# Paramedic to RN bridge….. options?



## LoadingCosta (Jan 22, 2022)

What’s up everyone? 

   I’m a paramedic in the state of Georgia. I’ve been a paramedic for three years now and I’m 28 years old. I work full time at a fire department but I am currently unhappy with my current situation. I’m seeking some solid advice. I’m not old by any means but I feel like I’m falling behind in finding what direction I want. I thought at one point I did have it all figured out. I thought nursing was the route I wanted. I have passion for traveling and seeing the world. I love taking care of patients and making a difference. I love the medicine model but I’m far from smart enough to become a doctor or physician assistant. I don’t even have a bachelors degree. I thought about doing a bridge program from paramedic to RN and than travel with my RN license and one day transition to maybe NP and specialize in cardiology or orthopedic. 

I recently was accepted into Albany State University bridge program and withdrew after a week. Many reasons for why I backed out. I’m not going to list them all here but I was driving two hours and 30 minutes to school and the material was “overwhelming.” I was taking two classes at the time. First class was nursing fundamentals that required 500 pages of text to read and Psych mental health reading over 300 pages. We would have a test every 2 weeks on each class and we had to finish the class with a minimum of 75. Only 6 module exams and one final exam. 50 questions on exams. 20 multiple choice and select all that apply and the rest was fill in the blanks and short answers. I also work full time at a fire department. I decided to withdraw after 1 week because I didn’t think that program was setting me up for success m. 

Now I’m sitting here debating if I want to go back to nursing school and try another program or not but all programs I have called mentioned they changed there material because previous years, students were buying test banks and using them to cheat. This is why now they are doing short answers and fill in the blanks. I really don’t know what direction I want to do anymore. I would love to be a nurse but I don’t believe I have the passion for nursing school. I want to leave the fire department and get off the ambulance but I don’t know what to do anymore seeing there are not many options. 

I thought about IT but the field is over saturated and it’s not very intriguing to me like medicine is. 

I had goals goals and now I truly do feel like a failure and stuck. 

I can’t do a traditional program because I’m single and by myself. Have bills to pay. 

If you read this. First, thank you. Secondly, any advice or wisdom would be greatly appreciated. Thank you so much and stay blessed!


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## mgr22 (Jan 22, 2022)

It's not unusual to change jobs and/or try different career paths. When I was your age, I'd just started my fourth full-time job in seven years. The fifth would be three years later. Each time, I expected to stay longer, but I ended up feeling I'd be happier elsewhere. Sometimes I was.

Other than medicine, what do you like to do? What do you think you're good at? Do you have any college or trade experience? How did you do in paramedic school? What did you do before you became a medic?

You said something about seeing the world. Have you considered military service?

You mentioned a program that didn't set you up for success. What does that mean to you -- i.e., how would you want to be set up for success?


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## MMiz (Jan 22, 2022)

This reminds me a lot of the time I took my evenings EMT basic class.

The drive was miserable, it was late at night, and just a few classes in I dropped the course.  It wasn't a good fit.

I ended up taking it over the summer and had a completely different experience that I fondly remember as some of my best days in college.

I wouldn't be so quick to dismiss nursing based on this poor experience.

I'd find a local nursing program where you can get your Associates Degree in nursing.

Once you have that you can easily pursue a BSN degree, or something else.

You'll find nursing school is likely overwhelming, but the payoff after a couple of years is immense.

As far as nursing not being your end goal in life, that's fine.  I've known nurses to become CRNAs, Physician Assistants, and completely leave the field for something else.

At the very least, keep moving forward.  Can you take some nursing pre-requisites online to be transferred to the program?  I was surprised to see that most community colleges now often nursing classes online.


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## CCCSD (Jan 22, 2022)

You either WANT it, or don’t. Sacrifice is part of life.


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## EpiEMS (Jan 22, 2022)

LoadingCosta said:


> I love the medicine model but I’m far from smart enough to become a doctor or physician assistant. I don’t even have a bachelors degree. I thought about doing a bridge program from paramedic to RN and than travel with my RN license and one day transition to maybe NP and specialize in cardiology or orthopedic.


That's not necessarily true! PA schools are practically meant for EMS providers and military medics (other than the hurdle of prerequisite coursework). You can turn your paramedic licensure into a good portion (something like 40-50 credit hours) of an associates' degree (I believe about 60 credit hours) and then you're halfway to a bachelors (120, roughly) - most of which could be as easy or as hard as you want.

I think an ADN makes sense based on what you're saying, but I don't think medical school or PA school is out of reach by any means!


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## akflightmedic (Jan 22, 2022)

LoadingCosta said:


> I can’t do a traditional program because I’m single and by myself. Have bills to pay.



What??? This is EXACTLY the time you do it...LOL. You think it is easier with a partner or a family??

FYI, I did the traditional program working TWO jobs and going through a divorce.


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## LoadingCosta (Jan 22, 2022)

akflightmedic said:


> What??? This is EXACTLY the time you do it...LOL. You think it is easier with a partner or a family??
> 
> FYI, I did the traditional program working TWO jobs and going through a divorce.


May I ask how you did this? Maybe you ate just amazing at what you do but I’m not sure how to accomplish this……


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## LoadingCosta (Jan 22, 2022)

CCCSD said:


> You either WANT it, or don’t. Sacrifice is part of life.


I absolutely agree. I also want to be make sure I am set up for success…


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## LoadingCosta (Jan 22, 2022)

CCCSD said:


> You either WANT it, or don’t. Sacrifice is part of life.


I absolutely agree. I also want to be make sure I am set up for access


mgr22 said:


> It's not unusual to change jobs and/or try different career paths. When I was your age, I'd just started my fourth full-time job in seven years. The fifth would be three years later. Each time, I expected to stay longer, but I ended up feeling I'd be happier elsewhere. Sometimes I was.
> 
> Other than medicine, what do you like to do? What do you think you're good at? Do you have any college or trade experience? How did you do in paramedic school? What did you do before you became a medic?
> 
> ...


You ask a good question. I’m good at sports and fitness. Don’t get me wrong, I enjoy video games but that is more of a stress relief if you will. 

I have college experience in regards to take my prerequisites for the nursing program and going to fire school but nothing major. I was actually working at a supermarket and a tire shop prior to joining the fire department. I’ve had plenty of other jobs like delivery driver for Pizza Hut but nothing major. 

I actually did very well in paramedic school. Passed first time at 75 questions. I was working at my current fire department as an EMT. 

I’m looking for a school that wants to teach students and doesn’t just throw 20 different websites and materials at us and tells us to read and see us next class. When I asked for help all they said was read. A lot of material is great but I also feel like too much can be overwhelming and it makes it hard to figure out what is important to study and what is not.


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## LoadingCosta (Jan 22, 2022)

MMiz said:


> This reminds me a lot of the time I took my evenings EMT basic class.
> 
> The drive was miserable, it was late at night, and just a few classes in I dropped the course.  It wasn't a good fit.
> 
> ...


Do you know where I would be able to find these kind of nursing programs prior to getting into a program? I’m not sure how that’s even possible honestly.


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## LoadingCosta (Jan 22, 2022)

EpiEMS said:


> That's not necessarily true! PA schools are practically meant for EMS providers and military medics (other than the hurdle of prerequisite coursework). You can turn your paramedic licensure into a good portion (something like 40-50 credit hours) of an associates' degree (I believe about 60 credit hours) and then you're halfway to a bachelors (120, roughly) - most of which could be as easy or as hard as you want.
> 
> I think an ADN makes sense based on what you're saying, but I don't think medical school or PA school is out of reach by any means!


I really appreciate your confidence in me but I felt like if I could not pass nursing school, how the heck can I even pass PA school? 

I definitely want a bachelor degree that I can fall back on and that’s why I choose nursing. I don’t want to go into debt for a useless degree if that makes sense.


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## MMiz (Jan 22, 2022)

Doesn’t every community college offer a nursing program?  I’d be inclined to go the community college route. 

I’ve known paramedics that successfully completed online nursing programs while working as paramedics.  Twenty years ago they went the Excelsior route, today I was able to find dozens of online programs in my state. 

If you’re just looking for a degree to have a degree, Western Governors University seems like a cheap and easy route. 

If you’re looking for your degree to help open doors I’d look at a more traditional state university after completing as many credits as possible at a community college. 

Going to school is a lot of work, sacrifice, and stress. You can do it. 

Where are you located?


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## LoadingCosta (Jan 22, 2022)

MMiz said:


> Doesn’t every community college offer a nursing program?  I’d be inclined to go the community college route.
> 
> I’ve known paramedics that successfully completed online nursing programs while working as paramedics.  Twenty years ago they went the Excelsior route, today I was able to find dozens of online programs in my state.
> 
> ...


I’m located in Georgia. Idk where these online programs are to take individual courses (nursing). 

Idk how to complete a traditional program as a single male working full time to pay bills.


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## akflightmedic (Jan 22, 2022)

My traditional nursing program for freshman year was every Monday and Wednesday 0800-1300, and Friday Clinical 12 hours. My senior year was every Tuesday and Thursday with Friday/Sat Clinical or Fri/Mon Clinical.

With that schedule it was easy to plan my life and jobs around school. Also, attendance for lectures was not mandatory, so I did skip a few but I had classmates record it for me, the college also recorded and uploaded their lectures as well. I just got them faster from classmates.  

