Medical Control - How Far is Too Far?

[Jeremy89]

Never bash someone unless you actually know what their training is or have worked as one. I do work with some incredible CNAs and wouldn't trade any of them for a 3 for 1 sale on EMTs. They understand the basic needs of the patient which 98% of the time is more useful than knowing how to pick up a BVM.

Maybe the BVM is a bad example. How many CNA's that you know can confirm breath sounds after intubation? I know its not that difficult, but I can't tell you how many I've done where I'm the only person in the room with a pair of ears. Yeah, there's the color change and the chest rise, but auscultation is usually the "everyone can breathe easy, we're in" confirmation. (no pun intended).

 

[VentMedic]

Maybe the BVM is a bad example. How many CNA's that you know can confirm breath sounds after intubation? I know its not that difficult, but I can't tell you how many I've done where I'm the only person in the room with a pair of ears. Yeah, there's the color change and the chest rise, but auscultation is usually the "everyone can breathe easy, we're in" confirmation. (no pun intended).

Are there no doctors, RNs or RRTs at your hospital?

We do have RNs, RRTs and MDs who can do these things so it is not always the CNA's responsibility to do the "heroics". They have a other responsibilties getting the equipment and stretcher to get the patient to CT Scan, ICU or where ever. It sounds like you still have not learned all the roles of the many health care workers that make up your team. Not everyone lives for a "heroic" moment. There are many, many things that go into patient care and expecially at a code. Maybe you should stop with the grandstanding and focus on the team effort.

The person who did the intubation should also confirm the breath sounds.
Too often a Paramedic, MD or RRT can get caught with the question for a misplaced tube "Did YOU listen?"

Have you ever worked as a CNA?

You seem hellbent on belittling them in an attempt to make your title look better.

 

[Jeremy89]

Are there no doctors, RNs or RRTs at your hospital?

We do have RNs, RRTs and MDs who can do these things so it is not always the CNA's responsibility to do the "heroics". They have a other responsibilties getting the equipment and stretcher to get the patient to CT Scan, ICU or where ever. It sounds like you still have not learned all the roles of the many health care workers that make up your team. Not everyone lives for a "heroic" moment. There are many, many things that go into patient care and expecially at a code. Maybe you should stop with the grandstanding and focus on the team effort.

The person who did the intubation should also confirm the breath sounds.
Too often a Paramedic, MD or RRT can get caught with the question for a misplaced tube "Did YOU listen?"

Have you ever worked as a CNA?

You seem hellbent on belittling them in an attempt to make your title look better.

The ED RCP also covers Trauma, Cath lab, Endoscopy, Transition, Radiology as well as responds to all rapid responses and codes if not in another RCP's "area". They also have to bring a vent from the trauma room when we intubate. We're often done by the time they arrive, OR they're running the ABG and miss the intubation. I've seen both happen many times.

And I just feel like I'd be allowed to do more, or at least be perceived as more competent, if the NA's had their EMT or were trained in additional areas such as basic assessment, airway (including Oral/nasal airways and proper suctioning techniques as well as auscultation), O2 application (only techs with their EMT can apply O2 without asking the RN- is it enforced? not really), and basic splinting (including C-collars). But more importantly- medication administration. Yes, I know its just nitro, ASA, glucose, charcoal, and Epi-pens, but the fact that we learn that makes us more competent then co-workers (RN's and MD's) think.

No, I've never been a CNA. I worked in a nursing home in high school, in the kitchen. I can't tell you what they're taught to do, but I know what their basic duties include in a hospital floor setting.

I agree- when there is a sick pt, it is a team effort. I do lots of those "little things" like weighing a stroke pt or getting a monitor or supplies the RN needs. I don't live for those "heroic" moments. I'm more than happy to get what the Doc needs, but I don't like that being my only job during critical pt care.

 

[Jon]

I like that we are discussing this... but it is a hot button issue, so please remain NICE... ok?

 

[NomadicMedic]

Almost this exact same subject came up during lunch at medic school today.

One guy said, "What if a Doc asks us to do something outside our scope of practice? Like a chest tube?" (And yes, stuff like this happens all of the time.)

Our clinical director has told us that if we know we can't do it it, to politely say "Thanks, but no thanks."

However, if it's something that the Doc is insistent about, and he takes responsibility, you're working under his license. For example, our MPD is adamant about the medic students getting experience under the guidance of the Doc and if he says "Come here and do this retrograde intubation, I'll show you how..." You can bet I'd be right there!

Our clinical director wants a phone call if we are about to do anything that's off the page. She really needs to know about it, preferably before it happens. And yes, our insurance covers us and the program from liability if we preform skills under a Doc's watchful eye.

And, just to eliminate any confusion about "who can do what", our clinical sites provide us with a "scope of practice" matrix that lists all of the procedures and skills we may perform, as well as those approved for other allied health students.

However, a doc instructing a medic student on an advanced procedure is a lot different than a basic simply "doing it..."

 

[s4l]

If a doctor is willing to take his time and teach you something out of your normal scope, go for it!

This. I had the chance to learn from my old facilities ER Director when we had the same rotation. I'm only a CNA (going to start EMT-B) and I learned A LOT of procedures from him (Small town hospital).

I'll never turn down the chance to learn from an experienced doctor.

 

[DrParasite]

So why bother with training if you get no autonomy.... You are then just an operator or technician.. Maybe a 4 year degree, Master or PHD in PreHospital Emergency care might allow you to practice as a professional.

It is hard to argue that direct supervision and step by step procedures are progressive and education is archaic

paramedics do have some autonomy. but they still need to follow the rules and guidelines of their medical director. now if they had a bachelors degree (as the basic) and a masters or PHD devoted solely to prehospital care, then I would be completely agreeing that they get total autonomy to not need medical control. but i don't see that happeneing.

