EMT Practicing ALS Skills??

[RES551CUE]

Here's a scenario that I am looking for some input on. No names or companies will be listed, but this did happen.

Scenario:

ALS unit/BLS unit/FD/PD dispatched to a male GSW. PD arrives on scene to find male shot once in chest and once in head, asking units to expedite. FD arrives shortly after with a First Responder as the driver (engine company drive alone). ALS and BLS arrive basically at same time, ALS unit staffed with Paramedic and EMT, BLS unit staffed with EMT driver and off-duty Paramedic. Paramedic on ALS attempts to start an IV and asks partner to attempt intubation (EMT partner that is going through paramedic school). EMT unable to intubate and Paramedic on ALS unit completes. Pt loaded and transported to nearest receiving due to extent of injuries. Needless to say that the outcome of the call is one dead. After call BLS unit and other employees of ALS unit complain of actions on call and want something done to ALS unit crew.

Questions to ponder:

What, if anything, should be done by ALS company to ALS unit crew for their actions?

What, if anything, should be done by Pennsylvania Department of Health to ALS unit crew for their actions?

Do you agree with Paramedic asking EMT partner to intubate?

[musicemt]

1) That would depend on the ALS company's written policies and procedures, but I would imagine the legal liabilities involved would result in some form of disciplinary action to both members of the crew.

2) That might depend on the written policies of the state health department when it comes to paramedic students. Here in KY, a paramedic student may not do ride time while being paid unless they are a 3rd crewmember so they can function fully as an ALS provider-in-training. If Pennsylvania has similar rules, it's pretty cut and dry. If not, there may be an arguing stance on the part of the crew.

3) #2 having been said, did my paramedic partners ask me to perform ALS skills while I was in (almost done with) medic school? Yes; I started a few IVs, handled some medications (nebs and reconstituting glucagon, as I recall), and provided an interpretation of an ECG or two. I didn't perform advanced airway management; that was something reserved exclusively for the medic on the truck. I think there are two factors at play here; the ALS unit's medic's trust in his partner to not screw up, and the medic's impression as to the survivability of the patient. While it's in poor taste to call a patient a "skill lab", this may have played a factor in letting the medic student practice. I don't know that I would let my partner intubate a patient, personally speaking.

Just my 0.02

[mike]

What, if anything, should be done by ALS company to ALS unit crew for their actions?

The medic was wrong for asking his partner (EMT) to Intubate. The EMT was wrong for doing so. Attending the class doesn’t always end in a license for a reason. 2 weeks into training, 6 months? Because it was done in public with multiple witness’s that did complain I think the company will be forced to do something or own the fact that an employee is practicing medicine outside of his scope of training and licensure level.




What, if anything, should be done by Pennsylvania Department of Health to ALS unit crew for their actions?

My guess is the EMT will get popped hard for performing a skill his licensure doesn’t support and the all bets are off on the medic. I could see them yanking his license.


Do you agree with Paramedic asking EMT partner to intubate?

My question is why the “off duty medic” didn’t act in the medic capacity if he came on a bus?

As far as asking your partner to do that in front of another medic/EMT you may or may not know, an engine crew and the local PD is throwing your partner under the bus. Maybe the EMT threw the medic under the bus “hey..I am going through medic school, can I intubate the next patient?” Who knows?

I wasn’t there so the above is just a quick guess of what I have read. I know I have worked with some partners I wouldn’t trust at all and everything has been 110% above board. Others I have never even thought twice about questioning their integrity.


In any case let us know how it plays out

[Cthippo]

The standard I apply when considering these things is did the actions of the crew adversely impact pt outcome. In this case I would say no it did not and therefore I would have a hard time justifying coming down hard on the crew. If the EMT (who we're assuming had some training on ET tubes) had not attempted the tube, then the pt would not have been better off. They may have been better to have asked the off-duty medic to do the tube, but on the other hand if the medic believed the pt was non-viable, then it makes sense to let the new guy have a shot at it. In addition, it's not like the stident was going out on his own and trying this, he was operating under the direct orders and supervision of a fully qualified medic.

