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Scope of Practice

Discussion in 'Firefighter/EMS Talk' started by FirNaTine, Jun 22, 2006.

  1. FirNaTine

    FirNaTine

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    I am interested in what the varying scope of practice for different levels of providers are. I am a NREMT-I '99. In Maryland I am licensed as a Cardiac Rescue Technician, but for short most jurisdictions refer to us as medics as opposed to paramedic for our NREMT-P's. There are some differences in consult requirement meds but the main difference is nasal intubation and needle/surgical cric's are p only skills and haldol / benzocaine spray (for nasal tubes) are p only drugs. The rest of the scope is the same for p's and i's. RSI is an optional program for p's only however most p's are not trained and certified on it.

    As far as BLS emt-b's are allowed AED usage, assist with NTG and albuterol, assist or ems service epi-pens, charcoal on consult, opa and npa adjuncts. IV access and glucometer usage is a local option.

    My personal scope: NREMT-I '99 in Maryland

    Drugs: c = consult so = standing order
    All meds listed are those carried by EMS

    adenosine - c
    albuterol - so
    aspirin - c
    atropine - so
    atrovent - so
    calcium chloride - c
    D50/D25(peds)/D10(newborn) - so
    diazepam - c
    diltiazem - c
    diphenhydramine - so
    dopamine - c
    epinephrine Iv/Sc/ - so
    epi neb - c
    furosemide - c
    glucagon - so
    lidocaine - so
    morphine - c
    narcan iv/im/intranasal - so
    nitroglycerin - so
    sodium bicarb - c
    terbutaline sc - so

    These are for primary uses and most circumstances, for example glucagon is standing order for hypoglycemia,
    but is consult for calcium channel blocker overdose.

    Selected Skills:
    Iv access limb and external jugular - so
    intraosseus - so
    EKG 3 lead and 12 lead - so
    defib/cardiversion/ pacing - so
    capnography - so
    combitube (dual lumen airway) - so
    cpap - so
    Orotracheal intubation laryngoscopy and forceps- so
    Needle decompression thoracostomy - c
     
  2. akulahawk

    akulahawk

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    I used to work in Sacramento County, California. We don't use adenosine, atrovent, diltiazem, intranasal Naloxone, or terbutaline. We also don't use CPAP or do Adult IO and can't do RSI. We do Nasotracheal intubation and can do stomal intubation if necessary. Everything else on your list is (at some point) standing order for Paramedics. A lot of the protocols have a combination of standing order / base consult. It's basically, standing order to a point and then a consult to proceed further. For interfacility transfers, usually the entire protocol is available. At the point where the 911 medic has to call for a consult, the interfacility medic just proceeds as if no consult was necessary. Then again, in most areas of the county, the farthest hospital is around 20 minutes away. You really don't get that far down the protocols, usually. Only with trauma patients is this going to normally happen. There's 2 trauma centers in the county, 3 authorized trauma destinations total, and only in dire circumstances (can't intubate/ventilate) can the medic just go to "any" hospital.
     

  3. FirNaTine

    FirNaTine

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    Some of those are rarely used. The intranasal narcan is mainly for IV drug abuser that have no available veins, while not officially stated it lets you wake them up without having to expose an IM site and potentially get stuck or have them get violent. The adult I/O I haven't even heard of being used. If we need a line that bad and cant get a limb vein we go for an EJ.

    If you don't use atropine or diltiazem do you use something else for svt / afib or do you cardiovert them?
     
  4. DaleGribble

    DaleGribble Sandwich!

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    I'm I-85 in SC and the only things I can use on SO are Oral Glucose and D50. I can administer Activated charcoal with online med control orders.

    I can do PT assisted meds with a few things, but that requires online med control orders.

    I've got a few skills I can do on SO.

    Endotrachial Intubation
    Nasal Intubation
    Laryngoscopy with forceps
    IV therapy in upper extremities and EJ's, lower extremities require online med control orders.
    And last but not least, IO in pediatric pt's.

    This state doesn't recognize I95 and probably never will!
     
  5. akulahawk

    akulahawk

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    Sternal IO is a useful (limited though) tool to gain vascular access. This is used when you can not get ANY line - even an EJ. This is not really used anywhere in California, but it has been studied and IS in service elsewhere in the US.

