# Replacing EMS with nursing revisited



## Veneficus

A few times in the past, I suggested that it might provide better care providers if nursing were to move into and take over EMS.

After reading about how new grad nurses are having trouble finding employment here on the forum, as well as the absolute objections of US EMS to move beyond simpleminded tech skills, I was thinking it might be time to once again look at the benefits nursing can bring.

Because they already have a general educational base in healthcare and already have practicioners functioning in home healthcare, home dialysis, wound care, etc. They already have the knowledge and skills to provide the service that will be the basis of future EMS as I see it, in commnity outreach and home care.

A "bridge" aka EMS specialty course could easily be added to their education. Much easier than a clinical science background to EMS providers.

Many physicians I have met in Europe start out working in EMS at least part time. As a result when they move back into the hospital they have a great range of skills and insight on patient behavior, conditions, etc. (not to mention the skills to handle emergencies) we could get that same thing from nursing. That might mean a whole generation of nurses who know how to recognize and react to emergencies in any environment they work. No more nursing homes without a clue. 

It would provide ample employment opportunity and advancement to qualified nurses as well as new grads. I can't say for sure, but if I would think a new nursing grad would be more inclined to work in EMS if it included preventative care than sit on unemployment. Plus there is a safety built in. Online medical control and the ability to transport.

As I understand, the principle of nursing was to help patients take care of thier basic human needs. Today that certainly includes help navigating the healthcare system as well as a healthcare provider that reaches out instead of making patients come to the ivory tower.

Educational problem solved. EMS advancement problem solved. New nurse employment problem solved. I am king!  

Clara Barton was a nurse.


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## Shishkabob

So, what say you about places like NZ, UK, AU that have Paramedics, and I use this term gritting my teeth, "on par" with nurses?  Should the nurses 'take over' EMS there as well?


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## Veneficus

Linuss said:


> So, what say you about places like NZ, UK, AU that have Paramedics, and I use this term gritting my teeth, "on par" with nurses?  Should the nurses 'take over' EMS there as well?



Why fix something that isn't broken?


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## Shishkabob

As long as you're open to Paramedics replacing nurses in the trauma room... or cardiology... or respiratory.


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## Veneficus

Linuss said:


> As long as you're open to Paramedics replacing nurses in the trauma room... or cardiology... or respiratory.



As soon as paramedics require a 4 year degree in basic and clinical sciences, I will support them going into any area of healthcare.

But they have had more than ample opportunity and not only do they refuse to take it, more than 90% of them fight against it.


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## Shishkabob

Veneficus said:


> But they have had more than ample opportunity and not only do they refuse to take it, more than 90% of them fight against it.





Proof?



Hey, you're always advocating evidence based medicine here


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## Veneficus

Linuss said:


> Proof?
> 
> 
> 
> Hey, you're always advocating evidence based medicine here



check out the percentage of EMS provided by the US fire service.

Also look at the position statements and actions from its leaders like Gary Ludwig.


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## Shishkabob

Veneficus said:


> check out the percentage of EMS provided by the US fire service.



Last figure I saw, it was 1/3, with the other 2/3 being governmental and private.


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## abckidsmom

My initial EMS training was a 9 month paramedic class in 1999.  I was a year out of nursing school, working in a level I trauma center's STICU.  We met on Tuesdays for 6 hours of lecture, and had the minimal clinicals that were part of the curriculum at that time.

I felt that paramedic class did not require much effort, academically, and because I'd been working in EMS for 4 years at that time, I didn't feel that I learned a whole lot practically speaking either.

I've always maintained that being a nurse has made me a much better medic than I would have been otherwise.  Even though I've never worked as a nurse in the community where I do EMS, I am much more aware of the resources available to patients, more willing to work the "helping people take care of their basic needs" part of the job than the medics I work with, and having the basic education that allows me to learn about more in-depth topics by reading articles, etc.

My husband has been in EMS a little bit longer than me, and has trained as a firefighter/paramedic through the same initial educational process as I did.  He's worked continuously in the field, while I've been out for maternity leave, barely active for about 5 out of the last 8 years. 

He still calls me if he runs into something he doesn't quite understand, if he has a good tricky medical call, I *always* have something to say about the patient that he hadn't thought of, and we always end up learning from the discussion.  I consider him to be one of the good medics. Since I don't even consider myself one of the best thinkers in the conversations here, I believe that points very clearly at the faults of the system in our country. 

The good, *thinking* nurses in ERs and critical care run about 40% of the total population of nurses in those environments.  In EMS, the good, *thinking* medics run about 10%.  Just to get that ratio a little closer would be great.

This is a radical idea, Vene.  I wonder what the ANA would say about it?  Could nursing as a whole stand to have a branch of nursing having that level of autonomous practice?


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## 8jimi8

We already have that autonomy in ICU.  Our protocols and guidelines function very much like standing orders.  Open heart starts flagging and pacer wires are still in place. you can bet your hiney i'm going to start that pacer before I make the phone call.  Isn't that close to what the situation in California is?  Critical Care nurses giving orders to medics over dispatch?


Vene i think this idea is outstanding.  Seriously you killed two birds with one stone on that one.  It has long been a notion I have endorsed that all RNs get at least an EMT-B.

Linuss (i'm not trying to call you out and be a ****) part of the proof is patch factory medics.  For being one of the strongest advocates for education and autonomy of Medics, i can't see why you haven't gone back to school.  For arguing so much of the equality of the two professions, wouldn't you agree you need more school to be the equivalent that you defend?


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## terrible one

I've often thought about this as well. Wont ever happen tho,

Fire Union to strong to allow their "medics" to go back to being First Responders.
Nursing Union to strong to allow their nurses to go out and make just above minimum wage on a box. 

While the patient might ultimatley benefit from this (more advanced care, less pt's to the ER, reducing oversaturation, more long term treatments) there are far too many politics in the way. Also who would pay for it? Since medicare is the biggest payer to private ambulance companies how do you justify an RN who can make upwards of $60k in a hospital setting to go work for $30k in an ambulance? 

The way I see it more FDs take over emergency transport companies more protocols get diminshed and eventually a paramedic in the US will be able to do little more than an IV and Oxygen. 
A perfect example is Los Angeles County the birthplace and the way things are going the death of pre hospital care. Since it's beginning almost 40 years ago paramedics could not do anything without talking to base. What's changed in 35 years? You have a protocol sheet one page long with about 10 drugs you are allowed to use without talking to "mommy". but do any of the 3500 paramedics in LA care? No, because they are making big bucks pulling hose and throwing ladders. Even though 80% of their calls are for medical aides they still call themselves a "Fire Dept" and refuse to perfect and become proficient at basic pre-hospital care. 

Oh well...


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## Sasha

Nurses taking over EMS would have the potential to make EMS more than just a fast ride to the hospital. You're going against tradition. It will never happen.


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## TransportJockey

Sasha said:


> Nurses taking over EMS would have the potential to make EMS more than just a fast ride to the hospital. You're going against tradition. It will never happen.



Especially against a FD. They are all about tradition to the detriment of the patient.


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## abckidsmom

8jimi8 said:


> We already have that autonomy in ICU.  Our protocols and guidelines function very much like standing orders.  Open heart starts flagging and pacer wires are still in place. you can bet your hiney i'm going to start that pacer before I make the phone call.  Isn't that close to what the situation in California is?  Critical Care nurses giving orders to medics over dispatch?



This is different, IMO, than the managment of an ICU patient.  Those patients are established, have a team of physicians, and have a sheath of orders.  You notice the patient's decline, you use your brain and get a set of labs, replace lytes, adjust the vent and turn on the pacer, but even though it's autonomous, it's not the same as being dispatched, arriving on the scene of a call, and dealing with the patient start to finish.

I see that the arrival at the ER would be much more seamless if this was the case.


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## 8jimi8

With a minimum educational entry, that would be a great reason to bump up that pay to something like 42-44 where alot of new grad nurses start.  21 bucks an hour to save another life.  Hell that beats 11 an hour where I see my medics hopping from job to job to live.


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## Shishkabob

Sasha said:


> Nurses taking over EMS would have the potential to make EMS more than just a fast ride to the hospital. You're going against tradition. It will never happen.




So what about Usalfyre / my agency?  What about agencies such as Wake County, Austin/Travis County, Williamson County, Cyrpress Creek and all the other renowned agencies who actually promote their medics to be care providers and not just rides?  Who put patient well-being and care infront of revenue?  





8jimi8 said:


> Linuss (i'm not trying to call you out and be a ****) part of the proof is patch factory medics.  For being one of the strongest advocates for education and autonomy of Medics, i can't see why you haven't gone back to school.  For arguing so much of the equality of the two professions, wouldn't you agree you need more school to be the equivalent that you defend?



I had been planning on going back to school after I got my medic for quite a while, but had put it off when I was doing IFT because I knew I wasn't going to stay at that company more than 6 months, and as such didn't want to buy a new place / start college before I got to an agency that I was going to spend some time at.  Now that I'm at an agency that I can see staying at for some time, I'm actually back into looking at classes.  My first mission is to find a college that will give me life credit for my Paramedic cert so I can finish my EMS degree, to which I've found a few, then move on to either my BA or do an RN bridge.

But like I said, the first step was actually getting settled in to a place to start school again.  There was no intention at just staying a certified medic and not moving up to Licensed Paramedic.


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## Sasha

8jimi8 said:


> With a minimum educational entry, that would be a great reason to bump up that pay to something like 42-44 where alot of new grad nurses start.  21 bucks an hour to save another life.  Hell that beats 11 an hour where I see my medics hopping from job to job to live.



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

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


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## WTEngel

If nurses wanted to ride on an ambulance, they would have gone to paramedic school.

It won't work because I have a feeling the majority of them will not want to do it.

I am an advocate of nurses in the pre hospital setting, I have worked pre hospital with nurses before and continue to do so. I have nothing but respect for them and their knowledge, and I feel they respect me and my knowledge (granted I don't fall into the category of most average paramedics.)

In my opinion, the transition of paramedics to nursing (with the appropriate training) seems to be more successful than nurses transitioning to the paramedic role. Keep in mind, I am not just talking about the actual attainment of the certification, but also the practical application of the skills and abilities required for the position. 

The thing that makes most nurses successful when they enter flight medicine of critical care transport is many years of experience and gradual increase in education beyond initial certification (the sa,e things that make a medic successful also.) 

Taking all of this into consideration, putting GNs in the field is a bad idea. No experience, probable lack of desire, and lastly a real lack of relevant experience for the GNs who want to enter the clinical setting (except for ER and possibly ICU, which is a portion of the overall nursing workforce.)

Remember, we always talk about skills do not equal education. The opposite is also true, education does not equal skills.


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## Sasha

> So what about Usalfyre / my agency? What about agencies such as Wake County, Austin/Travis County, Williamson County, Cyrpress Creek and all the other renowned agencies who actually promote their medics to be care providers and not just rides? Who put patient well-being and care infront of revenue?


The exception, not the rule.


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## 8jimi8

Linuss said:


> So what about Usalfyre / my agency?  What about agencies such as Wake County, Austin/Travis County, Williamson County, Cyrpress Creek and all the other renowned agencies who actually promote their medics to be care providers and not just rides?  Who put patient well-being and care infront of revenue?
> 
> 
> 
> 
> 
> I had been planning on going back to school after I got my medic for quite a while, but had put it off when I was doing IFT because I knew I wasn't going to stay at that company more than 6 months, and as such didn't want to buy a new place / start college before I got to an agency that I was going to spend some time at.  Now that I'm at an agency that I can see staying at for some time, I'm actually back into looking at classes.  My first mission is to find a college that will give me life credit for my Paramedic cert so I can finish my EMS degree, to which I've found a few, then move on to either my BA or do an RN bridge.
> 
> But like I said, the first step was actually getting settled in to a place to start school again.  There was no intention at just staying a certified medic and not moving up to Licensed Paramedic.




I didn't figure so, Bro, I just never knew what your plan was.


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## Shishkabob

8jimi8 said:


> I didn't figure so, Bro, I just never knew what your plan was.



It was always a secret!  




Sasha said:


> The exception, not the rule.



Yet the exception is steadily becoming the rule... atleast in the areas I see.

Plus, notice how many of the areas I named were in Texas?  Where the individual MC is allowed to choose what their medics do instead of beaurocrats that limit it to thing like "You need to call a nurse"?

Maybe if places like Cali and Florida actually, you know, treated EMS in a better light, they'd get better medics?


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## terrible one

Linuss said:


> My first mission is to find a college that will give me life credit for my Paramedic cert so I can finish my EMS degree, to which I've found a few, then move on to either my BA or do an RN bridge.



What degree? Is there an actual EMS degree? or do you mean something else?


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## Sasha

Linuss said:


> It was always a secret!
> 
> 
> 
> 
> Yet the exception is steadily becoming the rule... atleast in the areas I see.
> 
> Plus, notice how many of the areas I named were in Texas?  Where the individual MC is allowed to choose what their medics do instead of beaurocrats that limit it to thing like "You need to call a nurse"?
> 
> Maybe if places like Cali and Florida actually, you know, treated EMS in a better light, they'd get better medics?



Florida doesn't treat EMS poorly, it recognizes the need for more trained professionals beyond the Basic level and requires a medic on every truck.  Unfortunately the IAFF is a big beast and convince the public that Fire EMS is better than third service EMS.


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## Shishkabob

terrible one said:


> What degree? Is there an actual EMS degree? or do you mean something else?



Depending on the school, there's degrees in Paramedicine or degrees in Emergency Medical Serives / Emergency Medicine.


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## Shishkabob

Sasha said:


> Florida doesn't treat EMS poorly, it recognizes the need for more trained professionals beyond the Basic level and requires a medic on every truck.  Unfortunately the IAFF is a big beast and convince the public that Fire EMS is better than third service EMS.





I'd rather have less that care, than more that don't.


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## Aidey

I think the idea would be met with too much resistance all the way around honestly. Some people would support it, but the big players wouldn't. 

Given the current political climate in the US, just the money involved would prevent the idea from gaining widespread traction. No one is going to want to pay for a RN. Not the private companies, fire based EMS agencies, or the insurance companies. As someone pointed out the average RN wage in a hospital can easily be twice what a Paramedic makes working for a private agency. 

No service (private or fire based) is going to be willing to absorb that kind of increase in overhead costs. They will try and make up for it by increasing billing rates. Insurance companies will never go for it, arguing that it isn't necessary to have a RN on the ambulance, and they won't reimburse at a higher rate. The only way I can see insurance companies getting behind it is if there is a clear benefit to them. 

The fire unions will do everything within their power to fight it, as everyone in fire knows the only reason FDs are maintaining their funding and staffing levels is because of EMS calls. We can't even get them to support any sort of educational increase, I can't imagine their reaction to a takeover. 

I'm not trying to be a pessimist here, but I envision a lot of resistance from all sides.


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## Veneficus

But what about the highly motiated people who want an education and want to get on the truck?

It just makes nursing a prereq to be a paramedic. It also has the additional bonus of offering easy transitions to other nursing environments like the ICU when a provider is getting older, injured, or burnt out. Because of the fractured nature and nonportability of EMS, there are relatively few positions for a street medic to transition into comparitively to nursing.

Nursing also has the portability to work in multiple areas at once, where again the medic is severely limited in that. A vast majority of medics cannot work in a public health clinic one shift, home health the next, an occasional ICU rotation and answer emergency calls. 

Most who work in EMS do not have your background. Like in many professions EMS is judged by the lowest common denominator. Like I said, it is much easier to teach a nurse skills than a medic knowledge. It also requires less lead time and less radical system change.

2/3 covered by government non fire and private is absolutely laughable, considering the amount of paid EMS that is controlled by fire, look at the major departments covering EMS, From FDNY to LAFD, Chicago, Houston, Philly, Soon to be Cleveland, Memphis, San Diego, and the list goes on and on With a trend towards fire based. Even the nation's Capital is a fire service EMS model. 3rd service really is a minimal exception. Private also a rather small part comparitively when you eliminate IFT only agencies.

Just because a few places in Texas can get intelligent design in their textbooks or rewrite history does not make it a major competitor for nation wide fire based EMS or even a trend.

Now I know many people are proud of being a paramedic. I am still a paramedic. I plan on keeping my certification. I understand people fearing for their jobs in a nursing take over. But the hard truth is that EMS has been unable to unite into an educated valuable and viable profession. It has failed to increase it's value by providing service outside a taxi ride to the ED. It has failed to demonstrate its value as something other than an add on technical cert for fire. It continues to fail by every measure of both healthcare and public safety with the exception of a very few unique services.

US EMS is a failure. Both in system design and value to patients. Paramedics today are no more or less responsible for its failures than those of yesterday. But since EMS cannot seem to fix itself, then it should be fixed from outside, now and before, the best solution as I see it is nursing.

If people who want to work in the prehospital environment are forced to get a nursing degree to continue to be a "paramedic" or EMS provider, I have no sympathy for them. They should have made more effort to developing the trade to begin with.

As for the pay, I have said it before, so I guess one more time. The current amounts paid to EMS for what they provide is unsustainable. It will change because money will dictate it. To maintain value it will have to move into out of hospital care. Some progressive services like Wake county have figured this out. Most have not. They stick their heads in the sand hoping not to see the coming tide. It will not save them. 

Paying a nurse to keep people out of the hospital, directing them to the proper care, helping them avoid the need for emergency care with preventative care, and responding to the occasional "emergency" is worth every penny that is spent on it. It will also reduce the amount of pennies needed to be spent on it.


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## Sasha

Linuss said:


> I'd rather have less that care, than more that don't.



I'd rather have someone equipped to deal with my emergency. Basics normally aren't.


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## Journey

Linuss said:


> So, what say you about places like NZ, UK, AU that have Paramedics, and I use this term gritting my teeth, "on par" with nurses?  Should the nurses 'take over' EMS there as well?



The U.K. already utilizes nurses as Emergency Care Practitioners along with Paramedics.  The ECP utilizes the skills of both and it is not entry level.



Linuss said:


> As long as you're open to Paramedics replacing nurses in the trauma room... or cardiology... or respiratory.



As long as the Paramedic has 2 - 3 years of college concentrating on that specialty in addition to their Paramedic cert that could be done.  The idea of replacing other professions that specialize in something and with another specialty profession makes about as much sense as Physicial Therapists replacing Cardiovascular Technologists in the cath lab.  There will also be things done in other specialties and nursing that will exceed the Paramedic scope of practice which creates a problems with the RN or other professional cross covering a patient the Paramedic might have in the ED which can lead to confusion for charting and changing of assignments mid treatment.  

Every profession can have a few skills and knowledge that overlaps but if you have something that requires a specialist, someone with a few extra skills and a week's worth of training in that specialty will not do.  A nurse or a Paramedic can ambulate a patient in the hallway but a Physical Therapist would be more likely to know how to rehabilitate that person to regain close to full function without causing other problems.   A Paramedic might be able to do a few skills like a nurse in the ED but not every patient in the ED requires only emergent skills or the few medications the Paramedic is trained for. There are also other assessments that must be carried out to identify problems for preventitive and long term care.  

It seems some may choose a profession like being a Paramedic and then they think the grass is greener on the other side. But, instead of going back to school to be properly trained for that profession, they try to compare skills and some training to the other profession but without really knowing what is involved or seeing the whole picture of their education and training.


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## Veneficus

Aidey said:


> The only way I can see insurance companies getting behind it is if there is a clear benefit to them.



There is a clear benefit to them. Compare the price of sending a home healthcare nurse to a residence to make sure the patient is med complaint compared to the cost of an ALS response to a toxicity problem followed by an ED visit and an ICU stay. 

Then compare the cost of treat and release to same said ambulance ride to the ED and workup and discharge. 



Aidey said:


> The fire unions will do everything within their power to fight it, as everyone in fire knows the only reason FDs are maintaining their funding and staffing levels is because of EMS calls. We can't even get them to support any sort of educational increase, I can't imagine their reaction to a takeover.



Just wait till reimbursement is cut to the point that they lose more money than they make. They will drop it in 1/2 a heartbeat.



Aidey said:


> I'm not trying to be a pessimist here, but I envision a lot of resistance from all sides.



No change is ever without resistance.


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## Melclin

I've gotten into trouble regarding my thoughts on nurses in the prehospital environment before (unfairly I think). Before anyone has a go at me, I'm not having a shot at nurses and I'm not saying paramedics are better than nurses full stop or anything stupid like that. I'm essentially saying that the two roles are different enough to require significant cross training if you wanted to swap roles. 

I quite like the idea of paramedic practice being a nursing specialty, however, we have a pretty good system that is moving towards being an even better system as it stands so I don't know that, practically speaking, another change would be good. 

Also, as it stands now with the way nursing education is here, you couldn't put a nurse on an ambulance. University wise, the paramedic degree requires a much higher entry score than nursing, so it attracts a higher academic standard. There are a lot of people in the paramedic degree who wanted to do medicine and didn't quite make the cut, where as there are a lot of people doing nursing who are lucky to have gotten into university (I'm just talking about what I see around me at my own uni in terms of university entrance scores). Additionally, in the three years nurses spend at school, they don't ever seem to do a subject related entirely to proper patient assessment, Hx & Physical, and the idea of the primary survey being something more than a CPR checklist. Sure they do "obs", but there is a difference. For nurses in roles like the ED, they get taught later, mostly on the job and in the subsequent crit care qualifications as far as I can tell. 

I'd also like to add that there are a lot of RNs doing the paramedic degree and they have all been surprised at how much different it is working in less controlled environments, with less time, hands and advice. 

This will be an unpopular idea, but they have also commented on the difficulty of making clinical decisions when it is actually _your _decision (nurses words, not mine). Nurses often comment that they know what to do, they just need a doctor to sign off on it, but its a bit different when it really all falls to you (keeping in mind we don't have online medical control). Similar to the idea JP suggested in another thread the other day. I know nurses in America seem to have a more extensive scope than they do here and I know even here rural nurses, nurse practitioners and ICU nurses often have a lot of autonomy, but its an unfair comparison. They are nurses at the top of their game and I don't doubt their ability. But _every_ paramedic out of uni has to be able to make these decisions, where as nurses have many years to learn, grow and gain experience in clinical judgment in environments that require less autonomous decision making. Those who are not suited to that sort of practice can excel in other areas. When you compare apples with apples and oranges with oranges: Paramedic grad to Nursing grad, Intensive Care Paramedic with Intensive Care Nurse; paramedics at each stage have a greater burden of extensive and focused patient assessment as well as autonomous clinical decision making (this is not to say paramedics are better or necessarily smarter, just that the focus of their role is fundamentally different). I think that the fundamentals of our respective educations need to reflect that. 

Like I said, I like the idea in theory, because the most educational experiences I've had in my degree were my hospital placements. I think a year or two of doing rotations through various kinds of nursing before becoming a paramedic would be very beneficial. However, as I've said, you'd have to dramatically change the structure of nursing education if you were to do so.


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## Shishkabob

So, Vene, why the push to replace just Medics with RNs?  Why not replace RTs with RNs?  Sonograpghers with RNs?  Rad-techs with RNs?


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## Journey

Linuss said:


> So, Vene, why the push to replace just Medics with RNs?  Why not replace RTs with RNs?  Sonograpghers with RNs?  Rad-techs with RNs?



Not vene but RNs did all of those specialties at one time to some degree. Each profession you just mentioned such as RT, Sonographers and Radiology Technologists are relatively new professions that grew when it was realized these were specialties that required much more than just the performance of a few skills and a brief overview of the principles.


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## Veneficus

Linuss said:


> So, Vene, why the push to replace just Medics with RNs?  Why not replace RTs with RNs?  Sonograpghers with RNs?  Rad-techs with RNs?



Because there is very little wrong with what they are doing. It is EMS that can't seem to educate or advance itself.

Compare the standard requirements of those providers to that of EMS on a national scale.

Like I said, EMS has failed to keep up with the body of medical knowledge applicable to it. It has failed to develop value outside of transport. Many patients are not properly served by the ED, which in the US with less than a handful of exceptions is the only option for patients. (at a terrible waste of money) The services exemplifying the role of EMS in the future are not being emlulated. There has been a failure of standard in EMS. No matter what state (or country) you are from the requirements to take the NCLEX are standard. You can get a paramedic card in places and not take national registry. Ever.

You ever see a nurse patch factory? A rad tech patch factory? An RT patch factory?


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## 8jimi8

Linuss said:


> So, Vene, why the push to replace just Medics with RNs?  Why not replace RTs with RNs?  Sonograpghers with RNs?  Rad-techs with RNs?



You didn't realize that nurses used to do all of these jobs until they evolved into their specialized roles?


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## Shishkabob

8jimi8 said:


> You didn't realize that nurses used to do all of these jobs until they evolved into their specialized roles?



And EMS isn't specialized?  Only difference between RT and Paramedic is one currently requires a degree nationally, other only in certain states. 

Again, a problem that needs to be remedied, but not a problem that did not exist in other allied health professions at one time or another, either.  




Veneficus said:


> You ever see a nurse patch factory? A rad tech patch factory? An RT patch factory?



Yes, actually.


It's not like people in other professions don't try to find easy ways to certification too.


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## usalsfyre

Veneficus said:


> You ever see a nurse patch factory? A rad tech patch factory? An RT patch factory?



Actually, if you talk to nurse educators many of the new nursing schools that have sprung up and contributed to the surplus of new grads are the equivilent of "patch factories". And according to my wife, 9 to 10 month non-degree rad-tech programs exist. 

EMS failed when we let other people (the government, the fire service, private services) set the standards for entry. Until a committed group of career paramedics seizes control and raises the entry standards (yeah right) then EMS will continue in the crapper.


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## 8jimi8

Linuss said:


> And EMS isn't specialized?



Those other professions that you listed evolved out of nursing.  Evolved out of the generalist education base.

EMS did not evolve out of a standard body of education.


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## usalsfyre

The problem with EMS being involved in dispositioning patients to areas other than the ED is....

...MONEY. Plain and simple. 

When EMS gets paid for something other than transport, then paramedics will do more than transport. If this requires more medical knowledge, then they will be forced to obtain it if the services they work for wish to stay in business. At some point the burden of obtaining that knowledge will be shifted to the employee before hire rather than the employer through CE. 

However, fixing the reimbursment structure is abour as easy as fixing the educational requirements.


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## WTEngel

Actually RTs and paramedics are quite different....


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## usalsfyre

8jimi8 said:


> Those other professions that you listed evolved out of nursing.  Evolved out of the generalist education base.
> 
> EMS did not evolve out of a standard body of education.



Bull malarky. Nursing can't claim ownership of all allied health professions. While nurses may have actually turned the knobs on a ventilator or pressed the button on an x-ray machine, the body of knowledge in these professions is far more medicine than nursing based. If nurses had the base knowledge to perform these task it would just be another add on certification, instead of a "wound-care specialist" you'd be a "radiography specialist".

EMS, unfortunately evolved out of the quick and dirty "call the doc for everything" approach.


----------



## Veneficus

usalsfyre said:


> Actually, if you talk to nurse educators many of the new nursing schools that have sprung up and contributed to the surplus of new grads are the equivilent of "patch factories". And according to my wife, 9 to 10 month non-degree rad-tech programs exist.



Fair enough. I must then admit they do exist. I am surprised. But how many compared to medic mills I wonder? 



usalsfyre said:


> EMS failed when we let other people (the government, the fire service, private services) set the standards for entry. Until a committed group of career paramedics seizes control and raises the entry standards (yeah right) then EMS will continue in the crapper.



I don't really think there exists a large body of commited paramedics.

It has been demonstrated by some places like Seattle, Outside of DC (forgot the dept name) and even Oregon that the fire service has the capability to do EMS well. Unfortunately a majority of fire service EMS has chosen not to emulate them. I could advocate for such a universal system.

Government will always set the standards, because government is the majority payer. (He who pays the piper dictates the tune)

As for private service, I think seperating both the requirements and pay for IFT only providers would solve that problem. It could even make it a more profitable business if things were done properly. (I am a dreamer) Because if you reduce the training and vehicle requirements for the dialysis derby, (which no EMS curriculum prepares providers for) I think it is entirely possible to reduce payments and and increase profit margins when they don't need the same requirements as an emergency ambulance.


----------



## Shishkabob

Veneficus said:


> Unfortunately a majority of fire service EMS has chosen not to emulate them. I could advocate for such a universal system.



So, than, how is that a failure on EMS and not a failure on fire?  Or a failure on the beaurocrats that allowed themselves to be conned by fire?  Or on the general population for letting themselves being conned into accepting crappy service?


----------



## Journey

Linuss said:


> And EMS isn't specialized?  Only difference between RT and Paramedic is one currently requires a degree nationally, other only in certain states.



Are you referring to Radiology or Respiratory Therapy?  I have never seen a Paramedic do anything in the Radiology department.

For Respiratory Therapy, You might be trying to compare just giving a nebulizer or intubation.  

About the only medication a Paramedic does from just the Respiratory specialty is Albuterol.  Even RNs don't mess with some of the drugs and gases the Respiratory Therapists use.  Paramedics also get very, very little training on ventilators, gas laws, hemodynamics or most critical care medicine topics which is where the RTs excel.  They also get a whole semester in neonatal and pediatrics along with several days of clinicals with expected hands on.  For intubation, the RT will have to be ready to do more than the actual skill. They also work with many other tubes that most Paramedics will never see.  

Linuss, if you get your nursing degree and make it to the ICUs, you will see just how much each different profession does and their value to a health care team.


----------



## Veneficus

Linuss said:


> So, than, how is that a failure on EMS and not a failure on fire?  Or a failure on the beaurocrats that allowed themselves to be conned by fire?  Or on the general population for letting themselves being conned into accepting crappy service?



It is all one in the same. A fire service that does not provide EMS cannot fail at it. 

A fire service that does provide EMS can fail to provide good EMS. In such a case, the area EMS system fails. Like I said in my earlier posts, look at the amount of EMS coverage by fire service, a failure there, is a large percentage of EMS.

You are asking me if I blame the failure of EMS providers both individual and organizational to set a standard, increase their own education, demonstrate their value, and evolve with the changing demands of medical care on third parties who EMS had the same opportunity as Fire to demonstrate itself as superior and did not capitalize on?

Doctors tell people why doctors are valuable.

Nurses tell people why they are valuable.

The fire Service tells people why they are valuable.

EMS providers failed to do so and nobody even knows the difference between an EMT-Basic and a medic. It seems that EMS has nobody to blame but themselves to me.


----------



## Shishkabob

WTEngel said:


> Actually RTs and paramedics are quite different....



In the context of being a specialty, not in education/ role / skills / medications, as Journey incorrectly assumed.


----------



## Journey

Linuss said:


> In the context of being a specialty, not in education/ role / skills / medications, as Journey incorrectly assumed.



Since two of us thought you were comparing Paramedics to RTs, maybe it was how you wrote it.


----------



## Shishkabob

Veneficus said:


> EMS providers failed to do so and nobody even knows the difference between an EMT-Basic and a medic. It seems that EMS has nobody to blame but themselves to me.



Or nurses trying to keep them down. 

Or the IAFF trying to keep them down, take over EMS and water it down.

Or private agencies trying to keep their bottom dollar down.




There's more to blame than just the providers...


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## Shishkabob

Journey said:


> Since two of us thought you were comparing Paramedics to RTs, maybe it was how you wrote it.



Yet you're the one who cut out the "And EMS isn't specialized?" part, which following logical thought and English language rules, means that the following sentences in the same paragraph are probably about the same idea... the two being a specialty.


----------



## Veneficus

Linuss said:


> Or nurses trying to keep them down.
> 
> Or the IAFF trying to keep them down, take over EMS and water it down.
> 
> Or private agencies trying to keep their bottom dollar down.
> 
> There's more to blame than just the providers...



I faulted organizations in my last post as well.

But compare the EMS providers to Australasia or Europe. As Meclin pointed out, in places where EMS providers have advanced themselves and demonstrated value that could not be copied or better provided, nurses cannot hope to replace the paramedics there.