I saw something like this happen at the hospital a couple weeks ago. A senior medic and a student medic had brought in a pt and were doing the paperwork when a totally unrelated pt needed to be tubed. The student asked the doc if he could try for the tube and the doc agreed to let him. The conversation went something like "OK, the student gets one shot at it, the ER tech gets one shot at it, and if neither of you can do it then the senior medic gets to do it".

Really it sounds like a urinary ballistics competition between the ALS and BLS crews.

[mike]

Really it sounds like a urinary ballistics competition between the ALS and BLS crews.

I agree in regards to the pissing contest but if one crew pushes the issue the other crew might get nailed. Complaining about something verbally and putting that complaint in writing are two different things. One usually goes away on it’s own and the other forces someone to do something or risk getting caught up in it.

[CHASgirl6204]

1)

2) That might depend on the written policies of the state health department when it comes to paramedic students. Here in KY, a paramedic student may not do ride time while being paid unless they are a 3rd crewmember so they can function fully as an ALS provider-in-training. If Pennsylvania has similar rules, it's pretty cut and dry. If not, there may be an arguing stance on the part of the crew.




Just my 0.02

That's usually the standard. Thanks for saving me some typing!


The standard I apply when considering these things is did the actions of the crew adversely impact pt outcome. In this case I would say no it did not and therefore I would have a hard time justifying coming down hard on the crew.


Sorry, I have to disagree with you on that point. That's going back to the old adage that "hindsight is 20/20." Perhaps I'm mis-interpreting what you mean, but it sounds like ..."well, such and such pt. ended up dying so really it didn't constitute an adverse outcome." Kind of doesn't make sense. If the Basic was a member of a 2 person crew, plain and simple: he/she was practicing out of scope. There's not really much else to say.

[Cthippo]

Sorry, I have to disagree with you on that point. That's going back to the old adage that "hindsight is 20/20." Perhaps I'm mis-interpreting what you mean, but it sounds like ..."well, such and such pt. ended up dying so really it didn't constitute an adverse outcome." Kind of doesn't make sense. If the Basic was a member of a 2 person crew, plain and simple: he/she was practicing out of scope. There's not really much else to say.

What I'm saying is that the EMT made a good faith effort, under the direction and supervision of the medic, to help the patient, and his efforts did not make the patient worse. Essentially, he did no harm, and believed he was doing the right thing. Legally there may be a problem here (thought I wouldn't want to argue it in front of a jury), but ethically I don't think so.

[fdnyemt5330]

If the medic was precepting the EMT, and the EMT was cleared to do intubations under a preceptor's supervision, then I'm good with it.


If not, then they were right to report it.

[mediccjh]

Here's a scenario that I am looking for some input on. No names or companies will be listed, but this did happen.

Scenario:

ALS unit/BLS unit/FD/PD dispatched to a male GSW. PD arrives on scene to find male shot once in chest and once in head, asking units to expedite. FD arrives shortly after with a First Responder as the driver (engine company drive alone). ALS and BLS arrive basically at same time, ALS unit staffed with Paramedic and EMT, BLS unit staffed with EMT driver and off-duty Paramedic. Paramedic on ALS attempts to start an IV and asks partner to attempt intubation (EMT partner that is going through paramedic school). EMT unable to intubate and Paramedic on ALS unit completes. Pt loaded and transported to nearest receiving due to extent of injuries. Needless to say that the outcome of the call is one dead. After call BLS unit and other employees of ALS unit complain of actions on call and want something done to ALS unit crew.

Questions to ponder:

What, if anything, should be done by ALS company to ALS unit crew for their actions?

What, if anything, should be done by Pennsylvania Department of Health to ALS unit crew for their actions?

Do you agree with Paramedic asking EMT partner to intubate?

If the medic student is going through Luzerne's program, Jim and Mark are gonna eat him alive.

Medic should've intubated, EMT should've practiced basic airway skills.

[RES551CUE]

To answer some questions:

The medic student was being paid as an EMT at the time and not doing clinical time.

Even if he had been doing clinical time, medic students are not allowed to intubate in the field for any reason in our area.

The complaint is written and in hands of PADOH.

This is the medic students second round in class, having not passed the National Registary written.

As for the off-duty medic, it would have been ok for him to practice ALS skills even though on a BLS ambulance due to the fact that he has command with the ALS unit on scene. I believe he opted not to, his discretion.

