LA County EMT Scope of Practice (2011)

Who must approve the local scope of practice by EMS agencies?

State EMS authority

Who determines the Local EMT Scope of Practice?

LA County EMS Agency *Medical Director*

Give the reason for the development of the LA County Scope of Practice?

-Address the special needs of patients prior to arrival of ALS unit and during interfacility transport

-Expedite the care of patients in acute distress

What are the requirements that must be met by EMTs to be able to function within the LA county EMT scope of practice?

-Currently certified as an EMT in CA and working in LA County

--> Certification in CA

-Trained and tested in the knowledge and performance of procedures and skills included in the local scope of practice

What is meant by "the most appropriate receiving facility that meets the needs of the patient"?

Health care facility that is *staffed, equipped,* and *prepared* to administer emergency and/or definitive care appropriate for the needs of the patient

The facilities that EMTs should consider are:

-Most Accessible Receiving (MAR)

-Closest Emergency Department Approved for Pediatrics (EDAP)

-Closest Perinatal Center (newborn; difficult pregnancy)

-Closest Trauma Center

What are the facilities an EMT should consider?

Most Accessible Receiving (MAR)

EDAP

-Closest Emergency Department Approved for Pediatrics

Closest Perinatal Center

Closest Trauma Center

How does the Local EMT Scope of Practice increase the EMT's basic scope of practice?

-Assisting patients with administration of physician prescribed emergency medications

-Transporting patients with various tubes and indwelling vascular access lines

-Transporting patients with certain medication additives in intravenous solutions

-Transporting patients with specific patient operated medication pumps

**A BLS Unit is only allowed to carry glucose and oxygen

What is a BLS allowed to carry?

Glucose and Oxygen

What does it mean to assist patients with physician prescribed medications?

-Allow patient to self-administer prescribed medications in the presence of BLS providers

-Assist the patient in taking prescribed medications if the patient has difficulty with self-administration

-Administer the prescribed medication to the patient if the patient is physically incapable of administering the medication

**EMTs may only assist with PHYSICIAN PRESCRIBED EMERGENCY MEDICATIONS for the relief of acute symptoms or a current emergency condition

What is the criteria for assisting patients with physician prescribed emergency medications?

-Medications are listed in the LA County EMT Scope of Practice

-Medication is prescribed by a physician

-Medication is prescribed for the specific patient

-Medication meets indication for administration

-There are no contraindications present

**The administration of these medications is for emergency supportive therapy ONLY, and not a substitute for immediate medical care

What medications should be carried on the BLS unit that EMTs can administer *without* a prescription?

Oral Glucose preparations

Oxygen

What are the most common emergency medications? What are their administration limits?

*Oral glucose preparations*

*Nitroglycerin tablets or spray*

-Up to max 3 doses (includes patient self-administration dose)

*Epinephrine Auto-Injector*

-One dose

*Bronchodilator Inhaler or Nebulizer*

-May repeat 1 dose

What criteria must be met prior to the administration of sublingual nitroglycerin?

Systolic BP must be above 100

Patient has not taken sexual enhancing drugs within the previous 48 hours

What criteria must be met prior to administration of bronchodilator inhaler/nebulizer?

Patient must be *alert enough* to use inhaler/nebulizer

-EMTs may only add a *unit dose* to the nebulizer when assisting the patient with preparing a nebulizer

What criteria must be met prior to administration of epinephrine device (auto-injector)?

Patient must be awake

What IV solutions may EMTs monitor and/or maintain at a preset rate of infusion?

*Glucose solutions*

*Normal Saline*

*Lactated Ringer's*

-Boosts/gives more electrolytes

-Patient already has IV

**NOTE: In LA County, ONLY these solutions may be transported by EMTs; all other solutions require ALS transport

-EMT can transport ALS patient if ALS provider on the rig

How must IV solutions be?

TKO or at a preset rate

-TKO means "to keep open"--> Just to keep the vein open

Are EMTs allowed to make adjustments in the IV flow?

YES, they may re-adjust rates in the case the IV flow changes from the preset rate

When should the infusion be turned off?

If signs of infiltration occur during transport

EMTs are *NOT* allowed to discontinue IV catheters

What are the IV additives that EMTs may transport at a TKO rate?

