scope of practice and diabetes

[yay4stress]

Are EMT-Bs allowed to check blood glucose in PA? I work on ALS trucks, so if I do it, I do it under the supervision and instruction of a paramedic anyway. But it seems like since we can administer oral glucose with an order from command we should be allowed to check it if we have the glucometers....

We weren't taught how to check it during our class, but we also weren't taught how to administer anything other than oxygen - even what is in our scope. I vaguely remember the instructor saying something about how it involves sharps and such so we couldn't be taught it in class.

I guess the upshot after all this rambling is that if I end up on a BLS truck, am I going to have to rely on a pt to take it themselves before I get there or can I take my own reading?

 

[John E]

Isn't there a Pennsylvania state office or dept. of EMS that you can check with to get that sort of information? And wouldn't you be better off getting it from the office that governs that sort of thing?

John E.

 

[Ridryder911]

Okay, this bothers me. First an employee not knowing their scope or limits or even really their job. I have to admit, I like EMS forums, but would I ask anyone here about my local policies?

As well, as described get it straight from the authorities mouth... better yet in writing. Also, ever considered asking your education or supervisor/administrator?

Chances are if you were not taught, you may not be allowed.. albeit, most EMT training sucks, so one can not assume.

Contact your officials, and any other specific questions regarding your certifications and license needs to be addressed by your official representatives.

Good luck!

R/r 911

 

[BossyCow]

Chances are if you were not taught, you may not be allowed.. albeit, most EMT training sucks, so one can not assume.

Rid is sooo right here. Whether or not the protocols of a system will allow a skill, you can't do it without being properly trained in it. So, just because a skill is considered a BLS skill doesn't mean you stick a sharps in the hands of anyone with a cert and let them turn some poor diabetic into a pin cushion.

We are mandated by our ER and our MPD to do glucose checks on every pt we bring into the ER. I've had to justify it once when I brought in a Fx ankle without one. "Could have fallen because of bloodsugar issues" was the justification. But, that doesn't mean that all the EMTs are allowed to perform them. We have a specfic program designed by our MPD that they must take before they start doing the tests.

 

[mikeylikesit]

yeah but there is no harm i checking BS readings. change your lancet if thats the type that oyur using each time and your good. the coding issue shouldn't affect you too much but it does make a difference between 85 mg/dl as opposed to uncoded which could read 85-615 mg/dl. most of the field lancets are one time users, they self retract like epi pens and you just throw them in the sharps container.

 

[BossyCow]

yeah but there is no harm i checking BS readings. change your lancet if thats the type that oyur using each time and your good. the coding issue shouldn't affect you too much but it does make a difference between 85 mg/dl as opposed to uncoded which could read 85-615 mg/dl. most of the field lancets are one time users, they self retract like epi pens and you just throw them in the sharps container.

Ya know Mikey... I bet you learned all that in your class/training on the skill!

 

[Ridryder911]

yeah but there is no harm i checking BS readings. change your lancet if thats the type that oyur using each time and your good. the coding issue shouldn't affect you too much but it does make a difference between 85 mg/dl as opposed to uncoded which could read 85-615 mg/dl. most of the field lancets are one time users, they self retract like epi pens and you just throw them in the sharps container.

Actually there is harm. First it is considered an invasive procedure and unless licensed or certified, one cannot as an EMT but can as a civillian. As well, it is a "procedure" surely, not everyone is glucose levels unless there is evidence for a diabetic and or potential related need to perform one.

FSBS costs the patient to perform such. I know at my service it is $65.00 each time, to tell me Granny glucose is okay on that back pain. There is a difference in knowing when it is needed and appropriate than just being able to perform it.

Alike anything else we do and perform, we should have to be able to justify and defend why it is needed and performed.

R/r 911

 

[traumateam1]

Well I am not a PCP (Primary Care Paramedic) in BC (Canada) yet, but i haven been on car with PCP IV's many times and I do know that here in BC as a part of PCP IV protocol you do check BGL. Now me, I don't do that.. not yet, if I have a problem with the way a p/t is presenting I will call for a routine (no lights or sirens) to come do a check, of course unless it's an obvious emergency.

 

[firecoins]

As well, as described get it straight from the authorities mouth... better yet in writing. Also, ever considered asking your education or supervisor/administrator?
R/r 911

Isn't there a QA/QI guy in each company? This is something you need to ask with in each organization.

