RE: Re: Scope of Practice Questions

December 6, 2004

Kenny,

You are missing the point in the same way that many do, and that is, you are

talking about one intervention being what the patient needs.

What the patient really cares about is being ventilated. Ventilation is the

standard, not the use of any one device or technique.

There is no specific device or technique that will always allow you to

ventilate a patient; therefore, it is crucial that all known devices and

techniques

be available to the care giver. Surgical airway is the last resort, but

there are times when it is the only means available to ventilate a patient.

Gene G.

In a message dated 12/6/04 13:29:00, kenneth.navarro@...

writes:

>

> Wow, surely you are not arguing that a SLAM course is all any EMS

> provider needs to become proficient at airway management? If so,

> why would you need to go to a certificate paramedic school? Why not

> just go to the SLAM course and be the airway expert for your squad?

>

> The NSoP is creating another level of paramedic - not better, just

> different.

>

> If you need to provide transtracheal airway alternatives to your

> patient, why is the surgical cricothyrotomy better than the

> percutaneous cricothyrotomy. Do you think the patient really cares?

>

> Kenny Navarro

>

> > Why go to a 4 year degree whebn I can take a S.L.A.M. (steet level

> airway maintenance) course and get the same knowledge and skill. <<

>

December 6, 2004

Kenny,

You are missing the point in the same way that many do, and that is, you are

talking about one intervention being what the patient needs.

What the patient really cares about is being ventilated. Ventilation is the

standard, not the use of any one device or technique.

There is no specific device or technique that will always allow you to

ventilate a patient; therefore, it is crucial that all known devices and

techniques

be available to the care giver. Surgical airway is the last resort, but

there are times when it is the only means available to ventilate a patient.

Gene G.

In a message dated 12/6/04 13:29:00, kenneth.navarro@...

writes:

>

> Wow, surely you are not arguing that a SLAM course is all any EMS

> provider needs to become proficient at airway management? If so,

> why would you need to go to a certificate paramedic school? Why not

> just go to the SLAM course and be the airway expert for your squad?

>

> The NSoP is creating another level of paramedic - not better, just

> different.

>

> If you need to provide transtracheal airway alternatives to your

> patient, why is the surgical cricothyrotomy better than the

> percutaneous cricothyrotomy. Do you think the patient really cares?

>

> Kenny Navarro

>

> > Why go to a 4 year degree whebn I can take a S.L.A.M. (steet level

> airway maintenance) course and get the same knowledge and skill. <<

>

December 6, 2004

Rick,

Nobody seriously advocates allowing anyone to do any procedure for which he

has not had formal training. No medical director in his right mind would

allow those under his practice to perform procedures they had not been trained

in.

However, it does not take a BS degree to learn how to do RSI and surgical

airway procedures.

As to how often one needs to do those, fortunately not often. But when the

time comes, if that's what the patient needs and you cannot do it, then you

have precluded that patient from living.

And believe me, RSI and surgical crichs are well enough established as

being within the expertise of paramedics to perform, that if your patient could

have been saved through such a procedure and you didn't do it, you'll be taking

a long journey through the legal system.

GG

In a message dated 12/6/04 13:22:35, richard.lachance@...

writes:

>

> I keep seeing arguments for RSI and/or surgical trachs - I have to

> wonder just how many of these are done by an individual medic in a

> year's time. . .

> Also, I would much rather have someone who has formal training in an

> advanced procedure performing that procedure on me, as opposed to

> someone who merely has his medical director's permission.

>

> Rick LaChance

>

December 6, 2004

Go sit on the Group W Bench, Kenny.

GG

In a message dated 12/6/04 13:40:08, kenneth.navarro@...

writes:

>

> And then there were three...

>

> " And if three people do it, three, can you imagine, three people

> walking in singin a bar of Alice's Restaurant and walking out. They

> may think it's an organization. And can you imagine fifty people a

> day,I said fifty people a day walking in singin a bar of Alice's

> Restaurant and walking out. And friends they may think it's a

> movement. " - Arlo Guthrie

>

> Kenny Navarro

>

> >>

> Also, I would much rather have someone who has formal training in an

> advanced procedure performing that procedure on me, as opposed to

> someone who merely has his medical director's permission. <<

>

December 6, 2004

Go sit on the Group W Bench, Kenny.

GG

In a message dated 12/6/04 13:40:08, kenneth.navarro@...

writes:

>

> And then there were three...

