# Med control for Morphine?



## rhan101277 (Nov 15, 2009)

So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some.  She said even a paramedic must call med control before administration of a narcotic.  We can administer it without med control though so I decided not to argue.

Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash.  I explained that one must be developed so we can decide which protocol to follow and left it at that.

I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to.  Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<


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## Lifeguards For Life (Nov 15, 2009)

rhan101277 said:


> So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some.  She said even a paramedic must call med control before administration of a narcotic.  We can administer it without med control though so I decided not to argue.
> 
> Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash.  I explained that one must be developed so we can decide which protocol to follow and left it at that.
> 
> I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to.  Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<



I too have been put in many similar situations and am under the impression may rn preceptors i have had do not wish to have a student, and few seem too incompetent to have a student. I have had many paramedic preceptors that did not seem to know a whole lot.

And our medical director is pretty aggressive, we can give narcs in the field without consulting medical control as well.


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## FFMedic75 (Nov 16, 2009)

Alright guys, here is the deal with the nurses.  Remember the majority of them (with some exceptions i.e. flight nurses, NP, etc.) do not make decisions, they simply do what the doctor says.  The old adage in EMS that we don't diagnose as medics is BS.  Why do we do 12 Leads or take BGLs?  We diagnose symptoms and in many cases make definitive diagnoses prior to arriving at the hospital.  One example of this is transporting STEMI patients directly to the Cath Lab.  Many of the Nurses you will encounter are jealous of this.  Lots of others are just plain burnt out.  Having said that while doing clinicals you are there to practice specific skills like medication administration and IVs.  The majority of your patient assessment skills and clinical decision making will come when you do field internships.  The Paramedic Preceptors will be much more prepared and understanding to teach this.  My best advice now and throughout your career is not to piss off the nurses just go there practice your skills and be proactive.


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## Lifeguards For Life (Nov 16, 2009)

FFMedic75 said:


> Alright guys, here is the deal with the nurses.  Remember the majority of them (with some exceptions i.e. flight nurses, NP, etc.) do not make decisions, they simply do what the doctor says.  The old adage in EMS that we don't diagnose as medics is BS.  Why do we do 12 Leads or take BGLs?  We diagnose symptoms and in many cases make definitive diagnoses prior to arriving at the hospital.  One example of this is transporting STEMI patients directly to the Cath Lab.  Many of the Nurses you will encounter are jealous of this.  Lots of others are just plain burnt out.  Having said that while doing clinicals you are there to practice specific skills like medication administration and IVs.  The majority of your patient assessment skills and clinical decision making will come when you do field internships.  The Paramedic Preceptors will be much more prepared and understanding to teach this.  My best advice now and throughout your career is not to piss off the nurses just go there practice your skills and be proactive.



very well said. i


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## rhan101277 (Nov 16, 2009)

Thanks for the advice.  Where I will be working after class won't be in this area though.  I still want to make friends, so I will just do what I am told and try to get in there and get stuff done.  I have only been successful on 3 out of 13 total IV's attempted, most were hard sticks, hopefully I will get better.


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## downunderwunda (Nov 16, 2009)

Whats Med Control?

Waste of time.

You have the training, you have the knowledge, you should not have to talk to some Doctor to get permission to provide pain relief.


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## rhan101277 (Nov 16, 2009)

downunderwunda said:


> Whats Med Control?
> 
> Waste of time.
> 
> You have the training, you have the knowledge, you should not have to talk to some Doctor to get permission to provide pain relief.



And you don't, just an RN getting grumpy.


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## mycrofft (Nov 16, 2009)

*As a former EMT and current RN....(harrrumph)*

1. Some nurses are very status/pecking order oriented, and an EMT seems easy pickings. Or Peckings.
2. Some EMT's come in very self-inflated with their boots and their windshield punches and their stethoscopes around their necks and do not do what the receiving staff want, which is bring the pt in pumping with the data the staff  needs, then get out. Sometimes stuff goes missing. 
3. Some nurses or EMT's are not good at precepting anyone, and there is probably a rotation set up for who will watch the student that shift. I have met EMT's and RN's who refuse to help new people.
4. Some EMT's or Nurses are simply having a very cruddy day or life and you are the closest harmless thing to biff around.

Say to your preceptor "I am feeling that I am not doing anything right. Can you tell me specifically what I have to do better?". Write down their answer, or get it in writing and time and date it. If the answer is "Nothing, you're doing fine", it's your choice to talk about it or go to your instructor and ask for another preceptor. If the feedback seems odd or not real, take it to your instructor and talk about it. If the corrections are at all realistic, thank your preceptor and ask more questions about how you are doing.
If the preceptor says "You aren't cut out for this", consider it for a second, then talk to your instructor.

Been there done that.

As for the drug issue, learn your protocols but make sure the count is right at the beginning end and whenever you take out a narc, and when you are leaving shift you count the actual narcs to the oncoming person who looks at the book (or whatever), or you both count and read together. NEVER change shift by allowing the offgoing staff to hold the book and have the count read to *them* (too easy to say "good count" and instantly put it on the oncoming shift).


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## daedalus (Nov 16, 2009)

Ugh. I HATE the direction these threads go sometimes. While there may be very few RNs that envy being out in the field (I assure you, very few of them really want to be out on a rig when they could be making much more cash in the ED), there are many more paramedics I know who envy the RN's job. I say from experience, a lot of my paramedic partners have plans on going the RN route for better job stability, better benefits, better pay, better family friendly job. 

Also, very few RNs work under the old prejudices people have of them. They do not silently wait for orders from an MD and than go carry them out. Please shadow an RN in a modern ED or ICU/PICU/NICU/CCU if you do not believe me. 

In one nearby trauma center, the RNs typically have "ordered" most lab work before the doc sees the patient, and the MD/DO/PA just signs off on it. If you cannot do this competently, you will not last in that ED.

Also, common. RNs require a college education. We do not. Automatic trump. As painful as it is to admit, we have to fix this.

OP, I have encountered your situation as well. Keep your mouth shut and skate through your clinical and than in the field you will get to give all the morphine you want without calling base, and you can smile about it. You get what I mean.


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## VentMedic (Nov 16, 2009)

FFMedic75 said:


> Alright guys, here is the deal with the nurses. *Remember the majority of them (with some exceptions i.e. flight nurses, NP, etc.) do not make decisions,* they simply do what the doctor says. The old adage in EMS that we don't diagnose as medics is BS. Why do we do 12 Leads or take BGLs? We diagnose symptoms and in many cases make definitive diagnoses prior to arriving at the hospital. One example of this is transporting STEMI patients directly to the Cath Lab. Many of the Nurses you will encounter are jealous of this. Lots of others are just plain burnt out. Having said that while doing clinicals you are there to practice specific skills like medication administration and IVs. The majority of your patient assessment skills and clinical decision making will come when you do field internships. *The Paramedic Preceptors will be much more prepared and understanding to teach this. My best advice now and throughout your career is not to piss off the nurses j*ust go there practice your skills and be proactive.


 
Here we have another one who has absolutely no hospital experience and knows absolutely nothing beyond the back of an ambulance or fire truck. Yet, he feels the need to spout such crap to bash RNs to make up for whatever inadequacies exist in EMS and in himself. 

The major difference between RNs and those in EMS, besides the education, is that they know who they are and what they are capable of. They also know when, why and how to gain more education and respect in medicine. EMS still believes a few hours of training and their ability to drive real fast with their L&S automatically gives them respect.