    As far as IM Narcan, my experience with it is that you can generally get a site without too much difficulty. However, the intranasal route would provide a reasonably slow absorbtion and keep the patient from waking up too quickly.

    As far as our non-use of ADENOSINE or dilt, we basically use a stable/unstable protocol that is based on level of consciousness. If the patient is stable, we do the usual stuff stuff - mainly a fluid challenge and perhaps a valsalva. If we feel the need to cardiovert, we would have to get an order to sedate and cardiovert. If the patient is unstable (read altered or decreased level of consciousness) we can just simply cardiovert. This is what they came up with. I've seen adenosite and dilt work. They're quite useful and do work as indicated.

    We use atropine for bradycardias and we can pace if we max out the atropine or the patient is refractory to atropine (after the 1st dose). We also use atropine for nerve agent exposure / organophosphate poisoning. Atropine is good stuff.
     
  6. akulahawk

    akulahawk

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    I always thought that there were two kinds of NREMT-I's - the 85 and the 99... :supergrin:

    Out here in California, EMT-B's (EMT-1's) can administer oxygen and oral glucose. There is no provision for EMT-B's to use OLMC. EMT-I's (we call 'em EMT-2's) are not very common here. Some of what they do is done on SO, but mostly that's for cardiac arrest and hypoglycemia. Pretty much anything else is on OLMC.

    Santa Clara County is going to an expanded scope EMT-B. That scope of practice is almost EMT-2 without IV's. Basically they want the EMT-1 to handle chest pain, bronchospasm, and VF/VT, with the meds/equipment to match.
     
  7. hirundo82

    hirundo82

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    How do they expect them to handle VF/VT refractory to defibrillation without IV access?

    I volunteered as an I-99 in a rural area of Virginia. There was very little differentiation between us and paramedics.

    Meds:
    Aspirin (any EMT-so
    adenosine-so
    albuterol-so
    Atrovent-so
    atropine-so
    calcium chloride-c
    D50/D25/D12.5-so
    diazepam-so
    diphenhydramine-so
    dopamine-c
    epi 1:1000 SC-so
    epi 1:1000 neb-c
    epi 1:10,000 IV-so
    furosemide-so
    glucagon (any EMT)-so
    lidocaine-so
    mag sulfate-so
    methylprednisolone-so
    metoprolol-c
    midazolam-so
    morphine-so
    naloxone IV/IM-so
    NTG SL/TD-so
    promethazine-c
    sodium bicarb-so
    vasopressin-so

    Some of these--especially the narcs--require med control for repeat doses.

    Skills:
    IV peripheral and EJ-so
    Preexisting central line access in code-so
    Combitube-so
    crichothyrotomy (Melker kit)-so
    orotracheal intubation (including gum bougie)-so
    defib/pace/cardiovert-so
    Sternal IO pts>16y/o-so
    tibial IO pts<8y/o-so
    orogastric tube-so
    needle thoracotomy-so

    Paramedics could also nasotraceally intubate and do a surgical cric. No consult differences between EMT-I and EMT-P. I think they are thinking about adding RSI for selected EMT-P's.

    It was really nice to have that kind of latitude; I can count the number of times in the 5 years I was there that I had to call for orders on one hand.
     
  8. FirNaTine

    FirNaTine

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    Sorry, my previous post should have read adenosine and diltiazem not atropine. I see you caught that. Our protocol is more of a stable gets drugs unstable gets cardioverted.

    We use atropine for bradycardia and organophosphate / nerve agent poisoning also. (We also carry mark I kits but just enough for the crew)

    As for adult IO we currently use the ankle instead of the tibial IO common in kids. Our state police (MD's primary medevac) are using some type of "quick IO" tool and I believe somewhere here they have tried the sternal IO.

    I have only given naracan IV, but the advantage of not having to remove sombody's clothes and finding their "hypo kit" was explained to me by a Baltimore City medic who has handled more heroin od's than I probably ever will. He also mentioned that they have a huge HIV / Hep problem there and that it is one less contaminated sharp to deal with. The city has such a heroin problem they even considered teaching IVDA's to buddy administer narcan through the nasal route. Lately though there has been fentanyl analogues making their way around here. Instead of the ususal .4-2mg naloxone, we are being told to start at 2mg and consult up to 10mg for suspected fentanyl ananlogue od.
     
