scope of practice question

[DwayneEMTP]

fire_911medic, I'm not sure if you keep twisting things to look better of if I am, but here is what I've seen the argument become....

You are on scene with an acutely unstable pt. To survive the pt needs an intervention that you can provide but that falls outside of your scope of practice. Do you provide that intervention?

It seems to me that the question implies that you understand the intervention, are capable of providing it, and do so to the pt's betterment.

I guess I keep wondering why you continue to try to make it appear that I'm advocating for everyone simply doing whatever they want? When was that ever part of the discussion? Obviously rules are good. Rules are particularly good for weak medics. I am not advocating a life of crime, simply answering the simple question above.

If you have the opportunity to save a life by stepping outside the protocols, and again, I'm assuming it's an intelligent, logical, productive intervention, yet medical control has ordered you not to do so, what would you do?

Would you ‘be stupid’ and advocate for your pt, providing the intervention allowing them to live? Or would you follow medical direction, allow them to die, and follow the rules? I believe the “what about your future patients?” argument is ludicrous. I can’t imagine causing suffering to ‘this’ pt for the betterment of hypothetical future pts. So maybe we can agree that that’s a non issue?

Hopefully this puts us back on the same page.

Dwayne

[defib_wizard]

[if you have the opportunity to save a life by stepping outside the protocols, and again, I'm assuming it's an intelligent, logical, productive intervention, yet medical control has ordered you not to do so, what would you do?

/quote]

give me an example.

Will I-

perform a C-section on a dead woman ? NO!

amputate a limb to save a person ? NO!

I did not create the emergency, I am there to do no harm. Transport to definitive care. Stabilize the pt if possible within my scope of practice.

Nobody said it would be easy to be a paramedic.

[letmesleep]

Dwayne, I think I may understand what your trying to say, and I know that you will correct me if I am wrong. If MC is ordering you to NOT preform a procedure that a Pt needs while en route to the ED, and you know in your heart and soul that the Pt will die without it, then by all means do it. Your 100% right in that instance and you are being that advocate that you preach about being, I'm behind that thought process completely, error in favor of the Pt.

My question to you is tho, is that really outside your scope of practice? You used the IV analogy, so lets stick to that example. As medics this is a skill that we use daily, and are trained to preform this skill. Wouldn't outside our scope of practice be something that we are NOT trained on? A couple posts back I threw out the most extreme example that popped in my head, and asked about amputation. It is extreme but not unheard of either. Would you, for the sake of the Pt, take on this task yourself, or simply make the decision to have a surgeon respond to your scene? Obviously as medics we are not skilled or trained to preform this task, but does that mean there is no way we could figure it out in a pinch?

I may be completely off base here, but thats how I understood the question posed.

[DwayneEMTP]

Shoot letmesleep, I don't think you're off base at all, I just think we're still looking at the question differently.

Would you, for the sake of the Pt, take on this task yourself, or simply make the decision to have a surgeon respond to your scene?

I would absolutely provide supportive care until the surgeon arrived. Again, I'm not looking for a reason to breach scope of practice. I'm assuming the surgeon is not available. There is no issue that I can see if obvious solutions exist within your scope. I thought that the interesting question was "what if you had no choice but to sacrafice a life or breach your protocols?"

If I can resolve the issue within my protocols then I will do so. I have no need to show I'm above the protocols. It's simply that if my protocols are not adiquate to save this life, then I will choose to save it if it's within my power, and deal with the fallout later.

Cut off a limb to remove a pt from a burning vehicle? To me that's not even a close call. use a scalpel, my Gerber tool or gnaw it off with my teeth...he's coming out of the vehicle and all that believe that to be outside of my skill level, or outside of my area of responsibility can be damned.

There is no one on this planet that has the power to tell me that I may not use my hard earned skills to save the life of someone that wants to live. I can find a new job... but my morals, ethics and humanity are not so easily replaced.

Dwayne

[Timmy]

There’s a fine line between ethics/humanity and what is to be done.

Say you perform an intervention outside your scope to save one life, your found negligent, fired and de registered. Your company is having trouble finding another medic to fill your shift at such short notice. The following day there is a bus crash and because there short of a medic 4 maybe 5 patients subsequently die because you wanted to save one person. You can no longer work as a medic without registration and you end up working in a dead end job.

I’m a caring person and I will do everything possible within reason to help you but asking me to step outside my ‘bubble’ is out of the question.

As for going against medical direction, I think this is lack of respect. The person you’re talking to is there for a reason, if you want to go against there orders then why don’t you become a doctor? I work in a hospital, I see this time after time doctors making less than desirable decisions and us nurses knowing better. It kills me to tears sometimes when I see a doctor make a decision or perform an intervention that the nurses don’t view as the best option but I bite my tongue and go with it because I respect the doctors, I also wish to be walking though the hospital doors the next day.

No offence, but if your company decided to sack you because you went against a senior persons then I have no problem with that.

Everyone signs up to be a paramedic knowing what is expected of them, the rules and protocols, what is right and what is wrong if you step out of this variation you also have no self respect.

[DwayneEMTP]

There’s a fine line between ethics/humanity and what is to be done.

That's what makes it an interesting question.

Say you perform an intervention outside your scope to save one life, your found negligent, fired and de registered. Your company is having trouble finding another medic to fill your shift at such short notice. The following day there is a bus crash and because there short of a medic 4 maybe 5 patients subsequently die because you wanted to save one person.