So if you screw up and kill somebody, why blame somebody else?

that isn't what happens. it isn't about blame. in fact, you can do everything right, and still get sued. why do you think a doc's malpractice insurance is much higher than a nurses? ditto a PA and MD. not only that, every paramedic has killed someone, just like every doctor has killed some (albeit usually not intentionally). it's easier to fall back on "i was following the directions of my medical director" instead of "i did what i thought was right, and it all falls on my shoulders."

 

[mycrofft]

WuLabsWuTech,was your question "Can MDs direct me to do something outside my scope?"?

I think you will find that in an emergency a MD can have you assist in some sorts of procedures (obviously not open heart surgery, but holding rib spreaders during an emergency thoracotomy might pass), but as for having you do something out of scope later on since you were taught it, not kosher.

Sometimes "scope" has some wiggle room in the case of "standardized procedures" or "protocols". I was surprised at what LVN's were allowed to do in California IF their employer has medical direction and the written procedures/protocols; the lynchpin for their actions were that there could be no "decision process", all "If you see THIS, then you can do THAT". You would know if such prpotocols existed because you would have to be certified (if only in your hospital etc) through study and a test to use them.

If I remember, we had some posts about a MD at an emergency dept who was giving inappropriate radio dirctins to field folks?

 

[WuLabsWuTecH]

mycrofft: thanks for getting us a back on track just a bit (we weren't that far off).

Here's the question: SAME doctor. Now does doing the same thing later on with with him in the room pass?

And I guess now the new question for me to find out is: In the states I work in, at what point does my EMT license no longer apply to me?

Perhaps some quality time with the EMS Governing Bodies' websites will shed some longt on this!

 

[VentMedic]

And I just feel like I'd be allowed to do more, or at least be perceived as more competent, if the NA's had their EMT or were trained in additional areas such as basic assessment, airway (including Oral/nasal airways and proper suctioning techniques as well as auscultation), O2 application (only techs with their EMT can apply O2 without asking the RN- is it enforced? not really), and basic splinting (including C-collars). But more importantly- medication administration. Yes, I know its just nitro, ASA, glucose, charcoal, and Epi-pens, but the fact that we learn that makes us more competent then co-workers (RN's and MD's) think.

And many will say if only EMTs knew how to function in a hospital. There is not that much need for the first aid that an EMT does in that setting. I have also stated many times that an EMT would be better off doing a clinical with a CNA where they can do about 50 sets of vitals rather then one on an ambulance ride.

CNAs work with all the equipment you have mentioned and much more plus they get an understanding of how patients react to various situations from their experience in the many different areas of the hospital. CNAs may also be exposed to working in a critical care setting which is something few EMTs will ever see.

The problem with EMS is that it bases its whole worth on a few skills and the "I can do this and you can't" mentality. They don't think about the experience and education some have. Some Paramedics look down on an RN because "they don't intubate and we can" yet they have no idea what an RN can do. Many are surprised to learn an RN can intubate within their scope of practice but they also are educated enough to know there are many things that must be done besides the insertion of a tube down someones throat. An RRT can easily intubate but there are many other things they must be responsible for as well. Thus, they know that passing on ONE skill is not going to lessen them as a professional.

You must look at the whole patient care perspective before you start knocking down another lower level care provider. Also, think very carefully before you get into a "skills listing" match with a CNA because you might be surprised to find their list is a whole lot longer than yours but they aren't striving to get hugs and kisses from the ED doctor. They know their value and the licensed professionals know their value.

 

[VentMedic]

Here's the question: SAME doctor. Now does doing the same thing later on with with him in the room pass?

And I guess now the new question for me to find out is: In the states I work in, at what point does my EMT license no longer apply to me?

Perhaps some quality time with the EMS Governing Bodies' websites will shed some longt on this!

Or, you can ask the HR department at your employer.

Did they hire you as an EMT or did their hire you because the EMT gave you some training? Do they ask for your EMT card each time it is renewed to be on file? Of course you must also understand that for the position you hold, that may only be a "basic" requirement and by them changing your title you can expand into more areas provided they have listed that in your job description. There are some procedures only a recognized licensed health care worker can do and EMT rarely falls into that category.

 

[MrBrown]

You know this might be a good time for me to ask a pertinent question

WTF is with all these different people you have wandering around the ED? When I was in California they had "technicians" and "partners" and "care associates" and "wellness maintenance associate" and a bunch of other titles for people who seemed to do sweet F/A!

In our emergency department (and I think most other hospital areas) we have basically two groups of staff; nurses (RNs) and MDs, while there may be some "assistant or technician" level people they are not directly involved in patient care and as the name suggests they move patients, run equipment etc

The only exception I am aware of to this is an Anaesthetic Technician who is our equivalent of a CRNA.

 

[VentMedic]

You know this might be a good time for me to ask a pertinent question

WTF is with all these different people you have wandering around the ED? When I was in California they had "technicians" and "partners" and "care associates" and "wellness maintenance associate" and a bunch of other titles for people who seemed to do sweet F/A!

The primary players are MDs, RNs and occasionally RRTs will either be stationed there or pop in when needed. If the staff is lucky, they will have an ER Tech.

We do have Social Workers and Case Managers who help get the patients through the system with their special needs faster.

There may be Lab Technologists that come out to do their own blood draws.

Radiology Technicians will also be around doing X-rays or specialized scans.

Transporters may take the patients to their rooms or for tests in other parts of the hospital.

If one RN is caring for 4 - 10 ED patients at one time, it may be difficult for him/her to do everything all the time. Fighting with insurance companies and finding ways to get scripts filled for patients can be time consuming so there is a need for other specialists and techs to be around.

 

[MrBrown]

...Fighting with insurance companies...

Ah universal healthcare :wub: