It’s never comfortable to be placed under a microscope. Especially when the dude looking through the microscope is The Rogue Medic, Tim Noonan. Tim’s a great dude, but he’s not the guy you want picking through your knowledge sock drawer. He’s thorough, he’s smart and he’s willing to analyze the details long after you and I have gone to bed.
If you don’t already read Tim’s blog you should. He’s a fantastic EMS blogger. That being said, I wasn’t terribly excited when he posted a comment on my post “I’m Only An EMT Basic” announcing that his comments on the piece could be found over at Rogue Medic headquarters.
For the record, my piece received nothing but kind handling by Tim. The question he chose to focus his lens on? Are lung sounds a part of the EMT scope of practice?
The question is harder to answer than you might think. In fact, just deciding what “scope of practice” means for an EMT is surprisingly difficult. If you doubt me, take a look through the NHTSA National Scope of Practice Model. It spends page after page trying to get to the bottom of that very question.
The answer involves chart and graphs that look like this. —–>
Add to that the fact that there is no single reference for an EMT’s scope. Each individual state has to figure it out for themselves. And when they’re done, your medical director can adapt it even further.
So when it comes to the question of lung sounds, the answer to this EMT instructor seems obvious. Of course they’re in your scope of practice. I’ve been teaching EMT’s to listen to lung sounds for as long as I’ve been an EMT instructor. I dismiss your question with a wave of my hand and a hearty bagh! But guys like Tim are all about proof. And, as he points out, proof is harder than rhetoric, hand gestures and guttural pronouncements. Exclamations are easy. Proof is hard.
In Tim’s state, the legislators have punted a good deal of the scope-of-practice-ball to the EMT National Standard Curriculum. In my state, Colorado, the subject is given a little more focus in a document called The Rule 500. The appendices of the rule outline what Colorado refers to as the “acts allowed,” and it says, simply, that patient assessment is allowed at all levels.
Unfortunately, or fortunately, depending on how you look at it, you’re going to have to make up your own mind about what it means when your state says you can do things like “primary and secondary assessment.” The legislature really isn’t going to hold your hand on this one.
I think there are several good reasons to consider all non-invasive physical exams as part of your scope of practice.
1) You can choose to see the National Standard Curriculum (Or any curriculum for that matter.) as being the outer limit of what you are allowed to do as an EMT or you can consider it the minimum. Is the National Standard designed to set a minimum standard of knowledge competency or is it intended to define the maximum allowable skill set? Both views have their advantages, but I don’t necessarily see doing less as the safer option.
2) When it comes to simple, non-invasive patient assessments, nobody who matters cares what you do. Do appropriate medical evaluations and don’t worry about the finger waggers. They’re irrelevant. Check lung sounds, and pronator drift and nystagmus and oral hydration and don’t care if your EMT instructor taught those assessments to you or not. Learn it and do it. It’s an assessment.
Now, if you start checking cervical dilation or doing prostate exams, someone is going to care. But I’ve just never heard of anyone getting into serious trouble for doing an appropriate, non-invasive physical exam. If the person who cares happens to be your QA officer or medical director or someone like that, make sure you keep the conversation focused on medical appropriateness. Ask them to explain why what you did was medically inappropriate.
If you’re talking about lungs sounds, the entertainment value of the conversation should be worth the discipline. And you might want to consider moving on. When the day comes when you make a real error (And that day will come.) they aren’t going to have your back.
3) Physical assessments like lung sounds are implied by the treatments that fall within your scope. For instance, its’ difficult to argue that you should be allowed to administer albuterol and epinephrine but you should be prohibited from assessing the patients lung sounds and deciding if the respiratory condition is obstructive or congestive.
4) It isn’t safer to not do a proper assessment. If you think your protecting yourself from liability by doing less you’re fooling yourself. If you’re making decisions about giving epi-pins, nitro and albuterol but you’re afraid to do basic patient assessments like lung sounds, you’re not decreasing your risk. You’re taking larger risks by treating people without the foundation of appropriate medical assessment.
And when you do make a treatment error or miss something big because you were to afraid to assess your patient, who do you think is going to look out for you? Your supervisor who doesn’t think you should be listening to lung sounds?
The world of emergency medicine is a road that runs crooked through the woods. The right thing to do isn’t always obvious. It’s one of the things that makes the job so great.
You can’t shelter yourself from liability by hiding under a rock. The patient still need appropriate treatment. This is a job where you’re going to have to choose your own road. You’re going to have to decide what values you’re going to use to guide you when the path is unclear. When it comes to assessments and scope of practice, the path is certainly unclear. I hope both Tim and I have helped you consider the issue in a little more depth.
Now it’s your turn: What do you think. When your performing physical assessments are the boundaries of your scope of practice clear?