# Tb questions!



## emtbsnowboarder (Oct 13, 2009)

I am a basic in Oregon and the facility i am with wants me to start placing TB skin tests and reading them. Am i allowed to do this under my EMT scope of practice?  I don't recall anything about TB testing....i remember we can assist paramedics with stuff like EKG'S and other stuff...


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## medichopeful (Oct 13, 2009)

emtbsnowboarder said:


> I am a basic in Oregon and the facility i am with wants me to start placing TB skin tests and reading them. Am i allowed to do this under my EMT scope of practice?  I don't recall anything about TB testing....i remember we can assist paramedics with stuff like EKG'S and other stuff...



Seeing as a Mantoux test is an invasive procedure involving a needle, I would say that no, it probably is not within your scope of practice.  But check within your protocols.


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## emtbsnowboarder (Oct 13, 2009)

medichopeful said:


> Seeing as a Mantoux test is an invasive procedure involving a needle, I would say that no, it probably is not within your scope of practice.  But check within your protocols.



i didn't think so. I work in a clinic type setting so i don't work that much emergency type (no ambulances or transports to hospitals) stuff, mostly medical stuff. I didn't think this would be allowed i have my Oregon protocols here but am still having difficulty in figured out if i am allowed to even do it. My freind was saying that that joint commission (JCAHO) goes through all medical facilities and they allow it?

http://www.oregon.gov/DHS/ph/ems/certific/scope.shtml

Where can i found out for sure. I am pretty sure Oregon EMS does not allow the Planting of that...i mean we can give epi if required but...it doesn't say other types...

thanks


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## medichopeful (Oct 13, 2009)

emtbsnowboarder said:


> i didn't think so. I work in a clinic type setting so i don't work that much emergency type (no ambulances or transports to hospitals) stuff, mostly medical stuff. I didn't think this would be allowed i have my Oregon protocols here but am still having difficulty in figured out if i am allowed to even do it. My freind was saying that that joint commission (JCAHO) goes through all medical facilities and they allow it?
> 
> http://www.oregon.gov/DHS/ph/ems/certific/scope.shtml
> 
> ...



Epinephrine auto injectors are different.  They barely require any training.  You basically just hit the person with the correct end.

Actually inserting a needle and injecting something manually is a little bit different.  If you haven't been trained in it, you can be nearly 100% sure that you are not allowed to do it.  I don't know where you can find the actual answer (I looked through but didn't see it).

But consider the fact that a TB test is not really an EMS thing, so I really don't think you can do it.


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## emtbsnowboarder (Oct 13, 2009)

medichopeful said:


> Epinephrine auto injectors are different.  They barely require any training.  You basically just hit the person with the correct end.
> 
> Actually inserting a needle and injecting something manually is a little bit different.  If you haven't been trained in it, you can be nearly 100% sure that you are not allowed to do it.  I don't know where you can find the actual answer (I looked through but didn't see it).
> 
> But consider the fact that a TB test is not really an EMS thing, so I really don't think you can do it.



i feel the same way. The only training i ever got was from a paramedic who also works at the same place i do, she learned it from the nurse who used to work their....you are right. EMS does not place or read TB skins tests but the facility i work at wants me to but i am hired as a EMT-B...so regardless of what the facility wants i must remain under my EMS protocol right? the stuff on the Oregon web page? What if lets say the Doctor said its okay for you to plant TB skins tests and read them ( in this case would i be allowed since i have medical approval?) 

Where i get confused is are the docs allowed to okay us only on stuff w/ in the protocol or also stuff outside our protocol like this whole TB deal?

As for training i am supposed to be trained by someone who is actually allowed to do this type of procedure right? (like a nurse, doctor?)

she keeps telling me that its going to be part of the EMT......don't know if thats true or not, I ask her if its also going to be their for basic and then she said says she doesn't know about basics...she says it will be for paramedics...


one very confused person...

Thanks for your help, thoughts and insight!


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## JPINFV (Oct 13, 2009)

In  general, the scope of practice and treatment protocols for EMS personnel do not apply to hospital settings. That said, I wouldn't engage in treatments or tests that I haven't been trained and educated to do.


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## medichopeful (Oct 13, 2009)

emtbsnowboarder said:


> i feel the same way. The only training i ever got was from a paramedic who also works at the same place i do, she learned it from the nurse who used to work their....you are right. EMS does not place or read TB skins tests but the facility i work at wants me to but i am hired as a EMT-B...so regardless of what the facility wants i must remain under my EMS protocol right? the stuff on the Oregon web page? What if lets say the Doctor said its okay for you to plant TB skins tests and read them ( in this case would i be allowed since i have medical approval?)
> 
> Where i get confused is are the docs allowed to okay us only on stuff w/ in the protocol or also stuff outside our protocol like this whole TB deal?
> 
> ...



