scope of practice question

[letmesleep]

I was afraid this approch would happen with that question. Any lawsuites that may occur from one stepping outside their scope of practice is NOT, and I repeat NOT protecting the Pt, or being a good Pt advocate, it is fall out from one who has been less than a good Pt advocate, nothing more.

My point of asking that question, and it should be aimed at ALL of us (educated and less than educated) not just Dwayne. When we are with a Pt and a MD denies our request for treatment, and we take it upon ourselves to treat anyways, or we are in an extreme situation with the Pt in front of us that may require us to push the limit, who protects the Pt at that very time? Who are we to just blow off the direction from the MD(for lack of a better term), and preform the treatment as we see fit? Where is the line if we have the power to do such a thing?

I do agree that we are with the Pt and can see their immediate needs, but there is more that goes into medicine than we are trained on, as medics. With that I will also say that DOCTORS ARE NOT ALWAYS RIGHT, and we do have to question their orders from time to time, but isn't that how medicine works? Do we not "bounce" ideas off of each other to provide the Pts with what they need? Yes, we have to be educated, and we do have to be able to make desicions on our own, but if we take the whole role of medicine on ourselves and delete the rest, then who protects the Pts from us? If we had all the knowledge of that MD, we wouldn't have the EMT-P behind our name, we would be called Doctor.

[chbare]

Perhaps we need to define the topic of scope of practice. My SOP as an RN is dictated by the state BON and in most cases SOP is rather vague and broad. So, I really have a difficult time relating to all of this breaking protocol talk. With that, I guess we are talking about Third Watch drama stuff? Guy rolls his car, arm is pinned, the flames are coming closer, his pregnant wife and crippled little daughter are begging you to do what needs to be done so daddy can come home?

This may come out sounding very bad and some of you may not have respect for my opinion or me after this; however, here goes:

Medicine is my lively hood. I have never had any other job. (Other than bagging groceries for a while in High School.) I only know this one area. This is how I make my living. This is how I pay my bills, ensure my wife and I have a house, food, transport, and medical care. This is in part how her daughter was able to attend college and prosper.

A few years back, my wife had a serious medical problem. Because of what I do, my insurance package, and the money I make, she was sent to a specialist. One of the best in the field. Now, she continues to live a full, healthy, and happy life. I need to continue to do what I do to ensure this continues. You see, what I do and the consequences of my actions effect so much more than just my self.

I am always going to ensure that I can take care of my family and my self first. Is this not why they preach scene safety and security in our courses? Are we not number one? When did this concept change?

I would have to think long and hard before I potentially throw my life and my families life away on performing a technique that I am not educated to perform.

[becksdad]

I am truly amazed at the level of debate produced by the original question - which was ridiculously insufficient in content. Way too open-ended a question. But the debate has been good.

First, it seems all agree that practice outside scope is nearly always a mistake, not to mention dangerous. I wouldn't want some rogue who makes all his/her own rules all the time practicing on me or my family. But there are circumstances......

One of the best examples I've seen here was where Ruffems spoke of reducing a dislocated knee with longstanding circulatory compromise. I have never been in a position where I felt I needed to manipulate a dislocated joint (except for my own toes). But faced with the same circumstance Ruff was faced with, would I have done the same thing? I think so. I would be uncomfortable and unsure of my ability, but I would try because I know that the patients limb is in imminent danger of being lost.

As for the burning car scenario - IF I could get close enough, yeah, the leg would go and the patient would come out. But I think we need to remember that we are speaking of circumstances so incredibly unlikely, that protocols, SOP's, and scope of practice are practically useless. These are simply HUMAN circumstances being referenced, not just MEDICAL ones.

That being said, I watch people practice outside certain "scopes of practice" every day. I work in an emergency dept. now, after several years on the road. In the ER, physicians order all diagnostics and treatments, nurses and techs carry out those orders. Do you think it really happens that way? Nurses routinely order tests and initiate treatments. Hell, even I order tests sometimes before a Doc has even seen a patient. Usually the physician is consulted before actually performing a test or treatment, and the physician NEARLY ALWAYS approves this. Of course, this is in a situation where the staff have all worked together for a long time, and a great level of trust and confidence exists. I know that this is an entirely different discussion than has been going on in the thread, but it kind of underlines how open ended and inflammatory the original question was, doesn't it?

So, in my typically over-worded way, I guess I am agreeing with AKflightmedic, who so succinctly answered the original question ("would you work outside your scope of practice to save a life?"). Maybe.

By the way, if I was the person caught in a burning car, tethered only by strands of tissue from a nearly amputated leg: I would rip the leg off myself, get the hell out of the car, use something to tourniquet my leg, gee, maybe I could even find some strands from the steel-belted tires and suture my own arteries closed. Then I would look for some help. That's what I would do in that outragously unlikely circumstance while folks sat around debating whether to save my ass or not.

All tongue in cheek there, folks........ It's been a long time since I've been around the city, haven't had a computer for over a year now. I live in the stone age mostly....... but it's good to be back. Hi to all the folks I have missed.

[Doczilla]

Has everyone simply forgotten what the question was? And if so, why do we continue to go back to the "you're a menace" point of view?

In the general order of things, IF WE STAY ON TOPIC, it's seems simple to me. We have an acute pt that is near death. If we act outside of our scope, he lives (Implied by the question I think) If we don't, he dies (Dito).