There are many EMS services such as Washington DC that didn't have access to even valium or morphine until recently. I believe the morphine is still on a very limited basis with lots of hand holding from medical control. There are some EMS services in the U.S. that don't start any type of IV medications or fluids without medical control. There are also some areas such as California that just can not do much of anything due to their very limited state scope of practice which is why RNs are used on the CCTs and Flight teams. 

One of the reasons RNs and RRTs are utilized for Specialty teams is their ability to have very extensive scopes of practice extended to them by their states since they do have an established educational foundation that is consistent for the minimum and based on a college degree not a trade school diploma stating a few hundred hours. Thus, their job description can be as broad as necessary to get the job done. Even working on a flight team as a Paramedic with a fairly progressive scope of practice, I am still very limited when compared to my RN partner. In the ICUs and other nursing areas, there is no comparison as the RNs have extensive protocols to follow which fill books much larger than almost any Paramedic system in this country. 

However you are correct that the Paramedic preceptors should be better prepared to explain how it is in EMS. Most nurses will have a difficult time understanding how someone can do x but can not do y or how some don't even see that x and y should go together. Essentially, the limiting recipes of EMS make no sense to hospital staff who are about total care of the patient and providing all the meds necessary when needed and not "just this much". Sedation and RSI are good examples when the patient is given just enough to p** them off when procedures are attempted and not enough to do any good.

My other message to you is not to attempt to bash other health care professionals in an attempt to hide the problems that exist in EMS. Maybe if you address the problems that give rise to such discussions about EMS providers amongst other health care providers, there would be little need for threads like this.


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## mycrofft (Nov 16, 2009)

*I need to correct my last response!*

1. If you are coming on, YOU count the narcs while the offgoing reads the sign out/balance book to _*you*_, point being never accept a book count without personally correlating the actual eyes-on narcs to the count.
2. I am told I am still in the 19th century with that means of passing on control of controlled substances. Oh, well, so it goes...

We nurses need to recognize professionalism in whomever we meet when it is exhibited, whether it is a new MD, a medical assistant or technician, or the guy who refills the O2 cylinders. Actually, that's a good rule to live by period.


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## triemal04 (Nov 16, 2009)

mycrofft said:


> We nurses need to recognize professionalism in whomever we meet when it is exhibited, whether it is a new MD, a medical assistant or technician, or the guy who refills the O2 cylinders. Actually, that's a good rule to live by period.


Actually, that should just read "We," not just nurses.  But I agree with the overall sentiments completely.  Unfortunately, as can be seen with a couple of posts in this thread, it won't happen anytime soon.

To the OP:  don't worry about it.  Just as not every medic knows the in's and out's of each in-hospital care provider, not everyone of them will know about what we do.  It's not a bad idea to (politely and appropriately) explain why something that has bee said is wrong, but if you can't...meh.  It's not always possible with the various personalities you'll encounter.


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## MSDeltaFlt (Nov 16, 2009)

rhan101277 said:


> So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some. *She said even a paramedic must call med control before administration of a narcotic*. We can administer it without med control though so I decided not to argue.
> 
> *Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash*. I explained that one must be developed so we can decide which protocol to follow and left it at that.
> 
> I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to. Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<


 
Rhann, since we are both from Mississippi, let me explain it from first hand experience.

Mississippi EMT's have to sign a jurisdictional Medical Control agreement. If your offline med control has not restricted your scope of practice, then you write "none" in the restriction section. If you have any restrictions, then the restrictions will be written there and what they are. There are those that have that written and some some that probably should have it written.

With regards to narcotic administration: if you're hospital-based some on-line med controls may not want agressive narcotic adminstration prehospitally regardless of what your protocols, or even your off-line med control, may or may not allow you to do. If your not hospital-based, once your pt is in your ambulance they fall under your off-line med control's orders, not the receiving's orders.

Your pain management protocol probably says you can give so much morphine every so often up to a point then you have to call med control. If that's what it says, then do that.

What a lot of RN's tend to misunderstand is that protocols are like standing orders. RN's have standing orders all the time. You're doing what your standing orders (protocols) tell you to do just like they do. However, they're stnading orders are just not as broad as our's are in the field. 

You follow your protocols. Those that try to tell you how to do your job when they really don't have all of the necessary information just need a little patience.

If there's anything else I can do to help just ask.


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## FFMedic75 (Nov 16, 2009)

VentMedic said:


> Here we have another one who has absolutely no hospital experience and knows absolutely nothing beyond the back of an ambulance or fire truck. Yet, he feels the need to spout such crap to bash RNs to make up for whatever inadequacies exist in EMS and in himself.
> 
> The major difference between RNs and those in EMS, besides the education, is that they know who they are and what they are capable of. They also know when, why and how to gain more education and respect in medicine. EMS still believes a few hours of training and their ability to drive real fast with their L&S automatically gives them respect.
> 
> ...



I'm actually quit familiar with how things work in the hospital.  I was simply trying to point out where this particular problem may have originated.  I don't disagree that EMS has its own inadequacies especially when it comes to education and I can only hope it gets fixed one day. However you can't tell me you have never run in to this situation.  Yes nurses do have Standing Orders they function under in many locations.  They very different from place to place just as ALS Protocols are in the field.  I wasn't bashing RNs, simply the ones that think they are gods gift to everyone.  I have worked with several and they are great at what they do, however when the same nurse that may be great in the ER or ICU tries to bridge and become a Paramedic, it doesn't always work.  Just as I would be lost if you stuck me in the OR as a scrub nurse they lack the experience, practical knowledge and decision making skills to work in the field that Paramedics develop in their career, but they have no problem interjecting how well they think you do your job.  How many times have you heard one of them say, "what no IV?"  They have no clue what being one block from the ER means or the patient had no airway, I was by my self and no one would come and help.  Help in the hospital is always a call away.  You have a violent patient in the ER you call security, you can't get someone intubated you call Anesthesia.  We are by ourselves and many of them don't get it and they think they are better than us so they just criticize.  I have actually found that required field ride-alongs helps prevent some of this.  Again I am certainly not talking about every nurse I've ever worked with, however this situation certainly does exist across the US, and I was providing incite to what could be the source of someone's problem.  Nurses make errors just like Doctors and Paramedics, there are good one and bad ones.


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## VentMedic (Nov 16, 2009)

FFMedic75 said:


> I'm actually quit familiar with how things work in the hospital. I was simply trying to point out where this particular problem may have originated. I don't disagree that EMS has its own inadequacies especially when it comes to education and I can only hope it gets fixed one day. However you can't tell me you have never run in to this situation. Yes nurses do have Standing Orders they function under in many locations. They very different from place to place just as ALS Protocols are in the field. I wasn't bashing RNs, simply the ones that think they are gods gift to everyone. I have worked with several and they are great at what they do, however when the same nurse that may be great in the ER or ICU tries to bridge and become a Paramedic, it doesn't always work. Just as I would be lost if you stuck me in the OR as a scrub nurse they lack the experience, practical knowledge and decision making skills to work in the field that Paramedics develop in their career, but they have no problem interjecting how well they think you do your job. How many times have you heard one of them say, "what no IV?" They have no clue what being one block from the ER means or the patient had no airway, I was by my self and no one would come and help. Help in the hospital is always a call away. You have a violent patient in the ER you call security, you can't get someone intubated you call Anesthesia. We are by ourselves and many of them don't get it and they think they are better than us so they just criticize. I have actually found that required field ride-alongs helps prevent some of this. Again I am certainly not talking about every nurse I've ever worked with, however this situation certainly does exist across the US, and I was providing incite to what could be the source of someone's problem. Nurses make errors just like Doctors and Paramedics, there are good one and bad ones.


 
Again you are expressing ideas from what sounds like a very poorly run hospital with nurses you believe to be inadequate.

