# Texas Scope of Practice... what does it mean really?



## 8jimi8 (Feb 21, 2010)

I am currently and EMT-I85 student, the official title of my program is "Paramedic 1."

Regarding my upcoming "Final Check-offs."  In this class we do two 2 day skills practice checkoffs with a third  2 day "Final Check-Off."

My email to the program director of my online program below:

"As for our final skills checkoffs are we going to be tested over the entire paramedic skill set, or are we only doing the NREMT I-85 testable stations?

Also, for the sake of scope of practice (being that this class is the "Paramedic 1" class) is it within our scope of practice as students to do the advanced procedures (surgical crich, needle crich, needle decompression, Defibrillation and pushing ACLS drugs?)

I just wanted to see where your stance is on the topic because (and i understand how important it is)  it is difficult for me to separate myself from having the knowledge of appropriate interventions / stay within scope of practice.  I understand that technically I am an I-85 student, but for the practice session, I was thinking like a paramedic... i hope that perspective is understandable to you."

Response from PD of my course

"You are going to test on ALL the skills you went over in practice and for which you have a checksheet for in the course.  Be sure to ask **** to make sure to help you with ANY tips/tricks for the NR stations you will test while you are there, but NREMT-I will be a separate testing that you will be required to complete at one of their approved sites when you have finished our course and applied to take the NR test.

As for scope of practice, you are confusing nursing and EMS practice in Texas.  Texas does NOT have a scope of practice for EMS - it is a delegated practice state over and above a MINIMUM scope.  In other words, the National Standard Curriculum or any other item that TDSHS approves in rule is the MINIMUM standard for courses.  The rest is set by the medical director for the program.  As for which skills you can do in clinicals, you know that is an interesting thought because you are checked off when you finish skills testing to do ANY of the skills we teach in our course.  I do NOT know, however, if you would be limited in clinical through the clinical program to a ceiling or if you will be allowed to do everything we have tested you on for Intermediate in our program which is over and above if the opportunity arises (like needle cric, surg cric, administration of Epinephrine 1:10,000 IVP, NG/OG tubes, etc.)"

So what does Scope of Practice mean in Texas? (for the I-85)  (yes i plan on continuing on to Paramedic -- in a traditional class... don't get all huffy on me!) (oh and in my defense, this online class IS accredited)

Would some of the big dogs mind chiming in with your interpretations?


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## Shishkabob (Feb 22, 2010)

I don't get your question.  If I read it right, he already answered it the correct way:  You test the NREMT-I/85 skills for the NR, and scope of practice technically does not exist in Texas as it is up to our medical director what we can/ cannot do.  Typically you will be limited to I/85 in the real world as Texas doesn't recognize the I/99.


Did I miss something?


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## 8jimi8 (Feb 22, 2010)

The way I read it, if the medical director of the program allows me to, I can intervene with a full-on Paramedic scope of practice.

Why would services need to have paramedics if the medical director was comfortable letting his I-85's do ANYTHING in the protocol book?

I wanted confirmation from some of our long time professionals on the site, that the information that she is giving me is correct.

That is why i reposted her unedited comments.  I really can't believe that it is legal for me to act beyond the "scope of practice" of my license.

For instance, I am an RN and an EMT-B.  If i could somehow convince the medical directors at both of the organizations where I volunteer to let me lead an ALS ambulance, then I could practice the full scope of a paramedic without having the education or credentials.

this just seems improbable to the logic of my mind.


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## VentMedic (Feb 22, 2010)

8jimi8 said:


> For instance, I am an RN and an EMT-B. If i could somehow convince the medical directors at both of the organizations where I volunteer to let me lead an ALS ambulance, then I could practice the full scope of a paramedic without having the education or credentials.


 
Careful with that as you may run into conflicts with your RN license. This is a problem which some duel credentialed RN/EMT-P have in flight and which is why ENA would rather see RNs have their own prehospital credential or just have a scope for the RN only under a medical director. 

If the medical director is allowing you expanded skills as an EMT-I because of your RN training, it should be written only for the EMT-I. If he/she is working off your RN education/training for your scope, your RN license should be included specifically in your job description and it should be consistent with the Board of Nursing.


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## Shishkabob (Feb 22, 2010)

Texas is a delegated practice state, as was stated in the email.  What this comes down to is that the state doesn't decide your protocols.  You are practicing off your medical directors license, so he has the final say in what he will and will not let you do, at any skill level.

If he wants paramedics to be strictly BLS in skills, he has the authority to.  If he wants an EMT-B performing open heart surgery in the field, and trains them how, and allows them to do it under his license, he has the right  (extreme scenario put in for emphasis).  Like Dr Yamato here in the Metroplex... very progressive in his protocols.



According to a similar discussion on a Texas EMS site, there are 3 such states with this model, Texas, South Carolina, and Penn.


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## 8jimi8 (Feb 22, 2010)

Vent,

please believe that I would NEVER do such a thing as a mentioned in my post.

I take very seriously the education and import of the skills Paramedics are trusted to perform.

I am only trying to understand if what my director implied, means what I think it means.

I DON'T want to exceed my scope of practice, which is why I asked her in the first place because, it IS difficult to stop myself and say, " Wait, i am not legally trained or authorized to do this... even though I know it is the correct intervention."

For example, I was third rider on a call with a paramedic in the back.  I was at that time licensed as RN, EMT-B in Texas.  

We picked up a guy "so drunk he was nearly unresponsive,"  the Medic in the back asked me to help him prepare the NG tube, he was bagging and I was getting the supplies ready.  Lubed up the salem-sump and started looking at his nares (cause in my mind dropping the tube was indicated and appropriate)
But the medic caught that tunnel vision in my eyes and said "stop."  Here you bag, i'll do that.  I thought nothing of it.  But after the call was over he pulled me to the side and asked me if I would have dropped the tube, had he not stopped me.  I nodded yes and then he reminded me, that this was not in my scope of practice, in this arena.  Ever since this near slip, I have been very vigilant, not to exceed my "scope" in the pre-hospital arena.  


Back to my director's comments.  Had the paramedic delegated the task to me, it would have been legal, despite my lack of credentials, yes?


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## 8jimi8 (Feb 22, 2010)

Linuss said:


> Texas is a delegated practice state, as was stated in the email.  What this comes down to is that the state doesn't decide your protocols.  You are practicing off your medical directors license, so he has the final say in what he will and will not let you do, at any skill level.
> 
> If he wants paramedics to be strictly BLS in skills, he has the authority to.  If he wants an EMT-B performing open heart surgery in the field, and trains them how, and allows them to do it under his license, he has the right  (extreme scenario put in for emphasis).  Like Dr Yamato here in the Metroplex... very progressive in his protocols.
> 
> ...



Thanks for the clarification.  I guess it isn't too scary, because no MD would let his license flap out in the wind like that... At least no MD who wanted to keep it anyway


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## VentMedic (Feb 22, 2010)

8jimi8 said:


> Ever since this near slip, I have been very vigilant, not to exceed my "scope" in the pre-hospital arena.


 
Good luck to you.  That will be difficult at times.


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## 8jimi8 (Feb 22, 2010)

Thank you for your concern!

According to my program director, as long as the medical director of my clinical site approves it, I can't exceed my scope, since technically I am a paramedic student...  (edited to add ** and I have been checked off and approved to practice as a Paramedic Clinical Student)

right?...

I've waited a long long time to get the go ahead to practice ALS out of the hospital.  My diligence and practice have finally led me to the elysian fields.


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## medic417 (Feb 22, 2010)

8jimi8 said:


> Thank you for your concern!
> 
> According to my program director, as long as the medical director of my clinical site approves it, I can't exceed my scope, since technically I am a paramedic student...  (edited to add ** and I have been checked off and approved to practice as a Paramedic Clinical Student)
> 
> ...



If you are approved by the medical director in Texas you can do anything.  And yes many better programs have designed their Paramedic course so if you wish you can earn your EMT-I as you progress.  

I for example was doing more as a basic in Texas than many Paramedics are allowed.  So once I became a Paramedic I found it not much of a challenge.  How?  Because we do not have a Texas maximum skill level we have a minimum level that the medical director can raise as high as they are willing to risk their license with us doing.    

So short answer read the protocol book.  It will tell you what the medical director allows or doesn't allow.  And as a student you can do any skill you have been checked off by the school as long as the service you are doing ride outs with has protocols for that skill.  For example way back when I had to pass foley in class.  Most ambulances do not carry foley.  So I could not buy one and place it as it was not an approved protocol for the services I did ride outs with.  Now at the hospital I could place a foley.  

Again if the schools medical director requires you to be checked off on a skill you can use it as a student as long as it is allowed where you do clinicals.


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## reaper (Feb 22, 2010)

Linuss said:


> Texas is a delegated practice state, as was stated in the email.  What this comes down to is that the state doesn't decide your protocols.  You are practicing off your medical directors license, so he has the final say in what he will and will not let you do, at any skill level.
> 
> If he wants paramedics to be strictly BLS in skills, he has the authority to.  If he wants an EMT-B performing open heart surgery in the field, and trains them how, and allows them to do it under his license, he has the right  (extreme scenario put in for emphasis).  Like Dr Yamato here in the Metroplex... very progressive in his protocols.
> 
> ...




SC is not setup that way. There is a strict scope of practice for Paramedics. The State list procedures,skills,and meds that can be done. It is up to the MD to choose which of those they want to allow.

Seen a Medic lose his license over this very issue. Online med control ordered Mag sulfate for Asthma pt. Medic followed orders and lost it all. Mag Sulfate is not approved in the state for treatment of Asthma, Sucks, But not approved.

Now even if your MD does not approve of something on the state list, You can use anything on the list, if Online MC orders it!


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## 8jimi8 (Feb 22, 2010)

^^ 
an important distinction between our two practice states.  Obviously I need to familiarize myself much more intimately with the laws surrounding practice.  What a horrible way to lose your license!


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## xrsm002 (Dec 11, 2012)

I'm in Texas and was told that all of the following are skills an intermediate in TX can do. However I was told that 2 of these were medic skills. 

I was also told that for my Internediate skills test I will only NR tested on IV, IV med administration, IO, adult and pedi intubation, and 1 or 2 basic skills 


So for those of you in Texas what do y'all say?


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## xrsm002 (Dec 11, 2012)

Will be doing Friday.


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## xrsm002 (Feb 24, 2013)

You could always be a flight nurse in Texas. There is an RN here in Texas where I am that is also an I/85


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