If or when an ambulance and EMTs (emergency medical technicians) arrive at the scene of a serious medical emergency at about the same time as an MD (medical doctor), who should take charge, the lead EMT or the MD?

An excellent answer by . The short answer is: the senior paramedic. Every single time. However if there is no paramedic, then it depends on whether ALS is needed and prudent. If so, the doctor; if not, the EMT is the senior care giver. Either way the EMT maintains control of the remainder of the scene. Every caregiver has particular training and should recognize their expertise and limitations. I wouldn't want a paramedic or doctor taking X-rays or running a cat scan. And the comparisons between the two situations are very similar. Paramedics are experts at providing ALS in the field. They are capable of providing a reasonable level of care in hospital. Doctors are experts at providing care in their specialty which is not out of hospital care. Doctors who are qualified in basic ALS care can provide a reasonable level of care in the field. Doctors who aren't qualified to provide basic ALS care can provide a reasonable level of basic care in the field, no different than a basic EMT. In a hospital I would take a seasoned ER doc any day of the week, but in the field the tools are different and the tricks are many. Control of the scene and situational awareness in the field is something paramedics are trained for, doctors are not. To be very blunt, doctors are less qualified although better educated. Paramedics understand the environment, the equipment, the staffing, the practicality of providing care in the emergency vehicles, etc. When in a hospital and even in many clinic settings, docs have an almost unlimited staff and equipment. X-rays, labs, and plenty of trained hands. In the field, their are many restrictions and docs just aren't aware of what they capabilities and limitations are. There aren't 14 drug choices if X happens. There are 5 personnel options to consult when Y happens. "Dude. It's me and Jim. You want to do what?! In the field?! And while Jim drives down this winding mountain road in the pouring rain or through heavy city traffic that might include taking a curb, you want me to do what kind of care with just two of us?! Yeah. No." And there is a lot more to providing care in the field than just patient care.

GREAT QUESTION! Hollywood movies would have you think that having a doctor is all you need ("Somebody, get a doctor!!!!!!").  What many people forget is that doctors work in HOSPITALS which are big buildings with LOTS of equipment.  EMT's however, work in the street, crammed apartments, basements and smelly alleys.  They work in the cold, wet, and in the dark... Excellent explanation by Anderson! Having been a Boy Scout, an E.M.T. and a surgeon I've never been able to shake that desire to help out when someone is in need. But getting involved in emergency situations as a passerby will quickly teach you a couple of things: 1) If no EMS has yet arrived and nobody has taken charge and nobody is doing anything then THAT is the moment to take charge and get cracking. 2) If EMS has arrived and they display the professionalism that we have all come to expect (I've never seen them NOT display this in the U.S. or in Europe) then there is really very little that one can contribute, mainly because one's involvement is, in the end, a disruption in the work flow of a well-greased team of professionals (as Anderson so eloquently described). So, unless there is something in particular I witnessed or that I know about the patient that I feel the EMTs need to be made aware of I will usually stand aside or identify myself and make myself available as an extra set of capable hands. I have never had to do a burr hole on someone's head to drain a bleed by the side of the road or crack a chest for direct cardiac massage, but I trust that if the s#1t hit the fan my EMS colleagues would have my back and they would help me make the procedure a success.This answer is not a substitute for professional medical advic...

In general, the EMTs should take charge, because they know how to handle out-of-hospital emergencies and effect rapid transport.  You could certainly imagine situations where a doctor would be very helpful--say, an emergency medicine specialist at the scene of a trauma, or an obstetrician if there is a complex obstetrical emergency.  I knew a group of EMTs once who shared a strong belief that umbilical cord prolapse can't happen unless the fetus is already dead; I found this a little eerie (it's not true), and would rather have an OB there to help in that theoretical situation, but really the EMT's probably would have handled it fine--they said they would handle it by the book.  A doctor outside of the hospital is not necessarily going to be able to do things that the EMTs can't do, because that doctor doesn't have all the equipment and supplies that they use at the hospital.  Don't know if this is true but I read somewhere years ago that when Princess Diana was in her deadly car accident, the EMTs deferred to a cardiologist (or possibly cardiothoracic surgeon?) on scene and he was treating her and instructed them to drive the ambulance slowly to avoid jostling, but that actually if they had gone as fast as possible she might have survived because the in-hospital care would have been more effective if started sooner.

