Basics Doing Advanced Patient Care - Good Or Bad?

[Timmy]

I don't think you understood my post. A medical assistant can give almost any medication in the IM route if they are told to, but they have almost no training in pharmacology whatsoever. Why is this possible? Because no knowledge of pharmacology is required for their job description, the physician is present during the procedure. This is exactly what medical assistants are for. While prescribing morphine as a physician, or deciding to use morphine using independent clinical judgment is not menial task, giving an IM injection is. The physician can spend her time educating the patient or writing the chart while the assistant gives the injection.

"In every instance, prior to administration of medicine by a medical assistant, a licensed physician or podiatrist, or another appropriate licensed person shall verify the correct medication and dosage. The supervising physician or podiatrist must authorize any technical supportive services performed by the medical assistant and that supervising physician or podiatrist must be physically present in the treatment facility when procedures are performed, except as provided in section 2069(a) of the code."

Are medical assistants allowed to administer injections of scheduled drugs?

If after receiving the appropriate training as indicated in Item 1, medical assistants are allowed to administer injections of scheduled drugs only if the dosage is verified and the injection is intramuscular, intradermal or subcutaneous. The supervising physician or podiatrist must be on the premises as required in section 2069 of the Business and Professions Code, except as provided in subdivision (a) of that section. However, this does not include the administration of any anesthetic agent.

I wasn’t having a go at you but the whole situation just seems crazy. From what is said on these forums in regards to the American Healthcare System you guys just seem so hell bent on hard, cheap and fast providers. You have EMT Bs running around doing emergency medicine and Medical Assistance running around administering dangerous and addictive medications to people with no understanding what so ever but its ok because the doctor ordered it! Not good enough! It doesn’t matter if the doctor ordered the Morphine the fact is the Medical Assistant is administering an injection so they are ultimately responsible for what happens to that patient.

Doctors give me medications orders all the time it doesn’t necessarily mean they’ve actually examined the patient, like you said, they can just be within the same premises. On the morning rounds the doctors have a quick 20 second look over the chart, ask the patient to take a deep breath and cough then scribble some new medications onto the chart or simply just give a phone order based on our nursing assessment of the patient or in some situations prescribe without even seeing the patient. You’d be pleasantly surprised how many doctors actually prescribe medications that are not indicated in a certain situation, prescribe medication when its not needed or prescribe medication that will interact with another medication, how can you possibly advocated for these patients when you have no idea about A&P, clinical assessment or pharmacology? How can I maintain a professional registration when I’m administering medications that I have no idea about?

You need to take accountability and responsibility by having a basic knowledge on the medications you’re administering to provide this patient with an optimal outcome… If this means taking a minute or two to look the medication up in the drug handbook and have a quick glance over its action, precautions, interactions and adverse reactions then that’s what needs to be done. If I’m not comftable in giving that medication to that patient then Doctor Jones can give it to the patient himself but at the end of the day if I give a medication to a patient and my initials are signed on that drug chart then I have to be 100% certain that I’m not causing any harm to the patient and that this medication is the right medication for this patient.

I could be in ED with Mrs Smith who’s been brought in with a fractured NOF, I do a quick assessment and report the finding to the doctor who’s within the same building or even ascertain a phone order because there is no doctor on site. The doctor orders 5mg of Morphine IV or IM STAT and will R/V the patient when his free. So I go ahead, draw up the morphine and have it checked by another RN, we then make our way to the patient with our 5mg of morphine but wait, Mrs Smith is a frail of lady who weights in at 30kg…

Do I:

A - just give her the 5mg of morphine because that’s what the doctor ordered.

Or

B – use my clinical judgement and education and say hang on a minute, if I give Mrs Smith this 5mg of morphine am I at risk of sending her into an altered conscious state or even respiratory arrest because I know her small body mass and metabolism will not cope with such a large dose and maybe I should just give 2.5mg now and 2.5mg a little later?

I’m not saying we live in a perfect world were there are no medications errors, fact is errors will always occur but we can’t come back and say we haven’t had the right education because were provided with ample opportunity in both our undergraduate training, graduate training and continued education programs to gain knowledge on what ever we want. If we haven’t had the training and education then I strongly recommend not doing it.

