EMT-B administering saline under physician's license

[Schnit]

Hoping I can find the answer here.

First off, I am from Minnesota where only EMT-B and Paramedic are recognized. EMT-Bs generally are not allowed to do any fluid administration.

Second, I am an Army medic which means I am proficient in starting IVs.

Story, I work for a plasma center as medical staff and occasionally we have a donor who is hypovolemic after their donation and requires saline administration. We have a nurse and 2 paramedics who work with me but sometimes I am the only person working meaning that the only way for me to help the donor/patient is an expensive ambulance ride to the hospital for a 500ml bag of saline.

I work under a physician and we have both heard that as long as I'm doing IVs under his license with his approval that I can administer saline. The question neither of us know is what exactly is required to ensure that the physican, the company and myself are in the clear.

Anyone have any input?

Thank you.

 

[MMiz]

I am not a lawyer, and only speak from experience, but it is my understanding that you are allowed to provide services to the level that you're trained with medical oversight/direction and protocols. Your MD should have established medical protocols for administering saline, and the MD will need to sign off.

With additional training and medical oversight EMT-Basics do all kinds of stuff in the ER as ER-Techs that is beyond our scope of practice.

I hope that helps.

 

[medicdan]

Like Matt, I am also not a lawyer, but it may be valuable for you to get it all out on paper.

Your medical director can either write a protocol for that specefic patient, or write a document with a blanker order sounding something like this, "If a patient, after successful plasma donation shows signs of hypovolemia, such as hypotention... 500mL saline may be administered in existing vascular access... by facility staff... " There should be a mention in there of when to call an ambulance, how to document, etc.

 

[JPINFV]

As a general rule, when working in non-ambulance/first aid jobs (ER, blood donor centers, etc), you aren't working under your EMT cert/license. As such, your facilities medical director can delegate pretty much anything provided it complies with state law (i.e. if your state requires licensed phelbotomists if personnel don't hold specific licenses (MD/DO, MA, RN, PA, etc). Just because you are/aren't allowed to do a specific intervention under one license/cert doesn't mean you are/aren't allowed to do it under a sepatate license. The question is, then, which license/cert are you working under.

 

[berkeman]

500mL saline may be administered in existing vascular access... by facility staff... "

After the blood donation is done and the Pt is walking to the cookie table, there won't be any existing vascular access...

At least in Cali, I know a (now) medic who was able to routinely start IVs as an EMT-B with a supervising MD on-site.

 

[8jimi8]

All it takes is a sentinel event to find out the answer.

First patient that dies, or gets an infection and decides to sue.

Honestly, bro, providing care out of your scope of practice is a great way to lose your license.

How long do you think it will take your state to forgive you and reinstate your license after one of the two above scenarios unfolds.

It doesn't matter much if the doctor orders you to "start the iv," or "bolus them 500cc." If someone gives you an illegal order, you don't get forgiveness for following it.

Sorry to be the killjoy. But really... If you have routinely administered saline in the military, why is it so interesting out of uniform?

If you are taking the perspective that you are the ONLY person working and you need to administer a medication to someone, your medical oversight is seriously lacking. If it is immediately necessary for a person to receive a medication, a competent and prudent licensed person needs to be involved in the administration.

Go to school, earn your license and do it the right way. Remember you are not the person who has to live with the side effects of the "healthcare" you are administering.

 

[ExpatMedic0]

your not administering it as an EMT-B, and its under the doctors orders, simple as that I would think? My first medical job was as a medical assistant my only training was EMT-B I dident work under my cert, I worked under the doctors licence, we had one MA who wasent even an EMT-B but a retired army medic and he did more than the RN's.

I also worked in clinical research for a long time and the same thing applied to me there, although I had documentation from the company stating i had been trained in each skill I was allowed to do in the clinic and we kept all the training in a big binder. It was signed off by the doctor and my supervisor on each training paper.

 

[AnthonyM83]

All it takes is a sentinel event to find out the answer.

-break-

Honestly, bro, providing care out of your scope of practice is a great way to lose your license.

-break-

Sorry to be the killjoy. But really... If you have routinely administered saline in the military, why is it so interesting out of uniform?

If you are taking the perspective that you are the ONLY person working and you need to administer a medication to someone, your medical oversight is seriously lacking.