The answer to this question depends on the circumstances at the time. A variety of factors affect the circumstances: a) the severity of the patient b) the skill set of the EMT team present c) the ability of the MD to assess a scene, judge a) and b), determine if they feel      they can help or even if they need to, and then the MD's ability to communicate all of that to the lead EMT at the time. The Severity of the Patient: This is broad and not easily summed up for an answer as it depends on the nature of the "serious medical emergency." As an Army medic we were taught that you need to assess your scene and decide if you need assistance (usually tactical situation, number of casualties, etc) but for  most wounded it came down to two things: Stay and Play or Shoot and Scoot. Some patients can be stabilised at the scene. Some need an operating theatre. If the serious medical emergency is a medical condition, then often the EMT's will provide supportive measures on the way - there's often not much you can do to fix an acute exacerbation of a chronic condition. The Skill Set of the EMT Team: Terminology of different EMT qualifications changes depending on service, location etc so again I'll try to keep it general. Not all EMT teams are created equal. If you've got a transport team, then you'll either have uniformed first-aiders or a road crew on furlough (where I live the road crews get a two week rotation into patient transport for a break occasionally.) The road crew can cover most things well enough for the Shoot and Scoot and if resources allow for backup they can escalate to obtain more people with greater skills where they need to. They tend to work to protocols, which may or may not be a good thing. Above them are advanced care crews of all sorts. They have the ability to work to a more advanced level, with more advanced skills, and can deal with bigger issues. This type of EMT might be a paramedic, Registered Nurse/Paramedic (dual qualified), or a Retrieval MD (EMT teams can include all of the above, especially the helicopter crews). So these EMT's are generally more capable and might Stay and Play a while. The Ability of the M.D. With all of the above in mind, a junior MD might not be able to bring much to the table. Of course, this person might be too junior to appreciate that, so that then becomes an issue for the EMT leader of thanks, but no thanks. The MD might be a senior MD but have a completely irrelevant speciality to the condition at hand: gerontology, say. This person might just leave well alone, or offer skills as an extra pair of hands. A MD of a relevant speciality with enough skills to help might offer those skills to the EMT team: I've had patients survive accidents in very isolated areas where the EMT on scene was a solo guy because the person in the car behind the patient at the time of the accident was an anaesthetist and his wife was an anaesthetic nurse (on holiday!), saw the accident, called for help and then got busy. I know of the medical director of an ambulance service who had a work car fitted out as an ambulance. He'd listen to the radio, and either advise the EMT's at scene or show up at 3am like Superman, do one amazingly advanced procedure at the scene, go home back to bed and leave his people to it. The patient notes would record that the patient was brought in by ambulance, and that this funky thing (which you knew the EMT's could never do) had been done  PRIOR to transport. It was often the definitive thing that saved the patient's life. The last point to consider (I'm purposefully ignoring any indemnity insurance issues and reticence to assist for legal reasons) is perhaps the most important. EMT's are trained and experienced in dealing with scenes (houses, cars roadsides etc) and environmental factors (weather, light, stairs etc). These factors bring their own challenges. MD's don't always have this training. They usually have access to an entirely controlled environment, with the required equipment nearby. This can take an MD with a very useful set of skills and render them incapable of helping due to circumstances beyond their control. All of these factors help to answer the question, and no-one factor in particular is more important than another at the time. In the circumstances offered by the question, the assessment of these factors is often quick and dirty and the circumstances change rapidly. In practical terms, when both EMT and MD show up at once, most MD's would let the EMT's go and help where they can.

By "serious medical emergency" I'm going to assume something like a heart attack, or physical trauma, like a car accident or gunshot wound.  You said an MD arrived, but you didn't say what kind?  Someone off the street who was a podiatrist or dermatologist wouldn't be able to help me as much as an EMT, who is trained to stabilize patients until they can see the appropriate doctor for their condition.  So unless an ER doc just happened to show up, I'd prefer the EMT to be in charge.

Here's what my instructor told me when I took the class to become an EMT-basic a few years back in California. I'm not sure whether this is accurate, whether it's changed, or whether it's local policy to Southern California, but this is what she told us in that class. When it comes to a multiple-casualty incident where there are a number of people who need medical attention/transport here's how it works: The first person on the scene is in charge of running the site. If multiple people arrive together, the highest ranked is in charge. If multiple people have the same rank, the most experienced is in charge. If someone of higher rank arrives later, they are put in charge. Note that this is with respect to ranking within EMS, as in EMT-basic vs EMT-intermediate, vs paramedic, etc. and an MD doesn't really fall into that ranking system, so this chain of command just applies to EMS staff, from what I understand.

Doubtless there is a law or regulation about this where you live, and those present will know of it. I have been well-immersed in medicine for over fifty years, and in my experience (often on-site), the average doctor is almost useless at an accident scene. They are used to seeing 'normal' (i.e: walking patient) injuries in their surgery or clinic, but seeing massive damage, often in the dark and/or pouring rain, makes many of them feel sick or faint. The ambulance staff and paramedics are trained in fast action, and always make a 'better boss' on-site.

Here is the "Black page" from our state protocols. While we appreciate help, there are issues about whether or not someone actually is a doctor, what type of doctor they are and are allowed to legally practice medicine. We are allowed to let a doctor treat our patient, but only if our medical control doctor agrees.

Here in Los Angeles County, the County EMS Agency policy (Number 816 "Physician at the Scene" if you care to Google it, I'm just going to paraphrase it here) says that first the physician must show proper identification to the Paramedics  (it specifies their California Physicians and Surgeons License). Then the Paramedics need to notify their base hospital of the situation. And that finally if the physician on scene chooses to assume or retain responsibility for medical care, they MUST take total responsibility and MUST ride with the patient in the back of the ambulance to the hospital AND the ED doctor relieves them of care. Outside of a medical facility, physicians are not directly involved in EMS response here. So if there's a physician on scene, they were off work and merely happened across the scene (with no tools or equipment). Second many docs aren't trained in emergency response, when's the last time your average Podiatrist led a cardiac arrest? Or even know how to deal with sudden chest pain to the guy in line behind him at Starbucks? Even a cardiac surgeon in that case can't do anything more than call 911 and let the Paramedics treat/transport as normal. Now we are called somewhat regularly to nursing homes, standalone doctors offices (i.e. those not at the main hospital) and other tertiary care facilities. In those cases they'll typically  (hopefully. ..though not always) have a set of vital signs, the patient's medical history and list of medications and allergies ready and are able to give us a report on what happened for them to summon emergency responders to take their patient to the Emergency room. I've never seen one of them attempt to take control from the paramedic in that case. Usually because that's not their role and they know it (otherwise why call 911 in the first place?) and they have other patients to worry about and take care that they can't do if they put themselves in position to ride with that one patient. Therefore it's rare (I've never seen it, or heard of it happening to a fellow crew) for a physician to take charge from the Paramedics and ride in with us to the hospital.