expanded scope under physician??

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tooch

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Can someone answer this...As an EMT working in and emergency room, am I or anyone else allowed to work beyond our scope of practice as long as it is under direct supervision of an M.D.?? For example, we are certified to use an AED, but can we also use a difibulator overriding the AED ( using a LifePak) as long as the doctor is instructing and supervising us to do so? Your thoughts would be great. If anyone know of any links to this topic that pertain to Santa Clara County in California , that would be great.
 
I would not let anyone use any type of defibrillator AED or Manuel if they couldn't spell it correctly. If you are in the field of emergency medicine and cannot spell the name of such a critical piece of equipment, Im worried. :wacko:

To answer your question, if you are working (meaning on the payroll) for the hospital, in the ER, you are not bound to your state or county scope of practice, as it applies to field personnel. However, I am not aware of anywhere where ER techs can practice above the BLS level, granted a few exceptions. Perhaps if you are trusted by the nurses they may let you start an IV or two. In a cardiac arrest in the ER, usually the med students/residents and nurses preform the ALS of the code, and your role will be limited to compressions or bagging the patient.
 
Well, here where I am, even medics out in the field can perform advanced tasks such as a Pericardiocentesis and C-Section in the field under order and direction of the physician.
 
tooch said:
Can someone answer this...As an EMT working in and emergency room, am I or anyone else allowed to work beyond our scope of practice as long as it is under direct supervision of an M.D.?? For example, we are certified to use an AED, but can we also use a difibulator overriding the AED ( using a LifePak) as long as the doctor is instructing and supervising us to do so? Your thoughts would be great. If anyone know of any links to this topic that pertain to Santa Clara County in California , that would be great.
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Well, yes and no. Depending on the state, you may be authorized to perform anything your medical director allows (such as Texas). However, many hospitals will not allow it citing the "Nursing Practice Act". Again, your mileage will vary, but many NPA's prohibit unlicensed personnel from performing any invasive act while working within a healthcare facility.

With that in mind, there is no reason for you to need a manual defibrillator in the ER. First off, an AED will work just fine if needed for a cardiac arrest. Second, there are trained and licensed personnel who are present to use other needed equipment, no need for an EMT to be jumbling around with a monitor..................
 
When working in the hospital, your scope of practice is what ever the hospital wants you to do. This could mean you could do more simple procedures, like IV starts (provided you have a phlebotomy cert) as well as other things.
 
daedalus said:
,you are not bound to your state or county scope of practice, as it applies to field personnel.
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NOT true ! Remember who you certified or licensed through! As long as your job title is EMT then you are bound to those statutes of rules and policies, it does not matter if you are working in a mall or field or O.R. Remember, in negligence case you will be judged upon your education, and against your peer. If you are outside those realms, then you have placed yourself outside your certification level. When I worked for my State Department of Health, this was a common misconception that a lot of time was costly. Look at your card, who authority gave you such title?

Job Description is the key. If the hospital really wants you they will have a formal job description in detail of what you can & cannot do. If they want advanced procedures then they will hire advanced level EMT's. (Unless the law is written alike FlightLP described) They do not hire LPN/LVN's to perform RN level procedures the same principal.

Again, what makes us think were so special we are above the law?


Hastings said:
Well, here where I am, even medics out in the field can perform advanced tasks such as a Pericardiocentesis and C-Section in the field under order and direction of the physician.
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Want to bet? Were you trained and educated for that procedure? Look at previous court cases, where a physician guided C-sections were performed and medics lost their license and jobs.. even though the newborn lived.

Pericardiocentesis is not a field procedure. We used to do it all the time in the late 70's as well as intracardiac Epi.. no big deal but again, why? The risks is too dangerous as well most Paramedics fail to detect. I ask do you keep a pericardiocentesis tray available? Do you have alligator clips on your leads, so you can detect when you have entered the myocardium?.. Thought so. Again, the only reason it would be legal is it is a ACLS procedure for PEA.


JPINFV said:
When working in the hospital, your scope of practice is what ever the hospital wants you to do. This could mean you could do more simple procedures, like IV starts (provided you have a phlebotomy cert) as well as other things.
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Again, better check you local State EMS agency if you are calling yourself an EMT. Most states do not clarify between hospital or field. EMT is a EMT no matter where they work again similar to nurses have to have special consideration to intubate because it is not under their scope of practice as well to administer RSI. Which became a highly controversial debate that nurses were administering anesthesia.. finally most states have clarified such. Even EJ's may be prohibited by nurses in some states. Again on better be abreast of their local laws and State Statutes.


R/r 911
 
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So many EMTs still rely on their "EMT training" and "certification" when hired into a hospital job with its own job descriptions. Some hold themselves back from being able to take advantage of all of the "certs" and "training" a hospital can offer. If you get past the EMT mentality, the hospital can offer you a lot of opportunities. You'd be surprised what a Surigical Technician can do with a hospital OJT program. Or Ortho technician. Or HBO technician. You could even broaden your scope to PCT which can accumulate up to 700 hours of training. However, with just a certification, and not a license recognized within the walls of the hospital, you will be very limited when it comes to medications which may be off limits totally to you.

