Scope of Practice

Author Beware: Movie Patriots Day and Narcotic Distribution

/ Jordyn Redwood / Leave a comment

Recently, I took in the movie Patriots Day starring Mark Wahlberg that follows the events surrounding the Boston Marathon bombing that took place on Monday, April 15, 2013.

The movie is insightful and entertaining and I don’t think I’ll be spoiling anything by discussing it here. Plus, the issue I’m highlighting really has nothing to do with the events of the actual bombing.

Mark Wahlberg plays Sergeant Tommy Saunders. In the movie, he is suffering from some sort of chronic knee injury. He walks with a limp and is looking to get off patrol for this very reason.

In the aftermath of the bombing, he goes to one of the local hospitals to interview witnesses. He approaches the nurses’ desk and asks a nurse for something for pain. The nurse offers Lortab, a scheduled narcotic, but he declines and asks for Tylenol or ibuprofen instead.

Yea— just no.

Even in a disaster, a nurse is not going to be handing out scheduled medication for several reasons that I’ll highlight below.

First, what are scheduled medications? The FDA schedules medications that have the potential to be addictive. Schedule I medications are highly addictive and have no currently accepted medical use— drugs like heroin and LSD. Lortab is a Schedule II medication– which means it’s highly addictive, but does have a medical use. All scheduled drugs in the hospital have a process where they are counted to ensure no one is diverting (not using the medication for its intended purpose) the medication.

Narcotics counts where there is less drug there than should be are taken VERY seriously. Even in a disaster situation, these would be watched closely. The nurse would not be handed a bottle of Lortab to dispense as she wishes.

Why would a nurse not be able to simply give this police officer Lortab in a critical incident where there is a large influx of patients and things are generally crazy?

1. The police officer is not a patient. Any medical treatment rendered by the hospital should be documented. Now, I could see the nurse tossing him a few Ibuprofen considering these circumstances. In all likelihood, this would be frowned upon but understood. Not so with a narcotic.

2. It is outside the nurse’s scope of practice. Scope of practice deals with what a provider can and cannot do. It is generally determined by the state licensing board where the individual practices. Scope of practice issues tend to be a big pitfall for writers everywhere and I’ve blogged about it previously here and here.  A nurse cannot order medication for a patient without a standing protocol in place— this is a provider function. A nurse also cannot dispense medication— this is the function of a pharmacist. Even with automated medication dispensing systems, there is usually a pharmacy double check before the medication can be pulled from the machine. In an emergency this function can be overridden, but that is highly frowned upon.

Overall, Patriots Day was an entertaining film and most probably won’t even realize this error. However, in writing please keep in mind scope of practice issues. Not every medical provider can do every medical function— even during a disaster.

Author Beware: Provider Scope of Practice (EMS)

/ Jordyn Redwood / Leave a comment

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.

Author Beware: Medical Students

/ Jordyn Redwood / Leave a comment

I’ve blogged here a lot about the trouble many authors have with scope of practice issues. Scope of practice is what the licensing board says you can and can’t do to a patient. Every licensed healthcare professional has a defined scope of practice. For nurses, it is managed by their State Board of Nursing. For doctors, it is the Board of Healing Arts.

You can find other posts I did about scope of practice here, here and here.

I recently came across a novel written by a doctor that had an interesting medical scenario. In short, a medical student was running amok killing patients by overdosing them on potassium. Below are a few highlighted portions from the novel. I’m using asterisks instead of characters names to further disguise the story to protect the author.

This portion is written from the medical student’s (the killer’s) POV:

I was helping them (nurses) with their work. I’ve fixed IV pumps, drawn blood, placed catheters, even changed bedpans. It’s got me into their good graces, and a lot of them now pretty much trust me with anything. Like giving medications. 

They’d pull the IV bag from the electronic medication dispenser, log it into the system, hand it to me, and go back to doing the twenty other things they were trying to do at the same time. They never gave me or my poor little bag of potassium a second thought. 

