Oregon: The State with the Original Advanced Chiropractic Scope of Practice
ADVANCED PRACTICE
Laurence V. Hicks
DC, DO, Geoffrey
N. Hicks
David Booth
DC.
Following D. D. Palmer’s relocation from Iowa to Oregon, he postulated his novel concept that the three-legged stool of chiropractic included minor surgery, adjustments, and obstetrics. His notion may well have influenced the framework of regulatory statutes favoring a broad scope of practice for Oregon’s chiropractic physicians.
Here we will see that advanced chiropractic practice began in Oregon and includes minor surgery, the use of anesthetics and antiseptics, proprietary (OTC) medications, proctology, obstetrics (natural childbirth, midwifery), the signing of birth and death certificates, providing emergency first aid, including administering emergency oxygen, the use of radiopaque substances, etc.
Core Chiropractic
Under Oregon Revised Statutes (ORS), part 2, “chiropractic” is defined as:
• That system of adjusting with the hands the articulations of the bony framework of the human body, and the employment and practice of physiotherapy, electrotherapy, hydrotherapy, and minor surgery.
• The chiropractic diagnosis, treatment, and prevention of body dysfunction; correction, maintenance of the structural and functional integrity of the neuromusculoskeletal system and the effects thereof or interferences therewith by the utilization of all recognized and accepted chiropractic diagnostic procedures; and the employment of all rational therapeutic measures as taught in approved chiropractic colleges.
Except for inclusion of the term “minor surgery” in Oregon’s definition, this description might well have defined the chiropractic scope of practice for many jurisdictions.
In part 3, we see that “chiropractic physician” means a person licensed by ORS 677.060, 684.025, 684.100, 684.155 or 688.010 to 688.201 and this section as an attending physician.1
Advanced Chiropractic Procedures: Nonprescription drugs
Part 4 brings us to the understanding that the term “drugs” means all medicines and preparations and all substances, except over-the-counter (OTC) nonprescription substances, food, water, and nutritional supplements taken orally, used or intended to be used for the diagnosis, cure, treatment, mitigation or prevention of diseases or abnormalities of humans, which are recognized in the latest editions of the official United States Pharmacopoeia, official Homeopathic Pharmacopoeia, official National Formulary, or any supplement to any of them or otherwise established as drugs. Here, this section patently ascribes the use of OTC medications to be within the DC’s scope of practice.2
(3) This chapter does not prohibit a person licensed under ORS 684.054 from accepting a referral from a practitioner licensed under ORS chapter 686. The care rendered because of the referral must be in writing and in accordance with ORS 686.040...
Emergency Oxygen Administration
(4)...and only as prescribed and diagnosed by a licensee under ORS chapter 686. The applicable standard of care is established under ORS chapter 686. (4)(a) This chapter does not prevent a person licensed under ORS 684.054 from providing emergency first aid, including administering emergency oxygen, (b) A person may not administer emergency oxygen unless the person has received training in the administration of oxygen. The State Board of Chiropractic Examiners shall adopt rules that establish training requirements, (c) As used in this subsection, “emergency oxygen” means oxygen delivered at a minimum flow rate for a specified period as determined and regulated by the United States Food and Drug Administration. [F ormerly 684.115; 1987 c.726 §4; 1997 c.264 §5; 2007 c.618 §2] 684.030
Emergency oxygen is used primarily to correct mild to moderate hypoxia and reduce the work of the heart.3
Emergency oxygen should be considered for administration when:
An adult is breathing fewer than 12 or more than 20 breaths per minute.
• A child is breathing fewer than 15 or more than 30 breaths per minute.
• An infant is breathing fewer than 25 or more than 50 breaths per minute.
• Any person is not breathing at all.
