SECTION 1 - Purpose And Authority For Establishing Rules 1.1 The purpose of these rules is to define the duties and responsibilities of physician advisors to emergency medical care service agencies and to define the authorized medical acts of Emergency Medical Technicians (EMTs).

1.2 The general authority for the promulgation of these rules is set forth in Section 12-36-104 and Section 25-3.5-203, C.R.S.

1.3 These rules apply to and are controlling for any physician functioning as a physician advisor to an emergency medical services organization and who authorizes and directs the performarice of medical acts by EMTs at all levels of certification in the State of Colorado. SECTION 2 - DEFINITIONS All definitions which appear in Section 25-3.5-103, C.R.S., shall apply to these rules.

2.1 “Board” - The Colorado State Board of Medical Examiners.

2.2 “Division” - The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment.

2.3 “Emergency Medical Technician-Basic (EMT-Basic)” - an individual who has a current EMT-Basic certificate issued by the Division in accordance with the Rules Pertaining to Emergency Medical Services, 5-CCR-1004 (referred to herein as the “State EMS Rules”), and is authorized to provide basic emergency medical care in accordance with these rules of the Colorado State Board of Medical Examiners.

2.4 “Emergency Medical Technician-Intermediate (EMT-Intermediate)” - an individual who has a current EMT-Intermediate certificate issued by the Division 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 Colorado State Board of Medical Examiners.

2.5 “Emergency Medical Technician-Paramedic (EMT- Paramedic)” - an individual who has a current EMT-Paramedic certificate issued by the Division in accordance with the State EMS Rules and is authorized to provide advanced emergency medical care in accordance with the rules of the Colorado State Board of Medical Examiners.

2.6 “Graduate-EMT-Intermediate” - an individual who has successfully completed a Division-approved EMT-Intermediate training course but has not yet successfully completed the certification requirements set forth in the State EMS Rules.

2.7 “Graduate EMT-Paramedic” - an individual who has successfully completed a Division-approved EMT-Paramedic training course but has not yet successfully completed the certification requirements set forth in the State EMS Rules.

2.8 “EMT-Critical Care Paramedic (EMT-CCP)” - an individual who has successfully completed a Division approved EMT-CCP training course and has been certified as an EMT-CCP by the Division.

2.9 “Medical Base Station” - the source of direct medical communications with and supervision of the immediate field emergency care performance by EMT-Basics, EMT-Intermediates, or EMT- Paramedics.

2.10 “Physician Advisor” - a physician who establishes protocols and standing orders for medical acts performed by, EMT-Basics, EMT-Intermediates or EMT-Paramedics of a prehospital emergency medical care service agency and who is specifically identified as being responsible to assure the competency of the performance of those acts by such EMT-Basics, EMT-Intermediates or EMT- Paramedics as described in the physician's medical continuous quality improvement program.

2.11 “Protocol” - written standards for patient medical assessment and management.

2.12 “Service Agency” - any organized agency including but not limited to a “rescue unit” as defined in Section 25-3.5-103(11), C.R.S., using, EMT-Basics, EMT-Intermediates or EMT-Paramedics to render initial emergency medical care to a patient prior to or during transport or within an acute care setting such as a hospital or emergency care clinic. 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 Section 25-3.5-103(11), C.R.S. or are performing any medical act described in these rules.

2.13 “Standing Order” - written authorization by a physician advisor for the performance of specific medical acts by, EMT-Basics, EMT-Intermediates or EMT-Paramedics prior to their establishing communications with the supervising medical base station, or in the event of communications malfunctions with the medical base station.

SECTION 3 - Qualifications And Responsibilities Of Physician Advisors

3.1 A physician advisor shall possess the following minimum qualifications:

1. a) Be a physician currently licensed to practice medicine In the State of Colorado.
2. b) Be actively involved in the provision of emergency medical services in the community served by the service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a physician advisor, but does require such involvement during the time that he or she acts as a physician advisor. Active involvement in the community pertains to, by way of example and not limitation, those inherent, reasonable and appropriate responsibilities of a physician advisor to interact with the patient public served by the service agency, the hospital community, public safety agencies, the medical community, and other aspects of liaison and communication normally expected in the supervision of EMTs.
3. c) Be actively involved on a regular basis with the service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a physician advisor, but does require such involvement during the time that he or she acts as a physician advisor, Involvement could include, by way of example and not limitation, involvement in continuing education, audits, protocol development, as differentiated from passive or no involvement with the service agency and other aspects expected in the normal supervision of EMTs.
4. d) Be trained in Advanced Cardiac Life Support.