>

> " And if three people do it, three, can you imagine, three people

> walking in singin a bar of Alice's Restaurant and walking out. They

> may think it's an organization. And can you imagine fifty people a

> day,I said fifty people a day walking in singin a bar of Alice's

> Restaurant and walking out. And friends they may think it's a

> movement. " - Arlo Guthrie

>

> Kenny Navarro

>

> >>

> Also, I would much rather have someone who has formal training in an

> advanced procedure performing that procedure on me, as opposed to

> someone who merely has his medical director's permission. <<

>

December 6, 2004

Go sit on the Group W Bench, Kenny.

GG

In a message dated 12/6/04 13:40:08, kenneth.navarro@...

writes:

>

> And then there were three...

>

> " And if three people do it, three, can you imagine, three people

> walking in singin a bar of Alice's Restaurant and walking out. They

> may think it's an organization. And can you imagine fifty people a

> day,I said fifty people a day walking in singin a bar of Alice's

> Restaurant and walking out. And friends they may think it's a

> movement. " - Arlo Guthrie

>

> Kenny Navarro

>

> >>

> Also, I would much rather have someone who has formal training in an

> advanced procedure performing that procedure on me, as opposed to

> someone who merely has his medical director's permission. <<

>

December 6, 2004

Writes Alphonso:

" tis why when the time comes, I can point out it's beyond my Scope of

Practice so I didn't do it for risk of being arrested. :-) "

That's an interesting argument and one that would surely be set forth;

however, since scope or practice and standard of care are two different things,

a

service that chooses to limit scope of practice may in fact be guilty of failing

to provide the prevailing standard of care. The persons who will be liable

for that failure will be the administrators, owners, managers, and medical

directors.

Further, the SoP is sure to be attacked as an impermissible restriction on a

physician's medical practice, as interfering with the patient's 5th and 14th

Amendment rights, and so forth. The service that is chosen to be the

defendant in one of these cases will lose even if it wins.

GG

>

> >

> > And believe me, RSI and surgical crichs are well enough

> established as

> > being within the expertise of paramedics to perform, that if your

> patient could

> > have been saved through such a procedure and you didn't do it,

> you'll be taking

> > a long journey through the legal system.

> >

>

> '

>

> -aro

>

December 6, 2004

Writes Alphonso:

" tis why when the time comes, I can point out it's beyond my Scope of

Practice so I didn't do it for risk of being arrested. :-) "

That's an interesting argument and one that would surely be set forth;

however, since scope or practice and standard of care are two different things,

a

service that chooses to limit scope of practice may in fact be guilty of failing

to provide the prevailing standard of care. The persons who will be liable

for that failure will be the administrators, owners, managers, and medical

directors.

Further, the SoP is sure to be attacked as an impermissible restriction on a

physician's medical practice, as interfering with the patient's 5th and 14th

Amendment rights, and so forth. The service that is chosen to be the

defendant in one of these cases will lose even if it wins.

GG

>

> >

> > And believe me, RSI and surgical crichs are well enough

> established as

> > being within the expertise of paramedics to perform, that if your

> patient could

> > have been saved through such a procedure and you didn't do it,

> you'll be taking

> > a long journey through the legal system.

> >

>

> '

>

> -aro

>

December 6, 2004

Writes Alphonso:

" tis why when the time comes, I can point out it's beyond my Scope of

Practice so I didn't do it for risk of being arrested. :-) "

That's an interesting argument and one that would surely be set forth;

however, since scope or practice and standard of care are two different things,

a

service that chooses to limit scope of practice may in fact be guilty of failing

to provide the prevailing standard of care. The persons who will be liable

for that failure will be the administrators, owners, managers, and medical

directors.

Further, the SoP is sure to be attacked as an impermissible restriction on a

physician's medical practice, as interfering with the patient's 5th and 14th

Amendment rights, and so forth. The service that is chosen to be the

defendant in one of these cases will lose even if it wins.

GG

>

> >

> > And believe me, RSI and surgical crichs are well enough

> established as

> > being within the expertise of paramedics to perform, that if your

> patient could

> > have been saved through such a procedure and you didn't do it,

> you'll be taking

> > a long journey through the legal system.

> >

>

> '

>

> -aro

>

December 6, 2004

Why go to a 4 year degree whebn I can take a

S.L.A.M. (steet level airway maintenance) course and get the same knowledge and

skill.

