# Paramedic Scope of Pratice



## mikie (Sep 28, 2008)

We're often discussing/arguing what EMTs can and can't do. 

What about paramedics?  Do you think there are some interventions that are too 'advanced' (chest tube, etc) even after having more A & P background and far more diadatic & clinical training.  

I'm not trying to spark argument at all, I'm just looking at it from another perspective.  I'm not a medic (yet ), but am not familiar enough with all of their scope of practice.  

So speak *nicely* to each other

-another way to pose the question, what is an example of a more advanced intervention your dept/service allows?


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## Onceamedic (Sep 28, 2008)

Central lines and pericardiocentesis.  These two are pretty out there.


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## KEVD18 (Sep 28, 2008)

im confused. are you asking what skills medics are allowed to do and you think shouldnt be allowed, or arent allowed and you think should.


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## mikie (Sep 28, 2008)

KEVD18 said:


> im confused. are you asking what skills medics are allowed to do and you think shouldnt be allowed, or arent allowed and you think should.



I think I'm asking a few things but poorly worded it.  

Are there some invasive procedures medics shouldn't be doing (ie- a parallel argument: should basics be able to combitube)?

Is there something you (general question) think they should be allowed to do (ie-drilling a hole in the brain to reduce ICP (not really, but something like that))?  

Are medics in school long enough? (kinda a new question)


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## mikie (Sep 28, 2008)

Am I asking too much? :unsure:


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## VentMedic (Sep 28, 2008)

It all depends on the agency, the motivation of the individuals and the medical oversight.

There are Paramedics that have a very broad scope in EMS, CCT and Flight. And then there are those, Naples FD being a recent example (Washington DC another) that should not go near meds until they retrain, re-educate and re-demonstrate they are competent.


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## Hastings (Sep 28, 2008)

Well, in theory, I can be asked to do something that the doctor believes is immediately necessary without any training in doing so, and there have been rare situations where that occurred. As such, I make sure I know my anatomy so that if a doctor ever gets on the radio and starts walking me through an unfamiliar procedure, I am prepared.

I have protocols which define a default scope of practice, but in the end, I can do as much as the doctor feels is necessary. There's been at least instance where I've been walked through a procedure I had no training or experience doing.


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## VentMedic (Sep 28, 2008)

Hastings said:


> I have protocols which define a default scope of practice, but in the end, I can do as much as the doctor feels is necessary. There's been at least instance where I've been walked through a procedure I had no training or experience doing.


 
Is this doctor your medical director?


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## EMT-P633 (Sep 29, 2008)

Hastings said:


> I've been walked through a procedure I had no training or experience doing.




I would be interested in knowing what procedure was performed.  If you wouldnt mind sharing.


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## Hastings (Sep 29, 2008)

EMT-P633 said:


> I would be interested in knowing what procedure was performed.  If you wouldnt mind sharing.



Field pericardiocentesis on a cardiac arrest. Working in the upper peninsula of Michigan. Called in and the doctor chose to walk me through the procedure over the radio, despite never being taught how to do it before (trained in Lansing, where no one would even dream of a Paramedic doing something like that).



VentMedic said:


> Is this doctor your medical director?



Yes, he was.


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## EMT-P633 (Sep 29, 2008)

D:censored::censored:M,

You do got Brass ones. I wouldn't have attepted it. Not sure on the rules and regs for UP but down here in TN if a medic here had done that I would have to think he would be infront of the state EMS board.  Granted I am a new medic and it was your M.D. I honestly dont know how that would have played out down here. 

Still courious tho, what was the outcome?


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## Hastings (Sep 29, 2008)

EMT-P633 said:


> D:censored::censored:M,
> 
> You do got Brass ones. I wouldn't have attepted it. Not sure on the rules and regs for UP but down here in TN if a medic here had done that I would have to think he would be infront of the state EMS board.  Granted I am a new medic and it was your M.D. I honestly dont know how that would have played out down here.
> 
> Still courious tho, what was the outcome?



Brief return of pulse, but dead on arrival to the hospital.

The transport time was >15 minutes and the patient was dead. No helicopter support. Under any other circumstances, I wouldn't have. But at that point, there's really nothing to lose. I was scared to death, did the best I could, and it didn't turn out as I hoped. That's how it works. As for ordering it, I think it was justified. Under the circumstances as they are up there, I don't think anyone would have questioned it.


