# Texas ENA position paper against EMS



## TransportJockey (Apr 24, 2015)

http://unwiredmedic.com/2015/04/24/texas-enas-unprofessional-attack-on-ems/

I posted a blog with a rebuttal, but the original letter by the president of the ENA is there too.


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## Carlos Danger (Apr 25, 2015)

Never been a fan of the ENA, even when I briefly worked as an ED nurse, or the years that I worked as a flight nurse. I am well aware of times that the ENA _has_ unfairly attacked and frankly been quite insulting to paramedics.

But I didn't see any paramedic-bashing in this ENA letter. I would agree that the ENA overstates the differences in educational preparation between nurses and paramedics and also the ability of nurses to practice "autonomously" vs. a paramedic, but I wouldn't call that "fear mongering", or an attempt to "hold their siblings down in mediocrity" or "attack their intelligence", as the blog post says. In fact there's much more hyperbole in the blog post than in the ENA letter.

I'm generally not a fan of protectionism (using the law or politics to keep your competition at bay), but nor am I a fan the reverse of that, where profession A uses politics to crowd into profession B's territory when there is really no market demand for profession A there. I don't know if that's what is trying to be accomplished by the bills in question, but unless there is a real shortage of ER nurses and techs in Texas, it would appear that this is more a case of paramedics attacking RN's than the other way around.

What would Texas paramedics say about a bill that allows RN's to work EMS with no EMS training or certification? They would oppose it, of course, writing letters to each other stressing and exaggerating how much more highly prepared they are for the prehospital environment than nurses, and how nurses shouldn't be allowed on ambulances. And they'd be right.


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## DrParasite (Apr 25, 2015)

the ENA is probably just like the IAFF... they support only their point of view (and omitting any facts that they disagree with), support only their members, and do whatever they can to put forth their agenda, even if it is at the expense of other providers who their line staff work side by side with day in and day out.  

If you are in the ENA, you probably want them to do what they can, as you will probably benefit from what they are trying to do.

if you aren't in the ENA, you should probably work on creating a unified voice to advocate what you do, why you should get paid well to do it, and why people should listen to you, and not those idiots at the ENA who aren't looking out for your interests one bit.

BTW, if you were to write a response, I would start off with saying "a nurse can't fart without getting approval from a doctor; on the other hand, a paramedic can initiate care, establish IV access, put a tube down a person's throat, interpret a cardiac monitor and give medications based on what they see, establish a treatment plan, activate a trauma team, and only needs to call a doctor if they need to consult about a patient.  So who do you think is the autonomous provider?"

But then I would be just as one sided as the person who wrote the ENA letter.


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## OnceAnEMT (Apr 26, 2015)

I am very confused by this article, but perhaps I am just missing something. Everything stated can already be done, as long as there are standing orders or a verbal order given. Paramedics in the ED I am at push meds (a higher scope than "normal", but slightly less than RN, I do not know specifics). They can defibrilate. 

"The Texas Board of Nursing rules limits what tasks can be delegated to others. This restricts paramedics from administering medications and intravenous fluids in the hospital setting." Maybe the word "specific" is missing in here. 

Sounds like an RN is getting butt hurt over the fact that some paper says a Paramedic could intubate in the ED. I started a thread before about licensing and standing orders, and this thread seems to beg the same question. As long as a doc is giving the green light, they can do anything. Unless of course that doc has order restrictions from the hospital protocols, saying you can't order a Paramedic to intubate. 

But again, all of the above is already happening. So what is the fuss?


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## Carlos Danger (Apr 26, 2015)

DrParasite said:


> BTW, if you were to write a response, I would start off with saying "*a nurse can't fart without getting approval from a doctor; on the other hand, a paramedic can initiate care,* establish IV access, put a tube down a person's throat, interpret a cardiac monitor and give medications based on what they see, establish a treatment plan, activate a trauma team, and only needs to call a doctor if they need to consult about a patient.  So who do you think is the autonomous provider?"



Where in the US can a paramedic provide ALS-level care without a physicians' permission? RN's do every one of those things, too, and much more - with standing orders - just like paramedics do.
RN's and paramedics are actually almost identical in this way. It is an absolute myth perpetuated by ignorant paramedics that RN's in the hospital aren't allowed to do anything with a patient until a doctor comes by and tells them what to do. 

FWIW, the reason nursing organizations talk about RN's being "autonomous providers" is because _traditional_ nursing (not in the ICU or ED) is autonomous. Most nursing actions do not require a physician order. This is not really relevant to the discussion at hand, so it shouldn't have been even mentioned in the ENA email, but that is why they say it.



Grimes said:


> Sounds like an RN is getting butt hurt over the fact that some paper says a Paramedic could intubate in the ED.



I have no idea what prompted the email from the TENA, but I doubt it was over a paramedic intubating in the ED. Nurses tend not to get all worked up over individual skills like paramedics do.

As I said before, if a bill were presented that called for RN's to be able to work on ambulances, the EMS community's response would be very similar.


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## OnceAnEMT (Apr 26, 2015)

Remi said:


> As I said before, if a bill were presented that called for RN's to be able to work on ambulances, the EMS community's response would be very similar.



But what is the point of the bills presented? What would change if they became law? It really seems like a formality, just recognition of reality.


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## DrParasite (Apr 26, 2015)

Remi said:


> Where in the US can a paramedic provide ALS-level care without a physicians' permission? RN's do every one of those things, too, and much more - with standing orders - just like paramedics do.
> RN's and paramedics are actually almost identical in this way. It is an absolute myth perpetuated by ignorant paramedics that RN's in the hospital aren't allowed to do anything with a patient until a doctor comes by and tells them what to do.
> ...
> FWIW, the reason nursing organizations talk about RN's being "autonomous providers" is because _traditional_ nursing (not in the ICU or ED) is autonomous. Most nursing actions do not require a physician order. This is not really relevant to the discussion at hand, so it shouldn't have been even mentioned in the ENA email, but that is why they say it.


See, this is exactly what the ENA is doing.... putting information that isn't relevant to the situation to support their case.

The author in question is an EMERGENCY ROOM nurse.  As you stated, an ER nurse is not autonomous, and I'm pretty sure the issue in question involves EMERGENCY situations.  So the fact that traditional nursing is autonomous isn't relevant to the topic at hand, because the bill primarily deals with ER paramedics.

I didn't say a paramedic could provide care without a paramedics permission; what I said was a paramedic doesn't need to speak to a doctor before they treat a patient, and can perform all those interventions before they speak to a doctor, especially in an emergency situation.  I'm sure RNs have standing orders, just like paramedics; however, in an emergency setting, an RN still needs to get a doctors order to do something (see your statement about the ER and ICU, I didn't say that), while a paramedic can perform interventions (if they fall under their standing orders) and then consult with the doctor after if they want to do more or something else.

The exact quote from the author in question states "This bill allows EMTs and EMT-Paramedics the authority to provide healthcare services including advanced life support in hospital emergency rooms and freestanding emergency medical care facilities under a physician delegation."  So what nurses do in healthcare doesn't apply; the bill says it's only in a hospital ER or a freestanding ER, and in this case, a nurse needs to get a doctors approval (your words, not mine).


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## SandpitMedic (Apr 26, 2015)

DrParasite said:


> See, this is exactly what the ENA is doing.... putting information that isn't relevant to the situation to support their case.
> 
> The author in question is an EMERGENCY ROOM nurse.  As you stated, an ER nurse is not autonomous, and I'm pretty sure the issue in question involves EMERGENCY situations.  So the fact that traditional nursing is autonomous isn't relevant to the topic at hand, because the bill primarily deals with ER paramedics.
> 
> ...


This!

I love it when the RNs get all worked up about how they can do things autonomously too. (Like Remi's post, for example.)

There is a stark difference between the autonomous nature of what an ER RN can do and what a paramedic can do.

To ask where a paramedic can provide ALS procedures without a doctor's say so or over watch is like watching paint dry. It is a boring question with no real purpose. It's a spin. Sure, I have a protocol soup written by a doctor... However, those protocols are very fluid. They are broad and wide, and I can pick and choose what I want to and don't want to do based on what I find in my assessment. Without any "permission" on the scene, nor a doctor looking over my shoulder.

As a paramedic I am an extension of the doctor, with 99% authority to act autonomously. As a an ER RN you are not an extension of the physicia- you are a Registered Nurse. You can only go so far as to do what the doctor says, when he says to do it - period. (Not withstanding simple procedures like IV ACCESS, and CPR INITIALLY.) Even to draw blood and get a bag of NS takes an order. 

