Replacing EMS with nursing revisited

[BluesMedic]

I just realized after my last post, I never really addressed the initial question.

I do not believe that it is a viable option to use new, just-graduated nurses on an ambulance. Just as I believe that it is not viable to use new, just graduated paramedics to work as a nurse.

Anyone working in either field knows that school can only teach you so much. There is a large amount of "on the job training" in both fields. Both are obviously in the health care field but are very different in application even when you factor in pre-hospital critical care transport nurses and paramedics. Thus with current education practices, in my opinion, this cannot work and should not be allowed.

Furthermore, in my state there has been recent debate on allowing RN's with critical care experience to "challange" the state EMT-Paramedic test. It was shut down by the EMS community. I do not claim exclusive knowledge on the debate, but from what I can gather it was basically said that if an RN with critical care experience can challenge the medic test, then a medic with the same experience should be allowed to challenge the RN test. Of course, this was not allowed and so the debate continues. Until next time...

 

[uhbt420]

rather than transitioning to nurses, cant we move towards higher level degrees for paramedicine? nurses are trained to operate in a controlled setting and would need to be retrained from the ground up after graduating nursing school.

i dont say this out of ignorance, i've discussed this with a lot of medics who also work as RNs. tehy tell me its two different worlds.

even the netherlands is moving away from nursing-based ems to paramedic-based

not that US ems will ever transition to nurses anyway.

 

[Journey]

rather than transitioning to nurses, cant we move towards higher level degrees for paramedicine? nurses are trained to operate in a controlled setting and would need to be retrained from the ground up after graduating nursing school.

i dont say this out of ignorance, i've discussed this with a lot of medics who also work as RNs. tehy tell me its two different worlds.

even the netherlands is moving away from nursing-based ems to paramedic-based

not that US ems will ever transition to nurses anyway.

Those are interesting comments considering you are from OC, California. Where do the Paramedics work with RNs? I have not seen any Paramedics working in CA beyond an ER tech which might give them a different opinion of nurses since that makes RNs their direct supervisors. RNs are also still on the CCT trucks and Flight teams throughout most of California. The Paramedic scope of practice in California is very limited to where ED RNs must sometimes ride in the trucks to get from one hospital (closest) to another (more appropriate) on emergent calls involving strokes, MIs and trauma.

No, an RN would not have to be trained from the ground up. The could take an EMT course for the basic first-aid but they have college level Pharmacology, Anatomy and Physiology, Microbiology and Pathophysiology. They have a minimun of 2 years of college with 1000 - 1500 hours of clinicals which involves many patient contacts and ongoing assessments. They also get enough practice for their basic nursing skills everyday during their two years of clinicals. They are not starting from the zero to hero such as what some Paramedic schools graduate.

I also had not heard that the Netherlands was moving away from a nurse based EMS system because the nurses were not good at what they do. If the Netherlands were to go to a Paramedic system due to economic reasons, I would think they would not want something like the U.S. has since while that would be cheap labor, it could also cheapen the quality of care by their established standards.

If you have something that states otherwise about California or the Netherlands, please provide it. As I have stated before I was corrected about Oregon after I gave out wrong or misleading information.

 

[Journey]

Furthermore, in my state there has been recent debate on allowing RN's with critical care experience to "challange" the state EMT-Paramedic test. It was shut down by the EMS community. I do not claim exclusive knowledge on the debate, but from what I can gather it was basically said that if an RN with critical care experience can challenge the medic test, then a medic with the same experience should be allowed to challenge the RN test. Of course, this was not allowed and so the debate continues. Until next time...

I believe there is also the issue in NC about allowing the Paramedic to work under the title of Nurse Aide II by testing out or without completing the course.

There are several basic nursing duties for which a Paramedic has not rec'd much training such as for working with gastric tubes or IV pumps and foleys or other urinary systems. Just working CCT or Flight will also not give them much opportunity to perform all the basic nursing skills and assessments that must be done to provide quality ongoing care.

