DEPARTMENT OF REGULATORY AGENCIES Board of Medical Examiners COLORADO BOARD OF MEDICAL EXAMINERS RULES DEFINING THE DUTIES AND RESPONSIBILITIES OF EMERGENCY MEDICAL SERVICES MEDICAL DIRECTORS AND THE AUTHORIZED MEDICAL ACTS OF EMERGENCY MEDICAL TECHNICIANS 3-CCR-713-6 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] SECTION 1 - Purpose And Authority For Establishing Rules [Emer. Rule eff. 5/17/2007] 1.1 The purpose of these Rules is to define the duties and responsibilities of medical directors to EMS service agencies and to define the authorized medical acts of Emergency Medical Technicians (EMTs). [Emer. Rule eff. 5/17/2007] 1.2 The general authority for the promulgation of these Rules is set forth in § 12-36-104 and § 25-3.5- 203, C.R.S. [Emer. Rule eff. 5/17/2007] 1.3 These Rules apply to and are controlling for any physician functioning as a medical director to an emergency medical services organization and who authorizes and directs the performance of medical acts by EMTs at all levels of certification in the State of Colorado. These Rules also define the scope of practice for EMTs. [Emer. Rule eff. 5/17/2007] SECTION 2 - DEFINITIONS All definitions that appear in § 25-3.5-103, C.R.S., shall apply to these Rules. [Emer. Rule eff. 5/17/2007] 2.1 “BME” - The Colorado State Board of Medical Examiners. [Emer. Rule eff. 5/17/2007] 2.2 “Department” - The Colorado Department of Public Health and Environment. [Emer. Rule eff.

2.3 “Department-certified EMT” – any individual who has been certified by the Department to act as an EMT-Basic, an EMT-Intermediate or an EMT-Paramedic. [Emer. Rule eff. 5/17/2007] 2.4 “Emergency Medical Technician-Basic (EMT-Basic)” - an individual who has a current EMT-Basic certificate issued by the Department in accordance with the Rules Pertaining to Emergency Medical Services, 6 CCR 1015-3 (referred to herein as the “State EMS Rules” ), and is authorized to provide basic emergency medical care in accordance with these Rules of the BME. [Emer. Rule eff. 5/17/2007] 2.5 “Emergency Medical Technician-Basic with IV Authorization” – an individual who has a current EMT- Basic certificate issued by the Department in accordance with the State EMS Rules and has met the conditions defined in section 4.4 of these Rules. [Emer. Rule eff. 5/17/2007] 2.6 “Emergency Medical Technician-Intermediate (EMT-Intermediate)” - an individual who has a current EMT-Intermediate certificate issued by the Department in accordance with the State EMS Rules and is authorized to provide limited acts of advanced emergency medical care in accordance with these Rules of the BME. [Emer. Rule eff. 5/17/2007] 2.7 “Emergency Medical Technician-Paramedic (EMT- Paramedic)” - an individual who has a current EMT-Paramedic certificate issued by the Department in accordance with the State EMS Rules and is authorized to provide advanced emergency medical care in accordance with these Rules of the BME. [Emer. Rule eff. 5/17/2007] 2.8 “EMT Paramedic with Critical Care (CC) Authorization” – an individual who has a current EMT- Paramedic certificate issued by the Department in accordance with the State EMS Rules and whose medical director has successfully applied for a waiver as described in section 6.4 of these Rules or who is within the grace period described in section 6.4 of these Rules. [Emer. Rule eff.

2.9 “EMS Service Agency” - any organized agency including but not limited to a “rescue unit” as defined in § 25-3.5-103(11), C.R.S., using Department-certified EMTs to render initial emergency medical care to a patient prior to or during transport. This definition does not include criminal law enforcement agencies, unless the criminal law enforcement personnel are EMTs who function with a “rescue unit” as defined in § 25-3.5-103(11), C.R.S. or are performing any medical act described in these Rules. [Emer. Rule eff. 5/17/2007] 2.10 “Graduate EMT-Intermediate” - an individual who has a current EMT-Basic certificate issued by the Department in accordance with the State EMS Rules and has successfully completed a Department-approved EMT-Intermediate training course but has not yet successfully completed the certification requirements set forth in the State EMS Rules. [Emer. Rule eff. 5/17/2007] 2.11 “Graduate EMT-Paramedic” - an individual who has a current EMT-Basic certificate or a current EMT-Intermediate certificate issued by the Department in accordance with the State EMS Rules and has successfully completed a Department-approved EMT-Paramedic training course but has not yet successfully completed the certification requirements set forth in the State EMS Rules.

