# Scope of practice issue?



## jhall98 (Feb 13, 2019)

A gentleman asked me a question yesterday and I was not sure how to answer. E.g if an EMT-Basic is trained to push D-50 and a Medic is present, can he do so without violating scope of practice?


----------



## akflightmedic (Feb 13, 2019)

Under what license would an EMT be "trained to push D50"? In order to be trained to push this drug, you would first need to be trained on starting an IV, right? So since you cannot start an IV, then you cannot push D50.

Now if the medic is present, the medic has started he IV and the medic wants you to "push" a drug, any drug while they watch...I am going to go out on a limb here and say that medic is exceptionally foolish. The caveats to this scenario would be IF the EMT is in Medic school and the organization they work for agrees to this, if the Medical Director of said organization has signed off on this, or if the state guidelines allow for this.

I simply cannot fathom a situation where I would let an EMT just push a drug (any drug) barring none of the caveats above.


----------



## CWATT (Feb 13, 2019)

I understand where the OP is coming from as this ‘grey area’ was a hot topic for discussion in my EMT program.  Our scope of practice for EMTs included ‘IV access’ as well as ‘intravenous medication administration’ however drugs such as benzodiazepines were out of our scope.  So the question was, can we administer these drugs under the direction of an EMT-P.  

The direct answer is ‘no’ becuase things like ‘intravenous medication administration’ does not allow a provider to administer anything they would like.  So the question was, why have ‘Intravenous medication administration’ within our scope?  Because normal saline is considered a medication, albeit not one we typically think of (same as oxygen).  

The complicated answer was already addressed by akflightmedic and simply put — may be up to the discression of the service and their interpretation of the legislation.  

The main thing you need to ask yourself is, if I give this drug, do I know it’s indications, contraindications, method of administration, and am I able to recognize the signs and symptoms of an adverse reaction and be capable of initiating appropriate treatment?  A drug like D50W can cause severe tissue necrosis and is given SIVP (slow IV-push) for this reason, so if you answer ‘no’ to any of those questions you should not be administering that medication.


----------



## Akulahawk (Feb 13, 2019)

jhall98 said:


> A gentleman asked me a question yesterday and I was not sure how to answer. E.g if an EMT-Basic is trained to push D-50 and a Medic is present, can he do so without violating scope of practice?


Being "trained to do" a particular task and being "authorized to do" that same task are two separate things. I'm both a Paramedic and an RN. I'm going to focus specifically on the task of placing an EJ IV line as this highlights my point very well. As a Paramedic, if I deem it necessary to place an EJ IV line, then I can do so. Under that scope of practice, it's the same as any other peripheral IV placement. For a variety of reasons I prefer to _not_ place an EJ for my first attempt at PIV placement but if it's the only option I have, I can do it. As an RN, I can place PIV's nearly anywhere, but if my patient is a diabetic, I must obtain an order to place one in a lower extremity/foot. I may _NOT_ place a PIV in an EJ as it is not within my scope of practice at the hospital where I work. They do know and recognize that I'm also a Paramedic and therefore am trained in the task of EJ IV cannulation. Even if I obtain an order to place an EJ and have a provider present when I do, I still may not place that EJ IV. That would violate my authorized scope of practice. 

So extend that same process to your question, and you have your answer.


----------



## Peak (Feb 13, 2019)

Also keep in mind that there are also parts of this based on your service as well as the relevant legislation based on where you are at. In some states EMTs can take a short 2 day course that authorizes them to start IVs and give a small number of IV meds which usually includes D50.

In my state I can place central lines, A-Lines, RICs, suture, place chest tubes, intubate, and more under my nursing license but there is a degree to which we need to have good clinical judgement. I have placed A-Lines when the provider isn't available or occupied performing other critical tasks, but as a routine bedside or pre-operative procedure it would be highly frowned upon. I tube outside the hospital, but very rarely am I the most skilled available person to intubate a patient in the ED or units.

Same goes for EMS, can I delegate someone to push the shock button even if they are not ALS and there isn't another resonable option and I'm occupied? Sure. Would I routinely delegate that to someone if there is another ALS provider available? No.

I've used lay persons to help C-Spine, perform compressions, and many other tasks but it has to be reasonable for the situation. I'd have a hard time imagining many times when there was a paramedic available to start the IV, but unable to push the medications.


----------



## Bullets (Feb 14, 2019)

akflightmedic said:


> I simply cannot fathom a situation where I would let an EMT just push a drug (any drug) barring none of the caveats above.


Perhaps a uniquely NJ thing, but paramedics riding a BLS agency. Theres a number of well paid and run BLS agencies and even more medics who still volunteer with their local BLS squads from whence they came.


----------



## akflightmedic (Feb 14, 2019)

Wouldn't that fall under my list of caveats...


----------



## DrParasite (Feb 14, 2019)

Bullets said:


> Perhaps a uniquely NJ thing, but paramedics riding a BLS agency. Theres a number of well paid and run BLS agencies and even more medics who still volunteer with their local BLS squads from whence they came.


