# CA Bay Area - Scope of Practice



## drl (Jul 13, 2014)

As I did my EMT training in LA County, I'm sure there's some differences in the EMT scope of practice/protocols up in the Bay Area (Santa Clara Co., Alameda Co., etc). If some veterans could chime in on anything that comes to mind, that'd be fantastic.

A couple things I can think of:

- *Aspirin administration*: if it's prescribed to the patient, are EMTs allowed to assist?
- *Oral glucose*: are EMTs allowed to administer oral glucose to unresponsive patients? I believe LA Co. was fine with it as long as the patient has a gag reflex.
- *Nitroglycerin administration*: 100 mmHg was the cutoff for nationals and LA Co., but our instructor mentioned that some counties use 90 mmHg as the cutoff. Anyone know what it is in the Bay Area counties?

Thanks!


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## Akulahawk (Jul 13, 2014)

I might not be 100% accurate on this, but I believe that most of the Bay Area EMS agencies have their current Policies and Protocols online. It's usually best to go to the source anyway for that stuff. Also, the State EMSA may have a chart for what's allowed, by what level provider, and by county/EMS system.


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## Angel (Jul 13, 2014)

its specific to each county. not to mention (of course depending on county and what company you work), oxygen will be about as in depth youll get for med delivery. most of the 911 ambulances are pretty hard to get onto and take a while. as far as i know there are no BLS (ie emt/emt) rigs doing 911.


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## drl (Jul 13, 2014)

Thanks for the tips, both of you. Yeah, I've definitely heard 911 ambulance positions are a lot tougher to get in the Bay Area than down in LA, especially for someone straight out of EMT school.


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## Aprz (Jul 13, 2014)

Akulahawk is correct, this information is available online.

Alameda County
Santa Clara County



drl said:


> *Aspirin administration*: if it's prescribed to the patient, are EMTs allowed to assist?


In Santa Clara County, Policy S04 (Routine Medical Care - Adults) says



> BLS personnel may allow the patient to take his/her own
> medication; however, the patient must be alert enough to self-administer
> the medication. In most cases, these medications should only include:
> Nitroglycerin (if SBP >= 90 mmHg), Aspirin, anaphylaxis kit drugs, and
> metered dose inhalers.


Policy A08 (Suspected Cardiac Ischemia) says



> Assist patient to take their own medications


This is probably referring to aspirin and nitroglycerin.



drl said:


> *Oral glucose*: are EMTs allowed to administer oral glucose to unresponsive patients? I believe LA Co. was fine with it as long as the patient has a gag reflex.


Policy A03 (Hypoglycemia) says



> If suspected hypoglycemia, provide 1 tube of oral glucose paste under the
> following circumstances:
> o Known diabetic
> o Intact Gag Reflex
> ...





drl said:


> *Nitroglycerin administration*: 100 mmHg was the cutoff for nationals and LA Co., but our instructor mentioned that some counties use 90 mmHg as the cutoff. Anyone know what it is in the Bay Area counties?


Refer to question 1, but there is also an error. In policy A08 (Suspected Cardiac Ischemia) and policy A11 (Respiratory Distress), it says the cut off is 100 mmHg, not 90 mmHg. I doubt that they intended to allow BLS to administer nitroglycerin until a lower systolic versus ALS.

As bad as this may sound, I don't really think they care about specific BLS treatments (except oxygen, haha!). If a BLS crew has an emergency, they want you to divert to the closest facility or to transfer care to the contracted 911 provider as soon as possible (preferably transfer care to the contracted 911 provider whenever possible).

Personally, I would hold off on administering nitroglycerin in suspected cardiac ischemia.

I think nitroglycerin hasn't been proven to decrease morbidity and mortality. I think it's only given due to tradition and in theory it sounds like a good idea.

I've heard that nitroglycerin administration can "mask" STEMIs making it more difficult for paramedics to recognize an MI via 12-lead.