(That's not even to mention the advanced skills that RNs aren't even practiced or trained in: EJs, EKGs, needle decompressions, intubations, IOs, etc.)

Rediculous to say otherwise... As a nurse or anyone else. 

I am not discounting RNs. They play a vital role in the healthcare system, and an even more vital role in the ER. They are great at what they do. But there is no comparing the autonomy of each, it's apples to oranges.


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## SandpitMedic (Apr 26, 2015)

Also, I can deviate from those protocols, and notify a doctor via telemetry. 
And then fill out a .... Protocol deviation form. 

At least in my AO we have that ability.


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## OnceAnEMT (Apr 26, 2015)

SandpitMedic said:


> This!
> 
> I love it when the RNs get all worked up about how they can do things autonomously too. (Like Remi's post, for example.)
> 
> ...



...unless a physician provides standing orders. Or is that not a thing for RNs? I understand that yes, at some point a unique order will have to be given to be that bit of "definitive care", but is it simply too much to have standing orders? For instance, triage EKGs. An order may show up eventually, but we are preforming that EKG before the Pt is even in our system. I assume this is because in some dusty book somewhere in our director's office protocols are provided to physicians from the Chief Medical Officer of the hospital, and then a separate book defining standing orders for RNs and paramedics in the department.


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## SandpitMedic (Apr 26, 2015)

No, not standing orders in the EMS sense. (Besides like an I/V, O2, etc) Read- not invasive. Essentially, the answer is no, but folks will argue that because they don't like the ideology behind that little factoid. 

ERs here run stat EKGs on arrival here too- they print it and run the doctor with it. They have EKG techs. No one interprets it but the doc... Or a nearby medic (who has usually already done their own.) I've met few RNs who know about EKGs and even less that know anything other than ST elevation (only.)


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## Carlos Danger (Apr 26, 2015)

SandpitMedic said:


> I love it when the RNs get all worked up about how they can do things autonomously too. (Like Remi's post, for example.)



I'm not sure if you are just trying to bait me or what. The only folks I see getting worked up about anything here are the paramedics who get hysterical because of some stupid email sent out by some stupid state ENA chapter. I do not nor do I ever plan to live or work in Texas in any capacity. If I did move there for some reason, I would not likely work as either a paramedic or an RN. So frankly, I don't care in the least what happens there.

The only reason I even commented here was, quite honestly, to help you guys out. There is a lot of misunderstanding among paramedics about what nurses do, what their scope of practice is, and what there motivations may be for sending out communication like the one the TENA did. And your post here proves that perfectly; it's exactly the type of ignorance that keeps you guys chasing your tail about this stuff.   

"But....but.....we can INTUBATE, and they can't!!!"



SandpitMedic said:


> There is a stark difference between the autonomous nature of what an ER RN can do and what a paramedic can do.



No, there really isn't. Ask me how I know.

There is a stark difference in practice environment, obviously, and the out-of-hospital environment clearly lends itself to performing with less direct physician oversight. But that does not mean what you think it does. 

Again, ask me how I know.




Grimes said:


> ...unless a physician provides standing orders. Or is that not a thing for RNs?



Yes, it is a thing. Nurses start IV's, draw labs, treat labs, get EKG's, place foleys, start drips, titrate drips, D/C drips, run vents, run codes, call alerts, deviate from protocols, etc. - plus much more - all day long on standing orders, just like paramedics do. I've had many busy days in the ICU where I worked my *** off with a sick patient (or two) without ever seeing their physicians other than rounds first thing in the morning.

Paramedics cannot legally do _anything_ other than simple BLS without a physician's order. Neither can RN's. There is no difference.[/QUOTE]


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## SandpitMedic (Apr 26, 2015)

Once again- we are not talking about ICU nurses, Remi. 

Irrelevant.

Also, there is a little more to it than intubating. And as I said, my orders are fluid and encompass a whoooole lot, of which I can pick & choose what is appropriate for each patient. Not to mention, the protocol deviation. ER RNs do not have the same practice. 

Next.


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## SandpitMedic (Apr 26, 2015)

Also, paramedics get all "spun up" because it is us that are constantly trying to defend ourselves from all angles... Corporate, government, the public, clinical, and the guy writing the checks. 

We are treated like step children. And we're ****ing sick of it.

If the shoe were on the other foot, it would be the nurses getting all fired up. But it isn't.


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## Carlos Danger (Apr 26, 2015)

SandpitMedic said:


> Once again- we are not talking about ICU nurses, Remi.
> 
> Irrelevant.
> 
> ...


This attitude is a large part of the reason why you see so many people who move on from EMS fail to stay involved, even though they loved EMS and swore they'd never leave comepletely.

Keep believing these myths and wallowing in your own ignorance. No skin off my back.


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## SandpitMedic (Apr 26, 2015)

What am I talking about?!

I'm just a garbage man....right?


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## DrParasite (Apr 26, 2015)

Remi said:


> The only reason I even commented here was, quite honestly, to help you guys out. There is a lot of misunderstanding among paramedics about what nurses do, what their scope of practice is, and what there motivations may be for sending out communication like the one the TENA did. And your post here proves that perfectly; it's exactly the type of ignorance that keeps you guys chasing your tail about this stuff.
> 
> "But....but.....we can INTUBATE, and they can't!!!"


Ummmm I'm quite clear on what a nurse can do.... In an emergency situation (or any unplanned event), a paramedic can do more without asking for online medical control.  yes, both RN and paramedics have standing orders, but paramedics have a lot more autonomy than nurses.  In fact, the letter the Texas ENA president is sending out is spewing ignorance about paramedics, to a politician, and she is hoping to advance her profession at the expense of EMS professionals.

Quite honestly, they are acting like bullies; they feel threatened by paramedics so they are telling half truths to an important person, trying to say how awesome they are at the expense of another profession.  And if the roles were reversed, we both know that the nursing associations would be up in arms over it.





Remi said:


> Yes, it is a thing. Nurses start IV's, draw labs, treat labs, get EKG's, place foleys, start drips, titrate drips, D/C drips, run vents, run codes, call alerts, deviate from protocols, etc. - plus much more - all day long on standing orders, just like paramedics do. I've had many busy days in the ICU where I worked my *** off with a sick patient (or two) without ever seeing their physicians other than rounds first thing in the morning.
> 
> Paramedics cannot legally do _anything_ other than simple BLS without a physician's order. Neither can RN's. There is no difference.


So a nurse can administer morphine before a doctor tells them to do it?  they can interpret EKGs and initiate treatment based on it, correct?  The only time I have ever seen a nurse run a code is until a doctor arrives to take over.  Paramedics can place foleys too, just in case you were wondering.

BTW, a nurse can do more than a paramedic.  a nurse can administer blood products.  and can administer more medications.   and are much better trained to deal with long term care.  and end of life care.  and a bunch of other stuff.  This I completely understand, and I think most do too.

But in an emergency situation (whether it be an ER, a new patient and the urgent care, or a 911 call), a paramedic operates with more autonomy, and can treat a patient without a verbal consultation from a doctor on how the patient will be treated.


Remi said:


> This attitude is a large part of the reason why you see so many people who move on from EMS fail to stay involved, even though they loved EMS and swore they'd never leave comepletely.
> 
> Keep believing these myths and wallowing in your own ignorance. No skin off my back.


actually, it's usually because of the low pay for EMS, poor chances for advancement, lack of things to do besides be on an ambulance, and once your blow your back, you are pretty much screwed.  If you think otherwise, than you are "believing these myths and wallowing in your own ignorance."

Oh yeah, and the fact that there isn't any large scale group who can convince politicians that EMS is worth funding, at least compared to other jobs that do similar functions.

It isn't ignorance, but if you want to keep putting down your current profession (you are a paramedic right?), and keep drinking the nursing kool aid..... Maybe one day EMS will have their own organizations to convince the politicians to drink the EMS Kool aid...

Signed,
  An ambulance driver.


SandpitMedic said:


> Also, paramedics get all "spun up" because it is us that are constantly trying to defend ourselves from all angles... Corporate, government, the public, clinical, and the guy writing the checks.
> 
> We are treated like step children. And we're ****ing sick of it.
> 
> If the shoe were on the other foot, it would be the nurses getting all fired up. But it isn't.


Well said.  We, as an industry, are underpaid, under staffed, and no one wants to do anything for EMS until they need EMS.

