Guest guest Posted November 3, 2001 Report Share Posted November 3, 2001 In a message dated 11/3/01 9:27:48 PM Central Standard Time, King2001@... writes: > Nitro is the drug of choice of hypertension and TDH allows EMT-B's to give > Nitro. This set of protocols makes even EMT-P's call Medical Control to > admin. Nitro to hypertensive pts. I know that a services Medical Director > can > allow people to do advanced procedures as long as he feels confident that > the > person has an understanding of the procedure, but can the MD not allow what > TDH allows? This set of protocols wont allow EMT-B's or EMT-I's to > administer > Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, > according to TDH rules, can give this drug. I just wanted to know if there > is > anything out there that says that MD's have to follow what TDH says or not. > : Very good question that raises an issue that is not well understood by many people here in Texas. The answer to your question is fairly simple, actually. This is a very important concept, so I'm gonna sorta highlight it below: ******** In Texas, TDH does not authorize or allow ANYONE to do ANYTHING, in terms of protocols, scope of care, etc.******** We do NOT have regulated scope of practice in Texas. Some other states do, by the way. TDH does NOT establish protocols or even what skills are allowed by people. At all, in any circumstances, period. Now, if I have actually made that point clear, you know the answer to your original question. The medical director ABSOLUTELY has the authority, and the responsibility, to establish the scope of care provided by all persons operating under him/her, regardless of certification or license level. In fact, state rules (TSBME #197) require the medical director to authorize scope of practice on an individual basis prior to that individual providing care at any level to the community...this is a very important concept called " authorization " . Medical director authorization is critical to understanding the medical practice of EMS people in Texas. The medical director can authorize ECA's to do chest decompressions, and can also prevent paramedics from administering aspirin. Those two examples would be really bad ideas probably, but perfectly legal. Does that answer your question? , BS, LP Program Development Emergency Medical Certification, Inc. 1. <A HREF= " www.emcert.com " >www.emcert.com</A> Saving Lives Through Education TM Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 3, 2001 Report Share Posted November 3, 2001 Thanks, , for a provocative post. Please read down and I'll put in some comments. Gene Gandy, JD, LP In a message dated 11/3/2001 21:27:33 Central Standard Time, King2001@... writes: > Subj: Protocol Question > Date:11/3/2001 21:27:33 Central Standard Time > From:<A HREF= " mailto:King2001@... " >King2001@...</A> > > > I have a question about a recent set of protocols I looked at. As we all > know > Nitro is the drug of choice of hypertension and TDH allows EMT-B's to give > Nitro. Nitro is NOT the drug of choice for hypertension by a long shot. It is dangerous and can lead to lethal consequences in some patients. It is indeed questionable that hypertension by itself ever needs to be treated in the field; In fact, there currently may not be any such thing as a hypertensive emergency in the field. Nitro has some grave consequences when given to certain patients, those who have taken Viagra within the last 2-3 weeks for one, and others that we can't tell by looking at. There is currently no credible medical evidence that most or even any patients with hypertension need to have their BPs lowered in the field. And if they do, it should be with a titrated infusion that can be controlled so as not to lower systolic BP more than 15% within one hour. That means labetalol in most cases. Nitroprusside sodium if probably the better drug but because of its properties and storage difficulties it is not a choice to carry on the ambulance. Lowering the BP of a CVA patient can lead to fatal results, and patients with a Right Ventricular Infarct may also crash from hypotension after administration of Nitro. So it is NOT a benign drug. This set of protocols makes even EMT-P's call Medical Control to > > admin. Nitro to hypertensive pts. And there is a really good reason for this, as I have stated above. I know that a services Medical Director can > > allow people to do advanced procedures as long as he feels confident that > the > person has an understanding of the procedure, but can the MD not allow what > > TDH allows? The medical control MD can allow anything that s/he wants to, including the performance of brain surgery in the field, but s/he is totally and completely responsible for whatever happens. This set of protocols wont allow EMT-B's or EMT-I's to administer > > Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, > according to TDH rules, can give this drug. I just wanted to know if there > is > anything out there that says that MD's have to follow what TDH says or not. > > Nope, , there is not. All of us practice under the " delegated practice " of our medical directors. If a medical director wants to allow you to do only basic skills, then you have no rights or privileges under Texas law to do otherwise. There is no law or regulation allowing any " scope of practice " to any EMS practitioner in Texas. So your medical director can limit you to basic skills or, if s/he is willing to take full responsibility for you, allow you to do IVs, push meds, do chest decompression, intubate, or anything else s/he feels comfortable with you doing. But you have NO rights to do anything other than basic life support under Texas law. There are truly some pharmocological interventions that can be lifesaving, but Nitro is not usually one of them. Epi