Have you never seen a nurse run a code? Intubate? Put in central lines? Run a Rapid Response situation?  And, nurses also must function outside of their hospital element every day to accompany a patient on an ER to ER transfer because the Paramedic is not allowed to take most medicated drips.  They rise to occasion and go into whatever role required of them and if they have questions, they ask and seek out advice.  

Have you also considered what protocols for the Paramedic in that area?  Maybe they are like Washington DC where their Paramedics would never think of giving morphine with or without a doctor's order. It just isn't done and they are not the only EMS system in this country like that.  I can also think of a couple FDs in Florida that got their meds taken away and weren't allowed that many to begin with.   

Thus, unless you actually know this system personally, since the OP is only a student and is not working as a Paramedic, you can not say for certain if that nurse is right or wrong.


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## FFMedic75 (Nov 16, 2009)

You are right, I can't say the nurse is right or wrong, but to start and argument with a student over EMS scope of practice gleams of inadequacy.  I have worked in 3 states actually and aside from the Flight Nurses, whom I have never had an issue with because they understand what we do, I have never seen a non specialty nurse intubate, start central lines, etc.  It is not in their scope of practice in most places, and yes I can transport any medicated drip that has been established where I work.  I know that isn't the same everywhere.  There are lots of awful EMS systems with poor protocols but there are a lot of hospitals that are bad as well, and oddly enough I have run into more obnoxious staff in these facilities as compared to the busier Trauma Centers.  It's all an attitude issue.


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## rhan101277 (Nov 16, 2009)

Here is our pain management protocol.  They give us much lead way on such matters.  All of the protocols say consider, not you must etc.

http://img5.imageshack.us/img5/3073/painalgorithm.jpg

P.S.

I like distraction procedures for pain off 6 or less. Though there is no protocol for what those procedures are.


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## MSDeltaFlt (Nov 16, 2009)

rhan101277 said:


> Here is our pain management protocol. They give us much lead way on such matters. All of the protocols say consider, not you must etc.
> 
> http://img5.imageshack.us/img5/3073/painalgorithm.jpg
> 
> ...


 
Hehehe.  Yeah.  Thank God you're not a first responder.

However, technically it says "up to 10mg MSO4" *or* "50-100ug Fentanyl" and it says to contact Med Control PRN.  Meaning if one of the regimen didn't work, you'd have to call for more orders; as in add the other narcotic if the first didn't get rid of the pain adequately.  Granted the odds of you maxing out either one of these dosages is remote, but the operative word here is "or".

There is a difference between giving pain medication and *treating pain*.  I like the leeway they give you guys here.  They still give you an "out" with the "contact med control" bit.  Because your off line med control knows that you never say never and you never say always.

Hope this helps.


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## downunderwunda (Nov 16, 2009)

rhan101277 said:


> And you don't, just an RN getting grumpy.



You should not have to talk to anyone. You should be autonomous enough to be able to make a decision for that patient *without* outside interference.


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## VentMedic (Nov 16, 2009)

FFMedic75 said:


> You are right, I can't say the nurse is right or wrong, but to start and argument with a student over EMS scope of practice gleams of inadequacy. I have worked in 3 states actually and aside from the Flight Nurses, whom I have never had an issue with because they understand what we do, I have never seen a non specialty nurse intubate, start central lines, etc. *It is not in their scope of practice in most places, and* yes *I can transport any medicated drip that has been established where I work.* I know that isn't the same everywhere. There are lots of awful EMS systems with poor protocols but there are a lot of hospitals that are bad as well, and oddly enough I have run into more obnoxious staff in these facilities as compared to the busier Trauma Centers. It's all an attitude issue.


 
These skills are very much in their scope of practice in most states which is why there are Flight, CCTs and Specialty RNs. If he/she is working in an area that requires intubation, there rarely an issue if there is a need. However, for the same argument of having every FF be a Paramedic and then do maybe 1 intubation per year, it is impractical for a hospital to train over 1000 RNs to intubate. 

Central lines? RNs can do UAC/UVCs and PICCs. On Flight and Specialty the can do whatever is necessary to do their job. They get their training while working in the ICUs. 

But then, you may only have a very limited view from the ED and don't see the full extent of what RNs can do. 

As far as your drips, that could only be RL and NS with maybe one or two meds such as in CA. It is sometimes very difficult to find Paramedics that can take the drips some patients are on for IFT even if they claim to be "CCEMT-P" and then if they can, it is for watching only and they shut the IV pump off if it beeps. 

Thus, few paramedics are equal with the hospital and patients getting burned if they "assume" too much from some EMS providers.


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## VentMedic (Nov 16, 2009)

downunderwunda said:


> You should not have to talk to anyone. You should be autonomous enough to be able to make a decision for that patient *without* outside interference.


 
In many areasa of California, they have a nurse (MICN) sitting at the radio to read the protocols to the Paramedics.


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## FFMedic75 (Nov 16, 2009)

Whatever man, the sky is blue!!!  If you want someone to take care of your premature baby call a NICU Nurse, if you need someone to intubate call a CRNA,  If someone is having an MI call a CCU Nurse.  If you want someone who can deal with all of these problems effectively at your home in a blizzard or hurricane using a flashlight call for a Paramedic.  Whether they be fire based, 3rd party or private, paramedics ability to think outside the box and adapt to the worst of situations is their specialty.  Ya you can train people to specialize in all kinds of things but short of a flight nurse (who lets face is a very highly trained paramedic with lots of experience), you can't find anyone else who can function under the conditions that medics do with the same success.  Is it perfect, absolutely not.  Do we need to provide a higher level of training to all medics, sure.  Will this bring validity to our profession, I hope so.  The point I was trying to get across is the healthcare providers who understand what we do tend to respect us, the ignorant ones who think they are gods gift to their little world don't.  The important side note to this is remember how you treat people.  You will encounter home health aids, LPNs and CNAs who are thrust into emergency care not by choice, we shouldn't treat them poorly just as we shouldn't be treated poorly.  If you can constructively teach them something about emergency care that is a good thing, the same can be said for nurses who choose to constructively help paramedics with an issue.  I can't tell you how many times I've had a new medic who had trouble starting IVs, we would send them to the ER if the right nurses were working and they would get a world of experience.  This is how it supposed to work.  Not the Docs talk bad about the nurses, the nurses talk bad about the medics, the medics talk bad about the nursing home staff.


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## RyanMidd (Nov 16, 2009)

My girlfriend of 4 years is a year way from completion of her RN, and we often have open-minded (albeit terse) discussions about differences in procedure, objective, protocol, and even A&P.

However, we always make it a point to remind people that we are never competing; the jobs themselves are much, much different despite both being in the medical field. Specifically, nurses are trained in a very broad spectrum of health & wellness, including socioeconomical factors, sensitivity to religion and ethnicity, and even improving access to healthcare for minorities. I respect how much training they receive and how different it was than mine. They are the manpower that allows First World Medicine to exist, and in some places, flourish.

Emergency medicine, on the other hand, has a different objective, and as such, different training. Yes, we are able to administer medications without a doctor's orders or 'scrip pad, including some narcotics. This is because it is impractical to train as many doctors as there are EMS personnel and shove them into ambulances. Additionally, the things we do are decided upon by a group of people, including many MDs, who determine that it is probably the safest course of action for the greatest number of patients. This is patently imperfect, but it works well enough that pre-hospital medicine is considered an essential service in most of the world.