2.12 “Medical Base Station” - the source of direct medical communications with and supervision of the immediate field emergency care performance by Department-certified EMTs. [Emer. Rule eff.

2.13 “Medical Director” - a physician who holds an active Colorado medical license, who authorizes and directs, through protocols and standing orders, the performance of students-in-training enrolled in state accredited EMS education programs, graduate EMT-Intermediates or EMT-Paramedics, or Department-certified EMTs of a prehospital EMS service agency and who is specifically identified as being responsible to assure the competency of the performance of those acts by such Department-certified EMTs as described in the physician’s medical continuous quality improvement program. Any reference to a “physician advisor” in the State EMS Rules or in the BME’s previously-adopted Rules shall apply to a “medical director” as defined in these Rules.

2.14 “Protocol” - written standards for patient medical assessment and management. [Emer. Rule eff.

2.15 “Standing Order” - written authorization by a medical director for the performance of specific medical acts by Department-certified EMTs before such Department-certified EMTs are able to establish communications with the supervising medical base station, or in the event of communications malfunctions with the medical base station. [Emer. Rule eff. 5/17/2007] 2.16 “State EMS Rules” –Rules Pertaining to Emergency Medical Services, 6 CCR 1015-3, promulgated by the State Board of Health. [Emer. Rule eff. 5/17/2007] SECTION 3 - Qualifications And Responsibilities of Medical Directors [Emer. Rule eff. 5/17/2007] 3.1 A medical director shall possess the following minimum qualifications: [Emer. Rule eff. 5/17/2007]

1. a) Be a physician currently licensed to practice medicine in the State of Colorado. [Emer. Rule
   1. eff. 5/17/2007]
   2. b) Be actively involved in the provision of emergency medical services in the community served by the EMS service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director, but does require such involvement during the time that he or she acts as a medical director. Active involvement in the community could include, by way of example and not limitation, those inherent, reasonable and appropriate responsibilities of a medical director to interact with the patient public served by the EMS service agency, the hospital community, the public safety agencies, and the medical community, and should include other aspects of liaison oversight and communication normally expected in the supervision of Department- certified EMTs. [Emer. Rule eff. 5/17/2007] c) Be actively involved on a regular basis with the EMS service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director, but does require such involvement during the time that he or she acts as a medical director. Involvement could include, by way of example and not limitation, involvement in continuing education, audits, and protocol development. It is not acceptable merely to have passive or negligible involvement with the EMS service agency and supervision of Department-certified EMTs. [Emer. Rule eff. 5/17/2007] d) Be trained in Advanced Cardiac Life Support. [Emer. Rule eff. 5/17/2007] e) Physicians acting as Medical Directors for State accredited EMS Education Programs must possess authority under their licensure to perform all medical acts included in any and all curriculums presented by the program. [Emer. Rule eff. 5/17/2007]

3.2 The responsibilities of a medical director shall include: [Emer. Rule eff. 5/17/2007]

1. a) Notify the Department of the service agencies and individuals for which medical control functions are being provided. [Emer. Rule eff. 5/17/2007] b) Establish a medical continuous quality improvement program for each EMS service agency being supervised. The continuous quality improvement program must assure the continuing competency of the performance of that agency’s Department-certified EMTs. This medical continuous quality improvement program shall include, but not necessarily be limited to, appropriate protocols and standing orders, and provision for medical care audits, observation, critiques, primary and continuing medical education and direct supervisory communications. [Emer. Rule eff. 5/17/2007] c) Submit to the Department an affidavit that attests to the development and use of a medical continuous quality improvement program for an EMS service agency’s Department- certified EMTs. The Department and the BME may review the records of a medical director to determine compliance with the requirements in these Rules. [Emer. Rule eff.
   1. d) Provide monitoring and supervision of the medical field performance of each supervised EMS service agency’s Department-certified EMTs. This responsibility may be delegated to other physicians or other qualified health care professionals designated by the medical director. However, the medical director shall retain ultimate authority and responsibility for the monitoring and supervision, for establishing protocols and standing orders and for the competency of the performance of authorized medical acts. [Emer. Rule eff. 5/17/2007] e) Ensure that each direct verbal order, written standing order or protocol is appropriate for the certification and skill level of each of the individuals to whom the performance of medical acts is delegated and authorized. The medical director shall be familiar with the training, knowledge and competence of each of the individuals to whom the performance of such procedures is delegated. [Emer. Rule eff. 5/17/2007] f) Notify the BME and the Department within fourteen business days excluding State holidays of his or her cessation of duties as medical director pursuant to these Rules. [Emer. Rule
      1. eff. 5/17/2007]
   2. g) Notify the Department within fourteen business days excluding State holidays of his or her termination of the supervision of a Department-certified EMTs for reasons that may constitute good cause for disciplinary sanctions pursuant to the State EMS Rules. Such notification shall be in writing and shall include a statement of the actions or omissions resulting in termination of supervision and copies of all pertinent records. [Emer. Rule eff.
   3. h) Physicians acting as Medical Directors for EMS education programs approved by the Department that require clinical and field internship performance by students, shall be permitted to delegate authority to a student-in-training during their performance of program required medical acts and only while under the control of the education program.