And it doesn't apply in this case.  Most paramedics who are on BLS ambulances are either 1) operating at the agencies BLS level, as the agency is only licensed as a BLS agency or 2) functioning within the job description of an EMT, as that is the only role that the agency recognized.  Even the well paid BLS agencies (I know of one or two in Ocean County) that only hire paramedics, but they are still only permitted to function at the BLS level.

If you put two paramedics on a BLS ambulance, at a BLS agency, they are still unable to perform ALS procedures.  If you put two paramedics on a BLS ambulance, that is licensed only as a BLS ambulance, for an agency that has paramedics, they are still unable to perform ALS procedures until an ALS unit gets there.   That's NJ state EMS regulations. 

If a paramedic is working on a BLS ambulance, and performs ALS procedures while ALS is there, because they know the person is a paramedic and trust that he knows what he is doing, there is a 99.99% chance that said procedure will not be documented on the ALS run sheet as being done by the person on the BLS ambulance, nor will the BLS run sheet make any mention of it being done by the person on the BLS ambulance.  

Regular EMT-Bs are not allowed to push D-50, unless their medical director permits them to do it (I say this because I've been told that Texas medical directors can make any rules they want, so I guess if their medical director says it's allowed, and they are operating under his or her license, they can do it).  

Most state regulations don't allow it.


----------



## Akulahawk (Feb 14, 2019)

Bullets said:


> Perhaps a uniquely NJ thing, but paramedics riding a BLS agency. Theres a number of well paid and run BLS agencies and even more medics who still volunteer with their local BLS squads from whence they came.


Paramedics that are working in a BLS-only capacity are only authorized to function in that BLS-only capacity and may not exercise their full Paramedic scope of practice. The only potential exception to this would be an instance where a Paramedic could be specifically authorized to perform specific interventions but that situation would be rare. 

Here in California, I am automatically deemed an EMT and AEMT (used to be EMT-B and EMT-II) without any additional testing as I'm already a Paramedic and as such my scope of practice includes those lower scopes of practice. This means I could work in either lower capacity, using my "P number" and be restricted to that which the company authorizes me to perform. Where I live, if I hold current accreditation as a Paramedic and I'm either off-duty or working for another agency in a "lower capacity" I could perform to full scope if/when an on-duty Paramedic arrives on scene. Also as stated above, in the instance where a company would discipline me for following protocol/policy that allows me to function at a higher level at times, a gentlemen's agreement struck on-scene would likely result in me doing what's needed under the other Paramedic's direction/license and they'd chart it out as being done by them. 

It's all weird... but basically you must know your limitations and generally speaking, Paramedics working in a lower capacity may not exercise their full-scope from a legal standpoint. Informal agreements struck while on-scene don't change the legality, may result in better patient care, but also exposes all providers there to some legal risk... up to and including loss of certification/license if something goes wrong.


----------



## CCCSD (Feb 14, 2019)

Charting a procedure done by another and claiming it as your work would result in a disciplinary action...would it not?


----------



## Akulahawk (Feb 15, 2019)

CCCSD said:


> Charting a procedure done by another and claiming it as your work would result in a disciplinary action...would it not?


If discovered, absolutely possible. 

That's but _one_ reason I don't do it.


----------



## DrParasite (Feb 15, 2019)

Akulahawk said:


> It's all weird... but basically you must know your limitations and generally speaking, Paramedics working in a lower capacity may not exercise their full-scope from a legal standpoint. Informal agreements struck while on-scene don't change the legality, may result in better patient care, but also exposes all providers there to some legal risk... up to and including loss of certification/license if *something goes wrong.*


I've bolded and underlined the important factor.  If nothing goes wrong, if no one asks questions, if the patient is happy and better off in the end, there is a near certainty that no disciplinary action would occur.  

Have I seen EMT-I who were only credentialed as EMTs in that system start IVs?  yes.  The system did no allow EMT-I, but when the medic was tied up doing other things, and IV access is needed, stuff happens.  I've also seen a FF on the engine (who was an EMT-I for years) but is now part of a BLS only FD start an IV on a cardiac arrest in the back of an ambulance.  IV access was needed, and the medic was working on intubating the patient while we were doing compressions.  Most hands are needed, and there was only one paramedic on scene.

Is it legal?  probably not.  Does the medic have to have confidence with the EMT before they tell them to do it?  absolutely.  Is it a grey area?  not really, it's against the rules.  is it in the patient's best interest?  probably, especially on short staffed EMS systems, and the medic charts that he or she performed the action, because they are in charge and allowing it to occur.

As I mentioned before, as long as there are no complications for the action, no harm /  no foul.   I'm not saying it's right, but if you don't think it happens....


----------



## GMCmedic (Feb 15, 2019)

Indiana allows for a endless scope of practice IF your medical director provides both authorization and training. This is good thing since the only thing that moves slower than implementation of EBM is government. 

This means that a Medical Director could allow an EMT to push D50 under the supervision of a paramedic.

My personal opinion is, D50 is really the last drug I would ever ask an EMT to push as it doesn't usually correlate to time sensitive or busy.


----------



## johnrsemt (Feb 16, 2019)

Be able to justify it;  more than half of our response areas at both my PT and FT jobs don't have cell or radio coverage. so calling medical control for orders is hard a lot of the time.  So we do what we need to do, and ask forgiveness after the fact.

