Medical Direction

Medical Direction Q & A

This “Medical Direction Q & A” is provided for informational purposes only. Individual agencies should consult their medical director and legal counsel when drafting their own individualized protocols, trainings, and quality assurance processes.

Although a medical director can restrict elements of the Ohio scope of practice, the medical director shall never exceed the scope regardless of the training provided or protocols available.

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Scope of Practice

Paramedics are permitted to “maintain blood administration,” but what exactly is permissible from the State’s perspective?

  1. It is often appropriate to treat shock earlier with blood products rather than with crystalloid fluids. If the referring site has already INITIATED the transfusion of a unit of PRBCs, does “maintenance” include the Paramedic administering an additional (i.e., second) unit while on transport? For example, if the referring site has two units of PRBCs to administer, the transporting squad is there quickly, and the referring nurse has already verified that both units are O negative, it would seem to be in the patient’s best interest to “continue” with the administration of the second unit of PRBCs while enroute, once the first unit’s transfusion is complete. Does “maintaining” mean one specific unit of PRBCs, or does maintaining refer to the overall process of blood administration, as already physician ordered?
  2. Related to this, does “blood administration” mean PRBCs, or is it permissive to include other blood products? Again, one is often administering FFP along with the blood. So, is “blood” a somewhat generic term, and can FFP or platelets also be administered if the process of blood product administration has been initiated at the referring site?


The maintenance of a blood transfusion DOES NOT INCLUDE INITIATION even if it is subsequent units provided to an EMS provider regardless of who has checked the blood. If a patient is anticipated to require additional blood products beyond what is hanging at the time EMS presents for transport, the transferring physician should use a mobile intensive care unit (ground or air), rather than an ALS unit, as a registered nurse is required in the MoICU staffing matrix. Also, if a patient is sick enough to require the transfusion of additional blood products beyond what has been initiated, it is in the best interest of the patient to be transferred by the appropriate level of care which would be a mobile intensive care unit.

When an EMS unit accepts a patient for transport where maintenance of a blood transfusion is required and/or requested, they must be provided with orders from the transferring physician and/or the EMS medical director on how it should be administered, i.e. infusion rate. Physician orders must be provided to EMS for any infusing medication, including blood products.

The maintenance of a blood transfusion is inclusive of any blood product. It can be packed red blood cells, whole blood, FFP, platelets, etc. All of these blood products fall under the category of “blood”.

 


What is required (training, medical director approval, continuing education, quality assurance, written protocol, etc.) for EMS providers to transport patients with heparin drips? What about other types of IV drips such as Dobutamine, Norepinephrine, Potassium, Cardizen, Tridil, etc.?


The provision of all emergency medical services, including the administration of any medication, requires approval of the EMS medical director, a written protocol, training (far in advance of performing any skill or administering any medication), continuing education, and a quality assurance program or process. The maintenance of an IV and fluid administration is within the Ohio EMS scope of practice for the Advanced EMT (AEMT) and the Paramedic. This is cited in Ohio Revised Code 4765.38 (B)(1).

For AEMTs, the only medications that they are permitted to administer are those medications that have been approved by the Emergency Medical, Fire, and Transportation Services (EMFTS) Board. The medications that have been currently approved for administration by AEMTs are cited in Ohio Administrative Code 4765-16-01 (B)(1)(e).

For Paramedics, Ohio Revised Code 4765.39(B)(5) permits them to administer appropriate drugs and intravenous fluids. At this level of EMS certification, the EMFTS Board has not generated a list of medications that are specifically prohibited. As stated previously, all medication administrations and emergency medical services provided require approval, a written protocol, training, continuing education, and a quality assurance process provided by the medical director. For additional guidance, the EMFTS Board has also provided a position paper on interfacility transport of patients by EMS providers and the scope of practice.