Unfortunately in the US, paramedics (all EMS providers) cannot say the same.


----------



## Journey

Linuss said:


> Or nurses trying to keep them down.
> 
> Or the IAFF trying to keep them down, take over EMS and water it down.
> 
> Or private agencies trying to keep their bottom dollar down.
> 
> 
> 
> 
> There's more to blame than just the providers...



Other professions got past the blame game to move on.   The other professions also had much more to overcome since many of those professions  you pointed out were done by nursing.  It was a matter of proving a specialty was needed.  EMS does not have this issue with many RNs in the field working on an ambulance and the Paramedic is the new kid.


----------



## Shishkabob

Veneficus said:


> I faulted organizations in my last post as well.
> 
> But compare the EMS providers to Australasia or Europe. As Meclin pointed out, in places where EMS providers have advanced themselves and demonstrated value that could not be copied or better provided, nurses cannot hope to replace the paramedics there.
> 
> Unfortunately in the US, paramedics (all EMS providers) cannot say the same.



And in how many countries where it is "accepted" that their EMS is better, is EMS run in any significant number by private agencies or fire departments, and not just the government?



I think we found our problem, and at the same time, our answer.


----------



## Veneficus

Linuss said:


> And in how many countries where it is "accepted" that their EMS is better, is EMS run in any significant number by private agencies or fire departments, and not just the government?
> 
> 
> 
> I think we found our problem, and at the same time, our answer.



I think we always knew the problems. My OP was about the solution.


----------



## usalsfyre

Linuss said:


> Or nurses trying to keep them down.
> 
> Or the IAFF trying to keep them down, take over EMS and water it down.
> 
> Or private agencies trying to keep their bottom dollar down.
> 
> 
> 
> 
> There's more to blame than just the providers...



I'll say yes to the second two. The nursing ivory tower as a whole is far more concerned with thier asault on physicians to do more than growl at medics. Our lack of standardized education has kept us out of the hospitals more than nursing (although they have contributed some). 

If you REALLY wanted to see nursing fur fly, fix the LP program, give us a real, honest to God liscense we work on instead of the Doc's and petition legislature to let us opperate in EDs at the same level as RNs. I can hear the screams of "patient safety" from Austin now...


----------



## Journey

usalsfyre said:


> And according to my wife, 9 to 10 month non-degree rad-tech programs exist.



Radiology is still trying to find itself with a very rapidly growing field and  many different areas to specialize in with each requiring some depth of education and training.    Within their profession they have Radiography, Radiation Therapy, Limited X-ray Machine Operators, Nuclear Medicine Technology, Fusion Imaging, Magnetic Resonance, Mammography, Sonography, Computed Tomography, Cardiovascular Technologists and Fluoroscopy.  Like other professions, they are still trying to get each and all of these professions licensed in all the states.


----------



## Shishkabob

And they freaked out a decade ago when the push was made for the Licensed Paramedic 

Thing is, it developed no teeth, and an LP is no different than a CP.  It was intended to replace nurses in the trauma room, but alas...





I just love that how out in the field, I can choose to give any number of the 60 different drugs on my truck at my discretion, and give as much NS and LR to a patient as I want, yet I go in to a hospital and they (generic they) freak out if a Paramedic tech pushes 10cc of saline....  Yeah, they got their priorities right...


----------



## sir.shocksalot

I totally agree with Vene, I think EMS could advance way beyond where it is now if we let nurses do it. I would venture that after 500 hours of rides or so a Nurse would probably do just fine on their own. Plus you are not going to have to worry about the nurse on C shift who just wants to get on with fire and so s/he hasn't opened a book since nursing school, and there is a good chance they didn't open one then. Every nurse, regardless of whether they want to be on the rig or not, still wants to do well in medicine, because nursing is a REAL career with real opportunities for advancement clinically and academically.
As for Mel, well we know that AUS and NZ have a way different system that is, in almost every respect, better (hire me; no seriously I'm an Australian citizen so hire me!!!!!). Paramedics are well respected and well educated there, again there is no issue of the one dude that is just waiting for a fire job.

This is the only job I know of that doesn't reward people in it who continue to educate themselves. I went through the best program in the state, and am 2 classes away from my associates degree, yet the hosemonkey medics still tell me what to do even though they have never completed a college level biology course, let alone anatomy and physiology. I recently came of the opinion that EMS is going in the hole, especially in my state, and it's time to get into nursing while I can.


----------



## WTEngel

Good call usal...

I really have nothing but love for my RN colleagues, however, the BNE exerts a HUGE amount of leverage over what is considered safe and unsafe in regards to patient care, and most of what is considered unsafe has quite a bit to do with how no other profession can do certain tasks better than nurses.

Now, can EMS in the US be better? Certainly...so can every other allied health profession and nursing also. No one profession can claim they have reached a point of perfection.

Has EMS in the US failed? Not by a longshot. Education has improved since the inception of EMS. it has a long way to go, but it has improved. Ask patients whose life has been saved by a competent EMS professional if they feel like EMS is a failure. 

I understand the point you are making, and I agree with it. What I do not agree with is sensational statements like EMS is a failure.


----------



## JPINFV

usalsfyre said:


> If you REALLY wanted to see nursing fur fly, fix the LP program, give us a real, honest to God licsene we work on instead of the Doc's and petition legislature to let us opperate in EDs at the same level as RNs. I can hear the screams of "patient safety" from Austin now...



In terms of medical interventions, there's very little difference between how nurses implement medical orders and paramedics implement medical orders except the mix of patient specific orders (i.e. online control of paramedics, written orders for hospital) and standing orders (offline protocol for EMS). Even when it comes to nurse practitioners, there's a certain amount of legal dancing involved. For example, in California, the scope of practice for a RN and a NP is the same. NPs rely on "standardized procedures" in order to provide medical care beyond what an RN normally does. While I will admit that I am not familiar with the exact wording of the standardized procedures, I would guess that they are basically very broadly written standing orders that cover the "furnishing of drugs and medical devices" under a physicians supervision. 

It looks like you're advocating for independent practice rights which won't happen short of making paramedicine a doctorate level, which isn't going to happen for multiple reasons, including necessity. There's a need for better physician involvement, but unless you can separate prehospital care out of medicine like nursing has done in terms of nursing care or the cases of optometry and podiatry (both of which are doctorate level), you aren't going to see paramedics free of physicians.

In terms of license vs certificate, all 50 states license paramedics, even if they don't call it that.


----------



## Veneficus

WTEngel said:


> I understand the point you are making, and I agree with it. What I do not agree with is sensational statements like EMS is a failure.



What I guess I should have said is that EMS has failed to make itself what it could/should be.


----------



## Journey

usalsfyre said:


> petition legislature to let us opperate in EDs at the same level as RNs. I can hear the screams of "patient safety" from Austin now...



How much education does the Paramedic get in the national patient safety standards and goals for each of the different facilities?  These start getting emphasized in nursing education from day 1.  The same for all the other regulations and expected standards that are expected at the local, state and Federal levels. From what I have been reading, it seems EMS in the U.S.  has a difficult time with quality measurements.  You also can not talk reimbursement until you have some quality and compliance measurements within the expectations of the state and Federal insurers.   

Many hospitals are also trying to achieve Magnet Status which means raising the standards of their employees and services, not lowering them. This is also why the BSN is now expected along with their unit specialty certification for some hospitals as they evolve to more research-based nursing practice.


----------



## Journey

Linuss said:


> I just love that how out in the field, I can choose to give any number of the 60 different drugs on my truck at my discretion, and give as much NS and LR to a patient as I want, yet I go in to a hospital and they (generic they) freak out if a Paramedic tech pushes 10cc of saline....  Yeah, they got their priorities right...



Do you not have a medical director?  Do you at least push meds according to some guidelines even if it is ACLS?  I can not imagine a state like Texas that requires so little education for its Paramedics allowing you to have open practice without some type of medical oversight.


----------



## Veneficus

*Moderating my own thread*

I ask that any nurse vs. paramedic comments be restrained to whether it is beneficial or detrimental or somehow involved with nursing taking over EMS. 

No matter who is performing the role of EMS except for physicians, medical oversight will always be required.


----------



## Shishkabob

Journey said:


> Do you not have a medical director?  Do you at least push meds according to some guidelines even if it is ACLS?  I can not imagine a state like Texas that requires so little education for its Paramedics allowing you to have open practice without some type of medical oversight.




/can't tell if serious?


----------



## WTEngel

Magnet status is just like anything else...it can be achieved for the right price.

Don't get me wrong, Magnet designation is a good thing, but I have seen some facilities with pretty questionable nursing (and other) practices that have held the "prestigious" Magnet designation.

In my experience BSNs do not care for patients any better then their ADN colleagues. I can somewhat side with the management positions requiring a BSN, but the additional classes offered for the BSN degree have no effect at the bedside as far as I have seen.


----------



## PenguiNet

simple fix: make the paramedic didactic portion at least an A.S. level curriculum.  that's basically all an RN is.

the dismal level of academic rigor in EMS would be greatly alleviated by simply requiring college level anatomy and physiology courses (that is, one of each) as part of the curriculum.  that's all a paramedic really needs in addition to the current didactic curriculum.  a nursing education does not expand on what i just suggested in any significant way with respect to prehospital care.

suggesting that nurses replace paramedics is a slippery slope.  paramedics can already push medications and wipe puke and poo like nurses can...and we can run our own codes, intubate, perform thoracotomies and cricothyrotomies..unlike nurses.  we just need more academic rigor like our foreign compatriots.  otherwise you might as well replace the nurse paramedics with PA-paramedics...at least PAs can suture and prescribe medications in the field to prevent unnecessary transports.  why stop there?  let's replace paramedics with doctors!

a modicum of academic rigor is all we need as the first step towards uhh..professionalizing...our profession.


----------



## Veneficus

PenguiNet said:


> otherwise you might as well replace the nurse paramedics with PA-paramedics...at least PAs can suture and prescribe medications in the field to prevent unnecessary transports.  why stop there?  let's replace paramedics with doctors!.



Actually, a physician is the ideal medical provider in any environment. However, in the US, the problem of having physicians on ambulances is mostly, the lack of physicians. 

Would a PA be a good idea? 

Sure, why not? are there enough of them to go around? I doubt it.

I picked nurses because there seems to be a ready supply of them. Because they do have a "modicum of academic rigor" already. No grandfathering, no retraining.

But I started the thread because US EMS is stuck in the mud, and in the interest of advancing the care to patients, making the system more beneficial to patients, and lowering the costs, nursing just seems to be positioned to achieve all of that with the least amount of disruption compared to retraining every paramedic, or increasing the number of physicians or PAs.

Through the natural course of their professional advancement, it seems nursing for the future of out of hospital care is the logical conclusion.


----------



## JPINFV

Veneficus said:


> Actually, a physician is the ideal medical provider in any environment. However, in the US, the problem of having physicians on ambulances is mostly, the lack of physicians.



There's also the reimbursement issue. Concierge medicine gets around this by charging a lot up front. Emergency departments and clinics get around this by removing the response time element (which would be unreimbursed down time) and providing additional hands to help implement medical orders and monitor while the physician is busy assessing and initiating treatment/writing orders for other patients. However, it would be interesting to see what the results would be if a few physicians were targeted towards both the high end calls as well as the low end, more social work/basic medicine calls.


----------



## Veneficus

JPINFV said:


> There's also the reimbursement issue. Concierge medicine gets around this by charging a lot up front. Emergency departments and clinics get around this by removing the response time element (which would be unreimbursed down time) and providing additional hands to help implement medical orders and monitor while the physician is busy assessing and initiating treatment/writing orders for other patients. However, it would be interesting to see what the results would be if a few physicians were targeted towards both the high end calls as well as the low end, more social work/basic medicine calls.



Bill the low end calls the same as a visiting physician. It's already covered by medicare/medicade.

Still cheaper than an ALS ambulance to the ED.

High end, bill as emergency, just like in the ED. I think that would actually require the largest amount of trouble for reimbursement.

In hospitals that pay salary, make it part of the work week.


----------



## usalsfyre

Veneficus said:


> I ask that any nurse vs. paramedic comments be restrained to whether it is beneficial or detrimental or somehow involved with nursing taking over EMS.
> 
> No matter who is performing the role of EMS except for physicians, medical oversight will always be required.



Do I think current EMS practice will be improved by nursing taking it over? No, but I'm not a fan of much of the crap that passes for nursing "core concepts" currently.  

Do I think it would be worse than what we have now, probably not. 

Do I think with the current reimbursment structure it will happen? Absoloutely not.


----------



## JPINFV

Veneficus said:


> Bill the low end calls the same as a visiting physician. It's already covered by medicare/medicade.
> 
> Still cheaper than an ALS ambulance to the ED.
> 
> High end, bill as emergency, just like in the ED. I think that would actually require the largest amount of trouble for reimbursement.


 Good points


----------



## 18G

The field environment is its own little monster with a unique set of dynamics. Nurses go into nursing to work in a clean, clinical environment (ie OB, cath lab, ICU, ED, etc). The majority of nurses choose their profession because of what it offers (and what it doesn't). From my experiences the majority of nurses do not want anything to do with working on a street corner, in a muddy field, in pouring down rain, or any other of the adverse conditions EMS encounters. 

Pre-hospital nurses are more of an exception than the rule by a long shot. I think it would be great to have a combination nurse/paramedic provider, but under the current model I don't see it working. 

As already stated, sticking an RN on a Medic unit for $13-15 an hour with some employers not even offering benefits isn't gonna yield a gain of RNs working the field. But take a Paramedic who loves the field environment and blend their education with some of the core RN courses, we may have something that works. But a roadblock is still compensation. To get the best u have to pay for the best and some companies just can't and insurance isn't gonna increase reimbursements for the betterment of healhcare. And it's not even that EMS/Fire doesn't want to pay more... many do but can't based on lower call volumes and no municipality (or very little) help.


----------



## Journey

WTEngel said:


> Don't get me wrong, Magnet designation is a good thing, but I have seen some facilities with pretty questionable nursing (and other) practices that have held the "prestigious" Magnet designation.
> 
> In my experience BSNs do not care for patients any better then their ADN colleagues. I can somewhat side with the management positions requiring a BSN, but the additional classes offered for the BSN degree have no effect at the bedside as far as I have seen.



Do you know what Magnet Status consists of? Unless you are working in that envirionment and evaluating it, you may only be judging it by the snacks left in the EMS breakroom or the cafeteria. It is amazing how some do put the label of "prestigious" on something when more requirements are made which also involve patient care.  Do you know some of the 65 standards minimum that must be met? Is nurse to patient ratio of any importance? What about career advancement for the employees? How about consultation of other professionals? Ongoing education?  So many, many factors go into achieving magnet status that you may not know about or take for granted. 

Many in nursing will also argue that the ADN is too short to provide a well rounded education complete with all the reading, writing and arithmetic skills as well as the appropriate sciences to advance beyond the tech level which it is still largely considered with nursing now and rapidly becoming one of the  least educated professions in the hospital. 

But, I see your point and by your arguement, the 6 month cert in the U.S. may not be any better than a degree so EMS should stay right where they are for education.


----------



## Journey

Linuss said:


> /can't tell if serious?



Based on your previous posts, I don't know how you operate.

But, for your 10 cc flush comment for the hospital, the hospital will be responsible for your screwups.  Did you check to see what type of line you are flushing? Heparin or nonheparized flush required? Do you know the correct procedure for flushing this line? Did you notice what medications were hanging before you bolused them with a flush? Did you use the aseptic technique set by the hospital for entering that line? If this was a baby or child, did you check the sodium levels and use the appropriate flush?  You can get away with some things short term like in prehospital but in the hospital there are certain things that must be checked. If you infiltrate that line with a med the RN has started, the hospital pays for the damage.  If you cause an infection, the hospital pays for the damage.


----------



## Journey

18G said:


> As already stated, sticking an RN on a Medic unit for $13-15 an hour with some employers not even offering benefits isn't gonna yield a gain of RNs working the field. But take a Paramedic who loves the field environment and blend their education with some of the core RN courses, we may have something that works. But a roadblock is still compensation. To get the best u have to pay for the best and some companies just can't and insurance isn't gonna increase reimbursements for the betterment of healhcare. And it's not even that EMS/Fire doesn't want to pay more... many do but can't based on lower call volumes and no municipality (or very little) help.



What incentive is there to increase education if the Paramedics are already well paid? How many automotive employees got college degrees when they could make big money with just a GED?  

All the other professions and even nursing were very underpaid until they advanced their educational requirements and achieved some type of professional recogniition.  You can also see how insurances do reimburse for services by looking at Physical Therapy both in and out of the hospital to see how education can increase reimbursement.  FDs are also getting into billing for reimbursement to offset the expenses.   There are also many FF/Paramedics who may much more than nurses if you just base it per year.


----------



## Shishkabob

Journey said:


> Based on your previous posts, I don't know how you operate.
> 
> But, for your 10 cc flush comment for the hospital, the hospital will be responsible for your screwups.  Did you check to see what type of line you are flushing? Heparin or nonheparized flush required? Do you know the correct procedure for flushing this line? Did you notice what medications were hanging before you bolused them with a flush? Did you use the aseptic technique set by the hospital for entering that line? If this was a baby or child, did you check the sodium levels and use the appropriate flush?  You can get away with some things short term like in prehospital but in the hospital there are certain things that must be checked. If you infiltrate that line with a med the RN has started, the hospital pays for the damage.  If you cause an infection, the hospital pays for the damage.



You still clearly missed the whole point of my post, didn't you?


----------



## socalmedic

8jimi8 said:


> ...you can bet your hiney i'm going to start that pacer before I make the phone call.  Isn't that close to what the situation in California is?  Critical Care nurses giving orders to medics over dispatch?...




kinda, but not totaly correct. while we do make base hospital contact on the majority of our ALS, if they fit into our protocol nothing more needs to be said. "rampart, Squad 51, Limited contact call, 55 yo male, M6 chest pain, stable vitals, see you in 5" and continue with you treatment. other counties are almost exclusively standing orders NorCal, ICEMA, ventura, santa barbara, ect. 

while orders are nessissary for some procedures, lets take doapamine for ex. i call the BH, and MICN (mobile Intensive care nurse) picks up the phone and i tell her that i am calling for orders, she will then either get a MD or tell me to continue with report. i tell her what i want and why i want it she will then 90% tell me to go ahead with what i ordered, in 9 months i have never been told no. 

ex. "rampart, sq51 55yo male, general weakness, calling for orders" go ahead 51 "55 yo male, CC general weakness, AOx3(top score in LA), pale cool diaph, P-130 wt, bp-80/60, r-18, spo2 98, crackles in the bases. we have him semi-fowlers, -HAM, eta 20 min to your location, 30 min to next closest, i want an order for dopamine how do you copy, pt is 100kg" micn will then say "copy you, start dopamine 30gtts starting up to ***gtts, recontact with any changes, rampart clear"

not so hard, the nurses answering the phone are the same nurses we see everyday in the ER, we know them and they know us. there arent usaly any problems. would i like to see standing orders for everyone? kinda. there are some :censored::censored::censored::censored:ty medics here that i think need to call in every time. there are some great medics who dont need to. i know of some medics who say nothing on the phone other than "sq51, 55 year old male, chest pain, stable patient stable vitals, see you in 5" and that is all they say.

let me step off my box real quick.>>> ok,  CA really isnt that bad. there are some wish we hads but other than that its an ok system. i encourage you to read ventura, santa barbara, or ICEMA protocols, they really arent that restrictive.


----------



## MrBrown

Brown does not believe in physician based ambulances, but your helicopter and at least one response resource (usually a fast car) should have a doctor on it.

In the US where nursing is at least a two year degree and more-and-more a four year one, they are in an ideal position to take over EMS and become Nursamedics 

Why? Because the Fire Service, the privates and the volunteers/whackers are interested in keeping standards as low as possible, the public is largely ignorant and doesn't want to pay for it to be any other way.


----------



## socalmedic

brown, i prefer the term paranurse.


----------



## terrible one

socalmedic said:


> brown, i prefer the term paranurse.



Interesting in all those counties the FD has zero transporting units, save for a few units in the high desert in riverside co. Coincedence? You can add Kern, SLO counties to the list too.


----------



## Medic2409

IMHO, RN's and Medics are both highly trained, but from different standpoints.

Medics are trained to deal with emergency care and treatment.  Primarily, "what can we do to keep this person who is at the point of death alive until we get him to the ED?"  Typically, short term care, with oftentimes highly important interventions that must be done rapidly and correctly.

RN's are trained from the opposite standpoint.  "What do I need to do to make sure this person will continue to improve until s/he can go home?"  Longer term care, highly important interventions, which must be done correctly, however, not always interventions that must be done rapidly.


----------



## jjesusfreak01

Question. In the entirety of the nursing profession, what percentage of nurses would you (anyone may answer) say have ever had to observe, assess, and diagnose an emergent patient, followed by immediately creating a treatment plan based on medical knowledge and evidence based guidelines? 

ACLS doesn't count, that's pure cookbook medicine. 

PS: The Wake County protocols were adopted almost in their entirely as the new North Carolina protocols for 2010, though individual medical directors have discretion to change them. My 180hr EMT class is followed by 3+ months of time as third rider under the watchful eyes of FTOs before I can be solely responsible for any patient. This is the minimum level of any working provider in the county. ALS competency testing is done by the medical director himself, and any increase in provider level requires entry into the FTEP training program (yeah, just like law enforcement) to ensure there are no weak links in the system.


----------



## WTEngel

Journey said:


> Do you know what Magnet Status consists of? Unless you are working in that envirionment and evaluating it, you may only be judging it by the snacks left in the EMS breakroom or the cafeteria. It is amazing how some do put the label of "prestigious" on something when more requirements are made which also involve patient care.  Do you know some of the 65 standards minimum that must be met? Is nurse to patient ratio of any importance? What about career advancement for the employees? How about consultation of other professionals? Ongoing education?  So many, many factors go into achieving magnet status that you may not know about or take for granted.
> 
> Many in nursing will also argue that the ADN is too short to provide a well rounded education complete with all the reading, writing and arithmetic skills as well as the appropriate sciences to advance beyond the tech level which it is still largely considered with nursing now and rapidly becoming one of the  least educated professions in the hospital.
> 
> But, I see your point and by your arguement, the 6 month cert in the U.S. may not be any better than a degree so EMS should stay right where they are for education.



I am quite well versed in how Magnet designation is achieved. I was employed by one of the largest pediatric level 1 trauma centers in the nation during our push to achieve Magnet designation, and was involved at various levels and on multiple committees. That was the SECOND Magnet facility that I had the pleasure to work at, so yes, you could say I have more than just a "general" idea of what is involved in obtaining Magnet status. Please don't assume that because I am not a RN that I speak about these things without knowing what I am talking about.

My point was that all Magnet institutions are not created equal, and just because a facility met Magnet requirements during their evaluation does not mean they can't backslide and lose their designation on their next evaluation. It has happened before... 

Also, how you stacked assumptions in order to come to the conclusion that I feel a 6 month paramedic certification is adequate is beyond me. You can follow my posts in any thread related to education and see that my opinion is pretty clear on EMS degree programs are the only way to achieve professionalism in the industry.


----------



## rook901

I know I'm late coming into this, but I thought I'd throw in my two cents. LPN since 2006, EMT-IV since 2008, and new RN as of this year, so my opinion may not carry as much weight as the more experienced folks.

In the matter of taking new RN's and putting them on the bus, I'd have to say... not no... but, #&$% NO! With no other medical background, a new RN only knows enough to get themselves in trouble. Any good hospital will put a new RN into at least a 3-month orientation, following a preceptor around and not even thinking about looking at a patient funny without the preceptor weighing in. Even when they're out of orientation, they have LOTS of other nursing staff on the unit to help out if the SHTF. When you're out in the field, it's just the medic and the EMT. The only way that I would support putting an RN onto a unit is if you're riding two RN's, with the senior RN having at least a few years of experience.

Which leads to the next problem - money. No way is an RN spending anywhere from three to five years getting an ADN or BSN (counting pre-req's) only to get a job on the bus making $14/hr. I just don't see it happening, especially in the numbers that you would need to cover double-RN units across the whole of EMS. Of course, if it were mandated that ambulances had to be staffed by RN's, the pay scale may have to come up to whatever the market demanded. This would put the vast majority of privates out of business and would significantly increase taxes as government services would have to step in where the privates left off.

I'm not sure what the answer is, but I don't think this is it, simply based on cost. Unfortunately, EMS in the United States is what it is. It's a way to get people into the ED. Attempting to change EMS into some sort of community health service just isn't going to work, as much as I would like it to. Your truly sick patients need to go to the ED regardless of what you can offer them in the field. Your not-so-sick, attention-whoring, drug-seeking type patients are going to demand to go to the ED anyway. I think the number of patients that you would be able to keep out of the ED with a community health model would be nominal, and wouldn't justify the increased expense.


----------



## rook901

On another note, if I were able to make one suggestion that would be a huge improvement for EMS, it would be to disassociate EMS with Fire. EMS has always been and will always be nothing more than a way to increase call numbers for the FD to get more money to buy more shiny red engines. If the FD spent their money proportionately to the number of fire calls vs EMS calls, fire-based EMS would be something to marvel at. As it stands now, you have too many folks getting their medic just to get a ride on the engine and too many FD's sending engine companies along with their units on nosebleed calls just to chalk up another engine response.

Knock fire down to the first responder level, put EMS in the hands of the local Dept of Health, and go from there.


----------



## Medic2409

rook901 said:


> On another note, if I were able to make one suggestion that would be a huge improvement for EMS, it would be to disassociate EMS with Fire. EMS has always been and will always be nothing more than a way to increase call numbers for the FD to get more money to buy more shiny red engines. If the FD spent their money proportionately to the number of fire calls vs EMS calls, fire-based EMS would be something to marvel at. As it stands now, you have too many folks getting their medic just to get a ride on the engine.
> 
> Knock fire down to the first responder level, put EMS in the hands of the local Dept of Health, and go from there.



Amen Brutha!

I think the ATC EMS or Williamson Co. model are the best things going.

Third service, preferably County wide, and do it up right!

Prob is, and I know we're getting a bit off topic, how many counties are willing to spend the amount of money required to do it right?


----------



## abckidsmom

Medic2409 said:


> IMHO, RN's and Medics are both highly trained, but from different standpoints.
> 
> Medics are trained to deal with emergency care and treatment.  Primarily, "what can we do to keep this person who is at the point of death alive until we get him to the ED?"  Typically, short term care, with oftentimes highly important interventions that must be done rapidly and correctly.
> 
> RN's are trained from the opposite standpoint.  "What do I need to do to make sure this person will continue to improve until s/he can go home?"  Longer term care, highly important interventions, which must be done correctly, however, not always interventions that must be done rapidly.



I disagree with this notion.  As a medic, I seldom encounter a situation that is a true, life-threatening emergency.  And every single intervention we take, every decision we make- should be based on that long-term perspective.  Making decisions based on the needs of only the next hour is a way to engage tunnel vision.


----------



## abckidsmom

jjesusfreak01 said:


> Question. In the entirety of the nursing profession, what percentage of nurses would you (anyone may answer) say have ever had to observe, assess, and diagnose an emergent patient, followed by immediately creating a treatment plan based on medical knowledge and evidence based guidelines?
> 
> ACLS doesn't count, that's pure cookbook medicine.




ACLS isn't exactly cookbook medicine.  The algorithms all go to "consider the causes" and that's where the patients are actually fixed.

In the entirety of the nursing profession, not many nurses observe, assess and diagnose an emergent patient, but nurses CAN totally do this.  Not all nurses, I will definitely grant that most nurses wouldn't even want to function outside the hospital, but we've had flight nurses for a long time and they are typically pretty handy on scenes.

I don't realistically see this fix for the education problem happening, but if we had a magic switch date by which we could implement the paranurse system, I think it could work.

The real trouble is in the transition.  The IAFF will never let it happen, and I'd really doubt the ANA would either.


----------



## Aidey

When it comes to consider the causes though a RN can't do anything more than a Paramedic though.


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## Medic2409

abckidsmom said:


> I disagree with this notion.  As a medic, I seldom encounter a situation that is a true, life-threatening emergency.  And every single intervention we take, every decision we make- should be based on that long-term perspective.  Making decisions based on the needs of only the next hour is a way to engage tunnel vision.



I didn't say we always have to make rapid life/death decisions.  We are, however, trained to do so should the need arise.

Case in point, and only a possible example, most RN's aren't trained in how to extricate a patient in an MVC.  If not done right, further harm can be caused to the patient.  We have to know how to get the pt. properly extricated, packaged, stabilized, and transported.  Like I said, only an example.

I can, however, provide another example.  At a local ER a pt. arrived POV c/o pain in his leg/thigh, he was placed in the car by a friend, was unable to ambulate, and in pain.  The only Medic working in the ED that day was the one who told me about this.  He and several RN's went out to the car to assist the pt.  Upon making pt. contact it was discovered the pt. had classic shortening and rotation of his LLE, pointing to a??  Yep...fx. femur.  The Medic had to locate a Traction splint, and then teach the RN's how to apply it and get the pt. in the ER without causing further harm.  I'm not knocking the RN staff, but none of them knew how to do this, and could only assist the Medic as he did the job.

The practice of Medicine is a Team concept, far too many have forgotten this.


----------



## rook901

Aidey said:


> When it comes to consider the causes though a RN can't do anything more than a Paramedic though.



Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?


----------



## rook901

Medic2409 said:


> Prob is, and I know we're getting a bit off topic, how many counties are willing to spend the amount of money required to do it right?



Well, you take the portion of money that Fire is getting for their bloated call volume and dump it into DoH-run EMS, and I think you have your money right there.

But that's not going to happen as long as the IAFF is around, as others have pointed out.


----------



## abckidsmom

Medic2409 said:


> I didn't say we always have to make rapid life/death decisions.  We are, however, trained to do so should the need arise.
> 
> Case in point, and only a possible example, most RN's aren't trained in how to extricate a patient in an MVC.  If not done right, further harm can be caused to the patient.  We have to know how to get the pt. properly extricated, packaged, stabilized, and transported.  Like I said, only an example.
> 
> I can, however, provide another example.  At a local ER a pt. arrived POV c/o pain in his leg/thigh, he was placed in the car by a friend, was unable to ambulate, and in pain.  The only Medic working in the ED that day was the one who told me about this.  He and several RN's went out to the car to assist the pt.  Upon making pt. contact it was discovered the pt. had classic shortening and rotation of his LLE, pointing to a??  Yep...fx. femur.  The Medic had to locate a Traction splint, and then teach the RN's how to apply it and get the pt. in the ER without causing further harm.  I'm not knocking the RN staff, but none of them knew how to do this, and could only assist the Medic as he did the job.
> 
> The practice of Medicine is a Team concept, far too many have forgotten this.



RN/EMT-P team...champions!  

Seriously, though...both of those can be taught to the motivated provider in a completely reasonably-taught class of less than a couple of months.


----------



## Medic2409

rook901 said:


> Well, you take the portion of money that Fire is getting for their bloated call volume and dump it into DoH-run EMS, and I think you have your money right there.
> 
> But that's not going to happen as long as the IAFF is around, as others have pointed out.



Agreed.  Firefighters have pretty much worked themselves out of a job.  Kinda funny if you think about it, though, just a coupla decades ago FD's didn't have ANYTHING to do with Medical.


----------



## WTEngel

rook901 said:


> Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?



Yes, multiple times.


----------



## jjesusfreak01

abckidsmom said:


> In the entirety of the nursing profession, not many nurses observe, assess and diagnose an emergent patient, but nurses CAN totally do this.  Not all nurses, I will definitely grant that most nurses wouldn't even want to function outside the hospital, but we've had flight nurses for a long time and they are typically pretty handy on scenes.