Have you looked into Community Colleges?? They want butts in the seats and the schedules are not demanding. My first born is starting nursing school herself, but she has a FT M-F office job. How is she doing it?? The college offers an evening/weekend option for people like her.

I truly do not understand how you can say you cannot afford to do this as a single person. That is legit the BEST time ever to make extreme time sacrifices and get it done anyway possible. No Sig Other to sweat you, no one's mouth or roof to worry about except your own....


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## Akulahawk (Jan 23, 2022)

LoadingCosta said:


> I’m located in Georgia. Idk where these online programs are to take individual courses (nursing).
> 
> Idk how to complete a traditional program as a single male working full time to pay bills.


There are a number of different schedules available, you just have to find a program that offers non-traditional scheduling for your schooling. While you're young and single, that's the best time to take on an endeavor like this as you'll get to be much more flexible in your time commitments that you ever will once you've got a family. The one thing I must caution you about is that you really should focus on getting at least an Associate's Degree out of the experience. It'll help tremendously when/if you decide to return to do a Bachelor's. Why? All your lower division GE is DONE and won't have to be repeated. This alone makes it much faster to complete any Bachelor's. Having that ADN along with the RN license makes getting a BSN through an online program MUCH easier as you'll have already done the "hard work" in clinicals to get the BSN, you just have to take the additional theory and other Upper Division GE to earn that BSN.


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## LoadingCosta (Jan 23, 2022)

akflightmedic said:


> My traditional nursing program for freshman year was every Monday and Wednesday 0800-1300, and Friday Clinical 12 hours. My senior year was every Tuesday and Thursday with Friday/Sat Clinical or Fri/Mon Clinical.
> 
> With that schedule it was easy to plan my life and jobs around school. Also, attendance for lectures was not mandatory, so I did skip a few but I had classmates record it for me, the college also recorded and uploaded their lectures as well. I just got them faster from classmates.
> 
> ...


I’d have to look honestly but from what I read so far on schools in driving distance from my location, no schools are less than 3 days. All are a 4-5 days and sadly require a CNA license. 

There are a couple bridge programs around me that are closer and one I came across is making me nervous because the school program pass rate was below 70% and it makes me extremely nervous for that program. 

I’m trying to find a good program.


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## LoadingCosta (Jan 23, 2022)

Akulahawk said:


> There are a number of different schedules available, you just have to find a program that offers non-traditional scheduling for your schooling. While you're young and single, that's the best time to take on an endeavor like this as you'll get to be much more flexible in your time commitments that you ever will once you've got a family. The one thing I must caution you about is that you really should focus on getting at least an Associate's Degree out of the experience. It'll help tremendously when/if you decide to return to do a Bachelor's. Why? All your lower division GE is DONE and won't have to be repeated. This alone makes it much faster to complete any Bachelor's. Having that ADN along with the RN license makes getting a BSN through an online program MUCH easier as you'll have already done the "hard work" in clinicals to get the BSN, you just have to take the additional theory and other Upper Division GE to earn that BSN.


I agree with you. I am definitely trying my best to find a program. I’ve found a couple bridge programs but the pass rate for the school programs are below 70% which scares me honestly. Then all the traditional programs I’ve come across are requiring a CNA license. Just doesn’t seem right. I want to set myself for success for sure.


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## MMiz (Jan 23, 2022)

It seems like you're in a state of analysis paralysis.  You don't need to find the perfect program, you need to find a good program that works with your schedule.

I'd skip the bridge program and go through a traditional nursing program at a community college.

Most around me require a CNA cert, but that's just simply another relatively easy hoop to jump through.  Some might even be wiling to waive the requirement if you're a paramedic.


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## LoadingCosta (Jan 23, 2022)

MMiz said:


> It seems like you're in a state of analysis paralysis.  You don't need to find the perfect program, you need to find a good program that works with your schedule.
> 
> I'd skip the bridge program and go through a traditional nursing program at a community college.
> 
> Most around me require a CNA cert, but that's just simply another relatively easy hoop to jump through.  Some might even be wiling to waive the requirement if you're a paramedic.


I’m considering skipping the bridge programs but if I do than I need to retake AP 1 and 2 because my 5 year limit is up. I need to take a CNA course and I also need to find a program that will be doable for my schedule. It’s hard to find one in Georgia. 

I found Georgia Highlands College bridge program that I am considering because it’s not too far from my house. Only about an hour drive and I don’t have to worry about retaking AP. I’m trying to figure this all out. 

Unfortunately no program for the traditional programs will waive the CNA even though I have my paramedic.


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## Carlos Danger (Jan 23, 2022)

LoadingCosta said:


> Idk how to complete a traditional program as a single male working full time to pay bills.


I'm confused as to why you think you can't complete a traditional program just because you are single and work full time. You keep saying that, but you definitely wouldn't be the first (or the second, or even the third) participant of this discussion who did at least part of their education while working full time and supporting themselves if not also a family. 

If you are like many people, you probably live within a reasonable commute of at least two, maybe three or more community colleges that have two-year RN programs. Look into all of them. Talk to the program directors. Find out what the schedule would be like and how receptive they are to the idea of making some concessions for someone who works full time. Some are surprisingly flexible and supportive. Also think about what you can do with your work schedule that would make it easier to attend classes and study. It won't be easy to work and attend school full time, but it is entirely possible.

Another option is to just start taking non-nursing classes part-time that you can later fit into your nursing (or other) degree program. Taking the basic gen-ed requirements from a community college on a part-time basis is very affordable and generally pretty convenient to do while you keep your current FT job. Maybe this would build your academic confidence some and also give you time to figure out what you really want to do and how to move forward.

The last option is one that I would personally recommend the least, but is certainly a viable option if you really are convinced that it isn't possible for you to work FT and go to school FT at the same time: Enroll in a 4-year degree program (nursing or otherwise) at an affordable college and live mostly off student loans. Keep working in EMS part time and knock the whole thing out in a few years. Then hammer those student loans out in your first few years after graduation. If you go that route, it would probably benefit you (but certainly wouldn't be necessary) to try to first knock out a semester or so's worth of gen-ed courses through a community college while you look into and apply to 4-year programs and prepare yourself financially for the loss of income by cleaning up any credit card debt, selling your expensive truck to get rid of the the big payment, building up a bit of savings, etc. This would be the simplest and probably easiest option; the only downside is the student loan debt that you'll accumulate but that should be manageable as long as you live on the cheap and minimize how much you borrow.


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## FiremanMike (Jan 23, 2022)

I am in my final semester of my ADN program at a community college (nowhere near Georgia, sorry).  I have an admin job at the fire department, M-F 8-4 with a small amount of flex in that schedule.  I had been working at this for some time, so I completed every non-nursing class prior to starting.  Each of the first 3 semesters was 2 classes, a nursing class and a pharm class, the 4th semester was a nursing class and a human growth and development class, and this semester I only have my nursing capstone course.

I am a blended student.  I don't attend any lectures, which has it's advantages and disadvantages.  Coming into nursing school, I had completed a bachelors in public safety online without any issues, but the depth of knowledge for RN is so much greater, so self-study (even with recorded lectures) took a SIGNIFICANT amount of self discipline and devotion.  The advantage is that I only have to attend a lab once per week (sometimes once every other week) and most of my labs are in the evening.  

With clinical, I have been so lucky that each course has had a weekend and evening clinical available and I have managed to get into one of those every time so my work schedule is minimally interrupted (some days I need to take an hour of vacation to get to the hospital in time).  This semester is going to suck, because we have clinical 2x per week for 9 weeks.. I got saturday/sunday.. So yeah, 9 weeks of zero days off..

As to your comments on the volume of reading, that's just nursing school.  Like a lot of the folks in this thread, I was a "top of my class" medic student and always looked at as one of the stronger medics on the department, but I have found nursing school to be overall difficult and requires a significant amount of work.  I do think the grind of the last few semesters has improved me though, as this capstone class actually seems to be pretty smooth sailing.

I can't tell you if nursing is right for you or IT or underwater basketweaving..  For me it was originally medical school, but by the time my life was in a place that I could actually do it, I did some soul searching and realized I didn't want that life.  Docs work hard, and they work a lot of hours, and I do want to slow down at some point.  I went to RN with the plan on going direct to NP so that I could work at the provider level.  I did find that I enjoy direct patient care as an RN more than I expected, so I think I may take a few years to work as a nurse (part-time while I finish out my time in the pension system) and then decide.  

A final note on scheduling.  In 2007 I put myself through the police academy (wanted to be a state fire investigator, it never panned out).  That class was M-Th 6p-10p and every Saturday from 8a-5p for 6 months, mandatory in-person attendance.  At the time, I was working on company so 24/48.  Between vacation time and a small number of trades, I never missed a single class.  Working and going to school is doable, it just takes energy.


