scope of practice question

[DwayneEMTP]

I haven't read all the replies, so I apologize if this has already been addressed. I initially voted "no" and didn't give much consideration to the possibility of going outside my scope.

Thinking about this more though I thought of an extremely unlikely scenario where going outside my scope may be worth at least considering. In one service I work for we perform pediatric defib in manual mode (normally PCPs just use auto). What if there was a situation where the defib malfunctioned and would not go into auto mode while working for the other service? I could always just say the defib failed, do CPR and transport. But wouldn't it be better for the patient (at least if in a shockable rhythm) to go through the protocol in manual mode?

Unlikely scenario, and probably not what the OP was looking for since it is outside the scope technically but something that I am trained in and able to perform (in some instances) at the other service.

I think it's a great example. Protocols say you shouldn't, but in my world you should. Should I cut the last thread of tissue holding a pt in the car, preventing transport? I'm not trained for it, but my education tells that this is not going to add significanlty to his injury, but that it will allow me to transport, which will create significant possibilities for a positive outcome. So am I not obligated to make the cut? I think I am. Do I refuse the assistance of the surgeon on scene so that I can do it myself instead and be a hero? Of course not.

I simply think that if I have the CLEAR ability and knoweledge, and there are no reasonable, realistic better options, then I'm obligated to act. This is just right for me obviously, as I can't sustain the argument if I am limitted to using the SOPs and protocols.

I think this has been a great discussion. Thanks for taking the time to participate.

Dwayne

[Doczilla]

We love to talk about the scenario where we would do a procedure that is "outside the scope of practice", but what does that really mean to us, to the medical director, and to the patient?

Things that are outside of scope are outside of scope for a reason. Either it won't help the patient in that setting, has a high complication rate, has a narrow set of circumstances in which it will work, requires a skill set that is infrequently used, or has poor evidence supporting its use.

Most people consider themselves to be better-than-average drivers, and I think the same is true for our self-assessment skills as paramedics. The problem is not when an intervention outside the scope of practice is applied appropriately, but when it is done inappropriately. For example, let's say an EMT-I performs a needle decompression of a trauma patient. The patient perhaps had rib fractures on one side and maybe had some difficulty breathing, but was hemodynamically stable. Mistakenly thinking that NDC would be indicated, the EMT-I decompresses the patient. Now the patient has bought a chest tube because of the inappropriate decompression. Another example: blunt trauma patient loses his pulse in front of the paramedic, who has performed a thoracotomy as part of a cadaver lab in training. The medic performs a field thoracotomy, having not been completely trained and not fully understanding about it being indicated only for penetrating trauma arrest. He ends up with a bloody mess and a dead patient. Another example, an EMT-B has a patient with a wide complex rhythm. He reads the strip (which he's not fully trained in) and administers amiodarone to a patient who was actually had an accelerated idioventricular rhythm. The amiodarone knocks out this ventricular focus and the patient goes into asystole. Or another, a paramedic has read up on the procedure of surgical cric, but currently only Quicktrakes are approved for use. He grabs the scalpel out of the OB kit, incises to perform a surgical cric (which he has never done), it's a bloody mess because, well, they are, he can't find the landmarks and can't place the tube because he has never physically performed the skill.

It's easy to imagine yourself being the hero who thought outside the box and saved a patient's life. It's much more difficult to imagine the alternative scenario, where an intervention is applied inappropriately to the patient's detriment. Things outside the scope of practice are likely not things on which you are completely trained or perform frequently, and therefore far more dangerous.

'zilla

[Timmy]

It's easy to imagine yourself being the hero who thought outside the box and saved a patient's life. It's much more difficult to imagine the alternative scenario, where an intervention is applied inappropriately to the patient's detriment. Things outside the scope of practice are likely not things on which you are completely trained or perform frequently, and therefore far more dangerous.'zilla

[fireflymedic]

My sentiments exactly doc - thanks for jumping in.

[DwayneEMTP]

It's easy to imagine yourself being the hero who thought outside the box and saved a patient's life. It's much more difficult to imagine the alternative scenario, where an intervention is applied inappropriately to the patient's detriment. Things outside the scope of practice are likely not things on which you are completely trained or perform frequently, and therefore far more dangerous.

Couple of things...First, I agree with this of course. But I get confused...with me the only one on the other side of the fence, do I assume that this is a rebuttel to my arguments?

Can't you also think of a gazillion instances Doc where the protocols don't specifically relate to a life ending/altering situation yet a medic would be perfectly qualified to intervene? I'm guessing you can, 'specially if all of the horseshit protocols country wide are considered.

Also, I've tried to make it clear this isn't about heroism for me, yet for some reason we keep returning to that topic. Why can't someone simply choose to do the right thing, a thing they are confident that they are qualified to do, simply because they believe it to be right? Why does there have to be fantasies of heroism? Are many of you so far removed from simply trying to be a good neighbor and a good human being that you can't imagine taking a beating for what you believe in without first verifying that it will make the paper? I'm completely off in the ditch as to why it must be heroic simply because it's not common practice.