3.3 The medical director shall be accountable to the BME for all acts or omissions that fail to meet generally accepted standards of medical practice and/or that violate these Rules. The Department and the BME may review the records of a supervising physician to determine compliance with the requirements in these Rules. [Emer. Rule eff. 5/17/2007] SECTION 4 - Medical Acts Allowed for the EMT-Basic [Emer. Rule eff. 5/17/2007] 4.1 An EMT-Basic may, under the supervision and authorization of a medical director, perform emergency medical acts consistent with, and not to exceed those listed in Appendix A of these Rules in accordance with the provisions of Section 3 of these Rules. [Emer. Rule eff. 5/17/2007] 4.2 An EMT-Basic may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications defined in Appendix B of these Rules in accordance with the provisions of Section 3 of these Rules. [Emer. Rule eff. 5/17/2007] 4.3 Any EMT-Basic who is a member or employee of an EMS service agency and who performs said emergency medical acts must have authorization and be supervised by a medical director to perform said emergency medical acts. [Emer. Rule eff. 5/17/2007] 4.4 An EMT-Basic who has successfully completed a Department-approved intravenous training course may be referred to as an “Emergency Medical Technician – Basic with IV Authorization.” Any provisions of these Rules that are applicable to an EMT-Basic shall also be applicable to an EMT- Basic with IV Authorization. In addition to the acts an EMT-Basic is allowed to perform, an EMT- Basic with IV Authorization may, under supervision and authorization of a medical director, perform medical acts consistent with and not to exceed those listed in Appendix A of these Rules for an EMT-Basic with IV Authorization in accordance with the provisions of Section 3 of these Rules. In addition to the medications and classes of medications an EMT-Basic is allowed to administer and monitor pursuant to these Rules, an EMT-Basic with IV Authorization may, under supervision and authorization of a medical director, administer and monitor medications and classes of medications defined in Appendix B in accordance with the provisions of Section 3 of SECTION 5 - Medical Acts Allowed for the EMT-Intermediate [Emer. Rule eff. 5/17/2007] 5.1 In addition to the acts an EMT-Basic and an EMT-Basic with IV Authorization are allowed to perform pursuant to these Rules, an EMT-Intermediate may, under the supervision and authorization of a medical director perform advanced emergency medical care acts consistent with, and not to exceed those listed in Appendix A of these Rules in accordance with the provisions of section 3 of 5.2 In addition to the medications and classes of medications an EMT-Basic and an EMT-Basic with IV Authorization are allowed to administer and monitor pursuant to these Rules, an EMT- Intermediate may, under the supervision and authorization of a medical director administer and monitor medications and classes of medications defined in Appendix B in accordance with the provisions of Section 3 of these Rules. [Emer. Rule eff. 5/17/2007] 5.3 A medical director may allow an EMT-Intermediate to administer drugs described in Appendix B off- line, under the direct visual supervision of an EMT-Paramedic when the following conditions have been established: [Emer. Rule eff. 5/17/2007]

1. a) Drugs administered must be limited to those authorized by the BME for EMT-Intermediates as stated in Section 5 of the BME’s Rules regarding authorized medical acts of EMT- Intermediates. [Emer. Rule eff. 5/17/2007] b) The EMT-Paramedic must be supervised by the same physician supervising the EMT- Intermediate. [Emer. Rule eff. 5/17/2007] c) The medical director must amend the appropriate protocols and medical continuous quality improvement program used to supervise personnel to reflect this change in patient care.

