# NREMT-B vs. EMT-B



## yay4stress (Sep 21, 2007)

Hi, I'm a EMT-B in Pennsylvania.

as I wander around the EMS world, I keep encountering various bits of alphabet soup after people's names.

The two I am interested in are EMT-B (which follows my name) and NREMT-B.

is there something special one has to do to get added to the national registry?  or is that just a side effect of passing state exams that they don't tell you about?

TIA


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## BossyCow (Sep 21, 2007)

The National Registry is a separate registration that requires its own individual testing process.


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## yay4stress (Sep 21, 2007)

is there a reason why one should take such an exam?

not trying to be sarcastic, honestly wondering


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## seanm028 (Sep 21, 2007)

Some states require it.

For example, I'm a certified EMT-B in Arizona.  However, AZ doesn't have its own EMT test, so instead you go take the National Registry exam.  If you pass, you bring your certificate down to DHS and they add you to the list of AZ State Certified EMTs.

I think its purpose was to try and standardize things across different states.


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## rgnoon (Sep 21, 2007)

Welcome to the site!
Now...one potential advantage to having NREMT is that it CAN make applying for reciprocity easier depending on the state in which one applies. However, we here in NJ use the mid-atlantic standardized EMT-B test. It is my understanding that PA is part of the mid-atlantic consortium as well. So for us to apply for reciprocity in one of the other mid-atlantic states (i.e NJ to PA, PA to NY, NY to MD), NREMT really has no bearing. There are certainly other reasons to test for the national registry, but the reciprocity is the one i that i hear most often.


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## yay4stress (Sep 21, 2007)

ok

I guess since I don't intend to leave PA anytime soon, there really is no reason to bother.

Thanks


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## VentMedic (Sep 21, 2007)

Eventually your state may also go to the National Registry.  You may be grandfathered with your state tested EMT-B, but eventually somewhere down the road you may find it easier if you have the NR.  This is what some EMT-Bs are now finding in the state of Florida which recently changed from the state's test for EMT-B to the NR.


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## yay4stress (Sep 21, 2007)

thats kind of ridiculous.

there's no reason for the state to give up it's own ability to certify EMS personnel!

Actually, I just don't want to have to take another test...


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## Ridryder911 (Sep 21, 2007)

First you asked... don't be surprised of the answer. Second, actually it is not ridiculous, rather VERY smart. It costs money to produce tests and keep it current and legitimate, and valid. 

As well, many may not be like you wanting to remain in one state, as well you really do NOT know what the future holds for you too. Never say never... 
National testing promotes autonomy, professionalism, and having one being taught and credentialed by one test. Yes, each state can still license or certify dependent on their requirements then. Similar to physicians, PA's, RN's ,etc.

Just ridiculous for state's to pay for issuing, researching, and maintaining them...

R/r 911


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## VentMedic (Sep 21, 2007)

Actually there are many reasons for a state to go with the NR.
1. It is easier to attrack potential employees from other states through retroprocity.

2. It offers a more nationally recognized uniformity for standards which:
    a. offers the state and profession to lobby for more funding  by conforming with a national standard
    b. national standard sets the tone for educational improvement as a statewide endeavor.

3. Cheaper in the long run by offering a national test through a nationally recognized organization.

4. CEU providers will only have to worry about the NR accreditation for their educational offerings.

5. Ability to obtain CEUs without the extra state petitioning paperwork for approval for each class.

6. NR offers standard levels of certifications and combines the 6 or 8 different state certs in some states.  

The National Registry is not perfect but considering almost every other profession base their state licensure off of a national certification, it could work well if the educational standard is established and the NR follows the path.


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## BossyCow (Sep 21, 2007)

Also opportunities come up that require National Registry, exchanges with other systems, disaster relief, association with the system you work in and federal agencies such as National Parks, Forestry Service etc.  

If you know your stuff, there is nothing to fear in a test.  If you aren't secure in your knowledge, better to find out than go on blissfully ignorant of where you are weak until you need it on a patient.


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## rgnoon (Sep 21, 2007)

yay4stress said:


> thats kind of ridiculous.
> 
> there's no reason for the state to give up it's own ability to certify EMS personnel!
> 
> Actually, I just don't want to have to take another test...



Yeah the idea of taking another test can be daunting, but I know that many of us in NJ (ok maybe not MANY...but SOME)...myself included...take the NR in the name of staying on top of continuing ed. Maybe we also do it "just in case", although new jersey only just recently switched from NREMT to the mid-atlantic test, I'm not exactly sure why but I'd venture to guess that it had something to do with the NREMT going digital.


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## rgnoon (Sep 21, 2007)

BossyCow said:


> Also opportunities come up that require National Registry, exchanges with other systems, disaster relief, association with the system you work in and federal agencies such as National Parks, Forestry Service etc.