  9. hirundo82

    hirundo82

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    Do you actually have a special delivery system for the nasal Narcan, or is it the aerosolizing tip that fits on the end of a syringe that I have seen advertised?

    If the latter, I would think that there would be all sorts of other meds you could use it to deliver. I'm thinking BZD's for seizures for one--it is always fun trying to stick someone in status epilepticus.

    Are you using any sort of device for your ankle IO's, or is it the same "screw it into the bone" method that we are taught for pedi IO's? I was trained on sternal IO use but never got to use them before I left EMS; there did seem to be some issues still to be worked out with them.
     
  10. FirNaTine

    FirNaTine

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    Narcan- just a nasal atomization device on a syringe. Discussion of what else may work in that has taken place...

    IO - same needle as peds, altough we do carry more than one size IO 15g and 18g with different lengths of the top of my head. None are specifically marked peds or adult.
     
  11. DaleGribble

    DaleGribble Sandwich!

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    SC doesn't recognize I99 either! :supergrin:
     
  12. akulahawk

    akulahawk

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    Actually, they don't expect them to handle that... the protocol is basically spark'em x3, make transport decision simultaneously (is ALS or ED closer), load and run like the proverbial bat out of hades or sit & wait for ALS. The "EMT-Advanced" (an expanded scope EMT-B) protocols are designed basically for private emergency calls or interfacility transports that "go south".

    The tx protocol is 3 sets of stacked shocks with CPR between the sets. After 9th shock, the AED shuts down. BLS transporting such a patient SHOULD be pretty rare. Most of the Fire Departments have ALS engines now. They don't transport on the engine, but the medic CAN jump on a BLS unit and treat en-route.

    What that county now has (for a couple years now) non-911 ALS units now. Until a short time ago, all that was available was either 911 ALS system units OR a BLS unit OR an RN staffed CCT unit (rarely did prehospital stuff).

    Otherwise, most of the meds you listed are on SO for that county. Methylprednisolone, atrovent, metoprolol, midazolam, promethazine, and vasopressin are not used in Santa Clara County. No sternal IO, No gum bougie (otherwise OTI ok), no gastric tubes. Needle cric only.
     
  13. akulahawk

    akulahawk

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    Depending upon the county, there can be a great difference between EMT-2's (EMT-I's) and Paramedics or very small differences. The counties that don't have much of a difference typically have an EMT-2 based EMS system and very few Paramedics. There's only a couple counties that still even HAVE EMT-2's now. The primary reason is that those counties that still have primarily -2's is that it's cheaper to have a lot of -2's than a lot of medics. The call volume doesn't quite support the costs of Paramedics. Generally, the -2's have sufficient skills to handle things in those counties. If they are "in over their head", all they have to do is call in a helicopter. Yep, they're rural enough that when a helicopter is needed, it makes a huge difference. In those instances, you're looking at a large skill difference and a large time to hospital difference, even with the extended distances involved.

    In some counties in Northern California, you'd be looking at about 20-30 minutes to get to the scene in a helicopter, once launched. In some of these areas, it would take a couple HOURS to drive the patient to an appropriate hospital. Sometimes the local facility will do, and the helicopter isn't called in for those. Sometimes the closest facility really IS a long drive away.
     
  14. TraumaOne

    TraumaOne

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    Anything I order and anything I see fit to do. :;)
     
  15. Mickmedic

    Mickmedic Drug Pusher

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    I live, work and teach near Raleigh, NC.
    Many people think being from the South makes you backwards...but after seeing these various lists, I guess we are actually pretty progressive. This is the list from the NC Medical Board formulary and approved skills. Actually there are quite a few other drugs and skills on the list, but this is what we mainly use in my service.
    Each county (all 100 of them) has it's on Medical Director and you operate under his/her liscense and protocols. Most of the skills and meds are standing order (including narcs), but my county is implementing the P1/P2 system (P2 being higher qualified); Basically the P1s have to call for orders for RSI, Cardizem and Labetalol.

