# scope of practice and diabetes



## yay4stress (Jun 2, 2008)

Are EMT-Bs allowed to check blood glucose in PA?  I work on ALS trucks, so if I do it, I do it under the supervision and instruction of a paramedic anyway.  But it seems like since we can administer oral glucose with an order from command we should be allowed to check it if we have the glucometers....

We weren't taught how to check it during our class, but we also weren't taught how to administer anything other than oxygen - even what is in our scope.  I vaguely remember the instructor saying something about how it involves sharps and such so we couldn't be taught it in class.

I guess the upshot after all this rambling is that if I end up on a BLS truck, am I going to have to rely on a pt to take it themselves before I get there or can I take my own reading?


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## John E (Jun 2, 2008)

Isn't there a Pennsylvania state office or dept. of EMS that you can check with to get that sort of information? And wouldn't you be better off getting it from the office that governs that sort of thing?

John E.


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## Ridryder911 (Jun 2, 2008)

Okay, this bothers me. First an employee not knowing their scope or limits or even really their job. I have to admit, I like EMS forums, but would I ask anyone here about my local policies? 

As well, as described get it straight from the authorities mouth... better yet in writing. Also, ever considered asking your education or supervisor/administrator? 

Chances are if you were not taught, you may not be allowed.. albeit, most EMT training sucks, so one can not assume. 

Contact your officials, and any other specific questions regarding your certifications and license needs to be addressed by your official representatives. 

Good luck!

R/r 911


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## BossyCow (Jun 2, 2008)

> Chances are if you were not taught, you may not be allowed.. albeit, most EMT training sucks, so one can not assume.



Rid is sooo right here. Whether or not the protocols of a system will allow a skill, you can't do it without being properly trained in it. So, just because a skill is considered a BLS skill doesn't mean you stick a sharps in the hands of anyone with a cert and let them turn some poor diabetic into a pin cushion.

We are mandated by our ER and our MPD to do glucose checks on every pt we bring into the ER. I've had to justify it once when I brought in a Fx ankle without one. "Could have fallen because of bloodsugar issues" was the justification. But, that doesn't mean that all the EMTs are allowed to perform them. We have a specfic program designed by our MPD that they must take before they start doing the tests.


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## mikeylikesit (Jun 2, 2008)

yeah but there is no harm i checking BS readings. change your lancet if thats the type that oyur using each time and your good. the coding issue shouldn't affect you too much but it does make a difference between 85 mg/dl as opposed to uncoded which could read 85-615 mg/dl. most of the field lancets are one time users, they self retract like epi pens and you just throw them in the sharps container.


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## BossyCow (Jun 2, 2008)

mikeylikesit said:


> yeah but there is no harm i checking BS readings. change your lancet if thats the type that oyur using each time and your good. the coding issue shouldn't affect you too much but it does make a difference between 85 mg/dl as opposed to uncoded which could read 85-615 mg/dl. most of the field lancets are one time users, they self retract like epi pens and you just throw them in the sharps container.




Ya know Mikey... I bet you learned all that in your class/training on the skill!


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## Ridryder911 (Jun 2, 2008)

mikeylikesit said:


> yeah but there is no harm i checking BS readings. change your lancet if thats the type that oyur using each time and your good. the coding issue shouldn't affect you too much but it does make a difference between 85 mg/dl as opposed to uncoded which could read 85-615 mg/dl. most of the field lancets are one time users, they self retract like epi pens and you just throw them in the sharps container.



Actually there is harm. First it is considered an invasive procedure and unless licensed or certified, one cannot as an EMT but can as a civillian. As well, it is a "procedure" surely, not everyone is glucose levels unless there is evidence for a diabetic and or potential related need to perform one. 

FSBS costs the patient to perform such. I know at my service it is $65.00 each time, to tell me Granny glucose is okay on that back pain. There is a difference in knowing when it is needed and appropriate than just being able to perform it. 

Alike anything else we do and perform, we should have to be able to justify and defend why it is needed and performed. 