Maybe they can, maybe they can't, but in most states you don't get out of medic school (much less get a job anywhere) unless you can do this. For a medic, every skill they learn in class is a base skill. They have to be able to do every one at any point or someone dies. Sure, some nurses would make great paramedics, but its a totally different mindset. I neither fault them nor expect them to want to work in EMS, it isn't what most of them signed up for.



abckidsmom said:


> I disagree with this notion.  As a medic, I seldom encounter a situation that is a true, life-threatening emergency.  And every single intervention we take, every decision we make- should be based on that long-term perspective.  Making decisions based on the needs of only the next hour is a way to engage tunnel vision.



Two calls yesterday. 
1. Pulmonary Embolism showing as a STEMI
2. VT (with pulses, but on the edge of falling into Vfib) on a patient that was FTD when we arrived on scene (shocky as anything you've seen before). This patient would have been dead within a few minutes if a medic unit (on which I was riding) hadn't arrived to cardiovert. 

No decision made by the medics should be taken entirely without thought of long term effect. Long term consequences mean nothing if the patient dies, but evidenced based medicine in EMS strives to protect both the current and future well being of the patient. No protocol is going to prescribe a treatment that keeps a patient alive for 5 minutes if it guarantees they die in 10. 



rook901 said:


> Really? Just off the top of my head... ever set up a KCl drip as a medic?



Ever do that as a nurse without explicit doctor's orders? That's a silly example, pick something that a medic can't do because of their scope of practice, not something they can't do because they don't carry the drug on the truck.


----------



## abckidsmom

jjesusfreak01 said:


> Two calls yesterday.
> 1. Pulmonary Embolism showing as a STEMI
> 2. VT (with pulses, but on the edge of falling into Vfib) on a patient that was FTD when we arrived on scene (shocky as anything you've seen before). This patient would have been dead within a few minutes if a medic unit (on which I was riding) hadn't arrived to cardiovert.


 
Good day at work!  If all you did was drive the PE patient to the hospital, do you think the outcome would have changed?




> Ever do that as a nurse without explicit doctor's orders? That's a silly example, pick something that a medic can't do because of their scope of practice, not something they can't do because they don't carry the drug on the truck.



Nurses hang K all the time because the K is low.  No MD involved at all.


----------



## Aidey

rook901 said:


> Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?



No, but that isn't saying that medics can't.

Here is my problem with that example, in most cases an RN is doing that because a MD ordered it after reviewing lab tests. The exceptions I can think of are CCT teams that have I-Stat capabilities, and in those cases the team could have either an RN or a Paramedic on it.

Edit: Or the RN hung it because there are standing orders that if the patient's K is a certain number they get a drip at whatever appropriate rate.


----------



## Medic2409

rook901 said:


> Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?



Who gives a rat's ***?  C'mon now, want another real life example?

Young male, football player, bad hit, significant neck pain with numbness and tingling in all 4 extremities.

Medic crew arrives to find the pt. supine, pads removed, helmet left on.:blink::blink:

What do you do at this time?

Personally, I was taught they either both stay on, or they both are removed.  Never do you remove one without removing the other.

As the Medic crew began to properly remove the helmet, a RN on scene began to shriek at the crew, "No, you WILL NOT remove that helmet!"

Once it was proven that the RN was not a parent of the child, she was properly removed at EMS request.

Once the pt. was heli-evacuated the local FD (all vollies) stated to the EMS crew that the RN had taken over the scene, and removed the pads.  This occurred in an extremely small town where everyone knows everyone else, and since the RN worked in a Trauma Center in the big city, they thought she knew what she was doing.

Hmmmmm...................  makes ya wonder, now don't it!


----------



## rook901

jjesusfreak01 said:


> Ever do that as a nurse without explicit doctor's orders? That's a silly example, pick something that a medic can't do because of their scope of practice, not something they can't do because they don't carry the drug on the truck.



It's not on the truck because... *drumroll*... it's not within scope of practice.

Don't pull the "nurses just wait around for doctors to give them orders" nonsense. ER and ICU nurses have standing orders that allow them to operate without MD handholding. Medics do not practice medicine independent of MD supervision. Protocols are explicit doctor's orders. Online medical direction is the same.

Granted, a nurse will not hang blood without an order, but the statement I responded to was that RN's cannot do any more than a medic as far as ACLS goes (I would argue that hanging drugs/blood product is a component of addressing the causes in the scope of ACLS). Hanging KCl could be a standing order based on the labs. While the standing order is an explicit MD order, it is not handholding.


----------



## rook901

Medic2409 said:


> Who gives a rat's ***?  C'mon now, want another real life example?
> 
> (snipped)
> 
> Hmmmmm...................  makes ya wonder, now don't it!



Not sure where this is headed. I will never make the statement that RN > Medic. Ever. I addressed the statement that RN's cannot do any more than a medic in regards to the H&T's of ACLS (see above).


----------



## usalsfyre

Medic2409 said:


> I didn't say we always have to make rapid life/death decisions.  We are, however, trained to do so should the need arise.
> 
> Case in point, and only a possible example, most RN's aren't trained in how to extricate a patient in an MVC.  If not done right, further harm can be caused to the patient.  We have to know how to get the pt. properly extricated, packaged, stabilized, and transported.  Like I said, only an example.
> 
> I can, however, provide another example.  At a local ER a pt. arrived POV c/o pain in his leg/thigh, he was placed in the car by a friend, was unable to ambulate, and in pain.  The only Medic working in the ED that day was the one who told me about this.  He and several RN's went out to the car to assist the pt.  Upon making pt. contact it was discovered the pt. had classic shortening and rotation of his LLE, pointing to a??  Yep...fx. femur.  The Medic had to locate a Traction splint, and then teach the RN's how to apply it and get the pt. in the ER without causing further harm.  I'm not knocking the RN staff, but none of them knew how to do this, and could only assist the Medic as he did the job.
> 
> The practice of Medicine is a Team concept, far too many have forgotten this.



If this is the best argument we've got, than I guess I better start sizing white caps...

Barely motivated mongo fire recruits are taught this stuff in three weeks. Do you really think RNs couldn't be taught?


----------



## Medic2409

rook901 said:


> Not sure where this is headed. I will never make the statement that RN > Medic. Ever. I addressed the statement that RN's cannot do any more than a medic in regards to the H&T's of ACLS (see above).



Gotcha.  Peace and love all around.


----------



## rook901

WTEngel said:


> Yes, multiple times.



Just looking at your location, did you do this in Saudi Arabia or in TX? We're talking US EMS here. I just skimmed through a couple of regional TX EMS protocol lists here and was not able to find anything mentioning administration of potassium or blood.


----------



## Aidey

Paramedics could have those same standing orders, depending on the agency and Med director. 

I will revise my statement to make it a little clearer - 

RNs and Paramedics are limited to the same level of care when it comes to ACLS when they have equal access to lab tests and medications, assuming both have standing orders allowing them to interpret the tests and initiate treatment.


----------



## Medic2409

usalsfyre said:


> If this is the best argument we've got, than I guess I better start sizing white caps...
> 
> Barely motivated mongo fire recruits are taught this stuff in three weeks. Do you really think RNs couldn't be taught?



By no means the best argument, if there even should be an argument.

My overall point in each of my posts in this thread have been that Medics and RN's are trained in different ways, to do different things, from different standpoints.

Is there a lot of crossover?  Yep.  We are all part of a team, with the same goal, to take care of the sick and injured.  

To use a football analogy, sometimes the Halfback throws a pass.


----------



## Shishkabob

rook901 said:


> Just looking at your location, did you do this in Saudi Arabia or in TX? We're talking US EMS here. I just skimmed through a couple of regional TX EMS protocol lists here and was not able to find anything mentioning administration of potassium or blood.



There is no such thing as "Texas EMS protocols"

Texas is a delegated practice state, with individual medical directors deciding what they do and do not want their EMS personnell to do.

If my med control wants me to crack a chest on the field and teaches me how, I'm allowed to as a Paramedic.



Giving K+ or blood is not that rare here for IFTs


----------



## rook901

Aidey said:


> Paramedics could have those same standing orders, depending on the agency and Med director.
> 
> I will revise my statement to make it a little clearer -
> 
> RNs and Paramedics are limited to the same level of care when it comes to ACLS when they have equal access to lab tests and medications, assuming both have standing orders allowing them to interpret the tests and initiate treatment.



If a hospital were to set things up that way, I'd agree with that. But how many hospitals take on that level of perceived liability? (key word: perceived)

Typical ED setup is for the medic to work as a tech while the RN supervises patient care. Tennessee EMS regs even specifically notate that medics in the hospital setting are to be under nursing supervision. So, the trend is to not allow medics to function to their full scope. Even if they did, the protocols would have to be modified from the state-recommended protocols, which no service here strays from. (talking specifically about TN)

In the matter of medics independently taking patient loads in the ED, my only complaint against this is that it lowers my chances of getting an ED position as an RN.  

We're getting pretty off-topic here, though.


----------



## JPINFV

rook901 said:


> It's not on the truck because... *drumroll*... it's not within scope of practice.
> 
> Don't pull the "nurses just wait around for doctors to give them orders" nonsense. ER and ICU nurses have standing orders that allow them to operate without MD handholding. Medics do not practice medicine independent of MD supervision. Protocols are explicit doctor's orders. Online medical direction is the same.
> 
> *Granted, a nurse will not hang blood without an order,* but the statement I responded to was that RN's cannot do any more than a medic as far as ACLS goes (I would argue that hanging drugs/blood product is a component of addressing the causes in the scope of ACLS). Hanging KCl could be a standing order based on the labs. While the standing order is an explicit MD order, it is not handholding.



You know, this is where I get to sit back and laugh at these sort of arguments. Yes, RNs and paramedics work under both patient specific orders (written or online med control) AND under standing orders. Anything past that is going to be determined by the practice setting more than anything else. There's more than a slight difference between an RN poking the patient's emergency physician to clarify something than a paramedic calling in. Similarly, with a physician available to do things, like reviewing lab results, it's easier to justify more standing orders for paramedics. This is, of course, ignoring verbal orders where the RN gets a lab results, walks over to the physician and says something along the lines of, "Hey, the lab results came back with _____ for bed ___. Want me to hang ____?" Situations like that make the discussion about standing orders for RNs vs paramedics a 'missing the forest because of the trees' time discussion.


----------



## WTEngel

I am back in The States now, haven't updated my location yet.

When I have hung blood, colloids, and other drips it was in the US, right here in the Lone Star State. Granted, you won't find this stuff in very many if any ground 911 systems, however on most flight and critical care services you will find it more often than not. 

Even though there is a nurse and a paramedic on the heli, as the medic I had just as much ability to hang any of the above mentioned items as the nurse did. Every decision we made about patient care was made as a team, and our skill sets were identical. There were no skills exclusive to the RN or to the paramedic. Believe it or not this was more of an increase in scope and skills for the nurse than the paramedic.

I am not taking a side in this argument. I think the RN/Medic model in critical care is perfect because both professionals play off the strengths of the other, and also are there to have each others back when either person encounters difficulty.

The solution to the issues here is not to cut out any one profession, whether it be RN, medic, firefighter, first responder, etc. Even though I agree that professional medics need to have degrees, and there needs to be bachelor's and masters options for EMS professionals, I am also aware that there needs to be a vocational route for fire personnel and other first responders to be able to provide certain ALS interventions. Let's face the facts, there are too many rural areas where it is not possible to have close ALS coverage...require degrees for all ALS personnel, and the people residing in these communities will be waiting 30 mins, and hour, sometimes more for any sort of ALS care. 

I mentioned in a thread a month or two ago that with a little tweaking of the current accepted levels of certification or licensure in EMS, a lot of our woes could be alleviated.

Maintain the current ECA and EMTB certs. Eliminate the intermediate. Create a vocational paramedic certification reserved for professional who do not transport patients, but only provide care as a first responder. A hybrid between the current EMTI and the current EMTP.

For individuals who are going to work on transporting ALS units, require them to have a degree and call them a licensed professional paramedic. With this should follow an increase in scope of practice as appropriate.

Also, I don't think any patients should be treated by EMTBs, regardless of their acuity. If EMTBs are to be involved in transport, it should be as a driver only. People who provide care to patients should have degrees. I know that is going to rub some the wrong way, but if you're serious about wanting to be in EMS as a profession, bite the bullet and get your medic degree, simple as that.


----------



## rook901

Linuss said:


> There is no such thing as "Texas EMS protocols"
> 
> Texas is a delegated practice state, with individual medical directors deciding what they do and do not want their EMS personnell to do.
> 
> If my med control wants me to crack a chest on the field and teaches me how, I'm allowed to as a Paramedic.
> 
> 
> 
> Giving K+ or blood is not that rare here for IFTs



So, you don't have EMS protocols in Texas? I wonder what that nice list of protocols I linked to was for, then. Weird.

Transporting a patient from one facility to another with blood already hanging is one thing. Hanging the blood yourself is another. It's the same in Tennessee. The patient can pretty much have anything running IV for IFT's. The medic didn't initiate it. IFT with a solution already hanging has nothing to do with interventions that you're implementing during or post-resuscitation, which is what I was addressing with the blood/KCl comment (ACLS H&T's.. I feel like I'm repeating myself in every post I make).

I would question the legitimacy of your statement regarding the implication that a medic in TX can do anything that medical control tells them to. Where do you draw the line? Is the scope of practice unlimited?

Again, this is all getting off-topic and turning into a medic vs RN thread. My only point in rebutting what was mentioned re: ACLS H&T's was the ignorance of the statement, NOT to say that one profession is better than the other.


----------



## rook901

WTEngel said:


> When I have hung blood, colloids, and other drips it was in the US, right here in the Lone Star State. Granted, you won't find this stuff in very many if any ground 911 systems, however on most flight and critical care services you will find it more often than not.



Fair enough. When I think of EMS, I usually don't even think of flight services, because they're a completely different animal.


----------



## WTEngel

rook901 said:


> So, you don't have EMS protocols in Texas? I wonder what that nice list of protocols I linked to was for, then. Weird.
> 
> Transporting a patient from one facility to another with blood already hanging is one thing. Hanging the blood yourself is another. It's the same in Tennessee. The patient can pretty much have anything running IV for IFT's. The medic didn't initiate it. IFT with a solution already hanging has nothing to do with interventions that you're implementing during or post-resuscitation.
> 
> I would question the legitimacy of your statement regarding the implication that a medic in TX can do anything that medical control tells them to. Where do you draw the line? Is the scope of practice unlimited?
> 
> Again, this is all getting off-topic and turning into a medic vs RN thread. My only point in rebutting what was mentioned re: ACLS H&T's was the ignorance of the statement, NOT to say that one profession is better than the other.



Linuss is pointing out that while you may be looking at EMS protocols from certain agencies, the list is not exhaustive and there is no set in stone official "State of Texas Paramedic Scope of Practice."

Each agency has its own protocols, approved by the medical director of that agency. As Linuss pointed out earlier, if a medical director is willing to provide the training and take on the liability, he or she can authorize just about any prehospital treatment desired and have it carried out by the paramedic on the call.


----------



## clibb

Just saw a commercial about nursing and there was a nurse using a BVM in the back of an ambulance while they said (Nurses saving lives on the road during the day). GRRRR


----------



## rook901

WTEngel said:


> Linuss is pointing out that while you may be looking at EMS protocols from certain agencies, the list is not exhaustive and there is no set in stone official "State of Texas Paramedic Scope of Practice."



That much is understood. I'm sorry if I was unclear in my wording, but what I said was that I skimmed through a couple of regional protocols (not one uniform "state" protocol) and could not find anything related to hanging blood or K+.


----------



## rook901

clibb said:


> Just saw a commercial about nursing and there was a nurse using a BVM in the back of an ambulance while they said (Nurses saving lives on the road during the day). GRRRR



Sorry to burst your bubble, but there ARE prehospital nurses that do ride the bus. Some states have specific prehospital certification for RN's. I believe you're referring to the Johnson & Johnson nursing recruitment commercial. It's not a slam against EMS. It's just showing nurses working in different areas.


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## firetender

*Show Me The Money!*

It's been mentioned before but not quite this way. Nurses have done very well when it comes to setting minimum standards, specialties and ADEQUATE COMPENSATION at each level. I would imagine they have discussed a specialty or increased training in pre-hospital care but probably rejected it.

Why?

Let's listen to the Chairperson of the Board: "Wouldn't that be making us downwardly mobile?"

Case closed. 

To even re-vamp billing to reflect in-house visits covered by medicare still makes an R.N. (SPECIALIST!) with a minimum base salary of $20/hr. (you think they'd even stand for that little?!) out of reach for the uninsured. An ambulance would be a Boutique Service!

Paramedic is a specialty unto its own and should design its own upward mobility based on that specialty. There is no benefit to having a complete R.N. education; just more poop to juggle in your head when what the job demands is ACTION!


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## WTEngel

rook901 said:


> That much is understood. I'm sorry if I was unclear in my wording, but what I said was that I skimmed through a couple of regional protocols (not one uniform "state" protocol) and could not find anything related to hanging blood or K+.



That website also highlights only 10 cities or counties in the second largest state in the US. Of the agencies listed it doesn't even mention some of the more advanced in the state...

Don't get me wrong, colloids, blood, potassium, etc. in the prehopsital setting are the exception, not the rule, but they can be found in multiple ground and flight critical care services in Texas and I'm sure throughout the country. I don't think the average medic (or nurse for that matter) should be hanging these items or doing a number of other treatments reserved for practitioners with additional training and education, but the point is that there are many paramedics out there who are capable of competently doing so and increasing the chances of a positive patient outcome.

Like I said in the last post on the previous page, the solution is not as simple as cutting out any one provider all together and replacing them with someone who has more education...we are in too deep for that.


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## jjesusfreak01

WTEngel said:


> Also, I don't think any patients should be treated by EMTBs, regardless of their acuity. If EMTBs are to be involved in transport, it should be as a driver only. People who provide care to patients should have degrees. I know that is going to rub some the wrong way, but if you're serious about wanting to be in EMS as a profession, bite the bullet and get your medic degree, simple as that.



I consider myself "rubbed". As an EMT, I won't even think about asking to run a true code, or handle any patient best served by the skills and knowledge of a paramedic, but EMTs have their place in the back of an ambulance as a primary provider. Many many patients transported by EMS in the US need little more than a taxi ride to the hospital, and this gives the EMT the ability to practice assessment skills that they may use further down the line in their education as a paramedic, nurse, pa, or md. Remembering that I work in a system where all trucks have a medic, what is the harm in letting me take care of the kid with the broken arm, or even the woman having a panic attack? Who knows, at some point I may find myself alone providing care for a real medical emergency, and at that point, the last thing that needs to be going through my head is, "where is the medic". Although I agree that EMT-B should be considered an ephemeral position, a skin to be shed when one attains a higher level of training in the medical field, it is doing a disservice to EMTs to suggest that they cannot be primary providers. If all I am going to do is drive, my 180 hour class and 3+ months I will spend as a third rider to teach me proper assessment and treatment are totally wasted. They should just drop the EMT class down to 10 hours, teach you all the monkey skills, and then put you through a driving course. 

Also, nurses are still awesome, but have a totally different role from paramedics. Though both operate under standing and written orders, the nurses training can't be simply patched with a 2 month course to make them a paramedic, nor can the medic's training be easily patched to make them a nurse. There is a huge difference between operating under standing orders when the doctor is 10ft away and 10 miles away. You are trying to climb a huge hill here. Most nurses sign up to be nurses, which means that they wanted to take care of people, both physically and mentally, but what they aren't signing up for is diagnosing and treating emergent patients. This is what medics sign up for. Arguing that they can easily take each other's place is like arguing that a duck could replace a swan. Its just silly. 

On a practical note, I think it is possible to train nurses for EMS, but I think it would require a year of specialty emergency training, and selection for nurses that honestly desired to work in EMS. This is the heart of the issue. Every medic wanted to work in EMS, but few nurses do, or they would be paramedics.


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## usalsfyre

rook901 said:


> So, you don't have EMS protocols in Texas? I wonder what that nice list of protocols I linked to was for, then. Weird.
> 
> Transporting a patient from one facility to another with blood already hanging is one thing. Hanging the blood yourself is another. It's the same in Tennessee. The patient can pretty much have anything running IV for IFT's. The medic didn't initiate it. IFT with a solution already hanging has nothing to do with interventions that you're implementing during or post-resuscitation, which is what I was addressing with the blood/KCl comment (ACLS H&T's.. I feel like I'm repeating myself in every post I make).
> 
> I would question the legitimacy of your statement regarding the implication that a medic in TX can do anything that medical control tells them to. Where do you draw the line? Is the scope of practice unlimited?
> 
> Again, this is all getting off-topic and turning into a medic vs RN thread. My only point in rebutting what was mentioned re: ACLS H&T's was the ignorance of the statement, NOT to say that one profession is better than the other.



RIGHT, since being able to fill out the flow sheet is something only RNs are qualified to do  

Initiating blood is not terriblely hard, nor is monitoring for transfusion reaction. Deciding if it's a good or bad idea is a bit tougher.

I'm sure I can find any number of nurses who have never initiated or titrated any number of vasoactives that I've used as part of various protocols in the past.

Your right, this is becoming an RN vs Medic thread. If you really want to know what high level providers are capable of, seek out an experinced, well trained CCT crew. I can garuntee you can't tell who's the medic and who's the RN solely on knowledge base.


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## rook901

WTEngel said:


> Like I said in the last post on the previous page, the solution is not as simple as cutting out any one provider all together and replacing them with someone who has more education...we are in too deep for that.



If you read my initial response a few pages back, I'm on board with that same opinion. Handing EMS over to nursing is too cost-prohibitive and too dangerous (in regards to putting new RN's on the bus, as was suggested by the OP). 

On top of that, you're putting all the current EMT's and medics out of a job if they're unwilling to go through a nursing program. One of the OP's points was that new nurses are having a hard time finding jobs, so we could just automagically put them in EMS positions and give them jobs. What does the medic with 20 years on the job do when he can't ride the bus and there aren't enough ED tech jobs to go around?

Handing EMS over to nursing just isn't the answer.


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## Aidey

WTEngel said:


> I really have nothing but love for my RN colleagues, however, the BNE  exerts a HUGE amount of leverage over what is considered safe and unsafe  in regards to patient care, *and most of what is considered unsafe  has quite a bit to do with how no other profession can do certain tasks  better than nurses.*



An observation on that, I have noticed that there are problems with that  within nursing. I've most commonly seen it as ED RNs vs the rest of the  hospital RNs. Two examples I have personally witnessed are where IVs  are started, and restarting ED IVs. 

I know a couple of ED RNs that have been written up by non-ED RNs  because they started IVs in "unauthorized" places. I know a lot of  hospitals usually have policies on restarting field IVs within a certain  amount of time. I know at least 2 hospitals here also restart ED IVs  within the same 24 hour time frame as they restart field IVs. 

I will probably catch crap for saying this, but it seems like RNs who  work in more controlled environments tend to get more set on the rules  than RNs who don't.




Veneficus said:


> *It has been demonstrated by some places like Seattle*,  Outside of DC (forgot the dept name) and even Oregon that the fire  service has the capability to do EMS well. Unfortunately a majority of  fire service EMS has chosen not to emulate them. I could advocate for  such a universal system.



Say what? I'm not trying to be argumentative, but Seattle isn't as  awesome as it seems from outside the system. Yes, the Medic One program  is probably one of the most advanced Paramedic programs in the country,  but that doesn't mean it is immune from the crap that FDs try and pull. 

 Common occurrence in the Seattle area; a BLS private transport agency  responds along with the FD. The FD medic assesses the patient, starts an  IV, pushes meds, discontinues the the IV and sends the patient to the  hospital with the BLS ambulance (and not just locks the IV, takes it out  completely). This happens with everything from pain meds to allergic reactions. I work with someone who used to work in Seattle, and the  system allows the FD medics to cherry pick calls, and pawn off  everything else to the BLS private agencies. She has some scary stories about complications that have come up after the FD takes off.


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## WTEngel

jjesusfreak01 said:


> I consider myself "rubbed". As an EMT, I won't even think about asking to run a true code, or handle any patient best served by the skills and knowledge of a paramedic, but EMTs have their place in the back of an ambulance as a primary provider. Many many patients transported by EMS in the US need little more than a taxi ride to the hospital, and this gives the EMT the ability to practice assessment skills that they may use further down the line in their education as a paramedic, nurse, pa, or md. Remembering that I work in a system where all trucks have a medic, what is the harm in letting me take care of the kid with the broken arm, or even the woman having a panic attack? Who knows, at some point I may find myself alone providing care for a real medical emergency, and at that point, the last thing that needs to be going through my head is, "where is the medic". Although I agree that EMT-B should be considered an ephemeral position, a skin to be shed when one attains a higher level of training in the medical field, it is doing a disservice to EMTs to suggest that they cannot be primary providers. If all I am going to do is drive, my 180 hour class and 3+ months I will spend as a third rider to teach me proper assessment and treatment are totally wasted. They should just drop the EMT class down to 10 hours, teach you all the monkey skills, and then put you through a driving course.
> 
> Also, nurses are still awesome, but have a totally different role from paramedics. Though both operate under standing and written orders, the nurses training can't be simply patched with a 2 month course to make them a paramedic, nor can the medic's training be easily patched to make them a nurse. There is a huge difference between operating under standing orders when the doctor is 10ft away and 10 miles away. You are trying to climb a huge hill here. Most nurses sign up to be nurses, which means that they wanted to take care of people, both physically and mentally, but what they aren't signing up for is diagnosing and treating emergent patients. This is what medics sign up for. Arguing that they can easily take each other's place is like arguing that a duck could replace a swan. Its just silly.
> 
> On a practical note, I think it is possible to train nurses for EMS, but I think it would require a year of specialty emergency training, and selection for nurses that honestly desired to work in EMS. This is the heart of the issue. Every medic wanted to work in EMS, but few nurses do, or they would be paramedics.



I understand why you are rubbed and I would have been rubbed also earlier in my career (I am not accusing you of being early in your career, I am simply pointing out that at the beginning of my career is when I would have been rubbed by such a comment.)

In order to increase the professionalism of EMS, BLS roles in the field need to be limited to non transporting roles. As long as there are provisions for BLS providers to transport patients, employers will find creative ways to justify the use of BLS providers in as many transports as possible as a cost saving measure. I am not saying that BLS providers can not be competent caregivers, I have met many a good basic in my days, and I will admit that i have had a good basic save me a time or two early on in my career. What I am saying is that if people are truly passionate about EMS as a profession, then they need to bite the bullet and go all in. 

Do you think that ADNs and BSNs both being considered RNs is a coincidence? Absolutely not. The ANA and other associations supporting nursing understand that if there is a difference in skill set, there will always be a push by employers to hire the least expensive provider who can provide the bare minimum skills necessary. With EMS recognizing three and in some places four or more different levels of provider able to transport patients, we are allowing employers to come up with creative ways to decrease pay rates for all certification levels!


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## JPINFV

rook901 said:


> If you read my initial response a few pages back, I'm on board with that same opinion. Handing EMS over to nursing is too cost-prohibitive and too dangerous (in regards to putting new RN's on the bus, as was suggested by the OP).



Too dangerous? Really? Compared to a new paramedic? Any service that takes a fresh from school paramedic, EMT, or RN and just hands them the keys and drug box with a, "Have at it," is putting the public at risk. 

Cost-prohibitive? Sure, if all EMS is is a ride to the hospital. 


> On top of that, you're putting all the current EMT's and medics out of a job if they're unwilling to go through a nursing program.


Can't that be said about any increase in education requirements?



> Handing EMS over to nursing just isn't the answer.


While I agree with the statement, I disagree with the reasoning. It takes time to train a generalist to practice in any specialty, regardless of what the generalist is. A generalist that specializes is not necessarily better or worse at providing a specific service than a pure specialist, but the mobility of the pure specialist is limited and, depending on the education and training requirements, it can be harder to expand services. The solution for EMS is not to hand it over to nurses, but for paramedics to up their proverbial game.


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## Aidey

Veneficus said:


> Because there is very little wrong with what  they are doing. It is EMS that can't seem to educate or advance itself.
> 
> Compare the standard requirements of those providers to that of EMS on a national scale.
> 
> Like I said, EMS has failed to keep up with the body of medical  knowledge applicable to it. It has failed to develop value outside of  transport. Many patients are not properly served by the ED, which in the  US with less than a handful of exceptions is the only option for  patients. (at a terrible waste of money) The services exemplifying the  role of EMS in the future are not being emlulated. There has been a  failure of standard in EMS. No matter what state (or country) you are  from the requirements to take the NCLEX are standard. You can get a  paramedic card in places and not take national registry. Ever.
> 
> You ever see a nurse patch factory? A rad tech patch factory? An RT patch factory?



I agree with most everything you said, but I see a problem with where you place the blame. 

EMTs and Paramedics can advocate all they want for more education,  expanded scope etc, but when it comes down to it the DOT and the  individual medical directors control what happens. 

Yes, it is a bit of a catch 22. Bad providers lead MDs to reduce the  scope, leading to frustrated providers who feel they are nothing but  taxi drivers. Since the MDs honestly have little to no control over  keeping a person from practicing, they change the protocols for everyone  because of the actions of one person. 

An example of this is the situation in Florida. Don't agree with the MDs  rules? Get a new MD. MD revokes sponsorship of a particular person  because they keep screwing up? Find a new sponsor. Have a medic who  gives a patient a 200mcg dose of Fentanyl all at once and then forgets  that narcan exists? Change the protocol limiting everyone to .5mcg/kg doses. 

Any meaningful change is going to necessitate re-educating the  physicians who ultimately control the application of the system. I will  always advocate for more education, but it isn't going to get us very  far if things still get bottle necked at the MDs. This is also going to  mean that something would have to be done about the unions that fight to  keep bad providers in their jobs.


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## rook901

JPINFV said:


> Too dangerous? Really? Compared to a new paramedic? Any service that takes a fresh from school paramedic, EMT, or RN and just hands them the keys and drug box with a, "Have at it," is putting the public at risk.



Yes, compared to a new paramedic, a new RN is more dangerous on the unit. The entire paramedic program is geared toward prehospital. Adding a 3 or 6-credit prehospital course to the RN program is not going to prepare the RN for prehospital. Orienting a new paramedic to prehospital operations is not going to be the same as orienting a new RN.



JPINFV said:


> Cost-prohibitive? Sure, if all EMS is is a ride to the hospital.



What percentage of EMS calls would you say is NOT just a ride to the hospital? I work for a private company that has the contract for county EMS, which covers a broad range of settings, from strictly rural to very urban. Throughout our coverage area, I'd say roughly 5% of our calls require anything more than oxygen, reassurance, and a very expensive taxi ride.

To put you back on point, the cost-prohibitive aspect was in regards to the personnel cost of having two RN's on an ambulance versus having a medic and a basic, not the cost to the patient.



JPINFV said:


> Can't that be said about any increase in education requirements?



No. If you increase education requirements within one hierarchy, anyone already in the hierarchy is going to be grandfathered in. Ex: There are FNP's and PA's out there who still only have a Bachelor's degree, even though a Master's is now required in most (if not all) states. However, if you change the requirements so that you have to belong to a totally new hierarchy, you're not going to get grandfathered in. Paramedics will not be grandfathered into nursing.


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## JPINFV

rook901 said:


> Yes, compared to a new paramedic, a new RN is more dangerous on the unit. The entire paramedic program is geared toward emergency. Adding a 3 or 6-credit EMS course to the RN program is not going to prepare the RN for prehospital. Orienting a new paramedic is not going to be the same as orienting a new RN.



True, a 3 or 6 hour EMS course isn't going to make an RN into a paramedic, but it should be a heck of a lot less time than to go from EMT to paramedic. So, what exactly is a RN missing then? The ability to do an assessment? The ability to start an IV? Or is it the "the doctor isn't right behind me in the ER" safety net that will arguable put the RN into a different mind set than a paramedic. Alternatively, is it the handful of interventions such as intubation? I'd argue that the actual skill itself isn't hard, especially if there's already a solid anatomical and physiological foundation to build off of. Everything else is just psychomotor. 