If you have formal training (more than just a nurse teaching it to you or something similar), than you MIGHT be able to do it.  It has to be more than just someone who is able to do it.  I am able to give CPR.  Does that mean I am qualified and certified to teach it?

The protocols becomes a bit tricky.  Unless I am mistaken, your medical director is the one who creates the protocols, so if he wants you to do it, he can write a protocol that says that you can do it.  However, you can only do skills you are trained in.  So if, for example, he writes a protocol that says that you can intubate people, but the state does not allow basics to do that and you have not been trained, than there is a problem.

Letting a paramedic do a TB test is a LOT different than letting a basic do a TB test.  Paramedics have training in invasive procedures such as those involving needles.  EMT-Bs, for the most part, do not.  So just because an EMT-P can do it does NOT mean an EMT-B can.

My suggestion?  Don't do it.  Talk to your medical director and ask him what the protocols say.  If he says that the protocols say that you can do the test (which I doubt they will), and you don't have the training (or the state doesn't allow it), DO NOT do it.  You will get yourself in trouble, or you could potentially harm a patient.  If they for some reason pressure you into doing something illegal or beyond your scope of practice, you may want to reconsider working for them.

The thing is, like we have both said, I can see no reason why an EMT should be performing or administering a TB test.  It has NOTHING to do with EMS, so I don't see why you would be allowed to.

Hope this helps!
Eric


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## emtbsnowboarder (Oct 13, 2009)

Yea i agree w the different types of training w paramedics and basics. That is why i as so alarmed when they wanted me to start doing it. I don't have any problem reading the skin tests ( not invasive). I work in corrections so things are done a little differently and it just seems like things are not done to the same standards as say a hospital. Also, i agree with the training requirements too. The planting part was "taught"  by the paramedic but the reading part was done by a lady from the Oregon DHS health department who came to the facility and gave us a power point printout. 

I guess you guys can already sense my uneasiness with the whole idea of planting them... 

So if the doc i work for okays it (he is the medical director for the company i work for that the corrections facility contracts out and NOT the medical director the county)and i am trained by the proper person i can still do the planting even if it is outside the counties protocol? :unsure::unsure:


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## medichopeful (Oct 13, 2009)

emtbsnowboarder said:


> Yea i agree w the different types of training w paramedics and basics. That is why i as so alarmed when they wanted me to start doing it. I don't have any problem reading the skin tests ( not invasive). I work in corrections so things are done a little differently and it just seems like things are not done to the same standards as say a hospital. Also, i agree with the training requirements too. The planting part was "taught"  by the paramedic but the reading part was done by a lady from the Oregon DHS health department who came to the facility and gave us a power point printout.
> 
> I guess you guys can already sense my uneasiness with the whole idea of planting them...
> 
> So if the doc i work for okays it (he is the medical director for the company i work for that the corrections facility contracts out and NOT the medical director the county)and i am trained by the proper person i can still do the planting even if it is outside the counties protocol? :unsure::unsure:



If you are allowed to do it in your state, and your medical director allows it, then yes, you can do it.  But if you are uneasy, talk to somebody (such as your medical director) about it.

Eric


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## reaper (Oct 13, 2009)

You will want to really look into this. Almost all states require an RN or higher to read the test and sign off on it. I think they are setting you up for a fall!


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## JPINFV (Oct 13, 2009)

medichopeful said:


> The thing is, like we have both said, I can see no reason why an EMT should be performing or administering a TB test.  It has NOTHING to do with EMS, so I don't see why you would be allowed to.



While I agree that based on training and education, an EMT-B shouldn't be administering a TB test, I object to this line of reasoning. Prevention and public health should be a function of EMS. Otherwise it's like saying that the fire department shouldn't be involved with drafting building codes because it doesn't involve putting water on fire.


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## medichopeful (Oct 13, 2009)

JPINFV said:


> While I agree that based on training and education, an EMT-B shouldn't be administering a TB test, I object to this line of reasoning. Prevention and public health should be a function of EMS. Otherwise it's like saying that the fire department shouldn't be involved with drafting building codes because it doesn't involve putting water on fire.