[scotttt]

I'd be equally as concerned about the crew attempting an IV and ETI on a patient with a penetrating injury prior to transport. The patient needs a surgeon, not a medic.

As for the issue at hand, the state will deal with it. Hopefully no one loses their cert. or job (not saying discipline isn't warranted). There's far worse things someone could do.

[Philly Medic]

To answer some questions:

As for the off-duty medic, it would have been ok for him to practice ALS skills even though on a BLS ambulance due to the fact that he has command with the ALS unit on scene. I believe he opted not to, his discretion.


Why would he not want to assist another medic? Did he just stand there and watch him try to do all the ALS? Granted he isn't get paid as a medic but sometimes you gotta say what the fvck. I hope he is not involved in jamming up another medic for letting the EMT try the tube when he could have done it or maybe he doesn't trust his own skills.

There has to be more to this story or there is some serious backstabbing going on.

[mike]

There has to be more to this story or there is some serious backstabbing going on.

I bet you are right on one or both of those

[TerragonSix]

Well, down here in FL, Port Saint Lucie Fire/Rescue allows EMT-B's to start IV's, as long as they take an IV class and get approved by the Medical Director. (EMT-I's are not recognized in FL).

At the end of my EMT-B school, we got introduced to intubation, and IV's. I could perform the skill, but I wouldn't just for the fact that it is out of my scope of practice. I have a Combitube, OPA's and NPA's, I'm OK. :) Too bad with the company I'm with doesn't allow me to Combitube though.

[melinda]

I just finished paramedic school in December and have been working on an ALS unit for about a year now. Where I am, as long as I had a paramedic partner who was a certified preceptor, I was allowed to do anything that I had been trained on and checked off on in class. ie: I could intubate after we had been checked of in class, or I could push ACLS drugs after passing ACLS and getting my ACLS certification...but not before. I couldn't ride in with these patients, and I could only do these things while my partner was watching. Personally I did several intubations in the field before I was finished with school, mostly successful but not always.

[FF/EMTP1317]

My former partner had completed her medic class and was going through her registry testing process. My Lt said that even though I'm not an ALS preceptor she was allowed to do ALS procedures if I needed the extra hands. She did alot including an intubation attempt. A lot of the medics I rode with as an EMT would have me put the pt on the monitor or give NTG (MD EMTs can admin pt's anyway) or ASA if they were busy doing other things.
I agree that there is probably more to the story than is being told.

[mjaad03]

I would have to say it depended on the situation. Where I'm from if students are cleared to do certain procedures, even though they have not completed medic, they are able to attempt these procedures as long as they are being supervised by a medic. Also, our protocols state that if you are certified as a medic you may only practice at the paramedic level while on duty. Otherwise you are a basic that can only perform basic skills. Maybe the medic in charge didn't have any other options at the time and did the best he could under the circumstances. We all know calls don't go according to plan. I think I would have to hear all sides of the story before determining what disciplinary action, if any, should be taken. Also, who did the complaining? Another crew or what I think I missed that.

[Medic101Charlie]

What are the guidelines set forth by your medical director and by the state?

To me that is the ultimate question.

If the medical director through the training department states "ONLY licensed paramedics shall perform ALS skill" then it is pretty cut and dried.

I've done it before, let my partner drop a nitro while I was getting a line, or have him start a new neb while I was listening to breath sounds...BUT, I did it with the full cognizance that if something went wrong (enter Mr. Murphy and his law), it would be MY ass on the line answering why I let an EMT-D perform skills outside the scope of his training and the scope of his skills.

Where I am now, privates and some fire departments will write a complaint up on you in a heart beat.

Ultimately it's the licensed Paramedic who signed the run ticket as being "his" that will be accountable, both for patient care and what went on in the back of his bus.


Jim

[mediccjh]

In the Commonwealth of PA, only Paramedics, or EMTs functioning as a Paramedic Student (and not getting paid for it) are allowed to perform Endotracheal Intubation in the field.

If the EMT was functioning as a Paramedic Student, he would be allowed to; however, if he was working as an EMT only, it's a big no-no.

[Medic101Charlie]

In the Commonwealth of PA, only Paramedics, or EMTs functioning as a Paramedic Student (and not getting paid for it) are allowed to perform Endotracheal Intubation in the field.