Remi, I understand that everyone is looking out for themselves, but if you expect me to sit quietly while another healthcare professional tells half truths and lies to a politician about my industry, so they can advance their agenda, well, then maybe you should go back to nursing.  If you want to help out EMS, why don't you write a letter to a politician saying how as a credentialed nurse, a paramedics can do a whole lot more than the president of the Texas ENA chapter is claiming.  I mean, you are a supporter of EMS right?


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## Handsome Robb (Apr 26, 2015)

Pretty sure Remi was a Paramedic,  ER/ICU/Flight Nurse and is now a CRNA.

I really don't want to get involved in this but what I will say is while the letter is inflammatory we do have less education. 

They put us down in the letter, that's pretty obvious and some of the information is incorrect however we do operate similarly when it comes to standing orders, that's exactly what protocols are. Some systems allow deviation from protocol while others do not. Some systems allow a lot of autonomy while others require OLMC contact for damn near everything outside of an ALS assessment. 

What I don't understand is what are we accomplishing Pickering about semantics on an online forum?

Yes, ICU nurses operate under a rather comprehensive set of standing orders. Some ER nurses have a wide set of standing orders while others do not.


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## Tigger (Apr 27, 2015)

Yet another reason why paramedic certificates need to die. While I don't necessarily believe that having an associates or bachelor's degree in EMS would necessarily result in a drastic betterment in care, it would do a lot when this sort of crap comes up. At the end of the day, the "nursing voice" will win out over EMS's because they have the education that the healthcare community deems necessary. For the most part, EMS doesn't. 

If you want a seat at the big kid's table you have to earn it. We can stomp our feet all we want about how it's not fair, but that's not going to change the outcomes. All this arguing about skills and standing orders is a waste in the scheme of things. The rest of healthcare has moved far beyond this.


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## 04_edge (Apr 27, 2015)

I don't understand what the big deal is about all of this.  A single nurse wrote a letter on behalf of the ENA promoting her own agenda.  As someone else said, we would be just as emotional about this subject if it was being pushed for nurses to begin providing prehospital care.  I have worked part time as a tech in the ER and I enjoyed it.  It was easy money and good learning experience that i wouldn't have been able to get anywhere else.  However, not once did i ever have the desire to perform at the same scope of practice as i do pre-hospital.

If we want to be treated as professionals, we must first act as professionals.  Belittling nurses because "they can't intubate and we can," is not proactive and is exactly the mindset that has caused us be looked upon as less than professionals to begin with.


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## triemal04 (Apr 27, 2015)

Can I make a suggestion?

The thread that turned into a bickering match about Explorer-1 was an embarrassment, not only to everyone involved in it, but to everyone else who is in the same profession.

This thread is already on track to do the same.  Please don't let that happen again.

Which means that if you are going to compare the two professions here, you need to actually understand what the differences and similarities are, and not waste time blabbering about "well in *MY* department" or "at the ER that *I* go to" or "when *I* was a nurse" and so forth.  Becuase...you know...anecdotes don't matter.  

Just a suggestion.


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## SeeNoMore (Apr 27, 2015)

Like others have said, the intention of the letter is pretty clear. But I think the larger problem is how vulnerable paramedics are to such accusations. If the profession never advances (education, professionalism, evidence based interventions) than we don't have much to argue with.

Of course we can all think of a service that performs at a high level of quality with experienced edcuated providers, but we can also think of many more that fall below that threshold. Overall Paramedics are less educated and regarded as lower level providers. I don't think that means we are unable to work in Emergency Rooms but I think we are better served by showing our worth rather than trying to argue how much more autonomous we are than nurses. It just seems to come from a position of weakness because we all know full well that we are still low man on the totem pole of medicine.


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## Carlos Danger (Apr 27, 2015)

As I explained before, the only reason I even got involved in this discussion was to try to provide some objectivity and perspective and correct some apparent misconceptions. As far as I know, I am the only one involved in this discussion who is actually licensed as and has actually practiced as both a nurse and a paramedic, and continues to be involved in EMS even after going into advanced practice. But, if you think I just don't know what I'm talking about, that's fine. Take what I have to say for for whatever it's worth to you. I'm certainly not going to lose sleep over what a few cocky medics on some anonymous internet forum think of what I have to say.

But consider this: when you are going toe-to-toe on a serious political battle over important scope-of-practice issues, you are far better off doing so from a position of knowing as much as possible about your opponent and their possible motivations. No matter who started it or how unfair they are or how untruthful they are being, _your_ argument is very weak if it relies at all on untrue or half-true "facts". And I can assure you with 100% confidence that if you start spewing some silly BS about how "nurses can't do anything without a doctor's permission, yet paramedics are autonomous" to someone who is really knowledgable about nurse practice issues and knows that paramedics can only operate under a set of written protocols and a physician's explicit authorization, they will tear your argument to bloody shreds and leave you stuttering, trying to find the words to save just a little face, and you will have thoroughly lost the debate in the eyes of anyone watching. I promise. If you think I'm wrong, go ahead and try to fight this battle on that premise. I'll try not to say I told you so.

I'm not going to try to list all the things that can done by RN's on standing order. But everything that has been mentioned in this thread as an example of what nurses can't do without being told........is being done right now by an RN, in a hospital, on standing order. Not to mention the RN that is intubating a blood airway in the back of an ambulance, or the RN who is starting a central line in a helicopter on the long flight to a tertiary center. Or the paramedic who is working in an ED and NOT running the code or doing the intubation, because a physician is present and in charge, and for both RN's and paramedics, degree of autonomy and the skills they perform has more to do with practice environment than anything else.



DrParasite said:


> Ummmm I'm quite clear on what a nurse can do....



Obviously not, if that was a serious question about whether RN's can give morphine on standing order.



DrParasite said:


> Remi, I understand that everyone is looking out for themselves, but if you expect me to sit quietly while another healthcare professional tells half truths and lies to a politician about my industry, so they can advance their agenda, well, then maybe you should go back to nursing.



I don't expect you to sit quiet and do nothing.......I don't care what you do. But being quiet probably _is_ a better option than going off half-cocked about something you obviously know little about.



DrParasite said:


> If you want to help out EMS, why don't you write a letter to a politician saying how as a credentialed nurse, a paramedics can do a whole lot more than the president of the Texas ENA chapter is claiming.  I mean, you are a supporter of EMS right?



Please, spare me the guilt. I'm a CRNA in South Carolina who has never even been to Texas and has never been involved with the ENA anywhere - do you really think the Texas ENA or any legislators there give a crap what I have say in support of paramedics?

(You do know that traditionally, CRNA's and the larger nursing establishment tend not to get along very well, right? Of course you do, since you know so much about nursing practice.)

I've done a lot to support the paramedic profession, but sometimes I wonder whether they need my support at all, being that so many paramedics know everything already.


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## SandpitMedic (Apr 28, 2015)

As always. This is futile, Remi. Too stubborn to take off the blindfold to see the light. 

One last question for you directly, keep it to a yes or a no. 

In regards to the administration of Morphine... Are you suggesting, that via standing order, on a first encounter with a patient in an ER or urgent care, that an RN can just administer morphine if they deem it appropriate? Prior to that patient seeing a provider or mid-level provider? Yes or no?


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## Carlos Danger (Apr 28, 2015)

SandpitMedic said:


> As always. This is futile, Remi. Too stubborn to take off the blindfold to see the light.



You are the one insisting that you have more knowledge about something you've never even done, than someone who has actually done it. Yet _I'm_ the one being stubborn? You simply do not know what you are talking about.



SandpitMedic said:


> One last question for you directly, keep it to a yes or a no.
> 
> In regards to the administration of Morphine... Are you suggesting, that via standing order, on a first encounter with a patient in an ER or urgent care, that an RN can just administer morphine if they deem it appropriate? Prior to that patient seeing a provider or mid-level provider? Yes or no?



This isn't a yes or no question. But the short answer, if you insist, is yes, it is entirely possible that a protocol could exist that would allow an RN to give morphine to a patient who has not yet been seen.

When I worked in the ED I don't remember ever giving morphine on standing order before they were seen, but we did lots of other stuff before they were seen, and there's no reason morphine couldn't be added to the list of protocols. I don't know how common it is, but I do know it isn't a scope of practice issue by any means, and I'm sure there are places where it is done.

