Medical Control - How Far is Too Far?

[WuLabsWuTecH]

So here's an interesting question I've pondered for a month or so now.

Everyone knows that you have to follow the offline (written) medical control, but that you can ask for online medical control to do things that may not be normally authorized. When working in a hospital setting (versus a prehospital setting) how do you feel this changes for you?

EMTs were not designed with the hospital setting in mind, but most states have written their protocols taking into consideration only the prehospital environment. I know it is common at a lot of hospitals to have Basics doing blood draws, but what happens when it gets even more advanced? When is too much, too much?

I bring this up for a couple of reasons. 1st, I was asked to assist on placement of an NG tube, something that is way out of the scope of my practices as a Basic (not in Medic school, but I am premed going for a degree in Biomedical Engineering). The Doc was standing over me and asked me to assist the nurse. When I told him I had no idea what I was doing, he told me it was ok, and that he would teach me so a) I could learn, and b) in the future I could do one during a workup while he was still there but doing something else. Medical control doesn't get anymore online than this (with the doc 2 feet away literally having his hand on your shoulder). The second was asking me to help with a pericentesis. This is obviously a sterile procedure so I was doing more of just handing equipment and changing bottles and manipulating tubes to get a good flow, but it is still completely outside the scope of my practice. Finally, a paramedic student I know was asked to make an incision for a chest tube.

Which all leaves me wondering, is this normal? I just started working in the hospital environment as an EMT (i've only done prehospital settings before) so perhaps this is not so strange as both hospitals I work at have similar settings. Then again, the doctors just might not know what we are capable of (I have had a doc ask me, "Do Basics know how to take a set of vitals? Actually I just need a blood pressure and I can show you if you don't know how.")

I know that this may vary based on state and setting (urban vs rural, etc) but I just want some other people's thoughts on this. Something just seemed a little strange to me at first, although none of the other EMTs I talked to found it strange.

Oh, one last thing. Medical control is only valid if the MD has a license right? For example, 1st year residents/interns have an MD but no license to practice. In that case, they would not count as medical control and I could not in fact perform something out of my standing orders based on their orders correct? It's the license that matters, not the degree?

Thanks!

 

[JPINFV]

EMTs were not designed with the hospital setting in mind, but most states have written their protocols taking into consideration only the prehospital environment. I know it is common at a lot of hospitals to have Basics doing blood draws, but what happens when it gets even more advanced? When is too much, too much?

In most states, EMT-B protocols and scope of practice is limited to the prehosptial environment. When working in the hospital, your scope of practice and standing orders are what ever the hospital unit's medical director and nursing staff wants you to do. In the states that limits EMT-Bs to the prehospital environment only, hospitals just call them by a different name. If they want you to assist with a procedure, provided that you feel comfortable, in most cases they can. For example, I wouldn't fret over assisting with an NG tube placement provided you are comfortable assisting and have been told/taught what to do.

Oh, one last thing. Medical control is only valid if the MD has a license right? For example, 1st year residents/interns have an MD but no license to practice. In that case, they would not count as medical control and I could not in fact perform something out of my standing orders based on their orders correct? It's the license that matters, not the degree?

Thanks!

PGY 1s in most states have a restricted license to practice medicine at their training program. Yes, they can oversee you. If anything, I imagine it's the MS-4s on a sub-internship that would be more questionable, but they're going to have a shorter leash than a PGY-1 anyways. Yes, it's the license, not the degree, that matters.

 

[VentMedic]

Our ER Techs who happen to have an EMT-B cert do not work under the scope of an EMT-B in the hospital. The hospital designs their job description and will train them within the guidelines of what is acceptable for non-licensed personnel who may also obtain additional certs such as phlebotomy and CNA. This is to the ER Tech's advantage because if they worked just as an EMT-B, they would be practically useless in a hospital for many patient care situations.

Now as far as the Paramedic student doing some invasive procedures, if he is functioning as a student of a school, not as an employee, and if that invasive procedure is not covered in any liability agreement between the hospital and the school, that can be a big problem. Privileges are lost for both schools and physicians by those that extend more than they should.