-break-

Go to school, earn your license and do it the right way.

Breaking his scope of practice assumes he has a scope of practice...which would be assuming he's working as an EMT. College students routinely volunteer at a health clinics where they may take blood pressures and oral temperatures. They're not violating a scope of practice, because they aren't working as EMTs. Though "surgical/anesthesia tech" certificates exist (non-licensing), many hospitals simply train their techs themselves.

The poster painted the picture that this wasn't some severe medical emergency. Rather giving patients who pass out after donating is a semi-common occurrence for which they just give them a bolus, let them rest, then send them on their way. It's a nice helpful thing for them, rather than having to call an ALS unit.

But Jimi's first line still stands...it only takes one sentinel event to find out what they courts really think. So, yes, it might be better safe than sorry...but let's not accuse him of going out of scope.

As someone said, if it gets written into a standing protocol and receive in-house training, you're much more likely to be covered...

 

[DrParasite]

1) if you are acting as an EMT, then you are limited by the EMT scope of practice.

2) if you are not acting as an EMT, and as office staff, does that mean that any lay person can perform medical procedures as long as the MD says they can?

why not call the state dept of health and ask them? and they say you can, make sure you get it in writing so if something does go wrong, you have some defense to fall back on.

 

[Lone Star]

When I was an EMT-B in Michigan, I applied for an ER Tech position at a local hospital. One of the duties was initiating IVs. While this was a direct violation of my EMT-B license, it was explained that I wouldn't be working on my EMT-B license, but under the license of the hospital, and therefore I was able to start IVs because I wasn't an EMT at that point.

I further asked if this 'skill' then could be taken 'out in the field' and was told that in the field, working as an EMT-B, I was bound by the scope of practice that applied.

So it IS possible to start IVs in this instance without worrying about violating the EMT-B scope of practice.

 

[Schnit]

lecture....

It doesn't matter much if the doctor orders you to "start the iv," or "bolus them 500cc." If someone gives you an illegal order, you don't get forgiveness for following it.

Sorry to be the killjoy. But really... If you have routinely administered saline in the military, why is it so interesting out of uniform?

Go to school, earn your license and do it the right way. Remember you are not the person who has to live with the side effects of the "healthcare" you are administering.

In order of paragraphs.

#1. I am trying to find the LEGAL way of doing this. I never once said I was attempting to do it any other way. As also stated earlier, it is quite common for Bs to work outside their scope of practice when working UNDER their MD.

#2. I don't know what you mean by "interesting". I have patients under my care, it's my responsibility to be able to provide the best care possible. If I can legally start an IV to someone who needs it NOW it's better care than waiting 20 minutes for the ambulance to arrive and have them administer it. This is a plasma center where people donate more than 1 pint of blood, they have up to 880ml of plasma removed.

#3. Walk into any ER and tell all the EMTs who work outside their scope but under their doctors's license that they should go to school instead of doing what they are doing. I have friends in hospitals that are EMT-B and their JOB is to do IVs all day long. (I tried asking them, but they weren't much help).

For anyone who still doesn't quite understand, I am looking for the LEGAL way of doing this.

 

[VentMedic]

In order of paragraphs.

#1. I am trying to find the LEGAL way of doing this. I never once said I was attempting to do it any other way. As also stated earlier, it is quite common for Bs to work outside their scope of practice when working UNDER their MD.

Does your job description specifically say EMT-B or Plasma Center Technician?

If it specifically states EMT-B then your medical director will have to follow the scope of practice for the EMT-B or petition for an exception with the state if you are to continue using that title.

If you are under some other title, your medical director will have to abide by the regulatory agency that accredits plasma centers. Every center MUST have an SOP manual that also has a job description for each employee.

#2. I don't know what you mean by "interesting". I have patients under my care, it's my responsibility to be able to provide the best care possible. If I can legally start an IV to someone who needs it NOW it's better care than waiting 20 minutes for the ambulance to arrive and have them administer it. This is a plasma center where people donate more than 1 pint of blood, they have up to 880ml of plasma removed.

If this center does not meet the minimum requirements for staffing then there will be bigger issues to address as to whether this center is actually operating legally and in accordance with its regulatory standards.