> What percentage of EMS calls would you say is NOT just a ride to the hospital? I work for a private company that has the contract for county EMS, which covers a broad range of settings, from strictly rural to very urban. Throughout our coverage area, I'd say roughly 5% of our calls require anything more than oxygen, reassurance, and a very expensive taxi ride.


How many of those could be handled as an outpatient on scene provided that the provider has an appropriate level of education, oversight, and authorization to do a quick on scene workup and refer?  

How many of those can go to an alternative destination besides the ER?

Not all patients need a huge workup, and while arguable, EMS should be reserved for life threatening emergencies, reality is vastly different and I don't see it completely changing. You play the hand your dealt, not the hand you want, and sometimes the best way to play that hand is to treat and release on scene. However that's not appropriate when the top level of EMS provider is 1000 hours of training, if that. 



> No. If you increase education requirements within one hierarchy, anyone already in the hierarchy is going to be grandfathered in. Ex: There are FNP's and PA's out there who still only have a Bachelor's degree, even though a Master's is now required in most (if not all) states. However, if you change the requirements so that you have to belong to a totally new hierarchy, you're not going to get grandfathered in. Paramedics will not be grandfathered into nursing.



Strange. If I recall correctly with the current realignment from EMT-B/EMT-I85/EMT-I99/EMT-P to EMT/AEMT/paramedic, the rule is either take additional course work at recert time or drop to a lower level. That doesn't sound much like grandfathering people in to me. Additionally, I'd argue that there's a vast difference between going from patch mill to an actual education and going from one degree level to another in terms of changes in education.


----------



## Aidey

JPINFV said:


> How many of those could be handled as an outpatient on scene provided that the provider has an appropriate level of education, oversight, and authorization to do a quick on scene workup and refer?
> 
> How many of those can go to an alternative destination besides the ER?
> 
> Not all patients need a huge workup, and while arguable, EMS should be reserved for life threatening emergencies, reality is vastly different and I don't see it completely changing. You play the hand your dealt, not the hand you want, and sometimes the best way to play that hand is to treat and release on scene. However that's not appropriate when the top level of EMS provider is 1000 hours of training, if that.



Out of curiosity, do you think anyone without the ability to prescribe medications will be able to significantly impact the number of non-transports by either treating on scene or redirecting to a more appropriate place than the ER? 

I'm just thinking of the high number of people who demand to go, no matter what, and/or don't have other means of transport.


----------



## rook901

JPINFV said:


> True, a 3 or 6 hour EMS course isn't going to make an RN into a paramedic, but it should be a heck of a lot less time than to go from EMT to paramedic. So, what exactly is a RN missing then? The ability to do an assessment? The ability to start an IV? Or is it the "the doctor isn't right behind me in the ER" safety net that will arguable put the RN into a different mind set than a paramedic. Alternatively, is it the handful of interventions such as intubation? I'd argue that the actual skill itself isn't hard, especially if there's already a solid anatomical and physiological foundation to build off of. Everything else is just psychomotor.



None of the above. The RN is lacking the specialty education that the paramedic gets for the entire length of his/her program. The larger majority of what the RN learns simply does not apply to prehospital scenarios. Yes, an RN can be trained to do prehospital. An RN has the prerequisite knowledge and will be teachable. But in the context of the OP's suggestions, taking a new RN, who has a general medical education (let's not get into nursing vs medical here) and giving them a little prehospital education does not prepare them as well as the paramedic who has spent a huge portion of their program riding the bus, spending time in the hospital doing intubations, getting their 50 patient contacts as team leader, etc. It's just not a realistic expectation to assume that a new RN with a little prehospital training is going to be as good as a new medic. Period. Now, give me an RN who's been working in critical care for a couple of years, can identify rhythms and do ACLS as easily as nuking a Hot Pocket, etc. and I can see giving them a brief prehospital course and putting them on the bus.




JPINFV said:


> How many of those could be handled as an outpatient on scene provided that the provider has an appropriate level of education, oversight, and authorization to do a quick on scene workup and refer?
> 
> How many of those can go to an alternative destination besides the ER?
> 
> Not all patients need a huge workup, and while arguable, EMS should be reserved for life threatening emergencies, reality is vastly different and I don't see it completely changing. You play the hand your dealt, not the hand you want, and sometimes the best way to play that hand is to treat and release on scene. However that's not appropriate when the top level of EMS provider is 1000 hours of training, if that.



You're right. Many of these could be treat and release on scene, but they're not going to be. As I mentioned earlier, your truly sick patients need to go to the ED or at least an urgent care. Your folks who call 911 because they have had a toothache for two weeks and it's 2am and they can't get to sleep -- those folks are going to demand to go to the ED anyway, simply because they either don't have a car, don't want to drive, don't have a PCP or insurance, or they think that coming in by ambulance is going to get them seen faster. As I said, the number of people who will benefit from a community health model, with RN's riding the bus, is nominal at best.



JPINFV said:


> Strange. If I recall correctly with the current realignment from EMT-B/EMT-I85/EMT-I99/EMT-P to EMT/AEMT/paramedic, the rule is either take additional course work at recert time or drop to a lower level. That doesn't sound much like grandfathering people in to me. Additionally, I'd argue that there's a vast difference between going from patch mill to an actual education and going from one degree level to another in terms of changes in education.


We're talking about a relatively brief bridge course vs several years of school. Apples and oranges, my friend.


----------



## rook901

Aidey said:


> Out of curiosity, do you think anyone without the ability to prescribe medications will be able to significantly impact the number of non-transports by either treating on scene or redirecting to a more appropriate place than the ER?
> 
> I'm just thinking of the high number of people who demand to go, no matter what, and/or don't have other means of transport.



^^^ +1 for this.


----------



## JPINFV

Aidey said:


> Out of curiosity, do you think anyone without the ability to prescribe medications will be able to significantly impact the number of non-transports by either treating on scene or redirecting to a more appropriate place than the ER?
> 
> I'm just thinking of the high number of people who demand to go, no matter what, and/or don't have other means of transport.



As long as we're talking hypothetical future directions, why would EMS providers always lack the ability to furnish prescriptions within a specific set of rules as laid down by their medical director?


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## JPINFV

rook901 said:


> You're right. Many of these could be treat and release on scene, but they're not going to be. As I mentioned earlier, your truly sick patients need to go to the ED or at least an urgent care. Your folks who call 911 because they have had a toothache for two weeks and it's 2am and they can't get to sleep -- those folks are going to demand to go to the ED anyway, simply because they either don't have a car, don't want to drive, don't have a PCP or insurance, or they think that coming in by ambulance is going to get them seen faster. As I said, the number of people who will benefit from a community health model, with RN's riding the bus, is nominal at best.



...but here's the problem with something like that. You see a tooth ache, and I see everything from a cavity or bad gingivitis to something that can be life threatening. The question is, and this is where education in total comes into play, when is a tooth ache just a tooth ache and when is it something more? However just going off of a chief complaint, the "what if" game can be played for eternity with DDxs placed anywhere on the non-emergent to emergent scale. However this is where a community health program can come into play. You don't have to have a RN or community health paramedic on every ambulance. If the complaint is, "It burns when I pee," then you can send the community health paramedic or RN, essentially doing a reverse triage. If, based on an assessment and including additional POC testing (for the 'burns when I pee' patient, you could do a urine dipstick), it's either something that can be successfully refereed and treated based off of a clinical diagnosis ("Here's a script for Bactrim, get it filled in the AM and make an appointment in three days with the clinic for follow up." Uncomplicated UTIs make a great example for this), then do it. 

Additionally, who says every patient needs to be treated from now until forever? Yes, given the current standards, this all is a pipe dream. However why not change the current standards besides the fact that 'it's hard.'


----------



## rook901

JPINFV said:


> ...but here's the problem with something like that. You see a tooth ache, and I see everything from a cavity or bad gingivitis to something that can be life threatening. The question is, and this is where education in total comes into play, when is a tooth ache just a tooth ache and when is it something more? However just going off of a chief complaint, the "what if" game can be played for eternity with DDxs placed anywhere on the non-emergent to emergent scale. However this is where a community health program can come into play. You don't have to have a RN or community health paramedic on every ambulance. If the complaint is, "It burns when I pee," then you can send the community health paramedic or RN, essentially doing a reverse triage. If, based on an assessment and including additional POC testing (for the 'burns when I pee' patient, you could do a urine dipstick), it's either something that can be successfully refereed and treated based off of a clinical diagnosis ("Here's a script for Bactrim, get it filled in the AM and make an appointment in three days with the clinic for follow up." Uncomplicated UTIs make a great example for this), then do it.
> 
> Additionally, who says every patient needs to be treated from now until forever? Yes, given the current standards, this all is a pipe dream. However why not change the current standards besides the fact that 'it's hard.'



In all reality, for someone who's had a toothache for the past two weeks, the toothache is probably just a toothache. Unless there's an abscess, there probably isn't any emergent condition going on. But this person is going to demand to go to the ED, unless you're able to write and fill a script for Lortab and Amoxicillin in the field. (not saying they will get the script filled at the ED, but they will get some pain meds while there and probably some Rocephin to get them started)

On the subject of writing scripts in the field, it's not going to happen unless there's a Master's-prepared provider on the bus. An MD cannot authorize a medic or RN in the field to write a prescription, so the medic/RN will need to have prescriptive authority. In order for the state to give prescriptive authority, the state is likely going to require an education level on par with other providers that have prescriptive authority. In all cases, these are Master's level or above, so I doubt that the state would be willing to grant prescriptive authority to another class of provider with a lower education level.

So, now we're talking about putting Master's-prepared medics or RN's on the bus for this community health EMS model. This is even more unrealistic than having RN's take over EMS.

Granted, each state has the authority to determine who they give prescriptive authority to and what education requirements they want. Even still, the AMA and ANA will fight against giving prescriptive authority to a lesser-educated provider.

On top of that quagmire, we'll STILL have the people who just want you to take them to the ED no matter what. The field provider will not realistically be able to fill prescriptions on scene. So, it's 2AM, this person is in pain, we give them a nice piece of paper with some pretty writing and a fancy signature, and it's useless to them.

Yes, some people will take the script and go on with their life. This is going to be a minority. The majority will still either truly need to go to the ED or will demand it, and we end up being a Master's-prepared taxi driver anyway.


----------



## Aidey

JPINFV said:


> As long as we're talking hypothetical future directions, why would EMS providers always lack the ability to furnish prescriptions within a specific set of rules as laid down by their medical director?



I don't think it would, look at the Oz model of EMS. Or even some unique US models.*

I was specifically referring to Vene's idea of replacing Paramedics with RNs, without making any major changes to the Paramedic of RN curriculum. As things are now, I don't know that an RN would make that much of a difference, even if they had a significantly expanded scope. 

JP, what you describe is the only way in my head I could think of the system working. In which case, why use RNs as the person who responds? Why not use NPs and PAs since they are already set up to do exactly what would be needed? I'm just thinking of how this could be implemented now, rather than in 5-8 years. 

As someone pointed out too, how would any of this work for uninsured patients? If they couldn't pay out of pocket, would they be refused the expanded services? 


* I used to work remote medical, waaaaay remote. I had a fairly long list of meds I could give, including a few antibiotics and prednisone. I had urine dips, rapid strep tests etc, and could use the antibiotics accordingly. The protocol was that I had to call the doc within 24 hours of giving the antibiotics if I couldn't get a hold of them at the time. That wasn't even a firm rule, but if you didn't call you better have a good reason, like communications were down (which could/did happen).


----------



## JPINFV

Aidey said:


> I don't think it would, look at the Oz model of EMS. Or even some unique US models.*
> 
> I was specifically referring to Vene's idea of replacing Paramedics with RNs, without making any major changes to the Paramedic of RN curriculum. As things are now, I don't know that an RN would make that much of a difference, even if they had a significantly expanded scope.
> 
> JP, what you describe is the only way in my head I could think of the system working. In which case, why use RNs as the person who responds? Why not use NPs and PAs since they are already set up to do exactly what would be needed? I'm just thinking of how this could be implemented now, rather than in 5-8 years.


Using a current mid-level is definitely a valid concept, and truthfully, more so than trying to elevate another level to a mid-level type position. 



> As someone pointed out too, how would any of this work for uninsured patients? If they couldn't pay out of pocket, would they be refused the expanded services?


To an extent, maybe. The problem with the uninsured is that they're likely to be seen and treated (especially if it's communicable) in the ED anyways. So the big question is, since they're already accessing the emergency medical system at some point, is there a cheaper way of treating them if they're going to be treated anyways?


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## Veneficus

*I go to bed for a few hours and look at this place*

Pages of medic>nurse, nurse>medic with a handful of skills arguments.

Not exactly the intelligent debate I was looking for. 

I did see some stuff about mindset or personality type that I found interesting. 

The ever popular pay disparity was mentioned. But it was the usual short sighted "I am cheap labor, I want a pay raise and respect before I get an education or do anything else to earn it."

But here is a few points that I took away from it all.

Medics are extremely short sighted. What is probably the same ADD that draws them to the emergency field also stops them from any forward looking or thinking. How can anyone ever hope to build a profession or respect on that?

Many cannot see that econimics will be forcing the system to change in the very near future. They do not want to change, if they put their head in the sand, it will all get better. 

But really, paramedics are not upward mobile. Or sideways mobile, or mobile at all. The hyperspecialized training (not to be confused with education) that even I have carried the banner for is not applicable to todays needs and knowledge. Most calls are not emergencies. Most of the training is for emergencies that never happen. Even a lot of the treatments are in question.

Responding with ever growing fleets to take people who don't need an ED to an ED is really not worth :censored::censored::censored::censored:. Policy makers are figuring that out too.

Medics cannot argue education so they instead resort to the old standby of "there I was saving the patient from untold suffering and death with my device and skills."

There is a philosophy at least in European medicine that a provider must first be a generalist before a specialist. I agree with this thinking, otherwise, you never know when you are in over your head. Sometimes you still don't.

From the nursing side, I saw a missed opportunity. I could argue that it is that sort of indecision that makes then unsuited to EMS except as an armchair QB. I only recall one post where a nursing representative said something to the effect of "this is why we are better." 

So let me help. Nursing is portable. Within the profession you can specialize, you can increase your education and thereby practice capabilities. Medics simply can't.  No matter what branch they go to it essentially becomes a "do over." 

Also missing was one of the foundations of nursing. That everyday care leads to healthier lives. Healthier means less medical spending. Less suffering.

There was also the miss of coordination of care, something many US nurses I work with are proud of. They talk to the 3 different specialists not talking to each other. They know when they need to refer the pt up. There is a reason there are camp nurses and school nurses. (I worked as an EMT at a summer camp, I totally ripped those people off, looking back I had no idea what I didn't know, it was mostly just me guessing at stuff except when somebody needed a splint or bandaid)

Only JP put forth an argument of how the future might look with various providers in the role of EMS. 

Has it occured to anyone if patients had a viable alternative to the ED, they wouldn't go as much? Every other civilized country seems to. 

If I called the ambulance for a toothache, and it persisted for a while, causing pain and discomfort, which didn't progress to bacteremia/septic shock, or endocarditis/cardiac arrest, and the ambulance showed up, gave me some pain medications and made me an appointment at the local charity dental clinic, and found/offered me a ride that I might not need to go to the ED by emergency ambulance for the same thing?

If the ambulance showed up and gave my kid some tylenol, I wouldn't have to wait with her screaming and generally uncomfortable in a hospital waiting room for hours upon hours to get some cool aid and a tylenol.

Simple math, 

lets compare an economy car, gas and maintenence, adose of tylenol, zofran, some nasal spray and caugh syrup plus the cost of the RN/hour to A medium or light duty truck responding lights and sirens, a couple of paramedics, driving everyone to and from the hospital every 8 minutes.

Savings, even if you pay double than what you would for the medics. 

Now you could even add a bunch of ALS gear, priority dispatch, and a cell phone to the nurse, and use her (I used the feminine unless you want me to start calling the guys "sister"  ) as the ALS intercept with a couple of basics driving around in much cheaper ambulances. 

I keep trying to impress upon the ALS providers, it is not a need, it is a want.

Truthfully, if you guys want to keep your jobs, you better quit whining about the pay and start educating yourselves and branching out to be more valuable. As it stands, in a major cost cutting effort, replacing EMS providers with nurses is going to be a lot easier than EMS providers figuring out they need to be more valuable by society's standards, not by their own.


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## MrBrown

Aidey said:


> EMTs and Paramedics can advocate all they want for more education,  expanded scope etc, but when it comes down to it the DOT and the  individual medical directors control what happens.



Wrong.  It is the providers themselves who will ultimately determine the direction of the system.

It seems to Brown in the US there is no incentive for increased education, most Paramedics are ignorant to its benefits and would resist it, the evolution of EMS seems to have stopped at the "Paratechnician" level and never gone much beyond it.

Brown blames the lack of national unity, the Fire Service, volunteers, Parathinktheyare's, New World Order, public taxation, the media and American healthcare system.



Aidey said:


> Any meaningful change is going to necessitate re-educating the  physicians who ultimately control the application of the system. I will  always advocate for more education, but it isn't going to get us very  far if things still get bottle necked at the MDs.



Wrong.  It is going to mean re-educating the providers themselves.  When Paramedics prove they can be trusted with more than they have at the moment (thanks to those barely homeostasasing Parathinktheyare's who may or may not be Medicfighters) the medical director will listen.

Our medical director and regional medical advisors trust our Ambulance Officers with near total clinical autonomy (in line with reason and good clinical support) because they have proven capable of being trusted with it. 



Aidey said:


> This is also going to  mean that something would have to be done about the unions that fight to  keep bad providers in their jobs.



Man that is going to be almost as difficult as defeating the New World Order


----------



## MusicMedic

So i kinda skimmed the whole thread sorry if i repeat anything that has been said... 

What do you guys think of Doctors on Ambulances like they have in parts of Europe?... at least in Turkey (where my fam is from) they have a Doctor AND Paramedic on the rig... the Medic usually Drives, but also helps the Doctor with advanced on scene care.. 

Why cant we have a system with RN's and Medics on the rigs? i think that would up the standard of care quite dramatically.. or Hell Physicians and Medics!!

what about people in situations like me... I want the Education of an RN, but i want to work on a rig... once i become an RN, the only way i could work on a rig is either CCT (critical care transports) or Work as a Medic with a serious paycut and my scope limited... why does it have to be that way? 

and honestly who thinks that 6 months of schooling is adequate enough education to be a paramedic? why are the only Pre-Reqs for Medic school A&P, while for RN school its A&P/Microbio/English (this is the local pre reqs for ASN Program) 

I think Medics should still stick around, i just believe the education standards should be raised...


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## MrBrown

Brown thinks the use of Doctors in prehospital medicine should be restricted to the helicopter or a rapid repsonder model like HEMS/BASICS in the UK

Now, a history lesson .... 

*1969:* Miami, Seattle and Los Angeles get "Paramedics"
*1971:* Melbourne (Australia) launches MICA (mobile intensive care ambulance) and MICOs (mobile intensive care officers)
*1973:* New Zealand introduces Paramedic staffed mobile life support units (LSU)
*1983:* Ontario, Canada introduces ALS Paramedics in Oshawa, ON
*1990:* Paramedic training is introduced in the UK ....

... sad to see the rest of the world started later and has overtaken the US :sad:


----------



## Journey

Okay, RNs are in Flight, CCT, Specialty and can have PHRN or MICN certs to work in various out of hospital situations.

However, since we have now ventured to PAs and NPs, there is a large group of nurses, Public Health, who do work the streets with a variety of outreach services providing medical care. They may have NPs and PAs with them or they may be based out of clinics to see patients can be taken there. They don't drive around in flashy ambulances or wear a uniform and most in EMS will never know they are there. But, they are out there in many cities and they do prevent many calls to EMS and unnecessary deaths. The Public Health nurse will see many patients each day that need immediate medical attention and those who can be prevented from being a 911 call through maintenance of their diseases.  They also work with a health care team of many different professionals to see the patients get the proper ongoing care including housing, meds and psycho/social services.  Public Healh nurses have been around for over a century at least and probably assisted with some of the early ambulances.   NPs, PAs and Public Health nurses do try to address these issues at a national level while EMS is still trying to figure out what to call its providers and who can start an IV and who can not.  

RNs in hospitals also become very familiar with many, many different patient needs and not just the emergent ones.  Probably the med-surg RN is the better suited than someone who had done only critical care for long term maintenance, recongizing and preventing problems, understanding psycho/social needs, helps with arrangements if a  Case Manager is not around and does extensive education.  They had to expand their education to keep up with the demands of the patient care and there is also a specialization certification in Med-surg. Certs may not seem like a big deal espeically if some want compare it to the weekend courses offered in EMS which RNs can also take, but the prep work for nursing specialty certs is extensive and do require documented experience. 

In San Francisco, one Paramedic did go back to college to get a degree in Social Work/Public Health to start making a difference and worked along those who made up the Public Health Services. His also recognized the need to advance his education to achieve his goal.


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## Journey

MusicMedic said:


> what about people in situations like me... I want the Education of an RN, but i want to work on a rig... once i become an RN, the only way i could work on a rig is either CCT (critical care transports) or Work as a Medic with a serious paycut and my scope limited... why does it have to be that way?



You are selling your future career as an RN very short.  There are many specialty teams besides Flight and CCT that you could be part of. Because some have never been around them or they don't see the specialty ambulances flying at 80 mph with light and sirens, you don't think of these teams as being worthwhile. 

Stabilizing a critical neonate or pedicatric patient could take hours. You could also be hours away from your hospital and will travel by many different modes to transportation. Going to other countries to pick up babies and kids can be much more challenging than some of the situations that many of the situations you'll see working an EMS truck with may have just a 10 minute ride.  In these situations you will be expected to utilize all of your critical care experience and knowledge to intiate definitive treatment just as you would in the ICU.   For adults there are ECMO and cardiac teams or CCTs that are based from a specialty hospital that transport the patients who are a little more complex than just a cardiac monitor.  Obstetrics and high risk maternal transport is another specialty that does some very challenging calls. 

Organ procurement RN is also a great area and although you are dealing with basically a dead patient, you will be doing a full critical care resuscitative process while evaluating and treating a ton of labs for the goal of saving several other patients or improving their quality of life. In many states Organ Procurement RNs have an extended scope that might even go past some NPs when it comes to procedures like bronchoscopies. But, that job is a heavy responsibility with alot to be done in a very short time.  Of course you may also be at a different hospital every 2 - 3 days and you won't have an ambulance to ride around in unless you are in NYC.  There are some transplant physicians who may take their own OR RN to accompany them when they retrieve the organs which might give you the opportunity to ride in an ambulance. But again, just like any of the specialty teams, it may take much more education, training and years of experience to achieve the level to offer more than  a fast ambulance ride to a patient with just a few interventions that are done now in prehospital or even CCT.   

RNs that have these goals are not so stupid to think they'll get their dream job right away nor do they think they can just take over any profession unless they expand their own education and experience.  Getting the experience is a big part of their education. Paramedics now are having a difficult time finding clinicals or places for regular skills practice to get them or keep them proficient in the basic skills and knowledge needed for their prehospital specialty. However, RNs on specialty or Flight teams rarely have that problem even when it comes to getting practice with central lines or intubation.  

There are are some disadvantages to working Flight or CCT as an RN if the service is separate from the hospital such as a private ambulance. The RN will have to also work in a progressive ICU to stay current. There are too many advancements in critical care medicine that constantly change along with hospital protocols that the RNs should be aware of when assuming care. To stagnate by not staying current can make them very inefficient and even dangerous when it comes to transporting some of these patients.


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## Aidey

I'm not sure that Public Health nurses work the same everywhere, as I know we don't have a system like that in palace here. Yes, we have the Public Health system, with Public Health RNs, but they deal with all things communicable disease related, some routine care, well baby stuff and public education. 

I am 100% sure that I have never heard of any sort of organized home visit system through Public Health. I know there are home visiting RNs available through some of the home care agencies, but their patients are mainly people who are receiving in home care of some kind.


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## Journey

WTEngel said:


> I
> My point was that all Magnet institutions are not created equal, and just because a facility met Magnet requirements during their evaluation does not mean *they can't backslide and lose their designation on their next evaluation.* It has happened before...



This is the key. They are being evaluated and they are aware of the standards. If they get lax they know the consequences.

How many state and national agencies monitor EMS as closely? 

Attempting to achieve a higher standard should be seen as a good thing even if there are alot of kinks in the system to work out. It at least makes people aware of their imperfections in both the administrative and patient care process.   At least the hospitals are constantly doing something to make a difference even if it is trial and error.


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## MusicMedic

^those are some very good points Journey
i really didnt mean to Generalize CCT RN's soo much.. 
i was just speaking from my experience working at a private Transport Ambulance companies which consisted of Shorter Transport times.. 
but i would love to be a Flight CCT RN, the challenges seem worthwhile and rewarding

one of my goals is to become a Trauma RN or ICU RN, I want a fast paced challenging career.. 

but i appreciate your insight Journey!


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## Journey

Aidey said:


> I'm not sure that Public Health nurses work the same everywhere, as I know we don't have a system like that in palace here. Yes, we have the Public Health system, with Public Health RNs, but they deal with all things communicable disease related, some routine care, well baby stuff and public education.
> 
> I am 100% sure that I have never heard of any sort of organized home visit system through Public Health. I know there are home visiting RNs available through some of the home care agencies, but their patients are mainly people who are receiving in home care of some kind.



Home Health and Public Health are two very  different areas. 

Public Health, like School Nursing, in some states also want their RNs to have BSNs. Home Health nursing can be a variety of different providers including CNAs and LVNs. Case Managers and Social Workers also assist with setting up the most appropriate care by the appropriate agencies for these patients.

There should be a Public Health assoication in your state that is part of the national. I don't know what state you are in but I'm sure you should be able to find it on the web to know what they do. You could probably email them for more information rather than just guessing.  They usually quickly respond quickly to questions (may vary from state to state but the national is quick) and send you information.  You may only be aware of the obvious things they do in your area and may not know the full extent of what is being done in other cities. It will also vary with the funding a city or county can get for some services. It doesn't mean the Public Health nurses can't do something by job title but there may be no money for the job.


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## Journey

MusicMedic said:


> ^those are some very good points Journey
> i really didnt mean to Generalize CCT RN's soo much..
> i was just speaking from my experience working at a private Transport Ambulance companies which consisted of Shorter Transport times..
> but i would love to be a Flight CCT RN, the challenges seem worthwhile and rewarding
> 
> one of my goals is to become a Trauma RN or ICU RN, I want a fast paced challenging career..
> 
> but i appreciate your insight Journey!



Since you are in California you do have alot of opportunity as an RN including being involved in the State and county EMS organizations at the upper levels.  You also never know what the CNA will come up with for their next challenge and they are usually successful in most of their endeavors.

Good luck!


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## Aidey

Journey said:


> Home Health and Public Health are two very  different areas.
> 
> Public Health, like School Nursing, in some states also want their RNs to have BSNs. Home Health nursing can be a variety of different providers including CNAs and LVNs. Case Managers and Social Workers also assist with setting up the most appropriate care by the appropriate agencies for these patients.
> 
> There should be a Public Health assoication in your state that is part of the national. I don't know what state you are in but I'm sure you should be able to find it on the web to know what they do. You could probably email them for more information rather than just guessing.  They usually quickly respond quickly to questions (may vary from state to state but the national is quick) and send you information.  You may only be aware of the obvious things they do in your area and may not know the full extent of what is being done in other cities. It will also vary with the funding a city or county can get for some services. It doesn't mean the Public Health nurses can't do something by job title but there may be no money for the job.



I wasn't saying they can't do it, but that at the very least in my area they do not provide that service, I'm not guessing. 

I also know that home health agencies often have a variety of types of people working for them, and around here often there are RNs that do regular home checks on top of whatever in home care they receive from an aide or CNA.


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## Journey

This would be a great opportunity for some to look up what other professionals do or what a health care team consists of for just one patient that gets placed in a hospital or out patient services' program. It could also give some the opportunity to look for other out of hospital services that are offered to people to keep them from becoming your patients. Some of the posts here are just turf protecting or criticizing a profession based on how they see it from a very limited view and with only the education they might have as an MFR or EMT-B.   Many EMTs or Paramedics want recognition for what they do but still continue to bash what could be their biggest supporters. The butt wiping jokes and trying to belittle RNs because they don't do emergencies everyday the same as a Paramedic need to disappear. These jokes do nothing for the EMS profession. RNs do deal with emergencies but in a way that hopefully will prevent the patient from coding. RNs are responsible for monitoring and correcting by their own protocols many different lab values. They don't want to work an emergency such as a code everyday. 

Some do not know the extent of what another profession does. As someone posted they carry almost 60 meds and can't figure out why they shouldn't work in the hospital. But what they may not realize, a nurse will hand out well over 60 different meds in just his or her first rounds. Depending on the illness, 30 of those may be just for one patient.  

EMS also has its strong points and but it is a specialty. Unfortunately it also lacks the base education to make it flexible.  RNs have a base education that allows them to specialize.  An L&D RN would not feel comfortable in the ED unless there was a pregnant woman or some gyn emergency and a neonatal RN would not be thrilled about getting floated to an adult ICU. And, in the nursing world that would not happen without extensive training and orientation. EMS is a specialty and an RN is educated from the beginning they need extra training, education and precepted experience to work specialties. The Paramedic must recognize they are a specialty and it may not easily cross over with just skills or having bragging rights to 60 meds and an unlimited scope of practice to do as they want whenever they want.  

As I already stated before, a Radiology Technologist does not claim to be an RN because of an IV nor does an RN with an ultrasound cert claim to be a Radiologist Technologist or whatever license they might go under in that state. Specialities must be recognized as a valuable part of the whole health care team.  Going backwards in a hospital is not the answer either since LVNs and most of the professions that were considered to be only "techs" are now gone. The techs that only did EKGs have vanished and those duties have been taken over by other professionals. The LVNs are now primarily found only in LTC facilities and not in an acute hospital. The nursing unions do not even recognize them and they are often with the CNAs and other techs in SEIU.  So, it would be a stretch for a hospital to welcome someone with 6 months of training into a hospital with the same professional standing as those with established higher education entry levels. Even the RN is facing the challenges of being the least educated for entry in the hospital as all the other professions raise their standards. 

But, the RN does have a decent entry level foundation which allows them to expand into other professions if there is the opportunity. But, as health care and EMS are now in the U.S., why?  

ENA and ANA are addressing prehospital issues and are pushing for more states to have their own credentials for RNs in the  out of hospital situations  such PHRN. These organizations and the BONs of many states do not want an RN working as a lower level provider. They know the lower level license may not relieve them of the responsibility from knowing what they know as RNs.  NPs and PAs are also involved in legislative issues to provide more services. Their professionals websites offer a lot of information as do the associations for Public Health and Home Health.    These issues are all being discussed and there is new legislature  being presented every week.  The other associations are also making it about the patient more than having to be concerned what to call an EMT, who does what skill or if the FD is better than AMR.  Some of these associations with nursing, PAs and Social Workers  also concern themselves with lobbying for more funds for alternative transportation. This can also make those on ambulance services unhappy if EMTs are laid off just like when a service loses a 911 or transport contract.

 EMS has just not come together for a common cause to support or even address some of the bigger issues in the U.S.  Some services think they may have just invented the wheel but have failed to recognize or give credit to the professions who have been trying to keep those same services available to the people for years and have been under utilized by EMS providers.  The nonemergent issues in Public Health or extended care have not been exciting concerns for some in EMS.  

I can give an example of this. If a person falls and a public assist is called to help the person up, some in EMS will consider this as a nuisance call. If an RN is called to assist a fallen patient, they must assess "why?" along with necessary paperwork and to take the apppropriate action to see it does not happen again or make it less likely. There is no "let's wait and see if they fall and call again".