That's really a dumb question, though. Even if the answer were "no", it would not support your point. That's because in any ED where protocols do not exist to allow RN's to administer morphine prior to eval by an MD, I guarantee you that protocols would also not exist that allow an ED paramedic to do so. And any RN working outside the hospital will have the same types of standing orders to give morphine as any paramedic. So it isn't an issue of paramedic vs. nurse autonomy at all. As I explained in the last post, it has more to do with practice an environment. Paramedics give meds without the patient being seen out of necessity, bot because they are somehow better qualified to do so than RN's.

Paramedic practice and nursing practice is obviously very different. But you seem to think a paramedic is way bigger of a deal than you actually are. Do you ever wonder if that might have something to do with the perception that much of the rest of healthcare has of paramedics?


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## SandpitMedic (Apr 29, 2015)

....no....

The answer is no.

Prove me wrong with fact, or stop.

I'm more than willing to be corrected...

(But I'm also not talking about some backwoods county with 1 stop sign. I'm talking a normal to low average populated urban or rural area with a decent amount of patients. And not volunteer or anything. Just find me a normal ER that has this policy in place for MS for a regular ordinary RN...And I will shut up.)


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## Handsome Robb (Apr 29, 2015)

Sandpit, you're making all of us as Paramedics look ignorant. Just quit.

I'm a Paramedic. I am going to continue being a Paramedic whether it be ground, flight or fire. I have no aspirations of being a nurse and the only reason I'd go to nursing school would be to become a CRNA and I would spend as little time as possible working as an RN to achieve that. Even with that I'd rather go the route of AA, especially if they expand the regions they're allowed to practice in. So before you freak out and question my intentions I'm making my position in healthcare and my intentions in healthcare very apparent

We have less education, less clinical hours, lower entry requirements to our field and operate solely by standing orders as written by a physician. Yes, we make decisions to utilize or not utilize treatments authorized under these protocols however at the end of the day we cannot routinely go outside of those protocols except in circumstances which are extremely justifiable. Also, when we do deviate from protocol we're not doing anything outrageous or off the wall, we're doing widely accepted treatments which often require MD contact prior to doing them except in extreme circumstances. 

I work in a system that is patient care oriented and to an extent allows us to be "thinking" Paramedics however if I routinely go outside of protocol without justifiable cause I will be called to the table and have to answer for my actions because at the end of the day doing so constitutes practicing medicine without a license.

This letter put us down and might not have been nice but whenever Nurses talk about challenging the NREMT Paramedic Exam we get all up in arms about it. When Nurses try to move into the prehospital realm we get all up pissy about it so why is it unreasonable to expect RNs to do the same when we attempt to step into their arena? 

I like you Sandpit and Dr.P but this thread is astonishingly bad and as I said before displays a level of ignorance that you were the last person I'd expect it from.  

Cool, we can give morphine on standing orders and the vast majority of Nurses cannot however I'd be willing to bet there are nurses in an Urgent Care or ER setting that can do in areas with low Physician coverage. 

Cool, we can run codes however in the majority of systems to call that code we have to talk to a physician. EMS systems in some areas still require OLMD contact for things like CCBs, adenosine, amiodorone and many other drugs when the patient's condition is hemodynamically stable enough to allow for time to do so. 

Our charts are still reviewed, some by a Physician in certain circumstances so while we might not "have to talk to a doctor before we do something" we damn well have to answer to one after the fact. 

How is that any different? 

Respectfully, a *Paramedic*.


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## Carlos Danger (Apr 29, 2015)

SandpitMedic said:


> I'm sorry, I am just desperate for professional recognition and it drives me to cling to the belief that I am superior to RN's in every way, and make ridiculous arguments to defend that belief.



Sandpit, I fixed your last post for you.

Look, you are pretty too, OK? Really, really pretty. And I'm sure you give great morphine. I mean it.

Now will you stop embarrassing yourself and all the rest of us? Just go back to living in your narrow-minded Paramedics of Facebook fantasy world, where you are safe and better than all the nurses.


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## DrParasite (Apr 29, 2015)

Remi said:


> blah blah blah...
> 
> But consider this: when you are going toe-to-toe on a serious political battle over important scope-of-practice issues, you are far better off doing so from a position of knowing as much as possible about your opponent and their possible motivations. No matter who started it or how unfair they are or how untruthful they are being, _your_ argument is very weak if it relies at all on untrue or half-true "facts". And I can assure you with 100% confidence that if you start spewing some silly BS about how "nurses can't do anything without a doctor's permission, yet paramedics are autonomous" to someone who is really knowledgable about nurse practice issues and knows that paramedics can only operate under a set of written protocols and a physician's explicit authorization, they will tear your argument to bloody shreds and leave you stuttering, trying to find the words to save just a little face, and you will have thoroughly lost the debate in the eyes of anyone watching. I promise. If you think I'm wrong, go ahead and try to fight this battle on that premise. I'll try not to say I told you so.


apparently not... wait, are you telling me a paramedic is a physician extender, who can only do what the physician has told them to do? Color me amazed.... let me guess, nurses do the exact same thing? Oh wait, there is one pretty big difference: a paramedic has protocols to follow for EVERY patient, which are guidelines for how certain conditions are to be treated, based on the paramedics assessment.... while a nurse has standing orders for EVERY patient, but can only initiate many interventions after a doctor has assessed the patient and directed her how he or she wants the patient to be treated. Do you see the difference?



Remi said:


> I'm not going to try to list all the things that can done by RN's on standing order. But everything that has been mentioned in this thread as an example of what nurses can't do without being told........is being done right now by an RN, in a hospital, on standing order. Not to mention the RN that is intubating a blood airway in the back of an ambulance, or the RN who is starting a central line in a helicopter on the long flight to a tertiary center. Or the paramedic who is working in an ED and NOT running the code or doing the intubation, because a physician is present and in charge, and for both RN's and paramedics, degree of autonomy and the skills they perform has more to do with practice environment than anything else.


please list one hospital where a RN (not a CRNA, a plain old RN) is performing intubations on a regular basis, and I will concede that are correct. I am better you can't.



Remi said:


> I don't expect you to sit quiet and do nothing.......I don't care what you do. But being quiet probably _is_ a better option than going off half-cocked about something you obviously know little about.


you know, for someone who claims to know a lot about paramedicine, and nursing, you are making a lot of claims, and unable to back it up with facts. Lots of theory, not much reality, just saying.





Remi said:


> Please, spare me the guilt. I'm a CRNA in South Carolina who has never even been to Texas and has never been involved with the ENA anywhere - do you really think the Texas ENA or any legislators there give a crap what I have say in support of paramedics?


actually, I would think the texas ENA president would discard your comments out of hand... especially if you don't support their position. After all they deal in incorrect information, half truths, and anything that doesn't support their position obviously can't be right. Hey wait, maybe you two have more in common than you think.....

but I don't think your giving yourself enough credit when it comes to what the legislators think.... after all, a letter from Remi, NREMTP, RN, BSN, CRNA, might hold some weight, because it makes you sound like you know what you are talking about... well, in theory anyway....



Remi said:


> (You do know that traditionally, CRNA's and the larger nursing establishment tend not to get along very well, right? Of course you do, since you know so much about nursing practice.)


you think it has something to do with having much more education, and a much different job description than a regular old RN?



Remi said:


> That's really a dumb question, though. Even if the answer were "no", it would not support your point. That's because in any ED where protocols do not exist to allow RN's to administer morphine prior to eval by an MD, I guarantee you that protocols would also not exist that allow an ED paramedic to do so. And any RN working outside the hospital will have the same types of standing orders to give morphine as any paramedic. So it isn't an issue of paramedic vs. nurse autonomy at all. As I explained in the last post, it has more to do with practice an environment. Paramedics give meds without the patient being seen out of necessity, bot because they are somehow better qualified to do so than RN's.


I think it's a very valid one. You just don't like it because it goes against supporting your argument.

The texas ENA made a point to say that nurses act with more autonomy than paramedics. A paramedic is trained to work on a truck, to make decision without consulting with an MD. Yes, they have protocols, but they don't need to get a verbal order from a doctor to push morphine. They have standing orders, where based on their assessment, the patient needs it, and they are going to do it. A nurse, however, is trained to work in a hospital, where the doctor assesses and evaluates the patient. The nurse does too, but the doctor is the one who says “in this patient, if they are in pain, give morphine;"  it's not the nurses call.