In some states Basics are allowed to do more than in other states,  in some counties in the same state they can do more than in other counties.  So it can get really weird


----------



## DrParasite (Feb 16, 2019)

johnrsemt said:


> Be able to justify it;  more than half of our response areas at both my PT and FT jobs don't have cell or radio coverage. so calling medical control for orders is hard a lot of the time.  So we do what we need to do, and ask forgiveness after the fact.


totally off topic, but of pull up for a n MVA, and need additional resources (helicopter, 5 more ambulances, PD because one of the drivers is waving his gun around because he's drunk, etc) since you have no radio or cell coverage, how do  you call for help?


----------



## Tigger (Feb 16, 2019)

Colorado EMTs with IV endorsement are able to push all non-waived medications via an IV or IO route under the direction of a paramedic if the patient is in "extremis." Extremis is not defined anywhere, for what it's worth. Should I direct my EMT(s) to do that, I document it under my name.

The IV authorization allows EMTs to start their own IVs, hang fluids, and push D50, Narcan, and D50. They are still certified as EMTs, however. 



DrParasite said:


> totally off topic, but of pull up for a n MVA, and need additional resources (helicopter, 5 more ambulances, PD because one of the drivers is waving his gun around because he's drunk, etc) since you have no radio or cell coverage, how do  you call for help?


Drive away till you get service. Sometimes that's the rural EMS reality. I've requested helicopters using the patient's landline phone before.


----------



## StCEMT (Feb 17, 2019)

CWATT said:


> A drug like D50W can cause severe tissue necrosis and is given SIVP (slow IV-push) for this reason,



I thought it was because there is no such thing as pushing D50 fast?


----------



## NomadicMedic (Feb 17, 2019)

Tigger said:


> Colorado EMTs with IV endorsement are able to push all non-waived medications via an IV or IO route under the direction of a paramedic if the patient is in "extremis." Extremis is not defined anywhere, for what it's worth. Should I direct my EMT(s) to do that, I document it under my name.



A patient in extremis is a common definition. 
*Definition of in extremis*

: in extreme circumstancesespecially : at the point of death.


----------



## Tigger (Feb 17, 2019)

NomadicMedic said:


> A patient in extremis is a common definition.
> *Definition of in extremis*
> 
> : in extreme circumstancesespecially : at the point of death.


I understand the definition of the word, I just find it odd that the Colorado Acts Allowed do not define what that means despite defining pretty much every other term in the EMS vernacular. The effective practice is that EMTs push medications drawn up and ordered by paramedics in many, many different patient presentations.


----------



## NomadicMedic (Feb 18, 2019)

Tigger said:


> I understand the definition of the word, I just find it odd that the Colorado Acts Allowed do not define what that means despite defining pretty much every other term in the EMS vernacular. The effective practice is that EMTs push medications drawn up and ordered by paramedics in many, many different patient presentations.



I figured you knew what it meant. I just was saying it's a pretty common term for periarrest.


----------



## DesertMedic66 (Feb 18, 2019)

Only do what you are authorized to do by your company/state/county/etc. 

For example for my company, one of the first lines in our guidelines states that Paramedics and nurses are equal and can preform any and all skills/treatments in our guidelines. So I am trained and certified by the company for many different skills such as IV pumps, ventilators, RSI, chest tubes, surgical crics, escharotomy, etc. However those skills are not authorized as a paramedic skill in my state or county so legally I am not able to do those.


----------



## Peak (Feb 18, 2019)

DesertMedic66 said:


> ...For example for my company, one of the first lines in our guidelines states that Paramedics and nurses are equal and can preform any and all skills/treatments in our guidelines...



I don't understand this mentality. My paramedic training didn't make me a nurse, and my nursing school education would not have made me a paramedic. Especially given that most flight programs want ICU experience rather than ED experience, most flight nurses and flight medics think in very different ways and bring two different skill sets. Every time I do anything prehospital my role is complementary to our medics, and vice versa, not to be the exact same.


----------



## johnrsemt (Feb 23, 2019)

We have radio coverage at my FT job for the base we work at, and I have always had security or PD respond with us and 95% of the time fire (except during wildfire season when they are working one).  Just can't get in touch with Medical Control.
When our security guards are carrying SAW's or M-4's with M-203's the patients are usually pretty mellow.  LOL


----------



## johnrsemt (Feb 23, 2019)

PT job; can get hairy.  close to town we always have the police dispatched with us, or close by; and they don't care about the border (we overlap 2 states) and have 6 departments in the main towns:  the 2 towns (Utah town, and Nevada Town) 2 county Sherriff's and 2 State Police and I have had 5 of the 6 at the scene when it sounded bad.  So close to town we don't work,  farther out we have been on scene the entire time without the police so if he have a problem we may really have a problem.   and our coverage area is 60 miles from base east and west and 30 miles north (to the next state) and 45 miles south.  We have been on scene of a wreck got a patient out of truck, loaded and got halfway back to town, and passed the trooper on the way to the scene.  and when we get back to town then it is anywhere from 110-125 miles to the closest hospital.


----------

