Licensure/scope clarification

[OnceAnEMT]

This question is simply due to thinking too hard about things, but is a curiosity of mine. I understand that, generally, EMT/Paramedic schools allow you to sit for certification which then allows for testing/application for state licensure which seems to be the "golden ticket" to practicing. However, any and all practice requires "medical direction" of some sort. Even basic skills like trauma assessment and oxygen therapy are in that protocols book somewhere as standing orders. Everything we do is ordered one way or another. We are expected to know how to execute those orders, and that is where requirements for certification/licensure comes in.

So really, we are extensions of the physician, operating under their license with our own. So my question is, could a physician who trusted/taught/whatever someone the skills of an EMT/Paramedic (but the person does NOT have a certification) then allow that person to practice those skills in the field, under the physician's license, simply calling them "Physician Extenders" (a real title, mind you)?

Its a prying question that could be obviously answered by "but they wouldn't because of liability", but I'm just strictly interpreting the process.

 

[NomadicMedic]

Sure. They do it with MAs all the time. Paramedic and emt is just a convenient way to standardize the process.

 

[OnceAnEMT]

Sure. They do it with MAs all the time. Paramedic and emt is just a convenient way to standardize the process.

This is what I figured, I just wanted to make sure I had the right idea. I was thrown off by one of my AT (where once again everything is under medical direction) instructors saying certain treatment modalities couldn't be used "unless you had your AT or PT license" and I'm just thinking... what?

 

[NomadicMedic]

Texas is great example of this, even as a paramedic. If your medical director teaches you how to drill burr holes, and allows you to do it... get out the Dewalt.

 

[Carlos Danger]

It depends on the state. Some places a physician can authorize anyone to do anything as long as they are willing to take responsibility, others there are limits.

 

[OnceAnEMT]

It depends on the state. Some places a physician can authorize anyone to do anything as long as they are willing to take responsibility, others there are limits.

In the event that it is limited, how is this done? For example, does it state that intubation can only be authorized to be performed by specifically licensed individuals?

Thanks for the feedback guys, I appreciate it.

 

[RedAirplane]

In California, why don't medical directors authorize us to use pulse oximitery and glucose meters? Does the law prevent them from doing that, or are they just covering themselves?

 

[Ewok Jerky]

So really, we are extensions of the physician, operating under their license with our own. So my question is, could a physician who trusted/taught/whatever someone the skills of an EMT/Paramedic (but the person does NOT have a certification) then allow that person to practice those skills in the field, under the physician's license, simply calling them "Physician Extenders" (a real title, mind you)?

Its a prying question that could be obviously answered by "but they wouldn't because of liability", but I'm just strictly interpreting the process.

The person being trained would require some sort of license or certification. Joe Blow off the street can't just start performing procedures because Dr Smith said its OK. Even MAs have to be licensed (in Massachusetts anyways I don't know about all 50 states). Even then there are limits set by the state on what any one cert will allow an individual to do.

I'm not saying it doesn't happen, and that peeps don't practice beyond and their scope, but it ain't legal.

 

[DesertMedic66]

In California, why don't medical directors authorize us to use pulse oximitery and glucose meters? Does the law prevent them from doing that, or are they just covering themselves?

It depends on your county and your medical director. For my county EMTs can use SpO2 and check blood glucose.

 

[RedAirplane]

It depends on your county and your medical director. For my county EMTs can use SpO2 and check blood glucose.

One of the organizations I work with has its own medical direction separate from county because we work in many counties. The medical director said under California law he couldn't legally allow us to prick patients to get a blood glucose, but we have the meters if patients want to check themselves.

I'm not sure if such a state law actually exists, however.

 

[DesertMedic66]

One of the organizations I work with has its own medical direction separate from county because we work in many counties. The medical director said under California law he couldn't legally allow us to prick patients to get a blood glucose, but we have the meters if patients want to check themselves.

I'm not sure if such a state law actually exists, however.

For CA each company has to have their own medical director (some of the equipment we use can only be bought with a MD license or prescription) however the county medical director still decides the scope of practice for all employees who work in that county (event medicine, EMS, Fire).

Here is a link to the scope that CA has set for EMTs. LEMSA (county EMS agencies) can restrict what EMTs are allowed to do.

 

[Generic]

For CA each company has to have their own medical director (some of the equipment we use can only be bought with a MD license or prescription) however the county medical director still decides the scope of practice for all employees who work in that county (event medicine, EMS, Fire).