Remi said:


> Paramedic practice and nursing practice is obviously very different. But you seem to think a paramedic is way bigger of a deal than you actually are. Do you ever wonder if that might have something to do with the perception that much of the rest of healthcare has of paramedics?


interesting.... so you say both practices are different, but apparently the practice of nursing is a much bigger deal than what the lowly paramedics are doing day in and day out..... maybe nursing just has a much better lobbying group?


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## DrParasite (Apr 29, 2015)

Handsome Robb said:


> Sandpit, you're making all of us as Paramedics look ignorant. Just quit.


actually, he's not.  he's 100% correct.  he asked a simple question.  Remi said, "in theory yes.  in practice, no."  I think the answer is pretty clear, and it has nothing to do with ignorance.  The topic in question was a nurse's assertion that a nurse is much more autonomous than a paramedic, when I think the answer to the question shows that it's not the case.





Handsome Robb said:


> I'm a Paramedic. I am going to continue being a Paramedic whether it be ground, flight or fire. I have no aspirations of being a nurse and the only reason I'd go to nursing school would be to become a CRNA and I would spend as little time as possible working as an RN to achieve that. Even with that I'd rather go the route of AA, especially if they expand the regions they're allowed to practice in. So before you freak out and question my intentions I'm making my position in healthcare and my intentions in healthcare very apparent
> 
> We have less education, less clinical hours, lower entry requirements to our field and operate solely by standing orders as written by a physician. Yes, we make decisions to utilize or not utilize treatments authorized under these protocols however at the end of the day we cannot routinely go outside of those protocols except in circumstances which are extremely justifiable. Also, when we do deviate from protocol we're not doing anything outrageous or off the wall, we're doing widely accepted treatments which often require MD contact prior to doing them except in extreme circumstances.
> 
> I work in a system that is patient care oriented and to an extent allows us to be "thinking" Paramedics however if I routinely go outside of protocol without justifiable cause I will be called to the table and have to answer for my actions because at the end of the day doing so constitutes practicing medicine without a license.


and I don't think anyone is saying otherwise



Handsome Robb said:


> This letter put us down and might not have been nice but whenever Nurses talk about challenging the NREMT Paramedic Exam we get all up in arms about it. When Nurses try to move into the prehospital realm we get all up pissy about it so why is it unreasonable to expect RNs to do the same when we attempt to step into their arena?


really?  you get pissy about stuff like that?  I have worked with several RNs who did that... if they can pass the same written exams, and clinical exams, why are you getting all worked up over stuff like that?  might be a regional thing, but I have never heard of it.





Handsome Robb said:


> I like you Sandpit and Dr.P but this thread is astonishingly bad and as I said before displays a level of ignorance that you were the last person I'd expect it from.


so you expect it from me?  I'm a little hurt Rob......



Handsome Robb said:


> Cool, we can give morphine on standing orders and the vast majority of Nurses cannot however I'd be willing to bet there are nurses in an Urgent Care or ER setting that can do in areas with low Physician coverage.


sure.... give me one example.  that's all I want.  where a RN (not an NP or anything, a new grad RN) in an ER or urgent care setting can do it, and I will gladly accept it as true.





Handsome Robb said:


> Cool, we can run codes however in the majority of systems to call that code we have to talk to a physician. EMS systems in some areas still require OLMD contact for things like CCBs, adenosine, amiodorone and many other drugs when the patient's condition is hemodynamically stable enough to allow for time to do so.
> 
> Our charts are still reviewed, some by a Physician in certain circumstances so while we might not "have to talk to a doctor before we do something" we damn well have to answer to one after the fact.
> 
> How is that any different?


having physician oversight isn't the question, nor is standing orders. Because if you are called into a review session (in any level of healthcare), there is a good chance at least one of the people will have MD after their name.



Remi said:


> Look, you are pretty too, OK? Really, really pretty. And I'm sure you give great morphine. I mean it.
> 
> Now will you stop embarrassing yourself and all the rest of us? Just go back to living in your narrow-minded Paramedics of Facebook fantasy world, where you are safe and better than all the nurses.


it's not about being condecending or looking pretty.... in fact, you're the one who is embarrassing yourself.... a simple question was asked, and you gave a pretty poor answer to justify that in theory your profession (nursing) was better, when we both know the reality and the theory weren't on the same page.


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## DrParasite (Apr 29, 2015)

For the record, I don't care what the Texas ENA president says about their field. I don't live in texas, I have no intention of living in Texas, and I know the ENA president (in any chapter not just texas) is going to do whatever she can to support the nurses position.

The issue I have is when she says something to a legislator about how good nurses are, and does it at th expense of other professions, in this case, paramedics. And Yes, I have no problem supporting my industry, because I think we, as EMS professionals should speak with one voice and stand up for ourselves, especially when someone demeans our profession with half truths, inaccurate information, and downright lies.

If any paramedic thinks that legislators don't talk to one another, or Google various topics, than you are fooling yourself. If you think that a Nevada senator isn't going to find that letter and think “oh, if paramedics are that bad, we shouldn't even trust them to do xyz, and they definitely don't deserve any to get any more funding. Let's give that money to the nurses, they actually help people, I have a letter to support that” than are living in a fantasy world.

We don't have a strong national body, we don't have state lobbying groups, and the legislators consider us to be ambulance drivers at worst, and an expendable resource at best, able to be outsourced to the cheapest bidder if the budget called for it. In fact, most people don't want to fund us properly, or give us any money, until they have a medical emergency and call 911. So it is up to the individual to support the profession until some state or national leadership group is formed (probably won't happen in my career lifetime, but a man can dream).

For the record, I don't think paramedics are better than nurses. They both do their jobs well, and are trained for the environment they typically work in (paramedics in the field, and nurses in a hospital). And yes, when their environment changes, adaptations need to happen, and many paramedics work well in a hospital, while nurses work well out in the field.

But I don't think a nurse should be lobbying against the modification of a paramedic's scope of practice. I don't think that just because a paramedic goes from their field to a hospital they should have their hands tied and have their scope of practice legally reduced, because that is how the nurses operate in a ER (sorry if the truth stings a little to those who are going to deny it).  If you want to advance your profession, why don't you try doing it without stepping all over ours?

If you still don't get it, read the actual letter posted at http://unwiredmedic.com/2015/04/24/texas-enas-unprofessional-attack-on-ems/ then read the blogger's resposes. Instead of citing opinion, it cites several facts, points out the author's half truths, and pretty much says “you know where the letter says this? Yeah, it's BS, and here is why....” giving accurate information, instead of the inaccuracies the original author implied.

Ignore everything that was posted in this thread, read the letter for yourself, and read the blogger's responses. And draw your own opinion.


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## Carlos Danger (Apr 29, 2015)

DrParasite said:


> actually, he's not.  he's 100% correct.  he asked a simple question.  Remi said, "in theory yes.  in practice, no."  I think the answer is pretty clear, and it has nothing to do with ignorance.  The topic in question was a nurse's assertion that a nurse is much more autonomous than a paramedic, when I think the answer to the question shows that it's not the case.and I don't think anyone is saying otherwise
> 
> really?  you get pissy about stuff like that?  I have worked with several RNs who did that... if they can pass the same written exams, and clinical exams, why are you getting all worked up over stuff like that?  might be a regional thing, but I have never heard of it.so you expect it from me?  I'm a little hurt Rob......
> 
> ...


Don't worry, Parasite.....we see you too, and you are also pretty.


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## SandpitMedic (Apr 29, 2015)

Remi said:


> Don't worry, Parasite.....we see you too, and you are also pretty.


"When the debate is lost slander becomes the tool of the enemy."
-Socrates

I've been warned by moderators for getting a little too coarse  with my language, and substituting the word pretty for ******* may fool them... But it isn't fooling me.

And look here- just because you were the captain of the political debate team, and you can spin every answer you give into a pearl of information that seems to support your causes doesn't make you right. You're the one that is being ignorant, you're just articulate while ignorant. You may be fooling people like Robb (who I will address later) into dropping their arms and stepping on their ****s, but you aren't fooling me.

Mostly everything you said was assumption, theory, or a flat out lie. You stated very few facts. Spin it how you want; you should be president. #Remi2016!

You and the author of that letter are making a claim that the autonomy of RNs exceeds that of a Paramedic and that RNs hold some sort of eliteness - I asked you a simple question to challenge that and also demonstrates that those claims are not true. I'm also defending all paramedics, not myself.

What I said earlier was I am willing to be "corrected." I should have said I am willing to be educated - demonstrate a factual case in which a normal RN has the same autonomy... You can't. Because they don't.

This is not a **** measuring contest, nor it is a slam on any nurses. I have many nurse friends and will soon even be married to one. It is not even prudent for me to tell you that, because I have no need to defend myself against "nurse bigotry" to you, but just to add that little tidbit before you dive deeper into that slander. Nurses are doing a fabulous job, and an important job very well. But they are not "better" than paramedics, and paramedics are no "better" than nurses. Shoot, we even have EMS-RNs here... And I'm not up in arms about it- they're great!

However, that's not the focus of my points. My point is similar to what Dr.P is saying. I know we look prissy to you down here from up there on your high horse, but if the situation were reversed you had better believe it would entice the same response from the RN community.

I don't care about you. I don't care about Texas. I don't care about what other medics in ERs do. I also don't plan on being a paramedic forever.

However, I also am not gonna take a barrage of incorrect insults and insinuations about our profession to make another appear grandeur laying down. If we allow that collectively or passively, we set a further establish the precedent that a.) it is true, and b.) that it is okay.

It is not.


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## Summit (Apr 29, 2015)

Sandpit, Dr P, seriously, stop. Your attitudes and arrogance reflect extremely poorly on EMS. So does your double standard.

You are being intellectually dishonest by claiming that "RNs can't" then when told that they can, you switch your argument to "well, most usually don't" and then insinuate that is tantamount to "can't."


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## Carlos Danger (Apr 29, 2015)

SandpitMedic said:


> "When the debate is lost slander becomes the tool of the enemy."
> -Socrates



Slander requires 1) a spoken word, and 2) an intentional mistruth about someone. 

What I did was not slander, it was mockery. Big difference.



SandpitMedic said:


> You and the author of that letter are making a claim that the autonomy of RNs exceeds that of a Paramedic and that RNs hold some sort of eliteness



This could not be further from the truth. 

Apparently, your poor reading comprehension skills rob you of the ability to understand that I was squarely on the side of paramedics at the beginning of this thread, and was simply warning against using "but nurses can't do anything without a doctor telling them to, and we are autonomous" as a defense against the ENA's letter, because it's demonstrably untrue. That is all.

But that was just too much for some of you to be expected to grasp, I suppose.



SandpitMedic said:


> What I said earlier was I am willing to be "corrected." I should have said I am willing to be educated - demonstrate a factual case in which a normal RN has the same autonomy...e



I gave several examples. Re-read my posts.



SandpitMedic said:


> However, that's not the focus of my points. My point is similar to what Dr.P is saying. I know we look prissy to you down here from up there on your high horse



You don't look prissy, you look desperate. And you look ignorant about nursing practice. It is of course fine for someone who isn't a nurse to be ignorant about nursing practice......but you shouldn't pretend not to be. 



SandpitMedic said:


> However, I also am not gonna take a barrage of incorrect insults and insinuations about our profession to make another appear grandeur laying down.



I haven't insulted "your" profession once. I still love EMS and have great respect for paramedics, which is why I hang out here. I learn from paramedics all the time, and like to think that I am able to share some of what I know.

What I have no patience for is the repulsive combination of ignorance and cockiness that unfortunately afflicts so many individual paramedics, and makes life hard for all the good ones.


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## SandpitMedic (Apr 29, 2015)

Cockiness has nothing to do with it. I know my role. You should check your fire. The ENA is full of so much BS, period. And I don't know why you can't just concede that a field paramedic has more autonomy than an RN... 

You said ignorant, desperate, and cocky... I think "spoken word" translates into written word via forum in this case, but whatever.

Like I said, I don't care what you have to say about me personally. I'm all out of ****s to give. You can "hang out here" all you want- sometimes you know what you're talking about. I enjoy those times. #Remi2016!


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## SandpitMedic (Apr 29, 2015)

Deleted

Paramedics who want to keep on being treated like kids and disrespected... Reap what you sow.

Over it.


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## triemal04 (Apr 29, 2015)

I just don't understand this.  I really don't.

To anyone who actually understands the medical field, the letter that sparked everyone up is nothing more than an embarrassment to the author, and the group she represents.

Many of the response's here just further that embarrassment, for BOTH professions.

While there should be, and needs to be a public rebuttal to the false allegations and half-truth's put out by the ENA, countering with ignorance and hyperbole is counterproductive.


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## triemal04 (Apr 29, 2015)

Maybe somebody could actually do something like point out the differences and similarities between the 2 professions.

Differences:
RN: require an associate's degree.
Paramedic: require about a year's worth of schooling.

RN: taught primarily as a generalist with supportive care; if it was a field of medicine, it would be closest to family practice, with maybe palliative care I'd say.
Paramedic: taught primarily about emergency medicine.

RN:  focus on working primarily in a controlled setting with abundant resources.
Paramedic: focus on working primarily in a less-controlled setting with limited resources.

RN: focus on working in a team setting under more direct control.
Paramedic:  focus on working individually under indirect control.

Similarities:
Work under the supervision (direct or indirect) of a doctor.
Cannot function *in their capacity* as a paramedic or RN without the above supervision.
May provide higher level's of care in their capacity as a paramedic/RN in specific settings.
Require OJT or courses beyond the scope of their* primary* education for specific settings and functions.
Can work in multiple settings, including in/out of a hospital.
*At the base level*, with some exceptions, can administer the same meds and perform the same interventions.

There.  No hyperbole, no exaggerations, no miss placed anecdotes about local areas or settings.  No confusing extra training and advanced care settings for the basic level that is taught. 

If anyone wants to add something to those lists, please feel free.


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## Summit (Apr 29, 2015)

I think Triemal made a good post. I'll make some additions:

Average age of a Paramedic: 35
Average age of a RN: 45



triemal04 said:


> RN: require an associate's degree.


>50% of new graduate RNs have a BSN or MSN and this is growing.
>50% of all RNs have a BSN, MSN, or DNP.
Most hospitals are asking for a BSN minimum in order to work in acute care, an increasing trend.
~3% of new nurses enter the profession without a degree, instead completing a 3 year hospital diploma program. Of the total RN population, 10% of all RNs have no nursing degree.



> RN: taught primarily as a generalist with supportive care; if it was a field of medicine, it would be closest to family practice, with maybe palliative care I'd say.


I agree with the generalist training, but family practice + palliative is not quite the closest analogy. The primary aim of most RN programs which is inpatient acute  and procedural care. Back in school, 90% of my 1200 hours were critical care/ER/acute/procedural(OR/IR/EP). The other 10% were public/community health. 

~60% of RNs work in the hospital setting. The other ~40% are divided between public health, home health, community health, nursing education, transport nursing, ambulatory care, nursing homes, policy/case/insurance/legal etc.


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## triemal04 (Apr 29, 2015)

Summit said:


> I think Triemal made a good post. I'll make some additions:
> 
> Average age of a Paramedic: 35
> Average age of a RN: 45
> ...


But to have an honest and accurate conversation you really need to leave things like this out.  What really matters when comparing professions is what is required at the bottom level to hold that title; while there are plenty of BSN's out there, just as there are a fair amount of paramedics that hold a degree (in something, not neccasarily EMS) what matters is what is *required* at the base level. 



Summit said:


> I agree with the generalist training, but family practice + palliative is not quite the closest analogy. The primary aim of most RN programs which is inpatient acute  and procedural care. Back in school, 90% of my 1200 hours were critical care/ER/acute/procedural(OR/IR/EP). The other 10% were public/community health.


I was trying to come up with a way of saying "nursing care" without saying "nursing care," and avoiding personal experiences.


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## triemal04 (Apr 29, 2015)

Summit said:


> ~3% of new nurses enter the profession without a degree, instead completing a 3 year hospital diploma program. Of the total RN population, 10% of all RNs have no nursing degree.


That is interesting.  I didn't know it was even an option anymore.


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## Handsome Robb (Apr 29, 2015)

Dr.P I don't expect it from you either. Sorry, late night post and didn't add that in. I don't expect it from either of you.

I personally don't get all pissy about them challenging the test however I do personally think that if a Paramedic has an AA/AS/BS with appropriate science courses that we should be able to challenge the NCLEX but that will never happen.

I'd like to know how I've been fooled, Sandpit. Because I understand the limitations of Paramedics? Not only because of our education but also because understand how we practice and am willing to concede to the fact that we do still operate under the orders of a Physician. That we are not individual autonomous practitioners of medicine as we see fit?  If that's fooled then cool, but I'm not sure how you're going to argue that.