In all cases, it is our shared goal to provide the best service to the patient and to maximize patient safety. To achieve this goal, there are medications that are appropriate for EMS providers to administer. Likewise, there are medications that are more appropriate for administration by a registered nurse during transport with a mobile intensive care unit. The best practices are achieved when the patient’s healthcare and safety needs are the primary guiding light paired with educated decisions and common sense from the medical director.

 


Regarding the maximum dose of naloxone via mucosal atomization device by EMRs and Basic EMTs: My understanding is the maximum dosage is 2 mg total. However, our protocol states that more can be given if a positive change in the patient is noted. Please explain.


While the standard dose that is most often seen in the medical literature is 2 mg, this is certainly not the dose that is written in stone nor is it the maximum dose. For the treatment of a patient with altered mental status, 2 mg is a dose that is commonly used by EMS medical directors for the initial dose to administer to an adult, but varied doses may be warranted in certain patients.

Unless there is a change in the dose, strength, or type of opiate taken, chronic opiate abusers may respond to smaller doses of naloxone than a person whose body has not developed a tolerance to the opiate. This is one of the reasons why the opiate withdrawal symptoms after naloxone administration may be more prominent in a chronic opiate abuser.

Having said that, we live in a different world today than we did 10 years ago. The abuse of stronger opiates require much larger, and possibly multiple subsequent, doses of naloxone to reverse the respiratory depression associated with an opioid overdose. Fentanyl, which is 100 times more potent than morphine, is being sold on the streets or mixed with heroin. Even chronic opiate abusers may require much more than 2 mg of naloxone to reverse the effects of an overdose is fentanyl is involved.

So, the answer to your question is that if a patient with a confirmed or suspected opioid overdose does not respond to 2 mg of naloxone, it is perfectly acceptable to administer more naloxone.

 


A healthcare facility that frequently initiates care for acutely-ill patients that exceed their medical capabilities and resources contacts EMS to transfer these patients to a facility with a higher level of care. These requests for transport may involve patients with acute STEMIs, patients with PICC lines, or patients with nitroglycerin infusing via an IV pump. Assuming that an ALS unit is unavailable and the transferring physician feels that patient cannot wait for one to become available, would it be appropriate for a BLS unit to perform the interfacility transport this patient with the nitroglycerin infusing on an IV pump if the EMTs do not change, adjust, or stop the IV pump?


The transport of a patient with infusing medications and/or an IV or heplock in place lies outside of the Ohio EMS scope of practice for the EMT level of certification. A patient with an IV or heplock in place requires at least an Advanced Emergency Medical Technician (AEMT, formerly EMT-Intermediate) during transport. Although these patients are often very ill, a Paramedic, at a minimum, would be required for transport of a patient with infusing medication. Anything less would be a breach of the Ohio EMS scope of practice.

The only scenarios where the State Board of Emergency Medical, Fire, and Transportation Services (EMFTS) supports a variance in the Ohio EMS scope of practice is in the prehospital setting (e.g. EMS runs initiated by 9-1-1) and emergent interfacility (i.e. disaster, mass casualty incident) transfer of patients with pre-existing medical devices. This does not include the routine/scheduled interfacility transfers of patients nor does it include the transfer of patients out of an emergency department or hospital due to events such as emergency department overcrowding or physician convenience/impatience. The EMFTS Board’s stance on this can be found in their position paper on EMS provider transport of patients with pre-existing medical devices of drug administrations.

For example, if a BLS unit was dispatched to a residence where a patient had a PICC line in place as part of their outpatient treatment plan, the patient could be transported emergently to a healthcare facility without waiting for an AEMT or a Paramedic to arrive. This does not apply to patients who are receiving care in a healthcare facility such as a hospital or a nursing home. The only exception to the latter scenario is in the event of a declared disaster where the healthcare facility is being emergently evacuated.