Desert is right but it goes even further then that. The medical director is still under obligation of the California EMS Authority and title 22 of the health and safety code. The medical director cannot go above and beyond basic and optional scope of practice as defined in title 22. If the medical director of the local EMS agency wants to add an out of scope medication or procedure, he/she would have to submit for a trial study and then go from there.

 

[Tigger]

This is what I figured, I just wanted to make sure I had the right idea. I was thrown off by one of my AT (where once again everything is under medical direction) instructors saying certain treatment modalities couldn't be used "unless you had your AT or PT license" and I'm just thinking... what?

When I was a student trainer our ATCs worked under their own licensure. There was state statute stating what they could do, and anything else required a "physician consult." Must be different state to state. Mind you the physician could allow the ATC to pretty much whatever they wanted, to include having the student trainers perform said procedures.

 

[epipusher]

Indiana allows MA's to work without a certification. Due to this the OP asks a very good question.

 

[OnceAnEMT]

When I was a student trainer our ATCs worked under their own licensure. There was state statute stating what they could do, and anything else required a "physician consult." Must be different state to state. Mind you the physician could allow the ATC to pretty much whatever they wanted, to include having the student trainers perform said procedures.

I'm just going by what we are told, which varies. And the literature we are assigned is all national stuff. ATC is the national cert, but LAT is the state licensure here. Same as NREMT vs EMT. And here I believe they do completely work under a physician, as even when I do contract work we have a medical director that is basically an ortho friend who signed. I could be wrong and there is an LAT scope, I just haven't seen the legislation regarding it.

Edit: Quick search found the answer for AT. Finding EMT was harder, will keep trying.

§871.2 Scope of Practice
(a) A licensed athletic trainer prevents, recognizes, assesses,
manages, treats, disposes of, and reconditions athletic injuries
and illnesses under the direction of a physician licensed in this
state or another qualified, licensed health professional who is
authorized to refer for health care services within the scope of
the person's license. An athlete is a person who participates in
an organized sport or sport-related exercise or activity,
including interscholastic, intercollegiate, intramural,
semiprofessional, and professional sports activities.
(b) The activities listed in subsection (c)(1)-(7) of this section
may be performed in any setting authorized by a licensed
physician and may include, but not be limited to, an
educational institution, professional or amateur athletic
organization, an athletic facility, or a health care facility.
(c) Services provided by a licensed athletic trainer may
include, but are not limited to:
(1) planning and implementing a comprehensive athletic
injury and illness prevention program;
(2) conducting an initial assessment of an athlete's injury or
illness and formulating an impression of the injury or illness in
order to provide emergency or continued care and referral to a
physician for definitive diagnosis and treatment, if appropriate;
(3) administering first aid and emergency care for acute
athletic injuries and illnesses;
(4) coordinating, planning, and implementing a
comprehensive rehabilitation program for athletic injuries;
(5) coordinating, planning, and supervising all administrative
components of an athletic training or sports medicine program;
(6) providing health care information and counseling athletes;
and
(7) conducting research and providing instruction on subject
matter related to athletic training or sports medicine.

https://www.dshs.state.tx.us/at/pdf/AT-Rules-Dec-2014.pdf

So, ATs are completely dependent on medical direction, on every single thing. Technically the scope of practice is anything that a physician authorizes. But doesn't that kind of nullify the concept of "scope of practice"? Or I suppose here one can't look at scope of practice at such a board level (EMT, AT, etc), but must look at it more specifically (EMT-B for ATCEMS, AT under Dr. Bill Bob, etc).

 

[Akulahawk]

I'm just going by what we are told, which varies. And the literature we are assigned is all national stuff. ATC is the national cert, but LAT is the state licensure here. Same as NREMT vs EMT. And here I believe they do completely work under a physician, as even when I do contract work we have a medical director that is basically an ortho friend who signed. I could be wrong and there is an LAT scope, I just haven't seen the legislation regarding it.

Edit: Quick search found the answer for AT. Finding EMT was harder, will keep trying.

https://www.dshs.state.tx.us/at/pdf/AT-Rules-Dec-2014.pdf

So, ATs are completely dependent on medical direction, on every single thing. Technically the scope of practice is anything that a physician authorizes. But doesn't that kind of nullify the concept of "scope of practice"? Or I suppose here one can't look at scope of practice at such a board level (EMT, AT, etc), but must look at it more specifically (EMT-B for ATCEMS, AT under Dr. Bill Bob, etc).