I make it a point never to rub my scope of practice in another healthcare provider's nose, because they likely know and practice things every day that I would think inconceivable. Have I ever spent over 500 hours, unpaid, connecting with immigrants, low-income citizens, and the elderly and teaching them how to better access healthcare? How to read English? How to financially manage their health-related expenses? No, and I greatly respect that many nurses have similar experiences that are not relevant for pre-hospital medtechs.

I am grateful that medical direction puts their faith in our abilities, judgement, and skill, and if I encounter a catty nurse, or a specialist who thinks we are just IV-monkeys, I take it with a grain of salt, because I also know that I am often the first to deal with the family of the deceased, I am often the one speaking to a terrified 4-year-old who has just been in a car accident, and I am often the one who has mere seconds to decide whether to initiate a certain treatment or drug, and RNs and anesthesiologists are NOT trained to do THAT.


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## downunderwunda (Nov 16, 2009)

VentMedic said:


> In many areasa of California, they have a nurse (MICN) sitting at the radio to read the protocols to the Paramedics.



Vent,

shouldn't you know your protocol & pharmacology _*before*_ you go out & start practicing?


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## KELRAG (Nov 19, 2009)

VentMedic said:


> Again you are expressing ideas from what sounds like a very poorly run hospital with nurses you believe to be inadequate.
> 
> Have you never seen a nurse run a code? Intubate? Put in central lines? Run a Rapid Response situation?  And, nurses also must function outside of their hospital element every day to accompany a patient on an ER to ER transfer because the Paramedic is not allowed to take most medicated drips.  They rise to occasion and go into whatever role required of them and if they have questions, they ask and seek out advice.
> 
> ...




During my clinicals i've experienced this attitude before and I believe OP's underlying statment is the somewhat rare but existing resentment between RNs and medics.

I'm really not trying to belittle you as is a common theme on this forum.  You seem to have knowledge and experience.  

However, you did contridict yourself with the "poorly run hospital" and "DC's limited protocal" arguement using the extremes as generalizations, the norms. Generalization automatically debunks an argument but lets run with this.  The insinuation of ur statment is; unless a hospital allows RNs to work independently, then it is a poorly run insitution.  Furhter by extension, nurses are fully capable and competent to perform advanced procedures and if not the hospital sucks.  In my experience only, this is a rarity.  I've worked in a cath lab, a level 1 pediatric trauma center, a level 2 trauma center and I date a RN, she agrees.  Personally only seen one RN intubate and that was because the DR knew she was a medic previously.  A Level 2 in Washington (state) allows medics to practice all skills including intubations and not RN's... Im sure they are capable but this is what we are extensively trained in, not just a run through on a manikin and pig which is what the girlfriend did.  She went to Baylor Nursing. 

Im def not saying it doesnt happen, just to answer your question, no.. i've never seen it.  

You also generalized protocals prohibiting medics from taking certain drips.  Ive never been told I cant take a pt based on their medications.  Also, only once have I taken a nurse on a critical transfer and that was bc my :censored::censored::censored::censored:ty service didnt want to give me another set of hands so I had to ask the hospital.

Then you used as an example an EMS system with the most limited scope of practice i've heard of as the norm to justify an instance where a Medical Director has no faith in competence of Medics.  When in reality, many systems allow medics to give stabilizing drugs as well as begin infusions that will only be beneficial awhile after we get them on ya'lls bed.  IV steriods and terb for example.

Nurses and Medics' training differ in specialty.  Nurses are trained in mixing drips and long term care while medics are used to doing more tactile, emergent procedures like running initial ACLS drugs and airway.  There is no reason a nurse should be taught about extrications just as no reason medics need to know how to give a Foley and moniter a SICU pt.  The exception is obviously Flight.  

In refrence to flight jobs, the RN/medic combination is merging the skills of both, as a result each grows familiar with the others' expertise and allows for greater comprehensive care.  I only have experience with one flight program and they do not differentiate between RN/medic in the protocals.  Each is allowed to do any procedure.  No one person is in charge.  Often the medic runs the scene calls and nurses do the CC transfers.  However, this is a progressive system requiring ATLS.

You wont like this but many RN-medics have agreed, the train_ng is in objectivity_


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## KELRAG (Nov 19, 2009)

*Education is highly irrelevant*

In reference to your snide, passive-aggresive remark about "trade schools." The community college where i got my medic from also has a same length Resp tech and RN program. The top 10% school where i got my biochem from def doesn't have a resp tech.  Stop trying generalize about paramedics' lack of education, more than a few of the people I work with get their medic as a stepping stone to PA and med school because of the autonomy required.  I dont know any DRs or PAs that were nurses first.  Askin a doc about whether he would rather hire a PA or NP he went with PA.  He explained PAs are taught differential diagnosis and how to be independant from the beginning while nurses only start that when they begin their NP program.

Some of the best medics I know only have their cert and they are much better than I am.  RNs and LVNs at the trauma center in mycoverage area do the exact same job, but im sure thats because its a poorly run hospital.  Ap

I completely respect nurses and their capabilities.  There are nurses, medics, and DRs, good and bad.  In end... FFmedic and Ryan, feel free to push meds, intubate and decompres my chest.  Ventmedic, relax and when I need some albuterol... go find OP


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## VentMedic (Nov 19, 2009)

KELRAG said:


> In reference to your snide, passive-aggresive remark about "trade schools." The community college where i got my medic from also has a same length Resp tech and RN program.


 
Looks like we have a noobie to EMS and the world of medicine here as noted from the above two posts who also doesn't do his homework before spouting off things he knows little about. 



> I date a RN, she agrees.


 
That makes you an expert? Is that like sleeping at the Holiday Inn ad? Tell your girlfriend to get out more and see what her profession is all about so she can educate you better. You must be stifling her career. Jealous of her maybe? 

I expect you are not from Oregon but from a state like Washington that has 8 different "cert" levels all based on one skill. Also, if you are in Washington state you should know who is on the Flight teams there and who does the intubating. Majority of your flight teams are RN/RN or RN/RRT. Even if they hold a Paramedic cert, it is their RN or RRT license they work under since it supersedes a Paramedic certification. RNs can also challenge the Paramedic test in some states. Other states have the RNs and RRTs just take a few weeks of things that might pertain to EMS but rarely to they have to take the 10th grade pharmacology or A&P when they have had college level courses. Nor do they have to do ED rotations to learn IVs and most are already ACLS, NRP, PALS etc plus many other specialty certs that require actual experience and not just a weekend no fail course. In fact, most RNs that do prehospital will have worked more codes in the hospital in one year, including leading them, than some Paramedics will work their entire career. 

How many "hours of training" does you state require to be a Paramedic? Also, at that college, was the Associates degree MANDATORY or OPTIONAL with a "cert" program offered? I just checked the Washington website and their Paramedic "hours of training" requirement is no longer than most other states in the U.S. 

Guess what? Both the RT and the RN licenses require no less than an Associates degree. It is not an OPTION. 



> no reason medics need to know how to give a Foley and moniter a SICU pt.


 At least you are correct here. Most IFTs are out of the scope of care for a Paramedic and that includes the majority of nursing home calls since they involve complex medical conditions that many Paramedics have little to no understanding. 

BTW, you "insert" a Foley and not give it. The Foley catheter is not a medication. It is a tube that is passed through the urethra and into the bladder to drain urine. 

The difference between RNs, RRTs and Paramedics is that the RN and RRT gets a solid educational foundation to build on for whatever specialization they desire. Thus, when the job calls for learning how to run a code or rapid response team in the hospital or do CCT/Specialty/Flight or become a prehospital RN, it is not that big of a stretch. On the other hand, the Paramedic learns a few technical skills without a lot of whys behind it and very little A&P or pharmacology, thus, they should not be allowed to touch a critical care patient on any IFT until they have finished a minimum of a two year degree. In fact, allowing them expanded scope of practice of any type, especially CCT, is probably not advisable for some Paramedics. 

