# Prehospital nurses



## LucidResq (Mar 23, 2008)

Does anyone know of nurses working in the prehospital setting, not including the air? 

And would you feel comfortable allowing a good ER nurse with a little prehospital experience riding along with you? 

I'm asking because I'm currently an EMT-B student, but I'll have my BSN in 3 years or so. I plan on working in the ED, but I would like to ride on an ambulance occasionally on the side to gain some prehospital experience. Does that make sense? Is that possible?


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## MSDeltaFlt (Mar 23, 2008)

I believe that every ED RN should do ride alongs with EMS and vise versa.  However, depending on the state (I believe), you will be the higher level of care which will throw in a bunch of ethicolegal issues I'm not fully fluent on.  If you wanted to go that route, then you would probably need to check with, not only your local EMS agency (if private), but your employer as well; especially if hospital based.  You would also need to check with your state EMS and nursing agency.

I hope you can.  Good luck.


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## VentMedic (Mar 23, 2008)

There are states (*PA*, IL, KY) that now certify RNs as PHRN or MICN (CA, NJ). We are also hoping Florida will take the PHRN path and rewrite some old statutes on the books.  

These RNs will usually have ED experience and will most likely have the usual alphabet soup of CEN and/or CCRN with ACLS, PALS, TNCC, ATNC, NRP etc as required by EDs to work in the hospital environment as well as their college degrees with all the sciences. However the state may require additional training of 100 - 300 hours (1 -2 college semesters) to get a nurse accustomed to the prehospital setting prior to certification.    This is the one thing about nurses in general, rarely do they jump into a situation that they are not prepared to adequately take care of.  That is just a culture that has been ingrained in them from the very beginning of their education and work experience.   EMTs and Paramedics on the other hand, well, that's another story. 

This prehospital certification for RNs is not to be mistaken for a CCT, Flight Nurse or Specialty Transport RN which takes in most cases 5 yrs of experience and specialized training by their medical director. 

Link to ENA and NFNA's (aka ASTNA) position on this issue.  
http://www.ena.org/about/position/PDFs/Role-RN-PreHospital.PDF

example PHRN program:
http://www.hacc.edu/index.cfm?fuseaction=healthCareers.Programs+Offered&id=948


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## firecoins (Mar 23, 2008)

ALS tranfers in NJ require RNs and a medic.  Of course most of the RNS doing the transfers are or were paramedics.  This is usually who's interested in doing the interfacility transports anyway since its a pay raise for a medic to get the RN since they are already doing transfers.

In NY I have seen flight nurses on stat flight/lifenet, the helicopter in my avatar.  Pretty much they work like medics.


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## FFMedic1911 (Mar 23, 2008)

I live in Ky and have never heard of this cert for nurses.I even asked the wife who is a nurse and she hasn't.I know that we did use nurses on als transferes years ago when we was just bls.Could you point me to where the info is on this vent.Thanks


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## Jon (Mar 23, 2008)

In PA, a PHRN can do everything an EMT-P can do, and they can do more... they aren't limited to the state approved drug list, so they can do an interfacility transfer of patients with ANY IV's... including blood transfusions. This also means they can carry and use all the RSI drugs, because the state allows medics to only do limited facilitated intubations. PHRNs are interchangeable with medics when it comes to staffing an ALS vehicle... but few services will pay a RN to do a medic's job... so if a PHRN is working on a 911 rig in the field, they are often working at a pay rate similar to a EMT-P.

I hope to be a PA PHRN after I get through nursing school... so in about 4-5 years... if all goes well.

Anyway... as for knowing nurses... RidRyder IS a nurse! And we have some other RN's who are members on here too.


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## VentMedic (Mar 23, 2008)

FFMedic1911 said:


> I live in Ky and have never heard of this cert for nurses.I even asked the wife who is a nurse and she hasn't.I know that we did use nurses on als transferes years ago when we was just bls.Could you point me to where the info is on this vent.Thanks



According to KY's nursing statutes, it looks like an RN doesn't actually need the additional cert but is a nice option if they want additional training. 

http://www.kbn.ky.gov/NR/rdonlyres/8308B655-9066-48C8-AFA2-88CA96AA7AEF/0/aos26.pdf

One of my Flight co-workers worked for a ground EMS company as well as Flight in KY.   He had his EMT but practiced under his RN scope.  When he came to Florida, he took a written test to get his Florida EMT-P.  

