scope of practice and diabetes

[scottmcleod]

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?

If your Medical Director wrote and/or signed off on your standing orders, chances are, s/he has the right to allow for an exception.

By "medical director", I meant YOUR on-line medical control, not just some random doctor.

If someone can be sued for taking a BGL outside of their scope after MedControl says that's ok, I can understand why an instructor I know told me that ALL of the paramedics that were around her at Katrina (she happened to be down there at the time) were scared to treat patients, because it required emergency field medicine (and bending some rules) to save lives. [and they were afraid of getting sued, rather than the patient dying.]

Thank god Canada doesn't have litigatitis....

 

[mikeylikesit]

I can understand why our SR-P instructor told me that ALL of the paramedics that were around her at Katrina (she happened to be down there at the time) were scared to treat patients, because it required emergency field medicine (and bending some rules) to save lives.

Thank god Canada doesn't have litigatitis....

chances i think that all of us are willing to take for that outcome in that situation.

 

[scottmcleod]

chances i think that all of us are willing to take for that outcome in that situation.

Reading above, I'm not sure that I'd agree with you.

 

[John E]

Bravo, although it's overstating it, the Nuremburg trials kinda put the whole idea of "I was only following orders" to rest.

It was suggested in this thread that

"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."

I defy anyone here to refute that the above scenario is proper treatment for a patient.

It's not a slippery slope, it's a freakin avalanche.

Yeah, I know it's a bit over the top for a simple glucose test but come on people.

If your local scope of practice allows it, that's a whole nuther thing. But that's not what we're talking about here. We're talking about willfully stepping over the legal boundaries of an EMT's scope of practice.

John E.

P.S. There's such an obvious difference between what's being advocated here and the treatment of hurricane survivors as to not make it worth responding to.

 

[scottmcleod]

Bravo, although it's overstating it, the Nuremburg trials kinda put the whole idea of "I was only following orders" to rest.

It was suggested in this thread that

"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."

I defy anyone hear to refute that the above scenario is proper treatment for a patient.

It's not a slippery slope, it's a freakin avalanche.

Yeah, I know it's a bit over the top for a simple glucose test but come on people.

If your local scope of practice allows it, that's a whole nuther thing. But that's not what we're talking about here. We're talking about willfully stepping over the legal boundaries of an EMT's scope of practice.

John E.

P.S. There's such an obvious difference between what's being advocated here and the treatment of hurricane survivors as to not make it worth responding to.

... just using an example of EMT's that are more afraid of getting sued, than giving proper treatment to patient, even if it's outside of their scope. (I never said I was on either side of the fence.)

If it's life or death, obviously it's a different story entirely.

Is it a livesaving intervention (will the pt. die before they get to the hospital?) If so, talk to your medical direction, and DOCUMENT your need to perform/administer something.

If it's not life/death, why chance it?

 

[Jeremy89]

There are many cases where something is out of the scope of practice but can be done under medical direction if the EMT is trained. Here's one example:

http://www.emtlife.com/showthread.php?t=7820

Not saying that EMT's should be Intubating every pt just because they are trained, but if someone has the proper training then they should be allowed to step outside their scope of practice, especially if directed to do so by Med control. As someone said before, the reason in contacting med control is to cover your a$$. If the doc says so then the liability is with him/her.

 

[John E]

Only problem with your example is that by doing all of the training and taking all of the steps outlined, you have effectively changed the scope of practice to include intubation.

In other words, the folks who write the rules for whatever area that your example covers have changed the EMT's scope of practice. There aren't "many cases where something is out of the scope of practice but that can be done under medical direction", there aren't any at all for the simple fact that by allowing an EMT to act under medical control you are expanding their scope of practice by definition.

To put it even plainer, as an EMT-1 in Los Angeles county I have a scope of practice that I MUST follow, deviating or expanding from that is grounds for losing my certification, opening myself to possible litigation, and could easily turn into criminal charges depending on how one interprets the criminal definition of assault.

I don't work anywhere else but I would assume that every other county, state, province, etc. has similiar laws, if an EMT WILLFULLY performs a procedure that is outside of their scope of practice, which is what some people on this thread have advocated, then whatever government body that oversees them should and most likely will come down on them like a ton of bricks. I fail to see how some of you can't see this.

If you're not allowed to do it, you're not allowed to do it. How much simpler can something be?

John E.

 

[scottmcleod]

If you're not allowed to do it, you're not allowed to do it. How much simpler can something be?

Before, or after you ask MedControl for permission to do it?