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## Sasha

> If an RN is called to assist a fallen patient, they must assess "why?" along with necessary paperwork and to take the apppropriate action to see it does not happen again or make it less likely.



Or they put them back in bed, pretend nothing happened, and walk away.


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## DFW333

Sasha said:


> Or they put them back in bed, pretend nothing happened, and walk away.



Or, if the patient complains of chest pain just give them a nitro regardless of what the BP is. Had a call just last week where the DON of all people gave a nitro to a patient w/ a BP of 86/44. Thanks to those heroic efforts the patient was no longer complaining of chest pain...or anything else....or speaking at all for that matter. 

Director Of Nursing for that facility requires a masters degree. Just proof that it is possible to be an educated moron.


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## Sasha

I wasn't trying to make a joke. I just hate to see nurses put on a pedastal like they're perfect. We just had a thread about a nurse placing the blame on someone else and trying to CYA. Sure, most nurses would write a report, try to fix the problem. That's their job. A medic's job is not to figure out why some guy tripped beyond checking them out for medical emergencies that would cause a fall. They're not equipped to go above and beyond. Not all would find it a nuisance, just like not all nurses would look at what problem could be solved.


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## Aphrodite

*There is more to it*

There are alot of aspects that would need to looked at, I am an EMT and a Fire Fighter, I have the training to deal with a messy MVC, a nurse does not.  It would open them up for injury.  Our Paramedic Programs are rigorous, and teach alot of information, there is also a lot of clinical time that must be completed.


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## rook901

DFW333 said:


> Or, if the patient complains of chest pain just give them a nitro regardless of what the BP is. Had a call just last week where the DON of all people gave a nitro to a patient w/ a BP of 86/44. Thanks to those heroic efforts the patient was no longer complaining of chest pain...or anything else....or speaking at all for that matter.
> 
> Director Of Nursing for that facility requires a masters degree. Just proof that it is possible to be an educated moron.



Anyone who has worked alongside medics, RN's, and even MD's has plenty of stories about "that guy", who is an exception and not the rule for the profession.


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## Aphrodite

*More Over*



Sasha said:


> Nurses taking over EMS would have the potential to make EMS more than just a fast ride to the hospital. You're going against tradition. It will never happen.



Having higher level of care in the back of the rig, I forsee the Golden Hour flying out the window, They will feel it is not as important to get them there because they can handle more and it would cause patient care decrease.


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## Sasha

> forsee the Golden Hour flying out the window,



The Golden Hour has been proven a myth and is still being drilled into students! You honestly expect change?

Edited: I misread your post, forgive me. You just prove my point of going against tradition.


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## WTEngel

You're a little late on that one... The golden hour has been on its way out for at least a few years now..

Also, there is no reason to be hating on the nurses...as was mentioned earlier, it doesn't add to the conversation and we all have stories about "that one time..."

We can keep it professional right? I love my nurse partners and would work with any of them any day of the week, and I think they feel the same about me and the other medics they work with. Now, if you were to ask them if they would enjoy working on a regular 911 unit instead of critical care or in addition to critical care, the answer would be a resounding no. It doesn't matter what pay rate you offer them, I am fairly certain they have no interest.

To wrap up this whole thread into an idea we all seem to agree on, EMS in America is doing an acceptable job right now, but we need to do better, and we can do better. We owe it to our patients to professionalize, and if we don't increase our education minimum standards, we will be left behind eventually. The days of vocational training are dying out, and eventually they will be no more. A well rounded education makes better providers and improves patient outcomes.


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## ffemt8978

WTEngel said:


> You're a little late on that one... The golden hour has been on its way out for at least a few years now..
> 
> Also, there is no reason to be hating on the nurses...as was mentioned earlier, it doesn't add to the conversation and we all have stories about "that one time..."
> 
> We can keep it professional right? I love my nurse partners and would work with any of them any day of the week, and I think they feel the same about me and the other medics they work with. Now, if you were to ask them if they would enjoy working on a regular 911 unit instead of critical care or in addition to critical care, the answer would be a resounding no. It doesn't matter what pay rate you offer them, I am fairly certain they have no interest.
> 
> To wrap up this whole thread into an idea *we all seem to agree on, EMS in America is doing an acceptable job right now*, but we need to do better, and we can do better. We owe it to our patients to professionalize, and if we don't increase our education minimum standards, we will be left behind eventually. The days of vocational training are dying out, and eventually they will be no more. A well rounded education makes better providers and improves patient outcomes.



I agree with everything you said except the bolded part.


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## Sasha

> Also, there is no reason to be hating on the nurses...



No hatred for nurses, my career goal is actually DNP. 

My hatred is more towards the fact that there are good and bad of every profession, but more often than not nurses are put on a pedastal as if because they completed a 2 year or higher degree they can do no wrong, it's not possible to have a bad nurse, while on the flipside EMTs and Medics are automatically assumed to be bad. 

Perhaps I was trigger happy and should have saved it for another thread, but I stand by my feelings.


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## MrBrown

Some patients are time critical and some are not; the time period will vary with each patient individually.  Those who are older, smaller or more physiologically unstable would have a smaller time period in which to begin definitive treatment if seriously ill or injured than somebody who is young and healthy.  

Little old nana with heart failure, two previous heart attacks, COPD and who recently came off chemo is going to tolerate sepsis a hell of a lot less than somebody who is young, fit and no comorbidities.

Ambulance Officers need to recognise when a patient is time critical and treat and transport expediciously, it does not mean run everybody in on red lights because thats what the textbook and 30 years of tradition says to do.


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## jjesusfreak01

MrBrown said:


> Now, a history lesson ....
> 
> *1969:* Miami, Seattle and Los Angeles get "Paramedics"
> *1971:* Melbourne (Australia) launches MICA (mobile intensive care ambulance) and MICOs (mobile intensive care officers)
> *1973:* New Zealand introduces Paramedic staffed mobile life support units (LSU)
> *1983:* Ontario, Canada introduces ALS Paramedics in Oshawa, ON
> *1990:* Paramedic training is introduced in the UK ....
> 
> ... sad to see the rest of the world started later and has overtaken the US :sad:



We showed everyone else what not to do...eventually we'll catch back up.


----------



## Aphrodite

Im not sure where all of you are from, but here, EMS is a degree you can earn! Oh and its the same length of time as nursing

As far as the Golden hour, yes it is going away, all patients have different needs and time frames. 

Im not saying having nurses in the field would be entirely bad, but they would need a lot more training than just nursing school. 

We have had Doctors (surgeon) and nurses come to scenes via helicopter when needed they provided the best patient care possible under the circumstances, It wouldnt be a bad thing, I just dont forsee it happening


----------



## MrBrown

Aphrodite said:


> Im not sure where all of you are from, but here, EMS is a degree you can earn! Oh and its the same length of time as nursing
> 
> As far as the Golden hour, yes it is going away, all patients have different needs and time frames.
> 
> Im not saying having nurses in the field would be entirely bad, but they would need a lot more training than just nursing school.
> 
> We have had Doctors (surgeon) and nurses come to scenes via helicopter when needed they provided the best patient care possible under the circumstances, It wouldnt be a bad thing, I just dont forsee it happening



Same here mate, nurse and Paramedic here are the same length of time at University and Paramedic is probably way more selective on who they admit and graduate.  Intensive Care Paramedic (ALS) is another qualification ontop of the Bachelors Degree.

Pay is probably better too!

Alas, we dont have medicinos swanning down out the cirrus too often, and if we do, you are pretty crook.


----------



## Journey

Sasha said:


> I wasn't trying to make a joke. I just hate to see nurses put on a pedastal like they're perfect. We just had a thread about a nurse placing the blame on someone else and trying to CYA. Sure, most nurses would write a report, try to fix the problem. That's their job. A medic's job is not to figure out why some guy tripped beyond checking them out for medical emergencies that would cause a fall. They're not equipped to go above and beyond. Not all would find it a nuisance, just like not all nurses would look at what problem could be solved.



I'm not putting nurses on a pedastal but I am making a point that there are different expectations which are regulated for nursing by Federal and State rules which can then be followed by the accrediting agencies.  Nurses should not have the option to just walk away from a patient and with the regulations now in place. They know the consequences which can mean their license. There are bad apples in every profession.   Everybody wants to do CYA and it should be done through proper documentation.  If the incident is serious enough, there should be a reporting policy in place for EMS or the hospital to record their concerns. If you allow a serious incident to slide and another professional fully documents it as they see it, you would have no one to blame but yourself for not providing the proper documentation from your point of view in the first place. 

There are now many safeguards in place in an attempt to keep patients safe.  JCAHO inspects facilities for the insurers. State and Federal agencies also do their own inspections. Diagnostic testing labs are heavily inspected over and over again for many concerns.  In EMS, there are not alot of  Federal and state mandates that must be constantly evaluated to determine if an agency or facility can become accredited and receive reimbursement. Most mandates pertain to the truck.  If a facility loses its accreditation for whatever reason, no Medicare, Medicaid or MediCal payments.


----------



## Journey

Aphrodite said:


> Im not sure where all of you are from, but here, EMS is a degree you can earn! Oh and its the same length of time as nursing



Yes there are degrees in EMS but not mandatory. I was just recently corrected about Oregon. I had thought it required a two year degree but there are exceptions to that rule.  

But, the focus of the degree should also be considered when determining if one profession is just like another.  

Physical Therapists are now recommended to have a Doctorate of Physical Therapy.

Nurse Practitioners are pushing for a Doctorate Nurse Practitioner in 2015.

That does not mean an NP is a PT if both have doctorate degrees. 

A Cardiovascular Technologist has a two year degree and knows ACLS from every angle, works in a cath lab and does many of the skills with some of the same knowledge of an RN plus their own specialty education. But, that does not make them "just like an RN". But, an RN can specialize in Cath Lab under his or her own license and acquire some of the same skills.  You have to look at the differences in each profession and the special requirements that make it a specialty before you try to be just like or compare one to another.

However, a two year college degree in prehospital medicine would be a good start to getting the Paramedic recognized as a true specialty profession rather than a tech cert from the votech.


----------



## DFW333

Journey said:


> However, a two year college degree in prehospital medicine would be a good start to getting the Paramedic recognized as a true specialty profession rather than a tech cert from the votech.



And what good is it to be recognized as a specialty profession? The hobos will stop calling us for rides to the opposite side of town because they respect us? Our pay will increase? Never ending dialysis transports will go away? The general public will scratch their heads and say "It takes a degree to be an ambulance driver?"

All requiring a certain degree will do is make it where the profession is closed to those who cannot afford to pursue whatever degree it is. And it doesn't mean those in it will provide any better care. An educated idiot is probably more dangerous than one who didnt go to school.


----------



## Veneficus

*I think we have a winner!!!*



DFW333 said:


> And what good is it to be recognized as a specialty profession? The hobos will stop calling us for rides to the opposite side of town because they respect us? Our pay will increase? Never ending dialysis transports will go away?



There are easy soltions to those problems...

McDonalds. 

The hobos will still call you for help, but then they might receive it and call less.

Your pay might not decrease.

At the current moment, taking people to dialysis is what is keeping you gainfully employed. But it might not very much longer. What then?




DFW333 said:


> The general public will scratch their heads and say "It takes a degree to be an ambulance driver?"



The voices asking why we pay so much for an ambulance driver are steadily increasing.

But no, it doesn't take a degree to be an ambulance driver. It does take a degree to be a healthcare professional. You might want to consider the systems that still employ "ambulance drivers" and what they pay.

If the only value you feel EMS providers bring is driving patients around I suggest you take a real close look at this:

http://www.emtlife.com/showthread.php?t=20803

As firetender pointed out, medical transport is a business, as I pointed out look at the value of laborers world wide. 

If what EMS brings is not very special (requiring a degree) perhaps we coould find some people who would be happy to fill those spots for less pay? 



DFW333 said:


> All requiring a certain degree will do is make it where the profession is closed to those who cannot afford to pursue whatever degree it is.



Economics are a barrier to improving a persons' educational and career goals for sure. But I am not so sure on why other modern nations value education and the US doesn't. Maybe you have the answer?



DFW333 said:


> And it doesn't mean those in it will provide any better care.



Really? I'll bet dollars to doughnuts my education makes me a better care provider than you. 



DFW333 said:


> An educated idiot is probably more dangerous than one who didnt go to school.



LOL,

ladies and gentlemen, the prosecution rests.


----------



## MrBrown

DFW333 said:


> And what good is it to be recognized as a specialty profession? The hobos will stop calling us for rides to the opposite side of town because they respect us? Our pay will increase? Never ending dialysis transports will go away? The general public will scratch their heads and say "It takes a degree to be an ambulance driver?"



The hobos call you because your social security and healthcare are broken

The pay will increase because as professionals you can demand it

Dialysis transports are the realm of the Patient Transfer Officers and not frontline emergency ambulance Paramedics



DFW333 said:


> All requiring a certain degree will do is make it where the profession is closed to those who cannot afford to pursue whatever degree it is. And it doesn't mean those in it will provide any better care. An educated idiot is probably more dangerous than one who didnt go to school.



It will close it because unlike almost every other country you have no universal access to higher education.

... and if you think requiring proper education won't improve care then well, Brown will bite his tongue on that one.

As for a Degree, it needs to be a proper speciality University degree not some two year flout that includes basked weaving, computers 101 and art history as well as the DOT cirricula which has been massaged into a barely qualifying community college course.


----------



## Journey

DFW333 said:


> And what good is it to be recognized as a specialty profession? The hobos will stop calling us for rides to the opposite side of town because they respect us? Our pay will increase? Never ending dialysis transports will go away? The general public will scratch their heads and say "It takes a degree to be an ambulance driver?"



What if patients found out that their barber or dog groomer has 2x more hours of training than the Texas Paramedic?  It is to your advantage now that the public probably believes you to be better educated than you actually are.

The recognition is for reimbursement with professional status. This is currently one of the issues NEMSAC is looking at. 

Hobos (?) and dialysis patients also need care and transport. They are human beings also and should not be treated differently because of a stigma EMS has placed on these patients.    If all you do for a dialysis patient is drive, you are are doing them a great disservice and some insurers are probably paying you too much. 



DFW333 said:


> All requiring a certain degree will do is make it where the profession is closed to those who cannot afford to pursue whatever degree it is. And it doesn't mean those in it will provide any better care.  An educated idiot is probably more dangerous than one who didnt go to school.



We are talking about a two year degree. I used doctorates to illustrate the differences between NPs and PTs. However, PTs have no problem with their education if that is what they want to do. Many will work at minimum wage  jobs or as PT Assistants which is only a two year degree and doesn't pay much until they get their doctorate. The same for OT and and ST.  To be an RN requires a two year degree and many will work for minimum wage as CNAs until they get their license.  There are also many nonmedical professions that require at least a four year degree.  

My question to you would be, why do you not believe you need to know anything about the body, the medications, different illnesses and have good reading, writing or math skills to be a Paramedic?  Shouldn't you know some of the "whys?" for what you are doing?

Education is a difficult battle to win and to get techs to change their views when they are used to doing skills and protocols their way.  Nursing also changed slowly and there was a lag as the diploma RNs who were grandfathered  finally started leaving the profession.  Now, the BSNs will slowly gain ground as the ADNs who also want to keep nursing at a tech level similar to the other A.S. degrees.  I also don't want anyone to get the idea that I think the diploma RNs weren't good nurses. They were excellent but it was mostly their skills that they were known for and not their knowledge which lead to nursing not receiving very much respect as a profession.


----------



## Aidey

As someone who used to work in a dialysis clinic, dialysis patients who are being transported from home to the clinic or vice versa do not generally need care. Heck, there are people who drive themselves back and forth, and a large number who take medi-taxis or wheel chair vans. There is a subset who end up needing gurney transport, but it is because they need the gurney, not because of the dialysis itself.


----------



## Journey

Aidey said:


> As someone who used to work in a dialysis clinic, dialysis patients who are being transported from home to the clinic or vice versa do not generally need care. Heck, there are people who drive themselves back and forth, and a large number who take medi-taxis or wheel chair vans. There is a subset who end up needing gurney transport, but it is because they need the gurney, not because of the dialysis itself.



Some in EMS never see all the patients that can travel by car or van and the total number of dialysis patients each center does everyday.  If they did they might realize that the number they transport is actually quite small.

Our dialysis center is within the hospital and takes patients who might be considered a higher risk. The hospital's Rapid Response team will also come to assess and monitor a patient to see if a higher level of care is needed.  Dialysis can also be done in the back part of the ED on a monitor if the Rapid Response team determines they need longer monitoring than they can stay for and an admit is in the patient's future.  This dialysis center also averages around 200 - 240 patients per day. We also get quite a few BLS trucks that divert to our ED while transporting to and from other dialysis centers.  Luckily we are a dialysis center and can stabilize them rather than trying to get them to another hospital which by then will tie up an ICU bed for sure.


----------



## DFW333

Veneficus said:


> There are easy soltions to those problems...
> 
> McDonalds.
> 
> The hobos will still call you for help, but then they might receive it and call less.



Umm, it isnt a matter of them receiving help. They just want a ride to the other side of town and cannot pay for a taxi.




> Your pay might not decrease.



Can't get much lower than $7.50/hour



> At the current moment, taking people to dialysis is what is keeping you gainfully employed. But it might not very much longer. What then?



Actually the majority of my transports are interfacility transfers to specialty facilities.




> The voices asking why we pay so much for an ambulance driver are steadily increasing.
> 
> But no, it doesn't take a degree to be an ambulance driver. It does take a degree to be a healthcare professional. You might want to consider the systems that still employ "ambulance drivers" and what they pay.



A service here pays $12 an hour starting for EMT-B, $20/hour for medic.



> If the only value you feel EMS providers bring is driving patients around I suggest you take a real close look at this:
> 
> http://www.emtlife.com/showthread.php?t=20803
> 
> As firetender pointed out, medical transport is a business, as I pointed out look at the value of laborers world wide.
> 
> If what EMS brings is not very special (requiring a degree) perhaps we coould find some people who would be happy to fill those spots for less pay?



Going from point A to point B is all an ambulance is. Maybe one of every hundred transports is actually requiring an ambulance. But there's so many things that make them "qualified" such as isolation reasons. I always have to laugh when I document that patient meets medical necessity for ambulance transport due to isolation precautions for *insert disease here* but we are dropping them off in a dialysis center that does not have the ability to isolate the patient. Or when a hospital checks off the PCS to show the patient is bed confined...and the patient is being discharged to a home that cannot handle bed bound patients, or residence where they live alone.



> Economics are a barrier to improving a persons' educational and career goals for sure. But I am not so sure on why other modern nations value education and the US doesn't. Maybe you have the answer?



Because as part of our requirements we have to learn about so much useless crap. For example, as part of my bachelor's degree for firefighting I have to learn about the various sub-cultures that exist in today's prison systems. What the hell does that have to do with anything? I'm not going to be a prison warden, or even a cop. Yet I have to know what motivates a gay man to rape the guy who drops the soap.




> Really? I'll bet dollars to doughnuts my education makes me a better care provider than you.



Really? There's a post I made in this thread earlier about a director of nursing who has much more education than I do who nearly killed a patient. She actually said, "Well I knew the BP but I had to choose between good BP or getting rid of chest pain."




> LOL,
> 
> ladies and gentlemen, the prosecution rests.



And having a degree doesnt mean you're not an idiot. Barrack Obama and George W Bush both have degrees from Harvard. How many people think one or both of them are idiots?


----------



## Veneficus

DFW333 said:


> Can't get much lower than $7.50/hour
> 
> A service here pays $12 an hour starting for EMT-B, $20/hour for medic.



So you are cool with a $12.50/hour pay cut? 

Because when the required reimbursements from medicare are finally adjusted, without providing some kind of value, that might just be what you can expect.




DFW333 said:


> Going from point A to point B is all an ambulance is. Maybe one of every hundred transports is actually requiring an ambulance..



Yes, I am aware. So you can bet the people who pay for it are too.




DFW333 said:


> But there's so many things that make them "qualified" such as isolation reasons. I always have to laugh when I document that patient meets medical necessity for ambulance transport due to isolation precautions for *insert disease here* but we are dropping them off in a dialysis center that does not have the ability to isolate the patient. Or when a hospital checks off the PCS to show the patient is bed confined...and the patient is being discharged to a home that cannot handle bed bound patients, or residence where they live alone...



Is it possible that perhaps so many "qualifications" were written into the payment schedule so that people who did need transported but didn't qualify for aid or other means could get transported?

That it saves money by freeing up resources at the sending facility by moving patients out quicker?

Is it possible that the educated people who wrote those "qualifications" felt that complications requiring an EMT were 1 in $100,000 but felt it was worth giving everyone the best chance?

Is it possible that a group of "EMS" providers who owned or worked in an IFT companied lobbied that for profit or even to offer their employees a livable wage?




DFW333 said:


> Because as part of our requirements we have to learn about so much useless crap..



If knowledge is power, is there a such thing as useless knowledge?




DFW333 said:


> I always have to laugh when I document that patient meets medical necessity for ambulance transport due to isolation precautions for *insert disease here* but we are dropping them off in a dialysis center that does not have the ability to isolate the patient. Or when a hospital checks off the PCS to show the patient is bed confined...and the patient is being discharged to a home that cannot handle bed bound patients, or residence where they live alone
> 
> For example, as part of my bachelor's degree for firefighting I have to learn about the various sub-cultures that exist in today's prison systems. What the hell does that have to do with anything? I'm not going to be a prison warden, or even a cop. Yet I have to know what motivates a gay man to rape the guy who drops the soap.



But if you are erroneously or falsely checking off medical qualifications for billing, that last part might be damn useful information.  




DFW333 said:


> Really? There's a post I made in this thread earlier about a director of nursing who has much more education than I do who nearly killed a patient. She actually said, "Well I knew the BP but I had to choose between good BP or getting rid of chest pain.".



She is luckier than I.

I don't even know how many patients I probably killed following protocols I didn't understand while getting awards and accolades for my ability to do it.

Some even lived in spite of my attempts.

Looking back on some of the treatments I performed that I was taught to, expected to, and boasted my skill at, I am confronted with the reality that knowing what I know now, I probably did cause harm in many instances.

I don't dwell on it though, because it was the standard of the time, but it does make me wonder. If I had known more could I have done better? Made better decisions? Helped more people? At the very least harmed less?


----------



## EMSLaw

DFW333 said:


> Really? There's a post I made in this thread earlier about a director of nursing who has much more education than I do who nearly killed a patient. She actually said, "Well I knew the BP but I had to choose between good BP or getting rid of chest pain."
> 
> And having a degree doesnt mean you're not an idiot. Barrack Obama and George W Bush both have degrees from Harvard. How many people think one or both of them are idiots?



Your arguments are simply fallacies.  One case, even if true, does not disprove the case that a provider with a greater depth of knowledge is able to offer more to a patient than one who has a short technical course.  Moreover, the fact that the Nursing Director you mentioned made a mistake does not mean that, in general, she isn't a better provider, whatever a "better" provider is in this argument.  As we go on about time and time again in this forum, the plural of anecdote is not data.  

Your second argument likewise fails to hold any water.  While you may be right that a degree doesn't necessarily make you naturally smarter, it does make you more educated.  And while some might disagree with the policies of either or both of the presidents you mentioned, I don't think it's fair to call either of them "stupid", despite the sort of polemics that one sees thrown about on cable news.  

Anyway... the workforce in general is becoming increasingly more educated, and that's especially true in healthcare.  A doctorate degree was necessary for me to practice my profession, and has been necessary for a generation or more (one can still find a few very old attorneys with an LL.B., but that degree was actually the same thing - a three-year post-graduate degree - it was just called a Bachelor of Law).  Would you argue that because a paralegal and an attorney can both draft a complaint, they're the "same"?  Are a CPA and the "guy who does your taxes" the same?  

It's only in EMS that we maintain the fiction that being a technician is the same as, and just as good as, being a technologist (generally, the latter has a degree in the field, while the former went to trade school), on the rather tenuous basis that they can perform the same skills.  There's more to it than being able to cannulate a vein or perform an intubation or an emergency thoracotamy (or any other skill you can name).

Now... as to whether nurses should take over EMS.  I think the distinction here is that, for better or worse, what we consider to be EMS is a subset of medicine, not a subset of nursing.  While the distinction is sometimes very grey, what EMS does is diagnose (whatever you like to call it) and treat (however imperfectly) acute medical emergencies to stablize the condtition until the patient can be delivered to definitive care.  EMS does not generally develop nursing plans, provide for protracted care, or engage in wellness work or patient education.  Those are key functions (or some of them) of nurses, which is what makes the two professions (or jobs, since I'm hard pressed to call EMS a profession at the moment) different.  Even in the case of Nurse Practitioners, the focus is on traditional nursing areas - maintaining wellness, handling long-term care, and the like. 

You'll notice, for example, that in those states that don't have a separate EMS licensing authority, paramedics are credentialed by the Board of Medical Examiners, rather than by the Board of Nursing.  Indeed, the things that nurses have traditionally done very well are the things that EMS has traditionally done very poorly, if at all. 

Even if you talk about changing the nature of EMS in part to allow EMS providers to be, in limited circumstances, definitive care, you're still talking about the practice of medicine, albiet in a very limited way, rather than the practice of nursing. 

So, I think that the change in philosophy is significant enough that if you move nurses into EMS on a wholesale basis, you get some sort of hybrid that is no longer really a nurse.  Better to enhance the skills and education of EMS providers to allow them to flourish in their selected role.


----------



## Aphrodite

Journey said:


> Hobos (?) and dialysis patients also need care and transport. They are human beings also and should not be treated differently because of a stigma EMS has placed on these patients.    If all you do for a dialysis patient is drive, you are are doing them a great disservice and some insurers are probably paying you too much.



AMEN!!

We all have the frequent flyers and the not so fortunate, but why should that determine the amount of care you give?  

Bedside manner, care, and respect, the best care you can give, I could go on and on..

When you stop providing the best care you can to every patient GET OFF THE RIG!


----------



## fit4duty

EMSLaw said:


> Anyway... the workforce in general is becoming increasingly more educated, and that's especially true in healthcare.  A doctorate degree was necessary for me to practice my profession, and has been necessary for a generation or more (one can still find a few very old attorneys with an LL.B., but that degree was actually the same thing - a three-year post-graduate degree - it was just called a Bachelor of Law).  Would you argue that because a paralegal and an attorney can both draft a complaint, they're the "same"?  Are a CPA and the "guy who does your taxes" the same?
> 
> It's only in EMS that we maintain the fiction that being a technician is the same as, and just as good as, being a technologist (generally, the latter has a degree in the field, while the former went to trade school), on the rather tenuous basis that they can perform the same skills.  There's more to it than being able to cannulate a vein or perform an intubation or an emergency thoracotamy (or any other skill you can name).
> 
> Now... as to whether nurses should take over EMS.  I think the distinction here is that, for better or worse, what we consider to be EMS is a subset of medicine, not a subset of nursing.  While the distinction is sometimes very grey, what EMS does is diagnose (whatever you like to call it) and treat (however imperfectly) acute medical emergencies to stablize the condtition until the patient can be delivered to definitive care.  EMS does not generally develop nursing plans, provide for protracted care, or engage in wellness work or patient education.  Those are key functions (or some of them) of nurses, which is what makes the two professions (or jobs, since I'm hard pressed to call EMS a profession at the moment) different.



Couldn't agree more! What I have never been able to get is why we are so resistant to education? Professions require education. Period. 

S/N - it occurred to me two days after I finished my paramedic program that as thorough as the program was it wasn't enough. So I picked up a Bachelors in Physiology. In my senior level physio classes were BSN students and Med students - confirming in my mind that if I don't know what they know how can I effectively perform my own functions. And yes I am most definitely a more competent provider because of my education.


----------



## medicRob

I haven't read anything but the original post, nor do I intend to, seeing as this is a 14 page thread. However, I will weigh in by saying that one need only look to the majority of Trauma I based HEMS services which require all individuals on the medical crew to be a Registered Nurse (BSN preferred) at a minimum, if not dual RN / Medic or RN / EMT licenses. 

An RN, CEN could more than handle themselves in the prehospital environment. After all, let's be real.. We spent 3 years at a minimum in school if not 4, and were required to have courses such as REAL Anatomy & Physiology I and II, not just survey of anatomy, Microbiology, Pathophysiology, English Composition, Psychology, College algebra, Biology, Chemistry, and Nutrition amongst other courses along with our core nursing. We spend more time in clinicals than the paramedic does in class and clinicals (excluding systems such as NZ of course).


----------



## EMSLaw

fit4duty said:


> Couldn't agree more! What I have never been able to get is why we are so resistant to education? Professions require education. Period.



On one of the first days of law school, all the new 1Ls had a meeting with the Dean, who gave us a talk about the nature of the law school, the nature of law practice, etc.  She didn't mention the long hours and relative difficulty of finding a job, but that's besides the point...

One of the things that was mentioned, and this isn't original to the Dean in question, is that law is one of the three traditional professions, the other two being medicine and the clergy.  

What characterizes a profession?  Three things, generally: 1) A long period of formal learning; 2) self-regulation; and 3) a degree of monopoly rights.  

Lawyers spend at least 7 years in school, and have post-JD education and training requirements.  The Supreme Court or Board of Law Examiners (other lawyers) decide who gets to be a member of the profession.  Only lawyers, generally speaking, may take money to appear in court.  

Doctors spend 8 years in school, plus residency and other post-MD education and training.  The Board of Medical Examiners (other doctors) decide who gets to be a licensed doctor.  Generally speaking, only doctors may practice medicine, though they may delegate certain functions to other trained people.  

Clergy in many organized religions have a master's degree or equivalent.  The Bishop or some sort of other clergy determine who gets ordained.  In many churches with an organized clergy, only the properly ordained minister can perform certain functions. 

Paramedics spend approximately 1100 hours in school.  The state office, lead by a doctor or nurse, which may or may not include any paramedics at all, decides whether they get a certification or license.  They do have a certain monopoly on pre-hospital care, but then again, lots of other people can do the same things paramedics can do.  

Do we all see the difference here?  If you want the respect of other professionals, the first step is to have the same sort of credentials as other professionals.  But when even trades that measure education in clock hours tend to require many, many more of them (anyone ever looked at how long it takes to become a licensed plumber or electrician?), the arguments about EMS education start to ring hollow.


----------



## the_negro_puppy

Universities in my state are now offering dual degrees in Paramedicine and Nursing. 4 Years study at the end you can work as both an RN and a paramedic

http://www.courses.qut.edu.au/cgi-b...wa/selectMajorFromMain?pres=sf&courseID=12576

B)


If I was just finishing High School and interested in working as a Paramedic I would definitely consider this.


I already have a science degree and a masters (lol) but I am completing a diploma of paramedic science while working full-time in an ambulance. This qualifies me to work as a paramedic at the end of 2.5 years, with 2.5 years of paid experience under my belt (student paramedic earn around 50k)


----------



## Journey

medicRob said:


> I haven't read anything but the original post, nor do I intend to, seeing as this is a 14 page thread. However, I will weigh in by saying that one need only look to the majority of Trauma I based HEMS services which require all individuals on the medical crew to be a Registered Nurse (BSN preferred) at a minimum, if not dual RN / Medic or RN / EMT licenses.



Not always will they require the RN to actually get the state license for Paramedic but just test for the NREMT certification. The RN will continue to work under their own license and scope of practice which can be expanded for different roles.  Regardless, the EMT and Paramedic are often viewed as extra certs much like some the other specialty certs but sometimes easier to obtain. The EMT cert is basic first aid which everybody should have whether they are in medicine or not. The Paramedic cert can then be obtained by challenging the exam in some states. Colleges and trade schools can also give credit for the RN license and nursing classes to where the time spent in the program is about 150 - 200 hours which is also consistent with some PHRN programs. This is a lot shorter than some of their specialty certs such as hospital based critical care transport which may take them over a year of additional training  after they have gotten several years of experience in that area and are finally qualified to do transport for high acuity patients.   Every specialty for RN may require several weeks of additional classroom lecture and months of being precepted. Even the CCRN certs require about 18 months in that specialty.  