The other difference between RRTs, RNs and Paramedics is that RT and nursing saw what their weakest links were and did something about it. Thus, for that reason you will rarely see an LVN and the "Respiraty tech" is no more which means your information is very outdated. Both professions raised their educational standards after evaluating their bargaining and value in the world of medicine. They also realized medicine is constantly evolving and a "tech" cert is no longer good enough. EMS still has yet to embrace that concept. But, it is good that you at least got your degree.



> Often the medic runs the scene calls and nurses do the CC transfers. However, this is a progressive system requiring ATLS.


And here's a news flash for you, Paramedics can not be certified in ATLS. They may audit the class but not participate in most of the skills labs and the audit is allowed only if the program has space to allow it. 



> Im sure they are capable but this is what we are extensively trained in, not just a run through on a manikin and pig which is what the girlfriend did. She went to Baylor Nursing.


Define extensively. Some Paramedic programs only require 5 successful passes on a manikin. Was your nurse girlfriend in training for MICN or PHRN? If not it was probably just a demo. Once she decides she wants to do transport, she will be trained by the doctors and given the opportunity to do many live intubations. And, she'll have the advantage of having seen many intubations prior to that time and probably would have participated in RSI many times. Thus, all she will have to do is learn the "skill" since she will already know the hows and whys of intubation. Some new Paramedics are put out on the street without any live intubation experience and may not even have seen one done except on a manikin. Sad but true. Thus, EMS then wonders why the statistics for unsuccessful Paramedic intubations are getting noticed. 

There is one other little thing about the U.S. Paramedic that is now particularly annoying. It has be dumbed down to where every FF can become a Paramedic in just a few short months whether they want to or not. Most will do it for the extra few dollars of pay and "attempt" their one intubation per year while on an ALS engine. 



> You also generalized protocals prohibiting medics from taking certain drips. Ive never been told I cant take a pt based on their medications.


 
Have you actually read your protocols or are you just shooting from the hip here? "Taking" a drip and "managing" one are two very different things. Yes the RN can get the drip all set up for you to watch on your drive inbetween hospitals and hopefully you are not one that just shuts the IV pump off when it goes beep, beep. 



> RNs and LVNs at the trauma center in mycoverage area do the exact same job, but im sure thats because its a poorly run hospital.


 
A trauma center using LVNs? As CNAs I hope and not as actual nurses. I haven't seen an LVN in an acute hospital in well over 20 years? Where did you say you were from? 



> Askin a doc about whether he would rather hire a PA or NP he went with PA. He explained PAs are taught differential diagnosis and how to be independant from the beginning while nurses only start that when they begin their NP program.


 
Wow! You really have a very closed view of the world of medicine and of nurses. Is this a personal issue with your nurse girlfriend? 

Let me explain the world of NPs and PAs to you. A PA now requires a Masters degree in many states and soon that will be their entry standard. They first get an undergraduate degree which could be anything from Biology, Art history (as long as the sciences are present), RT, or a BSN. Following the 4 year degree they enter another 2 years of training. 

The NP has a lot more advancement ability and practice opportunities than the PA which is actually rather limited in some ways. Also, the NP is raising their educational standard to doctorate in a couple of years. Trauma Nurse Specialist, Neuro NPs, Pedi NPs and Neo NPs are a great asset to their field. The PA also has their place but the NPs have already organized their field and scope. I do have faith the PA will catch up as both of their organizations are also working together for improved patient care quality.

It sounds like you will never match my 30 years in EMS because you have too many low opinions of other health care professionals. You also believe the Paramedic is perfect and needs no improvement even when "hours of training" is still the standard. It also appears you don't believe the EMS degree is necessary even though you got one. No education is a waste of time. Until those in EMS realize the shortcomings of their profession, it will not advance. Take notes from what the RN, RRT, OT, SLP, PT etc have accomplished. 

BTW, since you are new, I will just give you some friendly advice. There is a spell check feature on this forum.


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## rhan101277 (Nov 19, 2009)

My program is certainly not dumbed down, I am sure there are some that are though.  We have to do 5 "live" intubations, those are mostly done in the OR.  Some are done on dead people that have only been dead a short period of time 10-15 minutes or whatnot.

Anyhow paramedics need to be recognized as professionals in their field and that is what the program that I attend is trying to do.  We are taught above and beyond what is required, which is minimum.  No one wants a "minimum level" trained paramedic.  There needs to be a lot less "cookbook" medics out there.


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## reaper (Nov 20, 2009)

rhan101277 said:


> My program is certainly not dumbed down, I am sure there are some that are though.  We have to do 5 "live" intubations, those are mostly done in the OR.  Some are done on dead people that have only been dead a short period of time 10-15 minutes or whatnot.
> 
> Anyhow paramedics need to be recognized as professionals in their field and that is what the program that I attend is trying to do.  We are taught above and beyond what is required, which is minimum.  No one wants a "minimum level" trained paramedic.  There needs to be a lot less "cookbook" medics out there.



No offense here, but a school that only requires 5 live intubation's, is kinda dumbed down!

You should have no less then 10 and preferably 20-30!


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## Jon (Nov 20, 2009)

In PA, I have several protocols that let me give 50-100 mcg Fentanyl or 2-5mg of Morphine before calling the doc. Off the top of my head, the protocols are for suspected cardiac chest pain, serious burns, and isolated extremity trauma. The protocols specify additional doses, but medical command contact is supposed to be made before giving additional doses.

And yes, we have a protocol to allow us to follow the protocol options/suggestions below the "command line" if we truly feel they are in the best intrest of the patient, and we have no way to communicate with medical command. Never seen this happen in 8 years around here... but as was mentioned in another thread, Rule 34 of EMS - If you can think of a scenario, it's happened.


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## wyoskibum (Nov 20, 2009)

There are a lot of services who can administer Morphine without contacting the "Online Medical Control" via "Standing Orders".  But you can't administer it without those standing orders from your "Medical Control".


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## Smash (Nov 20, 2009)

wyoskibum said:


> There are a lot of services who can administer Morphine without contacting the "Online Medical Control" via "Standing Orders".  But you can't administer it without those standing orders from your "Medical Control".



Indeed.  What many seem to forget is that we ALL have medical control in some form.  Be it offline, or online, we all act under certain protocols and the authority to do so is typically delegated by an MD.  The only real difference is that some need permission for each instance, others have a broader remit.
In my service I can administer as much or as little morphine as I see fit for the patient's presentation, and I have no upper limit on how much I can give.
This works where I am, but may not work everywhere for a wide range of reasons.  

What is really important though, is that we are doing the right thing for our patient.  We all want more autonomy, and I certainly think that it is an admirable cause to back (including the education to allow it), however it is not really about who has to ask for pain relief and who doesn't so long as the patient who needs pain relief gets it.

Of course there are issues with contacting med control in that the Dr or RN on the other end of the line cannot see you patient, so is entirely reliant on what you tell them, and of course it would be foolish to think that personal bias doesn't ever come into play either.  This is one of the reasons I support having offline medical control in the form of protocols, and in most instances the more liberal the better (with certain caveats of course).


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## rhan101277 (Nov 20, 2009)

We can give up to 10mg morphine here.  Any more call med control.


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## downunderwunda (Nov 20, 2009)

The issue is not how much or little you can give. The issue is the amount of autonomy you, the person with the patient, the person who can see the patient has.

Yes, we act withing guideline, usually referred to as protocols, but they, if written properly, should give you enough discretion to apply them as you see fit.


