Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

“I’m Only An EMT Basic”

I stole the title of this from Steve Whitehead. He wrote “I’m Only An EMT Basic” at The EMT Spot. I agree with all of what he wrote, and I do mean all, but here is the part that got my attention.

I had one EMT tell me that lung sounds were not in her scope of practice. I’m serious. She was worried someone might charge her with malpractice if she placed a stethoscope on someone’s chest and asked them to breath deep. I’m not making that up…lung sounds.

In Pennsylvania, we have our scope of practice specifically spelled our every year, or two, in state commonwealth law. Most people in EMS in Pennsylvania are probably aware of this, but I would be surprised if more than a tiny minority have actually looked at the web page. Most have probably seen a printout at some time in their career. Scope of practice changes every couple of years. What good is maybe having occasionally seen an old printout of the scope of practice on the back of a door? Not even the toilet door, where you might spend the time to read through it.

Depending on the way the law is interpreted, this may be very restrictive, or it might involve the use of common sense. From what I have seen of the way EMS education is handled in Pennsylvania, the law is presented as being interpreted in a very restrictive sense. There certainly are people who will write up others for violating their scope of practice.

I have been accused of violations of scope of practice several times. None of these write ups ever went beyond the level of the medical director, because I had not violated the scope of practice. What I had done was to use my head and not accept some silliness repeated by semi-literate EMS instructors worried about, What if . . . ? When questioned about these imagined violations, I always express disappointment at not having actually violated anything except someone’s delusions. I also mention my eagerness to do some violating in the future. 😉

One of the problems is that there are so many know it alls out there, full of misinformation. They are more than willing to tell everyone exactly what they don’t know. Unfortunately, there are not enough people willing to stand up to the know it alls. People are intimidated by the absolute certainty with which the know it alls present their misinformation.

Always ask for evidence to support any claim that anyone makes.

An honest person has nothing to fear from being questioned.

The dishonest person will change the subject, or accuse you of something, or just plain refuse to answer.

It becomes tricky when the know it all is a supervisor, instructor, or someone else with some authority to hurt you. You may need to find other ways to get the information you want, or you may decide that the potential consequences are not worth it. There may also be valid reasons for changing the subject or not answering, but these should be volunteered in private by the person who was not answering the question.

If you are in Pennsylvania, I have a link to the relevant information.[1] The EMS section of Pennsylvania’s web site[2] is not the easiest to get to without a link, nor is it easy to navigate once you do get there. Many of the links are .DOCs (Microsoft Word) or .PDFs, so clicking on one that is large can tie up your computer if you multitask, as I do. Have the cursor hover over the link before you click on it to see what it is, but that is a good idea with any link anywhere.

After all of that, what does that Scope of Practice document say about assessing breath sounds?

Assessment of Glasgow Coma Scale (GCS)
Assessment of Level of consciousness (LOC)
Assessment of Patient assessment skills identified in the NSC5
Assessment of Vital sign–body temperature
Assessment of Vital sign–pulse
Assessment of Vital sign–pupils
Assessment of Vital sign–respirations
Assessment of Vital sign–skin color/temperature & condition (CTC)

That is everything listed as assessment.

5 Is the footnote for the list of abbreviations used. Is there a link for any of these? Not that I could tell.

This only encourages the problem that Steve Whitehead pointed out. When confronted with a choice, doing less seems to be the safest route for a lot of people. Maybe not for the patient, but why deal with the important things? It’s all about the regulations. We work in EMS to give meaning to EMS regulations, not to provide appropriate care to patients. If you doubt me, try getting some patient information (that you are entitled to under HIPAA) from a bunch of hospitals. Some of them will just say, No. They don’t know what they are doing, but they have been told they will not get in trouble for doing less of their job than they are supposed to do. For some people, that is their dream job.

NSC = U. S. Department of Transportation National Standard Curriculum

So, wondering what the scope of practice of an EMT-Basic is, I have made my way to this document for answers. The listing for assessment of respirations only mentions Vital sign. Hmmmm. When I document vital signs, I am only documenting numbers – heart rate, respiratory rate, et cetera. Looking at this official site, the one that some will refer you to, does not answer the question of whether listening to lung sounds is in the EMT-Basic scope of practice. I need to track down the U. S. Department of Transportation National Standard Curriculum. Looking around the rest of the PA EMS web site, I did not find any link to the U. S. Department of Transportation National Standard Curriculum. That does not mean that the link is not there, just that I did not find any link anywhere I looked.

I tried a few search engines using ems and “national standard curriculum” as search terms. They all made it pretty easy to find what I wanted. The top link for each search engine was the EMT-B National Standard Curriculum, just with different links depending on search engine. I did not look for the path not taken.

Here is what I found cunningly hidden under the heading Curriculum in the last place anyone would think to look – Page 1.

Establish a Physician Board to review and approve all medical curriculum content.

Emphasize an assessment-based format rather than a diagnostic-based format for all levels and all ages.

Ensure that there is adequate focus on primary skills of assessment and ABCs in all provider levels (with emphasis on airway).[3]

I am only on page 1, but they make it quite clear that they consider airway assessment to be a big deal.

Are lung sounds part of airway assessment?

According to my scanning of the document, Yes and No.

It seems to state that listening to lung sounds is limited to determining the presence and equality of respirations in adults. Then, in some fit of irony, they appear to conclude that by avoiding training in auscultating for wheezes, rhonchi, crackles, et cetera in adults, students will be well prepared to auscultate for them in young children.

Anyway, I may have missed it in the National Standard Curriculum, but I don’t think so. It does appear that, while they do not specifically forbid auscultation for adventitious lung sounds, they do not seem to encourage it.

Steve, my interpretation is this. While auscultation of lung sounds does not appear to be forbidden, I wouldn’t be surprised if this was told to her by an instructor. Maybe with a stern warning about practicing medicine without a license.

Please, if you can point out where I am missing the inclusion of assessment of adult lung sounds for more than presence and equality, let me know.

In the mean time, about all I can add is, Augh!!!

Does that mean that an EMT-Basic may not auscultate lung sounds?

No.

Does that mean that an EMT-Basic documenting adventitious lung sounds on an adult will get in trouble in Pennsylvania?

I sure hope that is not what is intended either by PA or the NSC.

I remember discussions over the removal of education in lung sounds from the EMT-Basic curriculum years ago, even though the use of albuterol was being added to the EMT-Basic curriculum. Nobody had a good explanation except that it helped to keep the number of hours down. If we want to minimize the course hours, and I do not, why eliminate time from assessment.

The two most important skills in EMS are assessment and critical judgment. This appears to be detrimental to both.

Footnotes:

^ 1 Prehospital Practitioner Scope of Practice
[38 Pa.B. 6565]
[Saturday, November 29, 2008]
This appears to be the most recent publication of scope of practice.
Free Full Text of PA Bulletin 11/29/2008

Free PDF from PEHSC.org

^ 2 Pennsylvania Emergency Health Services Council (PEHSC.org) Home page
“The core mission of the Pennsylvania Emergency Health Services Council is to serve as an independent advisory body to the PA Department of Health and all other appropriate agencies on matters pertaining to Emergency Medical Services.”
The most useful parts all seem to be found in the tabs at the top. Resources, links, and legislative info are the ones I find most useful.
Web Page

^ 3 National Standard Curricula
NHTSA
EMS.gov links to the various National Standard Curricula in different formats.
Web Page

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