Because BLS isn't 12-lead capable, we are unable to see if the MI extends to the right ventricle. Patient's with right ventricular infarct are at high risk of significant drop in blood pressure after nitroglycerin administration. Their systolic may be low (90-100) barely meeting the criterium to normal (120), and nitroglycerin may drop their systolic way below 90. BLS providers will usually have no way to increase their blood pressure except with temporary measures such as trendelenburg (not effective), or to open their fluids wide open if the patient is being transported with IV fluids (BLS can transport with Normal Saline, Lactated Ringers, and any concentration of dextrose, usually D5W), which I would say patients are _rarely_ transported with IV fluids by BLS. In fact, I think a lot of nurses don't even think EMTs can transport with a saline lock cause they always ask me if they want them to take it out, haha!

For those reasons, I think the risks outweigh the benefits of assisting a patient with administering nitroglycerin.


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## drl (Jul 13, 2014)

Right, I found the policies online after Akulahawk mentioned it. Thanks for the comprehensive answer, interesting take on nitro admin--hadn't thought about a lot of that!


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## Akulahawk (Jul 13, 2014)

Aprz is mostly correct... however my experience with Bay Area EMT scope is that they won't allow the EMT to adjust any fluid infusion rates. They can maintain a set rate or shut it down. 

As far as NTG goes, as a Basic, I've never been in the position to give NTG on my own, without ALS right there. None of my patients had NTG on hand. That being said, had such a moment arrived, I'd have stuck very close to the BP parameters, which are usually higher than what ALS is allowed to work with because ALS can do something about the low BP that can occur with RVI after NTG is given. 

One of the few times I've taken an MI patient (ended up being a multi-lead STEMI), I could get the patient to the ED faster than ALS could get to me... why 911 wasn't called in that case, I'll never know.


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## Aprz (Jul 14, 2014)

I looked it up because I've seen the word "adjust" several times when reading through these in the past that I always thought it meant adjust as necessary, but it literally says to adjust as necessary to maintain a present rate. That means Akulahawk is correct about EMTs not being able to adjust (ie increase as needed) if the patient suddenly became hypotensive.

Santa Clara County Policy 808 (Interfacility Transport by Ground Ambulnace)


> Monitor IV Solutions of Normal Saline, Dextrose, and Lactated
> Ringers


http://www.sccgov.org/sites/ems/Documents/pcm800/808.pdf

Alameda County page 101 of field manual, Title 22 Division 9 Chapter 2 Article 2 Section 100063 #14 part 1 and 2, and Contra Costa County Policy 31 are all the same word for word verbatim.


> > Monitor intravenous lines delivering glucose solutions or isotonic balanced salt
> solutions including Ringer’s lactate for volume replacement;
> > Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow
> and turn off the flow of intravenous fluid;


http://www.emsa.ca.gov/Media/Default/PDF/ch2emtIupdate.pdf
http://www.acphd.org/media/330945/alco_fm_2014_final_draft_web.pdf
http://cchealth.org/ems/pdf/policy31.pdf

It's disappointing how little EMTs are trained and allowed to do out here, and they are still used as primary care provider during transport with the expectation to pull over and call 911 or to divert with lights and sirens to the closest facility.

Like I said earlier, it's rare for EMTs to transport even with a saline lock. Some EMTs actually ask nurses to remove the IV prior to transport, or nurses will offer to remove it prior to transport.

Also I think that if you did adjust it because the patient suddenly became hypotensive, it would be unlikely that you would get more than a slap in the hand, however, I do not encourage giving nitroglycerin in the first place.

Like Akulahawk said, it'll be rare that you will be put in this situation too. I've been working on an ambulance for three years, and I have never been put in this situation myself. Even on a critical care ambulance with a register nurse or paramedic transporting a patient to a cath lab, it's rare for them to even give nitroglycerin although they are more likely to give it than a BLS unit for sure, lol. It's just something to know and be prepared for, but it's unlikely to happen.