 

[Jon]

John:
I agree with you. I wasn't trying to say that it was a good idea, or the best thing for patient care at all... but we all know that in some systems, especially with single-provider paramedics, EMT's occasionally push the limits of "assisting ALS". I've seen it happen. Sometimes 3 or more things need to happen at once, and if there is only one medic... well, that can be a problem. I was trying to explain it, the best that I could, to everyone on here.

When I was going through paramedic school it was made VERY clear to us that we could only preform ALS skills in a clinical setting... and that we couldn't just go out and start putting in IV's for the local medics because we knew how.

Scott:
The first question is what do your protocols say. Some have more options for medical control. Some are specific in saying that EMT's can't preform invasive skills.

I had this discussion with my father last weekend. He asked about preforming a backcountry surgical cric, because we were talking about the possibility of severe anaphylaxis occurring at a Boy Scout event I was attending. I was very clear... I'd like to be involved in EMS in some way for the next 20+ years... I can't do that if I get my cert pulled by the DOH for trying to practice something I saw on ER.... even if it did mean that I got to watch someone die because I couldn't move air with the BVM. That would really suck... but I won't throw my EMT card away because of it. Now if one of the Family Medicine docs who occasionally are around volunteering decided to do something... well... that's on them... if I have any equipment that can be of use, they can have it.

 

[John E]

Scott,

All I can say is that it's a good thing that as you say in your signature:

"The views expressed here are my own, and do not reflect those of any agency I am associated with, or work for."

Cause I would hate to think that an EMS provider would have such a hard time understanding such a simple notion. Does your employer know what you think about things like scope of practice?

You seem to be trying to make the case that all an EMT has to do is ask permission from a doctor in order to perform procedures that they're not legally allowed to perform, is that really how you work?

John E.

 

[Ridryder911]

Whoa! I believe there is a misconception or confusion what is "scope of practice" and deviation from protocols.

Just because an MD/DO gave you permission or ordered you to perform a procedure does NOT make it legal! If you have not been authorized or sanctioned by the state to be able to perform that procedure, then technically you are violating the law! If caught and found guilty, may suffer the consequences.

There is a reason for each state local jurisdiction to have "allowed procedures" and unless it states..." or as authorized by local or medical control"... then you are breaking your level and license capability. Heck, I would have Doc's order tons of stuff for me to do, but I realize that is out of my protocols and scope of training and ability. There is a difference though, if I may want to administer a medication or deviate from the "norm or written" protocol.

One has to very, very, careful of what procedures and treatment modalities assuring that you are within reasons of your training and education level, and license.

R/r 911

 

[scottmcleod]

Scott,

All I can say is that it's a good thing that as you say in your signature:

"The views expressed here are my own, and do not reflect those of any agency I am associated with, or work for."

Cause I would hate to think that an EMS provider would have such a hard time understanding such a simple notion. Does your employer know what you think about things like scope of practice?

You seem to be trying to make the case that all an EMT has to do is ask permission from a doctor in order to perform procedures that they're not legally allowed to perform, is that really how you work?

John E.

EDIT: arguing on the internet is like... (you know the end of this one, and I'm tired of being part of the problem.)

 

[scottmcleod]

Whoa! I believe there is a misconception or confusion what is "scope of practice" and deviation from protocols.

Just because an MD/DO gave you permission or ordered you to perform a procedure does NOT make it legal! If you have not been authorized or sanctioned by the state to be able to perform that procedure, then technically you are violating the law! If caught and found guilty, may suffer the consequences.

There is a reason for each state local jurisdiction to have "allowed procedures" and unless it states..." or as authorized by local or medical control"... then you are breaking your level and license capability. Heck, I would have Doc's order tons of stuff for me to do, but I realize that is out of my protocols and scope of training and ability. There is a difference though, if I may want to administer a medication or deviate from the "norm or written" protocol.

One has to very, very, careful of what procedures and treatment modalities assuring that you are within reasons of your training and education level, and license.

R/r 911

That's what I was trying to say, in other words. Thank you for putting it more concisely.

 

[BossyCow]

I'm seeing the usual approach of 'let's take an exceptional, outside the norm incident, ask about how to handle the exception', then turn it into 'should EMTs follow protocols?'

Ya know folks, there are exceptional situations that will require us to flirt along the edges of our standard care. Does this mean that we are then allowed to always operate in that gray area? Of course it doesn't! Does the fact that I am sometimes allowed, in exceptional circumstances to give nitro to a patient who doesn't have a prescription for it, while following the specific orders of a physicial mean that I'm going to start giving nitro to everyone? Of course it doesn't!

Does the fact that on rare occasions, my MPD will order us to do something a bit out of the ordinary mean that I don't respect my scope of practice? Of course it doesn't.

