scope of practice question

[DwayneEMTP]

How long have you been a paramedic for Dwayne?

Why do you ask? I don't see how that relates to our conversation.

Dwayne

[Timmy]

Just out of curiosity

[Timmy]

I guess I have a bias opinion to this issue, I’m young, still learning and really want a career in the profession. But going out of my scope to save one patient when I potentially have years ahead of me is out of the question, I guess it comes down to one mistake could screw up the rest of my life, I really have no interest in other industries. I don’t have the experience, education and so on to do so anyway. But who knows, in 20 years time I could look back at this post and laugh thinking to my self what was I thinking. Until then, I think it best to play by the rules.

To anyone who practices out side the scope, good luck, it’s your prerogative. I just hope that you do have the educational ability, skills, decision making skills, experience, justification and willingness to expect consequences to do so.

[fireflymedic]

Here's a situation that kind of relates to a BLS/ALS deal that I actually dealt with several years ago. We performed mutual aid for a BLS service near the TN state line - there I held emt-iv certification, when crossing the line into the other state where our primary service was I was nothing more than a basic which actually quite restricted scope of practice due to state. IV's aren't even considered. Here you are either a basic or a medic. Nothing in between. Well, we had protocols in place that if in TN, I could start IV's as could anyone who held the certification. D-50, albuterol, sub Q epi, narcan, etc were some of the other things permissible. One day we were transporting a pt and the closest hospital was in TN. In my state I could do very little for this diabetic pt. ALS was not an option as there was one medic to staff the entire county per shift (and he was only on call). When in my state I couldn't start an IV something I was proficient at doing and administer D-50 which would have seriously benefited my patient. As soon as I crossed the state line, our individual protocols and TN scope of practice allowed me to do both significantly helping my patient. However, had I had to transport to a hospital within my state, the patient would have had to wait for the hospital to administer. With the long transport times we faced, that could have been potentially detrimental to them. Would I have started an IV and given the D 50 and risked my license? Absolutely not even though it was within my scope of practice across the state line and within our protocols for the same. I know of a few others that didn't agree with this mentality and only three are still practicing EMS. They were brought up by the state for practicing medicine without a license. They no longer have certifications even though they were trained and understood what they were doing, it was outside protocol and scope of practice for my state. It's never an easy decision, but do you want to help several people or just a few? Losing your license benefits no one.

[letmesleep]

For a couple of reasons. I was taught, and very much believe that the heart of paramedic medicine is pt advocacy. I am morally and ethically tasked with knowing as much medicine as possible, being physically fit, etc to protect my pts from illness and injury. I am also tasked with being mentally fit to protect them from poor advice that may be given by other medics, nurses, or even the medical director. That if, after bringing my education, training and experience to bear on a problem, I'm asked to provide or withhold an intervention that I believe to be in error, I'm morally and ethically obligated to refuse to follow through with it.

[Mateo_1387]

...but I had one question for you when I read this individual line:

Who protects your Pts from you?

LOL

Simple answer....education and law suites. So many uneducated medics are out there, so many. The public is not protected from them. I do not see too many EMS law suites, so I guess all that is left is education. You have to know what you are doing, why you are doing it, and when to do it.

[akflightmedic]

LOL

Simple answer....education and law suites. So many uneducated medics are out there, so many. The public is not protected from them. I do not see too many EMS law suites, so I guess all that is left is education. You have to know what you are doing, why you are doing it, and when to do it.

I beg to differ, I have seen a few law SUITES that were focused on medical malpractice, so I am sure that covers EMS as well.

However, as far as actual lawsuits, the reason you will not see or hear of too many, is because they settle out of court many, many times. Previous counties I have worked for, always settled out of court as it is much cheaper in the long run and draws much less public scrutiny.

[DwayneEMTP]

Good question letmesleep, I don't think it's harsh at all, it's very appropriate.

I guess where I'm getting lost is in the name of the thread, which I also believed to be the focus of the thread most times.

Would you work outside your scope of practice to save a life?

Doesn't the question itself demand that the pt is going to die if I don't choose to work outside of my scope of practice?

If it's assumed by the question that that is a fact, then why would the pt need protection? I'm assuming this is an acute case, or there is no reason for me to make this decision as a medic in almost all instances.

So the pt is certainly going to die if I don't act. If I act poorly, perhaps the pt will die sooner. If I act appropriately, then the pt will possibly survive at least a little longer, right? So why does the pt need protection from my good intentions?

Has everyone simply forgotten what the question was? And if so, why do we continue to go back to the "you're a menace" point of view?

In the general order of things, IF WE STAY ON TOPIC, it's seems simple to me. We have an acute pt that is near death. If we act outside of our scope, he lives (Implied by the question I think) If we don't, he dies (Dito).

The vast majority have chosen to sit by and allow him/her to die, neutered by the fact that acting in the PT's best interest could possibly cause them issues in the future.

So perhaps we're all just seeing the question differently.

Let me ask...

You are on scene of a critical, acute pt that you've determined after a thorough assessment is CTD. All SOP interventions have been exhausted, medical control can not be reached.

Using your education and experience you KNOW that you have an intervention that will in all likelihood reverse this person's fortune and allow then to live without deficits to the natural ending of their lives. Of course fire is there, along with the family, so there is no possibility that your intervention will go unnoticed, you will have to pay the price for saving this life....

What will you do?

Dwayne

[Doczilla]

Here's a situation that kind of relates to a BLS/ALS deal that I actually dealt with several years ago. We performed mutual aid for a BLS service near the TN state line - there I held emt-iv certification, when crossing the line into the other state where our primary service was I was nothing more than a basic which actually quite restricted scope of practice due to state. IV's aren't even considered. Here you are either a basic or a medic. Nothing in between. Well, we had protocols in place that if in TN, I could start IV's as could anyone who held the certification. D-50, albuterol, sub Q epi, narcan, etc were some of the other things permissible. One day we were transporting a pt and the closest hospital was in TN. In my state I could do very little for this diabetic pt. ALS was not an option as there was one medic to staff the entire county per shift (and he was only on call). When in my state I couldn't start an IV something I was proficient at doing and administer D-50 which would have seriously benefited my patient. As soon as I crossed the state line, our individual protocols and TN scope of practice allowed me to do both significantly helping my patient. However, had I had to transport to a hospital within my state, the patient would have had to wait for the hospital to administer. With the long transport times we faced, that could have been potentially detrimental to them. Would I have started an IV and given the D 50 and risked my license? Absolutely not even though it was within my scope of practice across the state line and within our protocols for the same.

With mutual aid agreements, medics providing mutual aid are governed by their responding agency's protocols, not those in the area in which they are providing mutual aid. This makes some logical sense, since you can not and should not be expected to know by heart the protocols of every service area which you may be asked to respond.

'zilla

[Doczilla]

What would your thoughts be Doc if a medic started a Versed drip on a status seizure patient when they don't have it in their protocol.

I would think that the patient would be better served by boluses of versed and valium rather than a drip if the patient is still seizing. That said, paramedics are trained to hang and calculate infusions and are expected to do so routinely. With online medical control guidance, I don't see a scope of practice violation here, just more of a protocol issue.

'zilla