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## NomadicMedic (Nov 21, 2009)

downunderwunda said:


> The issue is not how much or little you can give. The issue is the amount of autonomy you, the person with the patient, the person who can see the patient has.
> 
> Yes, we act withing guideline, usually referred to as protocols, but they, if written properly, should give you enough discretion to apply them as you see fit.



Exactly!!!! 

When you ask a medic why he gave Morphine, there are some who will say, "He had chest pain so I gave 2+2 up to 10. That's what I'm allowed to do". That's not good patient care. That's just following the cookbook.

Instead, A prudent medic will know that eliminating pain will reduce stress which will reduce those catecholamines the the patient is pumping out and help to stabilize heart rate and blood pressure. I know I answer the question by saying, "I gave the patient the appropriate dose of MS04 to drive his pain level as close to zero as possible." That's what my protocols allow.


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## rhan101277 (Nov 21, 2009)

n7lxi said:


> Exactly!!!!
> 
> When you ask a medic why he gave Morphine, there are some who will say, "He had chest pain so I gave 2+2 up to 10. That's what I'm allowed to do". That's not good patient care. That's just following the cookbook.
> 
> Instead, A prudent medic will know that eliminating pain will reduce stress which will reduce those catecholamines the the patient is pumping out and help to stabilize heart rate and blood pressure. I know I answer the question by saying, "I gave the patient the appropriate dose of MS04 to drive his pain level as close to zero as possible." That's what my protocols allow.



Oh I agree entirely, we are being taught not to be cookbook paramedics.  People die under cookbook paramedic care.  Not saying that others don't die, but those we just can't help.  You need to be able to think outside the box and if there is a better treatment call med control.  All of our protocols say "consider" which encourages independent thinking.  Know how everything works full circle will help you a lot.  I am trying to develop these skills in school and during clinicals.  Because when people see you come through the door they expect the best and most will think everything is great now, the ambulance is here.  I just want to to my best to not let them down.  To not do anything stupid to worsen the situation and give the best patient care that I am trained and educated to give.


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## downunderwunda (Nov 21, 2009)

There are times when 'cookbook' is to a degree appropriate. The example given was for chest pain. Most protocols call for the administration of ASA, Nitro & morphine as well as hi flow O2.

We know this regimin has an effect in preventing thrombus formation, dilation of the vascular bed & Morphine has dilation properties for the coronary arteries, but its most dramatic effect is reducing the pain, therfore reducing the anxiety level of the patient.

This is variable for all patients & needs to be administers based on the presentation of the patient at the time. We use nitro in a sub lingual for & can administer up to 3 dependent on systolic BP & morphine dependent on perfusion. Posture also plays a role & it is impossible to write a protocol based on a generic presentation as most differ in some way. 

To have the ability to adjust your treatment, acording to the presentation of the patient is vital. Can med control see the patient? No they cant. I have had patients who, even with pain, have had Morphine withheld because I felt the patients perfusion levels were not acceptable, my call. My protocol calls for a BP to be greater than or equal to 100mmHg, with a pt at 102 mmHg, I have with held nitro but given morphine, again, my call. 

What gives me that ability, knowledge of the drugs, their actions & the pathophysiology of the illness. No, I am not a specialist cardiologist, & I admit my knowledge will never be as detailed as a Cardiologist, but the knowledge I have is more than adequate for pre hospital care.


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## Achromatic (Nov 23, 2009)

VentMedic said:


> I expect you are not from Oregon but from a state like Washington ... Other states have the RNs and RRTs just take a few weeks of things that might pertain to EMS but rarely to they have to take the 10th grade pharmacology or A&P when they have had college level courses. Nor do they have to do ED rotations to learn IVs and most are already ACLS, NRP, PALS etc plus many other specialty certs that require actual experience and not just a weekend no fail course.





> And here's a news flash for you, Paramedics can not be certified in ATLS. They may audit the class but not participate in most of the skills labs and the audit is allowed only if the program has space to allow it.



Apropos of anything else, I found it amusing your denigration of some courses as "weekend no fail courses". The longest ATLS course I saw on the FACS site was a two day course. Interestingly, some were listed as being available to physician extenders, some to RN, some open.



> Define extensively. Some Paramedic programs only require 5 successful passes on a manikin. Was your nurse girlfriend in training for MICN or PHRN? If not it was probably just a demo. Once she decides she wants to do transport, she will be trained by the doctors and given the opportunity to do many live intubations. And, she'll have the advantage of having seen many intubations prior to that time and probably would have participated in RSI many times. Thus, all she will have to do is learn the "skill" since she will already know the hows and whys of intubation. Some new Paramedics are put out on the street without any live intubation experience and may not even have seen one done except on a manikin. Sad but true. Thus, EMS then wonders why the statistics for unsuccessful Paramedic intubations are getting noticed.



This, if true (and I am not pretending it is not - sadly, I recognize it to be true) is an utterly sad state of affairs. I can say, happily, that I know that EMT-Ps in our county, whose training is "arranged" by the county, get by mandate of our MPD, at least FIFTY live intubations in ED/OR before being unleashed on the world. 



> There is one other little thing about the U.S. Paramedic that is now particularly annoying. It has be dumbed down to where every FF can become a Paramedic in just a few short months whether they want to or not. Most will do it for the extra few dollars of pay and "attempt" their one intubation per year while on an ALS engine.



Hear, hear. I have zero interest in fighting fire. More power to those who do. I am stuck in a system whereby I will almost definitely need a firefighter cert to do ALS 911. Nothing pisses me off more than seeing FFs who view 'medic' as a patch needed to do their job, and who hold zero interest in doing it. I can appreciate their pain but I cannot and will not tolerate any that I interact with (big words for a student) half-assing a patient because they don't want to deal with medic calls, any more than I would expect them to tolerate me standing around scratching my *** on a structural fire. Every patient deserves 100%, even the "BLS tweeker" type calls that cause everyone involved to roll their eyes, even if only on the inside.




> Let me explain the world of NPs and PAs to you. A PA now requires a Masters degree in many states and soon that will be their entry standard. They first get an undergraduate degree which could be anything from Biology, Art history (as long as the sciences are present), RT, or a BSN. Following the 4 year degree they enter another 2 years of training.



Not to denigrate either NP or PA, as I think both are valuable, and both know a lot about their worlds, but to rephrase what you say, a student could conceivably become a PA with as "little" as some entry level maths, some gen chem and bio, and a year of upper division science (I am watching someone do O-chem, microbiol, and cell biol) who will have enough credits to enter a PA course, 2 years (though she will be doing a DVM). i.e. some foundational sciences, a year (though an intense year) of upper science, then 2 years to come out as a PA.


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## Shishkabob (Nov 23, 2009)

Meh, I chuck it off as some nurses not knwoing what medics/EMTs do, and vice versa.

I had a new grad RN (less then 6 months employment) go in a 5min explanation of what sedatives were and what they were used for... I didn't feel like telling her we have a handful of sedatives on our rig, and that I already knew what they were used for.

She probably thought I was an EMT student, and not a medic student 90% done with his course.


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## Achromatic (Nov 23, 2009)

Linuss said:


> Meh, I chuck it off as some nurses not knwoing what medics/EMTs do, and vice versa.
> 
> I had a new grad RN (less then 6 months employment) go in a 5min explanation of what sedatives were and what they were used for... I didn't feel like telling her we have a handful of sedatives on our rig, and that I already knew what they were used for.
> 
> She probably thought I was an EMT student, and not a medic student 90% done with his course.