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## VentMedic (Sep 29, 2008)

Hastings said:


> Brief return of pulse, but dead on arrival to the hospital.
> 
> The transport time was >15 minutes and the patient was dead. No helicopter support. Under any other circumstances, I wouldn't have. But at that point, there's really nothing to lose. I was scared to death, did the best I could, and it didn't turn out as I hoped. That's how it works. As for ordering it, I think it was justified. Under the circumstances as they are up there, I don't think anyone would have questioned it.


 
You could have had a lot to lose and so could your medical director. 

Even those of us who are allowed to do advanced procedures must have documentation of competency and even still can be called to answer why it was done especially when the patient dies. The ME could also state that your procedure prevented any chance of ROSC or led to pt's death. This happened recently to a flight team who did what they had to do or thought they had to. 

Your medical director would be questioned that if he felt you were capable of such procedures, why had he not bothered to train you?


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## Hastings (Sep 29, 2008)

VentMedic said:


> You could have had a lot to lose and so could your medical director.
> 
> Even those of us who are allowed to do advanced procedures must have documentation of competency and even still can be called to answer why it was done especially when the patient dies. The ME could also state that your procedure prevented any chance of ROSC or led to pt's death. This happened recently to a flight team who did what they had to do or thought they had to.
> 
> Your medical director would be questioned that if he felt you were capable of such procedures, why had he not bothered to train you?



Wasn't trained in the rural setting of the UP. Trained in urban Lansing, MI. Moved to UP to work for a bit. Standards might be different up there. All I know is that I was young, new, scared to death, and ordered to do a procedure I had no idea how to do. I explained that I had never been trained on it or done it before, doctor stated would walk me through it over radio. With nothing for the patient to lose, I tried it. Attempted it, got it, drained it, shocked it, return of pulse, lost it.

Whether justified at the time or not, thankfully nothing bad came of it. Doctor explained everything to the family, the family thanked him for doing everything he could, and that was that. I certainly have a different opinion of doing things like that now that I have more experience though.


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## reaper (Sep 29, 2008)

Most here that were trained more then 15 years ago can remember being taught things that you would never see in a medic class today. Things like, Chest tubes, centesis, and intercardiac epi. These are not taught any longer for reasons. 

I do not carry the proper equipment for a centesis and doubt anyone else does. I would have told the Dr., sorry not gonna happen!h34r:


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## medicdan (Sep 29, 2008)

Okay, slightly different question-- assuming you have all the training and equipment you need-- what interventions are just too much in prehospital 911 (excluding specialized CCT RN/Medic/RT teams)? 
I worked for some time with an MD on an ALS 911 truck-- and he knew his own limits. What procedures/therapies would you consiter to be too much for 911?


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## Ridryder911 (Sep 29, 2008)

His own limits? He is a licensed physician on or off duty. There is no difference for him, unlike an EMT, Nurse, etc... his license to practice medicine is 24 /7/ 365. It does not matter if he is in a hospital or in a ditch. Thus one of the many reasons many physicians do not get involved in EMS activities, they *CANNOT *be a lower level and will always be held accountable as a physician. 

R/r 911


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## medicdan (Sep 29, 2008)

R/R, I'm not talking about liability, but the limits of pre-hospital therapy. At what point is it too much-- pre-hospital ultrasound? Ex-Lap? Should we put a portable x-ray onto every ALS to rule out c-spine fracture? TPA? Human Blood? ICP monitors? Burr Holes? Who should be performing these skills? Under what circumstances?


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## Onceamedic (Sep 29, 2008)

Thought of a third one we are allowed to do - (all in Wisconsin - Arizona is a whole different ball of wax) - post mortem C section.  And as for the pericardiocentesis, we are taught to do it and expected to for tamponade.  (once again, that was in Wisconsin.  I think if I tried it here in Arizona I would be swinging off a pole)

PS - Ventmedic - no special equipment required.  All that is needed is a 14 gauge angiocath and a large syringe.


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## VentMedic (Sep 29, 2008)

Kaisu said:


> Thought of a third one we are allowed to do - (all in Wisconsin - Arizona is a whole different ball of wax) - post mortem C section. And as for the pericardiocentesis, we are taught to do it and expected to for tamponade. (once again, that was in Wisconsin. I think if I tried it here in Arizona I would be swinging off a pole)
> 
> PS - Ventmedic - no special equipment required. All that is needed is a 14 gauge angiocath and a large syringe.