5.4 In the event of disaster or emergency, the Chief Medical Officer for the Department of Public Health and Environment or the State EMS Medical Director may temporarily authorize the administration of other immunizations, vaccines, biologicals, or tests not listed in these Rules. [Emer. Rule eff. SECTION 6 - Medical Acts Allowed for the EMT-Paramedic [Emer. Rule eff. 5/17/2007] 6.1 In addition to the acts an EMT Intermediate is allowed to perform pursuant to these Rules, an EMT- Paramedic may, under the supervision and authorization of a medical director, perform advanced emergency medical care acts consistent with, and not to exceed those listed in Appendix A of these Rules in accordance with the provisions of section 3 of these Rules. [Emer. Rule eff.

6.2 In addition to the medications and classes of medications an EMT Intermediate is allowed to administer and monitor pursuant to these Rules, an EMT-Paramedic may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications defined in Appendix B, under standing order or direct verbal order of a physician including by electronic communications, in accordance with the provisions of Section 3 of these Rules. [Emer. Rule eff. 5/17/2007] 6.3 EMT-Paramedics may carry out a physician order for a mental health hold as set forth in § 27-10- 105(1), C.R.S. Such physician order may be a direct verbal order or by electronic communications. [Emer. Rule eff. 5/17/2007] 6.4 Except as provided below, an EMT-Paramedic with appropriate training and experience may, in conjunction with his or her medical director, apply for a waiver from the Board to designate the EMT-Paramedic as an “EMT-Paramedic with CC Authorization.” Any provisions of these Rules that are applicable to an EMT-Paramedic shall also be applicable to an EMT-Paramedic with CC Authorization. In addition to the acts an EMT-Paramedic is allowed to perform, an EMT- Paramedic with CC Authorization may, under supervision and authorization of a medical director, perform advanced medical care acts consistent with and not to exceed those listed in Appendix A of these Rules for an EMT- Paramedic with CC Authorization in accordance with the provisions of Section 3 of these Rules. In addition to the medications and classes of medications an EMT- Paramedic is allowed to administer and monitor pursuant to these Rules, an EMT- Paramedic with CC Authorization may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications defined in Appendix B under standing order or direct verbal order of a physician including by electronic communications, in accordance with the provisions of Section 3 of these Rules. Under prior Board Rules and Policies, some EMT-Paramedics have been functioning as EMT-Paramedics with CC Authorization without going through the waiver process. In recognition of the time required to complete the waiver process, the Board will permit such EMT-Paramedics who are functioning in this capacity prior to June 30, 2005, to continue to perform the acts and administer and monitor the medications referenced in this paragraph until April 14, 2007 without going through the waiver process. This grace period is not meant to encourage EMT-Paramedics and Medical Directors to postpone completing appropriate waiver applications, however. Instead, EMT-Paramedics and Medical Directors are encouraged to complete waiver applications as soon as possible. [Emer. Rule eff. The April 14, 2007 grace period above has been extended temporarily through this emergency rule and through a simultaneously adopted permanent rule. Upon the effective date of the permanent rule, this emergency rule shall no longer be in effect. [Emer. Rule eff. 5/17/2007] SECTION 7- General Acts Allowed [Emer. Rule eff. 5/17/2007] 7.1 Division-certified EMTs may function in acute care settings. Functioning in this environment must be in compliance with the BME’s statutes and Rules, under the auspices of a medical director and within parameters of the acts allowed or waiver as described in these Rules. [Emer. Rule eff.

7.2 EMTs may not practice in camps in a nursing capacity including the dispensing of medications.

7.3 Any EMT working for an EMS service agency must be supervised by a medical director who complies with the requirements in these Rules. [Emer. Rule eff. 5/17/2007] 7.4 Any medical director may apply to the BME for a waiver to allow additional medical acts for EMTs under his/her supervision in specific circumstances, based on established need, provided that on- going quality assurance of each EMT’s competency is maintained by the medical director. Applications for waiver are available from the BME or the Department. A waiver is not necessary under the circumstances described in BME Rule 800. [Emer. Rule eff. 5/17/2007] 7.5 A medical director may limit the scope of practice of any EMT. [Emer. Rule eff. 5/17/2007] SECTION 8 - Graduate EMT-Intermediates and Graduate EMT-Paramedics. [Emer. Rule eff.