Sorry for the two posts...but this is really why I got the national registry, as I work with a SAR team who gets called out to other states rather frequently. I have to admit that disaster relief was also in the back of my mind having volunteered in NOLA on multiple occasions. I just hope that I never have to provide my National Registry card for such an event.


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## Arkymedic (Sep 21, 2007)

yay4stress said:


> thats kind of ridiculous.
> 
> there's no reason for the state to give up it's own ability to certify EMS personnel!
> 
> Actually, I just don't want to have to take another test...



Well let me just say this since I come from a non-NR state. I am now a Paramedic in OK as well as AR. It cost me $200 for reciprocity and you have to be NREMT-P to obtain reciprocity. In AR your NR can lapse and as long as you meet state guidelines you can stay an AR Paramedic. Most Paramedics in this area that have been in EMS for lets say over 5 yrs have lapsed now. In OK they also use the National Registry FR and NREMT-I 99. With this system a Registered FR can work on an ambulance in OK.


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## Arkymedic (Sep 21, 2007)

rgnoon said:


> Sorry for the two posts...but this is really why I got the national registry, as I work with a SAR team who gets called out to other states rather frequently. I have to admit that disaster relief was also in the back of my mind having volunteered in NOLA on multiple occasions. I just hope that I never have to provide my National Registry card for such an event.



With the new attention being paid to disaster credentialing it is quite possible


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## rgnoon (Sep 21, 2007)

Ok...what i REALLY meant to say was that I hope i never have to respond to such an event... sorry 'bout that


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## Ridryder911 (Sep 21, 2007)

Arkymedic said:


> With the new attention being paid to disaster credentialing it is quite possible



Actually, most states have adopted the MCR as their credentialing criteria for disaster time. Medical Corp Reserve is the Federal Government division on local disaster responses, where as the Disaster Medical Assistance Team (DMAT) is for responses upon the Federal level. 

I know in OK one will not be allowed to work or enter a disaster site, unless they have an I.D. issued through Medical Reserve Corp. I don't care what medical license, national registry, etc..  


MCR has multiple levels from veterinary to public health, to initial disaster response teams. It is free, they perform FBI & local clearance background, as well provide free in-services. 

Here is a link to there web site : 

http://www.medicalreservecorps.gov/About

R/r 911


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## yay4stress (Sep 21, 2007)

fair enough, I concede

it's interesting how this discussion developed, I was just interested in the difference between an EMT and an NREMT...


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## Arkymedic (Sep 22, 2007)

Ridryder911 said:


> Actually, most states have adopted the MCR as their credentialing criteria for disaster time. Medical Corp Reserve is the Federal Government division on local disaster responses, where as the Disaster Medical Assistance Team (DMAT) is for responses upon the Federal level.
> 
> I know in OK one will not be allowed to work or enter a disaster site, unless they have an I.D. issued through Medical Reserve Corp. I don't care what medical license, national registry, etc..
> 
> ...



I play with MRC in both AR and OK Rid and AR has a new system we are trying out in addition to the MRC model. http://www.healthyarkansas.com/esar/


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## certguy (Sep 23, 2007)

Hi there , 
    Another advantage of Nat. registry is that if you respond to a large natural disaster or god forbid , another 911 , if you wind up working with an out of area EMT who's got the registry , you and that person have equivelant training . There's no guesswork about whether or not the skills are the same.

                         CERTGUY


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## medicdan (Sep 23, 2007)

certguy said:


> Hi there ,
> Another advantage of Nat. registry is that if you respond to a large natural disaster or god forbid , another 911 , if you wind up working with an out of area EMT who's got the registry , you and that person have equivelant training . There's no guesswork about whether or not the skills are the same.
> 
> CERTGUY



Correct me if I am wrong, but isnt the training essentially the same across the country? Doesn't the DOT monitor the training so, apart from a few skills, there is a national standard for education? Wouldn't the difference between states just be scope of practice and governing structure?


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## VentMedic (Sep 23, 2007)

The training does follow the DOT curriculum but there are many ways to present the training. Some schools might just give the DOT outline in a 3 week crash course.  Some may teach the course as a test prep giving just enough information to be barely compliant with the standards. 

The states that do not utilize the NR may have only a written test with no skills evaluation.  That was the case with Florida's EMT-B exam until the NR was finally adopted.  Recertifying by exam for license renewal was a piece of  cake. You could just do a couple hours for the test instead of 24 -32 hours for the recert classes and skills evaluation. With the NR, at least you should get your skills checked for renewal.

Nurses in Florida can challenge the Paramedic State exam in Florida and pass easily because it is totally a written exam without a skills evaluation.


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## triemal04 (Sep 23, 2007)

VentMedic said:


> Nurses in Florida can challenge the Paramedic State exam in Florida and pass easily because it is totally a written exam without a skills evaluation.


You have got to be kidding me.  If that applies only to RN's challenging it, that is screwed up.  If that applies to everyone taking the test, that is completely and utterly #$%#ed up.  I've heard lots of horror stories about the Florida medic factories and the 90 day wonders but this takes the prize.  Does anybody in that state have any clue how wrong that is?


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## VentMedic (Sep 23, 2007)

Yes, and Dentists, Doctors of any type, PAs as well as nurses can challenge the FL State Paramedic exam. However, they must take the EMT-B class. But, with the PDQ crash courses for that also, it's a cinch. 

This is partially because the Paramedic is still a "certificate" to most and not higher education. Until the education level and national testing is standard, it will continue to be treated as just another specialty certificate. 

Eventually, the RN may see the option of the PHRN (Pre-Hospital RN) certification which is now being offered in a few states. This will be more advantageous for the RNs to reduce conflicts in licensure practice and scope. 

Florida actually led the nation in A.S. degree programs for the Paramedic 25 years ago. But, the demand was for the PDQ Medic Factory.  The FD and ambulance companies also realized this was a way to get cheap labor fast. People were offered jobs that promised an exciting career "real quick".  This fueled the success of the EMT and Medic factories as people who were not academically motivated joined the ranks. The rest is history.


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## triemal04 (Sep 23, 2007)

VentMedic said:


> Yes, and Dentists, Doctors of any type, PAs as well as nurses can challenge the FL State Paramedic exam. However, they must take the EMT-B class. But, with the PDQ crash courses for that also, it's a cinch.
> 
> This is partially because the Paramedic is still a "certificate" to most and not higher education. Until the education level and national testing is standard, it will continue to be treated as just another specialty certificate.
> 
> ...


Ok, I'm officially shocked and disgusted at an even higher level than before. 

 So, even for medic's there isn't a practical portion of the state test?  Just a written?  I can see how some schools wouldn't want a long, intensive medic program, wouldn't want to require all the extra classes that come with a degree (or even just a good program), but when the state is complicit in that...that's horrible.  And people wonder why EMS isn't advancing like it should...

Docs and dentists (dentists...that's just flat out wrong) can challenge for a medic but have to take the...basic class?  Seriously, what the hell is wrong with that state?

Does anybody who works in Florida as a medic, wants to work there, or studied there have anything to say?  Is the situation really not that bad?  Worse?  I mean, this is just pathetic really.  I know there are supposed to be schools there that run a good program, but still...pretty #$%^ing sad it sounds like.


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## VentMedic (Sep 23, 2007)

No, the situation is not as bad as it appears in the statutes. Florida (Miami, Tampa, Hialeah, Lee County to name a few) has lead the way along with Seattle in testing new field applications over the past 35 years. Florida has many EMS systems which utilize almost exclusively paramedics. They have come along way from being a mostly volunteer state. Although, some of the early volunteer systems were ALS with paramedics and displayed more professionalism than the paid.  

And, the EMT-B is now NR. Hopefully the paramedic will follow suit.  Nurses employed by HEMS are looking at changing the one line in the EMS statutes for scene responders.  I know several that would like to adopt the PHRN. This certification (approx 60-80 hours) program would be much more beneficial than just challenging the exam or taking the entire paramedic certificate.  For a nurse, getting EMT-P has no affect on his/her pay. If it is another nursing certification, it can have a pay increase or career ladder loop. The people that challenge the paramedic exam may already be employed by a HEMS or ED. The others may just want the "letters" and have no interest in every working as a paramedic.


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## triemal04 (Sep 23, 2007)

VentMedic said:


> No, the situation is not as bad as it appears in the statutes. Florida (Miami, Tampa, Hialeah, Lee County to name a few) has lead the way along with Seattle in testing new field applications over the past 35 years. Florida has many EMS systems which utilize almost exclusively paramedics. They have come along way from being a mostly volunteer state. Although, some of the early volunteer systems were ALS with paramedics and displayed more professionalism than the paid.
> 
> And, the EMT-B is now NR. Hopefully the paramedic will follow suit.  Nurses employed by HEMS are looking at changing the one line in the EMS statutes for scene responders.  I know several that would like to adopt the PHRN. This certification (approx 60-80 hours) program would be much more beneficial than just challenging the exam or taking the entire paramedic certificate.  For a nurse, getting EMT-P has no affect on his/her pay. If it is another nursing certification, it can have a pay increase or career ladder loop. The people that challenge the paramedic exam may already be employed by a HEMS or ED. The others may just want the "letters" and have no interest in every working as a paramedic.


