In a meeting today, the medical director informs you of a new requirement for the paramedics in your organization. Effective immediately, all paramedics must demonstrate proficiency in intubations by successfully performing two intubations a year. If they can t meet this requirement in the field, they ll be required to spend time doing so in a hospital operating room (OR) under the guidance of an anesthesiologist.
You immediately wonder, Does this procedure present any issues or conflicts for my organization?
Who s who
The medical director plays an important role in the medical oversight of protocols and procedures performed in the prehospital environment. In this role, they may occasionally cross the boundary between medical control and service operations. Their approach is often more clinical than operational, and in almost all cases, the intent is to raise the level of patient care not to cause problems.
As the EMS manager or chief, you work with your medical director to monitor and enhance the patient care delivery system that your organization provides to its customers. You re responsible for the daily operations of delivering a standard of medical care to the community, so what is your reaction to this new requirement?
As the EMS manager, do you pass this information on to your paramedics and implement the policy?
Sort it out
The title of this commentary is EMS Manager 301, indicating the degree of difficulty in addressing such an issue with your medical director. Before reading the rest of this article, take a moment to list the potential problems this new policy might present for your organization. Next list the positive aspects of this action. Which list is longer and more detailed?
Hopefully, it took you several minutes, maybe up to 30 minutes, to discover the potential problems a procedure like this could present for your agency.
If faced with this decision, first consider determine if the procedure is indeed necessary. Is there a documented problem with intubations that your medical director feels is a liability to your agency? Is this an agency-wide problem or is it limited to a few providers?
Next are some specific areas to consider:
Scope of practice: Would performing intubations in the OR be within the scope of practice of your state s paramedics? You need to check with your state EMS certification or licensing agency to determine if paramedics, once certified or licensed, are permitted under state law or regulation to perform procedures in a hospital OR. In most states, the scope of practice is set by state statute, regulations or practice acts determined by a state EMS agency or committee; in some cases, continuing education and practical skills are predetermined. This is not an issue of initial paramedic training but of a medical director requirement, and, as such, the providers would not be viewed as students.
Liability insurance: Does your present insurance carrier cover your personnel for procedures performed in a medical facility? Most organizations have liability insurance and medical malpractice insurance for acts committed by paramedics and EMTs in the prehospital setting but not in the hospital. Verify and obtain written documentation that these procedures would be covered by your current department insurance policies.
Legal review: Be sure to have your legal counsel review this new procedure for any potential liability issues. Specifically, ensure that your organization and personnel would be protected in the event of an intubation-related patient injury caused by a paramedic in an OR.
Required documentation: If you plan to implement this new procedure, the following documents could help protect your organization. First, ensure the medical director specifically details the procedure in a written policy. Next, request a letter from the hospital administrator and chief of staff confirming that they re aware of the procedure and support the need for that level of training. These confirmation letters close the loophole that could otherwise allow hospital administration to claim ignorance in order to avoid liability and potential legal action related to an injury.
Discuss your concerns
Being able to perform a technical skill (such as intubation) after being certified or licensed is imperative; the question, however, is whether the skill needs to be confirmed on an otherwise healthy person who happens to be having surgery. Although it s important for your paramedics to be competent, being able to intubate a patient in the field is different from being able to intubate an anesthetized patient in the operating room. Additionally, anesthesiologists are often unfamiliar with field intubation techniques and may not be able to accurately assess a prehospital provider s abilities.
These issues may be secondary, however, if your agency is suffering significant problems with field intubations. Following your review, you may agree with the new requirement or you may have remaining concerns that should be discussed with your medical director.
Being an EMS manager sometimes requires you to challenge the bureaucracy, and, yes, that may include the medical director. Your first duty should be to your patients, followed by a commitment to your personnel. Occasionally, these priorities mean that you end up standing alone on one side of the fence. Being a leader means that you often have a different point of view, so don t be afraid to initiate conflict, question new or old procedures, or stand up for what s right. But remember to recognize that the medical director is also a leader, and that by working together, you can determine alternative ways to meet training objectives and deliver optimal patient care.