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## Carlos Danger (Apr 29, 2015)

Nursing is so broad a field and paramedicine such a focused and narrow one that it's hard to really compare them head to head like this.

It's easy to say "let's just compare entry-level to entry-level" - and we can do that, of course - but that doesn't really give an accurate picture of nursing, because entry-level nurses are a small percentage of total nurses. When a full 50% of members of a profession are entering with a 4-year degree (and more are obtaining that degree after entering), and many are doing things like ICU nursing and research and then advanced practice, I think that's an important part of the landscape.

The two look quite similar on the surface, but they really have many more differences than similarities.


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## Carlos Danger (Apr 29, 2015)

Summit said:


> You are being intellectually dishonest by claiming that "RNs can't" then when told that they can, you switch your argument to "well, most usually don't" and then insinuate that is tantamount to "can't."



Exactly. That pretty much sums up all of their incoherent and petulant rantings.


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## triemal04 (Apr 29, 2015)

**** it.  This is a waste of time.  Mods, just close this thread, it's worthless.


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## Summit (Apr 29, 2015)

triemal04 said:


> But to have an honest and accurate conversation you really need to leave things like this out.  What really matters when comparing professions is what is required at the bottom level to hold that title


Perhaps? But since the genesis of this discussion was the ED, my point was that if a RN wants to work in the ED, the _minimum _requirements are typically a BSN and 1-2 years acute/emergency/critical care RN experience. That's typical, and for major trauma centers almost universal.



> just as there are a fair amount of paramedics that hold a degree (in something, not neccasarily EMS)


That is only relevant if I consider what percent of RNs have a MBA, BS Physics, BA English, etc.



> what matters is what is *required* at the base level.


I think what is typical matters because the base level these days will get a nurse into a nursing home more often than a hospital.

>97% of new RNs have at least an Associates in NURSING
>50% of new/all RNs have at least a Bachelors in NURSING

Most Paramedics do not have a bachelors, and few have any degree in paramedicine.



> I was trying to come up with a way of saying "nursing care" without saying "nursing care," and avoiding personal experiences.


Fair enough. Avoiding, personal experience, the majority of RNs do work in the hospital, so I disagreed with the "family practice" analogy which implies outpatient/ambulatory/sub-acute.

Depending where you look, about >60% are in the hospital. The biggest groups there are:
1. Acute care (Med/Surg/Tele/Onc/OB etc)
2. Procedural Care (OR/PACU/EP/CCL/IR/GI/L&D etc)
3. ICU
4. ED

<30% of nurses provide care out of the hospital: transport, public/community/home health, nursing homes, ambulatory/rehab
~10% are in non-direct-care positions like education, research, management, informatics, case review, policy etc.


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## Carlos Danger (Apr 29, 2015)

triemal04 said:


> **** it.  This is a waste of time.  Mods, just close this thread, it's worthless.



I'm sorry things aren't as simple as you'd like them to be.


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## SandpitMedic (Apr 29, 2015)

Nurses coming out strong - super strong - for their positions! No wonder they make so much more money - never give up and make counter accusations all day without compromise!
 Wish more paramedics would post up.

Summit- nurse
Remi - nurse
Robb - nurse hopeful

Hmmmm?
Nurselife.com? Perhaps.

This is rediculous.... Like fer'real.


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## Carlos Danger (Apr 29, 2015)

SandpitMedic said:


> Nurses coming out strong for their positions! Wish more paramedics would.
> 
> Summit- nurse
> Remi - nurse
> ...



Summit - EMT
Remi - paramedic
Robb - paramedic

I'm not sure what your point is.....


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## SandpitMedic (Apr 29, 2015)

Don't you understand? Remi is never wrong. The nurses are never wrong. 

A nurse will do whatever they want. ****, a nurse is going to be the first person on Mars. WITH a degree! 

C'mon... You can't just compare entry level nurses to paramedics... Because nurses are so freaking amazing... New grads and all. 
Even those SNF nurses... 

......
Nurselife.com
......
#Remi2016!


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## Carlos Danger (Apr 29, 2015)

SandpitMedic said:


> Don't you understand? Remi is never wrong. The nurses are never wrong.



Oh I definitely understand. Your panties are all wadded up because everyone isn't constantly blowing rainbows at you about how paramedics are the awesomest thing ever.


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## SandpitMedic (Apr 29, 2015)

Run for office bro. Please. 
You're good at the politics game. 
I don't have enough tact or patients for it. I'm a realist.

But you... You're a politician. 

You should run for office; congress, school board or something.


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## SeeNoMore (Apr 30, 2015)

No matter what paramedics think we will always be regarded as below nurses until we mandate similar education and excercise similar professional advocacy. The name calling is silly. We all know great nurses and medics and weak ones. All the rest of the medical world sees when paramedics claim they are more autonomous or independent than nurses "who just follow orders" is childish boasting from a position of weakness.


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## DrParasite (Apr 30, 2015)

Summit said:


> Sandpit, Dr P, seriously, stop. Your attitudes and arrogance reflect extremely poorly on EMS. So does your double standard.



double standard?  Because I say in an emergency situation, a paramedic can assess, create a treatment plan, and begin interventions prior to seeing or speaking to a doctor using protocols where they can decide, using their education and experience, how they should be followed, while a nurse can't begin a treatment plan or most serious interventions before a doctor sees the patient?

I am standing up for my profession when it is being accused of being inferior to another healthcare profession, because someone who is using inaccurate information decided to slam it.



Summit said:


> You are being intellectually dishonest by claiming that "RNs can't" then when told that they can, you switch your argument to "well, most usually don't" and then insinuate that is tantamount to "can't."


when you can do something in theory, but you can't do it in reality, that is tantamount to can't.  In theory, a paramedic can do a C-section in the field, assuming they get permission from their medical control base to perform the procedure (because as long as the doctor is ok with it, you can do a lot of things).  In reality, those paramedics who did that are no longer paramedics.  See, that's the difference between a theory (a concept that is theoretically possible) and reality (what actually happens).

And I would drop the topic if anyone could name one health care facility where a nurse can administer a narcotic med to a patient prior to being seen by a doctor. But alas, even the all knowing CRNA couldn't provide one.

you know what? I give up.

For those of you who want to believe the lies and half truths spoken by a nurse about paramedics, do it.

for those of you who think nurses can do so much more than paramedics in an emergency situation, do it.

for those of you who like spin more than actual facts, than feel free to believe everything Remi says.

I don't care about the differences between paramedics and nurses.  I know there are many.  But the topic was supposed to be about a letter written by a chapter president of the ENA, saying how paramedics were inferior for various reason.   You want to continue thinking that, more power to you.

I'm done.


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## Summit (Apr 30, 2015)

DrParasite said:


> double standard?
> ...
> In reality, those paramedics who did that are no longer paramedics.
> ...
> And I would drop the topic if anyone could name one health care facility where a nurse can administer a narcotic med to a patient prior to being seen by a doctor.



Let me try one last time. RNs can do what paramedics can do if they work on a helicopter. I don't know every hospital's RN protocols...

Let let's just assume that the answer is NONE.

How many TX health care facilities can Paramedics do this?
Also None

What would it take to allow a RN to do the things mentioned?
MD and facility write a protocol, policy, and training.

What would it take to allow a paramedic to do the thigns in a hospital?
MD and facility write a protocol, policy, and training... AND A NEW LAW.

I say double standard because you are using exactly the disingenuous method that you are accusing the ENA of.

So explain to me why there should be a new law?

Paramedics can do all the things they do in the prehospital environment with the current training requirements they have because our society has, for some stupid reason, decided that we don't want to pay more. So you need a broad skillset provider at, sadly, a low cost who implements skills that are primarily either low risk/high gain or high risk/high gain with thresholds for implementation where the consequences of inaction are nearly as high. And to get enough of these providers to work for cheap enough, you have to settle for low education standards so the barrier to entry is low enough . That is how the healthcare system is designed to screw EMS in the US, vs how it is done in say Canada, NZ, AU etc with high compensation and education... or other countries where they use RNs or MDs.

And EMS providers in the US don't like it the low pay, but they do like the rather autonomous protocols. So someone decided the solution is to work in the ED, but imagine it would be a good idea to keep the liberal field protocols?