3.2 The responsibilities of a physician advisor shall include:

1. a) Notifying the Division of the service agencies and individuals for which medical control functions are being provided.
2. b) Establishing a medical continuous quality improvement program for each service agency being supervised which assures the continuing competency of the performance of that agency's, EMT-Basics, EMT-Intermediates or EMT-Paramedics. 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, continuing medical education and direct supervisory communications.
3. c) Submitting to the Division an affidavit that attests to the development and use of a medical continuous quality improvement program for a service agency's, EMT-Basics, EMT- Intermediates or EMT-Paramedics. The Division and the Board may review the records of a supervising physician to determine compliance with the requirements in these rules.

3.3 The physician advisor shall provide monitoring and supervision of the medical field performance of each supervised service agency's EMT-Basics, EMT-Intermediates or EMT-Paramedics. This responsibility may be delegated to other physicians or other qualified health care professionals designated by the physician advisor. However, the physician advisor 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.

3.4 The physician advisor shall ensure that each 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 physician advisor shall be familiar with the training, knowledge and competence of each of the individuals to whom the performance of such procedures is delegated.

3.5 The physician advisor shall be accountable to the Board for all actions in the authorization and delegation of medical acts, procedures, medical continuous quality improvement program or use of standing orders and established protocols which fail to meet generally accepted standards of medical care. The Division and the Board may review the records of a supervising physician to determine compliance with the requirements in these rules.

3.6 The physician advisor shall notify the Board and the Division within fourteen days of his or her termination as physician advisor pursuant to these rules.

3.7 The physician advisor shall notify the Division within fourteen days of his or her termination of the supervision of an EMT-Basic, EMT-Intermediate, or EMT-Paramedic that may constitute good cause for disciplinary sanctions pursuant to Section 8.1 of the 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.

SECTION 4 - Medical Acts Allowed for the EMT-Basic 4.1 An EMT-Basic may perform emergency medical acts consistent with, and not to exceed those listed in, the core minimum curriculum approved by the Division for EMT-Basic certification, excluding training content on advanced airway.

4.2 Any EMT-Basic who is a member or employee of a service agency and who performs said emergency medical acts must have authorization and be supervised by a physician advisor to perform said emergency medical acts.

4.3 An EMT-Basic under the authorization of a physician advisor, may perform advanced emergency medical care acts consistent with, and not to exceed those listed in appendix A of these rules 4.4 An EMT-Basic may administer and monitor medications and classes of medications defined in appendix A in accordance with the provisions of Section 3.

4.5 An EMT-Basic may, in addition to the acts allowed in Section 4, establish a peripheral intravenous line, administer crystalloid fluids for volume replacement, collect venous blood samples and administer intravenous dextrose provided the EMT-Basic has successfully completed a Division approved training course in these medical acts, and performs these acts under authorization from a physician advisor in accordance with the provisions of Section 3. SECTION 5 - Medical Acts Allowed for the EMT-Intermediate 5.1 In addition to the acts an EMT-Basic is allowed to perform pursuant to these rules, an EMT- Intermediate may, under the authorization of a physician advisor, perform advanced emergency medical care acts consistent with, and not to exceed those listed in appendix A of these rules.

5.2 In addition to the acts an EMT-Basic is allowed to perform pursuant to these rules, an EMT- Intermediate may administer and monitor medications and classes of medications defined in appendix A in accordance with the provisions of Section 3.