No nurse wants to precept someone licensed as an RN who does not know how to insert a foley, do a swallow eval, work with all the many different vascular access devices, be familiar with all the many different medications that are not emergent, insulin administration along with diet concerns and education to the patient, figure out all the appropriate preparations of various meds and routes (clog up a g-tube and find out what trouble that can cause), do skin integrity exams and ongoing assessment prevention, perform bowel programs and teach family members, artificial airway maintenance for short and long term, be able to order and analyze lab data to correct by protocol or know critical values, be familiar with specimen collection, know various sterile and aseptic techniques, know the various types of wound dressing orders, deal with many types of post op surgical drains, chest tube maintenance and dressing, be familiar with all the other health care team members and what they do and work with multiple patients at one time. I didn't name each skill the RN does nor did I get into any of the critical care duties. This listing was only for med-surg RNs and it is still only a very small sampling of what an RN in that area does each day. The preceptor would also assume the Paramedic had college level classes for Anatomy and Physiology, Pharmacology and Pathophysiology. I can not see how it would go very well if the preceptor has to dumb down or explain in detail from square one every process due to the lack of any of these courses.

This is an example of the med-surg credentialing exam. You will notice it is not about skills or general med knowledge but more specific to everyday care of a patient on that unit. The skills and general knowledge should already have been covered on the NCLEX.
http://www.nursecredentialing.org/Documents/Certification/TestContentOutlines/MedSurgNurseTCO.aspx

This is the CCRN application book for Critical Care certification. You can look through it and see how extensive the knowledge of an ICU RN can be.
http://www.aacn.org/WD/Certifications/Docs/CertExamHandbook.pdf

The NCLEX exam also can present a problem since the requirement is graduation from an accredited (NLNAC or CCNE) program. Not all Paramedic programs are even accredited by a nationally recognized association nor are all Paramedic programs the same within a state.

But, I do agree that RNs should probably not be obtaining a Paramedic cert unless it is to be used just as an extra knowledge cert and not for license. They should have their own credentialing requirements under the BON to prevent any conflicts when it comes to what they might be held accountable for.

 

[Shishkabob]

There are several basic nursing duties for which a Paramedic has not rec'd much training such as for working with gastric tubes or IV pumps and foleys

All standard practices for Paramedics with my agency. Exception? Sure. But let's not group all together when that just is not true.


There will always be someone better--- a better medic than a nurse and a better nurse than a medic. Thinking otherwise makes you (generic you) in to a fool.

 

[Journey]

There will always be someone better--- a better medic than a nurse and a better nurse than a medic. Thinking otherwise makes you (generic you) in to a fool.

The topic I addressed was about the Nurse Aide II title and the Paramedic in North Carolina.

All standard practices for Paramedics with my agency. Exception? Sure. But let's not group all together when that just is not true.

Are all the different gastric tubes, IV access device and pumps covered in just the 600 hours required by the State of Texas to be a Paramedic? If not how many additional hours of training did your company provide?

Foleys should be standard. How many insertions on both men and women are you required to do? How many have you done? How many different types and sizes do you carry on your truck?

Which gastric tubes are you trained for? I would hope that Paramedics throughout the country are trained for inserting one to decompress the stomach but I have found that is not always true either.

Do you administer medications through the gastric tubes? NGT? What about pegs? Can you tell the difference between Jejunostomy and Gastrosomy tubes? Do you vent the tubes?

Are you trained to do foleys and work with g or j tubes on kids also? If so, how many to establish competency? Do you keep the parents with the patient when establishing a foley on a child?

I'm not trying to be rude but rather would like to know what training is done initially and ongoing to maintain proficiency. These same questions are also asked to any other health care provider who works with these devices.

Regardless of what your title is, you should know what you are doing and with established competency. Just because you can does not always mean you should.

 

[Shishkabob]

Are all the different gastric tubes, IV access device and pumps covered in just the 600 hours required by the State of Texas to be a Paramedic?

Yes, just because a minimum exist means every single school does just the minimum. You're right, I have no education at all and have to go back to my medic book every time I post on this forum, and just paraphrase.

And just because someone has "RN" doesn't mean that they know about every different type of insturment used in the medical field as well... heck how many RNs not involved in the airway know what a murphey's eye is? Difference between a bougie and stylet?