Emergency oxygen units are available without prescription for first-aid use, provided they contain at least a 15-minute supply of oxygen and are designed to deliver a preset flow rate of at least 6 LPM. The type of system used (variable or fixed flow) impacts the type of delivery devices that can be used and the concentration of oxygen that can be delivered to a victim. Variable-flow-rate oxygen systems allow the rescuer to vary the flow of oxygen. This type of system must be assembled and the appropriate flow rate selected. Fixed-flow-rate oxygen systems include a regulator set at a fixed-flow rate, usually 15 LPM, or may have a dual-flow (high/low) setting. The cylinder, regulator, and delivery device are already connected.4
Additionally, chiropractic physicians shall observe and be subject to all state and municipal regulations relating to the control of contagious and infectious diseases, sign reports of live birth and death, and report all matters pertaining to public health laws to the proper health officers the same as other practitioners. [Amended by 2013 c.366 §78] 684.035 Chapter not applicable to other methods of healing.
Chiropractic Minor Surgery and Proctology
Part (5) interprets “minor surgery” to mean the use of electrical or other methods for the surgical repair and care incident thereto of superficial lacerations and abrasions, benign superficial lesions, and the removal of foreign bodies located in the superficial structures; and the use of antiseptics and local anesthetics in connection therewith. [Amended by 1953 c. 541 §2; 1975 c.492 §1; 1987 c.726 §1; 1995 c.493 §1; 1997 c.264 §4; 2005 c.627 §17; 2007 c.618 §1; 2009 c.697 §9; 2009 c.756 §49]
684.025 Application of chapter; rules.
1. This chapter does not prevent a person licensed under ORS 684.054 from the administration of the anesthetics or antiseptics authorized in ORS 684.010 or the use of radiopaque substances administered by mouth or rectum necessary for Roentgen diagnostic purposes.
CHANGES TO RULE: 811-015-0030 provide that a Minor Surgery and Proctology Review Committee will may be appointed by the Board of Examiners. Members will serve at the pleasure of the Board. The committee may review the applications and rotation plans. The committee will review the results of the rotation and make a recommendation to the Board regarding the certification. The committee may advise the Board on all issues related to minor surgery and proctology.
2. A chiropractic physician who wishes to practice minor surgery and/or proctology must apply to, and receive from, the Board a certification of special competency in minor surgery and/or proctology. To receive and maintain certification, the applicant must fulfill the following requirements:
• Give written application to the Board of Chiropractic Examiners to practice minor surgery and/or proctology.
• Provide evidence of completion of 36 hours of undergraduate or postgraduate course work in minor surgery and/or proctology.
• Propose a plan to complete a rotation for practical experience in not less than 25 minor surgery/proctology cases.
• The rotation must include no less than five cases where all aspects of the cases are performed solely by the chiropractic physician and observed by the supervising licensed physician.
• The remainder of the rotation shall consist of cases where the chiropractic physician observes and/or assists.
• Adequate documentation of the chiropractic physician’s participation in all cases is required on forms provided by, and returned to, the board signed by the supervising licensed physician.
• The rotation is to be completed within one year.
• Twelve hours of continuing education (seminar, course, or instruction) related to minor surgery and/ or proctology are to be completed every three years.
• Optionally, in lieu of eight hours of the continuing education requirement, a chiropractic physician may document performance or observation of 12 minor surgery/proctology procedures every three years.
• Reasonable documentation of the procedure or observation is a copy of the patient schedule and/or patient billing or other patient record with the patient’s name redacted, which indicates the type of procedure and date performed.
3. A chiropractic physician who is also licensed in Oregon as a doctor of naturopathy may make written application to practice minor surgery and proctology. The board may approve the application if the chiropractic physician can demonstrate their naturopathic training and experience is equivalent to that required under section (2).5 Chiropractic Obstetrics • Natural Childbirth • Midwifery
4. A chiropractic physician licensed in Oregon who wishes to practice natural childbirth and obstetrics must apply to and receive from the board a certification of special competency in natural childbirth/obstetrics. To receive and maintain certification, the applicant must fulfill the following requirements:
• Successfully complete at least 200 hours of direct instruction hours at an approved chiropractic, naturopathic, medical, osteopathic college, or hospital in obstetrics and furnish a signed log showing evidence that subsections (b) and (c) of this section have been completed under the direct supervision of a licensed practitioner with specialty training in obstetrics and/ or natural childbirth.
Take part in the care of 50 women in both the prenatal (including obstetrics intakes) and postnatal periods.