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## gclol (Jul 24, 2014)

Alameda county ems does have duel emt running code 2 911 calls


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## gclol (Jul 24, 2014)

Angel said:


> its specific to each county. not to mention (of course depending on county and what company you work), oxygen will be about as in depth youll get for med delivery. most of the 911 ambulances are pretty hard to get onto and take a while. as far as i know there are no BLS (ie emt/emt) rigs doing 911.





gclol said:


> Alameda county ems does have duel emt running code 2 911 calls


Correction I mean they are only running code 2 911 calls in Oakland


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## drl (Jul 24, 2014)

gclol said:


> Correction I mean they are only running code 2 911 calls in Oakland



Interesting. That's Paramedics Plus, or other companies as well?


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## NPO (Jul 31, 2014)

drl said:


> As I did my EMT training in LA County, I'm sure there's some differences in the EMT scope of practice/protocols up in the Bay Area (Santa Clara Co., Alameda Co., etc). If some veterans could chime in on anything that comes to mind, that'd be fantastic.
> 
> A couple things I can think of:
> 
> ...


When did you do your LA county EMT? Aspirin is now in the EMT scope for LA county but the policy is very vague. Just says "asprin - for suspected MI" no dose no route no indications, contraindications nothing. Wondering what the schools are saying about this. 

Also there are some odd ball policies in LA county like BLS transporting with an infusion pump. The policy limits it to basic fluids but that blows peoples minds when I mention it. I only ever took a pump BLS once, most hospitals don't hand those out.


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## TimRaven (Aug 19, 2014)

Correct me if I was wrong, I believe in Alameda EMT can not take oxygen saturation; in Contra Costa EMS don't use long spine board and can not give activated charcoal (even for Paramedic).


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## drl (Aug 20, 2014)

NPO said:


> When did you do your LA county EMT? Aspirin is now in the EMT scope for LA county but the policy is very vague. Just says "asprin - for suspected MI" no dose no route no indications, contraindications nothing. Wondering what the schools are saying about this.
> 
> Also there are some odd ball policies in LA county like BLS transporting with an infusion pump. The policy limits it to basic fluids but that blows peoples minds when I mention it. I only ever took a pump BLS once, most hospitals don't hand those out.



I did my LA Co. EMT April through June this year. Our instructors told us to watch out for that in the future since the policy is just being rolled out/clarified now. Thanks for the input though, that's interesting...



TimRaven said:


> Correct me if I was wrong, I believe in Alameda EMT can not take oxygen saturation; in Contra Costa EMS don't use long spine board and can not give activated charcoal (even for Paramedic).



I don't think pulse ox is strictly within EMT scope of practice (most EMT rigs don't seem to carry it), but at least in LA, the EMTs used it all the time to get vitals when we got to the ER.

Strange on the long spine board... what's the rationale behind that? I assume activated charcoal isn't used because it isn't effective in most situations?


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## TimRaven (Aug 20, 2014)

drl said:


> I did my LA Co. EMT April through June this year. Our instructors told us to watch out for that in the future since the policy is just being rolled out/clarified now. Thanks for the input though, that's interesting...
> 
> Strange on the long spine board... what's the rationale behind that? I assume activated charcoal isn't used because it isn't effective in most situations?



Should be more clear about board. Ambulance in Contra Costa (both BLS and ALS) switched to air splint awhile ago. I don't know if we could do NEXUS test though.


----
ok, I found our latest scope of practice here.
http://cchealth.org/ems/pdf/phcm-2014.pdf


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## Angel (Aug 23, 2014)

drl said:


> I did my LA Co. EMT April through June this year. Our instructors told us to watch out for that in the future since the policy is just being rolled out/clarified now. Thanks for the input though, that's interesting...
> 
> I assume activated charcoal isn't used because it isn't effective in most situations?



or depends on the med director. where im at we can use it, under specific guidelines and have to get a base order. in a previous county it wasn't even in the protocol. if they were severely symptomatic we'd treat what we saw and the first thing they'd get in the ED was usually charcoal. time and distance to nearest ED usually plays a large factor in med directors rationale behind protocols


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