# Medic Ambulance ALS-RN



## EMT Loris (Oct 1, 2020)

Does anybody here know about or have experience with the ALS RN program at Medic Ambulance in Solano County, California? I haven't really heard of anything like it anywhere else in California, and it seems like they hire new grad nurses as well which seems very...questionable.


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## CCCSD (Oct 1, 2020)

Why? They hire new EMTs..


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## DesertMedic66 (Oct 1, 2020)

CCCSD said:


> Why? They hire new EMTs..


Because the normal for CCT RNs is 2+ years as a RN typically in the ER/ICU.


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## CCCSD (Oct 1, 2020)

So, they can train. If they’re doing it, they’re probably following regulatory rules.


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## DesertMedic66 (Oct 2, 2020)

CCCSD said:


> So, they can train. If they’re doing it, they’re probably following regulatory rules.


There aren’t many regulations when it comes to CCT RNs. The main thing is that for CCT the RN usually the only advanced care provider in the ambulance and must feel comfortable with operating a ventilator, cardiac monitor, IV pumps, and other devices all at the same time. Which is not something most new grads are able to do or at least do competently.


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## supreme (Dec 11, 2020)

All the answers can be found with a simple google search



			https://www.solanocounty.com/civicax/filebank/blobdload.aspx?BlobID=26688
		


EMT Loris DesertMedic66 CCCSD


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## jgmedic (Dec 11, 2020)

supreme said:


> All the answers can be found with a simple google search
> 
> 
> 
> ...


Literally answered none of the questions or concerns posed.


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## Akulahawk (Dec 12, 2020)

EMT Loris said:


> Does anybody here know about or have experience with the ALS RN program at Medic Ambulance in Solano County, California? I haven't really heard of anything like it anywhere else in California, and it seems like they hire new grad nurses as well which seems very...questionable.


While I'm not exactly familiar with their ALS RN program, it's not hard to figure out what this program is. It's not going to be putting new grad RNs in a CCT role. This is basically going to be like putting a new grad RN through an orientation program with the end result being something like a Paramedic with a wider scope of practice. Being that the EMS Agency in Solano doesn't accredit RNs for prehospital work, it's probably more like an IFT-only job, basically a "CCT-Lite" kind of deal, stable-ish patients, out of Paramedic scope meds or meds on a pump, that sort of thing. Just looking over their EMS agreements, it appears that this is exactly what they're doing. CCT doesn't really have much in the way of regulations and whatnot, other than that a CCT-RN must have sufficient knowledge, skills, and ability to run a vent, utilize various patient monitors, and administer medications. That's usually gained through experience working in an ED or ICU for at least 2 years. In short, a CCT-RN can do all the things that an ALS-RN does, but the reverse isn't true, and therefore a new grad most likely wouldn't be hired into a CCT-RN position.


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## Peak (Dec 12, 2020)

To play a bit of the devils advocate the field is nowhere for a new grad nurse to start to practice.

The goal of nursing school is to develop a broad base of understanding so that they can then safely and efficaciously develop skills and knowledge to care for more specialized patients. This is best learned in a supportive comprehensive environment (nursing residency programs, extensive orientation, and so on).

To be quite honest the dozen or so times a year I’m put in the position to fly or ride in on the bus I know that my skills have shifted significantly away from the skills of a 911 medic. I ride to provide specialized care (either for specialized equipment or complex specialty patients). The skills to provide fast and specific EMS care without getting distracted by the detail of hospital or clinic medicine is  quite hard once you are accustomed to the time and detail allotted in the ED, unit, or other care areas.

If you are considering nursing school as a way to quickly enter into ALS EMS care I would recommend against it. These are two very different set of skills. Also you will have difficulty getting back into traditional nursing roles if it has been several years and you don’t have a strong history of acute care nursing (read as hospital care).


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## supreme (Dec 12, 2020)

jgmedic said:


> Literally answered none of the questions or concerns posed.