5.3 A physician advisor may allow an EMT-Intermediate to administer drugs described in appendix A off- line, under the direct visual supervision of an EMT-Paramedic when the following conditions have been established:

1. a) Drugs administered must be limited to those authorized by the Division and the Board of Medical Examiners for EMT-Intermediates as stated in Section 5 of the Board's rules regarding authorized medical acts of EMT-Intermediates.
2. b) The EMT-Paramedic must be supervised by the same physician supervising the EMT- Intermediate.
3. c) The physician advisor must amend the appropriate protocols and medical continuous quality improvement program used to supervise personnel to reflect this change in patient care. SECTION 6 - Medical Acts Allowed for the EMT-Paramedic

6.1 In addition to the acts an EMT-Basic is allowed to perform pursuant to these rules, an EMT- Paramedic may, under the authorization of a physician advisor, perform advanced emergency medical care acts consistent with, and not to exceed those listed in appendix A of these rules.

6.2 In addition to the acts an EMT-Basic is allowed to perform pursuant to these rules, an EMT- Paramedic may administer and monitor medications and classes of medications defined in appendix A, under standing order or direct verbal authorization of a physician including by electronic communications, in accordance with the provisions of Section 3.

6.3 EMT-Paramedics may carry out a physician order for a mental health hold as set forth in Section 27- 10-105(1), C.R.S. Such physician order may be verbal or by electronic communications.

6.4 Those acts prohibited by paragraphs 6.1 and 6.2, above, and appendix A, may be performed by an EMT-Paramedic only during an interfacility transfer. For purposes of this paragraph 6.4, an interfacility transfer shall be the transfer of a patient via ambulance from one healthcare facility to another. This paragraph 6.4 shall expire March 30, 2003. SECTION 7 - General Acts Allowed 7.1 EMTs may function in acute care settings. Functioning in this environment must be in compliance with the Board's statutes and rules, under the auspices of a physician advisor and within parameters of the acts allowed or waiver as described in these rules.

7.2 EMTs may not practice in camps in a nursing capacity including the dispensing of medications 7.3 Any EMT working for a service agency must be supervised by a physician advisor who complies with the requirements in these rules.

7.4 Any physician advisor may apply to the Board 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 physician advisor. Applications for waiver are available from the Board or the Division.

7.5 A physician advisor may limit the scope of practice of any EMT.

SECTION 8 - Graduate and Out-of-state Applicants for Certification 8.1 Physician advisors may supervise graduate EMT-Intermediates and EMT-Paramedics for a period of no more than six months following successful completion of an appropriate Division-approved training course. Graduate EMT-Intermediates and EMT-Paramedics must successfully complete certification requirements, as specified in the State EMS Rules, within six months of the successful completion of a training course to continue to function under the provisions of these rules.

SECTION 9 - Jurisdiction of Enforcement 9.1 All acts in violation of these rules by an EMT-Basic, EMT-Intermediate, or EMT-Paramedic shall be referred to the Division for review and appropriate action in accordance with the Colorado Emergency Medical Services Act, Section 25-3.5-101 et seq., C.R.S., and the State EMS Rules. Complaints in writing relating to the actions of any certified or graduate EMT-Basic, EMT- Intermediate or EMT- Paramedic pursuant to these rules of the Board may be initiated by any person or by the Board or the Division.

9.2 All acts in violation of these rules of the Board by a physician shall be referred to the Board 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 Board may be initiated by any person or by the Board or the Division.

RULES DEFINING THE DUTIES AND RESPONSIBILITIES OF EMERGENCY MEDICAL SERVICES PHYSICIAN ADVISORS AND THE AUTHORIZED MEDICAL ACTS OF EMERGENCY MEDICAL TECHNICIANS 3-CCR-713-6 APPENDIX A COLORADO EMERGENCY MEDICAL TECHNICIAN This document defines the maximum skills and medications that may be delegated to an EMT-Basic, EMT-Basic with IV Authorization, EMT-Intermediate, EMT-Paramedic and EMT-CCP, by a physician advisor.

Y=YES: May be performed by emergency medical technicians with physician supervision as described in these rules.

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.

B= Medical acts and skills that may be performed by an EMT-Basic with appropriate physician advisor supervision.

IV= Medical acts and skills that may be performed by an EMT-Basic with IV authorization with appropriate physician advisor supervision.

I= Medical acts and skills that may be performed by an EMT-Intermediate with appropriate physician advisor supervision.

P= Medical acts and skills that may be performed by an EMT-Paramedic with appropriate physician advisor supervision.