For the scenario that is described in the question where a patient is being transferred from a healthcare facility to a facility for specialized care or treatment, this is considered an interfacility transport. The position paper on pre-existing medical devices does not apply in this case. Even if the patient is direly ill, the EMS provider must maintain compliance with the Ohio EMS scope of practice for the respective level of Ohio EMS certification. In addition, the transferring physician, per federal EMTALA regulations, has a responsibility to transfer the patient via an appropriate level of care. For this scenario, an ALS unit is the minimum acceptable level of care that should be accompany this patient. An additional option would be to transport the patient via a ground or air mobile intensive care unit which requires a registered nurse in the medical team’s staffing matrix.

It is imperative for all EMS providers to be compliant with the authorized Ohio EMS scope of practice for their respective level of EMS certification. Failure of compliance or failure to decline patient transports that require skills that lie outside of the Ohio EMS scope of practice can result in fines, suspensions, revocation, or permanent revocation of one’s Ohio EMS certificate to practice.

 


If a patient with respiratory problems and has an Ohio DNR Comfort Care (DNR-CC) document, is the administration of bronchodilators permitted or does this constitute the resuscitation that they do not wish to receive? Is there anything in the Ohio EMS scope of practice to address these issues?


The Ohio DNR Comfort Care program was created by and is housed in the Ohio Department of Health. While the program provides the only transportable form of advance directive for EMS that provides immunity, the Ohio DNR-CC document and the associated patient care parameters apply to all healthcare institutions and professionals including EMS providers. As such, the program’s patient care parameters are not addressed in the Ohio EMS scope of practice.

Patients who are enrolled in the Ohio DNR Comfort Care do not wish to have a cardiac monitor applied. It is important to note that, for the Ohio DNR Comfort Care program, the definition of a cardiac arrest is the loss or lack of a palpable pulse. Unlike conventional ACLS protocols, this definition of cardiac arrest does not include or require the interpretation of the rhythm on a cardiac monitor. In addition, the definition of a respiratory arrest for the Ohio DNR Comfort Care program is agonal respirations or apnea.

For patients who are enrolled in the Ohio DNR Comfort Care program, the healthcare provider will perform the following actions:

  • Suction the airway
  • Administer oxygen
  • Position for comfort
  • Splint or immobilize
  • Control bleeding
  • Provide pain medication
  • Provide emotional support
  • Contact other appropriate health care providers such as hospice, home health, attending physician/clinical nurse specialist (CNS)/certified nurse practitioner (CNP)

For patients who are enrolled in the Ohio DNR Comfort Care program, the healthcare providers will not perform the following actions:

  • Administer chest compressions
  • Insert artificial airway
  • Administer resuscitative drugs
  • Defibrillate or cardiovert
  • Provide respiratory assistance (other than listed above)
  • Initiate resuscitative IV fluids
  • Initiate cardiac monitoring

“Do not resuscitate” is not equivalent to “do not treat”. The administration of bronchodilators to patients who have enrolled in the Ohio DNR Comfort Care program is permitted. Bronchodilators are not classified as resuscitative medications. They can be self-administered by the patient or administered passively via a nebulizer, non-rebreathing face mask, or via a non-invasive positive airway pressure device (BiPAP/CPAP). They cannot be administered via a device where the healthcare provider is actively providing respiratory assistance (e.g. bag valve mask, endotracheal tube). The administration of IV fluids for rehydration or medication administration is permitted, but they should not be given for the purpose of resuscitation from a cardiac and/or pulmonary arrest. If a patient has pneumonia or other infectious process, the administration of antibiotics is permitted unless declined by the patient. The medications that should not be administered to patients enrolled in the Ohio DNR Comfort Care are those that are used to treat ventricular fibrillation, pulseless ventricular fibrillation, pulseless electrical activity (PEA), or asystole as well as vasopressors.

For patients who are enrolled in the Ohio DNR Comfort Care-Arrest (DNR CCA) program, they wish to receive unrestricted medical care until they do not have a palpable pulse, develop agonal respirations, or become apneic. At that time, any cardiac monitoring equipment and/or invasive airway devices should be removed, and the Ohio DNR Comfort Care parameters immediately become effective in this patient population.