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## LoadingCosta (Jan 24, 2022)

FiremanMike said:


> I am in my final semester of my ADN program at a community college (nowhere near Georgia, sorry).  I have an admin job at the fire department, M-F 8-4 with a small amount of flex in that schedule.  I had been working at this for some time, so I completed every non-nursing class prior to starting.  Each of the first 3 semesters was 2 classes, a nursing class and a pharm class, the 4th semester was a nursing class and a human growth and development class, and this semester I only have my nursing capstone course.
> 
> I am a blended student.  I don't attend any lectures, which has it's advantages and disadvantages.  Coming into nursing school, I had completed a bachelors in public safety online without any issues, but the depth of knowledge for RN is so much greater, so self-study (even with recorded lectures) took a SIGNIFICANT amount of self discipline and devotion.  The advantage is that I only have to attend a lab once per week (sometimes once every other week) and most of my labs are in the evening.
> 
> ...


You sir sound like someone who majority of the population should aspire to be. You have to respect. You really do. Not many people can do what you do. 

It certainly does take energy. Right now in my life I am not sure how much I want this. Let me explain. Do I enjoy healthcare? Yes. Do I enjoy changing someone’s life for the better? Absolutely. 

My struggle right now is knowing the amount of working that is required. Knowing this, I’m struggling to make a decision if it is worth it or not. 

Is it worth it for me to sacrifice my mental health and physical health for a career and healthcare system that truly does not care. Our healthcare system is horrible. I’m not sure if what I need to sacrifice is worth it. 

You have so many nurses and videos of nurses at the 5 year mark, regret their career choice completely and would do anything to get out. I hear more of that than I do positives. 

Of course I have a huge respect for nurses and all professions but I’m struggling to understand why me learning how to properly fold a **** in a rectangle pattern hitting every corner in a specific way will lead to something. I feel like this system is so focused on pill popping and money. We have some that care but admin takes that spark away. 

Again, you have my total respect. You really do. I just don’t know if nursing is worth it. Nurses make great money because of the pandemic but is it worth it after? I personally am not sure. It’s not about the money. It’s about the quality of life and what this system truly should be. The other day at work, I saw a person go into cardiac arrest…. The nurses went into the room and sat ventricular fib on the monitor. They waited 2 minutes to shock it because they had to wait for a doctor to give permission…… 

You can clearly see the burn out and lack of compassion anymore…. I don’t know if I want to be apart of that anymore. 

Maybe I’ll go into Cardiovascular Tech or Cybersecurity. Who knows.


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## FiremanMike (Jan 24, 2022)

Well thanks for the kind words 

One thing I will say on nursing is that the return on investment (especially right now) is unmatched.  On top of the fact that nurses are currently making obscene amounts of money, there is so much you can do with an RN, and a good chunk of those jobs don't involve patient care at all. 

I'm honestly not sure there is a more versatile degree out there..


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## LoadingCosta (Jan 24, 2022)

FiremanMike said:


> Well thanks for the kind words
> 
> One thing I will say on nursing is that the return on investment (especially right now) is unmatched.  On top of the fact that nurses are currently making obscene amounts of money, there is so much you can do with an RN, and a good chunk of those jobs don't involve patient care at all.
> 
> I'm honestly not sure there is a more versatile degree out there…



Absolutely. Everything you mentioned is the exact reason why I wanted the nursing degree over other degrees. It’s very mobile and the pay certainly is unmatched as of right now due to the pandemic. Who knows what will happen after. 

Personally, after attending a nursing program and feeling it out and see what it offers… I just don’t agree with the material. Especially when you are already in healthcare and see how bs the school is. Idk. I understand this sounds like excuses but I’m just tired of making mistakes in life and I really want to make sure I finally make the right one.


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## CCCSD (Jan 24, 2022)

LoadingCosta said:


> You sir sound like someone who majority of the population should aspire to be. You have to respect. You really do. Not many people can do what you do.
> 
> It certainly does take energy. Right now in my life I am not sure how much I want this. Let me explain. Do I enjoy healthcare? Yes. Do I enjoy changing someone’s life for the better? Absolutely.
> 
> ...


Congratulations. You just talked yourself out of RN because you don’t want to commit to the work reqhired. You obviously don’t have the drive, and are fishing around for the easiest way you can game it. You can’t. It actually takes WORK and dedication.
Go into cybersecurity. You can do it online. No lives are at risk, and it doesn’t take much effort.


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## FiremanMike (Jan 24, 2022)

CCCSD said:


> Congratulations. You just talked yourself out of RN because you don’t want to commit to the work reqhired. You obviously don’t have the drive, and are fishing around for the easiest way you can game it. You can’t. It actually takes WORK and dedication.
> Go into cybersecurity. You can do it online. No lives are at risk, and it doesn’t take much effort.


Ouch

You're not wrong..  nursing school is a ton of work.  Some of it is hard, some of it is just tedious, but it is definitely a lot of work that can't be shortcutted.  I think it's fair to say that during my 8 weeks peds block, I was easily hitting 40+ hours per week of pure studying and homework..


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## akflightmedic (Jan 25, 2022)

So why did YOU wait 2 minutes to shock a witnessed Vfib? And at what point did you stand back, see the VF, and decide "I'm going to set my timer to see how long this takes"?


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## akflightmedic (Jan 25, 2022)

I truly do not know where people who are not nurses keep coming off with this "have to ask for or wait for doctor order BS"... I have worked many ERs now as a traveler, and I legit cannot think of times where I have had to ask permission for anything urgent. I drop orders before the doc ever sees the patient, I work them up before the doc ever sees them, in times of emergency we act. We do NOT work for the doctors, we work WITH the doctors. And in a professional environment where we interact 12+ hours a day, for many days in a row, pretty much talking medicine non-stop, your peers and colleagues all develop professional awareness and respect for each other. Your capabilities and weaknesses are known, and trust ensues. This leads to not having to ask for much of anything.


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## FiremanMike (Jan 25, 2022)

akflightmedic said:


> I truly do not know where people who are not nurses keep coming off with this "have to ask for or wait for doctor order BS"... I have worked many ERs now as a traveler, and I legit cannot think of times where I have had to ask permission for anything urgent. I drop orders before the doc ever sees the patient, I work them up before the doc ever sees them, in times of emergency we act. We do NOT work for the doctors, we work WITH the doctors. And in a professional environment where we interact 12+ hours a day, for many days in a row, pretty much talking medicine non-stop, your peers and colleagues all develop professional awareness and respect for each other. Your capabilities and weaknesses are known, and trust ensues. This leads to not having to ask for much of anything.


What I didn't realize (and I think it's true of most medics) is that between standing and PRN orders, RN's essentially have the same rules of engagement as medics.  Nurses can see, identify, and act just as much as paramedics, but with a much broader depth of knowledge and a bigger toolbox.  It really was a pleasant surprise for me..


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## mgr22 (Jan 25, 2022)

akflightmedic said:


> I truly do not know where people who are not nurses keep coming off with this "have to ask for or wait for doctor order BS"... I have worked many ERs now as a traveler, and I legit cannot think of times where I have had to ask permission for anything urgent. I drop orders before the doc ever sees the patient, I work them up before the doc ever sees them, in times of emergency we act. We do NOT work for the doctors, we work WITH the doctors. And in a professional environment where we interact 12+ hours a day, for many days in a row, pretty much talking medicine non-stop, your peers and colleagues all develop professional awareness and respect for each other. Your capabilities and weaknesses are known, and trust ensues. This leads to not having to ask for much of anything.


A lot of the disparaging remarks about nurses I've heard from EMS colleagues sound like contrived attempts to portray "street medicine" as the only real medicine -- danger, lives on the line, intubating upside down and all that. Even more ridiculous is when medics start second-guessing physicians with, say, 10 years more training, just because the docs don't ride ambulances. 

"Book learning" is often valued less than physical prowess, psychomotor skills, and years in the field. I think most medics who haven't been to medical school (or nursing school) aren't going to know what they don't know. I'd rather just take pride in what we do without turning it into a competition.


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## FiremanMike (Jan 25, 2022)

mgr22 said:


> A lot of the disparaging remarks about nurses I've heard from EMS colleagues sound like contrived attempts to portray "street medicine" as the only real medicine -- danger, lives on the line, intubating upside down and all that. Even more ridiculous is when medics start second-guessing physicians with, say, 10 years more training, just because the docs don't ride ambulances.
> 
> "Book learning" is often valued less than physical prowess, psychomotor skills, and years in the field. I think most medics who haven't been to medical school (or nursing school) aren't going to know what they don't know. I'd rather just take pride in what we do without turning it into a competition.


I want to like this twice


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## akflightmedic (Jan 25, 2022)

I have been physically assaulted more, been in more physical takedowns of patients, and been exposed to far more weapons of all types as a RN in the ER these past few years than I ever have as a Paramedic in the past 27 years. No, I have not forgot where I came from, nor will I, however there is so much that goes on in those 12 hours that many from EMS will never see, know about, or appreciate.

And to echo Fireman Mike...EXACTLY!! I legit have autonomy to do anything. I do not ever have to "sit and wait" on orders or advice. If RNs did that, the ERs would shut down. So many times, the Provider puts a patient up for discharge and then says "Oh I need to go lay eyes on them real quick". The reason that occurs is they trusted the RNs judgment, all labs and tests were completed, such a clear picture was painted, the Provider felt they had physically seen them already. I have dropped more IOs and done more EJs as a RN than I have as a Paramedic. While intubations are rare admittedly, at the small critical access facilities, what needs to happen, will happen.