is, and more emphasis should be placed upon teaching about the acute asthma patient to EMTs. Nitro can play a role in the CHF patient with pulmonary edema, in the alleviation of pain in the patient with chestpain and adequate cardiac output, but for a patient with elevated BP and headache, for example, it has no place. Gene King, EMT-B > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 3, 2001 Report Share Posted November 3, 2001 It is totally up to the Medical Director whether you do it or not. It doesn't matter that TDH allows certified/licensed personnel to perform certain procedures, if it's not in the Medical Director approved protocols, you can't do it. Eddie Protocol Question > I have a question about a recent set of protocols I looked at. As we all know > Nitro is the drug of choice of hypertension and TDH allows EMT-B's to give > Nitro. This set of protocols makes even EMT-P's call Medical Control to > admin. Nitro to hypertensive pts. I know that a services Medical Director can > allow people to do advanced procedures as long as he feels confident that the > person has an understanding of the procedure, but can the MD not allow what > TDH allows? This set of protocols wont allow EMT-B's or EMT-I's to administer > Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, > according to TDH rules, can give this drug. I just wanted to know if there is > anything out there that says that MD's have to follow what TDH says or not. > King, EMT-B > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2001 Report Share Posted November 4, 2001 , Remember that just because TDH says an EMT-B can do something doesn't meant the Medical Director wants them doing it. Also, EMT-B's (as with all of us) can only practice at the advanced level (giving certain Meds) with a Medical Director otherwise they MUST practice at the EMT-B level. take care, Protocol Question > I have a question about a recent set of protocols I looked at. As we all know > Nitro is the drug of choice of hypertension and TDH allows EMT-B's to give > Nitro. This set of protocols makes even EMT-P's call Medical Control to > admin. Nitro to hypertensive pts. I know that a services Medical Director can > allow people to do advanced procedures as long as he feels confident that the > person has an understanding of the procedure, but can the MD not allow what > TDH allows? This set of protocols wont allow EMT-B's or EMT-I's to administer > Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, > according to TDH rules, can give this drug. I just wanted to know if there is > anything out there that says that MD's have to follow what TDH says or not. > King, EMT-B > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2001 Report Share Posted November 4, 2001 We > all know that EMT-B's, > according to TDH rules, can give this drug. I > just wanted to know if there is > anything out there that says that MD's have to > follow what TDH says or not. > King, EMT-B > - I did a quick, dirty, and admittedly non-exhaustive check of the EMS Rules (available on the TDH web site, by the way), and I found nothing that says that any certificant (that would be you and me) must be allowed to give any drug. What I did find are requirements that EMS certification courses ***include curriculum regarding certain treatments and medications.*** stay safe - phil __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2001 Report Share Posted November 4, 2001 The state of Texas is very clear on the fact that EMT-B's can only administer nitroglycerin to a patient with chest pain provided that the Nitro is prescribed to that patient, after consulting medical control. This is what is being taught in the EMT curriculum, now what an individual medical director will allow is up to him. Bruce ________________________________________________________________ GET INTERNET ACCESS FROM JUNO! Juno offers FREE or PREMIUM Internet access for less! Join Juno today! For your FREE software, visit: http://dl.www.juno.com/get/web/. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 CONGRATS ON YOUR AWARD! I personally feel that if anybody deserves it, it's gotta be you. This is off the subject, but if anybody has a good " drug test policy " for employees, I could sure use some input. If you want to send it to my personal e-mail, feel free. Any and all replies would be greatly appreciated. Thanks, Re: Protocol Question Thanks, , for a provocative post. Please read down and I'll put in some comments. Gene Gandy, JD, LP In a message dated 11/3/2001 21:27:33 Central Standard Time, King2001@... writes: > Subj: Protocol Question > Date:11/3/2001 21:27:33 Central Standard Time > From:<A HREF= " mailto:King2001@... " >King2001@...</A> > > > I have a question about a recent set of protocols I looked at. As we all > know > Nitro is the drug of choice of hypertension and TDH allows EMT-B's to give > Nitro. Nitro is NOT the drug of choice for hypertension by a long shot. It is dangerous and can lead to lethal consequences in some patients. It is indeed questionable that hypertension by itself ever needs to be treated in the field; In fact, there currently may not be any such thing as a hypertensive emergency in the field. Nitro has some grave consequences when given to certain patients, those who have taken Viagra within the last 2-3 weeks for one, and others that we can't tell by looking at. There is currently no credible medical evidence that most or even any patients with hypertension need to have their BPs lowered in the field. And if they do, it should be with a titrated infusion that can be controlled so as not to lower systolic BP more than 15% within one hour. That means labetalol in most cases. Nitroprusside sodium if probably the better drug but because of its properties and storage difficulties it is not a choice