Challenging the  EMT-P is still an option for RNs in some states since it is considered only a certificate level training.  For that reason, many in Florida would like to see the PHRN such as in Pennsylvania where there is a little training required but the RN is still the license they use which can be more versatile than the EMT-P in some areas which makes the ambulance service more flexible for offering CCT as well as 911 service.


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## Ridryder911 (Mar 24, 2008)

There is no similar education between nursing and a Paramedic. The only similarities is patient care ( general i.e. anatomy & physiology, etc) I believe there is a need for specialty transport nurses, i.e neonatal, even for those on balloon pumps, etc. 

I believe if they want to work in the prehospital arena they need to enter and complete a whole Paramedic program. Sure, the basics can be eliminated but again nursing programs are not required to have any emergency or critical care in the curriculum. In fact NCLEX (RN) test, can NOT have any questions regarding such. 

There is now a board certification level for nurses, CTRN (certified transport RN) for those whose speciality is such, similar to CFRN (flight nurse), etc. 

My state requires the RN to enter from basic to Paramedic, no exceptions (clinicals can be changed to field in lieu of hospital). Personally, I like that. In the same comparison of a Paramedic to an RN. Two different professions and two different education programs. 

R/r 911


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## VentMedic (Mar 24, 2008)

Ridryder911 said:


> There is no similar education between nursing and a Paramedic. The only similarities is patient care ( general i.e. anatomy & physiology, etc) I believe there is a need for specialty transport nurses, i.e neonatal, even for those on balloon pumps, etc.
> 
> I believe if they want to work in the prehospital arena they need to enter and complete a whole Paramedic program. Sure, the basics can be eliminated but again nursing programs are not required to have any emergency or critical care in the curriculum. In fact NCLEX (RN) test, can NOT have any questions regarding such.
> 
> ...



Totally disagree with you there Rid on the education.  There is absolutely NO reason for an RN to go through the few weeks of basic A&P when they have had at least 2 semesters of college A&P, 1 semester of Micro, 2 semesters of college pharmacology.    What they do need is 100 - 300 hours of the field experience and those things that are specific to prehospital.  

The same with EMT-B.  A 24 -36 hour course of extrication and ambulance ride time should be done instead of making a BSN nurse sit through very basic A&P.   

Considering many EMT-Ps are "street ready" with just 1000 hours which includes only an overview of A&P and pharmacology that is specific just to the field, why insult nurses?   You are basically saying nurses are idiots who can not be taught anything in the "street" because they are nurses.  Yet, a paramedic student can go from flipping hamburgers to intubating in just a couple weeks in the medic mills without any college sciences or previous patient care experience.   It would be nice if the Paramedic clinicals were structured for a lot of patient experience but many are not.  That is truly where the EMT and Paramedic clinicals are virtually worthless in some schools.  For some a quality clinical is where the least calls are ran and who has the best TV screen. 

For Flight and CCT, we have had no problems teaching nurses intubation for all ages, central lines,  leading codes (which is old hat for many) and a variety of other skills and knowledge.  The one thing they do have is previous knowledge and a lot of patient contact experience.   We do respect our nurses for the education they have gotten, identify what they need and build from there.  It is more difficult to get the Paramedic to the same knowledge and experience level as the RN for some Flight and CCT programs even with skills being equal.

Again, one has to be careful with the PHRN, CTRN, MICU and CFRN.   The PHRN is not the same as CFRN.  Nor is the training for PHRN the same as a CCT RN.  PHRN is focused more like a paramedic in prehospital and CCT RNs are more Critical Care specialty.       

Remember that RNs taught the early paramedic classes and are still present in many educational systems because there are not enough Paramedics with advanced degrees (B.S. or M.S.) to teach or be on some boards.


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## BossyCow (Mar 24, 2008)

In our state, an RN doesn't license you to work in pre-hospital setting and you must have an additional cert as EMT or EMT-P. We have had situations where an RN on scene has attempted to dictate pt care to EMS personnel and in each case, EMS has been determined to be in control of the pt care until they swing through those ER doors. One instance was a nursing home RN who tried to cancel a code and quit CPR on a pt who still had a rhthym and full code status upon arrival of EMS. 

Another issue is that nasty headache of liability. If a nurse, who is licensed by the state and works in the local ER, rides in the back of another agency's rig on a call, and screws up, who is liable? The agency he/she is riding with or the agency where he/she works? This was the issue that stopped our attempt to get some ER nurses to do ride alongs.


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## firecoins (Mar 24, 2008)

Nurses need additional training in prehospital EMS.  They may not need the whole medic program but they need a BLS/ALS bridge class.