What I am truly enjoying as a ER RN currently is the ability of assessing a patient, forming my own plan of care, initiating it, then talking to the Providers about it, getting their thoughts, their ideas, and actually learning quite a bit, and then carrying out that plan of care according to how I fit it into my assignment. Let's not forget, I am doing this for a minimum of 4 patients (that change often typically), non-stop for 12 hours. And although it should not occur, the ratios are actually higher on most days and I have had to push back a few times and say no. And I am a huge Team Nurse, most if not all of my current colleagues are the same. So aside from my own assignment, I am in and out of theirs and vice versa. As EMS in general, we grossly underestimate the amount of knowledge and continuous exposure/learning which is taking place in our own local ER. We judge by how everyone seems to be relaxed or sitting when we roll through with that stretcher, all eyes on "us". Why aren't they coming over to assist us with our patient handover? They are just sitting waiting on doctor's orders anyways. We need to get back outside, they need us out there. In reality, we possibly did not know you were coming, we are assessing (especially all the crap NOT done), trying to see where the patient will go, and already mapping it into our timeline of planned events. When EMS rolls in, it is actually a good time to sit and pause or think. You had them for "20 minutes already", what's another 3 gonna hurt? Maybe "try" that IV again? And go a little higher since they are ABD pain?


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## FiremanMike (Jan 25, 2022)

akflightmedic said:


> I have been physically assaulted more, been in more physical takedowns of patients, and been exposed to far more weapons of all types as a RN in the ER these past few years than I ever have as a Paramedic in the past 27 years. No, I have not forgot where I came from, nor will I, however there is so much that goes on in those 12 hours that many from EMS will never see, know about, or appreciate.
> 
> And to echo Fireman Mike...EXACTLY!! I legit have autonomy to do anything. I do not ever have to "sit and wait" on orders or advice. If RNs did that, the ERs would shut down. So many times, the Provider puts a patient up for discharge and then says "Oh I need to go lay eyes on them real quick". The reason that occurs is they trusted the RNs judgment, all labs and tests were completed, such a clear picture was painted, the Provider felt they had physically seen them already. I have dropped more IOs and done more EJs as a RN than I have as a Paramedic. While intubations are rare admittedly, at the small critical access facilities, what needs to happen, will happen.
> 
> What I am truly enjoying as a ER RN currently is the ability of assessing a patient, forming my own plan of care, initiating it, then talking to the Providers about it, getting their thoughts, their ideas, and actually learning quite a bit, and then carrying out that plan of care according to how I fit it into my assignment. Let's not forget, I am doing this for a minimum of 4 patients (that change often typically), non-stop for 12 hours. And although it should not occur, the ratios are actually higher on most days and I have had to push back a few times and say no. And I am a huge Team Nurse, most if not all of my current colleagues are the same. So aside from my own assignment, I am in and out of theirs and vice versa. As EMS in general, we grossly underestimate the amount of knowledge and continuous exposure/learning which is taking place in our own local ER. We judge by how everyone seems to be relaxed or sitting when we roll through with that stretcher, all eyes on "us". Why aren't they coming over to assist us with our patient handover? They are just sitting waiting on doctor's orders anyways. We need to get back outside, they need us out there. In reality, we possibly did not know you were coming, we are assessing (especially all the crap NOT done), trying to see where the patient will go, and already mapping it into our timeline of planned events. When EMS rolls in, it is actually a good time to sit and pause or think. You had them for "20 minutes already", what's another 3 gonna hurt? Maybe "try" that IV again? And go a little higher since they are ABD pain?


I was today years old when I decided to move a bit further out and find an ER RN job at a critical access hospital..


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## EpiEMS (Jan 25, 2022)

How much of the ED RN scope is facility location and/or level dependent? I have to imagine there is a good deal of base level therapies available at most places (venous access, oxygen, anti-emetics…)?


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## Carlos Danger (Jan 26, 2022)

EpiEMS said:


> How much of the ED RN scope is facility location and/or level dependent? I have to imagine there is a good deal of base level therapies available at most places (venous access, oxygen, anti-emetics…)?


In most ED's you'll have standing orders for oxygen, IV access, labs, IVF, EKG, and _maybe _things like albuterol or anti-emetics or analgesics, putting in orders for imaging, etc. It really depends on where you work. Usually at that point not much else gets done until the patient is seen by a provider.


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## EpiEMS (Jan 26, 2022)

Carlos Danger said:


> In most ED's you'll have standing orders for oxygen, IV access, labs, IVF, EKG, and _maybe _things like albuterol or anti-emetics or analgesics, putting in orders for imaging, etc. It really depends on where you work. Usually at that point not much else gets done until the patient is seen by a provider.



Makes sense. Might have more in a rural setting?


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## akflightmedic (Jan 26, 2022)

Definitely have WAY greater scope in critical access facilities, however I am currently in a fairly booming area and our scope or ability to do whatever is fair game as described. There are "lazy" nurses who intentionally sit and wait to be told every move, either through fear, lack of knowledge, or intentional so they do not work as hard, however the majority drop orders left and right and get stuff done. It simply is not possible for the Provider to get through the day's load without the bulk of RNs doing this.

Another win for smaller facilities is the collaboration and ability to veer off script quite often as needed. I have not worked as a ER RN in a HUGE Level 1 or dense populated area where a facility is on every corner like NYC or something. However, I have yet to run across a place or a traveler where the operational plan is "wait for orders" or "let the doc think for you, then do what they say".

Fresh example from last night: I get a bradycardic/hypotensive from EMS, rate 52, systolic 53, feels disoriented and weak, 70 years old, visual disturbances. Rapid assessment, stroke scale, the usual exam for this type of pt. I start a line that actually works, but then it blows. I dropped an EJ, started fluids wide open. I ordered a CT w/o contrast STAT, 12 lead, and ordered all labs including lactic, threw in cultures even though currently afebrile, cause daughter shows up and mentions there was a fever earlier in day. Go ahead and order covid swab. Unable to pee, so straight cath for a sample as she is fairly dry. I then went and gave the Provider a rundown, no further orders, answered a few questions.

By time Provider laid eyes on the patient, he had early results in, other results trickling in, and based on our history with each other he was able to cut some of his exam time short. He told me to carry on. I hung a 3rd liter at 250/hour, her pulse had been steady climbing to the 60s and hanging, the BP was barely inching along, visual disturbances resolved. Through all this time, managing many other patients of higher and lower acuity, briefing provider on those, managing family, working the phones (we dont have secretary), and then of course she is Covid+ like 99% of all patients in ER currently. So I said to the doc, I think it is time we hang some levophed, shall I go ahead and start it? Patient's MAP was ****, widening pulse pressure, still inconclusive as to cause, not septic that we know of. He said good idea, go ahead. So I did.

That is just one short example of the dozens and dozens scenarios which occurs weekly. All day, every day. I am in no way hyping myself or comparing EMS to Nursing. I have just as much, if not more autonomy as a RN in the ERs I have experienced than I have in most EMS systems. As I said earlier, the knowledge is growing by leaps and bounds, and repeated exposure to so many outcomes, and seeing conclusions to all the EMS patients I once brought in through the door....there is NO comparison.

My only regret is not going to nursing many years ago. I always had it on my list, but then I put family, overtime, flight, expeditionary, contract, overseas, businesses, etc....I kept putting anything and everything in front of going to school and I used to spew the same stories and excuses without knowing what I truly did not know. Finally in my 40's I returned full time college and did traditional nursing program. Wish I did it 20 years ago, regardless I am doing it now, traveling, learning, making sick money, and loving it.


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## LoadingCosta (Jan 26, 2022)

akflightmedic said:


> So why did YOU wait 2 minutes to shock a witnessed Vfib? And at what point did you stand back, see the VF, and decide "I'm going to set my timer to see how long this takes"?


Because I’m not allowed to function as a paramedic in a hospital setting. 

So I’m in the wrong when there was 5 nurses in the room and 3 doctors and two PAs working in the ER? 

You are correct. This is completely my fault and I should of stepped into that Covid room without proper PPE and shocked that patient. 

Ill remember that for next time.


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## LoadingCosta (Jan 26, 2022)

mgr22 said:


> A lot of the disparaging remarks about nurses I've heard from EMS colleagues sound like contrived attempts to portray "street medicine" as the only real medicine -- danger, lives on the line, intubating upside down and all that. Even more ridiculous is when medics start second-guessing physicians with, say, 10 years more training, just because the docs don't ride ambulances.
> 
> "Book learning" is often valued less than physical prowess, psychomotor skills, and years in the field. I think most medics who haven't been to medical school (or nursing school) aren't going to know what they don't know. I'd rather just take pride in what we do without turning it into a competition.


I’m misunderstood. 

I’m not by any means crapping on nurses and degrading the importance. 

I’m used to the EMS profession being degraded on a daily basis. It’s normal. I have respect for my nurses and I would never bash the profession as a whole. For me personally, after going through the school… I did not feel like I wanted to be apart of the American health care system anymore.


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## LoadingCosta (Jan 26, 2022)

akflightmedic said:


> Definitely have WAY greater scope in critical access facilities, however I am currently in a fairly booming area and our scope or ability to do whatever is fair game as described. There are "lazy" nurses who intentionally sit and wait to be told every move, either through fear, lack of knowledge, or intentional so they do not work as hard, however the majority drop orders left and right and get stuff done. It simply is not possible for the Provider to get through the day's load without the bulk of RNs doing this.
> 
> Another win for smaller facilities is the collaboration and ability to veer off script quite often as needed. I have not worked as a ER RN in a HUGE Level 1 or dense populated area where a facility is on every corner like NYC or something. However, I have yet to run across a place or a traveler where the operational plan is "wait for orders" or "let the doc think for you, then do what they say".
> 
> ...


I’m happy and pleased to hear you found passion in what you wanted to do. I have a lot of respect for what you do and many other nurses do. Keep up the great work and stay safe.


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## CCCSD (Jan 26, 2022)

LoadingCosta said:


> I’m misunderstood.
> 
> I’m not by any means crapping on nurses and degrading the importance.
> 
> I’m used to the EMS profession being degraded on a daily basis. It’s normal. I have respect for my nurses and I would never bash the profession as a whole. For me personally, after going through the school… I did not feel like I wanted to be apart of the American health care system anymore.


Wow… Sooo much better everywhere else, eh? You aren’t misunderstood. Not at ALL.

You don’t HAVE to do this line of work, and should be focusing on anything but…


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## LoadingCosta (Jan 26, 2022)

CCCSD said:


> Wow… Sooo much better everywhere else, eh? You aren’t misunderstood. Not at ALL.
> 
> You don’t HAVE to do this line of work, and should be focusing on anything but…


Thank you. I am focusing on trying to find a new career path. Just trying to take into account my age at this point in my life. I think it’s time for me to stop responding because I feel like this thread is going in a bad direction and this was not my intentions at all from the beginning. I do really appreciate everyone who did share advice and wisdom. It is very appreciated. Trust me. I appreciate all you and everything you all do in your past and current professions!


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## akflightmedic (Jan 26, 2022)

LoadingCosta said:


> Because I’m not allowed to function as a paramedic in a hospital setting.
> 
> So I’m in the wrong when there was 5 nurses in the room and 3 doctors and two PAs working in the ER?
> 
> ...



Yes, it absolutely IS your fault. For many reasons...

1. Your story has now changed or been amended to add other professionals to the equation, when originally it was described as a nurse who could not function until told to do so by a provider. 
-What you now describe sounds like a leadership issue, not a scope issue. Too many chefs in the kitchen.

2. You also had a timer running, however initially laid all responsibility on the sole nurse, when actually there was an entire team there, all too dumb to know what to do.
-This is where it is your fault because you saw something, yet chose to say nothing. Medicine is a Team Sport, always. Instead of being smug and watching a clock, use your mouth. It is not license restricted, I assure you. Not speaking up and allowing others to fail is a horrible way to proceed through life and medicine. Do us a favor, and chase a different career.

*And it is now a COVID room so you could not step in...could not knock on the glass, could not knock on the door, could not open mouth. None of which require PPE or jeopardizing your safety. FYI, you can pretty much assume everyone has covid right now, we are two years into this and I find it comical how we do not PPE for the ankle fracture kid probably has covid but not being tested, however the known covid is uber PPE cautionary tale. 


Save your too cool for school stories for some other group you wish to disrespect. And no, I am not defensive because you told it about a nurse. It is how you told the story, it is about facts you left out, and it is your unwillingness to speak up when you see something wrong, and moreso simply clock watch, shrug your shoulders and say "not my job" or "not allowed to be a medic in ER".


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## LoadingCosta (Jan 26, 2022)

akflightmedic said:


> Yes, it absolutely IS your fault. For many reasons...
> 
> 1. Your story has now changed or been amended to add other professionals to the equation, when originally it was described as a nurse who could not function until told to do so by a provider.
> -What you now describe sounds like a leadership issue, not a scope issue. Too many chefs in the kitchen.
> ...


Absolutely. I apologize for any disrespect or “too cool” stories. Was never my intention and apparently somewhere along the lines a lot was taken way out context. You clearly have a lot of built up hostility somewhere. It’s understandable. The healthcare system is burdened right now especially with Covid still raging. 

You probably assumed I think all nurses need to ask for orders or wait for orders. That is not true from my perspective. I can’t speak on others. Doesn’t matter how many times i explain it won’t matter. I don’t think it’s about the “facts” I left out. Again I’m not going to sit here and argue with you when it’s not worth it over something so misunderstood. 

Again, I really do appreciate you and all the nurses who work during these times. I respect you all. Thank you for what you do.


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## akflightmedic (Jan 26, 2022)

You neglected to address why you never spoke up...

At the root of all this...nothing to do with hostility. Everything to do with integrity.


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## MonkeyArrow (Jan 26, 2022)

akflightmedic said:


> Fresh example from last night: I get a bradycardic/hypotensive from EMS, rate 52, systolic 53, feels disoriented and weak, 70 years old, visual disturbances. Rapid assessment, stroke scale, the usual exam for this type of pt. I start a line that actually works, but then it blows. I dropped an EJ, started fluids wide open. I ordered a CT w/o contrast STAT, 12 lead, and ordered all labs including lactic, threw in cultures even though currently afebrile, cause daughter shows up and mentions there was a fever earlier in day. Go ahead and order covid swab. Unable to pee, so straight cath for a sample as she is fairly dry. I then went and gave the Provider a rundown, no further orders, answered a few questions.


This is absolutely NOT what should be happening, and I will die on this hill. This patient, as described, is critically ill and needs to have a physician at the bedside immediately. Playing hero and doing all this stuff without notifying a physician to come to the bedside is poor practice and not in the patient's best interest.


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## CCCSD (Jan 26, 2022)

MonkeyArrow said:


> This is absolutely NOT what should be happening, and I will die on this hill. This patient, as described, is critically ill and needs to have a physician at the bedside immediately. Playing hero and doing all this stuff without notifying a physician to come to the bedside is poor practice and not in the patient's best interest.


Guess you didn’t read the post. ALL of the things you are so worried about CANT happen until the labs, tests, limes, meds are starte. What planet are you on where you think only an MD can do these things. Hint: MD not needed.

I was doing much the same as an IDC WITHOUT my PA present and we didn’t have an MD in house.
This ain’t 1950s Marcus Welby medicine.


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## akflightmedic (Jan 26, 2022)

Ahhhh, but I am in a 9 bed free standing ER with exactly 15 patients on stretchers (several ICU or Admission holds), 2 in subwaiting, 1 in Triage 2 and a lobby with 20+ waiting, with 3 RNs on duty, no secretary, no tech, and ONE provider....is it still hero? Or is it crisis nursing at it's finest in this particular area? Cause if all you took away was me playing a "hero card"...been there, done that. So simmer down Frances....

P.S Monkey....we have MULTIPLE "criticals" just sitting here....


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## CCCSD (Jan 26, 2022)

BTW. As you “Die on that hill”. Don’t expect to see an MD helping you out…


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## MonkeyArrow (Jan 26, 2022)

CCCSD said:


> Guess you didn’t read the post. ALL of the things you are so worried about CANT happen until the labs, tests, limes, meds are starte. What planet are you on where you think only an MD can do these things. Hint: MD not needed.


What are you even saying?


akflightmedic said:


> Ahhhh, but I am in a 9 bed free standing ER with exactly 15 patients on stretchers (several ICU or Admission holds), 2 in subwaiting, 1 in Triage 2 and a lobby with 20+ waiting, with 3 RNs on duty, no secretary, no tech, and ONE provider....is it still hero? Or is it crisis nursing at it's finest in this particular area? Cause if all you took away was me playing a "hero card"...been there, done that. So simmer down Frances....
> 
> P.S Monkey....we have MULTIPLE "criticals" just sitting here....


Your practice environment is apparently exceptional if you consistently have multiple peri-arrest patients at the same time in a 9 bed FSER.


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## akflightmedic (Jan 26, 2022)

Are you unaware what is happening across America right now? I have been FEMA traveling non-stop since September...did a few FEMA contracts prior to this lengthy deployment.


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## CCCSD (Jan 27, 2022)

MonkeyArrow said:


> What are you even saying?
> 
> Your practice environment is apparently exceptional if you consistently have multiple peri-arrest patients at the same time in a 9 bed FSER.


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## FiremanMike (Jan 27, 2022)

MonkeyArrow said:


> This is absolutely NOT what should be happening, and I will die on this hill. This patient, as described, is critically ill and needs to have a physician at the bedside immediately. Playing hero and doing all this stuff without notifying a physician to come to the bedside is poor practice and not in the patient's best interest.


You know how you can make decisions and initiate treatment in the back of the medic without a doctor present due to your EMS protocol?  

It’s the same thing..


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## akflightmedic (Jan 27, 2022)

Quit being logical you, you, HERO! HAHAHHA


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## MonkeyArrow (Jan 27, 2022)

akflightmedic said:


> Are you unaware what is happening across America right now? I have been FEMA traveling non-stop since September...did a few FEMA contracts prior to this lengthy deployment.


I am aware that there is high acuity across ERs in America, with no beds to admit to (ICU or floor) and no hospitals available to transfer patients out to, compounded/caused by critical staff shortages, leading to prolonged boarding of patients in the ED, causing all of the associated delays that come with that backlog. I obviously do not know the specifics of what is going on in every single ER in the country. I can tell you, between my experience and those of my colleagues around the country with whom I keep in touch, I have not heard of a setting so bad that a "provider" is unable to come to the bedside of a peri-arrest patient within a reasonable time frame.



FiremanMike said:


> You know how you can make decisions and initiate treatment in the back of the medic without a doctor present due to your EMS protocol?
> 
> It’s the same thing..


You know how its fundamentally different, because in the back of an ambulance, you don't have a doctor there, but in an ER, you do? (Or at least a "provider" as ak keeps saying.)


akflightmedic said:


> Quit being logical you, you, HERO! HAHAHHA


I see you want to engage in an adult conversation.


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## akflightmedic (Jan 27, 2022)

Monkey, do you work in the USA?

I ask because you seem to not like the word Provider, which is one of the most common references to a doctor in every environment I have worked. 

As for your recap of the dumpster fire we are experiencing, it is accurate, however your perception of operational flow in an ER seems quite deficient. Everything ordered and completed WAS in the best interest of the patient. No heroics involved. But according to you, "hey doc! I need you to leave that critical patient over there, and come over here to this critical patient now."....Doc..."ummm, ok, but I was about to go see that other critical that just rolled in with EMS"...no doc, it needs to be now because my patient is periarrest and my internet peers said what I described is impossible and you must do this to prevent me from being a hero and causing the patient harm.


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## FiremanMike (Jan 27, 2022)

MonkeyArrow said:


> I am aware that there is high acuity across ERs in America, with no beds to admit to (ICU or floor) and no hospitals available to transfer patients out to, compounded/caused by critical staff shortages, leading to prolonged boarding of patients in the ED, causing all of the associated delays that come with that backlog. I obviously do not know the specifics of what is going on in every single ER in the country. I can tell you, between my experience and those of my colleagues around the country with whom I keep in touch, I have not heard of a setting so bad that a "provider" is unable to come to the bedside of a peri-arrest patient within a reasonable time frame.
> 
> 
> You know how its fundamentally different, because in the back of an ambulance, you don't have a doctor there, but in an ER, you do? (Or at least a "provider" as ak keeps saying.)
> ...


A couple of things 

1.  The doc is available in the back of the medic  at all times via radio and there are probably still services that depend on online medical control.  

2.  The fallacy that you’re working from is that paramedic school prepares you for independent assessment, diagnosis, and decision making and nursing school does not.  You’re not the only paramedic who thinks that and before I was in nursing school I felt that way too.  

You’re going to just have to acknowledge that you don’t know what you don’t know.  My nursing textbooks and clinical experiences, on top of teaching significantly more detailed assessment, also go very in depth of treatment pathways.  

You should do an RN OB rotation in labor and delivery someday, it’ll really blow your mind..


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## MonkeyArrow (Jan 27, 2022)

akflightmedic said:


> Monkey, do you work in the USA?
> 
> I ask because you seem to not like the word Provider, which is one of the most common references to a doctor in every environment I have worked.
> 
> As for your recap of the dumpster fire we are experiencing, it is accurate, however your perception of operational flow in an ER seems quite deficient. Everything ordered and completed WAS in the best interest of the patient. No heroics involved. But according to you, "hey doc! I need you to leave that critical patient over there, and come over here to this critical patient now."....Doc..."ummm, ok, but I was about to go see that other critical that just rolled in with EMS"...no doc, it needs to be now because my patient is periarrest and my internet peers said what I described is impossible and you must do this to prevent me from being a hero and causing the patient harm.


Yes, I work in the US. I made a point of emphasizing provider because: 1. Many physicians don’t like being called providers (just like many PAs/NPs don’t like being called mid levels), so I don’t use (either) word and 2. I’m trying to get at the concept of what were the educational qualifications of this provider. Board certified EM MD? Old timey family medicine guy? PA? NP?

I don’t think my understanding of operational flow in an ER is lacking given I’ve spent my career in an ER and have been a “flow coordinator” (that was actually the title of my position) for several of those years, but I’m not going to get into a pissing match over who’s more qualified to opine. My point is that providers should be alerted to, and they should come to the bedside of, critically ill patients as soon as possible. If you’re running 3 codes and have a GSW in the hallway and a infant seizing in the waiting room in a 9 bed ER, well…there’s nothing I can say to that.


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## MonkeyArrow (Jan 27, 2022)

FiremanMike said:


> A couple of things
> 
> 1.  The doc is available in the back of the medic  at all times via radio and there are probably still services that depend on online medical control.
> 
> ...


1. C’mon. Not even close to the same thing.
2. I never said that. My implication was, however, and something that I stand behind fully is that medical school and residency training in emergency medicine prepares you for independent assessment, diagnosis, and decision making better than nursing school thus. Therefore, when you have a peri-arrest patient, the most qualified person should be called to the bedside immediately, as soon as feasible. I guess if you work somewhere like ak does, then it’s not feasible.


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## FiremanMike (Jan 27, 2022)

MonkeyArrow said:


> 1. C’mon. Not even close to the same thing.
> 2. I never said that. My implication was, however, and something that I stand behind fully is that medical school and residency training in emergency medicine prepares you for independent assessment, diagnosis, and decision making better than nursing school thus. Therefore, when you have a peri-arrest patient, the most qualified person should be called to the bedside immediately, as soon as feasible. I guess if you work somewhere like ak does, then it’s not feasible.


Why isn't it the same thing?  Pared down, your stance is that a doctor must evaluate a patient before a nurse can make a decision, but not a paramedic.  

*Obviously *doctors have more training in medicine, but that doesn't mean they are the only people capable of identifying a problem and making a decision.


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## akflightmedic (Jan 27, 2022)

I am feeling you have just chosen to take a stand and not be persuaded or convinced otherwise. Too late to back down...cause it is NOT just where I am that this is occurring, and with your stated level of experience, then any of this should have been instant no brainer for you to comprehend. Unless you are not currently practicing anywhere and have retired or been on hiatus. 

As for use of Provider...and Midlevel, they have all referenced themselves as that within all my personal experiences. 

But again, you seemingly do not want to dismount the high horse apparently and realize what is taking place quite commonly in many, many places is the current reality.


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## MonkeyArrow (Jan 27, 2022)

FiremanMike said:


> Why isn't it the same thing? Pared down, your stance is that a doctor must evaluate a patient before a nurse can make a decision, but not a paramedic.


You're missing a little nuance that makes a world of difference. My stance is that a doctor should evaluate a critically ill (ergo, time sensitive) patient when available. The key distinction is that in an ER, a doctor is always (I guess technically almost always) available. Prehospitally, a doctor is almost never physically available, at least in the US, hence the need for protocols. Yes, you can call a doctor on the phone for OLMC, but that is not the same as the physician being at the bedside and seeing the patient personally.


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## MonkeyArrow (Jan 27, 2022)

akflightmedic said:


> I am feeling you have just chosen to take a stand and not be persuaded or convinced otherwise. Too late to back down...cause it is NOT just where I am that this is occurring, and with your stated level of experience, then any of this should have been instant no brainer for you to comprehend. Unless you are not currently practicing anywhere and have retired or been on hiatus.
> 
> As for use of Provider...and Midlevel, they have all referenced themselves as that within all my personal experiences.
> 
> But again, you seemingly do not want to dismount the high horse apparently and realize what is taking place quite commonly in many, many places is the current reality.


You are completely correct that I am unconvinced the situation that you describe is happening regularly. I am not saying that it cannot happen; of course it can, but that is the unusual exception to the rule, not routine. Fundamentally, the question I propose you ask is: who is the sickest patient in the department at this time? In the overwhelming majority of cases, the patient you described is the sickest, and so the provider should be with that patient. I do not think having more peri-arrest patients simultaneously appearing than you have providers is at all a common occurrence anywhere in this country, and I think it is a mischaracterization to assert as such. (Sure, there are probably some centers that at least not rarely have multiple resuscitations going on at once, but those are also typically urban knife-and-gun club departments that are decidedly not single coverage, so the point is moot).


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## akflightmedic (Jan 28, 2022)

Wow...you are simply deluded and choose to remain ignorant then. Not much more to say here as you have your opinion based on dialogue with peers, and I have mine based on personal real time experience.


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## Akulahawk (Jan 28, 2022)

I used to work in a 16 bed ED that was at a Critical Access Hospital. We usually had 1 Physician and 1 PA on duty MOST of the time. Most of the time, all the beds were full. Our scope of practice _before_ a provider saw a new patient was basically what the Paramedics had, along with the authority to order some imaging and most labs by standing order. Notice I didn't indicate if the patient was initially seen at triage or brought in by EMS. This all starts because of my assessment. The labs and basic imaging could be already cooking before a provider is ready to see the patient. In more than a few instances, the provider wouldn't have to see the patient but once or twice (for MSE and discharge). It wasn't unheard of (actually relatively common) to have a code going when another would arrive so we'd get going on our own, under standing orders. Exactly as it's done in the field. This was well before COVID, we were seeing 70 patients/day so we had to have EVERYTHING going quickly for maximum throughput or the ED flow would grind to a halt because the providers would get completely buried.