[BushyFromOz]

From what is said on these forums in regards to the American Healthcare System you guys just seem so hell bent on hard, cheap and fast providers.

To be fair timmy, we are not doing any better at the moment.... Brumby and co are really pushing the whole ACO and CERT thing along, trying to get their response time KPI's without having to actually pay for ambo's. Its not limited to the US, but the whole concept just pisses me off.

[maverick56]

Please read my posts I NEVER said an EMT should be doing anything ALS. I have stated repedatly that EMTs need more education then 120hrs. I have always said EMTs should have more training but NEVER,NEVER go beyond their SOP.

Also I never complained about Medics what-so-ever. In fact I respect them (check my posts) and hold them in high regard.

My quoted post was in response to another poster saying EMTs dont have the knowlege to make a decision to call ALS. Thats all. As Aeromedic stated some EMTs have many many years experience under the belts and can make informed decisions. On my squad alone we have 4 memebers that recently celebrated 25 years with the squad, several members at 10 years, and a few with 2 to 5 years. Now I am not saying the 2 to 5 year guys should be making judgment calls but surely the 10 and 25 year members sure can.

As for more medics... concidering NJ is a hospital based ALS state talk with the hiring hospitals, some dont want ALS units and the ones that do keep the amount to a minimum so unfortunatly its not the medics that are in short supply its the jobs.

Don't take this the wrong way, but I don't see this that as being something all that great. I understand that these folks have a great deal of experience and it does count for a lot, but I honestly see a real problem with anyone being an EMT for 25 years! Why?? Why stay at the lowest possible level? Maybe it's just me, my upbringing to strive for the best and never settle, I don't know. I just see someone who has spent an entire career as an EMT, never pushing beyond that, as failing in their mission to provide the best possible patient care. You should never stop learning. I see the career EMT-B the same as I see the 40yr old E-4 with gray hair and beer gut. Just getting by, no drive, and not the first to be trusted when the heat's on. And that may very well be an unfair assessment on an individual basis, but that's me being honest. I've met quite a few career EMTs (8+ years) locally and with every one, honestly, the first thing that entered my mind when I met each one of them was "why couldn't they cut it? what's holding them back? are they just lazy, complacent? don't want the responsibility?" And it had nothing to do with what I thought of them as a person. I know people can get the "I'm just a volunteer" mentality, but it doesn't matter - you're still responsible for people's lives! That means a responsibility to educate yourself continuously. I don't know, I guess I've never understood people who shoot for mediocre. I definitely don't think people like that are doing the industry any great service, rather, they are holding it back.

[Timmy]

To be fair timmy, we are not doing any better at the moment.... Brumby and co are really pushing the whole ACO and CERT thing along, trying to get their response time KPI's without having to actually pay for ambo's. Its not limited to the US, but the whole concept just pisses me off.

Yeah I know and it pisses me off too… I’m no expert on ambulance and I’m happy to be corrected but generally speaking an ACO is normally paired with an ALS officer? And CERT is generally backed by an ALS crew? It’s not like we have CERT officers transporting patients to hospital? At some stage during your transfer from the scene to the hospital your, generally speaking more than likely going to come into contact with at least one ALS officer? I’m broadly speaking here because I understand some remote areas have double ACO crews, resources are pushed but I don’t work in the industry, you do and you would have a better idea of what’s happening than me.

It always comes down to money over lives, I see it with you guys and how hard they push you, I see it at work with doctors and nurses who should no longer hold a registration but if we say something who will cover those shifts, I see Personal Care Attendants slowly migrating into acute care, Div 2s working in ICU, NEPT transporting high acuity patients, St John covering insanely high risk events in remote areas and so on…

It’s all very disheartening when you go to Uni, get all hyped up about best practise, putting your newly learnt skills into practise and being lectured about all these wonderful things that supposedly happen. I read the nursing journal about all the promises the government makes in regards to more healthcare professionals, better education and training and better pay only to go to work the next day and find everything comes crashing down into a underfunded, under resourced, under staffed and kayotic mess.

Anyway, I’ll shut up now before I dig myself a deeper hole lol…

[daedalus]

I wasn't having a go at you but the whole situation just seems crazy. From what is said on these forums in regards to the American Healthcare System you guys just seem so hell bent on hard, cheap and fast providers. You have EMT Bs running around doing emergency medicine and Medical Assistance running around administering dangerous and addictive medications to people with no understanding what so ever but its ok because the doctor ordered it! Not good enough! It doesn't matter if the doctor ordered the Morphine the fact is the Medical Assistant is administering an injection so they are ultimately responsible for what happens to that patient.

Doctors give me medications orders all the time it doesn't necessarily mean they've actually examined the patient, like you said, they can just be within the same premises. On the morning rounds the doctors have a quick 20 second look over the chart, ask the patient to take a deep breath and cough then scribble some new medications onto the chart or simply just give a phone order based on our nursing assessment of the patient or in some situations prescribe without even seeing the patient. You'd be pleasantly surprised how many doctors actually prescribe medications that are not indicated in a certain situation, prescribe medication when its not needed or prescribe medication that will interact with another medication, how can you possibly advocated for these patients when you have no idea about A&P, clinical assessment or pharmacology? How can I maintain a professional registration when I'm administering medications that I have no idea about?

You need to take accountability and responsibility by having a basic knowledge on the medications you're administering to provide this patient with an optimal outcome… If this means taking a minute or two to look the medication up in the drug handbook and have a quick glance over its action, precautions, interactions and adverse reactions then that's what needs to be done. If I'm not comftable in giving that medication to that patient then Doctor Jones can give it to the patient himself but at the end of the day if I give a medication to a patient and my initials are signed on that drug chart then I have to be 100% certain that I'm not causing any harm to the patient and that this medication is the right medication for this patient.

I could be in ED with Mrs Smith who's been brought in with a fractured NOF, I do a quick assessment and report the finding to the doctor who's within the same building or even ascertain a phone order because there is no doctor on site. The doctor orders 5mg of Morphine IV or IM STAT and will R/V the patient when his free. So I go ahead, draw up the morphine and have it checked by another RN, we then make our way to the patient with our 5mg of morphine but wait, Mrs Smith is a frail of lady who weights in at 30kg…

Do I:

A - just give her the 5mg of morphine because that's what the doctor ordered.

Or

B – use my clinical judgement and education and say hang on a minute, if I give Mrs Smith this 5mg of morphine am I at risk of sending her into an altered conscious state or even respiratory arrest because I know her small body mass and metabolism will not cope with such a large dose and maybe I should just give 2.5mg now and 2.5mg a little later?

I'm not saying we live in a perfect world were there are no medications errors, fact is errors will always occur but we can't come back and say we haven't had the right education because were provided with ample opportunity in both our undergraduate training, graduate training and continued education programs to gain knowledge on what ever we want. If we haven't had the training and education then I strongly recommend not doing it.

I knew you were not having a go at me, I am sorry if my earlier post had that sort of a tone. I know, it sounds crazy, but I do not see medical assistants as any sort of a problem in our health care system. The role they fill is very specific and they do in fact go through classroom training. They are the doctor office receptionists and assistants, not licensed providers. They are not allowed to do anything (including taking vital signs) with out a physician requesting so, and everything they do must be from express delegation from the physician.

Did I mention that MAs CANNOT work in an acute care environment. No hospitals. They can only give meds in an outpatient doctors office in non emergency situations. They exist to make life easier for the physician. They cannot work independently, cannot preform assessments. In this type of situation, you can guarantee that the physician has spent time in the room with the patient due to environment and workings of outpatient medicine.

EMT-Bs on the other hand, and paramedics who go through mill programs, are huge embarrassment for our country.

Edited June 28, 2010 by daedalus

[uglyEMT]

Don't take this the wrong way, but I don't see this that as being something all that great. I understand that these folks have a great deal of experience and it does count for a lot, but I honestly see a real problem with anyone being an EMT for 25 years! Why?? Why stay at the lowest possible level? Maybe it's just me, my upbringing to strive for the best and never settle, I don't know. I just see someone who has spent an entire career as an EMT, never pushing beyond that, as failing in their mission to provide the best possible patient care. You should never stop learning. I see the career EMT-B the same as I see the 40yr old E-4 with gray hair and beer gut. Just getting by, no drive, and not the first to be trusted when the heat's on. And that may very well be an unfair assessment on an individual basis, but that's me being honest. I've met quite a few career EMTs (8+ years) locally and with every one, honestly, the first thing that entered my mind when I met each one of them was "why couldn't they cut it? what's holding them back? are they just lazy, complacent? don't want the responsibility?" And it had nothing to do with what I thought of them as a person. I know people can get the "I'm just a volunteer" mentality, but it doesn't matter - you're still responsible for people's lives! That means a responsibility to educate yourself continuously. I don't know, I guess I've never understood people who shoot for mediocre. I definitely don't think people like that are doing the industry any great service, rather, they are holding it back.