And why not? They’d seen me give IV medications to patients hundreds of times. Not one of the– not a single one– even bothered to check to see if the patient actually needed potassium, much less confirm that I’d actually given it.”

Honestly, it’s hard to know where to start with the medical inaccuracies this small piece of fiction highlights.

1. A medical student is not licensed healthcare provider. Therefore, they practice under someone else’s license. They are managed by their attending physician or resident. They are not monitored by nursing. A nurse is not going to let a medical student do these things to her patient. The most a medical student does is obtain a patient history, do a physical exam, and observe procedures by other physicians. If this author had made the medical student a resident– the scenario would be a little more plausible.

2. Every nurse is not that stupid. Sure, one nurse allowing a medical student to give her potassium I could believe. But, as in the novel, up to fifty? Remember, the nurse is likely more liable than the medical student under this circumstance. These nurses would all be fired. Nurses are not that blase about their licenses. Without one, even a license with a minor mark, and that nurse will not be working in nursing ever again. Medical students are learning. A nurse’s job is to protect her patient. We don’t trust medical students to be competent in what they’re doing for that reason alone.

3. The author also misses another layer of protection. Medical dispensing machines are another layer of protection. Hospital medications are approved for dispensing by the hospital pharmacist. So, a pharmacist can look up a patient’s lab results and check whether or not they need the potassium as well. All these medication orders on patients that don’t need potassium is going to raise some serious alarms. Can you override the medication dispensing system? Yes, but you better have a good reason. Many hospitals have removed concentrated forms of IV potassium because an error could be so potentially deadly to the patient. Also, patients who receive a bolus dose of IV potassium need to be placed on an ECG tracing (or continuous heart monitoring.) In this instance, they are generally in the ICU or on telemetry and not a basic med/surg unit.

The scenario could be plausible if written another way. Overall, the author needed a seasoned ICU nurse to review the manuscript.

Perinatal Providers: Scopes of Practice

/ Jordyn Redwood / Leave a comment

Heidi Creston returns today for her monthly blog post. Today, she covers a very important topic: scope of practice for different obstetrical providers. Scope of practice dictates what a medical provider can and cannot do so it is important to know a particular providers limitations. For instance, as a registered nurse, I cannot diagnose illness though most nurses are very good at this very thing and we may indicate to a family what we think is going on. However, only a physician, nurse practitioner, or physician’s assistant can diagnose.

Now, I’ll turn it over to Heidi.

It is especially challenging for the perinatal patient to understand the scopes of practice that different providers offer. As authors, we must remember that our audiences are impressionable, and may believe your fictional story as the Gospel truth. If your character is a perinatal provider it is imperative, that you keep them working within the means that their occupation allows.

The providers:  Obstetrician-Gynecologist, Perinatologist, Family practitioner, Certified Nurse Midwives, and Doula’s.

Obstetrician-Gynecologist (OB/GYN) is a medical doctor who provides both clinical and surgical care for their patients. The OBGYN serves not only the perinatal patient but all women’s medical issues from puberty to post hysterectomy.

Perinatologist is an obstetrician who specializes in the care management of high-risk pregnancies. Patients assigned to a perinatologist are referred out by their OBGYN or family practitioner due to the extensive or specialized care that is required maternally and or for the fetus. Patients with cardiac issues, diabetes, Eclampsia or HELLP, and multiple gestations are prime examples of patients referred to perinatologists. Fetuses with severe abnormalities such as gastrocentisis or Tetralogy of Fallot are also referred.

Family practitioner is a medical doctor who specializes in the health care of all family members. They are prepared to provide normal OB/GYN care, but usually refer pregnancies and other women’s health issues to an OB/GYN. All family practitioners are trained to perform Cesarean births in an emergency and also to assist other specialists in doing the procedure.

Certified Nurse Midwives are registered nurses who have earned their master’s degree in nursing, with a strong emphasis on clinical training in midwifery. Midwives work with obstetricians who are always available to assist if complications occur during pregnancy, labor, or delivery. CMW’S can assist with cesarean sections but can not perform them independently.