R/r 911


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## traumateam1 (Jun 2, 2008)

Well I am not a PCP (Primary Care Paramedic) in BC (Canada) yet, but i haven been on car with PCP IV's many times and I do know that here in BC as a part of PCP IV protocol you do check BGL. Now me, I don't do that.. not yet, if I have a problem with the way a p/t is presenting I will call for a routine (no lights or sirens) to come do a check, of course unless it's an obvious emergency.


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## firecoins (Jun 3, 2008)

Ridryder911 said:


> As well, as described get it straight from the authorities mouth... better yet in writing. Also, ever considered asking your education or supervisor/administrator?
> R/r 911


Isn't there a QA/QI guy in each company? This is something you need to ask with in each organization.


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## mikeylikesit (Jun 3, 2008)

BossyCow said:


> Ya know Mikey... I bet you learned all that in your class/training on the skill!


i am diabetic actually...maybe thats why i don't see it as a problem...Rid $65 really thats a lot for a lancet, a cotton ball, alcohol swab and a test strip isn't it?


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## daedalus (Jun 3, 2008)

mikeylikesit said:


> i am diabetic actually...maybe thats why i don't see it as a problem...Rid $65 really thats a lot for a lancet, a cotton ball, alcohol swab and a test strip isn't it?



Those damn strips are expensive! Plus we gotta sneak fuel surcharges in somewhere.


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## Ridryder911 (Jun 3, 2008)

daedalus said:


> Those damn strips are expensive! Plus we gotta sneak fuel surcharges in somewhere.



So true...

I don't know if most of you understand finances but; in real life most medical costs is usually several hundreds times over what is at "purchase price". Ever looked at hospital bills? 
That Morphine Injection that costs the patient $45.00 actually costs the hospital $1.25. or that band-aid was $4.50 Why? For several reasons:

1) Most patients are uninsured. Most do not pay for the bill, so costs are off set to those that do. 

2) Like to have a nice salary, benefits ? Money has to come from somewhere...

3) Like to have a MRI in a hospital ? There is no way that the procedures themselves could pay for the machine ( > million). 

EMS is the same. The EMS unit, salary, insurance, electric bills, and yes even diesel fuel costs.. and someone has to pay for it. 

Yes, $65 for a glucometer strip is expensive. So is the $180,000 EMS unit and my $10,000 LP12, and $11,000 stretcher. Do you think the "gang banger" that was shot had Blue Cross and Blue Shield? Again, it has to come from somewhere to off set .... 

R/r 911


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## Outbac1 (Jun 3, 2008)

Yay doesn't say where they currently work. Maybe he/she wants to move to PA. Information on protocols and procedures is best obtained from the source.


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## scottmcleod (Jun 3, 2008)

Our EMR SR-P providers can do BGL's, but that's it. (and they must be signed off in the protocols book, even after doing the course.)

As R/r pointed out, it IS an invasive procedure, and as such, you must be trained to do it, according to your dept's protocols.

EDIT: Removed hypothetical situation. Every time I ask a question around here, someone comes along and tears it apart


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## Jon (Jun 3, 2008)

OK folks... to answer the OP's question.

In PA, BGL is an ALS skill. It is an invasive skill, and NOT something you are allowed to do as an EMT... ever. Welcome to the Commonwealth of PA's EMS system.

There are some work-arounds that are commonly done in the field. If the patient has a glucometer, the PATIENT or a family member can check the BGL. Where I used to work (Medical responder with Security Department, non-official QRS service), we carried a glucometer with our equipment. I never used it on a patient...but I'd loan it to a patient to use. I'm not a big fan of this... but it was nice to have when the uncontrolled diabetics on the nighttime cleaning crew would "feel sick" and think their sugar was low or high.

Of course... off the record... sometimes things happen in the back of the rig. Of course... then the medic must document that they preformed the skill. I know LOTS of EMT's who have preformed fingerstick glucose readings. I also know EMT's who have started IV's... it is a slippery slope, and if the State finds out, you might find yourself missing your cert. If you are willing to risk it... then go ahead and do it.