The BSN is also highly recommended for RNs who want to work a specialty unit especially if it is a Magnet hospitial or if they want to join a specialized team such as transport.  But, just like those in EMS, for nursing the ones opposing the BSN are the ADNs who believe they have more than enough education.


----------



## BluesMedic

*Two Cents...*

I am brand new to this forum and this site, yet I am not new to the profession or the argument that is currently being debated.  I can see both sides of the argument and after reading many of the posts that have been written, I see no real-world, viable solutions.  

     There has always been a rift between nurses and medics, it seems there always will be.  If this thread can be said to comprise the "whole" of the EMS and RN community, we will never come together for what we all should be here for in the first place, the patient.  Paramedics are trained for a very narrow slice of the healthcare pie and I believe that as a whole, we are very good at it.  Nurses are trained (I claim no expertise on nursing education, just stating generalities here) for a broader piece of the same pie and they are very good at it as well.  I am very pro-education and I do believe that is the first step in elevating Paramedicine into a true profession. 

     But I also believe that having a degree does not make you a good practioner.  I can see 1- and 2-year long certification courses being just as effective at producing quality paramedics as a Associate degree program.  Yet, the world as a whole puts a lot of weight on formal education and as a profession, we in EMS need to understand this.  

     There has been a lot of mud slinging in this thread between Medics and RN's.  I see it as just another form of prejudice. Meaning there are a lot of people, on both sides, that reject the idea of cross training just on principle alone. "I am a Medic and I do not want to be a Nurse" and vise versa.

     How about this:  Come up with a nationwide degree program starting at the Associate level and going up through Master or Doctorate and calling it "Health Care" or something of the like.  Take "nurse" and "paramedic" out of it.  Give the same base education and then allow for a subset in the final year(s) for prehospital or in-hospital.  Much like an MD specializing in Emergency Medicine or Cardiology, etc.  That will allow cross training, provide education and take the stigmata of "nurse" and "medic" out of the equation.  

     Anyways, that's my two cents...


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## BluesMedic

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

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

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

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


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## uhbt420

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

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

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

not that US ems will ever transition to nurses anyway.


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## Journey

uhbt420 said:


> rather than transitioning to nurses, cant we move towards higher level degrees for paramedicine?  nurses are trained to operate in a controlled setting and would need to be retrained from the ground up after graduating nursing school.
> 
> i dont say this out of ignorance, i've discussed this with a lot of medics who also work as RNs.  tehy tell me its two different worlds.
> 
> even the netherlands is moving away from nursing-based ems to paramedic-based
> 
> not that US ems will ever transition to nurses anyway.



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

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

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

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


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## Journey

BluesMedic said:


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



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

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

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

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

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

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

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


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## Shishkabob

Journey said:


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



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


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


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## Journey

Linuss said:


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



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



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



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

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

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

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

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

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

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


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## Shishkabob

Journey said:


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



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

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



Journey said:


> Just because you can does not always mean you should.



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



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


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## Journey

Linuss said:


> Yes, just because a minimum exist means every single school does just the minimum.  You're right, I have no education at all and have to go back to my medic book every time I post on this forum, and just paraphrase.
> 
> 
> 
> Right, because I push the 70 different drugs on my truck just because I have them available to me.
> 
> I'm done answering your questions until you quit dodging mine about your credentials, education and certifications.



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

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

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


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## Shishkabob

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


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





Journey said:


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




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


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## Journey

Linuss said:


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



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

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



Linuss said:


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



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

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



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



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



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



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


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## uhbt420

Journey said:


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


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



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


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



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


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

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


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## Veneficus

uhbt420 said:


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



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

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

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

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

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

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


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## Shishkabob

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


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

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





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


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## Veneficus

Linuss said:


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



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




Linuss said:


> Paramedicine is still in its infancy.



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

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

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




Linuss said:


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



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

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



Linuss said:


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



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



Linuss said:


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



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



Linuss said:


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



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


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## Journey

Linuss said:


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



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

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

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

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


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## SerumK

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

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


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## Phlipper

> You're expecting people who can't grasp why 110 hours of education is not enough to provide adequate care to think long term rather than their intial knee jerk reaction against more education.
> 
> There are many people who feerl the educational requirements for a Paramedic as is, is acceptable. It's worked thus far, why should you improve it? They'd rather whine and get more money for nothing.



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

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


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## Veneficus

SerumK said:


> Vene... I always wanted EMS more, but the lack of education depth and career longevity/pay kept me from choosing it as a primary life long career. So I chose nursing because it had the things EMS was missing.
> 
> So, if you could please have this EMS-Nurse implemented nationally by May 2012, I'll buy you a case of your favorite wine/liqour/beer.



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


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## clibb

SerumK said:


> Vene... I always wanted EMS more, but the lack of education depth and career longevity/pay kept me from choosing it as a primary life long career. So I chose nursing because it had the things EMS was missing.
> 
> So, if you could please have this EMS-Nurse implemented nationally by May 2012, I'll buy you a case of your favorite wine/liqour/beer.



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


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## medicRob

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

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

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


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## Journey

medicRob said:


> I'm not saying this to be ugly, but it must be said. If I am working any job ambulance or otherwise where my official title is, "Registered Nurse" as opposed to "Paramedic", under no circumstance would I accept less than $25 an hour, which is almost laughable compared to what we as RN's can make, especially with credentials in emergency or critical care and equivalent experience.
> 
> As a Paramedic, $15 - $20 an hour sounds about right.
> 
> This is one thing to consider when talking about nurses replacing paramedics on the ambulance. The highest paying service I can think of pays $23 an hour for Critical Care Paramedic (which requires 2 years of experience in TN as a paramedic before being able to take the class, so about 3 years experience is the average). I know of no ambulance service that is going to pay anyone on their rigs anything above $26 an hour, especially not the $29+ an hour most RNs in emergency and critical care in metropolitan areas are accustomed too.



If you are going to compare wages with Critical Care Paramedics, what do the CCT and Flight RNs make in your state? I doubt if they take that much of a cut in pay.  In California RNs are on many of the CCT trucks with EMT drivers.  Some  hospitals do own a share of an ambulance service and function under the company's emergency license to use lights and sirens. This also gives them more control over the training of those who do IFT of their patient.  

It would be nice to see hospitals or health care districts take over the ambulances which would probably happen if more RNs were involved. One of issues discussed at the national EMS meetings was performance based transport. If RNs were involved, this would become a reality which would be recognized by the insurers much like specialty transports.

The system the U.K. has with the ECPs would be nice but again that would mean the Paramedics would have to advance their base education and then be expected to do some post grad work as well just like the nurses who are RCPs.  RNs would be a more logical choice to do what Wake County is attempting. RNs would know the services of each hospital better for they appropriate facility. They may have a better insight on diversion status. They  would also know the special needs of home bound patients that are labeled as frequent fliers because they have provided the care for these patients and have done the patient education. With their education, training and experience taking care of these patients on a daily basis, they would be much better qualified than the few extra hours of training a prehospital provider who has not provided care other then the emergent. There are too many things to consider and just scripted protocols don't always fit these patients.  Some criticize RNs for calling doctors but RNs do recognize there are exceptions to the protocols and not every patient fits the protocol nor should you attempt to fit the patient to the protocol. It may be better to create a new plan of care rather than plod along with one that is not effective for the long haul even if it seems to be a quick fix now.


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## medicRob

Journey said:


> If you are going to compare wages with Critical Care Paramedics, what do the CCT and Flight RNs make in your state? I doubt if they take that much of a cut in pay.  In California RNs are on many of the CCT trucks with EMT drivers.  Some  hospitals do own a share of an ambulance service and function under the company's emergency license to use lights and sirens. This also gives them more control over the training of those who do IFT of their patient.
> 
> It would be nice to see hospitals or health care districts take over the ambulances which would probably happen if more RNs were involved. One of issues discussed at the national EMS meetings was performance based transport. If RNs were involved, this would become a reality which would be recognized by the insurers much like specialty transports.
> 
> The system the U.K. has with the ECPs would be nice but again that would mean the Paramedics would have to advance their base education and then be expected to do some post grad work as well just like the nurses who are RCPs.  RNs would be a more logical choice to do what Wake County is attempting. RNs would know the services of each hospital better for they appropriate facility. They may have a better insight on diversion status. They  would also know the special needs of home bound patients that are labeled as frequent fliers because they have provided the care for these patients and have done the patient education. With their education, training and experience taking care of these patients on a daily basis, they would be much better qualified than the few extra hours of training a prehospital provider who has not provided care other then the emergent. There are too many things to consider and just scripted protocols don't always fit these patients.  Some criticize RNs for calling doctors but RNs do recognize there are exceptions to the protocols and not every patient fits the protocol nor should you attempt to fit the patient to the protocol. It may be better to create a new plan of care rather than plod along with one that is not effective for the long haul even if it seems to be a quick fix now.



I chose to focus on ground based transport services for one specific reason, I assumed this was the environment the OP was talking about putting RN's in instead of medics. Moreover, RNs have been in flight for quite some time, nothing new. Furthermore, you'd be surprised at what flight paramedics make, it is not what you are imagining, I am sure.. at least not here in TN, and yes I am talking about the choppers that are owned and operated by our major trauma I centers. I make more in the trauma unit than I do in flight.


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## Journey

medicRob said:


> I chose to focus on ground based transport services for one specific reason, I assumed this was the environment the OP was talking about putting RN's in instead of medics. Moreover, RNs have been in flight for quite some time, nothing new. Furthermore, you'd be surprised at what flight paramedics make, it is not what you are imagining, I am sure.. at least not here in TN, and yes I am talking about the choppers that are owned and operated by our major trauma I centers. I make more in the trauma unit than I do in flight.



I was not just talking about flight either. I mentioned CCT which are commonly ground ambulances. In places where the private ambulances have a nurse full time on that truck, the truck will say NURSE UNIT.  In some places like California, they are very prominent. Right now with the protocols being written by county, the RN would only be able to do what the Paramedics are doing in that county for 911 EMS.  In California for CCT, they must also abide by the county but those protocols now take into consideration it is an RN and the scope is expanded.  The same for some other states when the classification and regulations are changed to accomondate the professionals on that truck. 

While the number of CCTs and RNs might be small now, it does show they filled a void which could not be filled by Paramedics in that area.  As technology and medicine continues to advance, you will probably see more RNs doing high acuity IFTs officially and not just a throw on to get from one ED or ICU to the next. Hospitals are being more cautious now with EMTALA and making sure the transporting ambulances and teams are equipped to handle that patient. The days of RNs filling up the med pumps and trying to get the patient in a stable enough state for the Paramedics to drive real fast to the next hospital should have been a thing of the past decades ago.  It is dangerous medicine but still practiced today in some places even with the CCT Paramedics who have little to no experience in Critical Care or even on the ambulanes and the CCT education is somewhat lacking in the U.S.  

 Also, as long as the U.S. EMS systems have set their expectations to the lowest denominator, there is no need for RN in the field for 911 calls right now responding along with fire departments and private ambulances and their bickering.  However, the same is not true in the hospitals where the expectations are now higher and loved ones expect the hospitals to do the right thing for providing care that is more than just adequate.  So, for now it will be CCT (ground), Flight and Specialty where the RNs will continue to grow in professional strength and numbers.


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## BluesMedic

Most of this seems to be entirely off subject that was intended by the OP.  I understand the argument, but it is really going to happen?  Probably not.  Should it happen, not so sure.  I think a re-evaluation of the education is the best place to start.  But there is a myraid of problems concerning health care in general, paramedicine in specific.  

     I just do not see how a new grad student can function on an ambulance.  I will use my area's Level I trauma center as an example.  This is a huge facility that incoperates many specialties and is a nationally known medical school as well.  The emergency department will not allow a new nursing grad to work in the ED, they must have at minimum one year experience.  With one exception, if that new nurse was a paramedic before becoming a nurse, they will hire straight out and put said person to work in the ED.  If a new nurse can't be allowed to work in the ED, how can they function out of hospital?  Just to clarify, this is just the workings of one hospital, I mean no disrespect to any other facility or to nurses in general.

     Another question I have for all those reading is this; I have seen a lot of comments concerning the education of nurses concerning pharmacology, A&P, etc.  What about those paramedics that earned their medic through a nationally accredited college while obtaining an associates degree?  These particular people went through the same exact college level courses on A&P, English, History, Psychology, Pharmacology, Patient Assessment and the like along with courses specific to pre-hospital medicine.  Is a nurse any better at providing prehospital medicine than these people?

Until next time...


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## Veneficus

*alas, somebody gets it *



BluesMedic said:


> I just do not see how a new grad student can function on an ambulance.  I will use my area's Level I trauma center as an example.  This is a huge facility that incoperates many specialties and is a nationally known medical school as well.  The emergency department will not allow a new nursing grad to work in the ED, they must have at minimum one year experience.  With one exception, if that new nurse was a paramedic before becoming a nurse, they will hire straight out and put said person to work in the ED.  If a new nurse can't be allowed to work in the ED, how can they function out of hospital?



At one time I understand it was a relatively standard practice that a nurse had to have 1 year of experience before being moved to an ICU, and one year in the ICU before being moved to the ED. 

However, as the amount of interested providers (aka nurses) declined and those with more advanced educations like a BSN were preferred over the ADN, in a recruiting enticement, orereqs were largely dropped in many areas. I even know traveling nurses who as thier first job out of school demanded ICU or ED appointments. (and got them)

Now I agree that in the hospital there is much more help to fall back on, but here is the rub. If a paramedic can be expected to follow rather narrow protocols (please people I don't want to hear about how your agency is somehow different, I recognize exceptions to the national norm) A nurse cannot possibly be any less capable than a new paramedic simply because the paramedic was probably educated using those protocols. (which is a failure of education to use local protocols, but that is for another thread.)

Now as I originally stated, there would have to be some additional training for the nurse. But how much? 9 months of medic school? I doubt it. Maybe 3, so call it a semester. Then I think their employer would give them the normal initiation and FTO time that the rest of the medics get. 

Of course since you would have to pay the nurse more, you would have less "als" providers which of course in an emergency setting is beneficial. But then you also have providers who can and often do embrace preventative medicine that EMS only pays lip service to. 

Visiting nurses, like visiting physicians are already paid for under the current reimbursement. Which adds to potential revenue sources. Less than an ALS ambulance? Sure, but quantity is sometimes a quality all of its own. Pls I would rather be stiffed out of 60% of the bill for a visiting nurse than 60% of the bill for an ALS transport ambulance.

It also has the benefit of getting paid for treatment instead of soley on transport. So while it would require some minor legal tweaking, which the nurses associations more than have the political clout to achieve, every treat and release instead of getting eaten as an RMA, now would get billed an reimbursed for a visiting nurse. (considerably cheaper than the ER bill) Better care, less money. Afterall, all that specialized emergency stuff paramedics are "trained for" are relatively a minor portion of the calls. 

As for the patient, being able to recognize and treat or refer to the proper specialist for routine healthcare not only lowers the costs, but it also improves the health and quality of life. (the more I think about this nurse thing the better it looks)    





BluesMedic said:


> Another question I have for all those reading is this; I have seen a lot of comments concerning the education of nurses concerning pharmacology, A&P, etc.  What about those paramedics that earned their medic through a nationally accredited college while obtaining an associates degree?



Those medics are such a small percentage of the total workforce that it barely recognizes in percentile. It absolutely should be predominant if not the minimum, but right now they are outliers who barely factor in. Are they as capable? I gess that would depend on the nature of thier course. Afterall, if they have paramedic class, A&P, pharm, and a bunch of management classes, probably not. If they had 2 years+ of basic or clinical science, sure they should be more capable. But they are not right now.




BluesMedic said:


> These particular people went through the same exact college level courses on A&P, English, History, Psychology, Pharmacology, Patient Assessment and the like along with courses specific to pre-hospital medicine.  Is a nurse any better at providing prehospital medicine than these people?



Certaily not, but again look at the numbers. I don't know for sure but I would wager a bet there are more vocational factory trained medics in systems like Houston, LA, or NYC than there are paramedics with EMS degrees in the whole nation. Especially if we factor in those who got degrees after starting as operational medics.

Like I said in my OP, it is nobody's fault but the EMS providers (both individual and organizational) that they are so lacking in education and marketability. They have had plenty of time to get their act together and failed, so a viable replacement should be sought.

As cold as it is, the primary function is being eaten away by less "true" emergencies, and the narrowness of their role is really making them obsolete with today's needs. No different from a blacksmith or a wheelwright, they are more novelty than useful.


----------



## Journey

After reading the last paragraph of Veneficus's post, I saw this comment in  another thread.



> Doing IFT for 8 months hurt my assessment skills.  It hurt my ability to critically think.  It hurt my manual skills.    It hurt my ability to deal with acute situations.  It hurt my ability to control a scene.  It hurt my ability to interact with other agencies.



If many of the 911 calls are  not emergent situations requiring the Paramedic to utilize their skills, how do they maintain their crtical thinking and skills?  Although, I believe critical thinking is a process that can be applied to almost any medical situation even determining the best action to handle a nonemergent call.  Would it be beneficial to either the patient or the Paramedic to expand EMS into community health  or preventitive roles if the above statement is true for those in EMS?  

Isn't there still an expectation for a Paramedic to be able to function as a Paramedic on an ALS truck? Hospitals do call ALS ambulances with Paramedics for patients who have the potential to need intervention requiring the skills and critical thinking of a Paramedic.  Should hospitals be checking closer now to see how these Paramedics maintain competency when negotiating the contracts? 

Veneficus, I apologize  if I am off track on your thread.


----------



## Veneficus

Journey said:


> Although, I believe critical thinking is a process that can be applied to almost any medical situation even determining the best action to handle a nonemergent call.



I once Heard Dr. Thomas Scalea say that "critical care is not a place, it is a mindset."

I think that sums it up rather well.


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## medicRob

Veneficus said:


> I once Heard Dr. Thomas Scalea say that "critical care is not a place, it is a mindset."
> 
> I think that sums it up rather well.



Dr. Scalea is one of my personal heroes, and I hope to visit the R adams cowley, Shock Trauma center in Baltimore at some point in the near future.

/derail


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## Akulahawk

Veneficus said:


> I once Heard Dr. Thomas Scalea say that "critical care is not a place, it is a mindset."
> 
> I think that sums it up rather well.


I think the same can be said for Paramedics/Prehospital medicine as well. It's not so much a place as it is a mind-set. Education being equal, some people would do well in the less controlled environment of the street and some people would do well in the clinical environment. Many of my instructors and co-workers have been RNs that work in the transport environment (prehospital and IFT). In effect, they had to learn to "think like a medic" in order to be able to function well in that prehospital arena. It's not that they didn't have the skills or the knowledge, but they had to develop the right mind-set to use them in a more independent manner. More than one Chief Flight RN has told me that it takes significantly longer to train an RN that only has a clinical background that it does to train one that also has a Paramedic background, when getting that new RN ready for "scene" work. 

Education being equal... mind-set also becomes an issue. Even in the Pre-hospital arena, plug-n-play won't work.


----------



## Shishkabob

Journey said:


> If many of the 911 calls are  not emergent situations requiring the Paramedic to utilize their skills, how do they maintain their crtical thinking and skills?  Although, I believe critical thinking is a process that can be applied to almost any medical situation even determining the best action to handle a nonemergent call.  Would it be beneficial to either the patient or the Paramedic to expand EMS into community health  or preventitive roles if the above statement is true for those in EMS?
> 
> Isn't there still an expectation for a Paramedic to be able to function as a Paramedic on an ALS truck? Hospitals do call ALS ambulances with Paramedics for patients who have the potential to need intervention requiring the skills and critical thinking of a Paramedic.  Should hospitals be checking closer now to see how these Paramedics maintain competency when negotiating the contracts?




You've either misintrepreted what I said, or misrepresented it to suit your need... either way you're incorrect.

Barring something going oddly wrong:

Tell me the amount of assessment skills needed for your everyday BLS discharge?  The patient has already been diagnosed.

The amount of critical thinking required to bring a patient to dialysis for the day?  Minimal.

The amount of scene management required to, well, non-scene responses?  Again, minimal if any.



Pre-hospital (i.e. NOT IFT) you have to come up with a working diagnosis for the patient, you have to figure out what plan of action to implement, how to implement it with the minimal resources and personnel at hand, and how to control what could potentially be an uncontrolled scene.





Sorry, Vene, for continuing to go off topic, but I couldn't let her post that without a rebuttle.


----------



## Journey

Linuss said:


> You've either misintrepreted what I said, or misrepresented it to suit your need... either way you're incorrect.
> 
> Barring something going oddly wrong:
> 
> Tell me the amount of assessment skills needed for your everyday BLS discharge?  The patient has already been diagnosed.
> 
> The amount of critical thinking required to bring a patient to dialysis for the day?  Minimal.
> 
> The amount of scene management required to, well, non-scene responses?  Again, minimal if any.
> 
> 
> 
> Pre-hospital (i.e. NOT IFT) you have to come up with a working diagnosis for the patient, you have to figure out what plan of action to implement, how to implement it with the minimal resources and personnel at hand, and how to control what could potentially be an uncontrolled scene.
> 
> 
> 
> 
> 
> Sorry, Vene, for continuing to go off topic, but I couldn't let her post that without a rebuttle.



I did misunderstand you. I thought you were a Paramedic working on an ALS transfer truck since you stated you had 70 meds.   On an ALS transfer truck a Paramedic or RN will have both unknowns and knowns with more factors to consider. 

However, complacency with dialysis patients can lead to disaster. If you don't do some assessment and note changes, you will be caught off guard when you arrive with a very sick patient who can not go on dialysis and probably should have been taken to an ED at a hospital which also has dialysis. 

Hospitals are also discharging patients earlier than some probably should and you shouldn't take it for granted that the patient is perfectly healthy. Labeling a patient as BLS shouldn't excuse you from still assessing a patient. It is no unheard of for a truck to turn around and bring a patient back to the hospital whether it is BLS or ALS or whatever label you want to use.  
.


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## CowboyMedic

I read about half way through this and skipped to the last three pages so excuse me if this has already been stated/answered.

the CORE of the argument is that it would be beneficial for the EMS community to staff RNs on their rigs. Yes? But the benefits stated is that the RNs could treat and refer pts to other facilities that are more adequate for their diagnosis instead of an ER. So from what I understand the pts are already diagnosed cause RNs dont diagnose and Paramedics/EMTs "possible" diagnose. Doctors are the only ones that diagnose. 

If these pts are already diagnosed then they already qualify for in home nurse care which is covered. There are already private companies for in home RN visits set up for this. Many nursing homes and hospice care facilities have a list of staff that they can send for this service. What do they need my ambulance for then? 

The IDEA behind 911 is that it is suppose to be used for an emergency. Is it always an emergency? Hell no. If they are just asking for a ride to the doctors office or they stubbed their big toe they may get 'no ride' written. this is where the private ambulances pick up that slack. Again do they need to go to the ER? No. But they will. I dont see the benefit to bogging down a crew that has a RN staffed so they can treat someone who already knows they need treatment at such and such time.

For emergency purposes the RN idea doesnt work as far as I see it. As far as bogging down ERs with pts that is why the CDC has a triage system in place and there are hospitals with different trauma levels. If you live in the sticks you may only have one choice besides air lift. 

Education wise I hope to see alot of change. I would like to see an LP with some much greater difference in skill set and education than what it has now. A LP has as much teeth as a newborn right now. I think education is the big elephant that need some attention right now. You cant force ever Paramedic to retake a higher level of training to maintain their paramedic but you can increase the quality of education in CE programs and initial Paramedic courses and effectively elevate the quality of a certified Paramedic and some of those old school paramedics. Granted this has to be done gradually but I think it is the most effect way of approaching the EMS system. Yeah you will still have people who shock Asystole but over time they should either educate them self or be forced out of the profession.


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## JPINFV

CowboyMedic said:


> So from what I understand the pts are already diagnosed cause RNs dont diagnose and Paramedics/EMTs "possible" diagnose. Doctors are the only ones that diagnose.



Call it what you'd like, but anyone who makes a conclusion on a patient's condition based on a history and physical, augmented by medical testing as available, including point of care testing such as EKGs and blood glucose, and builds a treatment plan based on that conclusion has engaged in the process of making a diagnosis. If calling it a "possible" (differential) or working diagnosis helps you to sleep better at night, then so be it. However, it is still a diagnosis. 

More on my thoughts about this:
http://emtmedicalstudent.wordpress.com/2010/11/09/ems-and-diagnosis/ 



> The IDEA behind 911 is that it is suppose to be used for an emergency. Is it always an emergency? Hell no. If they are just asking for a ride to the doctors office or they stubbed their big toe they may get 'no ride' written. this is where the private ambulances pick up that slack. Again do they need to go to the ER? No. But they will. I dont see the benefit to bogging down a crew that has a RN staffed so they can treat someone who already knows they need treatment at such and such time.


Yes, the idea behind 911 is that it is for emergencies. The question now is, "Has the role of EMS evolved past just a ride to the hospital? If not, should it? If still no, can EMS survive as a government function as such a limited service?" The fire department is no longer just about putting out fires. The police department is no longer just about catching criminals. A large part of those departments are also about prevention. Why is it OK for EMS to sit back and ignore the effect it could have both on efficiency for the entire health care system as well as the possible role it has on prevention?


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## Veneficus

CowboyMedic said:


> the CORE of the argument is that it would be beneficial for the EMS community to staff RNs on their rigs. Yes? But the benefits stated is that the RNs could treat and refer pts to other facilities that are more adequate.



The argument is that because what society needs from EMS as demonstrated by other civilized nations as well as the inefficencies of US EMS, that a nurse is better positioned (though not perfect) to provide such level of service in the US.

Because of the hyperspecialization of sociological roles as well as the lack of adequete education among a majority of US citizens, there is a definate need for healthcare providers who reach out to the community for the purposes of taking care of minor problems that do not need a healthcare facility, refering patients to the appropriate source of care when they need something other than the ED, prevention of illness, and health maintenence. 

Since many if not most EMS providers think thier only role is a a ride to the ED for the critically ill, which is such a small minority of patients, even smaller when you consider viable ones, that they may be removing the need for themselves and therefore eliminating them from the marketplace.



CowboyMedic said:


> for their diagnosis instead of an ER. So from what I understand the pts are already diagnosed cause RNs dont diagnose and Paramedics/EMTs "possible" diagnose. Doctors are the only ones that diagnose.



I do not agree that only doctors diagnose. While a specific doctor may have the most accurate diagnosis, it is certainly not exclusive.

A person who is having an ACS, can also be having an MI, an anterior decending MI, and  infarct at the ramus intermedius.

All of these are diagnosis, for the same patient for the same complaint.



CowboyMedic said:


> If these pts are already diagnosed then they already qualify for in home nurse care which is covered..



What if they are not? Does An ED help a 5 year old with a temperature of 38.1? Is it cost effective? Does the trauma of the many tests outweigh the benefits? Because the parent is afraid and didn't know what if anything to give their first kid, didn't know what to do is it not an emergency to them? Who do they call? Could this be evaluated by a nurse, treated, and refered to follow up with a peds doc instead of the ED?



CowboyMedic said:


> There are already private companies for in home RN visits set up for this. Many nursing homes and hospice care facilities have a list of staff that they can send for this service. What do they need my ambulance for then?



THe point is nobody may need your ambulance, because what they get doesn't match their needs, for what they are expected to pay. 



CowboyMedic said:


> The IDEA behind 911 is that it is suppose to be used for an emergency. Is it always an emergency?



Emergency is a truly subjective term. Ask a 15 y/o female if her  months of missed menses is an emergency. Ask a 70 year old who cannot get to dialysis because of the snow if it is an emergency. Ask a mother if the blood coming from their kids head is an emergency? 

What about the 45 year old man who denies he is having a heart attack because he is too young, or just doesn't want to admit the possibility and doesn't think that he has an emergency?

Emergency is defined by the consumer, not by the provider.



CowboyMedic said:


> If they are just asking for a ride to the doctors office or they stubbed their big toe they may get 'no ride' written. this is where the private ambulances pick up that slack. Again do they need to go to the ER? No. But they will.



You don't see that as a failure and a waste?

It may come as a surprise to some, but all doctors are not equal. All facilities are not equal because there is a doctor there. The ED costs a lot and may not be able to help the person. What exactly is the point of that? It is like going to a fast food place when your car needs repaired.



CowboyMedic said:


> I dont see the benefit to bogging down a crew that has a RN staffed so they can treat someone who already knows they need treatment at such and such time.



KNowing a person needs treatment and getting to it are completely different animals. By having a more educated person on a unit, you can reduce transports, give patients what they need, instead of what is convienent for the provider, lower the costs, and improve the outcomes. 

Basically you reduce the inefficent waste EMS has become.



CowboyMedic said:


> For emergency purposes the RN idea doesnt work as far as I see it. As far as bogging down ERs with pts that is why the CDC has a triage system in place and there are hospitals with different trauma levels. If you live in the sticks you may only have one choice besides air lift.



There are not enough characters in the post for me to address this, but I see a serious deficency of knowledge from this post. 



CowboyMedic said:


> Education wise I hope to see alot of change. I would like to see an LP with some much greater difference in skill set and education than what it has now. A LP has as much teeth as a newborn right now. I think education is the big elephant that need some attention right now. You cant force ever Paramedic to retake a higher level of training to maintain their paramedic but you can increase the quality of education in CE programs and initial Paramedic courses and effectively elevate the quality of a certified Paramedic and some of those old school paramedics. Granted this has to be done gradually but I think it is the most effect way of approaching the EMS system. Yeah you will still have people who shock Asystole but over time they should either educate them self or be forced out of the profession.



There hasn't been an effective change for EMS education in at least 22 years. You can wish all you want, but until you can enact change by provider will or force, you will have people who not only perform poor patient care directly, but whose knowledge of the system and patients needs lead to poor patient care indirectly by serving the providers instead of the patients.


----------



## CowboyMedic

Veneficus said:


> Because of the hyperspecialization of sociological roles as well as the lack of adequete education among a majority of US citizens, there is a definate need for healthcare providers who reach out to the community for the purposes of taking care of minor problems that do not need a healthcare facility, refering patients to the appropriate source of care when they need something other than the ED, prevention of illness, and health maintenence.



There is a definitive need for referring pts to other facilities and yes it does generally fall on the ED. For illness prevention and health maintenance you are right to chalk that up to poor education. But who is going to pay for that? When I was putting a pulse oximeter on a pt and explaining to him what it was for one time his girlfriend replied see thats what I told you it was for in which the pt quickly replied man you should have became a doctor. Good luck educating and tackling that beast.:unsure:



Veneficus said:


> THe point is nobody may need your ambulance, because what they get doesn't match their needs, for what they are expected to pay.



So more along the lines of EMS shows up on scene and decides this is a no ride situation and isnt really constituted as an emergency and decides to call the RN unit to follow up and educate the individual provide any minor care needed and referrals. I can go with that aslong as paramedics are first on scene and decide if it is an emergency or not. If you can get that into legislature and have insurance pay for it I would definately be on board for that. I can also see that being an additional source of income for FDs that use EMS to float their budget. 



Veneficus said:


> Emergency is defined by the consumer, not by the provider.



This quote kinda contradicts the entire purpose of using RNs to refer persons to other facilities because it is not judged as an emergency.



Veneficus said:


> You don't see that as a failure and a waste?



Yes I do. That is why I wrote it. Im not on one side of the fence or another really. But that waste is my job right now.



Veneficus said:


> There hasn't been an effective change for EMS education in at least 22 years. You can wish all you want, but until you can enact change by provider will or force, you will have people who not only perform poor patient care directly, but whose knowledge of the system and patients needs lead to poor patient care indirectly by serving the providers instead of the patients.