to carry on the ambulance. Lowering the BP of a CVA patient can lead to fatal results, and patients with a Right Ventricular Infarct may also crash from hypotension after administration of Nitro. So it is NOT a benign drug. This set of protocols makes even EMT-P's call Medical Control to > > admin. Nitro to hypertensive pts. And there is a really good reason for this, as I have stated above. I know that a services Medical Director can > > allow people to do advanced procedures as long as he feels confident that > the > person has an understanding of the procedure, but can the MD not allow what > > TDH allows? The medical control MD can allow anything that s/he wants to, including the performance of brain surgery in the field, but s/he is totally and completely responsible for whatever happens. This set of protocols wont allow EMT-B's or EMT-I's to administer > > Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, > according to TDH rules, can give this drug. I just wanted to know if there > is > anything out there that says that MD's have to follow what TDH says or not. > > Nope, , there is not. All of us practice under the " delegated practice " of our medical directors. If a medical director wants to allow you to do only basic skills, then you have no rights or privileges under Texas law to do otherwise. There is no law or regulation allowing any " scope of practice " to any EMS practitioner in Texas. So your medical director can limit you to basic skills or, if s/he is willing to take full responsibility for you, allow you to do IVs, push meds, do chest decompression, intubate, or anything else s/he feels comfortable with you doing. But you have NO rights to do anything other than basic life support under Texas law. There are truly some pharmocological interventions that can be lifesaving, but Nitro is not usually one of them. Epi is, and more emphasis should be placed upon teaching about the acute asthma patient to EMTs. Nitro can play a role in the CHF patient with pulmonary edema, in the alleviation of pain in the patient with chestpain and adequate cardiac output, but for a patient with elevated BP and headache, for example, it has no place. Gene King, EMT-B > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 In a message dated 11/05/2001 03:10:35 PM Central Standard Time, rxmd911@... writes: > > Maybe this provider needs to talk with that medical director and see about > changing some of the protocols to where EMT's and EMT-I's can do more and > not just limit the advanced care to EMT-P. > > Boy does this sound familiar. That is what the hospitals did when the nursing shortages came around. They gave the LVN's, nurse tech all of the nursing jobs they could and reduced the number of required RN's per floor. Keep talking and we won't need paramedics or LP's on the trucks. It would sure be cheaper to pay Intermediates and Basic's to do the same things. Wake up people, and quit trying to give your jobs away. Andy Foote EMTP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 Drug administration with the exception of oxygen and possibly charcoal are always given through protocols and standing orders. That's why basic services must have medical directors if they want to administer meds. There's nothing that says a medical director must allow anybody to do anything. Also, just because somebody CAN do something doesn't mean they always should. Please see my previous comments regarding NTG. NTG is a DANGEROUS DRUG and anyone giving it must know exactly what to expect from it and how to deal with it's effects and possible untoward events. When I was a Basic EMT I was allowed to give NTG only from the patient's own prescription bottle. Now Basic EMTs can give it from their own supplies, but how many of them are taught and really understand the hemodynamic effects it can have? Some, I'm sure, but most probably don't, not to mention that if given to a patient on Viagra it can have disasterous effects, and, even worse, it can kill a patient who is having an MI with a right ventricular infarct. Now, how many paramedics can spot an RVI? Probably few who took the old curriculum and only those who have had good 12-lead courses and had this pointed out to them. I routinely see MI patients transported where only Lead II is monitored even when they are carrying 3 lead monitors and can make modified chest leads to mimic the V Leads where you can sometimes see this. I will state here and now that is is a breach of Standard of Care not to run at least I, II, and III, and probably MCL1. Because, you see, you might pick up suspicion of an RVI through changes that you would only see in II, III, and MCL1, or just III and MCL1. Then if you do, you can make a V4R and check out the RV. You see, folks, education DOES have a place in paramedicine. It can make the difference in lives lost and lives saved. So just because you CAN give NTG doesn't mean you ought to. I personally don't want to give it unless I have a line and am ready to administer rapid fluid volumes and both Beta 1 and Alpha 1 adrenergic drugs. If you don't know what I'm talking about, my point is doubly made. When I was a basic I would have fought for the right to give any drug known to man. That's just how uneducated and stupid I was. And it has not been until the last few years that I really have learned much of the information that I really needed to know from the beginning. It simply was not taught in the old curriculum. Now it is SUPPOSED to be taught in the new curriculum, but is it? For those who are going to the QUICK AND EASY SCHOOL OF PARAMEDICINE, let me remind you that you get what you pay for. And so do your employers. Odds are, someday I'll meet you in Court and it won't be to get together over a pleasant cup of coffee. Have your wallets and proofs of insurance