Did you even click the link?

It breaks down the scope of practice for each role in a IFT setting


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## supreme (Dec 12, 2020)

Akulahawk said:


> it's probably more like an IFT-only job, basically a "CCT-Lite" kind of deal, stable-ish patients, out of Paramedic scope meds or meds on a pump, that sort of thing. Just looking over their EMS agreements, it appears that this is exactly what they're doing.



100%, seems to be the equivalent of CCT-P in other counties.

see Alameda county’s CCP for comparison


			http://ems.acgov.org/ems-assets/docs/Documents-Forms/CCP%20Program%20Standards%20December%2011%202015.pdf


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## jgmedic (Dec 12, 2020)

supreme said:


> Did you even click the link?
> 
> It breaks down the scope of practice for each role in a IFT setting


I did. And that second link you posted to the AlCo policy was great, the first one was simply the form they use to request a transport, not a CCT policy or scope of practice. So when you come in here with a let me google that for you attitude, sorry.


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## Akulahawk (Dec 12, 2020)

Peak said:


> To play a bit of the devils advocate the field is nowhere for a new grad nurse to start to practice.
> 
> The goal of nursing school is to develop a broad base of understanding so that they can then safely and efficaciously develop skills and knowledge to care for more specialized patients. This is best learned in a supportive comprehensive environment (nursing residency programs, extensive orientation, and so on).
> 
> ...


I'm very much in agreement. This isn't a good way to get into ALS field care. From what I can tell, this is basically a way to put an ACLS-trained RN (even if new grad) in the back of an ambulance so you can take CCT-P level patients without having to train-up some Paramedics to a CCT-P level. It also appears that the ALS-RN trucks aren't used in field care, just IFT that's out of scope of a Paramedic but doesn't need quite the specialty knowledge of a CCT-RN. 

I have read a review or two that claim that the ALS-RN is only provided a few days of orientation before being turned loose. I'm not comfortable with that at all. Paramedics at least go through a 480 hour internship (in California anyawy) and then through an FTO process before being turned loose. The _only_ way that I would even _consider_ putting a new grad RN on an ALS truck as an "ALS-RN" would be if that new grad was already working as a Paramedic with some experience doing that (perhaps 2-4 years). 

Incidentally, one of the reasons I'm considering going back to Paramedic work is precisely because I want to work on that particular skillset.


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## Peak (Dec 13, 2020)

Akulahawk said:


> Incidentally, one of the reasons I'm considering going back to Paramedic work is precisely because I want to work on that particular skillset.


I have become soft and like indoor plumbing too much to want to go back to the streets for anything more than an occasional transport or facilitating one of the specialty programs.


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## DrParasite (Dec 13, 2020)

In my experience (which is, admittedly, very limited), many CCT runs are simply an IFT run with the patient on a cardiac monitor.  very stable patient, high probability of an uneventful trip.  There are some complicated runs (patient on multiple drips, dissecting aneurism, or the patient who is actively trying to die, etc) but those are both the minority and you usually know about them before you pick up the patient.

I've been on CCT runs with RNs who are borderlining on incompetent in the back of the truck.  They were PICU nurses, who knew PICU stuff, and were great in a PICU environment with PICU equipment, but the ambulance was not a PICU, despite having similar equipment.  So no, I would not want a random nurse on a 911 truck as an ALS provider, unless they were comfortable in that role and an experienced ALS provider had evaluated them and approved them to function in that role (similar to paramedic credentialing/internships).  

That being said, I have worked with plenty of nurses who were great as paramedics.  usually they had EMT or paramedic experience before they went to nursing school, so they could deal with unexpected hiccups, but not always.  As a general rule, I would not want a new grad (or even an experienced med/surg nurse, ortho nurse, or psych nurse) on a 911 truck, who had no EMS experience.  I like the idea of 2 years of ER/xICU experience prior to an EMS evaluation/internship/credentialling to function as an ALS provider; doing otherwise is a recipe for disaster, for the provider, the agency and the patient.


