Author Beware: Provider Scope of Practice (EMS)

Here I am, happily reading along one of my favorite mainstream suspense authors, when a glaring medical mistake takes me right out of the story. Bummer! Now I’m wondering how long it would have taken this well known author to make one phone call to determine if this situation was plausible or not.

The scenario: The hero in our story is injured but doesn’t want to be transported by EMS to the hospital. He’s got other important things to do– like catch a killer. Awesome. EMS has him sign a release form and he’s on his way BUT the EMS team has given him an oral dose of a narcotic and two to take in the future when the pain comes back.

Did you hear that? That was steam billowing out of my ears.

This is a very common mistake authors make— issues that deal with scope of practice. I’ve blogged about it several times. This post has links to several others that just deal with scope of practice.

In simple terms, scope of practice is what a health care provider can and cannot do. EVERY licensed health care provider (a nursing assistant, a nurse, an EMT, a paramedic, a physician, a physical therapist, a pharmacist) has a scope of practice that is governed by their licensing board– whoever that might be. These governing boards determine the rules of practice. If the licensee does something outside of these rules they can be brought up on disciplinary action and even potentially lose their license. Scope of practice rules can vary from state to state.

In short– it’s bad to operate outside your scope of practice.

For instance, this document gives a pretty detailed overview of the medical treatments different EMS professionals can do.

The first problem with the author’s scenario is that EMS professionals do not carry oral narcotics to give to patients. Only IV and those that can be administered nasally.

The second problem is that EMS professionals not only operate under scope of practice laws but also medical protocols which outline the things they can do in the field and under what conditions. In fact, here’s a whole document that lists the EMS protocols for one hospital in Colorado that would give a nice overview for what likely happens in the US. There will be differences state to state but you could reasonably generalize from this.

Essentially, a paramedic giving a patient (who is refusing medical treatment) three doses of an oral narcotic (which he doesn’t carry) is a serious violation of his scope of practice. Only a few medical roles can prescribe oral narcotics and dispensing oral narcotics is the role of a pharmacist.

Authors should take scope of practice as seriously as medical professionals do because though your book might be fiction– the public will take it as fact.

Near Death Experiences: A Paramedic’s Perspective

I’m pleased to host Tim Casey as he shares some of his patient experiences with near death.

Welcome, Tim!

Over my 30 plus years as a firefighter/paramedic I witnessed many souls depart this world, but also had the privilege to participate in the resuscitation of hundreds of patients. I developed a habit over the years of asking the previously lifeless about what they had experienced while dead.

As I was generally the very first face they saw upon rejoining the living, once I knew their physical well being was stable, I would simply ask them what they experienced. Some had a story and some had no memory of what had happened.

But first let me take you through the process of resuscitation in the field as a paramedic. We generally had advanced notice from our dispatch center that we were responding to a possible cardiac arrest, and a description of what was happening at the scene we were approaching. We would be advised if CPR had been initiated and if the patient was believed to be pulseless and not breathing (apneic).
This gave us time to mentally prepare for what procedures would be needed to begin as soon as we arrived. If in fact we found a dead human being defined as a person not breathing and without a heartbeat, the first thing to do is determine if there was any kind of heart rhythm we could treat. The patient was attached to a cardiac monitor to access what kind of electrical activity was occurring with the heart.
There are many heart rhythms that we can treat with electricity, but one quick note; we don’t shock what is colloquially known as a flatline. This rhythm is asystole and no amount of electricity will convert this rhythm back to a functional heartbeat. If a treatable rhythm is present we will “shock” the patient and in successful cases (cardio version) this will bring the heart beat back to a functional condition.

Many other things can happen following this first procedure including intubation of the airway, administration of drugs to assist life and other supportive care. Not all patients regain consciousness but in the rare case they did and they were not intubated, I felt compelled to question them about their experience.

Almost all these cases occurred in the back of an ambulance while transporting the patient emergent (lights and siren) to the hospital. I only had a handful of cognitive patients that could talk to me and describe what had happened.
All were profoundly at peace and their former life threatening condition seemed to become more stable. I must add a quick note, when I was on scene with a conscious patient that was on the verge of a heart attack but had not yet become unconscious; one of my primary questions was if the person felt an impending sense of doom. All said they did. They knew on a base level deep within themselves that their life was about to slip away.
The patients that had survived and regained consciousness had lost that feeling of doom. There was a noticeable change I could see right before my eyes. Now was this due to the treatment I had administered? The drugs and electricity that I had applied to a lifeless body?
I was told by these people it was not because of my efforts, it was in fact they felt that they had been sent back by someone or something. Many had complete memory of the whole event including what I had said. I always talked to my patients and encouraged them to help me, to stay alive. A common phrase in emergency medicine is this, “The last thing to go is the hearing.” and my experiences confirmed this for me.
On one occasion in a remote location where the ambulance was very far away I had the experience of resuscitating a gentleman in his bedroom. My engine crew was with me but because of his improved condition I had asked them to gather equipment to prepackage the patient for transport.
The gentleman and I were alone for a few moments. He had changed from ghostly white soaked in sweat to pink and dry, he smiled and thanked me. I had to ask.
“Did you see anything while you were gone?”
“I don’t believe I was gone. I was here. I watched you.” He said. “But there was another person here with us. I guess you could say, not a person, but God I believe. He told me it wasn’t my time and said I had to go back.”
“Did you see Him?” I was very excited.
“Not really, more felt Him, felt surrounded by Him I guess I would call it.” 
“And then what?” I asked.
“And then I was looking at you.” He said.
These experiences gave me a sense of my own spirituality. Maybe I wasn’t such a big deal as a paramedic after all. Maybe it was all predetermined and out of my hands. Or maybe God worked through me. Either way I guess I will never know until it is my time.

Tim Casey is a retired firefighter/paramedic with more than 30 years on the streets caring for the sick and injured. He has also written a memoir: Dangers, Toils, and Snares: Confessions of a Firefighter which has been number one on Amazon in the Kindle Store many times. Tim now
is a full time author and his new book on how to date a firefighter will be out later this year,