Yes, I completely agree that prevention and public health should be a function of EMS, but only to a degree.  If EMTs are allowed to conduct tests for TB, what will be next?  Testing for the flu?  

When it comes to firefighters, they have knowledge and expertise when it comes to what will burn and what won't.  What sort of knowledge does an EMT have about TB, besides the fact that it's bad?  

If an EMT is going to get involved in prevention and public health, they should begin to educate people about the risks.  They should not be actually performing any tests.  For an EMT, it should be education rather than testing.  Educate people about the risks, and tell them to go get tested by their doctor.

It is, in a way, like taking a hospital nurse or doctor and sticking them on an ambulance with little training in field medicine.  They are there to help prevent sickness and maintain health, too.  But would you really want them crossing over into a different "type" of medicine?


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## JPINFV (Oct 13, 2009)

medichopeful said:


> If an EMT is going to get involved in prevention and public health, they should begin to educate people about the risks.  They should not be actually performing any tests.  For an EMT, it should be education rather than testing.  Educate people about the risks, and tell them to go get tested by their doctor.


Let me quote myself here:


JPINFV said:


> While I agree that based on training and education, an EMT-B shouldn't be administering a TB test,



...and yes, I see absolutely no reason why EMS shouldn't be using field tests if available and either useful for deciding treatments or for assisting in collecting epidemiological data. Of course this also goes hand in hand with providing EMS options other than drive the patient to the hospital, do not pass go, do not collect $200. 



> It is, in a way, like taking a hospital nurse or doctor and sticking them on an ambulance with little training in field medicine.  They are there to help prevent sickness and maintain health, too.  But would you really want them crossing over into a different "type" of medicine?



...because there aren't systems that use emergency physicians to respond to field calls in the United States?


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## medichopeful (Oct 13, 2009)

JPINFV said:


> Let me quote myself here:
> 
> 
> ...and yes, I see absolutely no reason why EMS shouldn't be using field tests if available and either useful for deciding treatments or for assisting in collecting epidemiological data. Of course this also goes hand in hand with providing EMS options other than drive the patient to the hospital, do not pass go, do not collect $200.



As far as I know, a TB test takes a while to come back.  It is not something that comes back immediately that would allow an EMT to alter their treatment in the field.  Now, if there was a TB test that came back immediately, I MIGHT be more open to the idea, as long as they had the proper training (which we both agree on).  I may be young and stupid (it's actually very likely), but how would an EMT-B knowing whether or not a person had TB affect their treatment, besides more PPE/BSI?

In regards to different field tests, I am fine with educated and trained people doing them.  But I would not want a basic doing any invasive procedure besides an auto-injector.



> ...because there aren't systems that use emergency physicians to respond to field calls in the United States?



Yes, there are.  It was just an example.  Maybe a bad one, but an example none-the-less.  I could throw in extra circumstances all day long, but that wouldn't be useful.

As far as paramedics and possibly intermediates go, since they are trained to do invasive procedures, I would be much more open to them performing the tests.  But for this discussion, it has been all about basics.  

For the record, I think we are talking about different things.  I am talking more about lab-type tests.  You are talking about field tests.  This may have lead to a failure to communicate.


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## JPINFV (Oct 13, 2009)

medichopeful said:


> As far as I know, a TB test takes a while to come back.  It is not something that comes back immediately that would allow an EMT to alter their treatment in the field.  Now, if there was a TB test that came back immediately, I MIGHT be more open to the idea, as long as they had the proper training (which we both agree on).  I may be young and stupid (it's actually very likely), but how would an EMT-B knowing whether or not a person had TB affect their treatment, besides more PPE/BSI?


I was talking in generalities and specifically a reply to, 





> If an EMT is going to get involved in prevention and public health, they should begin to educate people about the risks.  They should not be actually performing any tests.



What happens if EMS gets dispatched to a 'flu like symptoms' call and the patient ends up signing out AMA (or ends up being a no transport due to no medical need in systems that allow it). If some sort of quick noninvasive test could be preformed, then EMS has the ability to add to public health statistics even though the patient isn't actually transported.

As far as TB skin test are concerned, a TB test (purified protein derivative) is an injection that gets checked for a reaction 48-72 hours following injection. It's not something that gets sent out to a lab. In this sense, it kinda of makes sense to have EMS administer it to at risk home bound populations since the prehospital provider has around a 24 hour period to return and check it at the patient's abode which could be worked around calls. Yes, it isn't something that should or could be done on a call, but even emergency physicians do a fair amount of primary care. 



> In regards to different field tests, I am fine with educated and trained people doing them.  But I would not want a basic doing any invasive procedure besides an auto-injector.



Again, I'll quote you. 


> The thing is, like we have both said, I can see no reason why an EMT should be performing or administering a TB test.  *It has NOTHING to do with EMS, so I don't see why you would be allowed to.*


You objected to not just EMT-Bs not doing a test due to lack of training, but also to anyone in EMS doing it because it isn't an emergency. How many emergencies could be prevented with proper care and monitoring? 



> For the record, I think we are talking about different things.  I am talking more about lab-type tests.  You are talking about field tests.  This may have lead to a failure to communicate.


The line between "lab-type tests" (which the PPD test is not) and field tests is constantly getting blurred. Examples include quick tests for Troponin 1 or the ever mentioned iSTAT point of care testing. I'm willing to bet money that within 10-15 years some sort of point of care blood testing will be as standard as a cardiac monitor or AED on ambulances.


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## medichopeful (Oct 13, 2009)

JPINFV said:


> I was talking in generalities and specifically a reply to,
> 
> What happens if EMS gets dispatched to a 'flu like symptoms' call and the patient ends up signing out AMA (or ends up being a no transport due to no medical need in systems that allow it). If some sort of quick noninvasive test could be preformed, then EMS has the ability to add to public health statistics even though the patient isn't actually transported.
> 
> ...



Alright, I've been contradicting myself a bit.  I'll admit it.  :blush:

Here is my take.  For an EMT-B, if they are trained (beyond the normal EMT course) to conduct basic, non-invasive tests that have relevance to EMS (I don't think things like HIV tests count), then that's fine.  

The same is true for paramedics, but they should be able to do it more in depth.

Of course, this is only if the state allows it, and they are properly trained and educated.

In regards to the OP, I think that he should be doing it only if he has the training and education (which we both agree on, JPINV), his state allows it, and his protocols direct it.  However, he is also in a different setting than a regular EMT is, so I don't really think that he should be doing it at all.  They should have a doctor or other trained health professional do it.

Sorry for the contradictions. :sad:B)


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## emtbsnowboarder (Oct 13, 2009)

reaper said:


> You will want to really look into this. Almost all states require an RN or higher to read the test and sign off on it. I think they are setting you up for a fall!



Hi thats what i have heard and am pretty sure it is true. But i cannot find it in writing...where can i find out for sure?????


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## emtbsnowboarder (Oct 13, 2009)

Oregon DHS EMS doesn't mention anything anywhere about TB planting or testing..so as far as the state goes i am assuming its not allowed. Now if the doc i work for says its okay you can go ahead and do it, then can i? (can the doc take me outside the dept. EMS protocol?) Also, are their special provisions for correctional facilities? I have goggled various key words and cant get anything useful!

For eg, in MN it says this

http://www.health.state.mn.us/divs/idepc/diseases/tb/factsheets/tst.html

Your health care provider will use a small needle to inject some harmless testing fluid (called “tuberculin”) under the skin on your arm. 
Your health care provider MUST check your arm 2 or 3 days after the TB skin test, even if your arm looks OK to you. 

"Health Care Provider" that does include ems but also nurses and doctors......agghhh its all so confusing!

I found this now.. lol sigh


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## emtbsnowboarder (Oct 13, 2009)

http://www.oregon.gov/DHS/ph/tb/index.shtml
I found this now.. lol sigh


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## JPINFV (Oct 13, 2009)

emtbsnowboarder said:


> Oregon DHS EMS doesn't mention anything anywhere about TB planting or testing..so as far as the state goes i am assuming its not allowed. Now if the doc i work for says its okay you can go ahead and do it, then can i? (can the doc take me outside the dept. EMS protocol?)



Are you working just in a hospital or in at a hospital based ambulance service?


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## emtbsnowboarder (Oct 13, 2009)

JPINFV said:


> Are you working just in a hospital or in at a hospital based ambulance service?



i work in a correctional facility


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## JPINFV (Oct 13, 2009)

Working in a correction facility would mean that you aren't covered nor protected by EMS treatment protocols and scope of practice. This is an issue that needs to be addressed with your correctional facilities medical office and the medical director for the facility. I highly doubt that contacting your local office of EMS would produce any tangable results.


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## VentMedic (Oct 13, 2009)

JPINFV said:


> Working in a correction facility would mean that you aren't covered nor protected by EMS treatment protocols and scope of practice.


 
That would also depend whether it is state or Federal. Federal facilities may not have to abide by certain state regulations that dominate TB testing.  This is true for other healthcare professionals as well.


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## redcrossemt (Oct 13, 2009)

Last two points sum it up well.

If it is federal, may not matter at all.

If it is state or local, you still aren't practicing as an EMS provider inside the facility (unless the facility licenses a first responder unit or something with the state, which I doubt). Instead, you are a healthcare professional, acting under the protocols and guidance of the medical director at the facility.

That being said, if you have or receive formal education in the provision of these TB skin tests, and approval from your medical director, you should be able to do it. That is, unless you are actually working for a licensed EMS provider - in which case you'd be restricted by the state scope of practice.


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## VentMedic (Oct 13, 2009)

redcrossemt said:


> Last two points sum it up well.
> 
> If it is federal, may not matter at all.
> 
> ...


 
That again depends on your state policy.  Most states require a licensed staff member to administer and read the test.  

Example for Florida:

http://www.doh.state.fl.us/Disease_ctrl/tb/guidelines/TB5-TBSkinTesting.pdf


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## emtbsnowboarder (Oct 13, 2009)

JPINFV said:


> Working in a correction facility would mean that you aren't covered nor protected by EMS treatment protocols and scope of practice. This is an issue that needs to be addressed with your correctional facilities medical office and the medical director for the facility. I highly doubt that contacting your local office of EMS would produce any tangable results.



I am hired as a EMT-B...i don't understand why my scope of practice changes though nor my protection? The correctional facility contracts out the medical work to a private company. Its is the company i work for, essentially i am a contractor for the county correctional facility.


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## emtbsnowboarder (Oct 13, 2009)

VentMedic said:


> That would also depend whether it is state or Federal. Federal facilities may not have to abide by certain state regulations that dominate TB testing.  This is true for other healthcare professionals as well.



Its a county correctional facility, not federal facility. We do receive federal inmates while they are being held sometimes.


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## emtbsnowboarder (Oct 13, 2009)

redcrossemt said:


> Last two points sum it up well.
> 
> If it is federal, may not matter at all.
> 
> ...




Your first paragraph i think explains everything well. We don't have a first responder...i have had poeple transported before, we have the local fire search and rescue serve the correctional facility for any ambulance transports. I am confused a little bit though, I am hired as a EMT-B, how can i not be practicing as a EMS provider? 

I am just so confused...
Is there some website or someplace where i can actually reference this the part about being a  healthcare professional, acting under the protocols and guidance of the medical director at the facility (since i work for corrections).  Not saying that you are making anything up. 


I am not working for a EMS provider (you mean like ambulance companies right? and the fire dept?)  in regards to your second paragraph. I don't believe i have received any "formal" education in planting the tests. The paramedic who works their just showed me one day, and she was taught by the nurse who used to work at the facility in regards to planting. For reading the TB plants however we did have a RN from the DHS health department come to your facility and give a seminar on how to read the plants. 


Thanks everyone for shedding light and providing your input. I hope this helps others too!


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## VentMedic (Oct 13, 2009)

I don't know what state you are in so I can not pull up the regulations for you but it is relatively easy to do.  Each state should have a Public Health Department and/or a site for TB information.  On it will generally be information about TB testing and a list of providers what can perform administer the test and who can read it.    It would be rare that an unlicensed healthcare provider could do both.   Your employer will also have to maintain records regarding your license, education and training.  Thus, it would be in their best interest to confirm this.   There should also be a P&P for this procedure that clearly explains who can and what is requireed.


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## emtbsnowboarder (Oct 13, 2009)

VentMedic said:


> I don't know what state you are in so I can not pull up the regulations for you but it is relatively easy to do.  Each state should have a Public Health Department and/or a site for TB information.  On it will generally be information about TB testing and a list of providers what can perform administer the test and who can read it.    It would be rare that an unlicensed healthcare provider could do both.   Your employer will also have to maintain records regarding your license, education and training.  Thus, it would be in their best interest to confirm this.   There should also be a P&P for this procedure that clearly explains who can and what is requireed.



i am in oregon

i have found this

http://www.oregon.gov/DHS/ph/tb/index.shtml

there is a ppt for "TB Control in Correctional Facilities"

i cant find anything about the levels of health care practitioners and who can and cant do it.

What is P&P?


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## redcrossemt (Oct 13, 2009)

P&P is Policies and Procedures.

While they may have hired you because of your experience or licensure as an EMT, you are not working under the EMT scope of practice and state protocols because you are not working for an EMS provider or under an authorized medical director or medical control authority or zone.


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