Patients who are enrolled in the Ohio DNR Comfort Care program can terminate their document verbally or in writing at any time; however spouses, family members, or friends cannot amend or nullify it without the patient’s permission. As in all patient scenarios, the patient always retains the right to refuse any medical intervention, treatment modality, or medication even if its provision is permitted within the parameters of the Ohio DNR Comfort Care program.

 


Patient Transport

EMS has been dispatched to a facility that provides long-term healthcare and short-term rehabilitation services. The staff at the facility is requesting a patient be transported to the hospital for evaluation, but the patient refuses transport. What is the responsibility of the Ohio EMS providers when staff at a healthcare facility insist a patient be transported, but the patient refuses?


The civil right of a competent adult to refuse medical treatment is established in federal law, specifically 42 CFR 483.10 of the Code of Federal Regulations. This civil right is not amended or voided based upon the residence or location of the patient. As such, it remains in effect even when a patient is a resident of a long-term or short-term healthcare facility. The competent adult can refuse treatment at any time before or during the course of a medical evaluation, treatment or transport to a medical facility. Violation of this civil right may result in criminal charges that include, but are not limited to, kidnapping, battery or assault.

The civil right of a competent adult to refuse medical evaluation, treatment, or transport to a medical facility cannot be amended or voided by a patient’s advance directives (e.g., living wills, do not resuscitate (DNR) documents or orders, Ohio Comfort Care) or a document stating that the patient had requested full or selected measures. In addition, a family member or power of attorney for healthcare cannot supersede a patient’s refusal of transport or treatment while the patient is clinically competent.

The only scenario where a competent patient can be transported to a healthcare facility against his or her will is if they meet one or more of the criteria cited in Ohio Revised Code 5122.01 (B). This is the law that allows patients who are suicidal, homicidal, exhibiting psychotic behavior, or those that may benefit from a psychiatric evaluation to be transported to a healthcare facility and held for up to 72 hours.

An adult who is clinically incompetent or unconscious is within the category of patients who have, due to their clinical condition, provided implied consent for medical treatment. These patients may undergo a medical evaluation, treatment and transport to a medical facility without obtaining formal consent and their inability to do so should not be considered equivalent to a refusal. In these cases, the civil right provided by 42 CFR 483.10 to refuse medical treatment becomes delegated to the person’s legal guardian or power of attorney for healthcare. For EMS providers, the delineation and confirmation of a legal guardian or power of attorney for healthcare can be difficult, if not impossible, to determine in the field. For these scenarios, the EMS medical director along with the EMS agency’s legal counsel should determine the protocol for which EMS providers should follow. An advance directive document may be a helpful guidance; however, the Ohio DNR Comfort Care program is currently the only form of advance directive that provides civil immunity to EMS providers who are compliant with the patient’s documented wishes.

 


DNR

What should I do if I respond to a patient who is DNR and the relatives or nursing home staff on scene want us to resuscitate the patient? Also, what happens if a patient in cardiac arrest is going through a divorce and his/her spouse informs us that the patient has a living will and does not want to be resuscitated?


Advance directives are available in a variety of formats. Traditional living wills can be generated by an attorney or by a physician. Durable power of attorney for healthcare documents allow a patient to designate his or her medical decision-making to another party in the event that the patient becomes mentally or physically incapacitated or incompetent. Living wills and power of attorney for healthcare documents can be generated by an attorney at the direction of a client who may be a patient or the patient’s legal guardian or can originate as a court order. In the past, durable power of attorney for healthcare documents were usually generated by attorneys; however, this resource is now available on the internet for individuals, as well as physicians, to complete and execute independent of legal counsel.