Makes me feel lucky... our county MPD is on the board of directors at our regional trauma center, and is a senior attending in its ED, so by virtue of that, _and_ some great nursing staff in said ED, everyone is very much aware of everyone else's capabilities and knowledge.


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## MrBrown (Nov 23, 2009)

Most of our hospital staff are pretty cool; some have no interest in helping ambos whatsoever and one or two very, very experienced ED/med nurses I've talked to shake thier head and think of the ambos as "cowboys". 

The topic at hand it would seem is an interesting one; I do not believe anybody with the correct knowledge and training should have to call a physician to give pain relief.  I couldn't immagine working in such a system! .. even if I was given an autonomous number, say, 10.

As a side note, the American Board of Anaesthesology states to be *minimally competent* thier members should be performing at least 200 intubations a year, eh, but we know like five during clinicals is cool right?


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## austinmedic2004 (Nov 24, 2009)

VentMedic said:


> Looks like we have a noobie to EMS and the world of medicine here as noted from the above two posts who also doesn't do his homework before spouting off things he knows little about.
> 
> 
> 
> ...



Looks like there are a lot of generalizations being made here with regards to the "quality" of education of different medical professionals. The education received is only as good as the person retaining and applying the information. 

Whether you are the graduate of a paramedic certification program, a paramedic AAS program, a nursing AAS program, a BSN program, a Registered Respiratory Therapist program, occupational therapy program, speech language pathologist program, physical therapy program, etc; the education alone does not make you "better". Certainly there is opportunity to be better prepared dependent on the amount of education provided by the program; but the real preparedness comes from the application of the knowledge in a practical setting as well as continuing education related to the specialty or desired specialty.

We as medical professionals (all of the above are included) need to further our education to suppliment the areas where we are weak and to expand our knowledge base.

The bottom line is, the answer cannot be found just in the amount of education but how it is applied.


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## MrBrown (Nov 24, 2009)

austinmedic2004 said:


> Looks like there are a lot of generalizations being made here with regards to the "quality" of education of different medical professionals. The education received is only as good as the person retaining and applying the information.
> 
> Whether you are the graduate of a paramedic certification program, a paramedic AAS program, a nursing AAS program, a BSN program, a Registered Respiratory Therapist program, occupational therapy program, speech language pathologist program, physical therapy program, etc; the education alone does not make you "better". Certainly there is opportunity to be better prepared dependent on the amount of education provided by the program; but the real preparedness comes from the application of the knowledge in a practical setting as well as continuing education related to the specialty or desired specialty.
> 
> ...



I sort of agree.  Having formal education at university level in adult learning and teaching I can say that education (as you say) is not just what you know (congitive) but also practical (psychomotor) however the first is required for the latter to be effective.

Anybody can teach somebody to stick an IV into a vein and pop an ampoule of adrenaline but can that same person also explain to you the whats and whys and what-ifs about the same thing? Probably not.

Competence in Paramedicine is often thought of in terms of practical dexterity to take out the stretcher, start an IV line, give meds and generally do ten things at once upside down in a ditch at one o'clock in the morning with some book learning thrown in while "competence" for counterparts in nursing and other health disclipines is about 60% theory 40% praxis; our Paramedic degree here is around 2,400 hours theory/sim and 1,200hrs on the street.

I take a very lowly view of anybody who says "oh you know, ambos dont need to know all that theory stuff, we never use it" oh but you do! If you have a solid background in the theory of the physiology, pharm and patho of what you are treating you'll be 100x more confident and .... I don't want to say "better" but maybe thats the right word ... in dealing with it because you can anticapte whats going to happen or what might happen and plan with it accordingly.

This is called "cognitive" knowledge and relies upon that knowledge you have to build up a picture based upon selectively using that knowledge to process information and draw up what you know to formulate a plan to react to the situatuon whereas this can be constrasted against "behaviourist" type reactions which are simply "ah, this is situation A so I will do B".

For example you take two ambo's and give them an asthma patient.  One knows resp physiology, the pathophysiology of asthma and the pharmacology of salbutamol and adrenaline because it's included in those college level courses he took.  He's able to use that information to process a plan of action based upon how sick the patient is, what tools he has and his experience.

The second ambo in this scenario can tell you the basics of what I've mentioned and he knows what to do because he's reacting to the stimulus the patient is giving off, but, he might not be able to tell you all the ifs and buts and hows and whys.

I would argue long and hard the first guy is who I want treating me.

A bloody fantastic follow on to this is dynamic hyperinflation when bagging an asthma patient.  I often smash my head on the desk in despiar because it's so hard to explain to people as they just can't grasp the underlying concepts of the physoology of how hyperventilating an asthma patient can be fatal because they just dont have the knowledge of A&P.


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## VentMedic (Nov 24, 2009)

austinmedic2004 said:


> Looks like there are a lot of generalizations being made here with regards to the "quality" of education of different medical professionals. The education received is only as good as the person retaining and applying the information.
> 
> Whether you are the graduate of a paramedic certification program, a paramedic AAS program, a nursing AAS program, a BSN program, a Registered Respiratory Therapist program, occupational therapy program, speech language pathologist program, physical therapy program, etc; the education alone does not make you "better". Certainly there is opportunity to be better prepared dependent on the amount of education provided by the program; but the real preparedness comes from the application of the knowledge in a practical setting as well as continuing education related to the specialty or desired specialty.
> 
> ...


 
I expected that this would be an agrument 0f someone TX which has one of the lowest "hours of training" requirements in the U.S. 

So should there be no minimum education required for any medical professional? Should doctors not go to college and maybe just be OJT? Should nurses for back to diploma programs? Is a 1 year LPN good enough for patients in ICUs? Should RRTs just go back to being a 1 year equipment tech? Should we just have the 2 year programs for NP and PA? Are these Physician Extenders just a waste of time and especially with all that education? 

You have good and bad in every profession whether it requires 1 day of training or 12 years. However, that does not mean you bash the higher education and eliminate it just to fit someone who didn't want to go beyond a few hours of training. 

Just because EMS has always accepted a few hundred hours of training as being good enough doesn't mean the rest of medicine has to lower its standards to make the lowest denominator look good. May you should spend less time criticizing other professionals about wasting their time on education and look at what education has done for those professionals. EMS needs to stop with this "we're so different crap" and become part of the medical community as a profession. 

It is also those with very little education that always seem to come up with the "just as good with little education as those with lots of education" comments probably because they don't know what they don't know but that "I've seen really great Paramedics with only 624 (TX) hours that are better blah, blah, blah". If you don't have a lot of "educated" Paramedics around you who have taken the time to get at least a 2 year degree, what do you really have to compare it with? Imagine how good those 624 hour Paramedics might be if they had a decent educational foundation. Performing a couple of "skills" well does not make a good Paramedic if they can't explain why or why not those skills are used. It may also not be enough to instill great confidence in your medical director that you are ready for protocols that you might have to think rather than calling med control and/or following the recipe exactly. 

You bash other professions for being educated and not knowing what they are doing but then maybe you don't know what they should be doing since you are not in their profession and have never worked alongside other health care professionals. Many judge nurses from a 1 minute conversation about the patient and few realize that is not his/her only patient that they are caring for. Again, EMS has alienated itself from the rest of the world just because some believe the "we're so different" and a couple of "skills" puts you way ahead of the rest. 

I guess by your way of thinking, all the Canadian and Australian Paramedics are also probably wasting their time because they are required to spend some time getting educated. Hell, they could just come to the U.S. and be a Paramedic in 3 -4 months instead of 3 - 4 years. Don't need none of that book learnin' to be worshiped by others who have the same about of "hours of training".