8.1 Medical directors may supervise Graduate EMT-Intermediates as defined in these Rules acting as EMT-Intermediates for a period of no more than six months following successful completion of an appropriate Department-approved training course. Medical directors may supervise Graduate EMT-Paramedics as defined in these Rules acting as EMT-Paramedics for a period of no more than six months following successful completion of an appropriate Department-approved training course. Such Graduate EMT-Intermediates and Graduate EMT-Paramedics must successfully complete certification requirements, as specified in the State EMS Rules, within six months of the successful completion of a Department-approved training course to continue to function under the provisions of these Rules. [Emer. Rule eff. 5/17/2007] SECTION 9 - Jurisdiction of Enforcement [Emer. Rule eff. 5/17/2007] 9.1 All acts in violation of these Rules by a Department-certified EMT shall be referred to the Department for review and appropriate action in accordance with the Colorado Emergency Medical Services Act, § 25-3.5-101 et seq., C.R.S., and the State EMS Rules. Complaints in writing relating to the actions of any a Department-certified EMT pursuant to these Rules of the BME may be initiated by any person or by the BME or the Department. [Emer. Rule eff. 5/17/2007] 9.2 Pursuant to § 12-36-106(2), C.R.S., any person who performs any of the acts constituting the practice of medicine as defined by § 12-36-106(1), C.R.S. and who is not licensed by the BME to practice medicine or exempt from licensure requirements by some provision of § 12-36-106, C.R.S. shall be deemed to be practicing medicine without a license. Such person may be held criminally liable pursuant to § 12-36-129(1), C.R.S. and/or may be the subject of injunctive proceedings by the BME in the name of the people of the state of Colorado pursuant to § 12-36- 132, C.R.S. [Emer. Rule eff. 5/17/2007] 9.3 All acts in violation of these Rules of the BME by a physician shall be referred to the BME for review and appropriate action in accordance with Section § 12-36-118, C.R.S. Complaints in writing relating to the actions of any physician pursuant to these Rules of the BME may be initiated by any person or by the BME or the Department. [Emer. Rule eff. 5/17/2007] APPENDIX A [Emer. Rule eff. 5/17/2007] MEDICAL SKILLS AND ACTS ALLOWED [Emer. Rule eff. 5/17/2007] This document defines the maximum skills that may be delegated to an EMT-Basic, EMT-Basic with IV Authorization, EMT-Intermediate, EMT-Paramedic and EMT-Paramedic with CC Authorization, by a medical director. [Emer. Rule eff. 5/17/2007] Y=YES: May be performed by emergency medical technicians with physician supervision as described in N=NO: May not be performed by emergency medical technicians except with a Board approved waiver as described in Section 7.4 of these Rules. [Emer. Rule eff. 5/17/2007] B= Medical acts and skills that may be performed by an EMT-Basic with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. 5/17/2007] B-IV= Medical acts and skills that may be performed by an EMT-Basic with IV Authorization with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. I= Medical acts and skills that may be performed by an EMT-Intermediate with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. 5/17/2007] P= Medical acts and skills that may be performed by an EMT-Paramedic with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. 5/17/2007] P-CC= Medical acts and skills that may be performed by an EMT-Paramedic with Critical Care Authorization with appropriate medical director supervision and training recognized by the Department once an appropriate waiver has been obtained pursuant to paragraph 6.4. [Emer. Rule eff. 5/17/2007] Airway/Ventilation/Oxygen Administration [Emer. Rule eff. 5/17/2007] Airway – Esophageal- N N N Single Lumen Airway – Laryngeal N N N Mask Airway – N N Y Esophageal/Tracheal – Multi Lumen Airway – Nasal Y Y Y Airway – Oral Y Y Y Bag – Valve – Mask Y Y Y (BVM)

1. Ventilation – Oxygen Y Y Y Powered Ventilation Device Chest Decompression – N N N Needle Chest Tube Insertion N N N Chest Tube Monitoring N N N CPAP/BiPAP/PEEP N N N Cricoid Pressure (Sellick) Y Y Y Cricothyroidotomy – N N N Needle Cricothyroidotomy – N N N Surgical Demand Valve – Oxygen Y Y Y Powered End Tidal CO2 N N Y Monitoring/Capnometry Gastric Decompression – N N N NG Tube Insertion Gastric Decompression – N N N OG Tube Insertion Head-tilt/Chin-lift Y Y Y Intubation – Digital N N N Intubation – Lighted N N Y Stylet Intubation – Medication N N N Assisted (non-paralytic)

   Intubation – Medication N N N Assisted (paralytics)

   (RSI)

   Intubation – Maintenance N N N with (paralytics)

   Intubation – Nasotracheal N N N Intubation – Orotracheal N N Y Intubation – Retrograde N N N Extubation N N Y Jaw-thrust Y Y Y Jaw-thrust – Modified Y Y Y (trauma)