Its a very simple answer actually. Here in NJ all ALS is hospital based. No squads, privates, or paid services are allowed to have a medic. If you want to be a medic you must work for the hospital. Not every hospital has an ALS unit and the ones that do have them, keep the number of medics ont he payroll very low to keep overhead down. Alot of carrer EMTs in the state do so because they work a regular full time job and cant afford to quit their job or carrer and persue the paramedic level of education and qualification with the uncertanty of finding a job when the become certified. I inquired about a medic level cert while I was doing my clinicals at a hospital with ALS. I told them I would be able to work nights, this way I could keep my carrer and continue my education, but was told unless I become a full time employee of the hospital I could not work for them. I said OK fine I can work a full time shift at night, they said no full time means I soley work for them that way they can schedule me whenever necessary.

This is the biggest problem in our state right now. Alot of folks want to become Medics but with such restrictions around folks stay as EMTs so they can keep their regular jobs. I feel this is a problem but until the State Board Of Health begins allowing nonhospital based ALS this will continue.

As for these folks not pushing themselves, yes some do the minimum, but most strive to continue their education and stay as current as possible with the latest in the field of emergent care. Just a quick not on our squads long timers, the 25yr person worked in the ER as an RN until retierment now serves our squad almost full time everyday. The 10yr folks are all ER techs with one in school right now becoming a PA. Some of the 2 to 5yr folks are younger guys and girls currently in college becoming RNs or PAs or higher. Using the experience on our squad to help further their understanding and education while in school. We also have a 7yr member that works for Medivac service as a flight medic and he is the one that complains the most about not being able to do his level of cert while on a BLS call with us. State regs dont allow him too. But with these folks and their experience in the fields of both ER and prehospital care I would not agree with them being mediocre.

Not trying to be crass or anything with anyone and again I will state unequiviclly that NO EMT-B should be doing ANYTHING ALS or beyond their SOP.

[EMS49393]

Its a very simple answer actually. Here in NJ all ALS is hospital based. No squads, privates, or paid services are allowed to have a medic. If you want to be a medic you must work for the hospital. Not every hospital has an ALS unit and the ones that do have them, keep the number of medics ont he payroll very low to keep overhead down. Alot of carrer EMTs in the state do so because they work a regular full time job and cant afford to quit their job or carrer and persue the paramedic level of education and qualification with the uncertanty of finding a job when the become certified. I inquired about a medic level cert while I was doing my clinicals at a hospital with ALS. I told them I would be able to work nights, this way I could keep my carrer and continue my education, but was told unless I become a full time employee of the hospital I could not work for them. I said OK fine I can work a full time shift at night, they said no full time means I soley work for them that way they can schedule me whenever necessary.

This is the biggest problem in our state right now. Alot of folks want to become Medics but with such restrictions around folks stay as EMTs so they can keep their regular jobs. I feel this is a problem but until the State Board Of Health begins allowing nonhospital based ALS this will continue.

As for these folks not pushing themselves, yes some do the minimum, but most strive to continue their education and stay as current as possible with the latest in the field of emergent care. Just a quick not on our squads long timers, the 25yr person worked in the ER as an RN until retierment now serves our squad almost full time everyday. The 10yr folks are all ER techs with one in school right now becoming a PA. Some of the 2 to 5yr folks are younger guys and girls currently in college becoming RNs or PAs or higher. Using the experience on our squad to help further their understanding and education while in school. We also have a 7yr member that works for Medivac service as a flight medic and he is the one that complains the most about not being able to do his level of cert while on a BLS call with us. State regs dont allow him too. But with these folks and their experience in the fields of both ER and prehospital care I would not agree with them being mediocre.

Not trying to be crass or anything with anyone and again I will state unequiviclly that NO EMT-B should be doing ANYTHING ALS or beyond their SOP.

Now that I live in Pennsylvania, I completely get your point. I moved here to take a job with a company that wanted it's own MICU. I was the first street paramedic hired. All of the other services in the area that are ALS are hospital based squad units. Aside from my company, there are only two other companies in the general area that have a MICU service, and they are RARELY hiring because of a low turn over. It takes an act of God to get hired by the hospital services, and you generally have to know people on the inside to get a spot. After almost a year, the company I work for is considering going back to letting the hospital provide ALS coverage rendering me jobless. Now, if I were an EMT-B, I could have my pick of jobs, as there are a pile of BLS companies in the area.

My point is that there are areas in the USA where being a paramedic is a detriment. I really never thought I'd end up unemployed as a paramedic. I always thought that if I did a good job, showed up for work, put in my best effort, and helped out when needed that I would always have a job. I only wonder if I will qualify for food stamps while I'm collecting my unemployment.

[uglyEMT]

Sorry to hear about the lack of employment. That sucks. But you are correct about our general area. It is a detriment sometimes. Again I am NOT advocating BLS doing ANYTHING ALS or ABOVE THEIR SOP. This general area does well with the BLS ALS thing but unfortunatly they do need more medics because the areas that these few medics cover is large and they are not always available. Hopefully one year the powers that be will wise up and change the status quo.

Our town is now talking with our current hospital ALS unit to see if we can have a unit staged at one of our towns squads thus offering a quicker response time then 20 minutes. Basically the talk is for the ALS to still be hospital based BUT during either the day or night have their second unit staffed and waiting in either of our squad buildings. At the end of the shift they would leave and go back down to the hospital. Its up to our medical director right now and the hospital to see if it will happen.

It is amazing to think that there are portions of the country that this is what is happening. Paramedics not having a job but BLS being a dime a dozen. It does create the whole "I will stay BLS just because" mentality. Thankfully though there are squads, mine is one, that stresses countinued education and maintaining skills. Im not just talking cookie cutter CEU classes but drills frequently involving other agencies and departments. Everything from water rescues (we work around a large lake) to MVAs to MCIs. Once a week we break out the training dolls and practice our PAs, CPR, lung sounds, ect. just to keep us proficient.

I know this doesnt make up for true education and I will never knock someone for going to the next level (which here in NJ is P, we did away with I a few years ago). I respect the medics I work with and understand all they went through to get where they are. I do not notice them looking down on us (EMTs) so much in general but the do "teach" the folks that are being mediocre. The medics I work with encourage an EMT to be the best they can within their SOP and like to see and hear from one when they get onboard. If you give them good vitals, lung sounds, PAs ect they actually invite the dialog and use it. If you BS through it, its the eye roll let the LP12 and my ears tell me.. you go sit down over there routine. When they are on board I pick their brains as much as I can. Not to be able to do what they are doing but as to why they are doing it.

I would NEVER try to do what they do but knowing alittle of the whys helps me understand the whats. If I have a difficulty breathing Pt with diminshed lung sounds and I let them know and they ask me what my assesment is I let them know honestly what I feel. If I am right they let me know and if I am wrong they let me know and explain why (not always in front of the Pt usually at the ED after the call). Thats good learning. When i watch them CPAP or other interventions and inquier as to why it actually does what it does vs what it does it helps me understand the body's response to the treatment and what to look for during continued assessment. It makes me a better provider that way. Again staying inside my SOP but advancing my knowledge of the human body and its functions and systems.

We come from many diffrent syatems here at this site, nationally and internationally, what works in one area doesn't sometimes in another. As was stated by the previous poster sometimes its detrimental sometimes its advantagous. We all work within our given system and make work what we have. Again I AM NOT ADVOCATING ON ANY LEVEL THAT A BLS SHOULD DO ALS ANYTIME ANYWHERE, I do feel American educational requierments are lacking, we strive twords minimalism, we rather have it quick and easy then long and right. But one thing we ALL have in common is our Patients, as long as we do the best of our ability and to the level we can then we will be the best advocate that we can.

AGAIN... BLS STAY INSIDE YOUR SOP AND DO NOT DO ALS WORK. If ALS asks you to lend a hand then by all means do what is asked of you BUT inside your SOP.

Edited June 28, 2010 by UGLyEMT