Question for Medics/Intermediates.

[Dwindlin]

I apologize as this may turn out a tad longer than I intended.

So earlier in the year the department I work for had a major blowup over an incident I would like to get some others opinions over. It revolves around a member who recently became a medic, and has been (in my personal opinion anyways) malignant to the department since a recent leadership change.

Anyways, the situation. The new chief (also a medic) and a EMTB respond to a person down in a bathroom. They arrive find them in cardiac arrest. We run 2 person crews with no engine response so while the basic began CPR, the jumped on the radio and calls for additional members to respond. By the time a third person shows up, the monitor has been applied (patient in asystole), and an IO in place. Anyways code is running very smoothly. Once the 3rd arrives they take over CPR and the medic asks the EMT to push a round of ACLS drugs while they are securing airway.

So while this is occurring this new medic (the malignant one!) shows up and begins to help in the code. Anyways, call progresses very smoothly, no issues brought up or anything mentioned during post call cool-down session.

Month later, we receive notice that a complaint was filed by the malignant one to the state against the new chief for having a EMT push the drugs.

So my question is how many medics/intermediates have deligated this to a EMT partner they trust? Personally I assumed this was a common practice and do it frequently with EMTs that (again) I trust.

In the end the state did nothing (as I'm sure they had bigger problems to deal with) but I was simply curious.

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[MediumDef]

Hmmmmm, tough one.

Does this happen all the time? Yes
Is this extraordinarily contrary to regs? Yes

I'm actually surprised the state did nothing since in my experience their pretty militant about basics handling needles and drugs.

All that being said I'll be surprised if your malignant medic doesn't wake up one night for a call only to find a steamer in his boot. The only reason to file a report in this instance is specifically to try and get people in trouble since it is definitely pretty standard practice especially in P/B setups to give the basic a little latitude once you hit the back of the truck since the hands are more important then who their attached too.

 

[TerraMedicX]

I've gotta agree with MediumDef, I'm surprised the state did nothing. This was actually been a fairly widely talked about problem in Colorado back when I was practicing there, and a number of people lost their certifications because of similar incidents.

Now, knowing that I was pretty careful in my time not to let basics push meds, even if I thought it was complete BS that they couldn't and even if I cut my teeth in EMS doing just that as an EMT...hell I had one partner who would nearly let me run anything short of a full COR on my own! When short of medics on scene I would usually just have my basic start the IV and then draw up the medications and hand them to me at the head. I could take a few seconds to push the med myself and as long as I trusted the basic, drawing up the med isn't illegal.

Personally I think that the pendulum swung WAY too far back the other direction and we started to be far too strict about that. Hopefully in the next few years we can relax back to a happy medium!


Nate.

 

[Paseo Del Norte]

I cannot really say anything productive about the "malignant" medic; however, working well outside of your SOP in most cases will be viewed as wrong.

When you delegate a task or procedure to another person, you do so with the understanding that the said person is educated and knowledgeable about the task or procedure in question. Telling your EMT-B partner to push a round of ACLS medications is not really delegation.

This also puts your EMT-B partner in a bad position. There are legal implications and this could be interpreted as an act of commission if there were any legal repercussions. This also puts you partner in a position where they are performing a procedure they are not educated to perform. What if you stated the incorrect dose or concentration of the medication? What if you stated the incorrect medication or in the confusion of the code miscommunicated what you wanted to be given? Does an EMT-B have enough knowledge and background in pharmacology to look at the situation, question a potentially incorrect order, and question or rectify the situation?

Additionally, the paramedic is put into a bad position related to documentation. How do you document this call? Are you really going to document that your EMT-B partner administered ACLS medications? Technically, yes. However, if you do not document what really occurred, then you have falsified your documentation.

All of this leads to overall badness. The reality of the situation is that medications do not make a difference in most cases of cardiac arrest, therefore I cannot see why anybody would risk their career and lively hood by having their EMT-B partner push medications.

 

[jbar]

The reason why a medic would ask a basic to push something is because it leads to better patient care. I used to work for a service that had a medic and a basic on a rig together. In a code situation the medic was often busy intubating while I did the line. Would it be not quite legal to have me push 1mg of epi as a basic? Probably. But that drug isn't being given because he has his hands full with something else. I'm not going to say that I ever pushed a drug beyond my SOPs, but lets just say that at this company when medics trusted their EMT it certainly happened.

As to delegation it can get into a grey area depending on how much additional training the EMT has had. As an EMT who was IV certified, had audited and passed ACLS, gone through a medic refresher and was the one who checks the drugs every day one could argue that delegating me to push 1mg of epi is reasonable given my training in spite of my cert.

As an aside this is an interesting question given that now I am a medical student and every day I am supervised doing things that may be technically beyond what a medical student is allowed to do, but it is okay because

1. I'm supervised by someone qualified

2. Nothing bad happens

3. I keep my mouth shut about who let me do that really cool thing and where I did it.

So far I've gotten to cut brain, put in a central line, cut skin on pedi patients in the OR etc. You could argue that having the doc tell me to push a drug that I can't given on my own (like on anesthesia) is the same as having a medic tell me to push something. But I know the state EMS board would disagree.

