What can the prehospital crews do in your area?

Specialties Emergency

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Specializes in ED, Neuro, Management, Clinical Educator.

In my region, I find that the paramedics really have their hands tied. Before returning to nursing school, I was a firefighter/medic for years (as my screen name suggests... I've used the same SN since the 90's and never changed it.) I relocated to this region (midatlantic) after graduating nursing school, and the prehospital crews here operate under a different set of protocols than I used when I was working on the road. I am quite taken aback by how limited they seem to be here!

Paramedics here can give pretty much all of the ACLS drugs. They can not pace. They can not perform RSI and thus carry no drugs that could be used for this purpose. They carry Morphine but can only administer it with an order from the Med Control doc. They carry Valium (not Ativan) and can give one dose to patients only if actively seizing. They are not allowed to carry McGill's forceps to facilitate removal of visualized foreign bodies in the airway. They are not allowed to perform nasal intubations.

One of the ED docs I work with is on the committee that decides their protocols and, when asked about this says that he "Does everything in his power to limit what they are allowed to do" because of "the quality of paramedics around here." I'm a bit baffled by this answer. I would think that any such problems would be easily remedied by reforms to the paramedic curriculum and teaching methodology, not by severely limiting the scope of practice of this very important group of professionals.

What is within the scope of practice of the prehospital providers in your areas?

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Specializes in CEN, CPEN, RN-BC.

I'm just astounded that they are not allowed to pace. Sorry Mr. 3rd degree heart block, enjoy your death.

I was talking to a medic I used to work with back in South West PA and he said they can't use RSI either because of the quality of the medics down there.

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Specializes in neurology, cardiology, ED.

I've noticed that paramedics around my area (upstate NY) have become less likely to intubate in the field, and more likely to use kings airway, etc. Wondering if that has been going on elsewhere.

Here they commonly give ASA, nitro, Zofran, etc. Not much else though.

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This is California's scope of practice for Paramedics.

http://www.emsa.ca.gov/personnel/Local_Scope/default.aspe

The state determines the overall scope of practice and then each county EMS medical director chooses from that scope what is appropriate for their area.

RNs staff the CCTs and Flight programs here since many of the medications used in the ICU/ED are beyond the scope of practice of a Paramedic.

Most ED physicians will agree that with limited oversight and only 1000 hours of training required, it is difficult to allow for a more extensive scope of practice safely. Some EMS agencies are currently under scrutiny because they can not produce the minimal required QA/QI data to the county and state.

I know the local Paramedics just started using CPAP and IOs but do not do 12 - lead EKGs and I haven't seen a field ETT placed in a long time. King or Combitubes are used. Definitely no RSI.

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When I was working as a paramedic in south Arkansas (two different agencies) our scope was essentially "you can do whatever paramedics are certified to do." That said, our protocols were liberal and mirrored a paramedic textbook (never read them actually). We didn't call in for anything but to give a patient report prior to arrival at a hospital.

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Specializes in ED, ICU, Education.

In NC, one county's EMT-Ps can RSI and TPA due to long transport times (approx 1 hour to the closest facility). For both they need to have a MD order. This particular county won National's in 2010.

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
I've noticed that paramedics around my area (upstate NY) have become less likely to intubate in the field, and more likely to use kings airway, etc. Wondering if that has been going on elsewhere.

Here they commonly give ASA, nitro, Zofran, etc. Not much else though.

Yes new guideline per AHA use blidly inserted airways on cardiac arrests instead of intubating. Takes a lot less time!

Happy

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

In NH the state goes by its modo " Live free or die" when it comes to protocols!

We carry a huge amount of drugs and the only one that is a med control is Heparin, everything else is standing order!

We can pace, cardiovert, defib of course, needle decompress if needed, intubate obviously, sedate ( for medical or psychotic patients), yes we carry Haldol! Can put in umbilical lines, have not had to do this though. Can alao access central lines including ports. Oh and lets not forget the IO, love that thing! CPAP whixh is the greatest thing ever in EMS, works fantasticly! We even have IV nitro, which not to many systems carry.

For drugs we carry for 911:

Ativan

fentanyl

morphine

versed

valium

albuterol

atrovent

xopenex

magnesium ( eclampsia and adult and pedi asthma)

Epi 1:10000 and 1:1000

Atropine

Benadryl IV/IM and PO

SoluMedrol

Solucortef

Norepi ( as a pressor)

dopamine

lidocaine (bolus and drip)

Cardizem

Amiodarone (bolus and drip)

Sodium bicarb ( TCA overdose or suspected hyperK)

Adenosine

D50, 25, 10

Narcan

Calcium chloride

Glucagon

Pit

Lasix

Bumex

PO tylenol and Mltrin

Toradol

NTG IV, SL, and paste

Heparin

Proparacaine (optic)

Hurricaine spray

neosynephryn (nasal)

ASA

Haldol

Romazicon

Zofran ( thank god!)

Compazine

Phenergan

I think I got them all, probably forgot 1 or 2, but you get the idea! I love working EMS in this state for this reason and because of the off line medical directio unless you need to consult them.

Happy

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When I was working as a paramedic in south Arkansas (two different agencies) our scope was essentially "you can do whatever paramedics are certified to do." That said, our protocols were liberal and mirrored a paramedic textbook (never read them actually). We didn't call in for anything but to give a patient report prior to arrival at a hospital.

Could not caring enough to even read the protocols be a reason why some MDs don't trust their Paramedics? Some in TX thought they were above reading the protocols for RSI and ended up with some bad results especially for the patient.

Textbooks can vary and so can the instruction by the schools. Also, just because your state scope of practice says you can does not always mean you should. A Paramedic who might get one intubation attempt per year, either successful or unsuccessful, probably should not be allowed to do RSI. A Paramedic who has never intubated a child or done a cric but just read about these procedures 10 years ago in a textbook without any additional retraining probably shouldn't be bragging about how they can do everything either.

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Can put in umbilical lines, have not had to do this though.

Is this for specialized neonatal teams, which do have expanded scope of practice?

Or, is this for the field Paramedic? If so, what size lines do you carry and what meds can be given without X-Ray confirmation?

Cannulation with an IV catheter is discussed as an option for IV access but by no means is it the same as the long umbilical lines placed by neonatal teams.

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Specializes in CCT.

Huge advocate for prehospital medicine, but...

EMS scope of practice is far to big for what passes as a paramedic in a lot of areas of the country.

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The Paramedic scope of practice used to be a lot larger and several more advanced procedures were taught in the Paramedic class. If you look in the earlier editions of Nancy Caroline's book you will find pericardiocentesis, chest tube placement, retrograde intubation and subclavian central lines. You will also notice the drug boxes were quite heavy for all the ACLS meds and NaHCO3 was given when in doubt for everything. But as more hospitals, trauma centers and HEMS programs developed, most of these advanced procedures were found to be unnecessary for every Paramedic service. Lasix is another drug that is no longer considered necessary for every patient with crackles.

So, it may not be that your scope is being limited but rather all the skills and meds done by one service in rural nowhere, like Ada county, may not be appropriate who for an ALS truck which has a hospital within 10 blocks from anywhere in their area. Medicine also evolves to where some medications or procedures may no longer be considered as appropriate but for some in EMS who do not keep up with the current trends, they may just think their Medical Director is picking on them. We could also get into a discussion as to how much is too much on scene and when you have the point of diminishing returns come about.

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