If the EMT was functioning as a Paramedic Student, he would be allowed to; however, if he was working as an EMT only, it's a big no-no.

Then to me it's cut and dried. Now, I'll be the first to admit that yes, as a Basic, I did stuff I shouldn't have under the direction of the Medic. And as a medic I had my basic do stuff that was out of his scope, mainly dropping a nitro or starting a neb or something of that nature.

But field endotracheal intubation is so fricking controversial right now. With Combi-Tubes and other intermediate airways, quite a few systems are moving away from ETs for their medics. With that being said, it should be no surprise that the medic got turned in for it.

Bottom line is it is his ass and his license on the line. He was the medic who signed out the ambulance.


Jim

[illmedic23]

Im from PA and dont understand my states protocols. In most of the neighboring stats intibation is part of an emt skill set. PA is light years behind in pre-hospital care. I have been on calls when I was an EMT and preformed outside my scope. I have always done whatever I can to help my pt and partner. On a call one medic has alot to handle, the second medic should have steped up from the begining instead of complaining later. Also reminder what goes on, on a call stays there. Reporting this situation was bull because even if the EMT didnt atempt the outcome would be the same. This shows the lack of respect for fellow EMS.

[Medic101Charlie]

Im from PA and dont understand my states protocols. In most of the neighboring stats intibation is part of an emt skill set. PA is light years behind in pre-hospital care. I have been on calls when I was an EMT and preformed outside my scope. I have always done whatever I can to help my pt and partner. On a call one medic has alot to handle, the second medic should have steped up from the begining instead of complaining later. Also reminder what goes on, on a call stays there. Reporting this situation was bull because even if the EMT didnt atempt the outcome would be the same. This shows the lack of respect for fellow EMS.

None of know the whole story here. We don't the history between the agencies, the history in the EMS region, or with their medical director or their services.

BUT, no matter WHAT you do, or what your paramedic partner does, it is ALWAYS his ass and his license on the line. HE is the paramedic. If you did something out of your scope and it adversely affected patient outcome, then HE will answer for it. HE is the one who has the privilege to practice as the ALS level under the medical director's license, not you.

Right, what happens on a call stays on a call...But how can you guarantee that when there is another agency on scene??? I'm always more on my toes when there's another agency on scene because I KNOW they're watching me.

Yes, there are states that allow EMTs to intubate, with extra classes and credentialling by the medical director. Then THEY are practicing under the medical director's license. BUT, if there is no agreement and no sign off from the medical director, then it is still the Medic's ass. Bottom line is it was his call and he needs to face the consequences.

In this hyper-litigous age how can we NOT be careful about this stuff????

And I wouldn't be surprised if the EMT loses his license as well for practicing outside of his scope and knowing better.

Bottom line is this is a Bog Boy World and there are Big Boy Rules. Falling back on the "what happens on the bus stays on the bus" is a bull**** argument. It's a cop out in my opinion.

<<end rant>>
Jim

[mediccjh]

Im from PA and dont understand my states protocols. In most of the neighboring stats intibation is part of an emt skill set. PA is light years behind in pre-hospital care. I have been on calls when I was an EMT and preformed outside my scope. I have always done whatever I can to help my pt and partner. On a call one medic has alot to handle, the second medic should have steped up from the begining instead of complaining later. Also reminder what goes on, on a call stays there. Reporting this situation was bull because even if the EMT didnt atempt the outcome would be the same. This shows the lack of respect for fellow EMS.

With some of the retards that PA passes for EMTs, I wouldn't want them touching my family, let alone ET equipment.

[Philly Medic]

Not sure but if the paramedic was onscene but was working as an EMT doesn't he still have a duty to act? And if so can't he get jammed up also?

[mediccjh]

Not sure but if the paramedic was onscene but was working as an EMT doesn't he still have a duty to act? And if so can't he get jammed up also?

Nope. If his service's Medical Director says he can't practice as a Paramedic, or he's working for a BLS company, he doesn't have any duty to act beyond an EMT.

[anthonyt]

I'd be equally as concerned about the crew attempting an IV and ETI on a patient with a penetrating injury prior to transport. The patient needs a surgeon, not a medic.

