RE: Paramedic procedures and charting

["Paul M. Wright, Jr." <pmwright@home.com>]

> Do you allow the paramedics to do chest tubes or
> central lines or venous cut downs?
>
from a general Arizona perspective:

	chest tubes - no
	central lines - yes
	venous cutdown - no

> If not, do you allow flight nurses to do these
> procedures? If you don't allow paramedics to do
> these procedures, but do allow nurses to do
> them  - what is your reasoning?

Arizona follows a model of centralized control of
the paramedic scope of practice that is much different
than the more distributed model under which I trained
in Colorado.

There is no expanded practice definition for flight
paramedics so one is generally obligated to observe the
established scope of practice both as regards
procedures and medications to be administered.


> Are flight paramedics generally regarded as
> subordinate members of the flight team? Is
> equal responsibility shared between nurses
> and medics for successes and problems in patient care?

Despite expressions of sentiment to the contrary, most
programs (and all those with which I have personal
experience) operate on a fairly nurse-centric model.
In part, this is due to the militancy of our Board of
Nursing.  In one high-profile case, our Board of Nursing
essentially charged a nurse with unlawful delegation of
practice for "permitting" a non-nurse member of a flight
crew to perform a procedure for which that individual
was demonstrably well-trained and this charge was made
in spite of a clinical record that showed the procedure
was competently performed to the patient's immediate
benefit.
On an individual level, many nurse-paramedic teams do work
efficiently and effectively as co-equals.  And with a few
programs, the QA processes are applied equally to both team
members.  But on an administrative level and in the legal
climate that exists, it would be imprudent to claim that no
hierarchy exists.
There is an interesting test you can apply to sort out the
wheat from the chaff.  Ask about the policy on covering
staffing emergencies. Chances are, even in programs where
equality is preached, that a program will cover a paramedic
shortage by flying nurse-nurse but will NOT cover a nursing
shortage by flying paramedic-paramedic.


> Do you allow paramedics to chart on patients?

No, we prefer that they chart on the paper we give them.  It
makes multiple copies and is MUCH easier to feed into the fax
machine.

> If so, under what circumstances? Do you believe that your
> program and your nurses have a greater degree of liability
> when paramedics are allowed to chart?

>From a civil liability point of view, I have seen no evidence
that the credentials of the person writing the record have any
impact on whether a jury finds the record credible.

>From a regulatory point of view, there is some reason to believe
that nurses may have a legitimate concern about how their
licensing board would see it.

An exception might be the multi-patient transport but even within
that narrow context there have been arguments made that the nurse
cannot safely delegate the creation of the chart.  Common sense
would dictate that the chart be completed by the caregiver most
directly involved in the patient's care but common sense doesn't
always prevail.


> Do you know of any national standard or guidelines
> that exist for regarding the scope of procedures flight
> paramedics can do and/or paramedic charting?

There was such a document published a couple of years ago under
the auspices of NFPA (the title was something similar to "Practice
Guidelines for Flight Paramedics) but I'll have to leave it
to someone else to supply the information on how to get a copy.

How much of it would fit within the confines of any State regulatory
authority would have to be determined jurisdiction by jurisdiction.



regards!

paul


Paul M. Wright, Jr. (retired flight paramedic/flight respiratory
therapist/program director)
Mesa, AZ



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