   Mouth-to-Barrier Y Y Y Mouth-to-Mouth Y Y Y Mouth-to-Nose Y Y Y Mouth-to-Stoma Y Y Y Obstruction – Direct N N Y Laryngoscopy Obstruction – Manual Y Y Y Oxygen Therapy – Y Y Y Humidifiers Oxygen Therapy – Nasal Y Y Y Cannula Oxygen Therapy – Non- Y Y Y rebreather Mask Oxygen Therapy – Y Y Y Simple Face Mask Oxygen Therapy – N N Y Venturi Mask Pulse Oximetry Y1 Y1 Y Suctioning – N N Y Tracheobronchial Suctioning – Upper Y Y Y Airway Ventilators – Automated N N N Transport (ATV)

   Peek Expiratory Flow N N Y Testing Tracheal Tube N N Y Maintenance – Includes replacement 1 WITH SUCCESSFUL COMPLETION OF TRAINING APPROVED BY THE EMT’S MEDICAL DIRECTOR. [Emer. Rule eff. 5/17/2007] Cardiovascular/Circulatory Support [Emer. Rule eff. 5/17/2007] Cardiac Monitoring – N N N Multi Lead (12 – non- interpretive)

   Cardiac Monitoring – N N N Multi Lead (12 – interpretive)

   Cardiac Monitoring – N N Y Single Lead (interpretive)

   Cardiopulmonary Y Y Y Resuscitation (CPR)

   Cardioversion – Electrical N N N Carotid Massage N N N Defibrillation – Y Y Y Automated/Semi- Automated (AED)

   Defibrillation – Manual N N Y Hemorrhage Control – Y Y Y Direct Pressure Hemorrhage Control – Y Y Y Pressure Point Hemorrhage Control – Y Y Y Tourniquet MAST/PASG Y Y Y Mechanical CPR Device Y Y Y Transcutaneous Pacing N N Y Transvenous Pacing – N N N Maintenance Implantable N N N Cardioverter/Defibrillator Magnet Use Arterial Blood Pressure N N N Indwelling Catheter – Maintenance Invasive Intracardiac N N N Catheters – Maintenance Central Venous Catheter N N N Insertion Central Venous Catheter N N Y Maintenance/Patency Central Venous Catheter N N N Maintenance/Interpretatio n Percutaneous N N N Pericardiocentesis Immobilization [Emer. Rule eff. 5/17/2007] Spinal Immobilization – Y Y Y Cervical Collar Spinal Immobilization – Y Y Y Long Board Spinal Immobilization – Y Y Y Manual Stabilization Spinal Immobilization – Y Y Y Seated Patient (KED, etc.)

   Splinting – Manual Y Y Y Splinting – Rigid Y Y Y Splinting – Soft Y Y Y Splinting – Traction Y Y Y Splinting – Vacuum Y Y Y Intravenous Cannulation/Fluid Administration/Fluid Maintenance [Emer. Rule eff. 5/17/2007] Blood/Blood By-Products N N N Initiation (out of facility initiation)

   Blood/Blood By-Products N N N Initiation (post facility initiation)

   Blood/Blood By-Products N N N Monitoring Colloids-(Albumin, N N N Dextran) – Initiation Crystalloid (D5W, LR, N Y Y NS) – Initiation Intraosseous – Initiation N N Y Peripheral – Excluding N Y Y External Jugular - Initiation Peripheral – Including N N Y External Jugular – Initiation Medicated IV Fluids N N Y Maintenance – Authorized Medications Non-medicated IV Fluids N Y Y Maintenance Parenteral Nutrition N N N Fluids Maintenance Use of Indwelling N N N Catheter for IV medications Medication Administration – Routes [Emer. Rule eff. 5/17/2007] Aerosolized/Nebulized N N Y Buccal Y Y Y Endotracheal Tube (ET) N N Y Intramuscular (IM) N N Y Intravenous (IV) N N Y Piggyback Intravenous (IV) Push N Y Y Nasogastric N N N Oral Y Y Y Rectal N N Y Subcutaneous Y Y Y Sub-lingual Y Y Y Intraosseous N N Y Opthalmic N N N Use of Mechanical N N Y Infusion Pumps Intranasal N N Y Intradermal N N Y Miscellaneous [Emer. Rule eff. 5/17/2007] Assisted Delivery Y Y Y Blood Glucose N Y Y Monitoring Dressing/Bandaging Y Y Y Eye Irrigation Y Y Y Noninvasive Eye Irrigation Morgan N N N Lense Over-the-counter N N N Medications (OTC)