And then, some get themselves into trouble because they think they are still on an ambulance as an EMT or Paramedic and didn't read their job description for the job they were hired to do.

In many states, the EMT cert does not exist within the walls of the hospital. You get hired because they think you might be able to take a BP and be able to do CPR. In California, the ER tech jobs are usually advertised as "someone with experience as an EMT, MA or Paramedic". The hospital will build upon that basic training. Hospitals are also very much aware of what you can and can not do according to state law for THEIR job descriptions since those are up for review by JCAHO. Your job description may have nothing to do with you being an EMT or Paramedic except for basing it as previous medical experience for a few skills You will be taking orders from RNs, who will have the responsibility of supervising you. You will follow your job description and if a physician asks you to do something that is not on that job description, you will inform him/her of you job title.

Being a California Certified Phlebotomist is probably a bigger plus then the EMT certificate. In California that even allows you to do arterial puncture if your hospital also allows it under that job description. Again, holding a certification or even license in a profession does not always mean you will be allowed to function to the fullest practice your state's scope allows. That will be dependent on the employer and medical director.

So, know your jpb description and if you have any questions, ask your immediate supervisor.
 
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Very good points Vent.. just remember though, a job description does NOT exclude your license or certification level. In other words, you cannot work above or outside such and call your self an EMT, Paramedic, etc.. The state is still your authority, not your employer.

It is best they have created a title for you, than to use the EMS titles. In other words, an ER tech may perform a lot of procedures the EMT cannot, but they are not technically working as an EMT, they are a ER tech. Now, the job description maybe have that you had completed an EMT program, or be experienced but again, that is not going to be your job.

Scope of Practice it just that. Why have one, if you are not going to enforce it? That is what is meant by the term.. SCOPE of PRACTICE! Within your realms of education, training, and policies of your license, certification level, other wise it would be free reins.

This is crucial. I have persecuted and had EMT's prosecuted for working outside their level as an EMT in a hospital, field, etc.. no matter if a physician was ordering to do so. A license or cert level is just that a certification or license granted through the State's license or Governing body that person is competent to perform such procedures as established by that regulating body (I can sound like a bureaucrat can't I?).

Again, be very, very, very cautious on working anything that is not written within your scope, even if there is a job title. Contact your State or local authority to be sure for a clarification and have a written response. Trust me, I have see the ill effects of those that did not...

R/r 911
 
Your concerns are acknowledged Rid.

The OP did not post his job title. However, I do know that the hospitals in California are smart enough to know that the California counties regulate the EMTs' (and Paramedics) scopes and really wish not to get into that mess.

The hospital would actually be very foolish to use "EMT" for the job title since that could be very restrictive.

The hospital also reserves the right to train the "EMT" to perform additional skills to meet the job description. If relying only on the EMT training, they may be very limited and even useless in some EDs that rely on their technician help. The hospital could also furnish them with CNA or PCT training to which is another certification for them to work under which does allow expansion in job duties. There are various other certifications that one can obtain through the hospital that would not limit them.

I surfed Santa Clara Valley, Sutter and Kaiser hospitals in that area and their web job descriptions are:

Emergency Dept Technician I

EDUCATION: High School Diploma/GED

LICENSE/CERTIFICATION: CA Certified Phlebotomy Technician (CPT) if job requires blood drawing. BLS.

QUALIFICATIONS: CA Certified Phlebotomy Technician (if job requires blood drawing). Six months related experience as an Emergency Medical Technician, Certified Nursing Assistant, or Medical Assistant with certification as specified by the Medical Board of California, or equivalent (e.g. military experience) or, completion of an ED or UCC externship in an unlicensed assistive personnel externship or, completion of first semester of clinical course work in a nursing program.

DUTIES: Performs within the scope and training of the EDT, and consistent State/ Federal regulations including EMTALA, HIPAA and other applicable regulations, including patient confidentialit
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Source: Kaiser's Job page
 
Again, on the same page of things. As an ER Manager I employed Paramedics as "Emergency Department Medics".. not as Paramedics. Again, this would restrict them legally and some of their practices were "outside" that of a Paramedic.

One has to be very careful that it does not go too far though, JCAHO is very picky on how, what each job titles is entitled and worded as well what accreditation agency ensures that this person is qualified to perform such measures. In other words.. one has to be very picky. (I know Vent is already quite aware of JCAHO requirements).

There are accredited Paramedic/ ER programs such as in Ohio. This is a bridge course that teaches Paramedics to become a knowledgeable ER tech. Again, as you stated many may not realize you have many bosses. Once in the hospital setting you no longer have the autonomy that one was had in the field. Again, one is usually placed under nursing services, and hence nurses is over and responsible for you. I have yet seen any Paramedics that are placed under any other services that their main focus was in ER other than nursing services, again another JCAHO control.

Again, I cannot emphasize enough to be sure to get a ruling before expanding any license or cert responsibility without taking the formal license/cert level education/test.