 

[pseudoknot]

As an aside this is an interesting question given that now I am a medical student and every day I am supervised doing things that may be technically beyond what a medical student is allowed to do, but it is okay because

1. I'm supervised by someone qualified

2. Nothing bad happens

3. I keep my mouth shut about who let me do that really cool thing and where I did it.

So far I've gotten to cut brain, put in a central line, cut skin on pedi patients in the OR etc. You could argue that having the doc tell me to push a drug that I can't given on my own (like on anesthesia) is the same as having a medic tell me to push something. But I know the state EMS board would disagree.

No, this is totally legal, precisely because you are in a training program under supervision. A medical student in his teaching hospital can do anything an MD can, provided it is OK with the attending. This is perhaps analogous to someone having only a basic cert being able to do ALS skills in the field while being precepted. That's not at all the same thing as a medic just delegating random stuff to a basic.

Speaking of medication, I'm on quite a bit at the moment, so apologies if this makes no sense or I misunderstood completely...

 

[leviathan]

As simple a procedure as it is, I'm assuming an EMT-B is not trained in how to do the drug calculation to draw up the right volume of medication, or how to give it properly. Sure if they had done it hundreds of times and proven they know what they're doing (like one does in paramedic training), I'd let them do it. But how is an EMT getting experience in the first place with this? Unless this person had training from some other field, who is trusting them to do it if it was their first time?

 

[jbar]

Hey,

I was saying I understand that in the hospital I am being supervised, but I've been in quite a few situations where someone (ie anesthesia) says "push 15ccs of this", not that different for the patient than a medic handing me a syringe and saying push this much. I understand the legal differences but functionally they are pretty similar.

As to leviathan's question, on our rig many of our meds were in pre filled syringes where that was the total dose you'd give. So in a cardiac arrest we pull out the 1mg of epi and push the whole thing, no calculations needed and no drawing up.

 

[Dwindlin]

Hey,

I was saying I understand that in the hospital I am being supervised, but I've been in quite a few situations where someone (ie anesthesia) says "push 15ccs of this", not that different for the patient than a medic handing me a syringe and saying push this much. I understand the legal differences but functionally they are pretty similar.

As to leviathan's question, on our rig many of our meds were in pre filled syringes where that was the total dose you'd give. So in a cardiac arrest we pull out the 1mg of epi and push the whole thing, no calculations needed and no drawing up.

Same in our service. With the exception of Dopamine all of our ACLS drugs are pre-filled. No measurement required.

 

[Paseo Del Norte]

Functionally, quite different. In the hospital, you should have the sense to ask what you are pushing. As a medical student, it is implied that you have an understanding of the medications pharmacology. The typical EMT-B spends a few hours talking about oxygen and self assisted medications. Therefore, the difference is quite profound.

As I stated earlier, I simply cannot see why you would risk your job by having an EMT-B administer a treatment that is outside their scope of practice, and not shown to be of much benefit to an arrest patient in the first place.

 

[jbar]

I'd argue that an EMT B who has gone through ACLS and a medic refresher knows a fair amount about arrest medications. I agree that one is taking a risk with you license but some medics trust their EMTs enough based on working with them for a long time to allow them to occasionally push a med.

They risk their cert because

1: It makes their job easier.

2: It makes their EMT (friend) happy.

3: And they feel that they have a low prob of getting brought in front of the state on charges. Hence they tend not to do it in front of some one like the *ahem* opinionated medic in the OPs story.

 

[leviathan]

Hey,

I was saying I understand that in the hospital I am being supervised, but I've been in quite a few situations where someone (ie anesthesia) says "push 15ccs of this", not that different for the patient than a medic handing me a syringe and saying push this much. I understand the legal differences but functionally they are pretty similar.

As to leviathan's question, on our rig many of our meds were in pre filled syringes where that was the total dose you'd give. So in a cardiac arrest we pull out the 1mg of epi and push the whole thing, no calculations needed and no drawing up.

Good call...I didn't think about the preloads. Hard to screw that up then if you just tell them "push this in the IV port". But with some of the people I've seen around, they could screw up anything if given the chance.

 

[jbar]

Good call...I didn't think about the preloads. Hard to screw that up then if you just tell them "push this in the IV port". But with some of the people I've seen around, they could screw up anything if given the chance.

Yeah, with the medics I work with it certaintly wasn't a "I let all EMTs push X." More like "I have worked with this person every day for a year, we train together, take classes together, talk about drugs; and I let them do X, sometimes."

 

[docB]

I think this issue goes deeper than drug dosages. Medicine is such a highly regulated industry that there is a rule for everything. The industry is always struggling to keep up with the regs. There are also a multitude of rules, regs and pitfalls that have nothing to do with the medical end.

The fact is that whenever there is a disgruntled member of the team they can start to cause problems by filing reports, complaints, allegations and so on. They do this to punish, retaliate, disrupt and occasionally for personal gain.

The issue here really isn't "should medics ever let EMTs push drugs?" because the answer in the regs is "absolutely not." The question is what do you do about a disgruntled team member who is out to get their colleagues and will use any deviations from the letter of the law to do that.

 

[pseudoknot]

The question is what do you do about a disgruntled team member who is out to get their colleagues and will use any deviations from the letter of the law to do that.

I agree that this is really the heart of the matter. The answer seems clear:
[YOUTUBE]http://www.youtube.com/watch?v=zEBCIjar8ls[/YOUTUBE]