Kenny Navarro wrote:

Certificate Paramedics under the proposed SoP will still be able to

perform chest decompression and percutaneous cricothyrotomy. Now,

you might argue that you won't be able to perform a surgical airway,

but wouldn't a properly performed percutaneous airway be just as

efficient (from the dying patient's perspective) as a surgical

airway?

Kenny Navarro

>> In my Opinion there are skills such as surgical airway

technequics, Chest decompression and the addition of a 4 year degree

to be able to preform them would put our service back to a basic

level service. <<

December 6, 2004

Why go to a 4 year degree whebn I can take a

S.L.A.M. (steet level airway maintenance) course and get the same knowledge and

skill.

Kenny Navarro wrote:

Certificate Paramedics under the proposed SoP will still be able to

perform chest decompression and percutaneous cricothyrotomy. Now,

you might argue that you won't be able to perform a surgical airway,

but wouldn't a properly performed percutaneous airway be just as

efficient (from the dying patient's perspective) as a surgical

airway?

Kenny Navarro

>> In my Opinion there are skills such as surgical airway

technequics, Chest decompression and the addition of a 4 year degree

to be able to preform them would put our service back to a basic

level service. <<

December 6, 2004

Why go to a 4 year degree whebn I can take a

S.L.A.M. (steet level airway maintenance) course and get the same knowledge and

skill.

Kenny Navarro wrote:

Certificate Paramedics under the proposed SoP will still be able to

perform chest decompression and percutaneous cricothyrotomy. Now,

you might argue that you won't be able to perform a surgical airway,

but wouldn't a properly performed percutaneous airway be just as

efficient (from the dying patient's perspective) as a surgical

airway?

Kenny Navarro

>> In my Opinion there are skills such as surgical airway

technequics, Chest decompression and the addition of a 4 year degree

to be able to preform them would put our service back to a basic

level service. <<

December 6, 2004

In a message dated 12/6/2004 5:03:23 PM Central Standard Time,

kenneth.navarro@... writes:

With any technique, device, or medication, the potential benefits

must always be weighed against the known risks. If percutaneous

cricothyrotomy and surgical cricothyrotomy have the same potential

benefits but one has more known risks, isn't it prudent to choose

the less risky device?

Only if you are allowed to.

Tom LeNeveu

Learning Paramedic

EMStock2004 was a RESOUNDING SUCCESS... Come See us Next year.

_www.emstock.com_ (http://www.emstock.com/)

_www.temsf.org_ (http://www.temsf.org/)

December 6, 2004

In a message dated 12/6/2004 5:03:23 PM Central Standard Time,

kenneth.navarro@... writes:

With any technique, device, or medication, the potential benefits

must always be weighed against the known risks. If percutaneous

cricothyrotomy and surgical cricothyrotomy have the same potential

benefits but one has more known risks, isn't it prudent to choose

the less risky device?

Only if you are allowed to.

Tom LeNeveu

Learning Paramedic

EMStock2004 was a RESOUNDING SUCCESS... Come See us Next year.

_www.emstock.com_ (http://www.emstock.com/)

_www.temsf.org_ (http://www.temsf.org/)

December 6, 2004

In a message dated 12/6/2004 5:03:23 PM Central Standard Time,

kenneth.navarro@... writes:

With any technique, device, or medication, the potential benefits

must always be weighed against the known risks. If percutaneous

cricothyrotomy and surgical cricothyrotomy have the same potential

benefits but one has more known risks, isn't it prudent to choose

the less risky device?

Only if you are allowed to.

Tom LeNeveu

Learning Paramedic

EMStock2004 was a RESOUNDING SUCCESS... Come See us Next year.

_www.emstock.com_ (http://www.emstock.com/)

_www.temsf.org_ (http://www.temsf.org/)

December 6, 2004

I keep seeing arguments for RSI and/or surgical trachs - I have to

wonder just how many of these are done by an individual medic in a

year's time. . .

Also, I would much rather have someone who has formal training in an

advanced procedure performing that procedure on me, as opposed to

someone who merely has his medical director's permission.

Rick LaChance

December 6, 2004

In a message dated 12/6/04 17:03:33, kenneth.navarro@...

writes:

>

> Sorry Gene, I don't think I am missing the point. The patient only

> cares about being ventilated, as you have stated (and I thought I

> said that as well).

>

> With any technique, device, or medication, the potential benefits

> must always be weighed against the known risks. If percutaneous

> cricothyrotomy and surgical cricothyrotomy have the same potential

> benefits but one has more known risks, isn't it prudent to choose

> the less risky device?

