I recently went on vacation & was on an airplane. A person on the plane had a seizure & then went into full arrest. There was another RN on the plane with me. We are both ER nurses & ALCS certified. We used a BVM & an AED. We started an IV and gave epi. All supplies were from the plane. My license is in California. We Diverted to Nevada.
Looking back I wonder if I was covered under the good Samaritans law or did I practice outside my state & scope of practice. Technically, although we left California we landed in Nevada so I wasn't in my state. Also, there was no doctor on the flight who gave the epi order.
When I responded I was simply letting OP know what part of that scenario would have bothered me personally. I have ACLS training myself and know what it's for. I was just saying that I would have felt slightly uncomfortable about doing that with no further direction from a physician. When I actually used my ACLS training in a hospital setting we always waited for a physician to show up before actually administering any meds- we would always start CPR, ect if needed but never actually administered meds until a physician was present or gave orders. I understand in this situation that's not really feasible (although other posters have expressed that you actually can get orders from a physician on the ground apparently).
I forgot to add to my first post that it sounds like a crazy situation and I probably would have done the same thing as OP. So kudos to you, OP, for helping that patient out of a tough spot.
I don't mean to offend, but if you start doing chest compressions and/or bagging a patient when they code, but wait for a physician to arrive before administering any meds, you're not using your ACLS training, you're using your BLS training.
The entire point of being ACLS certified is so you don't have to wait for a physician. Why wait when there's a protocol in place and you know what you need to do?
I don't mean to offend, but if you start doing chest compressions and/or bagging a patient when they code, but wait for a physician to arrive before administering any meds, you're not using your ACLS training, you're using your BLS training.
The entire point of being ACLS certified is so you don't have to wait for a physician. Why wait when there's a protocol in place and you know what you need to do?
I'm not offended- I actually thought the same thing when I wrote it. Honestly- in all the codes I was involved in we never had to actually wait more than maybe 2-3 mins for a dr, np, or pa to show up. It was a relatively small hospital so there was always someone within a few mins walk/ run of where we were. It usually took that long to get code cart, hook of defib, ect. So maybe I was just never in one where anyone had to actually make a decision prior to a provider showing up.
Let me word that differently. If you are holding epi based on telemetry reading alone, you're doing it wrong. If the patient is in PEA, you've just killed them. Treat the patient, not the monitor.
The current guidelines call for promptly beginning CPR, and AED as soon as it is available (assuming rhythm analysis reveals a shockable rhythm). Medications are secondary. Without an existing written medical protocol on board, or availability of a physician on the ground to give the order for epinephrine to a licensed nurse over the radio, I am inclined to believe that if the rescuers are nurses, even if the nurse/s are ACLS certified they would be acting outside of their scope of practice by administering epinephrine without a medical protocol or physician's orders. Compressions, yes; AED, yes, as soon as possible, to analyze the rhythm and deliver shocks if indicated; BVM if there are sufficient trained rescuers.
Let me word that differently. If you are holding epi based on telemetry reading alone, you're doing it wrong. If the patient is in PEA, you've just killed them. Treat the patient, not the monitor.
Specializes in Medical-Surgical/Float Pool/Stepdown.
The current guidelines call for promptly beginning CPR, and AED as soon as it is available (assuming rhythm analysis reveals a shockable rhythm). Medications are secondary. Without an existing written medical protocol on board, or availability of a physician on the ground to give the order for epinephrine to a licensed nurse over the radio, I am inclined to believe that if the rescuers are nurses, even if the nurse/s are ACLS certified they would be acting outside of their scope of practice by administering epinephrine without a medical protocol or physician's orders. Compressions, yes; AED, yes, as soon as possible, to analyze the rhythm and deliver shocks if indicated; BVM if there are sufficient trained rescuers.
If so...What then is the point of being ACLS certified? Pretty much the protocol is to follow the American Heart Association guidelines for ACLS...right? Every algorithm is pretty well spelled out.
I think of it as I would when someone's about to access a mediport, are they competent and have education/experience with properly accessing mediports? If not, go get someone that does, damn it! (Pet Peeve, I don't know how to competently access a mediport but plenty of people in my hospital think they're competent when they are clearly not! Can't we all just respect our limitations/comfort zones/egos for the sake of our patients?)
ACLS went over advanced airways but I know I'm not competent in that area, I would look to the many wonderful RT's for help there...but I would be expecting them to want me to return the favor by IVP the drugs for them. It would be my problem if I did not follow the specific guidelines...
Thanks for sharing an interesting scenario! From what I have always understood, RNs can give ACLS meds without a physician present because of standing orders and a physician will always sign later. The link posted to the article "Emergency at 30,000 Feet - What You Can Do" makes it sound like the pilots can easily get on the line with a physician, so I would imagine if that had been done there would be absolutely no problem with the RN administering ACLS meds. But I am really curious to hear from someone with the airline because I feel like there has to be some kind of policy about that, especially for the airlines stocking kits with meds! When else are you going to be in a situation with an ACLS stocked med kit but not associated with a medical facility? Maybe the laws are different because it's in the air . . . ?
And if the patient is in rapid a-fib or SVT and you give epinephrine you have just killed the patient. The monitor is a tool to guide your assessment.
Let me word that differently. If you are holding epi based on telemetry reading alone, you're doing it wrong. If the patient is in PEA, you've just killed them. Treat the patient, not the monitor.
And if the patient is in rapid a-fib or SVT and you give epinephrine you have just killed the patient. The monitor is a tool to guide your assessment.
I would certainly hope that no one would give Epi to a patient in rapid a-fib or SVT because these patients will have a pulse!!!! That would be a seriously bone-head move.
The current guidelines call for promptly beginning CPR, and AED as soon as it is available (assuming rhythm analysis reveals a shockable rhythm). Medications are secondary. Without an existing written medical protocol on board, or availability of a physician on the ground to give the order for epinephrine to a licensed nurse over the radio, I am inclined to believe that if the rescuers are nurses, even if the nurse/s are ACLS certified they would be acting outside of their scope of practice by administering epinephrine without a medical protocol or physician's orders. Compressions, yes; AED, yes, as soon as possible, to analyze the rhythm and deliver shocks if indicated; BVM if there are sufficient trained rescuers.
Very much agree that medications are secondary. In fact, there is no evidence they improve meaningful outcomes. Regardless, giving the meds is the protocol.
As far as as being outside of scope of practice, I completely disagree.
How can Defibrillation be within scope of practice, and epi be outside scope of practice? There is nothing benign about defibrillation, and if done on the wrong patient, can be a heck of a lot worse than epi. We even revert to the amount of electricity as a "dose".
I believe that in the absence of a doc, both are within scope of practice.
(Pet Peeve, I don't know how to competently access a mediport but plenty of people in my hospital think they're competent when they are clearly not! Can't we all just respect our limitations/comfort zones/egos for the sake of our patients?)
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I don't mean to offend, but if you start doing chest compressions and/or bagging a patient when they code, but wait for a physician to arrive before administering any meds, you're not using your ACLS training, you're using your BLS training.
The entire point of being ACLS certified is so you don't have to wait for a physician. Why wait when there's a protocol in place and you know what you need to do?