As for the issue at hand, the state will deal with it. Hopefully no one loses their cert. or job (not saying discipline isn't warranted). There's far worse things someone could do.

Ok, a patient without an airway, needs an airway, not a surgeon. Last I checked, paramedics, can provide definitive airways, the same as a surgeon could. So, he needs a medic, OR a surgeon. Without an airway, he is dead.

Once an airway is established, now, he needs a surgeon.

I am so sick of Paramedics that will not stabilize, to the best of their ability, prior to transporting... DO YOUR JOB!

[anthonyt]

Here's a scenario that I am looking for some input on. No names or companies will be listed, but this did happen.

Scenario:

ALS unit/BLS unit/FD/PD dispatched to a male GSW. PD arrives on scene to find male shot once in chest and once in head, asking units to expedite. FD arrives shortly after with a First Responder as the driver (engine company drive alone). ALS and BLS arrive basically at same time, ALS unit staffed with Paramedic and EMT, BLS unit staffed with EMT driver and off-duty Paramedic. Paramedic on ALS attempts to start an IV and asks partner to attempt intubation (EMT partner that is going through paramedic school). EMT unable to intubate and Paramedic on ALS unit completes. Pt loaded and transported to nearest receiving due to extent of injuries. Needless to say that the outcome of the call is one dead. After call BLS unit and other employees of ALS unit complain of actions on call and want something done to ALS unit crew.

Questions to ponder:

What, if anything, should be done by ALS company to ALS unit crew for their actions?

What, if anything, should be done by Pennsylvania Department of Health to ALS unit crew for their actions?

Do you agree with Paramedic asking EMT partner to intubate?

My views...

Ok, first and foremost, if this cat was shot in the head, did he have respirations? Was there gray matter exposed? If no respirations, and gray matter exposed, then HE'S DEAD JIM! No further action needed.

Second, the order of treatment is ABC... The medic should have handled the Airway, before he even thought about the IV.

Third, So what if the basic tried to intubate a dead body? It's good practice.

Forth, What happens on the truck stays on the truck. And that goes for other trucks, too. Even if you are not on that truck. The reporting crew should be flogged.

Fifth, if the off duty medic was on scene, then being described as being an off duty MEDIC, then I would assume that his Med Director, had cleared him to work as a Paramedic. Second, he IS a paramedic, and the toys were available. SHAME ON HIM, for not jumping in and doing the right thing. Sometimes doing what is told to us to be "Right," by our companies, or other ignorant people, and doing the RIGHT thing can be a little different. But, in the end, if you do the RIGHT thing, you'll be ok.

6th, the Basic should have said "No thanks, but I can hold C-Spine while you get the tube."

7th, and final... Since some unscrupulous bastard had to be a rat, Yes, the Basic should be sanctioned for attempting to work outside of his scope, and the medic should be disciplined, and re-mediated on his ABC's...

[Medic101Charlie]

My views...

Ok, first and foremost, if this cat was shot in the head, did he have respirations? Was there gray matter exposed? If no respirations, and gray matter exposed, then HE'S DEAD JIM! No further action needed.

Second, the order of treatment is ABC... The medic should have handled the Airway, before he even thought about the IV.

Third, So what if the basic tried to intubate a dead body? It's good practice.

Forth, What happens on the truck stays on the truck. And that goes for other trucks, too. Even if you are not on that truck. The reporting crew should be flogged.

Fifth, if the off duty medic was on scene, then being described as being an off duty MEDIC, then I would assume that his Med Director, had cleared him to work as a Paramedic. Second, he IS a paramedic, and the toys were available. SHAME ON HIM, for not jumping in and doing the right thing. Sometimes doing what is told to us to be "Right," by our companies, or other ignorant people, and doing the RIGHT thing can be a little different. But, in the end, if you do the RIGHT thing, you'll be ok.

6th, the Basic should have said "No thanks, but I can hold C-Spine while you get the tube."

7th, and final... Since some unscrupulous bastard had to be a rat, Yes, the Basic should be sanctioned for attempting to work outside of his scope, and the medic should be disciplined, and re-mediated on his ABC's...


Good practice or not, if the EMT did nothave the privilage to practice from the medical practice then HE WAS IN THE WRONG! Period. This again, is a cop out and a poor one at that.