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## scottmcleod (Jun 3, 2008)

Jon said:


> Of course... off the record... sometimes things happen in the back of the rig. Of course... then the medic must document that they preformed the skill. I know LOTS of EMT's who have preformed fingerstick glucose readings. I also know EMT's who have started IV's... it is a slippery slope, and if the State finds out, you might find yourself missing your cert. If you are willing to risk it... then go ahead and do it.



Isn't that what on-line medical direction is for?

"Hi, I'm medic _______, I have a patient presenting like _______, I would like to _________ even though it's outside of my current scope, it's a skill that I've trained."

It puts liability with your medical direction.

At least, that's how it works with our team, should the need arise.


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## Jon (Jun 3, 2008)

scottmcleod said:


> Isn't that what on-line medical direction is for?
> 
> "Hi, I'm medic _______, I have a patient presenting like _______, I would like to _________ even though it's outside of my current scope, it's a skill that I've trained."
> 
> ...


Scott... I see your point, but EMT's aren't supposed to be equipped to do it... and the prehospital training to do it is part of the Medic course... there isn't a secondary class for EMT's that is authorized.

So I can't see why the doc would want to take on that liability.


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## John E (Jun 3, 2008)

unbelievable...

A "workaround" that involves putting one's career, not too mention one's financial future at risk. Why not just get the certification required to do the stuff you want to do?

As for contacting medical control, since when can a faceless voice override standing orders and in some cases, the law? Are you saying that if some MD tells you, based on your claim to be trained but not allowed to perform a particular procedure, you can do it? Who gets sued if the worst case scenario happens, you or the MD who gave you permission to violate the standing orders?

John E.


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## BossyCow (Jun 3, 2008)

John E said:


> unbelievable....





> A "workaround" that involves putting one's career, not too mention one's financial future at risk. Why not just get the certification required to do the stuff you want to do?



In some cases its not that cut and dried. Different systems regulate these skills differently. For example, I know of an ambulance system that hired an EMT-I. They didn't have a job classification for EMT-I, only B and P. So, he rode with them as an EMT-B on their BLS unit. Liability-wise, if he performed an ILS skill on a BLS unit, he was within his scope of practice but not within the scope of the BLS unit. If there is a way to perform the skill, help the pt and still technically be within your scope on paper, I think its worth doing. But, as one poster put it, always good to have the MPD to back you up on this. 



> As for contacting medical control, since when can a faceless voice override standing orders and in some cases, the law? Are you saying that if some MD tells you, based on your claim to be trained but not allowed to perform a particular procedure, you can do it? Who gets sued if the worst case scenario happens, you or the MD who gave you permission to violate the standing orders?



Its not so much the 'faceless voice' as it is the licensure that the MPD holds. As EMS we operate under the license of the MPD so pretty much everything we do is his responsibilitiy and his liability, unless he can prove that we disregarded his direct order or protocol. 

We regularly get permission from our MPD to operate outside of our protocols or standing orders. Glucose checks is one of those. Not listed in our protocols as part of our scope, we have an addendum in our district that gives us permission to perform glucose checks after completion of a class on it. The class time must be documented and the evaluator has to sign off on the skill sheet. 

Another example is nitro. We carry it on our rigs and we are allowed to give it to anyone who already has a prescription for it. But, on several occasions, when I'm 15 - 20 minutes away from an ALS intercept, I have called the doc, given a pt report, including BP and been told to give them nitro. Now, if the 'worst happens' and someone gets sued, it would be the Doc for authorizing me to give an incorrect med, not for me following the direction of the MPD. But, if I were to give it myself, without calling or worse yet, documenting that I called the MPD, then it would be my butt in a sling.


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## Ridryder911 (Jun 3, 2008)

BossyCow said:


> In some cases its not that cut and dried. Different systems regulate these skills differently. For example, I know of an ambulance system that hired an EMT-I. They didn't have a job classification for EMT-I, only B and P. So, he rode with them as an EMT-B on their BLS unit. Liability-wise, if he performed an ILS skill on a BLS unit, he was within his scope of practice but not within the scope of the BLS unit. If there is a way to perform the skill, help the pt and still technically be within your scope on paper, I think its worth doing. But, as one poster put it, always good to have the MPD to back you up on this.
> 
> 
> 
> ...



Not always true. Do a Google search & you will find that just because a physician authorizes you to perform a procedure, does not always allow you to perform or be "guiltless". You as a certified or licensed EMT are aware of your limitations and scope of practice. If not, you need to be (ignorance is NOT allowed or blessed) also by knowing that you are not allowed to or have not be trained to do so, does not exempt you from liability. The physician will be sued, but you will also for operating outside your certification level. The same if the physician orders you to perform a procedure or orders a wrong dosage of a medication & you do so... You are still held accountable. 

R/r 911


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## scottmcleod (Jun 3, 2008)

John E said:


> As for contacting medical control, since when can a faceless voice override standing orders and in some cases, the law? Are you saying that if some MD tells you, based on your claim to be trained but not allowed to perform a particular procedure, you can do it? Who gets sued if the worst case scenario happens, you or the MD who gave you permission to violate the standing orders?



If your Medical Director wrote and/or signed off on your standing orders, chances are, s/he has the right to allow for an exception.

By "medical director", I meant YOUR on-line medical control, not just some random doctor.

If someone can be sued for taking a BGL outside of their scope after MedControl says that's ok, I can understand why an instructor I know told me that ALL of the paramedics that were around her at Katrina (she happened to be down there at the time) were scared to treat patients, because it required emergency field medicine (and bending some rules) to save lives. [and they were afraid of getting sued, rather than the patient dying.]

Thank god Canada doesn't have litigatitis....


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## mikeylikesit (Jun 3, 2008)

scottmcleod said:


> I can understand why our SR-P instructor told me that ALL of the paramedics that were around her at Katrina (she happened to be down there at the time) were scared to treat patients, because it required emergency field medicine (and bending some rules) to save lives.
> 
> Thank god Canada doesn't have litigatitis....


chances i think that all of us are willing to take for that outcome in that situation.


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## scottmcleod (Jun 3, 2008)

mikeylikesit said:


> chances i think that all of us are willing to take for that outcome in that situation.



Reading above, I'm not sure that I'd agree with you.


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## John E (Jun 3, 2008)

Bravo, although it's overstating it, the Nuremburg trials kinda put the whole idea of "I was only following orders" to rest.

It was suggested in this thread that

 "Of course... off the record... sometimes things happen in the back of the rig. Of course... then the medic must document that they preformed the skill. I know LOTS of EMT's who have preformed fingerstick glucose readings. I also know EMT's who have started IV's... it is a slippery slope, and if the State finds out, you might find yourself missing your cert. If you are willing to risk it... then go ahead and do it."

I defy anyone here to refute that the above scenario is proper treatment for a patient.

It's not a slippery slope, it's a freakin avalanche.

Yeah, I know it's a bit over the top for a simple glucose test but come on people. 

If your local scope of practice allows it, that's a whole nuther thing. But that's not what we're talking about here. We're talking about willfully stepping over the legal boundaries of an EMT's scope of practice.

John E.

P.S. There's such an obvious difference between what's being advocated here and the treatment of hurricane survivors as to not make it worth responding to.


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## scottmcleod (Jun 3, 2008)

John E said:


> Bravo, although it's overstating it, the Nuremburg trials kinda put the whole idea of "I was only following orders" to rest.
> 
> It was suggested in this thread that
> 
> ...



... just using an example of EMT's that are more afraid of getting sued, than giving proper treatment to patient, even if it's outside of their scope. (I never said I was on either side of the fence.)

If it's life or death, obviously it's a different story entirely.

Is it a livesaving intervention (will the pt. die before they get to the hospital?) If so, talk to your medical direction, and DOCUMENT your need to perform/administer something.

If it's not life/death, why chance it?