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## VFlutter (Dec 13, 2020)

I have no first hand experience however with talking to friends in CA it seems that like stated above many of the "CCT-RN" transfers are  typical ALS stuff and not what most would consider actual critical care.


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## BobBarker (Dec 14, 2020)

We do CCT and ALS in la county at the company I work for, all IFT. CCT nurses require a minimum of 2yrs ER/ICU experience and I know none who have less than 4 and who are still actively work part time for hospitals.
Majority of the cct calls are vent/drip calls that are non-emergency and simply transfer to our equipment and transfer back at destination, fairly easy. Unfortunately, a lot of the daily code 3 calls we get are for cct is simply because the pt can't go ALS with a drip/blood/vent and the facility does not have or want an RN to jump on board the ALS ambulance to monitor what a medic can't. Our RN's also handle ALS calls all the time on cct rigs when our als rigs are busy.
No ALS-RN here in la county, CCT is 1 RN and 2 EMT's although I think the perfect staffing would be 1 RN, 1 Medic and 1 EMT.
Besides the 1 week orientation, 2yrs ER/ICU experience and annual required competency training, I don't know what other regulations are in place


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## Peak (Dec 14, 2020)

BobBarker said:


> ...Besides the 1 week orientation...



That sounds like a sentinel event just waiting to happen


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## DesertMedic66 (Dec 14, 2020)

Peak said:


> That sounds like a sentinel event just waiting to happen


Welcome to the majority of CCT companies in CA.


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## BobBarker (Dec 14, 2020)

Peak said:


> That sounds like a sentinel event just waiting to happen


I forgot to mention 3-5 days/shifts with a Senior RN/FTO that is after oirentation. But, pretty standard for CCT companies in CA


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## Akulahawk (Dec 14, 2020)

BobBarker said:


> Besides the 1 week orientation





Peak said:


> That sounds like a sentinel event just waiting to happen


I tend to agree. About the only time that I would even _consider_ doing a 1 week orientation for an RN doing CCT _and_ taking ALS calls when the ALS trucks aren't available would be if the RN already has experience as a Paramedic. Otherwise you're betting that the EMTs are able to watch out for scene hazards that the RN might not even consider (among other operational concerns). I just think that a single week orientation on a truck for a CCT RN and then sending them out to occasionally pick up an ALS call, let alone CCT calls,  could very easily end up with a sentinel event.


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## BobBarker (Dec 14, 2020)

Akulahawk said:


> I tend to agree. About the only time that I would even _consider_ doing a 1 week orientation for an RN doing CCT _and_ taking ALS calls when the ALS trucks aren't available would be if the RN already has experience as a Paramedic. Otherwise you're betting that the EMTs are able to watch out for scene hazards that the RN might not even consider (among other operational concerns). I just think that a single week orientation on a truck for a CCT RN and then sending them out to occasionally pick up an ALS call, let alone CCT calls,  could very easily end up with a sentinel event.


A majority of the ALS calls we get because we are IFT simply more stable than CCT or don’t require drips, blood and/or vent. An intubated stemi pt would be CCT where as if they weren’t intubated it would be ALS going to the stemi center.


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## Rano Pano (Dec 15, 2020)

BobBarker said:


> A majority of the ALS calls we get because we are IFT simply more stable than CCT or don’t require drips, blood and/or vent. An intubated stemi pt would be CCT where as if they weren’t intubated it would be ALS going to the stemi center.


When you say RNs taking ALS calls you’re referring to transfers, right? I remember LA county CCT cars being dispatched to 911 and the RN would just stay in the rig. The county
allow them to do anything past BLS on a 911 scene, right?


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## BobBarker (Dec 15, 2020)

Rano Pano said:


> When you say RNs taking ALS calls you’re referring to transfers, right? I remember LA county CCT cars being dispatched to 911 and the RN would just stay in the rig. The county
> allow them to do anything past BLS on a 911 scene, right?