 

[alphatrauma]

Use Caution

In my experience, I have found that far too many ER docs have no clue as to what is in the scope of the technical staff (more specifically ER techs). If you are working in an ED, you had best know what is in your job description and what is not. Attendings/Residents will ask whoever is closest to them, to do whatever they need, at that given time. If you perform a task/skill that is not in your job description, "Dr so and so told me to do it" will not save you.

 

[Shishkabob]

If a doctor is willing to take his time and teach you something out of your normal scope, go for it!


I had doctors asking if I wanted to start IVs at my EMT clinicals.

 

[medicdan]

Medical Control pre-hospitably does have it's limits, as we learned just about 13 years ago with the NJ paramedics ordered to perform a c-section in the field with direction from medical control. If interested, check out NYT from Sept 27, 1997.

Essentially, a 37 year old female went into cardiac arrest while giving birth (the fetus was in the birth canal). After BLS personnel attempted resus, ALS arrived, and with consultation/direction from medical control, performed a field c-section, to save the baby. As I understand it, the baby came out in cardiac arrest, but was revived.
My understanding is that both the paramedics and the physician were heavily sanctioned, and I think the paramedics lost their certifications.

I will admit, however, I have benefited from proactive medical control in the field. While working in Israel (and on a truck that is always staffed by an MD and Paramedic), I was allowed to perform some procedures outside of my scope of practice, with the physician standing over my shoulder. Note that this is outside of the US, and the physician was on scene, directing me while visualizing my actions.

 

[Shishkabob]

Medical Control pre-hospitably does have it's limits, as we learned just about 13 years ago with the NJ paramedics ordered to perform a c-section in the field with direction from medical control.

Totally state dependent on what is and is not allowed. Here in Texas if my med control wants me to do a procedure... ANY procedure, in the field, they train me on it, and I do it under their license, it's all fair game, be it a c-section, pericardiocentesis, or any other number of things.

 

[MrBrown]

I think the old world model of physicans overseeing Paramedic care is long past due.

While legislative (and in some parts, educational) inadequacies drive such a model around the world I do not feel it is required.

Our clinical procedures are designed by a panel of emergency physicians and in the UK and Australia they have a multi disclipinary panel of trauma, paeds, emerg etc to do this but in these nations there is no online medical control and no requirements to contact a doctor to obtain authorisation to provide treatment.

In NZ ambo's do not have to speak to a doctor to obtain permission for any procedures although we do have a system where we can speak with the hospital and consult with them about which destination is most appropriate if we have a choice, most ambo's do not and they have one choice only except in the Auckland District.

Legally we must have an instrument of delegation from a physician to carry and administer all of our drugs as they are prescription only and until ambo's here become registered healthcare practitioners like in most other countries they will require a doctor's delegation to give these drugs. When that happens we will not.

 

[medicdan]

Totally state dependent on what is and is not allowed. Here in Texas if my med control wants me to do a procedure... ANY procedure, in the field, they train me on it, and I do it under their license, it's all fair game, be it a c-section, pericardiocentesis, or any other number of things.

Of course, as everything else in EMS, its regionally specific. What was important here was that the paramedics had no prior training in that procedure-- they were directed on it for the first time while on scene.

 

[DrParasite]

I think the old world model of physicans overseeing Paramedic care is long past due.

While legislative (and in some parts, educational) inadequacies drive such a model around the world I do not feel it is required.

that's great. you happen to be wrong but you are entitled to your opinion.

in the US, everything a medic does needs to be approved by a doctor. Every drug that a paramedic gives has to be approved by a doctor. Every procedure that a medic does has to be aproved by a doctor. If a medic wants to do something that is not in the preapproved orders, he or she can ask to do it, but the doctor can refuse to allow it.

historically, a paramedic has been a highly skilled lowly educated extension of the ER. they can do a lot with often no more than 3 months of training. that's how medics started.

There are some really smart medics out there, as well as some very educated ones. but it's still an associates degree program (if that), and when you compare the education of a medic to an MD, you see the medic falls well short.

