Who’s in charge here? Me or the EMT?
Question: I am a certified occupational health nurse working at an employer’s job site, a medium-sized manufacturing facility. I am in charge of the overall occupational health and safety program, working with a local physician, and the company also employs a certified emergency medical technician (EMT) on site.
There are times when I think it is prudent to have the EMT present as I assist an employee, such as one who is reporting breathing difficulty or when I respond to an injury event. The company’s position is that the EMT is in charge when we work together, but I feel that I should call the shots. Is there a clear answer as to who’s in charge? Does it change depending on whether the situation is just a cautionary exam or a full-fledged emergency?
Answer: Who’s in charge may depend on the exact situation, but the fact that you’re asking the question indicates a need for better communication and cooperation, suggests William Patterson, MD, FACOEM, MPH, chair of the Medical Policy Board at Occupational Health and Rehabilitation in Wilmington, MA.
While Patterson says he understands the nurse’s reluctance to simply step aside when an EMT walks in the room, he notes that there are some situations in which the EMT may be better qualified to lead the clinical response to an emergency.
"I am inclined to agree that it does matter what kind of situation it is. A full-fledged emergency may be better handled by an experienced EMT who may have more practice and training in CPR" and other emergency measures, Patterson says. "On the other hand, someone with shortness of breath — which could be asthma, anxiety, heartburn, or something else — might benefit more from an experienced nurse who takes the time to do a detailed history."
The American Association of Occupational Health Nurses (AAOHN) in Atlanta supports that position to some extent and says that nurses and EMTs should work collaboratively in the workplace. The AAOHN goes a step further, however, and says that nurses should be in charge when medical judgment is required in the workplace. (See the AAOHN position statement and a related story on the EMT side of the issue, both on p. 113.)
If there is conflict in this regard, Patterson suggests that the supervising occupational medicine physician should be consulted to help you sort out how the EMT and the occupational health nurse can best work together. He questions where the conflict originates, because that can affect the way the matter ultimately is resolved. If the EMT is insisting that he or she is in charge, then the problem could be a lack of communication that leaves the EMT feeling out of the loop. If ignored, some people respond by stepping back into the shadows, while others may feel compelled to step forward and assert themselves, just as a matter of pride. Also remember that the EMT may genuinely be worried that he or she is shirking responsibilities by not taking charge of an emergency, or perceived emergency.
In those situations, improved communication could make the EMT feel a valued part of the occupational health team, and it also could relieve the EMT of some of the obligation he or she feels.
If management is insisting that the EMT is in charge, that is a different sort of communication problem. In that case, Patterson suggests that the occupational health physician needs to intervene. He or she should convey to management how the EMT and occupational health nurse work together and how one or the other may call the shots in different situations. Remember that management may have pushed for the EMT’s autonomy simply because there was no communication from the physician to management explaining the arrangement. A lay manager may assume that an EMT is more qualified than a nurse. In the end, though, Patterson says management must not make this decision.
"It is not management’s responsibility to decide who treats whom," he says. "That is a medical question."
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