 
I didn't say anything about the equipment. Pericardiocentesis is still in my protocols for the helicopter and Specialty. I am still required go to the lab for training and retraining. I have used the skill only a few times in 30 years. 

My post was about liability for the untrained.


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## VentMedic (Sep 29, 2008)

reaper said:


> Most here that were trained more then 15 years ago can remember being taught things that you would never see in a medic class today. Things like, Chest tubes, centesis, and intercardiac epi. These are not taught any longer for reasons.


 
Yes, that was pretty standard in the programs and the textbooks. I can not imagine some of the procedures being taught today in the 3 month wonder classes. I can not imagine some of the agencies with poor medical oversight keeping their skills or knowledge up to par especially when even ETI and IV skills are in question. We seem to have a problem keeping people competent in the few skills and medications that are available now in prehospital. 

People want to do the "cool" stuff but quickly loose interest when they realize what type of commitment they will need to maintain their skills. The industry already has had too many botched crics because people thought since they were shown once in Paramedic school, they are proficient for a lifetime. I can see the same mentality happening with other procedures also. 

Many of the things emt-student mentioned are available to some EMS agencies. Most are available for Flight or specialty. Storage and cost are major issues. The cost is more from maintaining the skills of the providers. The number of times the skill may get used may not outweigh the cost or benefit. Very rural areas can be the exception. Many of the thrombolytics studies in the 80s and 90s were done in large city areas like Miami where you are not that far from any hospital. During that time we were also experiencing the Cath-in-a Can era which practically had a cath lab chasing the ambulance. 

Even the teams that do routinely use advanced skills are still required to train and retrain. That goes for the "regular" stuff like intubation and IVs. Much of the advanced practices actually require more education and knowledge than "tech" skills. IABP, LVADs and Ventilators are pieces of technology that doesn't take much to learn how to turn knobs but if one doesn't have the education and knowledge, one can do some serious harm to the patient.


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## Jon (Sep 29, 2008)

Kaisu said:


> Thought of a third one we are allowed to do - (all in Wisconsin - Arizona is a whole different ball of wax) - post mortem C section.  And as for the pericardiocentesis, we are taught to do it and expected to for tamponade.  (once again, that was in Wisconsin.  I think if I tried it here in Arizona I would be swinging off a pole)
> 
> PS - Ventmedic - no special equipment required.  All that is needed is a 14 gauge angiocath and a large syringe.


To show how varied we are - In Jersey... that will get your cert pulled.


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## medicdan (Sep 29, 2008)

Jon said:


> To show how varied we are - In Jersey... that will get your cert pulled.



I assume (and want to confirm) you are referencing the events from September, 1997, when a medic, under order from OLMC, performed a c-section on a dying patient, only to be sued. See article linked below for more info.

http://query.nytimes.com/gst/fullpa...sec=&spon=&partner=permalink&exprod=permalink


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## VentMedic (Sep 29, 2008)

There have been more recent cases. 

But, here's a good article for you:

*Perimortem cesarean section in the helicopter EMS setting: A case report

Air Medical Journal​January-February 2008 • Volume 27 • Number 1​* 
http://www.e-mergencia.com/foro/attachment.php?attachmentid=3054&d=1216074141


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## Foxbat (Sep 30, 2008)

emt-student said:


> I assume (and want to confirm) you are referencing the events from September, 1997, when a medic, under order from OLMC, performed a c-section on a dying patient, only to be sued. See article linked below for more info.
> 
> http://query.nytimes.com/gst/fullpa...sec=&spon=&partner=permalink&exprod=permalink



I'm not sure if this is the same case, but I heard that medics later faced murder charges, which were then downgraded to manslaughter. I think they were convicted....


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## Onceamedic (Sep 30, 2008)

VentMedic said:


> I didn't say anything about the equipment. Pericardiocentesis is still in my protocols for the helicopter and Specialty. I am still required go to the lab for training and retraining. I have used the skill only a few times in 30 years.
> 
> My post was about liability for the untrained.



so sorry - my bad....   :blush:


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## BLSBoy (Sep 30, 2008)

Foxbat said:


> I'm not sure if this is the same case, but I heard that medics later faced murder charges, which were then downgraded to manslaughter. I think they were convicted....



I searched NJ EMS website back to 1999. No suspensions or discipline for such incident back to 1999.


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## mikie (Sep 30, 2008)

How about chest tubes...

Does your protocols allow for them?  Too invasive*? (*stemming from original question)


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