    EMT-B = BLS ;Assist with some meds, AED ,12-Lead acquire ,Combitube/LMA

    EMT-I = IV, Monitor/Defib,12-Lead acquire, Med admin, Intubation

    EMT-P = IV/IO (ped and adult), Med admin, Intubation, RSI, CPAP, Needle thoracotomy, needle/surgical cricothyrotomy, Capnography, Monitor/Defib(12-Lead acquire/interpret), access central lines/porta-caths

    ACE inhibitors (Captopril)- P
    acetaminophen -B/I/P
    adenosine -P
    amiodarone -P
    anti-emetic preparations (Phenergan)-P
    aspirin -B/I/P
    atropine -B/I/P
    benzodiazepine preparations (Valium/Versed) -I/P
    beta agonist preparations (Albuterol)-B/I/P
    beta blockers (Labetalol)-P
    bretylium -P
    calcium channel blockers (Cardizem)-P
    calcium chloride/gluconate-/P
    charcoal -B/I/P
    crystalloid solutions (NS/LR)-I/P
    cyanide poisoning antidote kit -P
    diphenhydramine -B/I/P
    dopamine -P
    epinephrine(1:1K/1:10K)-B/I/P
    etomidate -P
    flumazenil -P
    furosemide -P
    glucagon -I/P
    glucose solutions -B/I/P
    ipratropium -I/P
    lidocaine-P
    magnesium sulfate -P
    mannitol -P
    narcotic analgesics (Morphine)-P
    narcotic antagonists (Narcan)-I/P
    nasal spray decongestant (for nose bleeds)-B/I/P
    nitroglycerin -B/I/P
    non-steroidal anti-inflammatory (Ibuprofen)-B/I/P
    oxygen -B/I/P
    paralytic agents (Succinylcholine)-P
    pralidoxime -B/I/P
    sodium bicarbonate -P
    steroid preparations (Solu Medrol)-P
    thiamine -I/P
    vasopressin - I/P

    Im a medic instructor, but mainly teach EMT-Is and the merit badge classes like PHTLS, ACLS and PALS.
     
  16. akulahawk

    akulahawk

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    Really, it's not that California thinks that the rest of the country is backwards, it is that the State of California trains it's pre-hospital providers to the lowest common ability instead of educating them to current capabilities. The medics here are taught how to pass the NREMTP test and that's about it. In essence, what you get here in California is a whole lot of "cookbook" medics and few medics that actually think through the problem and treat based on their findings. The field training generally reinforces the cookbook method because the FTO's can be VERY, VERY insistent that the Intern knows the local protocols verbatim instead of teaching them HOW to be good, safe new medics and therefore medics that are able to adapt their training and knowledge quickly to a new environment or county.

    So, the real end result is that MOST of the State of California is about 20 years behind the rest of the country as it pertains to pre-hospital care.

    Added: also each county is it's own completely separate EMS system (usually) and the state "Basic Scope of Practice" for Paramedics is changed according to what each county wants. Just one state North of us is Oregon... they have a state-wide scope of practice and protocols.
     
  17. D25

    D25 The Quick

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    I wish that were true. Oregon has a state-wide scope, but each county, and in some instances, each agency makes their own protocols which are not to exceed the state scope. I came from a very progressive agency with wide open protocols, to one with extremly outdated, cost-based, not patient-care based, protocols. Bertylium? Verapamil?

    It's not just Cali.
     
  18. fyrman

    fyrman

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    I am a FF/P here in Oregon and we carry almost all of the drugs listed in this post. The only drugs we have to call medical control for is charcoal, and vecuronium unless you're talking about a pediatric patient. The use of pain management in a trauma patient or abdominal pain is the only call in order when it comes to narcotic meds. In our system it is a requirement that all patients with a GCS of 8 or less get intubated and no medical consult is necessary. We also have the sternal I/O and its only used when you cant obtain any other means of access with the exception of a cardiac arrest on a water rescue incident and then it can be a first line if the medic decides to go that route.
     
  19. D25

    D25 The Quick

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    Where are you? SFLS?
     
  20. SLIDER in KY

    SLIDER in KY Millennium Member

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    I'm a Paramedic in KY. When it comes to IO's on adults, we have the sternal IO's as well as the new "electric drill" from VidaCare. The Vida Care IO can be placed in the tibia or shoulder. Lot's 'o fun!!! They just have to be run with pressure bags to get into the marrow.