Establishing a higher level of education gives a profession a chance to see which students are motivated to acheive that level of education and to provide a foundation for the professional to develop. It also gives the legislators a definition for that profession to be measured so that the proper reimbursement can established. 

Education is never meant to be an end all to the learning. Unfortunately, EMS has been in the tech schools too long where the "learn a few skills and start earning in a few weeks" mentality has become a slogan for EMS education in way too many areas in this country. 

So yes, keep on bashing higher education and stating examples where YOU don't believe it is necessary so that EMS can stick with the PDQ medic mills and continue on the same path it has for over 40 years. 

As far as the quality of EMS education, you failed to mention accreditation of EMS programs. Other professions do require accreditation for ALL of their educational programs. However, EMS is just starting to look at that. Except for California and most of the programs affiliated with colleges, accreditation is not really something a lot of EMS programs have obtained. At this time none of the EMS medic mills in FL have obtained accreditation and unfortunately they make up 50% of the programs in FL. TX lists 15 accredit programs which are the colleges. Are there others that are not college based in TX which aren't accredited? Now you are probably going to go on a rant that "accreditation" doesn't make a good school also and it may not but at least they have met some standards. 

In summary, tearing down other professions, including EMS in other countries, that have raised their education standards still doesn't eliminate the issues in EMS and the reasons some medical directors don't always extend a lot of protocols to their Paramedics. 

I have come to the conclusion that EMS is destined to continue as it has and there will be great resistance to any change including the new levels and the accreditaion because of those like yourself who feel it is better to hope for a few bright stars with a few "hours of training" rather than have the potential for many brighter stars to enter EMS for reasons other than the cool medic mill commercials which promise a fast education without alot of book learnin' to waste their time.


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## VentMedic (Nov 24, 2009)

MrBrown said:


> For example you take two ambo's and give them an asthma patient. One knows resp physiology, the pathophysiology of asthma and the pharmacology of salbutamol and adrenaline because it's included in those college level courses he took. He's able to use that information to process a plan of action based upon how sick the patient is, what tools he has and his experience.
> 
> The second ambo in this scenario can tell you the basics of what I've mentioned and he knows what to do because he's reacting to the stimulus the patient is giving off, but, he might not be able to tell you all the ifs and buts and hows and whys.
> 
> ...


 
Another good example to that would be those arguing which tidal volume is best with the "5-6 ml/kg" or "7-8 ml/kg" while totally missing the point that when resistance is high, you won't be able to ventilate regardless of what your recipe states. Sometimes the situation doesn't doesn't call for a particular "tidal volume" and now pressure control must become the concern and hopefully  adequate VT can be met or an adjustment to minute volume can be made. 

It is also for these reasons we do not take "phone orders" from physicians who are not near the patient and work under our own protocols for ventilator settings either in the unit or on transport. If they can't see the patient, the chest rise and the graphics or know the ventilators, they should not be ordering generic recipes. They can make suggestions but that is all. Some ALS/CCTs fail to know their own equipment and just try to "match numbers" from a big expensive ICU ventilator to their little ATV which unfortunately is all some are trusted with by their medical directors.


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## Seaglass (Nov 24, 2009)

MrBrown said:


> A bloody fantastic follow on to this is dynamic hyperinflation when bagging an asthma patient.  I often smash my head on the desk in despiar because it's so hard to explain to people as they just can't grasp the underlying concepts of the physoology of how hyperventilating an asthma patient can be fatal because they just dont have the knowledge of A&P.



The other night, I got yelled at by my training officer for not bagging an asthma patient quickly enough in a scenario. When I explained why, I got a blank stare and "You know our protocols say we need to bag at this rate when the patient is breathing at that rate." Desk, meet head.


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## Melclin (Nov 24, 2009)

rhan101277 said:


> Here is our pain management protocol.  They give us much lead way on such matters.  All of the protocols say consider, not you must etc.
> 
> http://img5.imageshack.us/img5/3073/painalgorithm.jpg
> 
> ...



"IV prochlorperazine"

Now this annoys me. I've been told again and again that you cannot give prochlorperazine IV because of the cataclysmic reaction it will have with the blood. Now I see this, I hop onto Ovid Medline, do a little research and see that IV prochlorperazine not only possible, but in fact, indicated for a number of conditions in the ED. Why must we be fed such bull:censored::censored::censored::censored:? 

Rant over.


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## MrBrown (Nov 25, 2009)

Melclin said:


> "IV prochlorperazine"
> 
> Now this annoys me. I've been told again and again that you cannot give prochlorperazine IV because of the cataclysmic reaction it will have with the blood. Now I see this, I hop onto Ovid Medline, do a little research and see that IV prochlorperazine not only possible, but in fact, indicated for a number of conditions in the ED. Why must we be fed such bull?
> 
> Rant over.



Well speaking from personal experience I got dosed on 25 of IV promethazine and even tho it was well diluted it burnt like a mother fu*ker man wow did that sting something horrid, got a big red rash all up my arm too but eh in a minute or two i was dancing on the ceiling with pink elephants and talking to sommersaulting purple dogs which did not exist, so, i didn't mind at all


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## swindlman (Jan 8, 2010)

rhan101277 said:


> So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some.  She said even a paramedic must call med control before administration of a narcotic.  We can administer it without med control though so I decided not to argue.
> 
> Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash.  I explained that one must be developed so we can decide which protocol to follow and left it at that.
> 
> I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to.  Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<



From my understanding is that if you have time for the med control then use it, just as with all meds. But if you are using your MONA and they Pt is refractory to you dropping 3 rounds of NTG to control the pain then start with your morph if the guy is going down the drain. And advise the Dr. when you call in what you did, as long as you have just cause for your actions then you will be alright. A lot of it depends on your relationships with the doctors and if they know you and trust your judgment. 

I have lucked out with how my program is set up, all my RN hosp preceptors were once medics and most still have their licenses. So they know how things work on the road and in the hospital. We get around a lot of the grudges between the RNs towards the Medics. Plus the docs trust them so they push the students in the middle of the codes so we get to participate in alot in the ER.


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## redcrossemt (Jan 9, 2010)

swindlman said:


> From my understanding is that if you have time for the med control then use it, just as with all meds.



You have to use med control for all medications?? Wow, that'd be a long, long day; and a lot of extra RF exposure...



swindlman said:


> But if you are using your MONA and they Pt is refractory to you dropping 3 rounds of NTG to control the pain then start with your morph if the guy is going down the drain.



Not exactly sure what you mean by "going down the drain"... but if my patient's BP is dropping or their mental status is decreasing, I'd be very, very careful with giving morphine. Especially without orders, not that I need them.



swindlman said:


> And advise the Dr. when you call in what you did, as long as you have just cause for your actions then you will be alright. A lot of it depends on your relationships with the doctors and if they know you and trust your judgment.



Someday this could get you in big trouble. Sure, you can get away with a lot of things not in the protocol. But wait until a patient gets worse, or better dies, and then you call med control and say, "hey I gave the morphine I wasn't supposed to, and now the patient is dead, okay, we'll see you in a minute." No doctor will support "cowboy" paramedicine after-the-fact, especially with a poor outcome. They don't want to be sued or tied up with the lawsuit against you.



swindlman said:


> I have lucked out with how my program is set up, all my RN hosp preceptors were once medics and most still have their licenses. So they know how things work on the road and in the hospital. We get around a lot of the grudges between the RNs towards the Medics. Plus the docs trust them so they push the students in the middle of the codes so we get to participate in alot in the ER.



If the above is what they are teaching you, I would suggest you be very careful. I'd be interested to know which school you are going to, and what your clinical sites are... I am glad that you get to participate, though.


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