I disagree the educate and knowledge of EMS has changed drastically. Just look at the evolution of equipment and tools over the years. Our understanding of the human body and the changes in CPR procedures. We are constantly getting better and finding ways of being more efficient at our jobs. It just takes time. Granted you are going to have people who perform poorly in any industry. In EMS that is generally in my opinion due to the patch factories that pass students who do not posses the skills or aptitude to be an EMT/Paramedic so therefore again we come full circle back to education.



JPINFV said:


> More on my thoughts about this:
> http://emtmedicalstudent.wordpress.com/2010/11/09/ems-and-diagnosis/



Very good read and very well written. Differential was the word I was looking for. Thank you.


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## CodyHolt83

Interesting topic!  Is this a reality in the future?


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## TraumaJunkie81004

8jimi8 said:


> We already have that autonomy in ICU.  Our protocols and guidelines function very much like standing orders.  Open heart starts flagging and pacer wires are still in place. you can bet your hiney i'm going to start that pacer before I make the phone call.  Isn't that close to what the situation in California is?  Critical Care nurses giving orders to medics over dispatch?
> 
> 
> Vene i think this idea is outstanding.  Seriously you killed two birds with one stone on that one.  It has long been a notion I have endorsed that all RNs get at least an EMT-B.
> 
> Linuss (i'm not trying to call you out and be a ****) part of the proof is patch factory medics.  For being one of the strongest advocates for education and autonomy of Medics, i can't see why you haven't gone back to school.  For arguing so much of the equality of the two professions, wouldn't you agree you need more school to be the equivalent that you defend?



Patch factory medics?! I disagree whole-heartedly.  There are reasons why ALL EMS PERSONNEL MUST pass National testing and maintain those standards along with incorporated CMEs. If I had my way all health care professionals would have at least basic level EMT training.


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## Journey

CowboyMedic said:


> I disagree the educate and knowledge of EMS has changed drastically. Just look at the evolution of equipment and tools over the years. Our understanding of the human body and the changes in CPR procedures. We are constantly getting better and finding ways of being more efficient at our jobs. It just takes time. Granted you are going to have people who perform poorly in any industry. In EMS that is generally in my opinion due to the patch factories that pass students who do not posses the skills or aptitude to be an EMT/Paramedic so therefore again we come full circle back to education.



The Paramedic course in many states still does not require any more anatomy, physiology, pharmacology or hours of training than it did over 30 years ago. It is the ones who have taken these extra courses at the college level that might see or recognize changes but for their own knowledge and not necessarily in their EMS protocols which is the frustrating part for them. CPR procedures are also taught to the layperson and they are now simple enough for almost all to understand and perform.  12 Lead ECGs have been available to EMS for almost 30 years but according to the AHA, only half of the ALS EMS trucks have them and those that do may rely on machine interpretation. The same for ETCO2 which is also not on many trucks now. CPAP is another example of it being not available to that many EMS systems and neither is the IO.  Evidence based medicine is still not prominent when it comes to EMS. Some in EMS also don't care about the EBM and may see it as if they are being penalized if a medication or skill is removed from their truck rather than if it was best for the patient.

It is true there have been many, many changes in medicine but just how many of those are EMS providers aware of and are constantly changing to would be a more appropriate question. In some ICUs, changes are occuring at least weekly. New protocols and policies are constantly being written for the many new meds, technology and procedures being introduced. There are countless more in Europe and Canada that have yet to hit the U.S. which are being anticipated for the moment someone gains approval to start their own research with or they are officially approved by the FDA.  It is also very easy for an RN who works only on a nonhospital based Flight team to get behind on the latest advancements in just a short time. The RN may have to also work in the ICUs to stay current on all the latest meds, equipment and protocols. Sepsis, burns, trauma and ARDS protocols are just a few examples. To effectively continue care from one hospital to the next, they must know what, how and why the patient is being treated as they are and should not just be trying to match numbers on the machines and pumps to get from point A to pont B.   

You also can not just blame the patch factories if the state standards are low. Texas requires only about 600 hours to become a Paramedic and there are no prerequisistes mentioned.  So of course so, even the better colleges or universities might take advantage of that and produce grads with a 3 - 4month program especially if they are also catering to the local FDs and ambulances. If the need perceived by those in the industry to extend the education is not there and certificate with the minimum hours is enough, then chances are that is what will be provided.  Any other education will be optional. 



> There is a definitive need for referring pts to other facilities and yes it does generally fall on the ED. For illness prevention and health maintenance you are right to chalk that up to poor education. When I was putting a pulse oximeter on a pt and explaining to him what it was for one time his girlfriend replied see thats what I told you it was for in which the pt quickly replied man you should have became a doctor. Good luck educating and tackling that beast.



I don't get the point you are making here. If you mean educating the layperson about pulse oximetry, RNs and LPNs do that everyday in the hospitals, clinics and home care. That same patient who thinks you are a doctor can learn the skill of pulse oximetry well enough to monitor her own child at home if necessary.  Also, pulse oximetry can be well reimbursed for different situations.  Many, many patients, regardless of their education, have been taught to manage their diabetes, COPD, asthma,  consequences of cancer such as a colostomy, a tracheostomy or a laryngectomy, home oxygen and even ventilators. 




> So more along the lines of EMS shows up on scene and decides this is a no ride situation and isnt really constituted as an emergency and decides to call the RN unit to follow up and educate the individual provide any minor care needed and referrals. I can go with that aslong as paramedics are first on scene and decide if it is an emergency or not.



Actually there should not be a need for EMS to show up. Some cities now have nurses in their dispatch centers who could send the most appropriate and this would be ideal for areas with high call volumes.  Paramedics at this time are also not educated, trained or have the appropriate experience  to recognize the many needs of a patient that are not immediately emergent but can be if not dealt with so actually an RN doing the initial determination might be the more approrpriate.  If it is an emergency, that can be handled also. 

Patient education is also not something a Paramedic is well versed or experienced  in when it comes to the long term.  If you use the pulse oximetry which you gave as an example, you can not always talk like a doctor when explaining a procedure for the layperson to comprehend.  There was recently a post somewhere on this forum where someone was trying, unsuccessfully, to convince a person they needed to go to the hospital by saying the patient was having an MI and their heart was ischemic. It may sound nice to impress the girlfriend but doesn't give an adequate explanation of what is happening.


----------



## 8jimi8

MrBrown said:


> As for a Degree, it needs to be a proper speciality University degree not some two year flout that includes basked weaving, computers 101 and art history as well as the DOT cirricula which has been massaged into a barely qualifying community college course.



My associates degree required no electives.  There is something to be said about taking a focused curriculae versus a 130 hour $50,000 dollar degree. (My RN cost $5,000.  With my psych degree I never earned more than 28,500/yr which was nearly doubled by my ASN)  My degree plan over 2 years was 50 clinical hours less than the 4 year University plan. The clinical competence of ASNs is evidenced by their preferential marketability here in Austin. Hospitas hire from the Community college grads preferentially because the ACC grads are more prepared to begin working out of school.  

This harkens back to specialty versus general education.  

Personally, I will complete my BSN and go on for a masters.  because while the associates allowed me entry into the profession, I'm not stopping at the entry level.  If you want paramedics doing community healthcare, they will need a masters to be competent.  Maybe that will be your "community health fly-car"


----------



## uhbt420

i would really love to continue this discussion but 

a) increasing medic education should be our focus, not putting nurses on ambulances, and

b) you are ventmedic


----------



## TraumaJunkie81004

WTEngel said:


> If nurses wanted to ride on an ambulance, they would have gone to paramedic school.
> 
> It won't work because I have a feeling the majority of them will not want to do it.
> 
> I am an advocate of nurses in the pre hospital setting, I have worked pre hospital with nurses before and continue to do so. I have nothing but respect for them and their knowledge, and I feel they respect me and my knowledge (granted I don't fall into the category of most average paramedics.)
> 
> In my opinion, the transition of paramedics to nursing (with the appropriate training) seems to be more successful than nurses transitioning to the paramedic role. Keep in mind, I am not just talking about the actual attainment of the certification, but also the practical application of the skills and abilities required for the position.
> 
> The thing that makes most nurses successful when they enter flight medicine of critical care transport is many years of experience and gradual increase in education beyond initial certification (the sa,e things that make a medic successful also.)
> 
> Taking all of this into consideration, putting GNs in the field is a bad idea. No experience, probable lack of desire, and lastly a real lack of relevant experience for the GNs who want to enter the clinical setting (except for ER and possibly ICU, which is a portion of the overall nursing workforce.)
> 
> Remember, we always talk about skills do not equal education. The opposite is also true, education does not equal skills.



I agree with all you said above.  I strongly agree that all of levels of EMS provider need more education.  I know I'm opening myself up to massive quantities of flack, but I think the the EMT-B level should either be eliminated or be changed.  EMT-B's should have at least I-85 training and, continuing on, Intermediates should be trained closer to Paramedics.  Paramedics training should be expanded/broadened.  I have functioned as a B and as an I on an ambulance, in a construction setting, and in a casino.  I cannot begin to tell you how frustrated I was at both levels.  I felt lacking in skills and felt there had to be more I could have done to help my patients.  I also have Paramedic friends who have experienced the same level of frustration.  Guess the bottom line for me: I'm all for more training. I take what I can when it's available.  I don't think that employing nurses in an ambulance setting, unless it's on a NICU/CCU designated rig, is the right move. Doctors/scientists, etc. are always coming up with new technology to be used in the field.  Other than that I feel EMS has stagnated.


----------



## Journey

TraumaJunkie81004 said:


> Patch factory medics?! I disagree whole-heartedly.  There are reasons why *ALL EMS PERSONNEL MUST pass National testing and maintain those standards along with incorporated CMEs. *If I had my way all health care professionals would have at least basic level EMT training.



There are still states with their own Paramedic and EMT exams.

CMEs are easy to obtain online and in your own living room. Refresher courses can be what you make of them good or bad and depends on how well they are done by the instructor. 

Maintaining standards generally correlates to the medical oversight and what you have in place to monitor quality.  

It is also not to difficult to teach one just to pass a test and unfortunately is being done rather than providing an education to go along with the memorization. 

I encourage everyone, including those planning a family, to get first aid training that may even exceed what is taught in the EMT class depending on their situation. Many who have no interest in becoming an EMT can get as  maybe more hours of training at the ARC. This can also include water safety and classes pertaining just to kids. Gun enthusiasts, hikers and rock climbers can also have first aid taught through their organizations to address their situations and some of these courses can be very extensive. Factory and  construction workers, teachers and coal miners may all get a significant amount of training in first aid during their education or job skill set. So it doesn't have to be just health care professionals.  

First aid as you know it in EMT class is not taught to those in the hospitals because there are other alternatives available. But, that does not mean they do not know how to control bleeding, recognize anaphylaxis or difficulty breathing and apply oxygen, identify diabetic emergencies, perform CPR, listen to breath (and heart) sounds, determine level of consciousness, log roll and do many different types of splints for immobilization.  It is a different environment, a different focus and different tools that coincide with availablility and the situation.  The EMT class taught just for the equipment and protocols used on an ambulance by an EMT-B may not be appropriate for inside the hospital.



8jimi8 said:


> Personally, I will complete my BSN and go on for a masters.  because while the associates allowed me entry into the profession, I'm not stopping at the entry level.  If you want paramedics doing community healthcare, they will need a masters to be competent.  Maybe that will be your "community health fly-car"



That is no understatement and that is provided the Paramedic had extensive clinical hours inside a hospital and LTC facilities to gain some experience.

Public Health and School RNs are recommended to have at least a Bachelors and many of them have a strong background in the ED for experience.


----------



## TraumaJunkie81004

Journey said:


> There are still states with their own Paramedic and EMT exams.
> 
> CMEs are easy to obtain online and in your own living room. Refresher courses can be what you make of them good or bad and depends on how well they are done by the instructor.
> 
> Maintaining standards generally correlates to the medical oversight and what you have in place to monitor quality.
> 
> It is also not to difficult to teach one just to pass a test and unfortunately is being done rather than providing an education to go along with the memorization.
> 
> I encourage everyone, including those planning a family, to get first aid training that may even exceed what is taught in the EMT class depending on their situation. Many who have no interest in becoming an EMT can get as  maybe more hours of training at the ARC. This can also include water safety and classes pertaining just to kids. Gun enthusiasts, hikers and rock climbers can also have first aid taught through their organizations to address their situations and some of these courses can be very extensive. Factory and  construction workers, teachers and coal miners may all get a significant amount of training in first aid during their education or job skill set. So it doesn't have to be just health care professionals.
> 
> First aid as you know it in EMT class is not taught to those in the hospitals because there are other alternatives available. But, that does not mean they do not know how to control bleeding, recognize anaphylaxis or difficulty breathing and apply oxygen, identify diabetic emergencies, perform CPR, listen to breath (and heart) sounds, determine level of consciousness, log roll and do many different types of splints for immobilization.  It is a different environment, a different focus and different tools that coincide with availablility and the situation.  The EMT class taught just for the equipment and protocols used on an ambulance by an EMT-B may not be appropriate for inside the hospital.



Journey: thanks for the insight. I guess I'm just a blind-hearted fool.  I believe that all education is what you make of it. You can memorize just to take a test and become a EMT (and believe me I've met plenty of those people who work in a confined setting like a casino), but I choose to believe that most of us took the education to heart and got into EMS to help others. All I can do is continue to further my education and pray that EMS evolves to the point where those who just want the pay (ha ha) drop out.  I would really like to see EMS become a place where all responders were focused on the patient and not grousing because they just heard a call on the radio about an overturned vehicle or structure fire - because in their world EMS is a distraction not an attraction.  PLEASE NOTE: I AM NOT SAYING ALL FIREFIGHTERS ARE LIKE THIS. THIS IS BASED SOLELY ON MY INTERACTIONS WITH THE COUNTY FIRE DEPARTMENT IN LAS VEGAS, NEVADA.


----------



## Journey

My comments were not toward any particular group either. The scandals in Massachusetts and New Hampshire didn't pertain to just one group. Hopefully that is not the norm but I would bet there are other in different states who have gotten away with something similar. This could also include other professions but I would not want to piss off the BON and risk losing several years of hard work. But, the years of education part can not be taken away and could be applied to another career.


----------



## Veneficus

CowboyMedic said:


> There is a definitive need for referring pts to other facilities and yes it does generally fall on the ED. For illness prevention and health maintenance you are right to chalk that up to poor education. But who is going to pay for that? When I was putting a pulse oximeter on a pt and explaining to him what it was for one time his girlfriend replied see thats what I told you it was for in which the pt quickly replied man you should have became a doctor. Good luck educating and tackling that beast.:unsure:



That is precisely why you need a nurse. They actually are responsible for patient education. 

As for who pays for it, it is already being payed for. An an extremely inflated cost. Anyone who seeks help must be seen in the ED. Tests must be run, ultimately some federal agency will pay part of the bill or it will be eaten by the hospital. By removing the need to take everyone to the ED, the cost that is already being paid is reduced. 



CowboyMedic said:


> So more along the lines of EMS shows up on scene and decides this is a no ride situation and isnt really constituted as an emergency and decides to call the RN unit to follow up and educate the individual provide any minor care needed and referrals. I can go with that aslong as paramedics are first on scene and decide if it is an emergency or not. If you can get that into legislature and have insurance pay for it I would definately be on board for that. I can also see that being an additional source of income for FDs that use EMS to float their budget.:



If you are not aware, only the most common life threatening situations are taught in paramedic class. It doesn't include 1/2 of them. So having an EMS vehicle show up and rule things out is not only an unneeded redundancy, it can miss a considerable amount. Have you ever seen a kid with Kwashiorkor? How serious is that? In today's economic climes and within certain populations of the US, it is quite possible you may run across it. Would you know it if you saw it? Do you think it is an emergency?



CowboyMedic said:


> This quote kinda contradicts the entire purpose of using RNs to refer persons to other facilities because it is not judged as an emergency.



Not in the least. Kid has a fever, calls 911, nurse is sent, decides it is not an emergency, gives antipyretic educates family on what to do, how to tell if kid is getting worse or better, creates followup. Emergency abated. Parents thought it was an emergency and their needs were met.



CowboyMedic said:


> Yes I do. That is why I wrote it. Im not on one side of the fence or another really. But that waste is my job right now..



The reason it is important to branch out in value is so the job is there tomorrow, next year, and next decade. US EMS as a whole does not see the value in this.



CowboyMedic said:


> I disagree the educate and knowledge of EMS has changed drastically. Just look at the evolution of equipment and tools over the years. Our understanding of the human body and the changes in CPR procedures. We are constantly getting better and finding ways of being more efficient at our jobs...



You are comparing EMS basic education to tweaking a few procedures and adding some gadgets? So what do you do when those gadgets are not available and you still have to treat patients, perhaps without the benefit of transport?

EMS claims to be useful in a disaster, but in the US, once you take away rapid transport, EMS falls on its *** in a big way.


----------



## Veneficus

uhbt420 said:


> i would really love to continue this discussion but
> 
> a) increasing medic education should be our focus, not putting nurses on ambulances,



In the interest of what is best for the patients and the public, since EMS has failed to increase its education or update its functions to the demands of today, finding a suitable alternative is a legitimate discourse.

It is about finding a solution to the needs. If EMS was making progress, or even effort, nobody would bother discussing it. But I am not the only one and this is not the only place this topic has been raised.


----------



## vquintessence

The horse is long since dead; the cadaver is beyond tender, yet the wolves continue to bark and fight amongst one another.


----------



## Journey

vquintessence said:


> The horse is long since dead; the cadaver is beyond tender, yet the wolves continue to bark and fight amongst one another.



True. There is probably not enough  interest in improving EMS beyond what it is now so it is basically a dead horse.  The two representatitves that have introduced a bill into the House are just wasting their time.   

Other professions wouldn't have achieved what they have if they hadn't kept the interest alive and not calling advancement a dead horse.  Some people just don't want to hear times are chaniging.

Some good ideas can come out of even an open EMT forum on the internet.


----------



## PenguiNet

Veneficus said:


> Not in the least. Kid has a fever, calls 911, nurse is sent, decides it is not an emergency, gives antipyretic educates family on what to do, how to tell if kid is getting worse or better, creates followup. Emergency abated. Parents thought it was an emergency and their needs were met.



a nurse has absolutely no authority or training to undertake a field-based, provider-initiated refusal.  you would need at LEAST a NP or PA for that.  you are forgetting that we live in a litigious society.  there is not a snowflake's chance in hell that a county EMS agency/fire department/private provider/etc would accept the liability for someone who is just a RN to, in essence, deny transport without online MD control.  guess what?  paramedics already have that.  

and kwashiorkor?  you are really grasping at straws here.  what is the definitive treatment for severe malnutrition?  something a nurse can fix in the field?  what's that?  that's precisely what i thought.  i'm sure we'll all be stocking NG tubes and cans of Ensure just to prepare for this sort of contingency lol.

admittedly, if i lived in some sort of EMS hell like you seem to...where silly, dumb, uneducated paramedics have NO IDEA that someone with kwashiorkor is "big sick", then of course i would push for someone with just a RN license to jump on the box and take over...RNs who magically went to medical school and have the training, expertise, and level of care of a MD to initiate transport denials masquerading as patient education.

you have simply not sufficiently qualified what it is that a RN can do in the field that a paramedic can't.  what kinds of medications can they push that paramedics can't?  i've never encountered a scenario where i opened up my medication bag and said to myself, "well, :censored::censored::censored::censored:...i sure wish i had <blank>".  

i posit that an EMS service with at least a modicum of progressive attitude has all the tools necessary to meet the demands of their constituency.  adding a RN simply does not increase the standard of care in the field in any appreciable way.


----------



## Chimpie

Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).

Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?


----------



## SerumK

Chimpie said:


> Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).
> 
> Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?



Arguably both?
1. The RN can provide expanded and more appropriate treatment due to increased educational depth.
2. The RN can be made to fit the roll of the mythical "Community Paramedic" idea that cannot come to pass because of the lack of educational breadth in US Paramedicine.


----------



## Veneficus

Chimpie said:


> Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).
> 
> Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?



yes to the better care.

Not primarily to reduce ED traffic, but that would be a side effect. The goal is to give patients an avenue of nonacute care and that directs them to the appropriate resource, medical or social to handle their problems that cannot be adequetly addressed by the ED.

It also adds a prevention component that can reduce the frequency of 911 calls because patient education is a primary function of nursing.

I think the future of EMS is less responding to "emergencies" and offering transport to an often ineffective and expensive ED, and more as a provider that is part of the community rather than secluded from it.


----------



## uhbt420

well here's my reasoning behind promoting medic education as opposed to transitioning to nursing.

to be a nurse, one obtains a four-year degree.  the advantages of this compared to a 2,000 hour medic course are numerous-- more experience, more education, etc.  however, an rn does not necessarily have a higher scope of practice in the context of emergencies.  for example, nurses can't cric AFAIK.

so here we have our RN's who would like to work on ambulances.  now they need an EMT-B course for first aid and operating in a prehospital setting, and afterwards a paramedic skills seminar to peform advanced treatments like crics.

would it not be simpler to build a 4-year medic degree?  no emt courses, no skill seminars, and the same body of knowledge that a BSN would have, though more in the context of emergencies.

am i making sense?

ninja edit:  i am in no way opposed to education.  i'm hoping for an AAS in paramedic one day, maybe even working my way towards a BSN.


----------



## usalsfyre

uhbt420 said:


> to be a nurse, one obtains a four-year degree.  the advantages of this compared to a 2,000 hour medic course are numerous-- more experience, more education, etc.  however, an rn does not necessarily have a higher scope of practice in the context of emergencies.  for example, nurses can't cric AFAIK.
> 
> so here we have our RN's who would like to work on ambulances.  now they need an EMT-B course for first aid and operating in a prehospital setting, and afterwards a paramedic skills seminar to peform advanced treatments like crics.



Why do people keep focusing on monkey skills? I'm fairly certain I could teach anyone who's able to identify the landmarks how to perform a cric.



> would it not be simpler to build a 4-year medic degree?



Honestly no, the procedures needed to operate in the prehospital environment could be taught is about a month, far, far better than many medic schools teach them. 

Veneficus, as much as I hate to admit this, maybe your right...


----------



## uhbt420

usalsfyre said:


> Why do people keep focusing on monkey skills? I'm fairly certain I could teach anyone who's able to identify the landmarks how to perform a cric.


crics, starting IVs, EKG interpretation, etc are actually not monkey skills, but its nice to see you sticking up for your profession


----------



## usalsfyre

uhbt420 said:


> crics, starting IVs, EKG interpretation, etc are actually not monkey skills, but its nice to see you sticking up for your profession



Horsesh!t. Crics, IV's, ect ARE nothing but monkey skills. I can teach nearly anyone ANY of these skills. I can teach anyone where to put the leads and to read off "ACUTE MI SUSPECTED" an an EKG. Intubation is taught in 4 hours in many EMT-I classes, IV's are taught to non-medical military personnel daily. I can actually teach most folks to go through the motions of a very through assessment as well. If this is what you equate paramedicine with, than *YOUR* part of the problem. 

Knowing when to use these things and how to correlate them clinically is where the value lies. Do you think medical school spends four years on how to start central lines? Management of a presenting medical condition relies on recognition and understanding. 

I stick up for my profession on a regular basis, to see it urinated on by people who value "cool skills" over the inate knowledge needed to back those "cool skills" up. I like to think of myself as a paramedic because of the knowledge contained above my shoulders and the proper way to apply it. I also work very, very hard to retain and increase that knowledge, to the point I consider what myself and many of my coworkers do to be far closer to what a mid-level does than what many ED nurses do. If you think because you can do a cric your special, I suggest you look at military medicine. Medics in the sandbox are doing them frequently, with only an EMT-B card. When you define yourself by a unique knowledge set, and not "skills" then you can puff your chest out at me about "standing up for your profession".


----------



## Shishkabob

This thread is silly / pointless.



Just laying that out there.


----------



## usalsfyre

Linuss said:


> This thread is silly / pointless.
> 
> 
> 
> Just laying that out there.



Agree, completely. We're just mentally pleasuring ourselves at this point. :unsure:


----------



## Shishkabob

usalsfyre said:


> Agree, completely. We're just mentally pleasuring ourselves at this point. :unsure:



The thing is, the BIGGEST complaint that this thread raises is a Paramedic's apparent inability to understand anything medical outside of emergency medicine.  (Which is a stupid fallacy in and of itself)


Truthfully, this isn't a problem of EMS and any supposed lack of education, but of the civilian population who utilize 911 for non-emergencies and primary healthcare.   If EMS / 911 were utilized only for true emergencies, I'd venture to guess this thread would not exist aside from people WANTING us to get in to community Paramedicine.  


And don't bring up that "The patient defines the emergency, not us" crap.  No.  A stubbed toe is not an emergency.


----------



## Journey

Chimpie said:


> Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?



I am surprised someone from Florida would as this. Florida has for decades be a leading in Community and Public health programs which include RNs. They also play a significant role in disaster preparedness and management since there is no way EMS could ever cover all the bases for the many health care and shelter needs in the community which includes medical patients and the homeless.  If these RNs did not go out into the community at senior citizen centers and homeless shelters, which includes under the bridges, to identify and get these people the necessary care, there is no way even the best EMS systems in the area could handle all the calls. 

Community and Public Health RNs, Social Workers and Case Managers (also could be RNs) have played a role in preventitive community medicine for investigating situations and providing them with the needed services which may involve calling the physicians associated with their agency for advise. There is absolutely nothing wrong with calling "med control". A few hours of training or even 2 or 4 years do not make anyone a doctor. This thing where Paramedics in the U.S. feel like it is bad to call a doctor just shows how little some might know about the many illnesses there are and may not realize their limitations.  These Community and Public Health RNs are involved in so many projects around the country which also includes child and elder abuse as well as identifying and caring for medical problems of the homeless under the bridge.  Many times they are called to investigate a person whose neighbor has seen EMS at the home many times but each time a "refusal form" is signed and EMS has cleared because the patient was okay since they know their name and place or didn't have any obvious trauma or illness. Unfortunately just knowing your name and where you are does not mean you can't be in need of some medical care or a different living situation. But, for many in EMS, "not my job to be a social worker, I just do the emergencies" is often the response. Is this just the lack of training or is it just "not my job" that prevents them from expanding their sight into preventitive care?

In San Francisco there is a Paramedic, Niels Tangherlini, who started an outreach program for frequent 911 users including the poor, homeless, mentally ill, elderly, disabled, and alcoholics and drug abusers. Prior to starting this program he got a degree from UC Berkeley in Social Welfare and formed an alliance with the Department of Public Health. He also enlisted the assistance of RNs and RRT as well as many others involved in the health care systems to cover the medical needs he did not have expertise in.  I would say Mr. Tangherlini had the foresight to know the limits of his Paramedic training and the limitations of the EMS system to see the bigger picture to provide the needed services.


----------



## SerumK

Linuss said:


> Truthfully, this isn't a problem of EMS and any supposed lack of education, but of the civilian population who utilize 911 for non-emergencies and primary healthcare.   If EMS / 911 were utilized only for true emergencies, I'd venture to guess this thread would not exist aside from people WANTING us to get in to community Paramedicine.



If wishes were kisses we'd all have herpes.



> And don't bring up that "The patient defines the emergency, not us" crap.  No.  A stubbed toe is not an emergency.



The patient defines the emergency. We define the urgency. Deal with it.

When people feel the situation is out of their control, they call for help: 911. No amount of attitude from you as an EMS provider will ever change that reality.

When the EMS provider has the educational breadth and depth to be entrusted with the power to treat and release or refer to a PCP rather than take the pt. to the ED, then we can truly define urgency beyond whether or not to turn on the blinkies and woowoos.


----------



## Journey

Linuss said:


> This thread is silly / pointless.
> 
> 
> 
> Just laying that out there.



This is also a strange comment for someone from Texas where RNs are already being trialled in the dispatch centers and have also had a long standing in Community and Public Health to make a difference in some parts of your state.



usalsfyre said:


> Agree, completely. We're just mentally pleasuring ourselves at this point. :unsure:



For some on this forum it might be just mental masturbation but if you look at the Association websites of other professionals, including RNs (community, public, ED nursing), Social Workers, Case Managers, Emergency Preparedness, OT, PT and RT, you will see what is being done to keep programs alive and to support preventative and long term care before EMS is needed for a real emergency. These professions have established themselves and now they can lobby for the patient. EMS is still focused on themselves and what is the best name to be called to represent a skill they can do.

You have to see the broader picture and recognize there are many very capable health care providers in medicine that can assume many responsibilities with their initial education, additional education and lack of adversion to education and change.


----------



## Shishkabob

SerumK said:


> The patient defines the emergency. We define the urgency. Deal with it.



No, seriosuly, that saying is just as stupid as "EMTs save Paramedics".

It holds no basis and just exists to make someone feel better.




> When people feel the situation is out of their control, they call for help: 911.


  Never disputed that.  But having a stubbed toe is not beyond someones control, and is of no reason to call 911. 



> No amount of attitude from you as an EMS provider will ever change that reality.


  Attitude?  No.

Educating people on when and when not to call 911?  Heck yeah, as it should be.


----------



## usalsfyre

Journey said:


> This is also a strange comment for someone from Texas where RNs are already being trialled in the dispatch centers and have also had a long standing in Community and Public Health to make a difference in some parts of your state.



Trialed by a massively overburdened EMS system due to refusal by an FD administration to put the correct amount of trucks on the road. 





Journey said:


> For some on this forum it might be just mental masturbation but if you look at the Association websites of other professionals, including RNs (community, public, ED nursing), Social Workers, Case Managers, Emergency Preparedness, OT, PT and RT, you will see what is being done to keep programs alive and to support preventative and long term care before EMS is needed for a real emergency. These professions have established themselves and now they can lobby for the patient. EMS is still focused on themselves and what is the best name to be called to represent a skill they can do.
> 
> You have to see the broader picture and recognize there are many very capable health care providers in medicine that can assume many responsibilities with their initial education, additional education and lack of adversion to education and change.



If you really have that rosy of a view of the world that those organizations are "speaking for the patient" and not lobbying for their members in the form of "it's good for the patient" than you are truly naive.  

I know at some point in your past EMS "wronged" you, but the vendetta is getting old. Isn't their a more constructive outlet than coming on here and bashing paramedics?


----------



## Shishkabob

usalsfyre said:


> Isn't their a more constructive outlet than coming on here and bashing paramedics?



Perhaps at an RT forum?

Just sayin'.


----------



## Journey

Linuss said:


> Educating people on when and when not to call 911?  Heck yeah, as it should be.



How do you educate those with dementia although to EMS they might appear perfectly normal because they still know their name and can still sign it?

What about all of those with mental illnesses whose services have been drastically cut over the past 10 years?

How about all of those with substance abuse problems?

What about those who just have no close alternatives to health care?

What about the kids, taught about calling 911 by their parents, who now will get mixed messages from you that it is bad to call 911 and they can get into trouble?

The ones you do educate are those who can afford TVs in houses to see the public service messages. These may also be the ones who do take your message to heart and don't want to be a bother such as the elderly who truly do need your services. Or, it might give the businessman a reason for not calling EMS for his chest discomfort because he wouldn't want to be accused of abusing the system and embarrassed. 



> The patient defines the emergency. We define the urgency. Deal with it.





> It holds no basis and just exists to make someone feel better.



You might not think something like an amputated finger or a broken leg is not a big deal but the patient might think otherwise and so might the person who you tell to drive that person to the hospital because it is not an emergency to you.  People have different pain and blood threshholds and making blanket statements like that impairs you own judgement for what is and isn't an emergency.  It is like when you already form an opinion about a patient just by how it is dispatched or the neighborhood especially if it is predominantly a different race or socioeconomic status than you. You might also form your own opinion, as you already have stated, about dialysis and nursing home patients before ever seeing them.


----------



## usalsfyre

SerumK said:


> The patient defines the emergency. We define the urgency. Deal with it.



There's the patients inability to deal with the situation, and then there's a true emergent/urgent complaint.  