 

[mikeylikesit]

Ya know Mikey... I bet you learned all that in your class/training on the skill!

i am diabetic actually...maybe thats why i don't see it as a problem...Rid $65 really thats a lot for a lancet, a cotton ball, alcohol swab and a test strip isn't it?

 

[daedalus]

i am diabetic actually...maybe thats why i don't see it as a problem...Rid $65 really thats a lot for a lancet, a cotton ball, alcohol swab and a test strip isn't it?

Those damn strips are expensive! Plus we gotta sneak fuel surcharges in somewhere.

 

[Ridryder911]

Those damn strips are expensive! Plus we gotta sneak fuel surcharges in somewhere.

So true...

I don't know if most of you understand finances but; in real life most medical costs is usually several hundreds times over what is at "purchase price". Ever looked at hospital bills?
That Morphine Injection that costs the patient $45.00 actually costs the hospital $1.25. or that band-aid was $4.50 Why? For several reasons:

1) Most patients are uninsured. Most do not pay for the bill, so costs are off set to those that do.

2) Like to have a nice salary, benefits ? Money has to come from somewhere...

3) Like to have a MRI in a hospital ? There is no way that the procedures themselves could pay for the machine ( > million).

EMS is the same. The EMS unit, salary, insurance, electric bills, and yes even diesel fuel costs.. and someone has to pay for it.

Yes, $65 for a glucometer strip is expensive. So is the $180,000 EMS unit and my $10,000 LP12, and $11,000 stretcher. Do you think the "gang banger" that was shot had Blue Cross and Blue Shield? Again, it has to come from somewhere to off set ....

R/r 911

 

[Outbac1]

Yay doesn't say where they currently work. Maybe he/she wants to move to PA. Information on protocols and procedures is best obtained from the source.

 

[scottmcleod]

Our EMR SR-P providers can do BGL's, but that's it. (and they must be signed off in the protocols book, even after doing the course.)

As R/r pointed out, it IS an invasive procedure, and as such, you must be trained to do it, according to your dept's protocols.

EDIT: Removed hypothetical situation. Every time I ask a question around here, someone comes along and tears it apart

 

[Jon]

OK folks... to answer the OP's question.

In PA, BGL is an ALS skill. It is an invasive skill, and NOT something you are allowed to do as an EMT... ever. Welcome to the Commonwealth of PA's EMS system.

There are some work-arounds that are commonly done in the field. If the patient has a glucometer, the PATIENT or a family member can check the BGL. Where I used to work (Medical responder with Security Department, non-official QRS service), we carried a glucometer with our equipment. I never used it on a patient...but I'd loan it to a patient to use. I'm not a big fan of this... but it was nice to have when the uncontrolled diabetics on the nighttime cleaning crew would "feel sick" and think their sugar was low or high.

Of course... off the record... sometimes things happen in the back of the rig. Of course... then the medic must document that they preformed the skill. I know LOTS of EMT's who have preformed fingerstick glucose readings. I also know EMT's who have started IV's... it is a slippery slope, and if the State finds out, you might find yourself missing your cert. If you are willing to risk it... then go ahead and do it.

 

[scottmcleod]

Of course... off the record... sometimes things happen in the back of the rig. Of course... then the medic must document that they preformed the skill. I know LOTS of EMT's who have preformed fingerstick glucose readings. I also know EMT's who have started IV's... it is a slippery slope, and if the State finds out, you might find yourself missing your cert. If you are willing to risk it... then go ahead and do it.

Isn't that what on-line medical direction is for?

"Hi, I'm medic _______, I have a patient presenting like _______, I would like to _________ even though it's outside of my current scope, it's a skill that I've trained."

It puts liability with your medical direction.

At least, that's how it works with our team, should the need arise.

 

[Jon]

Isn't that what on-line medical direction is for?

"Hi, I'm medic _______, I have a patient presenting like _______, I would like to _________ even though it's outside of my current scope, it's a skill that I've trained."

It puts liability with your medical direction.

At least, that's how it works with our team, should the need arise.

Scott... I see your point, but EMT's aren't supposed to be equipped to do it... and the prehospital training to do it is part of the Medic course... there isn't a secondary class for EMT's that is authorized.

So I can't see why the doc would want to take on that liability.

 

[John E]

unbelievable...

A "workaround" that involves putting one's career, not too mention one's financial future at risk. Why not just get the certification required to do the stuff you want to do?

