrol outta the way to get at someone with a hurt knee.

 

[austintr]

Seems like most everyone here has the right idea, in my opinion. When I was working as a medic, the only situation guaranteed to make everything 10x more difficult was a physician showing up to "help out". Helping out is one thing, but when the urologist comes on scene to "handle" his neighbor's status epilepticus, things go south. Also the cardiologist that says you "don't know ACLS" since you're using an Autopulse and NRB with continuous compressions (per protocol) while waiting to light up the witnessed Vfib arrest outside his office...sure, that's helpful.

Not to say having an EM doc on scene can't be helpful, because sometimes having a trained set of hands (or at least a set of hands not paralyzed by fear) can be great. But all of the places I worked had similar protocols when it came to docs on scene: if you want to run the show, that is now YOUR pt, YOU'RE coming to the hospital with them, and we were just there to provide the ride. That was enough to dissuade most.

One thing that is important to remember is that most EMS staff are good at what they do...but they're at the mercy of nearly any doc that wants to call the shots. We were trained well, but if someone with a medical license was on scene and wanting to give orders, it was damned near heresy to refuse to comply.

TL;DR: help out if you feel you can be useful, but understand that whomever is there for EMS is probably way more effective at handling these kinds of things out of hospital.

 

[shookwell]

One thing that is important to remember is that most EMS staff are good at what they do...but they're at the mercy of nearly any doc that wants to call the shots. We were trained well, but if someone with a medical license was on scene and wanting to give orders, it was damned near heresy to refuse to comply.

This may or may not be true depending on where you are. Where I work my paramedics are not allowed to take direction from a random non-EMS physician. In order to give directions to paramedics you require certification from the regional EMS council, and even then, the agency medical director can decide whether paramedics working for the agency can take direction from other (even certified) physicians. Physicians without EMS certification can help at a BLS level only (i.e. take a turn at chest compressions, maybe, if the medics decide to let you).

 

[austintr]

This may or may not be true depending on where you are. Where I work my paramedics are not allowed to take direction from a random non-EMS physician. In order to give directions to paramedics you require certification from the regional EMS council, and even then, the agency medical director can decide whether paramedics working for the agency can take direction from other (even certified) physicians. Physicians without EMS certification can help at a BLS level only (i.e. take a turn at chest compressions, maybe, if the medics decide to let you).

It sounds like your state would be a good place to be in EMS, then. As with almost everything, there will be regional/state differences, so thanks for bringing this up. All of my EMS work was done in the same part of the country and mostly one state, so it's good to learn about how other areas do things.

 

[theKingLT]

It sounds like your state would be a good place to be in EMS, then. As with almost everything, there will be regional/state differences, so thanks for bringing this up. All of my EMS work was done in the same part of the country and mostly one state, so it's good to learn about how other areas do things.

It's incredible how much states vary on EMS laws and norms. Makes me wonder what the point of the NREMT is