Just because you can does not always mean you should.

Right, because I push the 70 different drugs on my truck just because I have them available to me, just like every other Paramedic. I'm sure Vene does. Heck, I'm sure JPIN pushes the 6 drugs he has access to on the ambulance too, right? Obviously my "600 hours of education" never taught me to critically think. That's what you're getting at, right? That I lack even a percentage of the critical thinking skills of someone with "3 times as much clinical experience as I do didactic"?



I'm done answering your questions until you quit dodging mine about your credentials, education and certifications.

 

[Journey]

Yes, just because a minimum exist means every single school does just the minimum. You're right, I have no education at all and have to go back to my medic book every time I post on this forum, and just paraphrase.



Right, because I push the 70 different drugs on my truck just because I have them available to me.

I'm done answering your questions until you quit dodging mine about your credentials, education and certifications.

You've added 10 more drugs to make it a total of 70 (to push) that you carry on your truck in just a couple of days. Which ones did you just add?

Linuss, if other health care professionals must show competency and answer those same questions, why can't you when you have stated they are in your training and scope of practice? You seem to be making excuses to avoid answering legitimate questions. If you make such statements about your training, protocols and meds, you should be able to answer and back up what you claim to do. I was also referencing the state of TX requirements.
Instead of just answering a few simple questions about how things are done in your area, you take it vey personally and make off the wall statement about "having no education".

I also have not bragged about what I can or can not do but am merely referencing information which can be easily looked up on different states' websites.

 

[Shishkabob]

Oh yes, darn me for making a generic point rather than giving specifics on the drugs I carry. That obviously defeats the whole purpose of the point I was trying to make, doesn't it?


Correct, you haven't bragged, but you have claimed knowledge. Now, is this knowledge strictly from Google, or do you have actual education to back it up? I'm even counting a Boy Scout badge on first aid as education. Not saying it's BAD to use Google and medical references, as hey references are great in discussion, but as you might know, having credentials tends to add credence to what you state. Especially if you call out someone else's education.

Instead of just answering a few simple questions about how things are done in your area, you take it vey personally and make off the wall statement about "having no education".

Yup... you call out that I've not answered a "few simple questions" but you've continually refused to answer ONE simple question. Makes sense.

 

[Journey]

And just because someone has "RN" doesn't mean that they know about every different type of insturment used in the medical field as well... heck how many RNs not involved in the airway know what a murphey's eye is? Difference between a bougie and stylet?

Linuss, as several here have mentioned, nurses can specialize. A nurse specializing in Onocology probably would not know the details of an ETT. Does that make them less of a nurse?

However, a nurse in the ICU or ED may know all the parts, have done the set up, given all the meds and may even have done the intubation especially if they were on a transport team.

Right, because I push the 70 different drugs on my truck just because I have them available to me, just like every other Paramedic. I'm sure Vene does. Heck, I'm sure JPIN pushes the 6 drugs he has access to on the ambulance too, right? Obviously my "600 hours of education" never taught me to critically think. That's what you're getting at, right? That I lack even a percentage of the critical thinking skills of someone with "3 times as much clinical experience as I do didactic"?

Not every Paramedic will have 70 drugs on their truck. You just stated JPIN has only 6 drugs to push. Each state is different. Each county is different. Each agency is different. Each medical director is different.

I did not even mention you in my posts so I did not attack you personally in any way and wasn't even thinking about you when I typed the last few posts.

Correct, you haven't bragged, but you have claimed knowledge.

I have posted things which can be easily referenced and some of which is common knowledge. Some have made claims the public knows nothing but then when a member of the public does show knowledge, you blast them with insults.

Yup... you call out that I've not answered a "few simple questions" but you've continually refused to answer ONE simple question. Makes sense.

The questions about foleys and g-tubes were not personal. They were about how the education and training is provided to you in your area for extra skills.

