Medical Director / Licensure

RedAirplane

RedAirplane

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This is a question just out of curiosity.

What is the role of state licensure of an EMT/Paramedic if an MD has to be overseeing the operation, and anyone acting under the MD does so under the MD's orders?

As an example, in many places throughout the country, Red Cross does first aid stations with personnel trained to the EMR level. In most places, EMR is not a state-recognized EMS license, so it is a certificate issued by Red Cross. Similarly, my understanding for camps etc is that the "nurse" has some sort of first aid training and a medical director, but may or may not actually have some sort of state-issued license. The Medical Director approves protocols and such, but as far as the state is concerned, the people practicing under those protocols aren't carrying any sort of state license.

So... where did the business about EMT licenses come from? Does it have to do with the fact that they are transporting patients? If I am a medical director opening an operation, why would I choose to hire licensed EMTs instead of just people I know and teaching them how to practice medicine?
 
It's more complicated than that. Delegation is handled differently in each state as is the provision of emergency services. But in general, just because in a broad sense a physician can delegate his practice of medicine to others, doesn't mean he can have anybody do anything willy-nilly. That's why a nurse can push a drug under an order, but you can't very reasonably sign a order for the nurse saying "Transplant this dude's heart and then take care of him, I'm going home." They wouldn't because they're not qualified for it, it's not in their own scope of practice, and you'd be wrong to try and make them.

It all varies. My understanding is that in Texas they don't really have any state protocols or scope other than whatever each medical director determines for their service. (That's certainly not the case elsewhere.) But even there, do you think a medical director would be wrong to say, "Okay, tomorrow we're all going to start doing brain surgery in the field!" If you think about the various levels on which that would be (appropriately) resisted, you'll get an idea for how these things play out.

(not a lawyer)
 
Brandon O said:
It's more complicated than that. Delegation is handled differently in each state as is the provision of emergency services. But in general, just because in a broad sense a physician can delegate his practice of medicine to others, doesn't mean he can have anybody do anything willy-nilly. That's why a nurse can push a drug under an order, but you can't very reasonably sign a order for the nurse saying "Transplant this dude's heart and then take care of him, I'm going home." They wouldn't because they're not qualified for it, it's not in their own scope of practice, and you'd be wrong to try and make them.

It all varies. My understanding is that in Texas they don't really have any state protocols or scope other than whatever each medical director determines for their service. (That's certainly not the case elsewhere.) But even there, do you think a medical director would be wrong to say, "Okay, tomorrow we're all going to start doing brain surgery in the field!" If you think about the various levels on which that would be (appropriately) resisted, you'll get an idea for how these things play out.

(not a lawyer)
Click to expand...

Correct in saying the Medical Directors here calls the shots. Still waiting on the brain surgery protocol though...
 
Interesting. Back in my first responder training, I was told that if Dr. ABCDE (our medical director) gave me emergency phone instructions on how to do some sort of surgery with makeshift tools, I should do it UNLESS I believed him to no longer sound of mind.
 
Well, maybe you should. But don't expect you won't hear about it. Do you know the sordid story of the field C-section?
 
Brandon O said:
Well, maybe you should. But don't expect you won't hear about it. Do you know the sordid story of the field C-section?
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No I don't. A quick google search makes it seem someone got in trouble for something?
 
Every state that I've worked in has specifically prevented me from doing anything outside my scope. I can deviate from protocols with MD order but not practice above my scope.

For example: I CAN administer glucagon for esophageal relaxation, but I CANNOT perform a surgical procedure.
 
RedAirplane said:
No I don't. A quick google search makes it seem someone got in trouble for something?
Click to expand...

So this is from 1997 in North Bergen, New Jersey.

A dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

What's the lesson here? Well, I don't know, maybe there isn't one. But I can take a stab at a few:

1. Rarely is it as simple as "right" or "wrong." In any question of scope of practice there may be numerous parties with an opinion, with the ability to enforce their opinion in various ways.

2. If you are under the direction of a physician you may not be in violation of any laws regarding the illegal practice of medicine. However, you may still hear that...
- Your service doesn't want you doing that and can fire you.
- Your state EMS board doesn't want you doing that and can pull your license.
- Somebody's going to sue you.

3. You can argue with any of the above, but would probably rather not.

4. Doing something you're not comfortable, trained, or qualified to do may be a bad idea for reasons other than being illegal.
 
I am certainly not a lawyer and all of this will depend on many things. But to bring it back to your original point, why would it make very little sense for a medical director to enable a bunch of random people off the street to take care of sick people?