An AT's scope of practice is pretty much what the physician will authorize, within the limits of the law/regulations. EMT and Paramedic aren't any different. They all can perform basic first aid without medical direction but if care above that level is needed, then physician oversight (in some way, even if indirect) is required. While assessment skills aren't usually restricted, it certainly would have been odd for me to roll into an ED, as an EMT or Paramedic, with an athlete and give a report that includes some physical exam findings that aren't typically taught to pre-hospital personnel.

For EMT, usually there'll be something similar to what you found. In most states, you'll find a similar deal for Paramedics too. Texas is odd in that they allow medical directors to set the scope of practice for their area. It can be incredibly wide or very restrictive. When that happens, just be very certain that you know exactly what you're allowed and not allowed to do.

In California, pre-hospital scope is pretty well explained in Title 22 and (when I last checked) doesn't include AT's because they're not certified/licensed by the State. Another odd situation with California to be sure.

 

[TheLocalMedic]

In California, why don't medical directors authorize us to use pulse oximitery and glucose meters? Does the law prevent them from doing that, or are they just covering themselves?

I know exactly why those things are (sometimes) restricted to EMTs...

Pulse ox: Because all too often EMTs (and even medics) get hung up on the numbers and forget to look at the patient. "Oh my God! His sat is 60%!"....... and the person is sitting there perfectly fine with a complaint of ankle pain and just has cold hands. I worked in a rural area where a BLS service (which now is under review to see if their ability to use pulse ox should be taken away) would frequently request an ALS unit code 3 to rendezvous with them because of a low sat reading only to find that they weren't using the device correctly or the person was wearing nail polish or had cold hands. I cannot express how ridiculous that is. On more than one occasion I threatened to take their machines away myself.

Blood glucose: This one's a two-parter.... First, some areas believe that technically because you're pricking their finger that checking a BG is an "invasive procedure". I know that's silly, but that's generally what they say, so EMTs aren't allowed to do it. Secondly there's this quandary: If you check their sugar and it's abnormal, what can an EMT do about it? A basic EMT (in California) can't start an IV to give dextrose or give glucagon, so knowing for certain that you're dealing with a sugar issue doesn't really change your care. Besides, if a patient is altered, then ALS should be requested anyhow, and they'll have a glucometer.

Now, on to the bigger question: SHOULD EMTs be allowed to do these things? YES. But they just need to be taught how to do them appropriately and given the tools (i.e. glucagon) to be successful. Unfortunately we have to teach to the lowest common denominator and until we are willing to raise the EMT bar to something more than just a glorified first aid attendant I don't see California broadly changing what's in the current EMT scope.

 

[PotatoMedic]

Blood glucose: This one's a two-parter.... First, some areas believe that technically because you're pricking their finger that checking a BG is an "invasive procedure". I know that's silly, but that's generally what they say, so EMTs aren't allowed to do it. Secondly there's this quandary: If you check their sugar and it's abnormal, what can an EMT do about it? A basic EMT (in California) can't start an IV to give dextrose or give glucagon, so knowing for certain that you're dealing with a sugar issue doesn't really change your care. Besides, if a patient is altered, then ALS should be requested anyhow, and they'll have a glucometer.

True an EMT cannot start and IV or give the dextrose or glucagon. But if the PT is altered and able to swallow and I can check BGL and I find it low. I (in Washington) can give oral glucose. I don't have enough fingers or toes to be able to count how many hypoglycemic pt's I have left a PT at home after giving oral glucose where all the medics did was stand in the hallway and say, "we're out!"

 

[TheLocalMedic]

True an EMT cannot start and IV or give the dextrose or glucagon. But if the PT is altered and able to swallow and I can check BGL and I find it low. I (in Washington) can give oral glucose. I don't have enough fingers or toes to be able to count how many hypoglycemic pt's I have left a PT at home after giving oral glucose where all the medics did was stand in the hallway and say, "we're out!"

We carry oral glucose and it works just fine. Typically though, if someone is able to swallow they'll also be able to tell you if they're a diabetic, even if they're getting loopy from low sugar. Or someone else can confirm it. If someone is altered with a history of diabetes, it's generally a pretty solid bet that their sugar is low, so EMTs are always encouraged to give oral glucose in those situations.