Doulas are not licensed or certified personnel. Doulas are support liaisons hired by the patient, to assist them through the pregnancy, and offer support during the labor process. There currently are no mandatory qualifications, regulations or requirements necessary in order for someone to become a doula.

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 

Medical Question: Scope of Practice

/ Jordyn Redwood / 1 Comment
Elaine asks:
I have some medical questions from my WIP. I have a character who has had multiple concussions from past sports (ice hockey). I wondered if concussions are considered a “traumatic brain injury”?
Also, or along with the above, I have the hero suffering a fall at a remote location in Hawaii on some lava rocks which leads to possibly another concussion and a dislocated shoulder. My heroine, who is an athletic trainer, arrives on the scene and I thought it was reasonable to assume that she could try to reduce (is that the right word?) his shoulder since there is no way for help to arrive, i.e. no one else on scene and no cell phone reception plus a 30-minute hike back up to the road where her car is. Is it reasonable to assume that with his help they get to her car and she takes him to a minor emergency clinic who will probably send him to an actual emergency room for x-rays, or more tests? Also, that he might not show signs of any disability or impairment from the concussion until later?
Jordyn says:
Yes, concussions are considered traumatic brain injuries.
 1. http://www.webmd.com/brain/concussion-traumatic-brain-injury-symptoms-causes-treatments: General concussion overview.
 2. http://www.cdc.gov/TraumaticBrainInjury/: General overview.
 3. http://www.post-gazette.com/healthscience/20000229hconcush2.asp: News piece looking at testing post concussion. What you’ll find in patients who have had a lot of concussions can be learning disabilities, headaches, issues with balance to name a few. Sometimes, symptoms suffered post head injury are termed post-concussion syndrome.
 4. http://www.centerforbrainhealth.net/Assessment%20Services/concussion.html: Post concussion syndrome.



Photobucket/emilillylouloumay

As far as the question concerning your athletic trainer, I think it would be outside her “scope of practice” to try and reduce (yes, that is the correct term) a dislocated shoulder.

Most often, the patient will be splinted in a position of comfort and sent to the ED. General ED management, depending on the type of dislocation, is to take an x-ray (sometimes a pre-reduction x-ray is not done), IV placement, IV medication for pain/relaxation, the reduction is complete and stabilized— for the shoulder this is typically a sling/swath. Then post-reduction films are taken to ensure that everything is back in place as it should be.

One instance I could see this trainer attempting the reduction would be if there were problems with perfusion to the hand. For example, it’s numb (this would be worrisome for nerve entrapment, compromise), it’s pale or purple (which would suggest poor blood flow). This may actually be good for your fiction because it would be great internal conflict for the character. She’s performing a procedure outside her scope of practice but to help her friend lessen his chances for permanent damage. If you choose this, I would make it clear to the reader it’s outside her scope of practice but she’s willing to take the risk and consequences of doing the procedure.
Actually, this question started to intrigue me and I started looking up athletic training protocols to see if it was a possibility. I found one from the University of Georgia— read it. It does outline a scenario like the one I describe above with some qualifications of the person who may be allowed to try.
 http://www.csmfoundation.org/Univ._of_Georgia_-_Orthopedic_Injury_Protocol.pdf
Any other suggestions for Elaine?
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Elaine Clampitt is currently melding her passion for writing and ice hockey into a series about women in the world of professional ice hockey. She owned her own business which manufactured women’s apparel and has been able to continue to fulfill her love for numbers as treasurer of various organizations. An “empty-nester”, Elaine enjoys encouraging others in their writing and going to as many Avs games as possible.  This is her second year serving as the Secretary/Treasurer for Mile High Scribes, the ACFW South Denver chapter. You can find out more about Elaine at her websites: elaine@emclampitt.com, http://www.thewomenofhockey.com/.