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## Jeremy89 (Jun 3, 2008)

There are many cases where something is out of the scope of practice but can be done under medical direction if the EMT is trained.  Here's one example:

http://www.emtlife.com/showthread.php?t=7820

Not saying that EMT's should be Intubating every pt just because they are trained, but if someone has the proper training then they should be allowed to step outside their scope of practice, especially if directed to do so by Med control.  As someone said before, the reason in contacting med control is to cover your a$$.  If the doc says so then the liability is with him/her.


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## John E (Jun 3, 2008)

Only problem with your example is that by doing all of the training and taking all of the steps outlined, you have effectively changed the scope of practice to include intubation.

In other words, the folks who write the rules for whatever area that your example covers have changed the EMT's scope of practice. There aren't "many cases where something is out of the scope of practice but that can be done under medical direction", there aren't any at all for the simple fact that by allowing an EMT to act under medical control you are expanding their scope of practice by definition. 

To put it even plainer, as an EMT-1 in Los Angeles county I have a scope of practice that I MUST follow, deviating or expanding from that is grounds for losing my certification, opening myself to possible litigation, and could easily turn into criminal charges depending on how one interprets the criminal definition of assault.

I don't work anywhere else but I would assume that every other county, state, province, etc. has similiar laws, if an EMT WILLFULLY performs a procedure that is outside of their scope of practice, which is what some people on this thread have advocated, then whatever government body that oversees them should and most likely will come down on them like a ton of bricks. I fail to see how some of you can't see this.

If you're not allowed to do it, you're not allowed to do it. How much simpler can something be? 

John E.


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## scottmcleod (Jun 3, 2008)

John E said:


> If you're not allowed to do it, you're not allowed to do it. How much simpler can something be?



Before, or after you ask MedControl for permission to do it?


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## Jon (Jun 3, 2008)

John:
I agree with you. I wasn't trying to say that it was a good idea, or the best thing for patient care at all... but we all know that in some systems, especially with single-provider paramedics, EMT's occasionally push the limits of "assisting ALS". I've seen it happen. Sometimes 3 or more things need to happen at once, and if there is only one medic... well, that can be a problem. I was trying to explain it, the best that I could, to everyone on here.

When I was going through paramedic school it was made VERY clear to us that we could only preform ALS skills in a clinical setting... and that we couldn't just go out and start putting in IV's for the local medics because we knew how.

Scott:
The first question is what do your protocols say. Some have more options for medical control. Some are specific in saying that EMT's can't preform invasive skills.

I had this discussion with my father last weekend. He asked about preforming a backcountry surgical cric, because we were talking about the possibility of severe anaphylaxis occurring at a Boy Scout event I was attending. I was very clear... I'd like to be involved in EMS in some way for the next 20+ years... I can't do that if I get my cert pulled by the DOH for trying to practice something I saw on ER.... even if it did mean that I got to watch someone die because I couldn't move air with the BVM. That would really suck... but I won't throw my EMT card away because of it. Now if one of the Family Medicine docs who occasionally are around volunteering decided to do something... well... that's on them... if I have any equipment that can be of use, they can have it.


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## John E (Jun 3, 2008)

Scott, 

All I can say is that it's a good thing that as you say in your signature:

"The views expressed here are my own, and do not reflect those of any agency I am associated with, or work for."

Cause I would hate to think that an EMS provider would have such a hard time understanding such a simple notion. Does your employer know what you think about things like scope of practice? 

You seem to be trying to make the case that all an EMT has to do is ask permission from a doctor in order to perform procedures that they're not legally allowed to perform, is that really how you work?

John E.


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## Ridryder911 (Jun 3, 2008)

*Whoa!* I believe there is a misconception or confusion what is "scope of practice" and deviation from protocols.

Just because an MD/DO gave you permission or ordered you to perform a procedure does NOT make it legal! If you have not been authorized or sanctioned by the state to be able to perform that procedure, then technically you are violating the law! If caught and found guilty, may suffer the consequences. 

There is a reason for each state local jurisdiction to have "allowed procedures" and unless it states..." or as authorized by local or medical control"... then you are breaking your level and license capability. Heck, I would have Doc's order tons of stuff for me to do, but I realize that is out of my protocols and scope of training and ability. There is a difference though, if I may want to administer a medication or deviate from the "norm or written" protocol.