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## Jon (Mar 24, 2008)

In PA, the RN needs to go through a PHRN class, which (using my google-fu) seems to be in the 130-hour range. From my understanding, the class teaches the medic "monkey skills" of IV, intubation, etc., as well as prehospital protocols and operation. PA requires RN's to have their EMT, and it looks like they take the NREMT-P test.... does this make them a medic too?

http://www.dsf.health.state.pa.us/health/lib/health/ems/emsib_56.pdf


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## firecoins (Mar 24, 2008)

Jon said:


> In PA, the RN needs to go through a PHRN class, which (using my google-fu) seems to be in the 130-hour range. From my understanding, the class teaches the medic "monkey skills" of IV, intubation, etc., as well as prehospital protocols and operation. PA requires RN's to have their EMT, and it looks like they take the NREMT-P test.... does this make them a medic too?
> 
> http://www.dsf.health.state.pa.us/health/lib/health/ems/emsib_56.pdf



If they pass the NREMT-P, yes it does.


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## VentMedic (Mar 24, 2008)

Jon said:


> In PA, the RN needs to go through a PHRN class, which (using my google-fu) seems to be in the 130-hour range. From my understanding, the class teaches the medic "monkey skills" of IV, intubation, etc., as well as prehospital protocols and operation. PA requires RN's to have their EMT, and it looks like they take the NREMT-P test.... does this make them a medic too?
> 
> http://www.dsf.health.state.pa.us/health/lib/health/ems/emsib_56.pdf



Actually for your state it is probably better if they work under their RN license with the PHRN.  In some states Paramedics are restricted by scope in their statutes and PA  paramedics have had an issue in the past with RSI.  The RNs did not have the same problem.  

Even as an RRT, I have a broader scope for transport than what my Paramedic license allows.  However, when I am on the helicopter wearing a Paramedic patch, that is the scope I must follow. When I am doing CCT or Specialty transport as an RRT, I never even mention that I am a paramedic or sign my name as such.  The higher scope and education trump in those transports.  So, it depends under what title and job description I am working under.   The Paramedic is still a certificate which is less hours than some of the other certificates of training required for specialty ICUs.    

As far as a BLS/ALS bridge, many of the nurses applying for PHRN may already be maxed for "ALS" certifications.  They just need some extra training and exposure to the field to apply their knowledge.  Where they have the most problem adapting is they try to use advanced critical care thinking and knowledge which they would be doing in the ED or ICU.   They have to scale it back a little for most prehospital situations.


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## firecoins (Mar 24, 2008)

VentMedic said:


> Actually for your state it is probably better if they work under their RN license with the PHRN.  In some states Paramedics are restricted by scope in their statutes and PA  paramedics have had an issue in the past with RSI.  The RNs did not have the same problem.
> 
> Even as an RRT, I have a broader scope for transport than what my Paramedic license allows.  However, when I am on the helicopter wearing a Paramedic patch, that is the scope I must follow. When I am doing CCT or Specialty transport as an RRT, I never even mention that I am a paramedic or sign my name as such.  The higher scope and education trump in those transports.  So, it depends under what title and job description I am working under.   The Paramedic is still a certificate which is less hours than some of the other certificates of training required for specialty ICUs.
> 
> As far as a BLS/ALS bridge, many of the nurses applying for PHRN may already be maxed for "ALS" certifications.  They just need some extra training and exposure to the field to apply their knowledge.  Where they have the most problem adapting is they try to use advanced critical care thinking and knowledge which they would be doing in the ED or ICU.   They have to scale it back a little for most prehospital situations.




we have MDs and PAs who work as paramedics.  They don't find it too difficult.  They understand the liability and limits and do it anyway because they enjoy it.  We don't even do RSI as medics in NYC.  We sedate but paralytics are not used.


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## VentMedic (Mar 24, 2008)

firecoins said:


> we have MDs and PAs who work as paramedics.  They don't find it too difficult.


I would hope not!



firecoins said:


> They understand the liability and limits and do it anyway because they enjoy it.



As a hobby? Extra money?   I can see getting some field experience but it would be frustrating to be either of them and not to be utilized to the fullest extent of their scope of practice.  Yes, we also have those professionals working in various situations involving transport, but under their own license.   



firecoins said:


> We don't even do RSI as medics in NYC.  We sedate but paralytics are not used.



That is why in some areas it may be necessary to have someone with a different license and scope to do what paramedics are not allowed to do.  We see this often for ER to ER or Cath lab transports when an RN must accompany the patient because of various medications that are beyond the scope of many field paramedics. 