Correct, transfers. We rarely do backup. If on scene of a still alarm, RN’s can use up to the ALS scope of practice.


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## supreme (Dec 15, 2020)

Akulahawk said:


> I tend to agree. About the only time that I would even _consider_ doing a 1 week orientation for an RN doing CCT _and_ taking ALS calls when the ALS trucks aren't available would be if the RN already has experience as a Paramedic. Otherwise you're betting that the EMTs are able to watch out for scene hazards that the RN might not even consider (among other operational concerns). I just think that a single week orientation on a truck for a CCT RN and then sending them out to occasionally pick up an ALS call, let alone CCT calls,  could very easily end up with a sentinel event.



ALS meaning ALS 911 calls or ALS IFT calls?

Technically, California allows RN's to response to ALS prehospital calls.

1797.56.​“Authorized registered nurse,” “mobile intensive care nurse,” or “MICN” means a registered nurse who is functioning pursuant to Section 2725 of the Business and Professions Code and who has been authorized by the medical director of the local EMS agency as qualified to provide prehospital advanced life support or to issue instructions to prehospital emergency medical care personnel within an EMS system according to standardized procedures developed by the local EMS agency consistent with statewide guidelines established by the authority. Nothing in this section shall be deemed to abridge or restrict the duties or functions of a registered nurse or mobile intensive care nurse as otherwise provided by law.

1797.52.​“Advanced life support” means special services designed to provide definitive prehospital emergency medical care, including, but not limited to, cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation, advanced airway management, intravenous therapy, administration of specified drugs and other medicinal preparations, and other specified techniques and procedures administered by authorized personnel under the direct supervision of a base hospital as part of a local EMS system at the scene of an emergency, during transport to an acute care hospital, during interfacility transfer, and while in the emergency department of an acute care hospital until responsibility is assumed by the emergency or other medical staff of that hospital.


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## Akulahawk (Dec 15, 2020)

supreme said:


> ALS meaning ALS 911 calls or ALS IFT calls?
> 
> Technically, California allows RN's to response to ALS prehospital calls.
> 
> ...


The MICN is a Base Hospital ED RN that has received some additional education and (typically) an 8 hour OBSERVATION ride-along. Sure the MICN might be technically authorized to provide prehospital care but they're primarily used to provide instructions to prehospital providers because they're working at a base hospital and are assigned to answer the prehospital radio/phone. If the RN isn't working at a base hospital, that base hospital isn't going to be able to sponsor them for MICN. Now then, MICN isn't the ONLY kind of RN that provides prehospital field care. Those are usually flight nurses that receive recognition through an agreement with various LEMSAs and the flight provider. That agreement basically relies on the flight provider doing adequate orientation and training of their RNs in performing field care. Since flight providers aren't usually limited to a single county, they're not going to typically access the base hospitals for prehospital orders as their own standardized procedures will be used instead of the prehospital ALS orders. This also means that the LEMSAs aren't going to be the ones accrediting those field RNs. An MICN is going to be effectively bound to their LEMSA orders. On a more practical level, I've not heard of (recently for certain) an MICN training course (which takes place over 1-2 days) doing much (if any) advanced airway management training.


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## fm_emt (Dec 16, 2020)

VFlutter said:


> I have no first hand experience however with talking to friends in CA it seems that like stated above many of the "CCT-RN" transfers are  typical ALS stuff and not what most would consider actual critical care.


Having talked to some, this is how it seems. I am unsure why they can't use a Paramedic for most of these. We took vent & drip patients quite often in Texas and other non-California states. Is there a benefit to the company on the billing side to use a CCT-RN instead? Or is this a case of "it's just how it's done here" instead?