The reason that RNs don't have more liberal universal standing orders is because MDs and hospitals don't want them to because there isn't a huge need for it. NOT BECAUSE THEY CAN'T. In order to provide better patient care and achieve more autonomy in the hospital where MD/PA/NP/CRNA are close at hand, RNs raised their educational standards so that 2 year degree RNs can barely find a hospital job and the ED/ICU wants years of experience. Now why would the hospital want to bring in paramedics to do what they could have their RNs do with the same policy/protocol change and without a new law? One reason: Paramedics are cheaper because their training is less expensive and faster. So after the RNs fought for higher educational standards, there is a proposed law change to allow providers who may only have one year of technician training in to supplant them with more autonomy... yea... I bet they are frothing at the mouth just like you are in this thread. How does that make sense?

The other question is do the ED physicians really want paramedics in the ED with more autonomy than their RNs? Or is this a push by hospital corps? Or is this a push by EMS associations?


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## SandpitMedic (Apr 30, 2015)

Summit said:


> Let me try one last time. RNs can do what paramedics can do if they work on a helicopter. ..





I LOVE LAMP! 
Are you a brick wall or a human being? 
This debate has been about emergency room RNs and prehospital field paramedics. 
Why are you bringing up HEMS?!

Irrelevant.



> The reason that RNs don't have more liberal universal standing orders is because MDs and hospitals don't want them to because .....


STOP!




Just stop. That is quite an astounding assumption. Also, that's the dumbest thing I've ever heard.

You're the Palin equivalent for Remi.

#REMI.SUMMIT2016!



> The other question is do the ED physicians really want paramedics in the ED with more autonomy than their RNs? Or is this a push by hospital corps? Or is this a push by EMS associations?



This is actually a fantastic question.


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## RocketMedic (Apr 30, 2015)

I fully support the Texas nurses and ENA. Paramedics are not educated enough to be able to perform the same tasks as nurses in facilities as a standard, we lack the professional development mechanisms to improve most of our entry-level personnel and we fiercely defend our islands of ignorance. 

Putting paramedics at full scope into EDs is a shortcut for education that only appeals to the lazy, semi-literate and arrogant among us- explaining why Sandpit is so vehemently for it.


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## Summit (Apr 30, 2015)

SandpitMedic said:


> This debate has been about emergency room RNs and prehospital field paramedics. Why are you bringing up HEMS?!


Why do you think RNs have liberal universal standing orders in HEMS?



> Just stop. That is quite an astounding assumption. Also, that's the dumbest thing I've ever heard.


Why do you think RNs do not have liberal universal standing orders in the ED?


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## Carlos Danger (Apr 30, 2015)

First, I really don't understand the fixation with morphine on standing orders. Even as a mere example, it's a stupid way to try to define autonomy, for numerous reasons.  

Second, it's important to understand that paramedics have liberal protocols based on _necessity_, not because they possess some superior clinical judgment. It's impractical to call for orders for everything that happens in the field. On the other hand, in the hospital, doctors are everywhere, and it's generally not hard to get orders when you need them, hence less reliance on written protocols. It has nothing to do with autonomy, and everything to do with practice environment and the availability of physicians. The same exact is true of invasive skills - paramedics don't intubate and cardiovert because they are better at it than everyone else; they do it because there are no physicians around to do it.

The real proof that the level of autonomy has much less to do with licensure than with practice environment rests in the simple fact that when they are placed in the same environment, RN's and paramedics typically have very similar levels of autonomy.  For instance, flight and CCT nurses generally follow the same if not more liberal protocols (yes, I can give several examples) as flight or CCT paramedics. Paramedics who work in the hospital, on the other hand, are generally not going around running trauma alerts and running codes and ordering meds and dropping tubes all by themselves; they are usually working at a level similar to an RN, if not as a PCT.

I thought the whole thing was so dumb, in fact, that I wasn't going to bother taking the time to respond to it. Eventually, though, you've worn me down. So I thought I'd take a quick look and address these inane demands, just to put them to rest and prove that you don't know what you are talking about.




SandpitMedic said:


> In regards to the administration of Morphine... *Are you suggesting, that via standing order, on a first encounter with a patient in an ER or urgent care, that an RN can just administer morphine if they deem it appropriate?* Prior to that patient seeing a provider or mid-level provider? Yes or no?






SandpitMedic said:


> *The answer is no.*
> 
> *Prove me wrong with fact*, or stop.





DrParasite said:


> double standard?
> And *I would drop the topic if anyone could name ONE health care facility where a nurse can administer a narcotic med to a patient prior to being seen by a doctor*. But alas, even the all knowing CRNA couldn't provide one.





DrParasite said:


> sure.... *give me ONE example.  that's all I want.*  where a RN (not an NP or anything, a new grad RN) in an ER or urgent care setting can do it <administer morphine on standing order, and I will gladly accept it as true.


​It took me less than 5 minutes to find several examples of "proof" that in some places, RN's do in fact give morphine in the ED, on standing order, prior to the patient being seen by a physician. I googled a couple terms, and the search engine suggested "emergency department triage nurse initiated pain management". I clicked on that and quickly looked at the first few hits. 

The third search result was this article, which is about a study done at Chula Vista Medical Center in San Diego, on the way that their nurse initiated pain protocol affects time-to-analgesia and patient satisfaction. The protocol "is based on the patient's pain score *and ranges from Tylenol for mild pain to morphine for severe pain*", says the article. 

So there you go. There's your one example. And it's not at some teeny-tiny shack of an ED out in the middle of nowhere.

I wouldn't have looked any further, but the fifth hit caught my eye because it was from Medscape Anesthesiology - one of my favorite references. It is an article in which a physician promotes the practice of RN-initiated opioid pain management, based on several studies that are cited. You can't study something that doesn't happen, can you?

This is only two examples, but that's twice what you demanded, and it literally took less than 5 minutes to find. Even though most ED's don't bother publishing their nursing protocols online, I have no doubt that I could find many more examples if I cared enough to really rub your nose in it. 

See, I told you so.

-----------------------------------

And with that......I'm out. Apologies to everyone about the way this discussion slid from reasonable debate to silly arguing. I'm honestly a bit embarrassed at how long it dragged out.


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## SandpitMedic (Apr 30, 2015)

RocketMedic said:


> Putting paramedics at full scope into EDs is a shortcut for education that only appeals to the lazy, semi-literate and arrogant among us- explaining why Sandpit is so vehemently for it.







I never, ever, not even once said anything remotely similar to being a proponent of placing paramedics in the ER. 

I have stated and debated that field paramedics have more autonomy than ER RNs.

Check your fire.


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## SandpitMedic (Apr 30, 2015)

Remi said:


> First, I really don't *like to be wrong.*




There, *fixed* that for you.



> I thought the whole thing was so dumb, in fact, that I wasn't going to bother taking the time to respond to it. Eventually, though, you've worn me down.









​


> It took me less than 5 minutes to find several examples of "proof" that in some places, RN's do in fact give morphine in the ED, on standing order, prior to the patient being seen by a physician.



The title is very specific as is this order- and it applies to one thing only... Long bone fx. It's not a general standing order that allows for the administration of MS as the RN sees fit. And this is at one hospital in one emergency room... Not like in every ambulance- oh, I dunno... Everywhere. But whatever- apparently I was wrong technically about the MS. Not about autonomy though.
Implementation of Nurse-Initiated Pain Protocol in Improving Time-to-Pain Treatment for Long Bone Fracture 


> See, I told you so.








> And with that......I'm out.


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## SandpitMedic (May 1, 2015)

http://www.ems1.com/ems-products/co...2165643-Anatomy-of-a-grassroots-EMS-movement/


The ENA is apologizing and back pedaling. And paramedics standing up for themselves, as they should, are making big waves and accomplishments.


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## Summit (May 1, 2015)

SandpitMedic said:


> http://www.ems1.com/ems-products/co...2165643-Anatomy-of-a-grassroots-EMS-movement/
> 
> 
> The ENA is apologizing and back pedaling. And paramedics standing up for themselves, as they should, are making big waves and accomplishments.


The article you linked to says that TX ENA and national ENA disavowed the offensive letter written by some city chapter president that caused this thread.

Looks like ENA got the bill changed too... although it is possible they may achieved further change if that idiot hadn't written an idiotic letter.

Anyhow, since this thread is still going, I'm interested to hear your response to these questions I asked previously:

Why do you think RNs have liberal universal standing orders in HEMS?
Why do you think RNs don't have liberal universal standing orders in the ED?


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## SandpitMedic (May 1, 2015)

I don't work in HEMS.

And I don't work in an ER.

I don't know, and it wouldn't be prudent for me to assume other than to say out of necessity.


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