BossyCow said:


> In our state, an RN doesn't license you to work in pre-hospital setting and you must have an additional cert as EMT or EMT-P.



In Washington State there are at least two helicopter services that utilize RNs for scene response.  Even if they do have an EMT cert for some extrication skills, that is not the license/certification they will function with to give meds and intubate.    The same goes for the RRTs who are also partners with the RNs on one service.  The other service is RN/RN. 

Certifications are not necessarily licenses depending on their purpose.   An RN or MD can take an EMT or Paramedic certification class for some knowledge but may not have to be licensed in that profession.  The NREMT may be enough.   You also have several Paramedics who have nursing degrees but do not have an RN license either for not being able to pass the test or found the CEUs and experience difficult to keep up.


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## firecoins (Mar 24, 2008)

VentMedic said:


> Where they have the most problem adapting is they try to use advanced critical care thinking and knowledge which they would be doing in the ED or ICU. They have to scale it back a little for most prehospital situations.


I meant that they didn't find it difficult to scale it back.  They don't need to get too imaginative. Its not like they spend any large amount of time with the patient.


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## paramedix (Mar 26, 2008)

We had a ride-along course for the ER Nurses from certain hospitals to ride with us, but they are not allowed to do anything on the road. 

Some of the RN's that do the exams for the Trauma Qualification have (to) ride with the paramedics.

As far as I understand we do not allow nursing staff on our vehicles. They are regulated by the Nursing Council and not the Health Council where our doctors, paramedics, physios... etc, are registered.

Thus they cannot practice their protocols on the road.


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## medicsRULE (Dec 30, 2008)

*Apples aren't oranges -- Nurses are NOT medics*



VentMedic said:


> You are basically saying nurses are idiots who can not be taught anything in the "street" because they are nurses.  Yet, a paramedic student can go from flipping hamburgers to intubating in just a couple weeks in the medic mills without any college sciences or previous patient care experience.



Why, by the same token, insult paramedics???  

I have never met a paramedic who has gone from flipping hamburgers to intubating in a couple of weeks.  What are you saying?? Get real!

I'll tell you why some nurses and pedants insult paramedics: they are green with envy!  Paramedics know autonomy and gratification that few nurses will ever know, and good medics have plenty of room to shine independently.

In any case, the spirit of what you suggest is malicious.  It's a slap in the face to EMS Physicians and State EMS coordinators to suggest that medics are underachievers with a few weeks of training.

I do know a Stop & Shop bag-lady who became a registered nurse.  She was packing my cold-cuts one day and sitting at a triage desk the next.  So what?  To each his own.

There are inept paramedics, and there are inept nurses -- but it works both ways.  With respect to education, all the medics I know took as long or longer than ASN level registered nurses to attain and maintain their credentials, so let's be fair.

From EMT Basic, mandatory field time, Paramedic school (up to two full years), internship and CMEs, paramedics on the whole are thoroughly trained and well educated; it's just that their scope of expertise is extremely focused.

If you're envious and want to be a paramedic instead of carping and insulting them (or if you want to be a GOOD medic instead of a resentful one), take the full medic program and practice, practice, practice... otherwise get over it!  

Nurses are NOT medics... If you think RNs and EMT-Ps are one and the same, let it work both ways.  Let qualified medics memorize the requisite drug tables and take take 100 hours of butt-wiping and bed-making rotations, then let them transfer into a full nursing license.

Not everyone who puts "EMT-P" after their name is a REAL medic, admittedly... but true brothers and sisters stick together.  :glare:


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## VentMedic (Dec 30, 2008)

medicsRULE said:


> Why, by the same token, insult paramedics???
> 
> I have never met a paramedic who has gone from flipping hamburgers to intubating in a couple of weeks. What are you saying?? Get real!
> 
> ...


 
Wow! Someone who doesn't have a clue about other professionals in medicine. It is easy to tell by your post you have not been much past the ED doors. 

I do not think they are the same.

I have held an Associates degree as a Paramedic since 1979. Unfortunately I am the minority. 

Only one state in the U.S. requires Paramedics to have a mere 2 year degree. Paramedic education continues to be measured in hours. It is possible to become a Paramedic in 3 months in this country. It is not possible to become an RN in that short length of time. Some medics say they took "as long" as RNs but without a degree to show for it, you might just say the "stretched out their hours". 

The EMS profession is only as strong as its weakest link which right now is the low education minimum requirements for entry level as a Paramedic with some states being as low as 500 hours of training. 

The sooner you realize how far EMS still has to go in correcting its problems, the sooner it can become a medical profession with established standards and respect as medical professionals. Do something to clean up your own back yard before you attempt to bash a profession which you have shown to know so little about.