Things outside the scope of practice are likely not things on which you are completely trained or perform frequently, and therefore far more dangerous.

Again, isn't this the whole point of the question? If you performed it daily, then it'd likely have a protocol, then it wouldn't and shouldn't be part of this discussion. Someone claimed once that there are systems where a medic needs permission from medical control to start an IV. So if I start an IV on a trauma, or OD, or preeclamptic woman, or an anaphylaxic (sp) pt....then I have only done so to be a hero? When I'm sitting next to those supplies, and drugs, yet the tired, bitchy medical control doc who believes I have time to make it to the hospital denies my orders, do I then watch little Suzie suffocate? I mean, starting an IV is outside of my protocols. Do I then watch her die because I'm unwilling to break a rule?

I know that everyone here can think up at least a dozen more realistic scenarios where this might apply and be desireable...but only one or two are even able to consider it without going into near seizures at the thought of breaking a rule?

I thought for sure that once I clarified that we were talking about, not common practice, but that once in a career decision that most would say, "Oh well, yeah! If I know the implications for and against and am comfortable and qualified, of course I would choose to save a life." I'm truly a little weirded out that it didn't happen.

Rules before life? Where did my education and life experience go so far off into the ditch that I thought it was supposed to be the other way around?

Dwayne

[letmesleep]

I thought for sure that once I clarified that we were talking about, not common practice, but that once in a career decision that most would say, "Oh well, yeah! If I know the implications for and against and am comfortable and qualified, of course I would choose to save a life." I'm truly a little weirded out that it didn't happen.

Even tho you may not do it daily as your previous post stated, if the highlighted area is true, wouldn't you assume that there would be a protocol in place for this as well? I see where your headed, but as long as your "comfortable and qualified" wouldn't you still be within your scope to some degree? If your not qualified and comfortable with a procedure it's because you may not have the knowledge to do such a procedure, and I'm thinking you should stay away from it, just a thought.

As far as making the paper, I have no interest in such, around here that stunt will cost the next round at the local tavern.

[Timmy]

a thing they are confident that they are qualified to do, simply because they believe it to be right?

I don’t get it Dwayne…

You say you’re qualified, educated and comftable to perform an intervention outside your scope of practise and do so if needed but why aren’t you working for someone who will let you do this? You seem so contempt to practice out side it just seems strange that you haven’t perused a career that legally lets you perform to your level of education and confidence. You should be sitting down with your company and telling them you have these skills and feel confident to practice them onroad.

Here in Australia Paramedics work to guidelines not protocols and we don’t have medical direction but that doesn’t mean they can go around working out side there scope of practice because they feel its needed. Our paramedics also complete a 3 year degree but have a lesser scope of practice on road to there level of education, this does not mean they can perform outside there scope.

[vs-eh?]

Agreed.

What procedure's are people talking about that they "can" or "feel they can" do (on whatever level, but apparently were are educated in said procedure), but are somehow restricted based on their current "protocols"? Please give me your grossly hypothetical and reasonably hypothetical situations...

I have standing orders to do a surgical cric and needle thoracostomy. Can I do them? Yup. Do I feel comfortable with them? Absolutely not. Will I do it? If all other airway solutions have failed or the patient is hemodynamically unstable secondary to the pneumo then yes.

Is it like having a patient in a pseudo unstable rapid afib or something and thinking that giving amiodarone would be of benefit, but you can't? I know that amio can be given to said patient, and I think it would work so I'll just do it?

I don't get.

Added to the fact that a proportion of US medics with potentially substantially less education have a higher scope to begin with is a little unnerving.

[akroeze]

Agreed.

What procedure's are people talking about that they "can" or "feel they can" do (on whatever level, but apparently were are educated in said procedure), but are somehow restricted based on their current "protocols"? Please give me your grossly hypothetical and reasonably hypothetical situations...

I have standing orders to do a surgical cric and needle thoracostomy. Can I do them? Yup. Do I feel comfortable with them? Absolutely not. Will I do it? If all other airway solutions have failed or the patient is hemodynamically unstable secondary to the pneumo then yes.

Is it like having a patient in a pseudo unstable rapid afib or something and thinking that giving amiodarone would be of benefit, but you can't? I know that amio can be given to said patient, and I think it would work so I'll just do it?

I don't get.

Added to the fact that a proportion of US medics with potentially substantially less education have a higher scope to begin with is a little unnerving.

I'll give you an example that happens in Ontario. A medic who is an ACP at one service and a PCP at another (BLS only) service. They get into a situation where they have a tension pneumothorax and are pretty sure the person won't make it to the hospital.... do they perform the decompression even though today they are wearing the uniform of a PCP?

[vs-eh?]

They can't.

The breaks of having a BLS only service. I wouldn't have some delusions of grandeur that just because I am an ACP in X service, that my education and experience should override the policies of a PCP only service. That is the DOCTORS and MUNICIPALITIES decision, not mine.

If this paramedic is an ACP in another service they realize going in that they will always be restricted (unless some type of patching system is set up, but it won't be).

People die, regardless of what you think MAY HAVE been beneficial, you are restricted to the service you practice in.