1. It would be dumb for him, since he will be (on some level) responsible for them killing people.

2. It would be dumb for them, since they will be killing people.

3. Any company hiring these people or board overseeing them will presumably want nothing to do with this.

And so forth. None of this, you'll notice, has much to do with the legal matter of delegating care.

(Note that when you go to the doctor's office, the nurse draws your blood under the doctor's orders, but that doesn't mean they could have just as easily had the secretary do it.)
 
Brandon O said:
I am certainly not a lawyer and all of this will depend on many things. But to bring it back to your original point, why would it make very little sense for a medical director to enable a bunch of random people off the street to take care of sick people?

1. It would be dumb for him, since he will be (on some level) responsible for them killing people.

2. It would be dumb for them, since they will be killing people.

3. Any company hiring these people or board overseeing them will presumably want nothing to do with this.

And so forth. None of this, you'll notice, has much to do with the legal matter of delegating care.

(Note that when you go to the doctor's office, the nurse draws your blood under the doctor's orders, but that doesn't mean they could have just as easily had the secretary do it.)
Click to expand...

Makes sense.

I just wasn't sure what the deal with the state license was. With EMR or CPR or First Aid, its a card printed by the teacher of the class essentially. And for those first aid tents, the medical director is apparently happy with that. But to do work on an ambulance... yes, you have a MD, but before that, you have to get fingerprinted by the state etc. What's the magic dotted line that thrusts EMTs and higher into needing so much more vetting?
 
In most states EMR and CPR/First Aid actually falls under the good samaritan law. Each state good samaritan law is different from the next, But "offer legal protection to people who give reasonable assistance to those who are, or who they believe to be, injured, ill, in peril, or otherwise incapacitated" (Wiki cause it was the first google search) Now some states include EMS into this, other states do not. I have never been in a state where EMS falls under the this.

Each state is different when it comes to the practice of EMS, and Nurses.

Now to your original question about hiring someone who is already an EMT vs Training them. Most of the time when you are running an Event, Camp, ext you have some sort of Liability Insurance for the Event. The Insurance company usually determines what they want or states if you have this type of medical care on site than you pay XYZ vs this level of care you pay HKJ. Also, depending on the location and how many people you have on site there are county/state regulations for "Mass Gatherings" which can also determine what is required to be on site for Medical coverage.

The Vetting thing, this also changes from state to state. I have worked in States that require Finger Prints and back ground check through DHS and other states that say it is the responsibility of the Agency you work for. The reason is for EMT and Above you are working 911 and you automatically have to have the trust of the citizens of which you are responding too because you are gaining access to peoples home, and the citizens have no way to determine in the emergency if you are a sex offender, have a criminal back ground, ext. This also puts the company at a high liability if you are a sex offender lets say and you were hired by ABC EMS and you walk into a home and you sexually assault a patient. That patient reports it and a criminal investigation is launched and they find out that you are a sex offender, now the company can also be liable for your actions because they did not protect you by determining if the provider is a risk or not.

(I am also not a layer so some of my wordage may not be correct in legal world)
 
A physician cannot give you an order that violates state law. A physician's delegatory authority is limited in each state by statute and/or board of medicine regulations, but in general, they can only delegate a medical act to a person who has adequate training to perform that act. A physician can give an order to a paramedic to intubate someone, knowing that the paramedic has been trained in this activity - but to tell them to do a C-Section would be an illegal delegation of authority since that would not be an act that a paramedic is trained to do. A physician can direct a surgical assistant in surgery to assist with his surgery (they do a surprising amount in some places) but that assistant can't do surgery on their own. In states where AAs such as myself can practice under delegatory authority rather than licensure, the activities we do are all things we are trained to do. That anesthesiologist could not delegate those same acts to their office medical assistant.
 
RedAirplane said:
such, but as far as the state is concerned, the people practicing under those protocols aren't carrying any sort of state license.

So... where did the business about EMT licenses come from? Does it have to do with the fact that they are transporting patients? If I am a medical director opening an operation, why would I choose to hire licensed EMTs instead of just people I know and teaching them how to practice medicine?
Click to expand...
It is much easier to determine someone's competency as a provider if that competency has already been vetted by an organization. Even if state law allowed non-licensed individuals to perform prehospital care, why would a medical director want to go through the process of vetting all competencies himself?
 
Tigger said:
It is much easier to determine someone's competency as a provider if that competency has already been vetted by an organization. Even if state law allowed non-licensed individuals to perform prehospital care, why would a medical director want to go through the process of vetting all competencies himself?
Click to expand...

Not saying they should, I like the idea of having some sort of uniform standard, but was curious as to where the arbitrary demarcation in the law came from.
 
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