True brothers and sisters don't stick their head in the sand and pretend the world of EMS is perfect.


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## marineman (Dec 30, 2008)

BossyCow said:


> In our state, an RN doesn't license you to work in pre-hospital setting and you must have an additional cert as EMT or EMT-P. We have had situations where an RN on scene has attempted to dictate pt care to EMS personnel and in each case, EMS has been determined to be in control of the pt care until they swing through those ER doors. One instance was a nursing home RN who tried to cancel a code and quit CPR on a pt who still had a rhthym and full code status upon arrival of EMS.
> 
> Another issue is that nasty headache of liability. If a nurse, who is licensed by the state and works in the local ER, rides in the back of another agency's rig on a call, and screws up, who is liable? The agency he/she is riding with or the agency where he/she works? This was the issue that stopped our attempt to get some ER nurses to do ride alongs.



That's an interesting scenario I've never really thought about. On a 911 response we have had several times that there are RN's on scene as bystanders (actually had another areas medical director once) where even as a first responder I was deemed in charge of patient care until the medics came, then they were in charge the Nurses and even the doc had absolutely no say. 

Also the company that I'm doing my ride-alongs with has done several long distance transfers (few hours one way) where both medics stay in the front of the rig and the hospital sends a team usually an RN or two and possibly an RRT depending on the patients condition. At that point the RN's are in charge of patient care (obviously since both medics are in the front). I'm sure if I was a little more versed in law I would be able to point out the reasoning but for now I'll just accept it.

For anyone else that does transfers with a nurse riding along as the primary patient care provider what happens if the patient codes, does it then become an emergency where you're in charge or is the nurse still in charge?


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## marineman (Dec 30, 2008)

VentMedic said:


> Only one state in the U.S. requires Paramedics to have a mere 2 year degree.



Purely out of laziness to operate google which state requires a 2 year degree? I'd like to do some research on that. Ever since R/r's hate thread got me fired up I've wanted to assemble some jaw dropping facts to send to my senators, State EMS board, the whole works to see if WI can't at least get to that point.


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## medicsRULE (Dec 30, 2008)

*Lies.*

If it's possible to go from zero to paramedic in three months, as you said, then it is not legitimate... and I would like you to name the school specifically or clam up... please don't point me to an online institution that's accredited in Nigeria.  

The very suggestion in this open forum is an insult to all paramedics, including yourself.  I've never heard of such a thing.  

While I am ALL FOR more states REQUIRING a mimimum 2 year degree accreditation for all paramedics, what is REQUIRED and what is DONE IN PRACTICE are two disparate issues.  Most paramedics have put in their time.

It took me three long years of intense training to become a paramedic, including 52 college credits worth of classroom time -- eight hours a day for a period of nine straight months with no vacations or breaks (a full time academic program).   This was the FDNY (formerly NYC-EMS) paramedic program.  

At the time, I qualified for a class that had 400+ applicants with less than 25 available slots -- an admission ratio more formidable than most medical schools.  This program, with a few extra credits from a local university, translates into an Associates degree -- ie, the same credentials as an ASN, and that is NOT INCLUDING THE PREREQUISITE YEARS OF EMT FIELD EXPERIENCE REQUIRED.

THREE MONTHS!?  HA!!  Check this man's narcotic bag!

I consider myself and my colleagues to be the academically the peers of nurses -- superior to them when it comes to autonomy in out-of-hospital critical care, and rightfully humbled by them in their ability to deliver a wide array of therapies in coordinating with physicians.  There is always mutual respect.  We are a life-saving team.

Most nurses I have met, unfortunately, think they are superior in every way to paramedics.  They outnumber us and, it is true, they "out credential" us, regardless of their abilities, clinical skills, and talents.

But your argument is grossly biased against medics; it is glib and outright ludicrous.  Respect the profession or rip off your medic patch.  It's malicious mouthpieces like you that have eroded EMS expectations and reduced paramedics, in the eyes of some, to boy scouts trained in first aid.

Get a clue, please.


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## KEVD18 (Dec 30, 2008)

two things:

one, it was nice having you for such a short time medicsrule, but i forsee a ticket on the banned bus for you if you dont drop the attitude and holier than thou approach to posting.

two, did that old thread/anti bumping feature actually get installed or was that a joke?


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## marineman (Dec 30, 2008)

holy crap I didn't even notice the original post date


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## ffemt8978 (Dec 30, 2008)

Closed for a 24 hour cool off period.


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