There is one advantage to always having to be under a doc. the liability insurance that each medic has is significantly less, as much of the burden can be pushed off on the doc

 

[medicdan]

that's great. you happen to be wrong but you are entitled to your opinion.

in the US, everything a medic does needs to be approved by a doctor. Every drug that a paramedic gives has to be approved by a doctor. Every procedure that a medic does has to be aproved by a doctor. If a medic wants to do something that is not in the preapproved orders, he or she can ask to do it, but the doctor can refuse to allow it.

historically, a paramedic has been a highly skilled lowly educated extension of the ER. they can do a lot with often no more than 3 months of training. that's how medics started.

There are some really smart medics out there, as well as some very educated ones. but it's still an associates degree program (if that), and when you compare the education of a medic to an MD, you see the medic falls well short.

There is one advantage to always having to be under a doc. the liability insurance that each medic has is significantly less, as much of the burden can be pushed off on the doc

Why can't we consider moving towards the system utilized by English Paramedics (CoEMS aside). Their paramedics are all educated at degree-earning programs, and like nurses, PAs, etc. are registered with the government. With their increased education comes an autonomy that allows them to act independently within protocols for the region.
If you want to be allowed to perform pre-hospital C-sections, or whatever, you need to be educated, there is no way around it.

 

[MrBrown]

in the US, everything a medic does needs to be approved by a doctor ....there is one advantage to always having to be under a doc. the liability insurance that each medic has is significantly less, as much of the burden can be pushed off on the doc

So if you screw up and kill somebody, why blame somebody else?

 

[Melclin]

in the US, everything a medic does needs to be approved by a doctor. Every drug that a paramedic gives has to be approved by a doctor. Every procedure that a medic does has to be aproved by a doctor. If a medic wants to do something that is not in the preapproved orders, he or she can ask to do it, but the doctor can refuse to allow it.

historically, a paramedic has been a highly skilled lowly educated extension of the ER. they can do a lot with often no more than 3 months of training. that's how medics started.

There are some really smart medics out there, as well as some very educated ones. but it's still an associates degree program (if that), and when you compare the education of a medic to an MD, you see the medic falls well short.

Yes that's ENTIRELY the point. That system is archaic and its just absurd for ambulance personnel to be practicing at those levels without good education. Many places in America clearly need to have their hands held by MD's because of their education levels. But hey whats the point in all that education stuff...I'm sure its fine to be making clinical judgments like this:

 

[VentMedic]

Totally state dependent on what is and is not allowed. Here in Texas if my med control wants me to do a procedure... ANY procedure, in the field, they train me on it, and I do it under their license, it's all fair game, be it a c-section, pericardiocentesis, or any other number of things.

That is YOUR medical director training you. It is not a random ED doctor who might even be a rent-a-doc and not regular staff who over extends the liability agreement with the hospital. If you also knowingly do something not within your scope or something agreed upon without prior permission from your school, as it was mentioned this was a student, paramedic or from your supervisor AND medical director, you also will held personally accountable.

 

[Scout]

that's great. you happen to be wrong but you are entitled to your opinion.

So why bother with training if you get no autonomy.... You are then just an operator or technician.. Maybe a 4 year degree, Master or PHD in PreHospital Emergency care might allow you to practice as a professional.

It is hard to argue that direct supervision and step by step procedures are progressive and education is archaic

 

[Jeremy89]

As a tech in an ED, we are trained with additional skills by the hospital. These include blood draws (soon to be IV insertion/care), EKG's, wound, ear, and eye irrigation, foley catheters, (pending approval) transport of stable tele pt's, and we can assist with basically any procedure we do in the ED. Because of the fact that some techs are CNA's, our scope is limited. I was just thinking about this the other day:

If a pt goes into respiratory arrest, I can suction/ start bagging, and perform basic airway management. But would a tech who is a CNA know how to do the same thing? Not likely.

During codes, I've been asked by nurses to grab an Epi and prep the pre-filled syringe. I've gotten scolded for it by other nurses because "if they gave the wrong med because I handed it to them...", well I said its their responsibility to check the med, which I would do as a nurse- even in a code. I asked our educator the other day, and he said it was a gray area. Basically if the wrong med was given it would fall on both of us- me for getting the wrong one, and the RN for not checking it.
So I can give 0.3mg of Epi for anaphylaxis, but I'm not "competent" to get epi out of the code cart. I understand the concept, but it just seems a little ridiculous to me.