with you. Gene G. E. Gandy, JD, LP EMS Professions Program Tyler Junior College Tyler, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 As you have probably found out, the medical director for the service sets the guidelines under which you operate. We don't always agree with them. Maybe this provider needs to talk with that medical director and see about changing some of the protocols to where EMT's and EMT-I's can do more and not just limit the advanced care to EMT-P. I hope that you are not looking at Biocare, because they are worse. Wayne >From: King2001@... >Reply-To: >To: >Subject: Protocol Question >Date: Sat, 3 Nov 2001 22:26:49 EST > >I have a question about a recent set of protocols I looked at. As we all >know >Nitro is the drug of choice of hypertension and TDH allows EMT-B's to give >Nitro. This set of protocols makes even EMT-P's call Medical Control to >admin. Nitro to hypertensive pts. I know that a services Medical Director >can >allow people to do advanced procedures as long as he feels confident that >the >person has an understanding of the procedure, but can the MD not allow what >TDH allows? This set of protocols wont allow EMT-B's or EMT-I's to >administer >Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, >according to TDH rules, can give this drug. I just wanted to know if there >is >anything out there that says that MD's have to follow what TDH says or not. > King, EMT-B > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 I know that this has been brought up before, so what is one more time. Maybe EMS should have a " scope of practice " law just like the other professions do. Also, in the other post, I'm not agreeing that Nitro should be given for HTN pts, and that it should be used with caution on all patients because of the reasons that Gene has pointed out. WD >From: wegandy@... >Reply-To: >To: >Subject: Re: Protocol Question >Date: Sat, 3 Nov 2001 23:29:48 EST > >Thanks, , for a provocative post. Please read down and I'll put in >some >comments. > >Gene Gandy, JD, LP > >In a message dated 11/3/2001 21:27:33 Central Standard Time, >King2001@... writes: > > > > Subj: Protocol Question > > Date:11/3/2001 21:27:33 Central Standard Time > > From:<A HREF= " mailto:King2001@... " >King2001@...</A> > > > > > > I have a question about a recent set of protocols I looked at. As we all > > know > > Nitro is the drug of choice of hypertension and TDH allows EMT-B's to >give > > Nitro. > >Nitro is NOT the drug of choice for hypertension by a long shot. It is >dangerous and can lead to lethal consequences in some patients. It is >indeed >questionable that hypertension by itself ever needs to be treated in the >field; In fact, there currently may not be any such thing as a >hypertensive >emergency in the field. Nitro has some grave consequences when given to >certain patients, those who have taken Viagra within the last 2-3 weeks for >one, and others that we can't tell by looking at. There is currently no >credible medical evidence that most or even any patients with hypertension >need to have their BPs lowered in the field. And if they do, it should be >with a titrated infusion that can be controlled so as not to lower systolic >BP more than 15% within one hour. That means labetalol in most cases. >Nitroprusside sodium if probably the better drug but because of its >properties and storage difficulties it is not a choice to carry on the >ambulance. > >Lowering the BP of a CVA patient can lead to fatal results, and patients >with >a Right Ventricular Infarct may also crash from hypotension after >administration of Nitro. So it is NOT a benign drug. > >This set of protocols makes even EMT-P's call Medical Control to > > > > admin. Nitro to hypertensive pts. > >And there is a really good reason for this, as I have stated above. > > I know that a services Medical Director can > > > > allow people to do advanced procedures as long as he feels confident >that > > the > > person has an understanding of the procedure, but can the MD not allow >what > > > > TDH allows? > >The medical control MD can allow anything that s/he wants to, including the >performance of brain surgery in the field, but s/he is totally and >completely >responsible for whatever happens. > >This set of protocols wont allow EMT-B's or EMT-I's to administer > > > > Albuterol only EMT-P's. Is that allowed too? We all know that EMT-B's, > > according to TDH rules, can give this drug. I just wanted to know if >there > > is > > anything out there that says that MD's have to follow what TDH says or >not. > > > > >Nope, , there is not. All of us practice under the " delegated >practice " of our medical directors. If a medical director wants to allow >you >to do only basic skills, then you have no rights or privileges under Texas >law to do otherwise. There is no law or regulation allowing any " scope of >practice " to any EMS practitioner in Texas. So your medical director can >limit you to basic skills or, if s/he is willing to take full >responsibility >for you, allow you to do IVs, push meds, do chest decompression, intubate, >or >anything else s/he feels comfortable with you doing. But you have NO >rights >to do anything other than basic life support under Texas law. > >There are truly some pharmocological interventions that can be lifesaving, >but Nitro is not usually one of them. Epi is, and more emphasis should be >placed upon teaching about the acute asthma patient to EMTs. Nitro can >play >a role in the CHF patient with pulmonary edema, in the alleviation of pain >in >the patient with chestpain and adequate cardiac output, but for a patient >with elevated BP and headache, for example, it has no place. > >Gene > > King, EMT-B > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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