Observe and assist in the intrapartum care and delivery of 50 natural childbirths in a hospital or alternative birth setting, under the supervision of a licensed practitioner with specialty training in page 11 of 14 obstetrics and/or natural childbirth. A labor and delivery that starts under the care of someone licensed to assist in childbirth and includes hospitalization shall count as a birth.
Pass a certification exam in obstetrics and gynecology given by or approved by the board.
Submit annually 15 hours of board-approved continuing education in obstetrics. Seven of the 15 hours in obstetrics may be used to satisfy OAR 811015-0025(4).
Every other year, an approved class in neonatal resuscitation shall be part of this continuing education requirement.
5. Licensing action by the board under ORS 684 shall be deemed to have an equal effect upon a certificate of special competency issued the practitioner, unless specifically provided otherwise in the board action. However, under subsection (a), when the subject of a disciplinary proceeding relates specifically to the practice of minor surgery, proctology, or natural childbirth/obstetrics by a licensee who possesses a certificate of special competency, the license action may, in lieu of affecting the entire scope of the licensee’s practice, suspend, revoke, or curtail only the practitioner’s authority under the certificate of special competency. Under subsection (b), to address emergency or other circumstances, which indicate the use of substances or procedures not authorized for use by chiropractic physicians, a plan to access these must be developed in a timely fashion and entered in the patient’s chart.6
Section 6, notwithstanding section 4, provides that a chiropractic physician may obtain a license as a direct entry midwife from the Board of Direct Entry Midwifery. Any chiropractic physician licensed as a naturopathic physician and certified in natural childbirth by the Oregon Board of Naturopathic Examiners may also practice natural childbirth/obstetrics as a chiropractic physician to the extent allowed by ORS 684. Statutory/Other Authority: ORS 684 Statutes.
Additional Advanced Practice Allocations
A wide birth of various procedures, methods and substances has been permitted including:
• Ordering a CPAP machine and/or a sleep study
• Administering an EpiPen to a person who is suffering from anaphylactic shock when unable to inject the EpiPen personally
• The MD peel micro-abrasion device and procedure
• Treatment of allergies, ordering RAST tests, and injecting intradermal substances for allergy testing
• Auriculotherapy
• Ordering or performing biofeedback
• Providing breast thermography imaging, following verbal communication with the patient and a written informed consent form
• Colonic therapy
• Cupping
• Electrolysis (i.e., removal of hair) is a minor surgical procedure as is treating hemorrhoids with electrotherapy
• Paraspinal surface electrode EMG testing and NCV testing
• Fissurectomy
• Low-level laser and light therapy for NMS conditions
• Manipulation under anesthesia
• Topical uses of colloidal silver, occasional use of intranasal argyrol applications for sinusitis, silver allowed in multimineral formulations, including small doses of colloidal silver below the allowable EPA limits
• Fluori-methane spray may be used as a topical anesthetic in minor surgery only
• Order pulmonary studies
• Use of OTC salicylates and lidocaine substances in phonoor iontophoresis
• Use of OTC lidocaine for nasal specifics or coccyx adjustments, with patient’s informed consent prior to treatment
• Use of oriental herbs
• Hyperbaric oxygen therapy
• Pap smears.5
Prohibited Practices.
No matter how broad a scope of practice may be, under 684.015, prohibitions do exist, delineated as:
• No person shall practice or attempt to practice chiropractic by buying, selling, or fraudulently obtaining a diploma or license to practice chiropractic.
• The display of chiropractic titles fraudulently.
• No person practicing under this chapter shall administer or write prescriptions for, or dispense drugs, practice optometry or naturopathic medicine, or do major surgery. [Formerly 684.110] 684.020
• License required to practice chiropractic shall not apply to a student of chiropractic engaging in clinical studies during the period of the student’s enrollment in an institution authorized to confer a doctoral degree in chiropractic.
• Neither section ORS 684.025 nor ORS 684.010 authorizes the administration of any substance by the penetration of the skin or mucous membrane of the human body for a therapeutic purpose.