Traditional do-not-resuscitate orders may exist as a verbal physician order or as a written physician order documented in a patient’s hospital or extended care facility medical record. This may include a physician order to exclude specific resuscitative and/or nutritional measures in addition to an order not to resuscitate a patient in the event of a cardiac arrest. The legal authority of these orders are usually limited to the healthcare facility in which they are written and, in some institutions, must be renewed at the time of readmission to a facility. While the paradigms of physician orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST) have been initiated in other states; however, POLST and MOLST programs have not currently been legislated or implemented in Ohio.

At this time, there are two legislative citations from the State of Ohio regarding advance directives, including do not resuscitate (DNR) orders, that have the greatest impact upon Ohio EMS providers. The Ohio DNR Comfort Care program, which includes the Ohio DNR Comfort Care and the Ohio DNR Comfort Care-Arrest protocols, is housed in the Ohio Department of Health. It is the only form of advance directive that provides civil immunity to Ohio EMS providers. It is also the only form of DNR order that is transportable with the patient during transitions between various facilities. Once completed, the only parties authorized to void the Ohio DNR Comfort Care document is the patient (or the patient’s power of attorney for healthcare if this individual was the signatory on the document at the time of enrollment in the program) or two physicians who agree that the document should be temporarily or permanently voided. The Ohio DNR Comfort Care form and the patient care parameters associated with the program can be found HERE.

While the presentation of the Ohio DNR Comfort Care document to EMS providers is preferable, the Ohio Department of Health has designed a DNR Comfort Care logo that is printed on all of their materials. As soon as Ohio EMS providers see the DNR Comfort Care logo on or accompanying a patient, they may initiate the patient care parameters outlined in the program immediately and retain civil immunity. Wallet cards and wristbands bearing this logo are readily available and can be more conveniently carried by a patient enrolled in this program (click HERE to see Ohio Department of Health DNR resources). The legislation and regulation regarding the Ohio Department of Health’s DNR Comfort Care program are cited in the Ohio Revised Code 2133.21 through 2133.26 and in the Ohio Administrative Code 3701-62. Additional resources provided by the Ohio Department of Health are available HERE.

The second legislative citation that may impact Ohio EMS providers in the course of patient treatment where resuscitation issues may be involved is Substitute House Bill 451 which prevents certain persons from making life support decisions. This bill was signed by Governor Kasich on January 4, 2017, and the law will become effective on April 6, 2017. This new law “provides that an individual's statutory priority to decide whether or not to withhold or withdraw life-sustaining treatment for the individual's relative is forfeited if the individual is the subject of a temporary protection order or civil protection order and the relative is the alleged victim or if the individual and the relative are married and the parties to a divorce, dissolution, legal separation, or annulment proceeding, to void any objections to a living will made by a person whose statutory priority would be so forfeited, provides that an attorney in fact under a durable power of attorney for health care is competent to make decisions pertaining to life-sustaining treatment, nutrition, or hydration, only if the attorney in fact is not subject to a temporary protection order or civil protection order in which the principal is the alleged victim.”

For the Ohio EMS provider and other emergency care providers, it may be difficult or impossible to definitively determine the existence or status of a temporary protection order or civil protection order or the legal familial or marital status between a patient and another person. Likewise, it may be impossible to determine the validity or active status of the other previously mentioned advance directive documents (living wills, DNR orders that are not Ohio DNR Comfort Care, power of attorney for healthcare, etc.) while on scene.

From a medicolegal standpoint, the Ohio DNR Comfort Care program is the only form of advance directive that provides immunity to the Ohio EMS provider as long as the comfort care parameters are followed. For all other cases, it is advisable to initiate resuscitation if a person’s DNR status is unknown or cannot be quickly determined or confirmed and to contact medical direction. For the patient care and decision-making process for those not enrolled in the Ohio Department of Health’s Ohio DNR Comfort Care program, the EMS medical director ultimately has the authority on how these patient scenarios should be managed. The EMS agencies and EMS providers should follow the protocols provided to them by their EMS medical director.

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