>

> Kenny Navarro

>

Always, Kenny, always! But if you choose the one with less risks and it

doesn't work, either you do the next thing or your patient's dead. Even though

I teach people how to do the surgical procedure, I emphasize as strongly as I

possibly can that it's the very last resort and carries with it significant

risks; however, in weighing risks, If I'm going to die unless a surgical airway

is performed, I'll accept possible tracheal stenosis in the future for the

chance to hear Alice's Restaurant one more time.

GG

>

> >> Kenny, you are missing the point...What the patient really cares

> about is being ventilated. Ventilation is the standard, not the use

> of any one device or technique. <<

>

December 6, 2004

In a message dated 12/6/04 17:03:33, kenneth.navarro@...

writes:

>

> Sorry Gene, I don't think I am missing the point. The patient only

> cares about being ventilated, as you have stated (and I thought I

> said that as well).

>

> With any technique, device, or medication, the potential benefits

> must always be weighed against the known risks. If percutaneous

> cricothyrotomy and surgical cricothyrotomy have the same potential

> benefits but one has more known risks, isn't it prudent to choose

> the less risky device?

>

> Kenny Navarro

>

Always, Kenny, always! But if you choose the one with less risks and it

doesn't work, either you do the next thing or your patient's dead. Even though

I teach people how to do the surgical procedure, I emphasize as strongly as I

possibly can that it's the very last resort and carries with it significant

risks; however, in weighing risks, If I'm going to die unless a surgical airway

is performed, I'll accept possible tracheal stenosis in the future for the

chance to hear Alice's Restaurant one more time.

GG

>

> >> Kenny, you are missing the point...What the patient really cares

> about is being ventilated. Ventilation is the standard, not the use

> of any one device or technique. <<

>

December 6, 2004

You got it, my friend. 12-lead is standard of care. It is well within the

means of most services to provide it. So some lawyer, somewhere, will

attempt to hold a service liable for not providing " standard of care. "

Remember, SOC is a question of fact. Try to find an expert in emergency

cardiac care who will testify that 12-lead is not standard of care? Then the

question becomes whether or not it is reasonable to deviate from SOC. Some may

argue that they deviate because they simply do not have the funds to acquire

the equipment necessary. To win that argument, it had better be demonstrably

true.

Here's an example of deviation from SOC justified by economic concerns:

Your community hospital doesn't have a CT or an MRI because it cannot afford it.

But a reconditioned 12-lead monitor isn't the same as a CT or MRI, and there

are grants available. See what I mean?

Standard of Care is always going to be determined by a jury based upon the

testimony presented by experts. I'm only trying to explain what the experts

are going to say.

Even if you cannot afford a 12-lead, everybody can use Marriot's or Modified

Chest leads to approximate a 12 lead and learn enough to identify a possible

right sided MI. Failure to do even that is, in my judgment, indefensible.

GG

>

> So you're saying, if I'm interpreting this correctly, is if I work for

> a service that only has 3-lead EKG capabilities and the prevailing

> standard of care is 12-lead EKG capability, the company,

> administration, and medical director can be held liable?

>

> -aro

>

> > Writes Alphonso:

> >

> > " tis why when the time comes, I can point out it's beyond my Scope of

> > Practice so I didn't do it for risk of being arrested. :-) "

> >

> > That's an interesting argument and one that would surely be set forth;

> > however, since scope or practice and standard of care are two

> different things, a

> > service that chooses to limit scope of practice may in fact be

> guilty of failing

> > to provide the prevailing standard of care. The persons who will

> be liable

> > for that failure will be the administrators, owners, managers, and

> medical

> > directors.

> >

> > Further, the SoP is sure to be attacked as an impermissible

> restriction on a

> > physician's medical practice, as interfering with the patient's 5th

> and 14th

> > Amendment rights, and so forth. The service that is chosen to be the

> > defendant in one of these cases will lose even if it wins.

> >

> > GG

> > In a message dated 12/6/04 16:44:08, asclapius@a... writes:

> >

> > >

> > > >

> > > > And believe me, RSI and surgical crichs are well enough

> > > established as

> > > > being within the expertise of paramedics to perform, that if your

> > > patient could

> > > > have been saved through such a procedure and you didn't do it,

> > > you'll be taking

> > > > a long journey through the legal system.

> > > >

> > >

> > > '

> > >

> > > -aro

> > >

December 6, 2004