SerumK said:


> When people feel the situation is out of their control, they call for help: 911. No amount of attitude from you as an EMS provider will ever change that reality.



Who said anything about attitude? But there is definitely a difference between an honest to God emergency, an urgent complaint that still needs treatment and transport or referral and those who just don't need medical services. Which is not something the patient defines. 

More education is needed, but arguing that the patient is the only one able to define an emergency is dumb.

Why is it when anyone mentions that the majority of patients we treat and transport are not true medical emergencies (many times however they do fit in the urgent category) they get accused of being an uncaring bigoted ogre who lets their patients die?


----------



## uhbt420

usalsfyre said:


> When you define yourself by a unique knowledge set, and not "skills" then you can puff your chest out at me about "standing up for your profession".


relax, we're on the same side

i would also like to point out that Journey is ventmedic and it's so obvious that it hurts


----------



## Journey

usalsfyre said:


> If you really have that rosy of a view of the world that those organizations are "speaking for the patient" and not lobbying for their members in the form of "it's good for the patient" than you are truly naive.
> 
> I know at some point in your past EMS "wronged" you, but the vendetta is getting old. Isn't their a more constructive outlet than coming on here and bashing paramedics?



I only got involved in this thread because it was linked on another forum.  On that forum we do discuss major issues facing health care especially in the EDs and critical care. Believe it or not but all those patients brought to the hospital by EMS do end up someplace so it is our concern also.  I will say we also have a strong political stance for our positions and have gotten several bills passed which have kept patients being provided for many long term services. 

It isn't about being wronged in EMS or a vendetta that RNs and other health care professionals see and have done and do things differently. It is about knowing how vast medicine and the health care or social welfare systems are.  It seems some in EMS would rather make personal accusations or attacks rather than do a little research on the many topics that just this thread has touched on.

This is not about being naive but about actually working in health care to make a difference. If you can make life a little better even for one patient each day, then your job is not a waste.

Please feel free to look up any of the other websites to see what bills they have introduced to keep services available for those who need them in the community and in home care.  State and Federal insurers such as Medicare are a constant challenge. EMS should take that more seriously and figure out how they can improve their role in the system.


----------



## Shishkabob

Journey said:


> How do you educate those with dementia although to EMS they might appear perfectly normal because they still know their name and can still sign it?
> 
> What about all of those with mental illnesses whose services have been drastically cut over the past 10 years?
> 
> How about all of those with substance abuse problems?
> 
> What about those who just have no close alternatives to health care?


So, we're too uneducated to do our job, but educated enough to be drug counselors, mental issue counselors, and primary care providers?




> What about the kids, taught about calling 911 by their parents, who now will get mixed messages from you that it is bad to call 911 and they can get into trouble?



I've yet to see a kid told NOT to call 911.

However, I have told a mom that calling 911 because her daughter started bleeding (Bleeding as in less blood than losing a tooth) in the mouth after brushing her teeth real hard before going to the dentist is probably not the best use of emergency personnel.   






> You might not think something like an amputated finger or a broken leg is not a big deal but the patient might think otherwise and so might the person who you tell to drive that person to the hospital because it is not an emergency to you.



Where did I ever say actual physical injuries that needed intervention were no big deal?

You continue to make stuff up to suit your case.





uhbt420 said:


> i would also like to point out that Journey is ventmedic and it's so obvious that it hurts


A few of us have known this for weeks.  Haven't you seen us alluding to it in our posts? ^_^


----------



## usalsfyre

uhbt420 said:


> relax, we're on the same side
> 
> i would also like to point out that Journey is ventmedic and it's so obvious that it hurts



Sorry to go nuclear on you, just had some very, very frustrating experiences here lately with people not being able to tell me "why" before they did (or for that matter, did not) do an intervention.


----------



## Journey

Linuss said:


> So, we're too uneducated to do our job, but educated enough to be drug counselors, mental issue counselors, and primary care providers?



In several of your posts you have referred to being too uneducated to do your job rather than providing an agrument as to why you feel the hours of training in Texas to be a Paramedic is enough and qualifies those who only do the minimum to have so many skills and drugs at their access. 

Do you know what a drug or mental health care counselor does?  If you did you would see you are not either. I don't believe there is any state that will allow a Paramedic to even declare a person mentally incompetent for an involuntary mental evaluation hold. 

Primary Care Providers are usually physicians or physician extenders which the Paramedic is neither.

The other examples are things I've gathered from your previous posts since you seem to be my biggest fan, I thought I'd see what other points you are so adamant about.


----------



## uhbt420

usalsfyre said:


> Sorry to go nuclear on you, just had some very, very frustrating experiences here lately with people not being able to tell me "why" before they did (or for that matter, did not) do an intervention.



not a problem, that's life on the internet

didn't Brown go to college for 4 years to be a medic in New Zealand?  wonder if he thinks RNs would be any better than a medic with a degree


----------



## usalsfyre

Journey said:


> It seems some in EMS would rather make personal accusations or attacks rather than do a little research on the many topics that just this thread has touched on.



I guess everyone needs to vent. 


And yes, many people refuse to be educated. But wholesale replacement with another profession does not necessarily fix the issue.


----------



## Journey

usalsfyre said:


> I guess everyone needs to vent
> 
> 
> And yes, many people refuse to be educated. But wholesale replacement with another profession does not necessarily fix the issue. Especially when the other profession is more geared towards "observe and report" as well as the "unicorns and rainbows" approach to healthcare.



Your vent is acknowledged. But that does not mean you should not see what others are doing in health care and to see where EMS could fit in.

The Paramedic in San Francisco realized he could not tackle the problem by himself and that EMS alone was not the answer.



uhbt420 said:


> didn't Brown go to college for 4 years to be a medic in New Zealand?  wonder if he thinks RNs would be any better than a medic with a degree



Their EMS system is not as broken as that in the U.S. so it probably is not an issue.


----------



## Shishkabob

Journey said:


> In several of your posts you have referred to being too uneducated to do your job rather than providing an agrument as to why you feel the hours of training in Texas to be a Paramedic is enough and qualifies those who only do the minimum to have so many skills and drugs at their access.



Where did I ever state the Texas minimum was enough?



> Do you know what a drug or mental health care counselor does?  If you did you would see you are not either.


  Uh, kind of the point that I was making to YOUR post.  



> I don't believe there is any state that will allow a Paramedic to even declare a person mentally incompetent for an involuntary mental evaluation hold.


  Honestly, that's a moot point considering cops, with no medical education, can do an APOWW for psychiatric evaluation.



> Primary Care Providers are usually physicians or physician extenders which the Paramedic is neither.



Again, you missed the point I was making of your very own post...


----------



## usalsfyre

Journey said:


> Do you know what a drug or mental health care counselor does?  If you did you would see you are not either. I don't believe there is any state that will allow a Paramedic to even declare a person mentally incompetent for an involuntary mental evaluation hold.



I think Linuss's point was we are wholly unqualified to do either.


----------



## usalsfyre

Journey said:


> Your vent is acknowledged. But that does not mean you should not see what others are doing in health care and to see where EMS could fit in.



I have no problem with this, and encourage others to do the same.


----------



## Journey

Unfortunately there are more who think with a very narrow focus in EMS which drags down the whole profession and anyone who comes up with an innovative solution will be criticized by some who just can't see the broader picture.

I guess I have learned now to stay on forums where making a difference and providing quality health care is still a good discussion especially when there are so many issues to prepare for in the next year where patients can benefit from our support.


----------



## Aidey

This wasn't a good discussion from the moment it turned into a hostile "All paramedics are uneducated idiots who are hopeless and should just be eliminated" rant. There are people who are more than willing to discuss making a difference and providing quality health care but this thread has not been a productive discussion.


----------



## Veneficus

Linuss said:


> The thing is, the BIGGEST complaint that this thread raises is a Paramedic's apparent inability to understand anything medical outside of emergency medicine.  (Which is a stupid fallacy in and of itself)



I thought the point of the thread was to explore the possibility of replacing tech level EMS with licensed educated providers for the purpose of bringing EMS up to par with other modern nations. What do I know?




Linuss said:


> Truthfully, this isn't a problem of EMS and any supposed lack of education, but of the civilian population who utilize 911 for non-emergencies and primary healthcare.   If EMS / 911 were utilized only for true emergencies, I'd venture to guess this thread would not exist aside from people WANTING us to get in to community Paramedicine.)



If in the perfect world from an EMS point of view the public only called for true emergencies, how many paramedics do you think would need to be employed? Since the common wisdom that 5% or less of all patients who activate EMS or go to the ED have an "actual emergency" then wouldn't that mean that only 5% or less of the nations paramedics would be needed? Where does that leave you?

I get to advocate for patients. I have no financial interest in bringing EMS up to date. I will never be an EMS medical director, I will probably never operate on an ambulance again. (past my 7 required days for school left)

It is not that I want to bring community paramedicine, it is that it has been demonstrated that is the future of EMS. Not just in Europe or Australasia, but in progressive EMS systems in the US as well. All of my harping on education and the lack of it is my attempt to pull EMS out of the 1970s. With the exception of the new gadgets employed, that is the dated treatment and perceived role of EMS by a large number of providers.

Honestly, if EMS had the ability to do what it needed to increase or even keep its value in society, a thread like this would be pointless. But I didn't make this gem up. There are physicians discussing this as the alternate to the resistance of EMS providers who don't like it. It is primarily being discussed as a potential form of healthcare waste that can be eliminated. 

It affects every EMS provider in the US, whether you want to face it or not.

If reimbursement is substantially decreased, how will that change the game for FDs who use the revenue to prop up their budgets?

How will it affect the 3rd service EMS agencies where billing is the major part of the budget. I know at least 1 3rd service agency where only 20% of the total budget comes from taxes, the rest from soft billing. If they lost a substantial part of their revenue, they would be lucky to field 1/2 of thier current units. (which isn't enough for the area and volume now)

How will it affect private EMS providers whose sole source of income is billing?     



Linuss said:


> And don't bring up that "The patient defines the emergency, not us" crap.  No.  A stubbed toe is not an emergency.



At anytime a patient can walk into an ED or call 911. Tell me, what makes EMS so special they only have to see emergencies that they deem appropriate? 

What makes a paramedic so great they can tell people when to call for EMS when a physician in the ED takes care within the best of her ability and confines of resources any patient who comes in for any reason? 

Do you think figuring out what to do about the chronic drug seeker is the best use of the talents of emergency physicians?

Do you think that some girl who comes in for a pregnancy test to the ED is the best use of that resource? Did you know that many EDs actually hand out plan B pills?

Do you know how many PID patients I have seen in the ED at 3 am as both a paramedic and medical student? It has to be in the hundreds.

Yet nobody tells them to stop coming because it is not an emergency. 

That patient with the stubbed toe who calls 911 is probably keeping your system economically alive. They will be billed as emergency ALS response. The amount of resources used on them is utterly minimal. That maximizes payment/overhead.

If you think the patient doesn't define the emergency, I think you will have a lot of trouble convincing that to the rest of the healthcare fields.

US EMS has failed to advance itself in more than 30 years. If it can't get its head out of its *** and finally take the next steps, it will get left behind. Not because I think so. It is a demonstrated pattern in all antiquated industries.

Perhaps you are a lost cause for advancing EMS? But perhaps somebody reading this will be reached.


----------



## Veneficus

Linuss said:


> However, I have told a mom that calling 911 because her daughter started bleeding (Bleeding as in less blood than losing a tooth) in the mouth after brushing her teeth real hard before going to the dentist is probably not the best use of emergency personnel.


 
Just out of curiosity, how do you know it wasn't an early sign of Scurvy?


----------



## Shishkabob

Veneficus said:


> Just out of curiosity, how do you know it wasn't an early sign of Scurvy?



Is scurvy caused by a sharp edge of a tooth-brush with a cut to the roof of the mouth?


----------



## Veneficus

Linuss said:


> Is scurvy caused by a sharp edge of a tooth-brush with a cut to the roof of the mouth?



No, but it is caused by life threatening vitamin C deficency which manifests in weak collagen fibres which are more easily cut by a toothbrush sharp end or otherwise.


----------



## Aidey

Veneficus said:


> ...
> 
> Yet nobody tells them to stop coming because it is not an emergency.
> ...



No, they turf them over to the fast track/urgent care part of the ED, so that the ER MDs time is used for people who have more acute problems.


----------



## Veneficus

Aidey said:


> No, they turf them over to the fast track/urgent care part of the ED, so that the ER MDs time is used for people who have more acute problems.



When there are fast track and urgent care in house. Which is not as common as it should be, usually due to older construction and the limit of space.


----------



## usalsfyre

Veneficus said:


> Just out of curiosity, how do you know it wasn't an early sign of Scurvy?



Honestly, outside of determining diet/social history/"hey do you have any weird spots on your skin", do you really think the ED is going to evaluate for scurvy?


----------



## Shishkabob

Veneficus said:


> No, but it is caused by life threatening vitamin C deficency which manifests in weak collagen fibres which are more easily cut by a toothbrush sharp end or otherwise.



And how, on the off chance that it was scurvy, is it a true emergency that a Paramedic should have dealt with, let alone taking to the ED, when the patient was going to the dentist, with much more education on the matter than the average ED MD, in mere minutes?

And how would a nurse on an ambulance been any better in said situation than a Paramedic?  Do nurses have the ability to test for scurvy in the field any more than a Paramedic?


----------



## Aidey

The correlation is still relevant. They determine that the person does not need the services of the full ED, and they send them to an appropriate level of care. When we determine that someone does not need the full services of an ED we are still generally required to transport them. 

Take the example of the pregnancy test and Plan B. Because I am not allowed to refuse transport or dissuade people from transport via ambulance I can't advise this person that they would better served by one of the 6+ or so urgent care centers in the area, and that pharmacies without a moral hang up will give Plan B to women 18 and older without a prescription.

Edit: Just to add, in this situation I would theoretically have maps showing the locations of the urgent care centers, pharmacies (specifically 24 hour ones), along with the appropriate contact information. I would be able to write out the instructions on a triplicate form that the patient would sign, providing both of us with a copy showing exactly what the instructions were, and that the pt willingly accepted them in lieu of transport.


----------



## Veneficus

usalsfyre said:


> Honestly, outside of determining diet/social history/"hey do you have any weird spots on your skin", do you really think the ED is going to evaluate for scurvy?



honestly I am pretty sure that Linuss's assessment was quite accurate, but I just wanted to make a point that there exists possibilities outside the obvious if you don't know what you are looking for.

No, I do not think the ED is going to evaluate for malnutrition, which is something more frequently done by Peds or family practice. 

But there in lies one of the main tenants of the argument, the kid is better served by a dentist than by an emergency department. Unless of course an EMS provider was going to instruct them on how to brush their teeth and deal with oral wounds rather then giving them the riot act on what constitutes a worthy emergency.


----------



## usalsfyre

But this isn't really an EMS failure, it's a US healthcare in general failing.


----------



## Veneficus

usalsfyre said:


> But this isn't really an EMS failure, it's a US healthcare in general failing.



Yes, and EMS is part of the healthcare system. As such, I thin it has a duty to help meet thehealthcare needs of the public, not define its own role. 

Moreover, since the US healthcare system is failing, wouldn't it feel better to be a valuable part of the solution rather than the weak link?


----------



## usalsfyre

Veneficus said:


> Yes, and EMS is part of the healthcare system. As such, I thin it has a duty to help meet thehealthcare needs of the public, not define its own role.
> 
> Moreover, since the US healthcare system is failing, wouldn't it feel better to be a valuable part of the solution rather than the weak link?



^^^^^

When you put it that way, it's a darn good point. Unfortunately, we're currently a slave to the reimbursement model, and community health doesn't make money for the FD, county, private company managers, base hospital, ect....


----------



## SerumK

usalsfyre said:


> There's the patients inability to deal with the situation, and then there's a true emergent/urgent complaint.
> 
> Who said anything about attitude? But there is definitely a difference between an honest to God emergency, an urgent complaint that still needs treatment and transport or referral and those who just don't need medical services. Which is not something the patient defines.
> 
> More education is needed, but arguing that the patient is the only one able to define an emergency is dumb.
> 
> Why is it when anyone mentions that the majority of patients we treat and transport are not true medical emergencies (many times however they do fit in the urgent category) they get accused of being an uncaring bigoted ogre who lets their patients die?



I said the patient defines the emergency (thus they call 911) and we define the urgency (evaluate the situation and deal appropriately ALL things considered).


----------



## Shishkabob

Since I got...umm... flak, from a certain person in a way I cannot discuss,  for my previous post, I shall reword it and make it "compelling":

"This thread is............... *dramatic pause*................... silly


We all agree that education lacks, yet disagree on whether that should be fixed or scrap Paramedicine altogether and just give it to nurses.  Obviously, other of your "better" EMS countries separate EMS from Nursing, so why must we combine them?

Why was nursing given so long to change, yet EMS is expected to practically overnight?

Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?




Silly, silly, silly."


----------



## Chimpie

Linuss said:


> <snip>
> 
> Why was nursing given so long to change, yet EMS is expected to practically overnight?
> 
> Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?"



There are over 270 posts in this thread so I may have missed it, but who said EMS is expected to change overnight?

I completely agree that EMS has progressed, but just because it's progressed doesn't mean that we can stop now.

The Japanese use the word Kaizen which means "continuous improvement".  Yes, we've made improvements.  Now we have to look at where we are and we're going and create a plan.


----------



## SerumK

I have no idea why my image illustrating my point of pt emergency vs provider urgency was removed... it seemed to illustrate my point as well as be worth of its own thread for those people who have stopped bothering with this thread. If you want to see the image, click here:

http://www.emtlife.com/showthread.php?t=21204

Do it! It is hilarious!


----------



## Chimpie

Chimpie said:


> Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).
> 
> Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?





Journey said:


> I am surprised someone from Florida would as this.



My apologies for not being clearer.  I wanted to know what Veneficus's view was for creating this thread.



			
				Journey said:
			
		

> Florida has for decades be a leading in Community and Public health programs which include RNs. They also play a significant role in disaster preparedness and management since there is no way EMS could ever cover all the bases for the many health care and shelter needs in the community which includes medical patients and the homeless.  If these RNs did not go out into the community at senior citizen centers and homeless shelters, which includes under the bridges, to identify and get these people the necessary care, there is no way even the best EMS systems in the area could handle all the calls.
> 
> Community and Public Health RNs, Social Workers and Case Managers (also could be RNs) have played a role in preventitive community medicine for investigating situations and providing them with the needed services which may involve calling the physicians associated with their agency for advise. There is absolutely nothing wrong with calling "med control". A few hours of training or even 2 or 4 years do not make anyone a doctor. This thing where Paramedics in the U.S. feel like it is bad to call a doctor just shows how little some might know about the many illnesses there are and may not realize their limitations.  These Community and Public Health RNs are involved in so many projects around the country which also includes child and elder abuse as well as identifying and caring for medical problems of the homeless under the bridge.  Many times they are called to investigate a person whose neighbor has seen EMS at the home many times but each time a "refusal form" is signed and EMS has cleared because the patient was okay since they know their name and place or didn't have any obvious trauma or illness. Unfortunately just knowing your name and where you are does not mean you can't be in need of some medical care or a different living situation. But, for many in EMS, "not my job to be a social worker, I just do the emergencies" is often the response. Is this just the lack of training or is it just "not my job" that prevents them from expanding their sight into preventitive care?
> 
> In San Francisco there is a Paramedic, Niels Tangherlini, who started an outreach program for frequent 911 users including the poor, homeless, mentally ill, elderly, disabled, and alcoholics and drug abusers. Prior to starting this program he got a degree from UC Berkeley in Social Welfare and formed an alliance with the Department of Public Health. He also enlisted the assistance of RNs and RRT as well as many others involved in the health care systems to cover the medical needs he did not have expertise in.  I would say Mr. Tangherlini had the foresight to know the limits of his Paramedic training and the limitations of the EMS system to see the bigger picture to provide the needed services.



Very good points all the way around.


----------



## Veneficus

Linuss said:


> We all agree that education lacks, yet disagree on whether that should be fixed or scrap Paramedicine altogether and just give it to nurses.



I would hope that bringing such discussion to light would serve to help EMS step up rather than languishing in its complacency.




Linuss said:


> Obviously, other of your "better" EMS countries separate EMS from Nursing, so why must we combine them?



Because their providers did step up. US providers are not. If a trade cannot maintain relevance it gets eliminated. Natural order of economics.



Linuss said:


> Why was nursing given so long to change, yet EMS is expected to practically overnight?



Nursing wasn't given so long, it changed of its own accord. It saw what the future demanded and worked towards it. In fairness, they didn't have other nations who already figured it out to emulate. So EMS really isn't being asked to be the groundbreaking model that nobody ever saw before, it simply needs to copy what others have figured out.



Linuss said:


> Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?



The progress? I taught EMS for 7 years, I resigned this september because it is actually going backwards. That means there is no progress there is regress. 

I understand very well what is being introduced. Even more well how it will be improperly implemented.

Perhaps in skills and toys you think there is progress, but I would be sort of concerned when technology makes my job so easy anyone could do it.  

I have reviewed EMS texts and I can tell you that the quality is going down, not up. That the trend is being demanded by the publishers not the authors. So why would a publisher demand that? Because it wants to sell books. So it plays to its audiance, like any successful business. Those in EMS who want to see it advanced are a small minority. The voices of those holding it back are much louder. I think that they do it for mental security, not out of malice. But like I have said, sticking your (not you particularly) head in the sand telling yourself you are doing all right when every similar industry in  modern nations in the world has surpassed you by condiderable margins is not really a good thing. 

Is it too late? I don't think so, I think that with the recent political look at eliminating ALS in the urban environment with short transport times. The economic issues facing healthcare which no party wants to be cut from, but EMS is isolating itself and not doing what is required to assure it is not the loser in the endgame. That the time may be at hand.

As I keep pointing out, the very worst thing it is doing is defining what it wants itself to be, with more ferver than ever, rather than being what is needed. 

The door is starting to close on EMS so while it is not too late, considering the speed at which it moves, it had better get it together because the voices against it are only going to grow.  



Linuss said:


> Silly, silly, silly."



If I were banking on making a career in EMS, I wouldn't think silly, so much as I would think "scary."

If you feel the discussion is not worth the time, why be part of it?


----------



## JPINFV

Linuss said:


> Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?



The problem is that change has to occur, be it over night or the long run. The problem is that if EMS changing, it's changing in the wrong direction. 

As far as how fast the change can occur, again, look at other professions. It was only about 100 years ago that medicine (physicians, not nurses) began to install national standards. Medicine is a lot older than EMS, but they were somehow able to pull off closing bad schools and requiring increased educational standards relatively quickly, even overnight compared to how EMS handles change. Why is it that one of the original professions can change on a dime, but a trade trying to become a profession seems to have it's wheels spinning in the mud?


----------



## Veneficus

*I missed this in all of the excitement.*



Linuss said:


> And how, on the off chance that it was scurvy, is it a true emergency that a Paramedic should have dealt with, let alone taking to the ED, when the patient was going to the dentist, with much more education on the matter than the average ED MD, in mere minutes?



For the benefit of those still reading I would like to just off topic a little and discuss this.

Vitamin C deficency is caused from malnutrition. Which means other malnutrition states are possible. But the life threatening sequele for the benefit of clinical education. (malnutrition can be a sign of neglect, which is serious enough to require mandatory reporting)

Defect in type I collagen. (which your blood vessles have) can cause your blood vessles to be unstable and rupture. (trouble there)

In addition you can lose your teeth. Which is not only an asthetic problem that can lead to psychosocial problems but can also lead to further malnurishment.

Furthermore the potential hemarthrosis can be mistaken for hemophilia A. Which could lead to a misdiagnosis and inappropriate treatment in the hospital.



Linuss said:


> And how would a nurse on an ambulance been any better in said situation than a Paramedic?  Do nurses have the ability to test for scurvy in the field any more than a Paramedic?



I was under the impression that nurses are responsible for assessing the nutritional status of patients as part of their nursing assessment. But that is just what I have been told by nurses I know. I have no reason to doubt them, so I consider it true.

Ok, clinical time over, back to the topic at hand.


----------



## Aidey

What is the major difference between the systems in the UK/OZ/NZ/etc that have been touted as so much better, and evolved so much fast. 

Universal healthcare with EMS run by a central agency. 

We don't have either of those, and aren't going to anytime soon. It is a lot easier for change to be made when it is done from the top down than the bottom up. Comparing the evolution of EMS in those countries to the evolution of EMS in the US isn't a fair comparison because the way we get from Point A to Point B is totally different than those places.


----------



## Veneficus

Aidey said:


> What is the major difference between the systems in the UK/OZ/NZ/etc that have been touted as so much better, and evolved so much fast.
> 
> Universal healthcare with EMS run by a central agency.
> 
> We don't have either of those, and aren't going to anytime soon. It is a lot easier for change to be made when it is done from the top down than the bottom up. Comparing the evolution of EMS in those countries to the evolution of EMS in the US isn't a fair comparison because the way we get from Point A to Point B is totally different than those places.



I think it is a very fair comparison. 

In those countries, cost containment is a serious issue. In the US, cost containment has become a serious issue. 

Yes our system is different, it is failing. But public or private, industries still need to meet the needs of the consumer. EMS is no different. 

There is a lot of talk about what is reimbursed and what isn't. But that is subject to change. Additionally as was pointed out earlier, there is reimbursement for home healthcare. 

Similarly, a business (fire department, county service, etc) which opens up new revenue streams or provides additional value while reducing costs is a successful enterprise. 

In any industry it is rare for the techs to be given a voice at the discussion when professionals and power players are discussing where cuts are going to be made. 

If it potentially means your job, is it not worth what it takes to make sure your interests are represented?


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## Aidey

Veneficus said:


> I was under the impression that nurses are responsible for assessing the nutritional status of patients as part of their nursing assessment. But that is just what I have been told by nurses I know. I have no reason to doubt them, so I consider it true.
> 
> Ok, clinical time over, back to the topic at hand.



As someone who has had the unfortunate opportunity to have multiple ER visits this year, I've never had my overall nutritional status assessed. Even after a documented 100+ lb weight loss between my ER visits this year and my previous ER visits. The closest thing I had to a discussion about nutrition was when my gallbladder went bad and the MD asked me about fatty foods and alcohol. 

Even my GP doesn't go much past are you getting enough of the good stuff, and are you going easy on the caffeine? And she is an awesome GP, who leans towards the holistic side of things. 

Now, I do remember when I did the geriatric clinicals during Paramedic school when the RNs did intake assessments on patients being admitted to the SNF (that was literally attached to the hospital) they assessed nutrition status. I also often notice information on the patients diet and eating habits in charts sent out from SNFs. 


Soooooooooooooooo, my end point is that I suspect that things like a nutritional assessment are done on an as needed basis depending on the situation, complaint,  setting etc. I don't think it is something done on every patient, all the time, especially in the ER.


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## TransportJockey

Aidey said:


> As someone who has had the unfortunate opportunity to have multiple ER visits this year, I've never had my overall nutritional status assessed. Even after a documented 100+ lb weight loss between my ER visits this year and my previous ER visits. The closest thing I had to a discussion about nutrition was when my gallbladder went bad and the MD asked me about fatty foods and alcohol.
> 
> Even my GP doesn't go much past are you getting enough of the good stuff, and are you going easy on the caffeine? And she is an awesome GP, who leans towards the holistic side of things.
> 
> Now, I do remember when I did the geriatric clinicals during Paramedic school when the RNs did intake assessments on patients being admitted to the SNF (that was literally attached to the hospital) they assessed nutrition status. I also often notice information on the patients diet and eating habits in charts sent out from SNFs.
> 
> 
> Soooooooooooooooo, my end point is that I suspect that things like a nutritional assessment are done on an as needed basis depending on the situation, complaint,  setting etc. I don't think it is something done on every patient, all the time, especially in the ER.



Nutritional assessments are done on pretty much every patient that is admitted to the hospital. But they are done by (at my old hospital system) dieticians and nutritionists.


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## Veneficus

Aidey said:


> As someone who has had the unfortunate opportunity to have multiple ER visits this year, I've never had my overall nutritional status assessed. Even after a documented 100+ lb weight loss between my ER visits this year and my previous ER visits. The closest thing I had to a discussion about nutrition was when my gallbladder went bad and the MD asked me about fatty foods and alcohol.
> 
> Even my GP doesn't go much past are you getting enough of the good stuff, and are you going easy on the caffeine? And she is an awesome GP, who leans towards the holistic side of things.
> 
> Now, I do remember when I did the geriatric clinicals during Paramedic school when the RNs did intake assessments on patients being admitted to the SNF (that was literally attached to the hospital) they assessed nutrition status. I also often notice information on the patients diet and eating habits in charts sent out from SNFs.
> 
> 
> Soooooooooooooooo, my end point is that I suspect that things like a nutritional assessment are done on an as needed basis depending on the situation, complaint,  setting etc. I don't think it is something done on every patient, all the time, especially in the ER.



Just because something isn't done, doesn't mean it shouldn't be done. 

I know that it is not routine in the ED, which is one of the reasons there can be misdiagnosis, but lack of treatment because with the exception of thiamine and perhaps b12, the ED really isn't the best place to attempt to treat malnurishment. 

I have no doubt to your experience though.


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## Aidey

Veneficus said:


> I think it is a very fair comparison.
> 
> In those countries, cost containment is a serious issue. In the US, cost containment has become a serious issue.
> 
> Yes our system is different, it is failing. But public or private, industries still need to meet the needs of the consumer. EMS is no different.
> 
> There is a lot of talk about what is reimbursed and what isn't. But that is subject to change. Additionally as was pointed out earlier, there is reimbursement for home healthcare.
> 
> Similarly, a business (fire department, county service, etc) which opens up new revenue streams or provides additional value while reducing costs is a successful enterprise.
> 
> In any industry it is rare for the techs to be given a voice at the discussion when professionals and power players are discussing where cuts are going to be made.
> 
> If it potentially means your job, is it not worth what it takes to make sure your interests are represented?



There are definitely similar problems, I don't disagree with that. My observation is on the management side of things. If the NHS wants to change something about how the ambulances work, they can, and it affects all of the ambulances equally.* Who exactly in the US has the power to do that? No one, the DOT sets educational minimums, but they have no enforcement ability. Individual states, cities, counties and services within those entities have a lot of freedom of what they want to allow EMS to do. There is no way to make a national change easily like exists in the countries that have more advanced EMS. 


* I'm assuming equally, I don't know if the zip code lottery affects ambulance care the same way it affects hospital care.


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## Shishkabob

Veneficus said:


> Just because something isn't done, doesn't mean it shouldn't be done.
> 
> I know that it is not routine in the ED, which is one of the reasons there can be misdiagnosis, but lack of treatment because with the exception of thiamine and perhaps b12, the ED really isn't the best place to attempt to treat malnurishment.
> 
> I have no doubt to your experience though.



It's also neither routine to be checked in the field, and we have thiamine as well... so I'm confused as to why you even brought it up as a point against Paramedics in the first place?


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## Veneficus

Linuss said:


> It's also neither routine to be checked in the field, and we have thiamine as well... so I'm confused as to why you even brought it up as a point against Paramedics in the first place?



Because if an agency is doing or has a home healthcare component it should be part of the regular assessment. Especially in the children or elderly.

Despite some of the back and forth, this was never meant to be a paramedic vs. nurse thread, it was supposed to focus mainly on how nursing could be the solution to the dilemas facing EMS.

Physicians are taught and tested on nutrition, and as was pointed out, they may not be assessing it properly either. It still doesn't mean it shouldn't be done.

It is not that I don't want EMS to succeed, they are simply their own worst enemy. I am trying to move on from the problem and discuss solution.


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## Aidey

I should have added that my case may not be the best example, since all the ER docs who treated me know me, so they were probably much more trusting than they would be of some random person.


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## ffemt8978

Rather than waste time going through the 200 posts in this thread to remove the off topic posts this thread is closed.


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