As for contacting medical control, since when can a faceless voice override standing orders and in some cases, the law? Are you saying that if some MD tells you, based on your claim to be trained but not allowed to perform a particular procedure, you can do it? Who gets sued if the worst case scenario happens, you or the MD who gave you permission to violate the standing orders?

John E.

 

[BossyCow]

unbelievable....

A "workaround" that involves putting one's career, not too mention one's financial future at risk. Why not just get the certification required to do the stuff you want to do?

In some cases its not that cut and dried. Different systems regulate these skills differently. For example, I know of an ambulance system that hired an EMT-I. They didn't have a job classification for EMT-I, only B and P. So, he rode with them as an EMT-B on their BLS unit. Liability-wise, if he performed an ILS skill on a BLS unit, he was within his scope of practice but not within the scope of the BLS unit. If there is a way to perform the skill, help the pt and still technically be within your scope on paper, I think its worth doing. But, as one poster put it, always good to have the MPD to back you up on this.

As for contacting medical control, since when can a faceless voice override standing orders and in some cases, the law? Are you saying that if some MD tells you, based on your claim to be trained but not allowed to perform a particular procedure, you can do it? Who gets sued if the worst case scenario happens, you or the MD who gave you permission to violate the standing orders?

Its not so much the 'faceless voice' as it is the licensure that the MPD holds. As EMS we operate under the license of the MPD so pretty much everything we do is his responsibilitiy and his liability, unless he can prove that we disregarded his direct order or protocol.

We regularly get permission from our MPD to operate outside of our protocols or standing orders. Glucose checks is one of those. Not listed in our protocols as part of our scope, we have an addendum in our district that gives us permission to perform glucose checks after completion of a class on it. The class time must be documented and the evaluator has to sign off on the skill sheet.

Another example is nitro. We carry it on our rigs and we are allowed to give it to anyone who already has a prescription for it. But, on several occasions, when I'm 15 - 20 minutes away from an ALS intercept, I have called the doc, given a pt report, including BP and been told to give them nitro. Now, if the 'worst happens' and someone gets sued, it would be the Doc for authorizing me to give an incorrect med, not for me following the direction of the MPD. But, if I were to give it myself, without calling or worse yet, documenting that I called the MPD, then it would be my butt in a sling.

 

[Ridryder911]

In some cases its not that cut and dried. Different systems regulate these skills differently. For example, I know of an ambulance system that hired an EMT-I. They didn't have a job classification for EMT-I, only B and P. So, he rode with them as an EMT-B on their BLS unit. Liability-wise, if he performed an ILS skill on a BLS unit, he was within his scope of practice but not within the scope of the BLS unit. If there is a way to perform the skill, help the pt and still technically be within your scope on paper, I think its worth doing. But, as one poster put it, always good to have the MPD to back you up on this.



Its not so much the 'faceless voice' as it is the licensure that the MPD holds. As EMS we operate under the license of the MPD so pretty much everything we do is his responsibility and his liability, unless he can prove that we disregarded his direct order or protocol.

We regularly get permission from our MPD to operate outside of our protocols or standing orders. Glucose checks is one of those. Not listed in our protocols as part of our scope, we have an addendum in our district that gives us permission to perform glucose checks after completion of a class on it. The class time must be documented and the evaluator has to sign off on the skill sheet.

Another example is nitro. We carry it on our rigs and we are allowed to give it to anyone who already has a prescription for it. But, on several occasions, when I'm 15 - 20 minutes away from an ALS intercept, I have called the doc, given a pt report, including BP and been told to give them nitro. Now, if the 'worst happens' and someone gets sued, it would be the Doc for authorizing me to give an incorrect med, not for me following the direction of the MPD. But, if I were to give it myself, without calling or worse yet, documenting that I called the MPD, then it would be my butt in a sling.

Not always true. Do a Google search & you will find that just because a physician authorizes you to perform a procedure, does not always allow you to perform or be "guiltless". You as a certified or licensed EMT are aware of your limitations and scope of practice. If not, you need to be (ignorance is NOT allowed or blessed) also by knowing that you are not allowed to or have not be trained to do so, does not exempt you from liability. The physician will be sued, but you will also for operating outside your certification level. The same if the physician orders you to perform a procedure or orders a wrong dosage of a medication & you do so... You are still held accountable.

R/r 911