#3. Walk into any ER and tell all the EMTs who work outside their scope but under their doctors's license that they should go to school instead of doing what they are doing. I have friends in hospitals that are EMT-B and their JOB is to do IVs all day long. (I tried asking them, but they weren't much help).

EMT-Bs are NOT generally working as "EMT-Bs" in the ED. They are working under a hospital defined title with a specifically written job description that is allowed within the laws of the state for them to function within that job description with training provided by the hospital. Just the "skills" of the EMT-B are of little use in most hospital EDs. The EMT-B cert is just proof that you have had some training and may have a little work experience with that title. In many situations it may not even be required to maintain their EMT-B cert as long as they maintain competency for their job description with the hospital. However, many do keep the cert in case they want to change jobs later.

For anyone who still doesn't quite understand, I am looking for the LEGAL way of doing this.

Again that will depend on your job description and title. You should then contact the agency that regulates Plasma Centers. If you believe you are working solely under your EMT-B cert, then you Medical Director needs to become familiar with your state's EMT scope of practice.

Regardless of what health care profession you are in, the medical director will have to abide by the scope for the profession of the title being used or to petition for an advanced practice exception. EMS titles rarely have an open ended scope of practice to where the medical director fully determines additional responsibilities that are not listed in the statute. If you are not working under the EMT title but something related to plasma centers, then the medical director will have to follow the personnel practice scope established by the specific regulatory agencies that may also have to take into consideration state laws for administering fluids by non licensed personnel.

I am rather surprised that there is not at least an LVN present at your center so administering fluids would not an issue but most do know it is a definite reality. It seems your center is operating below the recommended standard by having only an "EMT-B" on duty.

 

[alphatrauma]

In order of paragraphs.

#1. I am trying to find the LEGAL way of doing this. I never once said I was attempting to do it any other way. As also stated earlier, it is quite common for Bs to work outside their scope of practice when working UNDER their MD.

Why are YOU trying to find a legal way of doing anything? This is the responsibility of your employer and their legal/risk management dept. You are responsible for performing your job according the parameters in your job description.

EMT-(whatever) may practice certain specific skills, outside their scope, when working in a clinical/hospital setting. But lets not get this twisted... MDs are generally employees or contracted staff of the respected company and often have little if anything to do with what EMT-(whoever) can perform. The only exception I can see, is if the physician you are working with owns the company, and so the buck will stop with him/her.

#2. I don't know what you mean by "interesting". I have patients under my care, it's my responsibility to be able to provide the best care possible. If I can legally start an IV to someone who needs it NOW it's better care than waiting 20 minutes for the ambulance to arrive and have them administer it. This is a plasma center where people donate more than 1 pint of blood, they have up to 880ml of plasma removed.

If the plasma center does not have staff present (excluding you) to start IVs, then I would argue that they need to seriously re-evaluate their staffing practices.

#3. Walk into any ER and tell all the EMTs who work outside their scope but under their doctors's license that they should go to school instead of doing what they are doing. I have friends in hospitals that are EMT-B and their JOB is to do IVs all day long. (I tried asking them, but they weren't much help).

They (your EMT friends) are doing what they are doing, because their job allows it. It has nothing to do with physician oversight/permission or some grandiose notion of standing orders. Maybe you should seek employment at a hospital emergency department. Then you can safely administer IV access and not have to worry about circumventing job restrictions.

For anyone who still doesn't quite understand, I am looking for the LEGAL way of doing this.

I think we understand what it is you want, unfortunately you will not find an answer here... at least not the answer you want to hear. TALK WITH YOUR EMPLOYER.

 

[AnthonyM83]

why not call the state dept of health and ask them? and they say you can, make sure you get it in writing so if something does go wrong, you have some defense to fall back on.

That's probably the best bet, actually.
People keep going off on you about it being an employer's problem, but nothing wrong with information seeking yourself.

 

[VentMedic]

That's probably the best bet, actually.
People keep going off on you about it being an employer's problem, but nothing wrong with information seeking yourself.

Plasma Centers have been a source of controversy for over 20 years. They are regulated by the FDA as well as other Federal and State regulations but even with that their oversight has been vague in some areas. Hopefully this center is also certified by the IQPP.

It would be wise for Schnit and the Medical Director of this plasma center to check with their accrediting agencies since when it involves patient safety and regulatory compliance, neither will be able to claim ignorance when it comes to their license and/or certification.