Where I work now, I'm in a 29 bed ED that's in an urban/suburban environment and we usually have 3-4 providers on and while the providers do lean on the nurse doing the triage to get some things done, they're able see patients very quickly, they've got scribes, and they can get orders in very quickly. My hospital system wants most of the orders entered by a provider and wants "verbal orders" to be used as infrequently as possible. If we've got 60-ish or 85-ish patients in our 29 bed ED and one of my patients needs something, I just ask for it, provider puts in the order, and I go do it. The providers I work with trust my judgment. It's been that way for several years... long before COVID. While I'd like to have the authority level I had at the CAH at my current job, our providers are able to get going on things fast enough most of the time that I'd only beat them by a couple minutes in getting that stuff ordered. Incidentally, we're usually seeing upwards of 160 patients per day with effectively a 10 bed (or less) ED because how many holds (psych, tele, ICU) we have. Our process isn't the greatest, but it works reasonably well for our circumstances.


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## MonkeyArrow (Jan 28, 2022)

akflightmedic said:


> Wow...you are simply deluded and choose to remain ignorant then. Not much more to say here as you have your opinion based on dialogue with peers, and I have mine based on personal real time experience.


It's ironic that you think my personal experiences are worth less than yours, but ignoring that. Let's approach this from a different perspective.

National data shows that there are between 300,000 and 400,000 out of hospital cardiac arrests annually in the U.S. I chose cardiac arrest because it is a patient population with well-reported data and who clearly needs resuscitation; I obviously recognize that there are may be other patients, not in cardiac arrest, but who are still critically ill. I believe the general principle displayed by this assumption holds for my larger point, however. Another source puts it at 111 per 100,000 people. With a U.S. population of 330,000,000, that means there are 366,300 OHCAs every year. Divided by 365 days a year, that comes out to 1003.56 arrests a day. There are ~4000 hospitals in the US. That means, on average, each hospital is expected to see 0.25 arrests a day. 

(Now, this "model" makes significant simplifying assumptions, but which I think are appropriate for a back-of-napkin calculation like this. For example, these numbers are reliant on every OHCA being transported to an ER. Additionally, we assume that each ER sees an equivalent number of arrests each day, which we know is not accurate, since higher volume centers will see a larger absolute number of arrests, by definition. However, because we're interested in a smaller-than-average sized ER, my calculation will actually overestimate the true event rate, which is fine.)

We can model the number of cardiac arrests seen in an ER by a Poisson distribution. Again, a Poisson distribution is not perfect, but it is a good enough approximation. The average rate is 0.25, and our random variable is 2 (that is, we are interested in how often any given ER should see >=2 OHCAs a day). The probability of X>=x (or of seeing at least 2 arrests a day) is 0.02650, or 2.65%. However, remember that this is over a full 24 hour period; the likelihood of seeing 2 (or more) arrests within one hour, where the single provider would already be tied up and unavailable to come see the new patient, is much much lower.

To summarize:
Do I think that having more critically unstable patients than you have providers is theoretically possible? Yes.
Do I think that having more critically unstable patients than you have providers actually happens? Of course it does.
Do I think that having more critically unstable patients than you have providers happens regularly? Or is commonplace? Or is "taking place quite commonly in many, many places [and] is the current reality"? No. 

I'm not saying that you aren't seeing more critically unstable patients than you have providers available to see in a timely manner, or that you aren't overwhelmed with patients, or even that this isn't an infrequent occurrence in your experience. Most things in the real world follow a distribution, and distributions have tails that hold outliers and extreme values, and due to unique geography/patient factors/happenstance/luck, you could work at ER(s) that see an unexpectedly large number of critically unstable patients. Who am I to say whether you do or not? You work there, I don't. However, it is not true that this experience is generalizable or largely applicable to most other ERs, who do fall closer to average values.


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## CCCSD (Jan 28, 2022)

Backpedaling: an American art.


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## FiremanMike (Jan 28, 2022)

MonkeyArrow said:


> It's ironic that you think my personal experiences are worth less than yours, but ignoring that. Let's approach this from a different perspective.
> 
> National data shows that there are between 300,000 and 400,000 out of hospital cardiac arrests annually in the U.S. I chose cardiac arrest because it is a patient population with well-reported data and who clearly needs resuscitation; I obviously recognize that there are may be other patients, not in cardiac arrest, but who are still critically ill. I believe the general principle displayed by this assumption holds for my larger point, however. Another source puts it at 111 per 100,000 people. With a U.S. population of 330,000,000, that means there are 366,300 OHCAs every year. Divided by 365 days a year, that comes out to 1003.56 arrests a day. There are ~4000 hospitals in the US. That means, on average, each hospital is expected to see 0.25 arrests a day.
> 
> ...


None of this has anything to do with your assertion throughout this entire thread that paramedics are capable of evaluating and making decisions based on protocols and experience without direct physician input, but nurses are not.


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## MonkeyArrow (Jan 28, 2022)

FiremanMike said:


> None of this has anything to do with your assertion throughout this entire thread that paramedics are capable of evaluating and making decisions based on protocols and experience without direct physician input, but nurses are not.


Where did I say this?


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## mgr22 (Jan 28, 2022)

To those who've been both nurses and medics: If you were to make a list of traits and talents most important for nurses and a second list of traits and talents most important for medics, are there any items that wouldn't be on both lists?


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## CCCSD (Jan 28, 2022)

MonkeyArrow said:


> Where did I say this?


Everywhere.


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## FiremanMike (Jan 28, 2022)

mgr22 said:


> To those who've been both nurses and medics: If you were to make a list of traits and talents most important for nurses and a second list of traits and talents most important for medics, are there any items that wouldn't be on both lists?


I saw this - going to answer tomorrow with my opinion as an almost nurse lol


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## Carlos Danger (Jan 28, 2022)

FiremanMike said:


> None of this has anything to do with your assertion throughout this entire thread that paramedics are capable of evaluating and making decisions based on protocols and experience without direct physician input, but nurses are not.





CCCSD said:


> Everywhere.


Quotes?


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## CCCSD (Jan 28, 2022)

Carlos Danger said:


> Quotes?


Read the lines. It’s pretty obvious.


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## Carlos Danger (Jan 28, 2022)

CCCSD said:


> Read the lines. It’s pretty obvious.


I’ve read it all. I don’t necessarily agree with all of it, but I also don’t recall examples of what you and FiremanMike are asserting. I’d like you to post quotes so I know what comments you are referring to.


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## akflightmedic (Jan 29, 2022)

You wrote a nice dissertation there on cardiac arrests and stats...not once did I mention working cardiac arrests. Unsure how those stats even apply to the subject being discussed. 

Anyways, ironically, I did just get home due to being held over 1.5 hours due to the fact among the many holds in the ED, the usual gamut of ER patients, we had an urgent appendicitis, a tension pneumo, and then a cardiac arrest. All within an hour's time...very quickly overwhelms this FSER, however it is what it is. One provider, bouncing for those three criticals, while myself and the others do what we do. You know, the stuff you simply think does not happen all that often, yet it does. As we were wrapping up the chest tube patient, the transfer ambulance arrived to take the nSTEMI to another facility, after sitting in our ER for about 36 hours, lo and behold she decides to code. Glad the crew stayed to play, and you know what....the doc was NOT in the room the entire time (gasp!).


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## FiremanMike (Jan 29, 2022)

Carlos Danger said:


> Quotes?





MonkeyArrow said:


> This is absolutely NOT what should be happening, and I will die on this hill. This patient, as described, is critically ill and needs to have a physician at the bedside immediately. Playing hero and doing all this stuff without notifying a physician to come to the bedside is poor practice and not in the patient's best interest.





MonkeyArrow said:


> You know how its fundamentally different, because in the back of an ambulance, you don't have a doctor there, but in an ER, you do? (Or at least a "provider" as ak keeps saying.)



It's pretty much this and the continued theme of "nurses shouldn't do anything before the doc sees the patient".

Did I oversimplify his point with my summary of "medics can but nurses can't?" maybe.. but at it's core, it's really what he's saying. 

Lest we forget, we pretty much all felt that way about nurses at least some point in our lives as paramedics..


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## FiremanMike (Jan 29, 2022)

mgr22 said:


> To those who've been both nurses and medics: If you were to make a list of traits and talents most important for nurses and a second list of traits and talents most important for medics, are there any items that wouldn't be on both lists?


In my opinion, the traits and talents _should _be the same between a good nurse and a good medic.

In practice, it's different.

I think paramedics _must _be more decisive than nurses, because if I nurse gets stuck they have other people immediately available they can lean on, whereas the paramedic is generally going to be the highest level of care in the room.  

Nurses _must _be better at multitasking than medics, because it's pretty rare for a medic to be juggling more than 1 patient, and they almost never have more than 2.

In practice, medics don't generally need to consider all the nuances of how various disease processes work together, medics are mostly focused on the immediate problem and mitigating it, whereas nurses think a few more steps down the line at any given moment.


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## MonkeyArrow (Jan 29, 2022)

akflightmedic said:


> You wrote a nice dissertation there on cardiac arrests and stats...not once did I mention working cardiac arrests. Unsure how those stats even apply to the subject being discussed.
> 
> Anyways, ironically, I did just get home due to being held over 1.5 hours due to the fact among the many holds in the ED, the usual gamut of ER patients, we had an urgent appendicitis, a tension pneumo, and then a cardiac arrest. All within an hour's time...very quickly overwhelms this FSER, however it is what it is. One provider, bouncing for those three criticals, while myself and the others do what we do. You know, the stuff you simply think does not happen all that often, yet it does. As we were wrapping up the chest tube patient, the transfer ambulance arrived to take the nSTEMI to another facility, after sitting in our ER for about 36 hours, lo and behold she decides to code. Glad the crew stayed to play, and you know what....the doc was NOT in the room the entire time (gasp!).