   Urinary Catheterization N N N Venous Blood Sampling – N Y Y Obtaining Maintenance of N N N Intracranial Monitoring Lines Aortic Balloon Pump N N N Monitoring APPENDIX B [Emer. Rule eff. 5/17/2007] FORMULARY OF MEDICATIONS ALLOWED TO BE ADMINISTERED [Emer. Rule eff. 5/17/2007] COLORADO EMERGENCY MEDICAL TECHNICIAN [Emer. Rule eff. 5/17/2007] This document defines the medications that an EMT-Basic, EMT-Basic with IV Authorization, EMT- Intermediate, EMT-Paramedic and EMT-Paramedic with CC Authorization may delegate under appropriate supervision by a medical director. [Emer. Rule eff. 5/17/2007] Y=YES: May be performed by emergency medical technicians with physician supervision as described in N=NO: May not be performed by emergency medical technician except with a Board approved waiver as described in Section 7.4 of these Rules. [Emer. Rule eff. 5/17/2007] B= Medical acts and skills that may be performed by an EMT-Basic with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. 5/17/2007] B-IV= Medical acts and skills that may be performed by an EMT-Basic with IV Authorization with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. I= Medical acts and skills that may be performed by an EMT-Intermediate with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. 5/17/2007] P= Medical acts and skills that may be performed by an EMT-Paramedic with appropriate medical director supervision and training recognized by the Department. [Emer. Rule eff. 5/17/2007] P-CC= Medical acts and skills that may be performed by an EMT-Paramedic with Critical Care Authorization with appropriate medical director supervision and training recognized by the Department once an appropriate waiver has been obtained pursuant to paragraph 6.4. [Emer. Rule eff. 5/17/2007] CLASSES OF MEDICATIONS [Emer. Rule eff. 5/17/2007] Where the below formularies list classes of medications rather than individual medications, the Department, with expert consultation when appropriate, shall be responsible for maintaining lists of individual drugs within those categories that may be administered by an EMT (hereinafter, “the Department’s individual approved medication list” ). [Emer. Rule eff. 5/17/2007] The Department’s individual approved medication list may be updated and amended by the Department, with expert consultation when appropriate. On an annual basis, the Department shall provide the Board with a copy of the Department’s individual approved medication list for Board input. [Emer. Rule eff. Where the following formularies reference a class of medication rather than an individual medication, the Medical Director and the EMT shall consult the Department’s individual approved medication list to determine what individual medications within the class of medication may lawfully be administered by an

EMT. Substitution of drugs within the same category is not permitted if the individual drug is not included on the Department’s individual approved medication list. [Emer. Rule eff. 5/17/2007] EMT-Basic Formulary [Emer. Rule eff. 5/17/2007] Medical directors may choose to delegate administration of the below drugs to an EMT-Basic under direct verbal order: [Emer. Rule eff. 5/17/2007] 1. Activated charcoal [Emer. Rule eff. 5/17/2007] 2. Oral glucose [Emer. Rule eff. 5/17/2007] 3. Chewable baby aspirin [Emer. Rule eff. 5/17/2007] 4. Epinephrine auto-injector [Emer. Rule eff. 5/17/2007] Medical directors may choose to delegate administration of the below drugs by an EMT-Basic under direct verbal order, when the following medications are prescribed to a patient and these medications are present at the scene of an emergency. [Emer. Rule eff. 5/17/2007] 1. Nitroglycerin [Emer. Rule eff. 5/17/2007] 2. Meter dosed inhalers [Emer. Rule eff. 5/17/2007] EMT-Basic with Intravenous Authorization Formulary [Emer. Rule eff. 5/17/2007] Medical directors may choose to delegate medication administration under direct verbal order of the below drugs to an EMT-Basic who is qualified to perform intravenous therapy as defined in these Rules.