 

[uhbt420]

Those are interesting comments considering you are from OC, California. Where do the Paramedics work with RNs? I have not seen any Paramedics working in CA beyond an ER tech which might give them a different opinion of nurses since that makes RNs their direct supervisors. RNs are also still on the CCT trucks and Flight teams throughout most of California. The Paramedic scope of practice in California is very limited to where ED RNs must sometimes ride in the trucks to get from one hospital (closest) to another (more appropriate) on emergent calls involving strokes, MIs and trauma.

i was referring to medics who go to nursing school and work as nurses, mostly due to pay and avoiding the fire service.

They are not starting from the zero to hero such as what some Paramedic schools graduate.

Most medics come out with about about 700 hours of clinicals if i recall correctly, not as much as nurses but no minor amount either

I also had not heard that the Netherlands was moving away from a nurse based EMS system because the nurses were not good at what they do. If the Netherlands were to go to a Paramedic system due to economic reasons, I would think they would not want something like the U.S. has since while that would be cheap labor, it could also cheapen the quality of care by their established standards.

don't have hard info on it, just what i've heard.

if medics were required to have four-year degrees we wouldn't even have people proposing to put RNs on ambulances. why not improve medic education instead of taking a clinical provider and thrusting them into the field

 

[Veneficus]

if medics were required to have four-year degrees we wouldn't even have people proposing to put RNs on ambulances. why not improve medic education instead of taking a clinical provider and thrusting them into the field

Many have tried to increase paramedic education over my whole career. None have succeeded. There is simply too much resistance. I have in the past suggested this because nursing has already caught on that branching and higher ed is the key.

I am not a nurse, I was never nor will ever be a nurse, however, I do give credit where it is due, and seeing what Emergency and critical care nurses can do, I can honestly say even if they had no EMS training I would trust them (all but a handful of exceptions)to show up and figure something out on me or my family.

I have the same confidence in only about 10% of the medics I have seen perform. In fact, I can name all of them.

But I figure if that holds true throughout all of EMS, of which I have seen quite a bit, then it would simply require less energy and effort to bring nurses up to speed.

I don't think that is a good thing, but nobody here has offered any decisive argument why all the time, money, and effort should be used to drag up the rank and file medics who actually don't want or think they need an education.

It is near impossible to teach people that don't want to learn or put forth effort into learing.

 

[Shishkabob]

TO be fair, how long did it take for nursing to get to this point? Over one hundred years, from conception to now? And how many obstacles and resisting personnel did they have?


Paramedicine is still in its infancy. If it can be done in the UK, AU, NZ, it can still be done here. Will it take work? Heck yeah. More than it should have originally? Sadly, yes. But as you baby-boomers retire, more from my generation will get in control in places that can actually make a difference....

And many of the people resisiting are the older ones stating "This is how we always did it", not the new ones going "Why do we do it like this?"





Now.. my generation getting in control of the presidency and courts? We're screwed there...

 

[Veneficus]

TO be fair, how long did it take for nursing to get to this point? Over one hundred years, from conception to now? And how many obstacles and resisting personnel did they have?

While that is true, it seems they really made some major gains in a small period of that time.

Paramedicine is still in its infancy.

unfortnately with the amount of healthcare professions that have been founded years after EMS that quickly embraced education, there is the possibility that EMS may actually be going backwards.

From the anecdotal perspective, my EMT class was about 3-4 times as the current requirement. We had to demonstrate competence to physicians who wanted to see understanding.

There has been considerable movement for skills based learning programs, and the very textbooks are declining in complexity because of pressures on the publishers. If not instructors, who is applying that pressure?

If it can be done in the UK, AU, NZ, it can still be done here. Will it take work? Heck yeah. More than it should have originally? Sadly, yes.

I am not so optimistic, there is a large percentage of people in the US who have been paid disproportionately high compared to their education and service provided. This population still believes that should be the case.

The second major hurdle is that education is not actually valued in the US. An educated society benefits society, look at how primary and secondary begs for money, often to be turned down. I won't start on the teachers' unions, but paying people for years in service rather than results seems counter intuitive to me.

But as you baby-boomers retire, more from my generation will get in control in places that can actually make a difference.....