Ah, so the story unravels. Those three patients are not the same level of "critical". The principle I will again espouse is that the physician must attend to the sickest patient in the department first, at least until stabilization has begun. Let me remind you, that this all started when I said it was inappropriate for a complete workup and medication administration to be done without the physician ever assessing a critically unstable patient. I never opined on what should happen with stable patients or that the physician has to stay in the room the whole time. 

Unless the appendicitis was in fulminant septic shock, they can wait. By definition, a tension pneumo causes hemodynamic compromise. However, we both know that there is a little bit of wiggle room with what that means. If they are tachy to 110 and have an spo2 of 94, they can wait. If not, a crash chest tube should take 5 minutes at most, and that is being generous. No need to use lidocaine when the patient is peri-arrest. And that frees the physician up to attend to the code. 

I will let you go back and re-read why I chose to use cardiac arrests above as my example. Without knowledge of your patient volume and arrival times and clinical course, I won't be able to model probabilities for any one specific hospital anyways.


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## MonkeyArrow (Jan 29, 2022)

FiremanMike said:


> It's pretty much this and the continued theme of "nurses shouldn't do anything before the doc sees the patient".
> 
> Did I oversimplify his point with my summary of "medics can but nurses can't?" maybe.. but at it's core, it's really what he's saying.
> 
> Lest we forget, we pretty much all felt that way about nurses at least some point in our lives as paramedics..


Again, where did I say that "nurses shouldn't do anything before the doc sees the patient"?

I have been very clear and very particular with the claims I have made in this thread. Your "oversimplification" is wrong. I never commented on anything beyond what should happen with a critically unstable patient in an ER. 

I never compared nurses' ability to think independently vs. paramedics', because they are not directly comparable in my opinion. They work in very different environments.


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## FiremanMike (Jan 29, 2022)

MonkeyArrow said:


> Again, where did I say that "nurses shouldn't do anything before the doc sees the patient"?
> 
> I have been very clear and very particular with the claims I have made in this thread. Your "oversimplification" is wrong. I never commented on anything beyond what should happen with a critically unstable patient in an ER.
> 
> I never compared nurses' ability to think independently vs. paramedics', because they are not directly comparable in my opinion. They work in very different environments.


You entered this thread to quote an experienced ER nurse sharing their experiences working and sharing a story of some of the things they had accomplished before the doc could get to a critical patient.

You said it was a hill you would die on because that was completely inappropriate.

If you're now insisting that this isn't what you meant, then fine.  I'm done bickering over this with you..


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## akflightmedic (Jan 29, 2022)

Monkey...did you used to work for me?

I lose who is who with the screen names, however you remind me of one of my former employees as I had several here at one time or another on this site. As this conversation evolves, you sure are ringing some bells.

And just an observation, but your word choice and usage, are interesting. And you sure as heck love using peri-arrest.


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## MonkeyArrow (Jan 29, 2022)

akflightmedic said:


> Monkey...did you used to work for me?
> 
> I lose who is who with the screen names, however you remind me of one of my former employees as I had several here at one time or another on this site. As this conversation evolves, you sure are ringing some bells.
> 
> And just an observation, but your word choice and usage, are interesting. And you sure as heck love using peri-arrest.


No, I did not (nor do I currently) work for you.

I do like the word peri-arrest. I keep using it here because it nicely encapsulates the precise clinical scenario that I am referring to and that is at the crux of this scenario.


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## akflightmedic (Jan 30, 2022)

Good old morbid curiosity strikes, I scrolled through all of your posts. Just an observation, tangential one of course, since that is where we are now. However, post after post, you bring in articles, links, journals, etc. All fine teaching points. And it is always great to learn and be exposed to new information. With the exception of a few one offs in the random discussion thread (and even those are devoid), nearly every single one of your posts is constructed in a way where there is absolutely no personal experience related, no examples to break it down, no making it human so one may understand better.

Your replies often acknowledge what someone says, and then the way your words are laid out, there is absolutely no claim to any of the above. And often, after your one hit, there is little to no participation beyond that. Occasionally yes, but more exception than the rule. 

I have meet quite a few here over the years who often wrote in similar format or style. 

Meh, not drawing any conclusions, but just found the observation rather fascinating. Could be wrong, could be tired, or simply could be dumb...who knows, right?


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## MonkeyArrow (Jan 30, 2022)

akflightmedic said:


> Good old morbid curiosity strikes, I scrolled through all of your posts. Just an observation, tangential one of course, since that is where we are now. However, post after post, you bring in articles, links, journals, etc. All fine teaching points. And it is always great to learn and be exposed to new information. With the exception of a few one offs in the random discussion thread (and even those are devoid), nearly every single one of your posts is constructed in a way where there is absolutely no personal experience related, no examples to break it down, no making it human so one may understand better.
> 
> Your replies often acknowledge what someone says, and then the way your words are laid out, there is absolutely no claim to any of the above. And often, after your one hit, there is little to no participation beyond that. Occasionally yes, but more exception than the rule.
> 
> ...


I am unsure how this relates to the points I've raised in this thread, but against my better judgement, I'll take the bait.

Good. That is exactly how I wish to come across. I interpret your description of my posting as a complement. I try to learn and practice based on the best science and evidence that is available, and I think the field should too. Therefore, I come on here and post said things that I think may be useful for others. We should be practicing based on evidence, not anecdote. I don't think my posting of war stories is all that helpful to anyone.

If your claim is that this is not an effective form of teaching...ok. I am not getting paid to teach. I come to this forum volitionally and specifically for the clinical discussions. If someone cares enough about what I posted, they should try to read the primary source and engage in a discussion if they have questions/disagree/have a different experience.


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## CCCSD (Jan 30, 2022)

Then stop posting as if your “opinions” are the only thing that is truth. And please, get ride of the $20 words. They don’t make you sound educated, they come across as a pontifical horses rear end.


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## silver (Jan 30, 2022)

Well this thread evolved interestingly.

To provide a different perspective, I would say I find myself frequently asking a RN "what do you want to do?" or "what orders do you want?" to which he/she may reply "Well I already did XXXX, so can I have an order for it?" Majority of time it's a reasonable start to get things going for an initial eval or resuscitation. I would never discredit a nurse's assessment skills. Sometimes I don't agree with it or the things they did without me, but end up taking it into account with developing my own assessment.

In regards to how tough RN/NP/PA/MD/DO school is: it's like training to be an athlete. You won't excel in nursing or medicine unless you put in the reps first. I remember helping teach a skills day for an EMT class while I was in college and one of the more senior instructors was a ED RN who was in scrubs coming directly from an overnight shift to teach. She was a 4th year medical student who during her BSN worked as a paramedic and then during medical school was working as a RN. As a college student, I thought she was out of her mind for working that much. Now I'm wondering if she is giving life and retirement advice.


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## akflightmedic (Jan 30, 2022)

Meh, I will take the bait of your intentional disregard for my subtle/no so subtle implication (was chum really, bait is next). 

First, I did not state war stories need to be shared. There is a HUGE difference between war stories and stories of experiences or relevance which teach/educate, or reinforce valuable lessons. 

Second, I was calling out the fact that darn near every single post of yours, anyone could do (and has previously), because it lacks substance. It lacks relevance in the sense that if your only contributions are links to other sources and then you vanish from the thread, it then begs the question of who are you and what your intent is. One notable character was Mr. Brown and other aliases, much of the same flair if you will. 

So you will drop a source, stand firm it is the ONLY way, and then vanish. Anything contrary to your preconceived opinion is garbage because apparently the tower (ivory?) upon which you stand should be enough. And that unto itself is grossly dishonest, and unfair, to not only "your dear readers", but also to yourself. You seem to kill amazing learning opportunities by taking this method of delivery, and in my past experiences I often found this was due to lack of knowledge, lack of experience, or both. 

So as amazing as you are standing upon this rock (tower, rock, meh) of only delivering factual, objective data, peer reviewed studies, preserving the sanctity of healthcare delivery by highlighting how often all are wrong, yet never ever once bringing an expansion of a topic from a personal lens (which indeed, DOES help) and/or display a modicum of humbleness, in all truthfulness despite my eagerness to read, and learn, I typically skip your posts. Now you can respond that is my loss, or state you are not here for me anyways, and if you do that, then again my intention will have been missed. Take this as constructive feedback to help you become a better beacon of light for all things EEMS, medical, or whatever. Change the delivery of your message so it can actually be heard. Engage and converse, show you actually understand what you are posting. Share a story of personal relevance and how that study or practice applied or does not apply. Share LESSONS LEARNED...one of the greatest teachers of all time. In short, drop the pompous arrogance, and just be human.


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## ffemt8978 (Jan 30, 2022)

Do I really need to make this thread the focus of my complete and undivided attention?

So far it hasn't broken any rules but it is headed that way unless several members take a deep breath and relax a bit.


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