684.100: Further under section 1, the State Board of Chiropractic Examiners may refuse to grant a license to any applicant or may discipline a person upon any of the following grounds:
• Fraud or misrepresentation.
• The practice of chiropractic under a false or assumed name.
• The impersonation of another practitioner of like or different name.
• A conviction of a felony or misdemeanor involving moral turpitude. A copy of the record of conviction, certified to by the clerk of the court entering the conviction, is conclusive evidence of the conviction.
• Impairment as defined in ORS 676.303.
• Unprofessional or dishonorable conduct, including but not limited to:
Any conduct or practice contrary to recognized standard of ethics of the chiropractic profession or any conduct or practice that does or might constitute a danger to the health or safety of a patient or the public or any conduct, practice, or condition that does or might adversely affect a physician’s ability safely and skillfully to practice chiropractic.
• Willful ordering or performance of unnecessary laboratory tests or studies; administration of unnecessary treatment; failure to obtain consultations or perform referrals when failing to do so is not consistent with the standard of care; or otherwise ordering or performing any chiropractic service, X-ray, or treatment that is contrary to recognized standards of chiropractic professional practice.8
Conclusion
In summary, we have seen that advanced chiropractic practice originated in Oregon and includes minor surgery, the use of anesthetics and antiseptics, proprietary (OTC) medications, proctology, obstetrics (natural childbirth, midwifery), the signing of birth and death certificates, providing emergency first aid, including administering emergency oxygen, and the use of radiopaque substances, as well as many other vouchsafed privileges.
As always, the board’s opinion will trump any interpretative errors the authors may have inadvertently arrived upon.
References
1. https://www.njchiropractors.com aws ANJC PUBLIC whatis
2. https://www.fda.gov > drugs > buying-using-medicine-safely > understandin...
3. What is Emergency Oxygen? - EMS Safety Services • www. emssafetyservices.com > wp-content > uploads > 2014 06 > Emergenc...
4. https://www. redcross. org content dam redcross atg PDFs AdministeringEmergencyOxygenFactandSkill.pdf
5. https://www.oregon.gov/OBCE/puhlications/Guide to PolicyPractice 031518.pdf
6. Permanent Administrative Order BCE 9-2019 Chapter 811 Board Of Chiropractic Examiners Filed 07/31 2019 3:07 Pm Archives Division Secretary Of State & Legislative Counsel Filing Caption: Minor Corrections, GrammaticalBoard Will Continue Review Of Ca Rule For Training And Ce Requirements Effective Date: 07/31 2019 Agency Approved Date: 07/25/2019 Contact: Kelly Beringer 503-373-1573 [email protected] 530 Center St NE Suite 620 Salem, OR 97301. Filed By: Kelly Beringer Rules Coordinator • https://www.oregon.gov/OBCE/Rules/BCE 9-2019TrackedChanges.pdf
7. https://www.oregon.gov > oha > HLO > Pages > Board-DirectEntry-Mi dw...
8. Chapter 684—Chiropractors - Oregon.gov • https://www.oregon.gov > DC Applicant > Statutes and Rules March 2018
Dr. Laurence Hicks is a Board certified Osteopathic Family Physician and a Chiropractic physician nutrition specialist. He practices full time, and has, for over 35 years. As an avid teacher in medicine, Dr. Hicks has trained many medical, chiropractic PA and NP students and practitioners. He is currently the instructor of the Clinical Nutrition Certification modules which lead to an Advanced practice licensure for qualified Idaho chiropractic physicians. Tel: 208-733444.
Geoffrey N. Hicks is a Family Nurse Practitioner (FNP) and a co-owner of the Falls Centre for Functional Medicine, PLLC. He is certified in family practice and working on certification in pain management. Geoffrey is interested in both conventional and complementary approaches to health care. He holds a MSN as a FNP from Samford University and a HMD form KCNH.
Dr. Booth is an honor graduate of the University of Western States • Western States Chiropractic College in 1995. Over the last 24 years he has amassed a number of chiropractic experiences and techniques. He is a recent graduate of the Certified Clinical Nutrition advanced practice training program in Idaho and is currently eligible for licensure.