Why should the reporting crew get flogged??? Because they saw something that was wrong and did something to correct it? That is crap, in my opinion. What happens on the truck stays on the truck only goes so far. Whether it should have been reported or not is beside the point. It was. Now they have to man up and take the consquences.

Just because he has a medic card does NOT mean he automatically has the right to practice. If he was "off duty" and in a different jurisdicition, he very well might not have had the privilage to practice from the medical director.

Get off the fact that he should not have been reported. It wasn't your call and none of us know the full story. Nor do any of us know the history between the agencies. What happens on the truck stays on the truck may work for you, but how do you enforce it on another crew? Another agency?

And how is he a rat bastard? Do we know the technique the EMT used? What is acceptad practice? Was it detrimental? And the fact that probably would not have survived is a crap excuse and cop out.

Bottom line is we practice under the medical license of our medical director. HE gives us the privilage. It's not ours simply by being a medic or having the skills. And since when is the back of a bus a cadaver lab for "good practice"? That just irks me. It smacks of "screw it, he's dead anyway so let's play." I won't even go there.


Jim

[anthonyt]

Good practice or not, if the EMT did nothave the privilage to practice from the medical practice then HE WAS IN THE WRONG! Period. This again, is a cop out and a poor one at that.

Why should the reporting crew get flogged??? Because they saw something that was wrong and did something to correct it? That is crap, in my opinion. What happens on the truck stays on the truck only goes so far. Whether it should have been reported or not is beside the point. It was. Now they have to man up and take the consquences.

Just because he has a medic card does NOT mean he automatically has the right to practice. If he was "off duty" and in a different jurisdicition, he very well might not have had the privilage to practice from the medical director.

Get off the fact that he should not have been reported. It wasn't your call and none of us know the full story. Nor do any of us know the history between the agencies. What happens on the truck stays on the truck may work for you, but how do you enforce it on another crew? Another agency?

And how is he a rat bastard? Do we know the technique the EMT used? What is acceptad practice? Was it detrimental? And the fact that probably would not have survived is a crap excuse and cop out.

Bottom line is we practice under the medical license of our medical director. HE gives us the privilage. It's not ours simply by being a medic or having the skills. And since when is the back of a bus a cadaver lab for "good practice"? That just irks me. It smacks of "screw it, he's dead anyway so let's play." I won't even go there.


Jim

Well stated...

First, once you are licensed, and have the equipment at your disposal, you are required to act. If you are off duty, and responding on a truck, then you are now ON DUTY...

Maybe I read it wrong, but it didnt sound like they were from another agency, only a different level of truck, from the same agency...

The bottom line is this, several things went wrong... None of the stated actions contributed to the ultimate demise of the patient. And therefore, if you have a problem with what I do on my bus, you come talk to me about and we handle it like men... on the level. If you don't like my reason, or think that I am trying to kill people then after you talk to me about it, go talk to my boss. (From your handle I am going to assume that you are a military man, and have a firm understanding of just what a chain of command is.)

Or better yet, if you see me screwing the pooch, say something and stop me. Be a man, not a ratbastard. If you hold a medic card in your pocket, you have a duty... PERIOD! At least to stop another medic from doing something detrimental to patient care. You know better.

The bottom line is this, if your dead, I cant kill you. So therefore no actions by either member of the crew caused this guys death...The bullet in his head did. Go find and prosecute the shooter, and leave the guy alone. Christ, you all act as if you've never tried to do something that you thought was the right thing to do, given the circumstances, even if you knew it might get you in trouble.

I have more respect for the EMT jumping in to help, than I do for the ***** medic, who abstained from acting because he was off duty, but still riding on an ambulance.


It's really that easy.

[strwblue]

Gotta Love Watching the Paramedics Duke it out. LOL

I have on one or two occations been mistaken for a Paramedic and ask to do a task that is a Paramedic task.. I advised said Paramedic that I was a basic and was not authorized to do said task. But I would do anything I could to assit said Paramedic in accomplishing thier needed tasks to save the patient without and let me repeat that WITHOUT going outside the parameters of my training.

Now all that being said, Have I treated patients in a South American Country with the consent and direct supervision of our medical director YES. But again foriegn country many many many patients and limited amount of time for treatment.

Battle All My Paramedic Brothers.