R/r 911
 
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I'm not 100% on the legality or the ethics of it, but its fairly common practice at my local ER for EMTs to assist / perform a number of procedures they normally would not on the street.

IV starts, blood draws, discharge instructions, some low risk med administration, all fairly standard practice. Difference is that the RN signs off as "supervising."

It really works out well for such a small ER (10 beds). The EMTs don't do anything both the RNs / MD or they themselves are not comfortable with.
 
rmellish said:
I'm not 100% on the legality or the ethics of it, but its fairly common practice at my local ER for EMTs to assist / perform a number of procedures they normally would not on the street.

IV starts, blood draws, discharge instructions, some low risk med administration, all fairly standard practice. Difference is that the RN signs off as "supervising."

It really works out well for such a small ER (10 beds). The EMTs don't do anything both the RNs / MD or they themselves are not comfortable with.
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Does your state clarify that an RN can give orders or an EMT works under the control of a RN?

Again, what is done and what is legal is quite a different thing. Everything is okay, until someone messes up.. then one finds out what authority and control means. Alike I said, I used to work for a State Dept. of Health, and I can assure you many find out what ***ume means. Unfortunately, some RN's assume that EMT's are alike LPN's and Nurses Aide that can work under the RN license for supervisory guide. Again, most states DO NOT make such mention for EMT's in the Scope of Practice for nursing.

I am a firm believer of the saying .. if you were not taught it in class, tested over it for license, then chances are.. you are NOT supposed to be doing it. Now, that is not saying I have not continued on past my license levels in speciality courses and classes, expanding my practice.

Be very careful out there folks.. there are many tempting situations and well meaning health care professionals; but are they willing to loose their license for you? ...

R/r 911
 
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I wouldnt disagree with you Rid. I'm sure its not kosher with the state. I'm also not going to sit here and say something like "Thats how its always been done, it must be ok!" This is just an observation of local SOPs flawed as they may be.
 
Ridryder911 said:
Again, I cannot emphasize enough to be sure to get a ruling before expanding any license or cert responsibility without taking the formal license/cert level education/test.


R/r 911
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If the job is asking for "certification", they may just be asking for proof of training. If they are not requiring the license or a STATE certification card or putting in your job description specifically that you maintain certification/licensure in your state, then you may not be held to that certification.

The MA is a "training certificate" in some states and not recognized as a State Certification/Licensure. The same can also be with CNA in some areas.

Massage Therapists in California can take a weekend course and be "certified" which is recognized by the county they work in. In Florida and New York (and 30+ other states), the Massage Therapist may require up to 2000 hours of education (2 year degrees available) and application for state licensure. The Massage Therapist is very much a part of the healthcare team in many hospitals across the country also for those not familiar with them.

In the job description I posted, only the Phlebotomy cert and BLS, which is CPR in some hospital language, is required.

You can also ask directly if you are required to maintain your EMT certification. If the answer is no, you could let it lapse and go by the job title/description in the hospital where you will no longer have to worry about conflicts.

In the hospital as an RRT, I am not allowed to use EMT-P anywhere on my name tag or signature. It is not recognized and would be very limiting in my hospital practice which is dictated by my medical director under the scope of practice for RRTs. The EMT-P has a very limited scope of practice in the state which is specifically spelled out while the RRT is more open ended and left to the discretion of the medical director. I could see the confusion if someone saw me doing something with EMT-P on my tag as an RRT that was known not to be in the scope of practice for EMT-P. Whatever title and job description at whatever employer is the one that I will be following.
 
rmellish said:
I wouldnt disagree with you Rid. I'm sure its not kosher with the state. I'm also not going to sit here and say something like "Thats how its always been done, it must be ok!" This is just an observation of local SOPs flawed as they may be.
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I understand this. Alike many others, we all bend and stretch the rules more than they should.. I won't say anymore, just in case.. ;)
 
The hospitals should then consider only hiring CNAs, PCTs and MAs with Phlebotomy certifications as their unlicensed assistive personnel in the ED and leave the EMTs in the street.

They can easily have their job descriptions expanded within the guidelines of State, Federal and JCAHO mandates. They also know the hospital culture better and are accustomed to working with many different professionals.
 
Our hospital uses EMTs and Nursing students primarily as ERTs. The way the job description is written, and I couldn't find a copy but will keep looking, sets it up as a sort of glorified ward clerk. The work is primarily clerical in nature.

They want experience as an EMT or Nursing student, or CNA for the experience in dealing with patients and a basic understanding of medical terminology.

According to the head of our ED, an EMT cert in our state doesn't mean :censored: inside the doors of the hospital. It's a field cert only. They also refuse to allow their RNs to do ride alongs with the ambulances for the same reason. RN doesn't apply in the back of an ambulance.

This is why the Tech position is not called EMT, but ERT inside the ED. They do some patient lifting, can assist with the placement of monitors, perform CPR, and not much else. Our phlebotomists come from the hospital lab. Very few of the nurses even do the blood draws here.
 
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