We can only hope, but don't forget many people emulate their first teachers, look who a lot of those teachers are today.

And many of the people resisiting are the older ones stating "This is how we always did it", not the new ones going "Why do we do it like this?"

Again something we can hope happens, but too little too late?

Now.. my generation getting in control of the presidency and courts? We're screwed there...

Not sure if it can get much worse than it has been over the last decade.

 

[Journey]

TO be fair, how long did it take for nursing to get to this point? Over one hundred years, from conception to now? And how many obstacles and resisting personnel did they have?

To be fair, nursing had some major obstacles to overcome in the last 100 years since nursing has been largely made up of women.

Women did not get the right to vote until 1920. They still had very little representation on legislative issues pertaining to them for years after that.

Education for women was not prominent until after WWII and even then there was a larger focus on family rather than the working mother.

The Vietnam War was a turning point for nurses and that is when advancing the education got a serious look. Nursing was finally able to take the step to becoming a profession. This was also the same time medics started getting recognition. The other professions that have come out of all the technological advances took note of the successes and failures of nursing. This helped them get to where they needed to be quickly to be a profession. EMS had all the opportunities and then some but just didn't run with it. Maybe it was because EMS alienated itself and did not view itself as being part of health care the same as other professions did. As some have stated here, they have some very harsh opinions of those working in a hospital and they want to be different than what they perceive medical professionals to be especially with all the talk against education and siting examples of a few educated idiots to prove their point. The concept of education for future growth and benefits can not be argued against such logic.

 

[SerumK]

Vene... I always wanted EMS more, but the lack of education depth and career longevity/pay kept me from choosing it as a primary life long career. So I chose nursing because it had the things EMS was missing.

So, if you could please have this EMS-Nurse implemented nationally by May 2012, I'll buy you a case of your favorite wine/liqour/beer.

 

[Phlipper]

You're expecting people who can't grasp why 110 hours of education is not enough to provide adequate care to think long term rather than their intial knee jerk reaction against more education.

There are many people who feerl the educational requirements for a Paramedic as is, is acceptable. It's worked thus far, why should you improve it? They'd rather whine and get more money for nothing.

From my short time in the job, this seems to be dead on, to me. And that's a shame, too.

Until those of us in EMS become willing to understand our shortcomings as practitioners, admit where we're lacking as health care PROFESSIONALS, and support (rather than fight) the calls for increased education and national licensing we will never move forward and will always be considered glorified ambulance drivers. And we will continue to be regarded as exactly that by our peer professions and paid accordingly. It's on us.

 

[Veneficus]

Vene... I always wanted EMS more, but the lack of education depth and career longevity/pay kept me from choosing it as a primary life long career. So I chose nursing because it had the things EMS was missing.

So, if you could please have this EMS-Nurse implemented nationally by May 2012, I'll buy you a case of your favorite wine/liqour/beer.

Move to PA or another state that has prehospital RNs as soon as you are done with school.

 

[clibb]

Vene... I always wanted EMS more, but the lack of education depth and career longevity/pay kept me from choosing it as a primary life long career. So I chose nursing because it had the things EMS was missing.

So, if you could please have this EMS-Nurse implemented nationally by May 2012, I'll buy you a case of your favorite wine/liqour/beer.

You'll buy him a case of Opus One? You are so nice!

 

[medicRob]

I'm not saying this to be ugly, but it must be said. If I am working any job ambulance or otherwise where my official title is, "Registered Nurse" as opposed to "Paramedic", under no circumstance would I accept less than $25 an hour, which is almost laughable compared to what we as RN's can make, especially with credentials in emergency or critical care and equivalent experience.

As a Paramedic, $15 - $20 an hour sounds about right.

This is one thing to consider when talking about nurses replacing paramedics on the ambulance. The highest paying service I can think of pays $23 an hour for Critical Care Paramedic (which requires 2 years of experience in TN as a paramedic before being able to take the class, so about 3 years experience is the average). I know of no ambulance service that is going to pay anyone on their rigs anything above $26 an hour, especially not the $29+ an hour most RNs in emergency and critical care in metropolitan areas are accustomed too.