I know County hospital here has a tech position where they can practice ACLS skills. That's definitely something that could be good or bad.

I'm technically not allowed to flush saline into an IV line. Have I done it? possibly... :unsure:
I was assisting a doctor in putting in a central line. She asked me to hook up the flushes and draw back to check for blood, then flush them in. She knew I was a tech, but since she was supervising me, I assumed any liability would have fallen on her.

Just a couple of scenarios from someone in a hospital

Jeremy

 

[VentMedic]

If a pt goes into respiratory arrest, I can suction/ start bagging, and perform basic airway management. But would a tech who is a CNA know how to do the same thing? Not likely.

You have seem to have a dislike for CNAs. Jealous? Many spend more hours training and eeducating for patient care and don't just base their worth on one or two skills. Most CNAs are there to clear up the vomit and clear an airway as well as knowing basic CPR. Believe it or not but a lay person can be trained to use a BVM. The CNA can easily be taught the few skills of an EMT and they have mastered skills that few EMTs have and that includes taking vitals and communication with the patient and other professionals.

So I can give 0.3mg of Epi for anaphylaxis, but I'm not "competent" to get epi out of the code cart. I understand the concept, but it just seems a little ridiculous to me.

What hospital is allowing you to give Epi?

I know County hospital here has a tech position where they can practice ACLS skills. That's definitely something that could be good or bad.

ACLS skills?

I'm technically not allowed to flush saline into an IV line. Have I done it? possibly... :unsure:
I was assisting a doctor in putting in a central line. She asked me to hook up the flushes and draw back to check for blood, then flush them in. She knew I was a tech, but since she was supervising me, I assumed any liability would have fallen on her.

You need to discuss your job description with your supervisor and don't assume anything. While this may be acceptable, it is good to know what your limits are. Doctors do not have time to review the job descriptions of every technician they meet.

Just a couple of scenarios from someone in a hospital

Jeremy

Never bash someone unless you actually know what their training is or have worked as one. I do work with some incredible CNAs and wouldn't trade any of them for a 3 for 1 sale on EMTs. They understand the basic needs of the patient which 98% of the time is more useful than knowing how to pick up a BVM.

 

[Jeremy89]

Never bash someone unless you actually know what their training is or have worked as one. I do work with some incredible CNAs and wouldn't trade any of them for a 3 for 1 sale on EMTs. They understand the basic needs of the patient which 98% of the time is more useful than knowing how to pick up a BVM.

RE: Epi

in the form of an epi auto-injector. It still requires us to verify the med, pt, dose and route...

Re: CNA's
I may have been a bit rough on them, but the ones on the floors at my hospital really make me wonder sometimes. I watched what one did during a code once. He didn't do any compressions or anything but rather stood there with a vitals machine trying to get a blood pressure the whole time. There is an "auto" button on those... But anyways, I would trust an NA who's been in the ED awhile over a newly certified EMT (in most cases)

Re: central lines and MD's
She clearly knew I'd never done it before, but still had me do it while the RN stood there and watched me.

Re: ACLS
Basic knowledge of code drugs and the ability to push them, as well as identification of lethal rhythm's and their treatments.

 

[VentMedic]

Re: ACLS
Basic knowledge of code drugs and the ability to push them, as well as identification of lethal rhythm's and their treatments.

What is their exact title?


Yes, there are some that have been approved but that depends on whether the Paramedic cert can be recognized in the hospital. Some states wanted EMS to be so unique that they limited the Paramedic with the wording "prehospital" in their statutes for scope and definition.

 

[Jeremy89]

What is their exact title?


Yes, there are some that have been approved but that depends on whether the Paramedic cert can be recognized in the hospital. Some states wanted EMS to be so unique that they limited the Paramedic with the wording "prehospital" in their statutes for scope and definition.

Honestly I'm not sure. I ran into a guy from my EMT class and we were talking. His medic partner told me about it the other day.