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## Akulahawk (Dec 17, 2020)

VFlutter said:


> many of the "CCT-RN" transfers are typical ALS stuff and not what most would consider actual critical care.





fm_emt said:


> Having talked to some, this is how it seems. I am unsure why they can't use a Paramedic for most of these. We took vent & drip patients quite often in Texas and other non-California states. Is there a benefit to the company on the billing side to use a CCT-RN instead? Or is this a case of "it's just how it's done here" instead?


It's basically a "that's how it's done here" because the RN lobby didn't want Paramedics to encroach too much into "their" areas. Seriously. If California Paramedics suddenly could do the things that Tx Paramedics do, the majority of the need for CCT-RN trucks would disappear overnight.


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## DesertMedic66 (Dec 17, 2020)

Akulahawk said:


> It's basically a "that's how it's done here" because the RN lobby didn't want Paramedics to encroach too much into "their" areas. Seriously. If California Paramedics suddenly could do the things that Tx Paramedics do, the majority of the need for CCT-RN trucks would disappear overnight.


This. Even on the flight side we are facing issues. We have been trying to get a statewide expanded scope for flight medics that our flight nurses are in complete agreement with however we hit roadblocks at every step.


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## BobBarker (Dec 17, 2020)

Akulahawk said:


> It's basically a "that's how it's done here" because the RN lobby didn't want Paramedics to encroach too much into "their" areas. Seriously. If California Paramedics suddenly could do the things that Tx Paramedics do, the majority of the need for CCT-RN trucks would disappear overnight.


Orange county started allowing medics to transport vents and some drips including antibiotics


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## Akulahawk (Dec 17, 2020)

BobBarker said:


> Orange county started allowing medics to transport vents and some drips including antibiotics


When did OC add in the ability to monitor drips, specifically antibiotics? I looked and found only monitoring of heparin, nitroglycerin, and TPA.


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## BobBarker (Dec 17, 2020)

Akulahawk said:


> When did OC add in the ability to monitor drips, specifically antibiotics? I looked and found only monitoring of heparin, nitroglycerin, and TPA.


IFT-SO-3 Policy says they can monitor preset antibiotic, antiviral and antifungal agents administered by the sending facility. It was revised 10/23/19 and that's actually BLS. ALS adds what you mentioned plus dopamine, lidocaine, amio, benzos and mag.


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## BobBarker (Dec 17, 2020)

fm_emt said:


> Having talked to some, this is how it seems. I am unsure why they can't use a Paramedic for most of these. We took vent & drip patients quite often in Texas and other non-California states. Is there a benefit to the company on the billing side to use a CCT-RN instead? Or is this a case of "it's just how it's done here" instead?


Last I heard an ALS call on our contract runs for $500-$700 where as a CCT call could generate 2-3x that.


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## Akulahawk (Dec 17, 2020)

BobBarker said:


> IFT-SO-3 Policy says they can monitor preset antibiotic, antiviral and antifungal agents administered by the sending facility. It was revised 10/23/19 and that's actually BLS. ALS adds what you mentioned plus dopamine, lidocaine, amio, benzos and mag.


Looks like OC EMS took advantage of the EMT Optional Scope and managed to get all that through the EMSA approval process. That's significantly wider (for BLS anyway) than anything I've heard of recently for California EMTs.


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## BobBarker (Dec 17, 2020)

Akulahawk said:


> Looks like OC EMS took advantage of the EMT Optional Scope and managed to get all that through the EMSA approval process. That's significantly wider (for BLS anyway) than anything I've heard of recently for California EMTs.


Yup, considering we couldn't even transport mag with a preclampsia patient last night in la county as ALS.


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## Jim37F (Dec 17, 2020)

Yet another reason why when people ask me if I'm interested in eventually moving back to LA I just kinda laugh and say "no" (even though I'm just a BLS hose monkey lol... the other day one of our EMS medics asked if one of us wanted to start an IV because he knew I used to be an EMT, and he just kinda assumed that was a normal thing, since EMTs here can do that, and I had to briefly explain that back in CA I probably wasn't even allowed to look at the BSG lancets much less start any IVs lol)


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