One has to very, very, careful of what procedures and treatment modalities assuring that you are within reasons of your training and education level, and license. 

R/r 911


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## scottmcleod (Jun 4, 2008)

John E said:


> Scott,
> 
> All I can say is that it's a good thing that as you say in your signature:
> 
> ...



EDIT: arguing on the internet is like... (you know the end of this one, and I'm tired of being part of the problem.)


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## scottmcleod (Jun 4, 2008)

Ridryder911 said:


> *Whoa!* I believe there is a misconception or confusion what is "scope of practice" and deviation from protocols.
> 
> Just because an MD/DO gave you permission or ordered you to perform a procedure does NOT make it legal! If you have not been authorized or sanctioned by the state to be able to perform that procedure, then technically you are violating the law! If caught and found guilty, may suffer the consequences.
> 
> ...



That's what I was trying to say, in other words. Thank you for putting it more concisely.


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## BossyCow (Jun 4, 2008)

I'm seeing the usual approach of 'let's take an exceptional, outside the norm incident, ask about how to handle the exception', then turn it into 'should EMTs follow protocols?'

Ya know folks, there are exceptional situations that will require us to flirt along the edges of our standard care. Does this mean that we are then allowed to always operate in that gray area? Of course it doesn't! Does the fact that I am sometimes allowed, in exceptional circumstances to give nitro to a patient who doesn't have a prescription for it, while following the specific orders of a physicial mean that I'm going to start giving nitro to everyone? Of course it doesn't!  

Does the fact that on rare occasions, my MPD will order us to do something a bit out of the ordinary mean that I don't respect my scope of practice? Of course it doesn't. 

I am in a unique area, with a unique set of problems. I may not have ALS available. I may be 30 - 45 minutes from a hospital with a critical patient on board. This means that my MPD will sometimes instruct us to move beyond what we do in the run of the mill, standard of care. This is an exception, not the rule and we honor it as such. 

I do not regard this as a way cool toy that I've just been allowed to take out of the box. It's scary, and it should be. If its not upping your sphincter factor, you aren't paying attention.


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## Jon (Jun 4, 2008)

I think Bossy's got a good point folks. PLEASE be nice to each other.


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## emt357085 (Jun 4, 2008)

check your local protocals


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## Jon (Jun 4, 2008)

And.. for the record, here is the Commonwealth of PA's statewide BLS protocols:
http://www.dsf.health.state.pa.us/health/lib/health/ems/bls_protocols_2004.pdf

And the statewide ALS protocols, for kicks:
http://www.dsf.health.state.pa.us/health/lib/health/ems/als_protocols-effective_07-01-07.pdf

And some selections from the protocols:


> When providing patient care under the EMS Act, EMS personnel of all levels must follow
> applicable protocols. Although the Statewide BLS Protocols are written for BLS-level
> care, they also apply to the BLS-level care that is administered by ALS practitioners.
> Since written protocols cannot feasibly address all patient care situations that may develop,
> ...


And the diabetic protocol:


> ALTERED LEVEL OF CONSCIOUSNESS/ DIABETIC EMERGENCY
> STATEWIDE BLS PROTOCOL
> Criteria:
> A. Patient with new decrease in level of consciousness. Causes may include:
> ...


The only mention of blood glucose in the BLS protocols is on the refusal form example, where it is mentions that BGL testing is ALS Only.

On the ALS protocols:


> Electronic glucose testing meters must be carried by all ALS services, and these services must have either a CLIA license or certificate of waiver. An ambulance service performing glucose testing with a meter cleared for home use by the FDA must hold a CLIA certificate of waiver. A CLIA certificate of waiver (CoW) is good for two years. Each service is responsible for determining whether a CLIA license or waiver is required.


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## 1799687 (Jun 8, 2008)

of course local protocols differ but around here basics are not to check fsbs. 
will your medic let you? probably. especially if youre just using flash blood from the iv he/she started. is it against SOP? yes. can you get in trouble? yes. can the medic get in trouble? yes.


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