The vast majority have chosen to sit by and allow him/her to die, neutered by the fact that acting in the PT's best interest could possibly cause them issues in the future.

So perhaps we're all just seeing the question differently.

Let me ask...

You are on scene of a critical, acute pt that you've determined after a thorough assessment is CTD. All SOP interventions have been exhausted, medical control can not be reached.

Using your education and experience you KNOW that you have an intervention that will in all likelihood reverse this person's fortune and allow then to live without deficits to the natural ending of their lives. Of course fire is there, along with the family, so there is no possibility that your intervention will go unnoticed, you will have to pay the price for saving this life....

What will you do?

Or you might pay the price for mangling a patient and making a bad situation worse. This discussion of knowing one's limitations. You can't expect to competently perform a complex intervention on a patient that you have not been adequately trained on. That's the problem of KNOWING that an intervention, with which you have passing familiarity, will save your patient's life. Will it really? Do you know for sure, or at least what the chances are? On a procedure which you have not performed and are not authorized to perform, and have not been formally trained or at least trained only once a long time ago briefly in an ACLS class? Do you know exactly the indications and contraindications and pitfalls of the procedure? Roberts and Hedges might make it look easy, but there are greater questions that you have to know the answer to before pulling out the scalpel/needle/drugs. The "I have the tools to save him but not the authorization" is an extremely unlikely scenario, particularly when you consider that the "tools" also include the required knowledge.

For your "can't contact medical control" issue, medics are usually expected to continue with the protocol as if med control had been contacted.

There is a BIG difference between giving a drug that you frequently give but which doesn't EXACTLY fit the protocol (no protocol can cover every conceivable situation) and going off the reservation with a procedure that you don't ever do.

'zilla

[p3medic]

I had a situation that might qualify. 40 yo male, single stab wound to the L chest, just below the nipple, holding himself up off the sidewalk with one outstretched arm, cyanotic and non verbal with JVD to the jaw, loses consciousness. We started to ventilate pt, clear bs with ventilation w/good compliance, sinus tach 130's w/o palpable pulses. Drop a needle into his L chest, no change, I am sure this guy has a tamponade, however pericardialcentesis is not within the paramedics scope of practice in my state. I have been educated on the procedure and have performed it in ATLS and in live animal labs and it crosses my mind that it MIGHT help, certainly not going to hurt at this point. Anyway, I don't perform the procedure, he gets a thoracotomy on arrival to the hospital and his pericardium is opened and evacuated, taken to the OR were he expires. Did I do the right thing? I don't know. Would he have survived if I had done it? Don't know. I do know that I sleep ok at night knowing I did everything I could within bounds of my authorized level of care.

[reaper]

Do you even carry the needle and clip, to do it?

[vs-eh?]

p3, you should sleep well at night.

Again, I'll wait for some medical scenario's (not once in a career trauma) that people are willing to step outside their scope of practice for...

Clinically the patient appears to be hyperkalemic (and say somewhat unstable) - are you busting out that bicarb that you "know" should be administered?

Do you administer 0.8mg of SL NTG to that CHF patient when you can only administer 0.4mg as per your "protocols"? Better yet do you mix a bag with NTG to give IV? I honestly don't know if you can mix metered dose NTG and mix it in a bag to give say a 4mcg/ml bag. This is just for arguement sake.

Do you administer glucagon IV to that query betablocker OD without any orders?

Wait...That CHF'er was actually a pneumonia patient and you killed them with your awesomeness.

Kudos.

Go ahead hero...

[Mateo_1387]

I beg to differ, I have seen a few law SUITES that were focused on medical malpractice, so I am sure that covers EMS as well.

However, as far as actual lawsuits, the reason you will not see or hear of too many, is because they settle out of court many, many times. Previous counties I have worked for, always settled out of court as it is much cheaper in the long run and draws much less public scrutiny.

I was not aware of the number that are settled outside of the courtroom. It is just not something that I hear of all that often. That being said, education is what is left to protect the patient. If you do what is right for the patient, with your level of education, then education acts as the protector.

law SUITES

Aww hell........my bad :oops:

Any law suites that may occur from one stepping outside their scope of practice is NOT, and I repeat NOT protecting the Pt, or being a good Pt advocate, it is fall out from one who has been less than a good Pt advocate, nothing more.

The way I see, lawsuits protect patients by placing fear in the provider if they "screw up.".

All tongue in cheek there, folks........ It's been a long time since I've been around the city, haven't had a computer for over a year now. I live in the stone age mostly....... but it's good to be back. Hi to all the folks I have missed.

:shock: He does live !

[Michael]

As for the burning car scenario - IF I could get close enough, yeah, the leg would go and the patient would come out

Damn. Just my luck.

By the way, if I was the person caught in a burning car, tethered only by strands of tissue from a nearly amputated leg: I would rip the leg off myself, get the hell out of the car, use something to tourniquet my leg, gee, maybe I could even find some strands from the steel-belted tires and suture my own arteries closed. Then I would look for some help.

I see.

All tongue in cheek there, folks

And whose cheek might that be this time?

[letmesleep]

The way I see, lawsuits protect patients by placing fear in the provider if they "screw up.".

I see your point, but wouldn't you agree that this is the wrong way to practice medicine? Would it NOT be a safer (for the Pt) practice to be more concerned with how you can negatively change someone's life instead of how much it may cost you later? The fear should be doing harm to your Pt, not how they are going to take control of your life in the next year, thus lawsuits being fall out of poor Pt care.