*Folic acid*- 1mg/1000ml

*Multivitamins (MV)*- maximum 1 vial/1000ml

*Magnesium Sulfate*- maximum 2 grams/1000ml ONLY

*Thiamine*- 100mg/1000ml

What are the maximum concentrations of the additives that EMTs can transport at a TKO rate?

Folic acid - 1mg/1000ml

Multivitamin- 1 vial/1000ml

Magnesium Sulfate- mex 2 grams/1000ml

Thiamine 100mg/1000ml

What IV additives/solutions require an infusion pump during transport?

*Potassium chloride*- 20mEq/1000ml

-For cardiac efficiency

*Total Parenteral Nutrition (TPN)*

-Way of giving food

What is an infusion pump?

Preset calculated drop rate, and on a pump

-Fool proof; should not have to adjust it!

What additives require an infusion pump for transport?

Potassium Chloride

Total Parenteral Nutrition (TPN)

-All rates must be preset by hospital/home health personnel whether the pump is supplied by BLS provider, hospital, or from home

-EMTs may be instructed in the operation of the pump in case of infiltration or fluid overload

What IV medications may EMTs transport via special infusion pumps?

Any prescribed medication with an *automated or patient operated medication pump*

Any prescribed pain medication via a patient controlled analgesia (PCA) pump

-Can transport patient with pain meds

-Automated or patient operated medication pumps may be either implanted or external

-OCA pumps must be on a locked setting and may ONLY be activated by patient or caregiver

-EMTs are NOT allowed to activate or adjust rates for these IV delivery systems

What first aid mesaures should be initiated in case of exposure to a chemotherapeutic agent?

*Skin*- Wash IMMEDIATELY with soap and water

*Eyes*- Flush with normal SALINE for 5 minutes

**ALL exposures must be reporated and evaluated by a physician

What advanced airway adjuncts may EMTs ventilate?

-Endotracheal tube

-Esophageal tracheal airway device (Comitube)

-Perilaryngeal airway device (King LTS-D)

-Tracheostomy tube/stoma

What do all advanced adjuncts require?

15mm adapter to attach a valve-mask device

How are patients with a stoma ventilated?

Only with a bag-mask-valve device

-Use a pediatric mask to obtain the best seal

What advanced airway adjunct and surgical airway are EMTs required to suction?

Tracheostomy tube

Stoma

What is measured suctioning?

Length of the tracheostomy tube

What is deep suctioning?

Part the tracheostomy tube, just above the carina

What should be checked when transporting patients with Heparin/saline locks?

Ensure locks are *taped securely prior to transport*

Apply pressure dressing if catheter becomes dislodged from vein

Foley catheter

Keep the bag *below the level of the bladder*

-Secure the tube and avoid kinks

-Empty the drainage in the bag prior to transport

-Use chevron taping to secure

-Document amount of urine emptied out of bag

Nasogastric tube

Clamp/plug the tubing

-Secure the tube and avoid kinks in tubing

-Use butterfly bandage or chevron tape to secure the tube

Gastrostomy tube

Clamp/plug the tubing

Secure tube and avoid tension or kinks

Pre-existing Vascular Access Devices/Indwelling vascular access lines

Monitor for bleeding at site

Apply pressure to site if needed and transport with the line in place

-Piccline example

Ventricular Assist Device (VAD).. what should and should not be done?

*DO NOT START COMPRESSIONS* if the patient is in cardiac arrest

-May dislodge the internal VAD tubes resulting in bleeding into the thoracic cavity

Depending on the device, pulses may not be obtainable, assessment should consist of general appearance, skin signs, level of consciousness and respiratory status

-Patients are anticoagulant and are prone to bleeding

What are common drains?

-Jackson-Pratt--> plastic bulb

-Hemovac--> negative suction pressure when compressed

-Penrose

-Negative pressure wound therapy pump/wound vaccuum

-Use clean technique around drain to prevent introducing bacteria

-Ensure that drain apparatus is secured

-Keep gravity drains at the appropriate level for proper functioning

What should be done with loose patches?

Place in plastic closed container (sharps container) and transport with patient

What infusion lines may be transported by EMTs?

*Pre-existing Vascular Access Device/Indwelling Vascular Access Line*

-Catheters

*Peripheral Inserted Central Catheter (PICC)* line

What tubes and monitoring devices may EMTs *NOT* transport?

Central Venous Pressure (CVP) Monitoring Device

Arterial lines

-Require nurse transport team

Swan Ganz catheters

Chest tubes