Ruminations on earlier threads.

[Just Plain Ruff]

Ok, I am sort of asking this in a new thread but not sure where it will lead.

It was stated in a previous thread and I'm quoting from the earlier thread credit goes to FFEMT4100

Adapt,improvise and overcome.Let's face it , this happens all the time and everyone knows it.Bid deal, who cares and yes it is what was best for the pt.With that said i have seen alot, right or wrong the pt. is my priority!!!!

Here is my question:

If it is what is best for the patient, right or wrong the patient being my priority(paraphrasing above) what would you as medics/emt/flight crews and doctors do that might cross the line.

If I read the quote from FFEMT right, and forgive me if I'm putting words in his/her mouth but it sure sounds like you would do anything for the patient be it right or wrong.

So,,, to this community I ask, where do we draw the line? We have an EMT pushing meds on request of the medic in a previous thread by NREMT

I witnessed a EMT - Nursing Student run a full cardiac arrest from starting the iv to giving the meds to intubating and shocking the patient. The Medic just stood there and took orders from this emt/nursing student. (background on this call - medic and emt partner were long time partners and the emt was going to nursing school. I was the new hire EMT so I just went along with things cause I was too new to understand at the time that what they were doing was wrong - I'm older now and know better)

I know that this sort of thing happens all the time according to the thread and this disturbs me in the greatest sense. Not only does it put our licenses on the line when we do something like this it puts your career and the reputation of the service you work for on the line. If word gets out that people for a certain service are practicing outside their scope of practice then litigation begins and a service can be ruined for this.

Well off the soap box - Where do we draw the line at acceptable behaviour?

Just questions that have been going around in my mind.

Dust, come knock some sense into me mkay

[Ridryder 911]

One has to use good "common sense". Does this mean I will not apply oxygen if I am assisting an EMS off duty or even establish an IV in the same predicament ?

There is a difference in performing unnecessary risks and being a fool. The difference is again wise judgement.

I personally do not like Rescue Randy that are presumptuous off duty, at the same time I really do not like those that are "bound by the book" of protocols and procedures. Sometimes in this business one has to have "gonads" (sorry, not to be sexist) and break the rules in the best behalf of the patient. Otherwise, nothing ever gets changed ...

I was the first Paramedic in my state that diverted from local facility to another appropriate facility which was quite a bit of distance. Yes, many wanted me to be "burned at the stake"; and if it was not for some "gutsy" physicians that proved my decision was right, I would be non-licensed. Ironically, afterwards the state changed its policies and now it is a common protocol (which, I got to write :wink: ) ..

There is no "right or wrong" answer. It goes there is a time and place.... knowing when is the hard part. It comes with experience, maintaining competency, and again wise critical thinking skills that only comes with practice.

R/r 911

[nsmedic393]

Yes, I have operated outside of my scope of practice. One thing i believe in is standing behind what you do so i will tell you about it.

As a basic on a few occasions I pushed meds for my als partner. Never while i was working by myself, it was always a joint decision between myself and my partner as to what drug to give and it was not always in a case of absolute necessity.(sometimes it was just due to what side of the patient I was standing on) As I have mentioned before, and as in rids case, these type of situations were reviewed by our medical director and now we have a province wide policy that BLS providers can administer medications at the direction of their ALS partners.

I have diverted to a regional hospital above a semi-rural hospital due to the patients presenting condition. I believe it was a stroke and annother was a broken femur. Both times i did call online medical but well after we were underway.(too busy)

We had a protol change a few years ago for giving Lasix. It seems that an alarming ammount of medics were having a problem differentiating CHF from pneumonia so the powers that be restricted lasix use to patients already on a diuretic. I personally believe this is punishing the patients instead of the stupid medics and have on a couple of occasions given lasix to patient who needed it but was not on a diuretic already.

I would also like to add that none of this was covered up or falsified in my PCR. It was all included in my report to the hospital, my PCR and answered for during call review in some cases.

[vs-eh?]

I will restate and expand my previous answer in that thread...

Approach your medical director/base hospital physician and ask for your standing orders/protocols to be ammended to allow BLS/lesser scopes of practice to do any procedure that is outside of their scope. Give all the stipulations under which you would allow BLS/lesser scope to administer medications (like it already apparently does that's "ok"). Tell them that you also concede that you will outline on the form when and why this had to happen. Ask them to do this...or see what they say...

My friend out east has a fine policy in place. But keep in mind it ONLY applies to pushing drugs and in the end, the advanced provider can refuse AS CAN THE LESSER SCOPED PROVIDER. That plus good QA/QI...

Here is the link to our policys, it is the last one on the list #6174. EHS Policies

Generally speaking in Ontario, their is only ONE ALS provider on the scene of a cardiac arrest (as an example of a multi ALS procedure call, not necessarily hard). That paramedic intubates, starts the IV, pushes drugs, sets up dopamine if needed, etc... Now they have a (usually) educated PCP partner and 3 (we'll say EMT Bish) FF. However, the ACP is the ONLY one that that can do the listed procedures, REGARDLESS OF THE OTHERS EDUCATION OR BACKGROUND. If they are not a recognized ALS provider in ambulance working at that moment, they cannot do any ALS procedure, or if they choose to and the on duty ACP says it's ok, they basically MUST call the base hospital ASAP to confess. This latter is an EXTREMELY rare instance, not as the apparent "common" occurances that my friends in the US have. Anything less and you risk WAYYYYYYY too much... It's not worth it AT ALL. There are PLENTY of PCP's that have ACP education or may even be finished school and are "in limbo". There are even CCP's (like my man Lithium) that practice FAR beneath their potential/past scope. They can't simply do things because they are educated to without calling a doctor, etc...

If you think that you as a higher scoped provider can simply delegate to a lower scope that has NO STANDING ORDERS OR PROTOCOLS OUTLINING THAT PROCDURE. Then simply document who actually did the procedures as they actually happened. If you don't, then you know it is wrong and very likely illegal.

Simple

[1EMT-P]

From a medico-legal point of view the answer is no we cannot practice outside of our scope of practice, because that my friends would be considered practicing medicine without a license. It would be nice if we were allowed to have a more flexible scope of practice, but the truth of the matter is that the lawyers & politicians have limited what we can & cannot do in the field.

[Ridryder 911]

Actually, in the U.S. most do not have a true "scope of practice. There is a difference between protocols and "scope of practice".

Remember, the "scope of practice: was shot down.

R/r 911

[emtkelley]

I have never had the situation come up but I can tell you this: I worked too damn hard for my licence to have it taken away. I am working even harder to obtain my Paramedic. I will do almost anything for my patient (short of practicing outside my scope) but how will I serve my other patients when I am still mixing Mojitas at the bar after losing my licencure because of poor decisions?

[AZCEP]

Perhaps thinking critically isn't a popular activity for prehospital providers, but when it is used correctly it is very useful.

Rid makes a good point regarding the actual lack of a national "scope of practice". Many locations are operating with the understanding that DOT/NHTSA have a set of rules for what is allowed. Unfortunately, they don't. The DOT curriculum from '99 is the closest you get.

I can't count the number of times that I've thought and done things that many wouldn't consider. Just a few examples:

--Lidocaine for pre-intubation. At the time, unheard of locally.

--Magnesium for refractory bronchospasm. Again, not in protocol, and eyebrows raised during review.

--Epinephrine infusion during cardiac arrest. Amazing what a little math can do for you.

--Benadryl for pain relief/sedation. Maybe it just looked like they were itching.

--Overdrive paced Torsade at 165/minute. Luckily, the pacer was able to capture it.

There's probably more, but that should be plenty for now.

Until the patients that want my help decide that they will follow the protocols that are in place, I don't feel a particular need to give them the ability to decide every step that I will follow. Some providers need the structure that protocols provide, some don't. Patients don't want to follow the rules that I do, why should I force treatment on them that I'm reasonably sure isn't going to work?

[nsmedic393]

As for the question of where to draw the line, I say let someone else draw it for you. If your medical director would hang you out to dry for operating outside of your protocols/scope than I would suggest you not do that.

Here we have always been given the benifit of the doubt and our director and QCMs have been very understanding when we have needed to bend the rules a bit for the sake of the patients. In some cases we bent the rules, explained why and then the rules were changed.