It is a hollow argument to withhold treatment for THIS pt for the sake of future pts. I hope if this is truly your opinion that you never treat my family. What happens if you decide saving my son is not as important as saving your hypothetical future pts? You have stopped being a paramedic when you choose to stop doing everything in your power to advocate for my son. This is a silly scenario and I think you're plenty smart to see that. If you think operating outside your scope of practice has a weak argument, try telling your medical director you made a decision for your current pts care based on how you think a future pt would have responded to it....

You can no longer work as a medic without registration and you end up working in a dead end job.

I have many options. I don't need to be a medic to avoid a dead end job. If you don't believe me ask the scores of medics that leave the field every week for better jobs if that was their only option.

I’m a caring person and I will do everything possible within reason to help you but asking me to step outside my ‘bubble’ is out of the question.

Fair enough.

No offence, but if your company decided to sack you because you went against a senior persons then I have no problem with that.

Nor do I. I never said that doing what I believe is right would have no consequences; I simply said that I would do what I believe to be right despite those consequences.

Everyone signs up to be a paramedic knowing what is expected of them, the rules and protocols

Agreed. But evidently we see the base issues differently. If you see the Dr. doing something that you KNOW is detrimental, yet say nothing, than you can no longer pretend to be a paramedic. You may be called a paramedic, but when you've chosen to allow your pt to be damaged in your presence then you've failed to be your pt's advocate. Simple to me.

...if you step out of this variation you also have no self respect.

Please explain this statement. Grabbing some random issue and stating that is shows that I have no self respect doesn't fly...You're going to need to flesh this statement out a bit...But if you're going to claim that I have no self respect then you need to be prepared to back it up and then go to the mat. Respect, for myself and for others is something I take very seriously.

Dwayne

[Timmy]

My comments weren’t directed at you, this is why I didn’t quote you. I merely used some points in my context of generality.

To me, my scenario is not hollow. It may be hypothetical but I certainly am not withholding treatment, I will be treating a patient to my scope of practice. If your son dies because I’ve stayed within my scope of practice it would not phase me, I have done everything I could and done what is expected of me to the best of my ability.

Sure, I may have a little guilt but what if I’ve made the situation worse? I’d rather the guilt of knowing that I’ve stayed within my scope, even though I may think I can benefit the patient by stepping outside my scope than causing further harm and not having a leg to stand on.

There’s a fine line between emotions and common sense, if I’m stepping outside my scope of practice to treat a patient I think emotion may be playing a bigger part.

If a medical professional has harmed a patient in my presence I will follow the proper channels in addressing this issue. Same goes when I’m treating a patient, if I feel I could benefit this patient in another way that is outside of my scope of practice then I will follow the appropriate channels and make a suggestion to the relevant persons to include such a skill in my scope of practice. I will need to show them that I am capable, well educated and skilled to perform such a treatment intervention. I will also need to show this relevant person some evidence and justify why I think this skill needs to be added to my scope of practice, it’s called being proactive, not just yahooing around stepping out of my scope of practice when I feel like it because I think it may be best in the spur of the moment. If I was to witness a medical professional practice outside of ones scope then I will also follow the appropriate channels to reporting this person for being negligent .

Another question, if you have been trained to perform such a skill yet it is not include in your scope of practice why are you working for a company that is holding you back?

This is medicine, don’t play with peoples lives.

[DwayneEMTP]

So it sounds to me as if you're a good company/corporate man Timmy. Let the problem go now and do the correct paperwork later. Good for you. Doesn’t work for me.

If making excuses for a lack of action after it's too late to create a positive outcome for that pt is acceptable to you, then good on you man. But don't attempt to put if off as being morally superior because you were afraid to act but are willing to "do the paperwork" afterwards.

Deciding now that you will allow those in your charge to be victims, while in your charge, victims of shallow protocols, of medical direction, of circumstances, makes you a pretender as a medic. I realize you are not practicing at the medic level now, so I make this as a general statement and not one aimed at you.

As a medic you are ethically charged with fending for your patients. As a human you are morally charged with defending those that can't defend themselves. You can wrap your decision not to do so until it's to late any way you want, file all the post incident reports, do any amount of finger pointing, but that pt will never care, right? Cause they’re dead now, right?

Also, if you weren't responding to me, who were you responding to? I seem to be the only one at the moment with this opinion, right?

Dwayne

[Timmy]

You have your opinion, I have mine. I don’t believe in breaking the rules, this applies to every practice in my life. I don’t feel comftable breaking the rules for one person.

Lack of action may be but you’re still breaking the rules. If things happen to go pear shaped your, your senior medical crew and service may suffer from irreversible damage. If you’re not happy with the scope of practice your service currently has and you have the urge to practice out side of your scope of practice then why are you working for this company?

Following the correct channels may not be so bleak. If you follow the correct channels post incident who is to say that a new intervention is not added to the scope of practice, in this case you and every other paramedic in your service may be granted this new intervention on the count of your suggestion, who knows how many lives it may save. Every medic has this new scope or it’s just a one off stunt that you’ve pulled to help one patient and you’re happy to fill in the paperwork?

If you’re willing to take the consequences for your actions, no matter how server they may be, then I respect that.

We both reside in different countries and have different experiences. I can see your point and respect your empathy towards patients but it goes against my morals and values. You appear to be clinically sound and I’d hate to see you suffer from the ill effect of a one off mistake, it would be such a waste. It will prove futile in any further debate as we are so strongly opposed to one another. Good day.

[reaper]

Would you want your family doctor preforming heart surgery on your son?

I for one, would want my son to have a person that is trained to preform the procedure, doing it.

You could sit here all day and go back and forth on this issue. Timmy stated it right, When you became a medic you knew what was expected of you. If you want to do more for a pt, then go to med school and learn how!

If you do something minor, that may be a little outside your SOP, then as long as you can back up your decision, go for it!