1. Intravenous Dextrose [Emer. Rule eff. 5/17/2007] EMT – Intermediate Formulary [Emer. Rule eff. 5/17/2007] Medical directors may choose to delegate medication administration of the below drugs to an EMT- Intermediate. Medications with * may be given on standing orders. All other medications must be administered under direct verbal order or with approved waiver from the BME. Medications used in cardiopulmonary arrest may be given under direct verbal order. [Emer. Rule eff. 5/17/2007] 1. Epinephrine [Emer. Rule eff. 5/17/2007] 2. Atropine [Emer. Rule eff. 5/17/2007] 3. Sodium Bicarbonate [Emer. Rule eff. 5/17/2007] 4. Lidocaine [Emer. Rule eff. 5/17/2007] 5. Bronchodilators – nebulized [Emer. Rule eff. 5/17/2007] 6. Oxygen * [Emer. Rule eff. 5/17/2007] 7. Glucose/Dextrose * [Emer. Rule eff. 5/17/2007] 8. Nitroglycerine (sublingual) [Emer. Rule eff. 5/17/2007] 9. Naloxone hydrochloride [Emer. Rule eff. 5/17/2007] 10. Aspirin * [Emer. Rule eff. 5/17/2007] 11. Decadron [Emer. Rule eff. 5/17/2007] 12. Solu-Medrol [Emer. Rule eff. 5/17/2007] 13. Valium [Emer. Rule eff. 5/17/2007] 14. Lasix [Emer. Rule eff. 5/17/2007] 15. Morphine Sulfate [Emer. Rule eff. 5/17/2007] 16. Adenosine [Emer. Rule eff. 5/17/2007] 17. Amiodarone [Emer. Rule eff. 5/17/2007] 18. Vasopressin [Emer. Rule eff. 5/17/2007] EMT – Paramedic Formulary [Emer. Rule eff. 5/17/2007] Medical directors may choose to delegate medication administration of the below drug classes under standing or direct verbal orders. Medications whose primary indication does not fall into one of the below drug classes cannot be delegated to the EMT-Paramedic unless a waiver has been granted as described in Section 7.4 of these Rules. [Emer. Rule eff. 5/17/2007] 1. Analgesics and antagonist [Emer. Rule eff. 5/17/2007] 2. Antianxiety, sedative and hypnotic drugs [Emer. Rule eff. 5/17/2007] 3. Anticonvulsants [Emer. Rule eff. 5/17/2007] 4. Drugs affecting the sympathetic nervous system [Emer. Rule eff. 5/17/2007] 5. Antidysrhythmics [Emer. Rule eff. 5/17/2007] 6. Diuretics [Emer. Rule eff. 5/17/2007] 7. Adrenergic inhibiting (sympatholytic) [Emer. Rule eff. 5/17/2007] 8. Vasodilators [Emer. Rule eff. 5/17/2007] 9. Calcium channel blockers [Emer. Rule eff. 5/17/2007] 10. Anticoagulants [Emer. Rule eff. 5/17/2007] 11. Bronchodilators [Emer. Rule eff. 5/17/2007] 12. Antiemetics [Emer. Rule eff. 5/17/2007] 13. Glucocorticoids [Emer. Rule eff. 5/17/2007] 14. Nonsteroidal anti-inflammatory [Emer. Rule eff. 5/17/2007] 15. Fluids and electrolytes [Emer. Rule eff. 5/17/2007] 16. Oxygen [Emer. Rule eff. 5/17/2007] 17. Glucose/Dextrose/Glucagon [Emer. Rule eff. 5/17/2007] 18. Antihistamines [Emer. Rule eff. 5/17/2007] 19. Antagonist/Antidotes [Emer. Rule eff. 5/17/2007] 20. Parasympathetic blockers [Emer. Rule eff. 5/17/2007] 21. Emetics [Emer. Rule eff. 5/17/2007] 22. Influenza Vaccine [Emer. Rule eff. 5/17/2007] 23. Topical Antibiotics [Emer. Rule eff. 5/17/2007] 24. Antipyretics [Emer. Rule eff. 5/17/2007] EMT – Paramedic with Critical Care Authorization Formulary [Emer. Rule eff. 5/17/2007] Medical directors may choose to delegate medication administration of the below drug classes under standing or direct verbal order. Medications that do not fall into one of the below drug classes cannot be delegated to the EMT-Paramedic with Critical Care Authorization unless a waiver has been granted as described in section 7.4 of these Rules. [Emer. Rule eff. 5/17/2007] 1. Antiplatelet agents (monitor only) [Emer. Rule eff. 5/17/2007] 2. Paralytic agents [Emer. Rule eff. 5/17/2007] 3. Insulin [Emer. Rule eff. 5/17/2007] 4. Antibiotics (monitor only) [Emer. Rule eff. 5/17/2007] 5. Parental nutrition (monitor only) [Emer. Rule eff. 5/17/2007] 6. Multivitamin (monitor only) [Emer. Rule eff. 5/17/2007] 7. Pitocin [Emer. Rule eff. 5/17/2007] 8. Thrombolytic therapy (monitor only)

Revised 2/9/06; effective 3/31/06; revised 5/17/07; effective 5/17/07. _____________________________________________________ Editor’s Notes History Entire Rule eff. 5/17/2007.