 

[Schnit]

Thanks to those who provided helpful replies. To those of you who suggested that I find work elsewhere, your condescending replies on the subject were not helpful nor were they asked for.

Couple facts about the matter.
#1. My job title is "Physicain Substitute" which, yes is quite a "B.S." title...But it was the FDA that created the job title specifically for plasma centers so call the FDA if you have a problem with the name.
#2. My employer now requires that everyone in my position be EMT-P or above (I was grandfathered in).
#3. Yes it is my employers problem that I am just an EMT-B. However, just because it is my employer's problem does not mean that it's up to them to find the best possible way solve this problem. (Yes I know going to school for para solves this problem, but that's 3+ years out since I deploy to Afghanistan soon).

As suggested, tomorrow I will call the Minnesota Emergency Medical Services Regulatory Board and find out what they have to say about it.

Thanks again to those who had (or at least attempted) productive input.

 

[VentMedic]

#1. My job title is "Physicain Substitute" which, yes is quite a "B.S." title...But it was the FDA that created the job title specifically for plasma centers so call the FDA if you have a problem with the name.

There shouldn't be any problem with the usage of the term Physician Substitute since it appears in many medical situations. However, "Physician Substitute" should not be confused with "Physician Extender" which is a title granted to NPs and PAs.

As Physician Substitute is merely a licensed healthcare professional that can , while under the direct supervision of a Physician (Medical Director), perform specific duties that a physician might also perform. This is,of course, unless there is a direct conflict with the scope of practice for that licensed health care professional concerning some procedures.

#2. My employer now requires that everyone in my position be EMT-P or above (I was grandfathered in).

Actually your employer is following the FDA standards for the definition of Physician Substitute. As an EMT-B you no longer qualify and your employer should have made staffing adjustments to where a Physician Substitute by the FDA standards (and I believe there is another regulatory agency controlling the definition as well for plasma centers) is present.

#3. Yes it is my employers problem that I am just an EMT-B. However, just because it is my employer's problem does not mean that it's up to them to find the best possible way solve this problem. (Yes I know going to school for para solves this problem, but that's 3+ years out since I deploy to Afghanistan soon).

It will definitely be your employer's problem if something goes very wrong with a patient. The agencies regulating this center will want to know if it has any issues complying with their standards. Thus, grandfathered or not, this agency will have to make adjustments for your lack of licensure before it becomes a problem.

 

[grich242]

One of the er's that I currently work in recently required all of their tech to become emt-B's. They also now start iv's in the er I can tell you this was quite intensely investigated... First of all when you work on the road you follow protocols under the supervising medical authority for that area be it county city etc... they define your scope of practice. If you are not working in an ems system covered under that scope of practice ie in a clinic, er, plasma center etc, you fall under that facility's medical director. ems licenses are closest to pa's (in the way they operate) in that they do follow under the physicians license. you are not working "out of your scope of care" because it is defined by the facility. the same way that 2 basic's in the same state but different area's have different protocols.That being said as vent stated you need to have documentation that your are trained to do it and have a protocol written by the director to follow like a "standing order".

 

[VentMedic]

ems licenses are closest to pa's (in the way they operate) in that they do follow under the physicians license.

Not even close. A PA is a true physician extender.

Almost every health care professional in every health care field works under a medical director. That includes RNs, RRTs, PTs, OTs and Athletic Trainers.

you are not working "out of your scope of care" because it is defined by the facility. the same way that 2 basic's in the same state but different area's have different protocols.That being said as vent stated you need to have documentation that your are trained to do it and have a protocol written by the director to follow like a "standing order".

The problem lies in that as an EMT-B, he does not qualify as a Physician Substitute. The EMT-B is not among the licensed health care professionals by the definition defined by the regulatory agencies.

One of the er's that I currently work in recently required all of their tech to become emt-B's.

They could also have required them to become CNAs or PCTs but the EMT may have been the easiest for them to obtain. A good PCT program may take 500+ hours. If they become CNAs they may also have to float throughout the hospital and those that work in the EDs hate that although they should see what happens in other patient care areas.

 

[firecoins]

I once tried to tie my shoes under a physician's license. It was easier once I out license back in his wallet.