I am in a unique area, with a unique set of problems. I may not have ALS available. I may be 30 - 45 minutes from a hospital with a critical patient on board. This means that my MPD will sometimes instruct us to move beyond what we do in the run of the mill, standard of care. This is an exception, not the rule and we honor it as such.

I do not regard this as a way cool toy that I've just been allowed to take out of the box. It's scary, and it should be. If its not upping your sphincter factor, you aren't paying attention.

 

[Jon]

I think Bossy's got a good point folks. PLEASE be nice to each other.

 

[emt357085]

check your local protocals

 

[Jon]

And.. for the record, here is the Commonwealth of PA's statewide BLS protocols:
http://www.dsf.health.state.pa.us/health/lib/health/ems/bls_protocols_2004.pdf

And the statewide ALS protocols, for kicks:
http://www.dsf.health.state.pa.us/health/lib/health/ems/als_protocols-effective_07-01-07.pdf

And some selections from the protocols:

When providing patient care under the EMS Act, EMS personnel of all levels must follow
applicable protocols. Although the Statewide BLS Protocols are written for BLS-level
care, they also apply to the BLS-level care that is administered by ALS practitioners.
Since written protocols cannot feasibly address all patient care situations that may develop,
the Department expects EMS personnel to use their training and judgment regarding any
protocol-driven care that would be harmful to a patient. When the practitioner believes
that following a protocol is not in the best interest of the patient, the EMS
practitioner should contact a medical command physician if possible. Cases where
deviation from the protocol is justified are rare. The reason for any deviation should be
documented. All deviations are subject to investigation to determine whether or not they
were appropriate. In all cases, EMS personnel are expected to deliver care within the
scope of practice for their level of certification.

And the diabetic protocol:

ALTERED LEVEL OF CONSCIOUSNESS/ DIABETIC EMERGENCY
STATEWIDE BLS PROTOCOL
Criteria:
A. Patient with new decrease in level of consciousness. Causes may include:
1. Hypoglycemia.
2. Drug overdose.
3. Stroke.
4. Head Trauma.
5. Seizure.
Exclusion Criteria:
A. If stroke is suspected - see Stroke Protocol # 706.
B. If carbon monoxide, drug overdose, or other poisoning is suspected - see Poisoning Protocol
#831
Treatment:
A. All patients:
1. Initial Patient Contact – see Protocol # 201.
a. Consider call for ALS if available.
2. Manage Airway and assist ventilation as necessary.
3. Administer high concentration oxygen.1
4. Examine patient for evidence of specific causes (for example Stroke, Poisoning, Head
Injury, or Seizure) and follow other protocols when appropriate:
a. Medic alert tag.
b. Needle marks.
c. Medicine containers.
d. Insect stings or bites.
e. Head trauma
f. Incontinence of urine.
g. Tongue bite wounds
h. Stroke
5. If patient is unresponsive and there is no concern for trauma, place patient in the lateral
recumbent (recovery) position and continue to monitor airway.
6. Administer oral glucose if hypoglycemia is suspected and patient can swallow. 2
7. Transport immediately.
8. Re-assess the patient.
Notes:
1. See Pulsoximetry Protocol #226. Pulsoximetry may only be used by BLS services and personnel
that meet DOH pulsoximetry requirements. If used, pulsoximetry must not delay the application
of oxygen. Record SpO2 after administration of oxygen. If pulsoximetry is used and patient does
not tolerate NRB mask, may switch to nasal cannula as long as SpO2 remains >95%.
2. Hypoglycemia is suspected if patient has a history of diabetes or takes insulin or oral diabetes
medications. If the patient can’t swallow but still has gag reflex, oral glucose may be placed
between the cheek and gum in small amounts.
Performance Parameters:
A. Review all uses of oral glucose for appropriate assessment for non-diabetic causes of altered
consciousness.

The only mention of blood glucose in the BLS protocols is on the refusal form example, where it is mentions that BGL testing is ALS Only.

On the ALS protocols:

Electronic glucose testing meters must be carried by all ALS services, and these services must have either a CLIA license or certificate of waiver. An ambulance service performing glucose testing with a meter cleared for home use by the FDA must hold a CLIA certificate of waiver. A CLIA certificate of waiver (CoW) is good for two years. Each service is responsible for determining whether a CLIA license or waiver is required.

 

[1799687]

of course local protocols differ but around here basics are not to check fsbs.
will your medic let you? probably. especially if youre just using flash blood from the iv he/she started. is it against SOP? yes. can you get in trouble? yes. can the medic get in trouble? yes.