CCP= Medical acts and skills that may be performed by an EMT-paramedic with appropriate physician advisor supervision and training recognized by the department. Airway/Ventilation/Oxygen Administration Airway- Esophageal- N N N Single Lumen Airway - Laryngeal Mask N N N 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)

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 Cdcoid Pressure (Sellick) N N 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 - Simple Y Y Y Face Mask Oxygen Therapy- Venturi N N Y Mask Pulse Oximetry N N Y Suctioning - N N Y Tracheobronchlal 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 Cardiovascular/Circulatory Support 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 ControI- Y Y Y Tourniquet MAST/PASG Y Y Y Mechanical CPR Devise 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 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 - Ridged Y Y Y Splinting - Soft Y Y Y Splinting - Traction Y Y Y Splinting - Vacuum Y Y Y Intravenous Cannulation/Fluid Administration/Fluid Maintenance 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. R/L, 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 - Authodzed 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 SKILL. B IV I Aerosolized/Nebulized N N Y Buccal Y Y Y Endotracheal Tube (E-T) 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 N N Y Sub-lingual Y Y Y Intraosseous N N Y Opthalmic N N N Use of Mechanical N N Y Infusion Pumps Miscellaneous 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 EMT-Basic Formulary Physician Advisors may choose to delegate administration of the below drugs to an EMT-Basic with the direct verbal order:

1. Activated charcoal 2. Oral glucose 3. Chewable baby aspirin 4. Epinephrine auto-injector Physician Advisors may choose to delegate administration of the below drugs by an EMT-Basic with direct verbal communications, when the following medications are prescribed to a patient and these medications are present at the scene of an emergency.

1. Nitroglycerin 2. Meter dosed inhalers EMT-Basic with Intravenous Authorization Formulary Physician advisors may choose to delegate medication administration of the below drugs to an EMT- Basic who is qualified to perform intravenous therapy as defined in these rules.

1. Intravenous Dextrose EMT - Intermediate Formulary Physician advisors 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 with on-line medical control or with approved waiver from the Board. Medications used in cardiopulmonary arrest may be given while contacting on-line medical control.

1. Epinephrine 2. Atropine 3. Sodium Bicarbonate 4. Lidocaine 5. Bronchodilators - nebulized 6. Oxygen * 7. Glucose/Dextrose* 8. Nitroglycerine (sublingual)

9. Naloxone hydrochloride 10. Aspirin* 11. Neosynephrine (nasal)* 12. Decadron 13. Solu-Medrol 14. Valium 15. Lasix 16. Morphine Sulfate 17. Adenosine 18. Amiodarone 19. Vasopressin EMT - Paramedic Formulary Physician advisors may choose to delegate medication administration of the below drug classes. Medications that do not fall into one of the above drug classes cannot be delegated to the EMT- Paramedic unless a waiver has been granted as described in Section 7.4 of these rules.

1. Analgesics and antagonist 2. Antianxiety, sedative and hypnotic drugs 3. Anticonvulsants 4. Drugs affecting the sympathetic nervous system 5. Antidysrhythmics 6. Diuretics 7. Adrenergic inhibiting (sympatholytic)

8. Vasodilators 9. Calcium channel blockers 10. Anticoagulants 11. Bronchodilators 12. Antiemetics 13. Glucocorticoids 14. Nonsteroidal anti-inflammatory 15. Fluids and electrolytes 16. Oxygen 17. Glucose/Dextrose/Glucagon 18. Antihistamines 19. Antagonist/Antidotes 20. Parasympathetic blockers 21. Emetics 22. Influenza Vaccine 23. Topical Antibiotics 24. Antipyretics EMT - Paramedic Critical Care Formulary Physician advisors may choose to delegate medication administration of the below drug classes. Medications that do not fall into one of the below drug classes cannot be delegated to the EMT- Paramedic Critical Care unless a waiver has been granted as described in section 7.4 of these rules.

1. Antiplatelet agents (monitor only)

2. Paralytic agents 3. Insulin 4. Antibiotics (monitor only)

5. Parental nutrition (monitor only)

6. Multivitamin (monitor only)

7. Pitocin 8. Thrombolytic therapy (monitor only)

Revised 5/15/03; effective 7/30/03