That's good, but I'm going to need more convincing.  Being involved in field testing equipment doesn't mean that it's a good system, either at a state or local level.  A lot of places get contacted to test new equipment because of their high call volume.  Makes sense really.  The same goes for only using paramedics to transport.  This can even be detrimental sometimes if you have medics getting burned out taking BLS after BLS call and rarely utilizing the ALS skills and knowledge.  A medic on every corner is not a good thing, though it seems like this is the path that Florida wants to go.  (side note, this isn't to say that there aren't good systems or medics in Florida, just that the state seems to be a bit screwy)

It is still extremely disturbing that someone can go from medic school to working in the streets without every being tested on their skills.  Intubation is one of the most (if not the most) invasive procedures that we can do; to not know that everyone going out there to work can do it is ridiculous.  Same goes for IV's...pt assessments...rhythm interpretation...working codes...all that good stuff that most places test people on BEFORE they send them out to do it on real pt's.

The whole situation just sounds wrong.  Pre-hospital RN's are a nice idea, but the point of having Paramedics is so that you don't have to have them.  A medic get's trained to work autonomously, a RN doesn't.  A medic has skills that a nurse doesn't, and a nurse has skills that a medic doesn't.  If places are having to implement PHRN's, or want to, something is wrong with the paramedic system in that area.


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## VentMedic (Sep 23, 2007)

The dual paramedics units are in the EMS systems. Florida cities cover a lot of territory with high concentration of condos. They don't have a medic on every corner. There are still plenty of BLS and ALS transport companies to do the routine calls. 

I personally am in favor of the PHRN.  It might raise the bar a little on prehospital providers. RNs are already utilized in many areas out of the hospital and are very autonomous in their protocols. Plus, they if they are ICU, CVICU, NICU or PICU, they have many, many more protocols than most paramedics. Intubation and central lines for RNs that are involved in transport is actually less of a problem than trying to get paramedics some extra tube time.  Many RNs involved in interfacility transport or HEMS provide advanced skills and are comfortable with ICU patients and their specialized equipment.  Many of the interfacility transports are fresh trauma. If at scene the FD usually provides extrication and packaging. 

All of my RN partners on HEMS intubated, did lines, IOs, extricated if necessary on equal footing with the paramedics. However, when it came to ICU patients, they clearly had the advantage...until I bacame an RT.

Apologies for getting off track on this thread.


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## Arkymedic (Sep 23, 2007)

triemal04 said:


> That's good, but I'm going to need more convincing.  Being involved in field testing equipment doesn't mean that it's a good system, either at a state or local level.  A lot of places get contacted to test new equipment because of their high call volume.  Makes sense really.  The same goes for only using paramedics to transport.  This can even be detrimental sometimes if you have medics getting burned out taking BLS after BLS call and rarely utilizing the ALS skills and knowledge.  A medic on every corner is not a good thing, though it seems like this is the path that Florida wants to go.  (side note, this isn't to say that there aren't good systems or medics in Florida, just that the state seems to be a bit screwy)
> 
> It is still extremely disturbing that someone can go from medic school to working in the streets without every being tested on their skills.  Intubation is one of the most (if not the most) invasive procedures that we can do; to not know that everyone going out there to work can do it is ridiculous.  Same goes for IV's...pt assessments...rhythm interpretation...working codes...all that good stuff that most places test people on BEFORE they send them out to do it on real pt's.
> 
> The whole situation just sounds wrong.  Pre-hospital RN's are a nice idea, but the point of having Paramedics is so that you don't have to have them.  A medic get's trained to work autonomously, a RN doesn't.  A medic has skills that a nurse doesn't, and a nurse has skills that a medic doesn't.  If places are having to implement PHRN's, or want to, something is wrong with the paramedic system in that area.



The PHRN program makes a lot of sense especially for industry work where RNs need more prehospital knowledge than they have.


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## Gbro (Sep 23, 2007)

Ridryder911 said:


> Actually, most states have adopted the MCR as their credentialing criteria for disaster time. Medical Corp Reserve is the Federal Government division on local disaster responses, where as the Disaster Medical Assistance Team (DMAT) is for responses upon the Federal level.
> 
> *I know in OK one will not be allowed to work or enter a disaster site, unless they have an I.D. issued through Medical Reserve Corp. I don't care what medical license, national registry, etc..  *
> MCR has multiple levels from veterinary to public health, to initial disaster response teams. It is free, they perform FBI & local clearance background, as well provide free in-services.
> ...


After reading about it on the link you refered to, i am wondering what states are listed, and you left me thinking that;(i am just asking)
If there were a local disaster and say FEMA rolled in and took charge, and it is in my community, and say i and all of crew having no ID through MCR, would be turned away?


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## Gbro (Sep 23, 2007)

yay4stress said:


> Hi, I'm a EMT-B in Pennsylvania.
> 
> as I wander around the EMS world, I keep encountering various bits of alphabet soup after people's names.
> 
> ...



Here in Minnesota, One must pass the National registry of EMT's as that is the state standard. 
Once that is done, we have to refresh every other year, 24 hr. along with the refresher we must pass the EMT-B practical exam, as we now have ongoing testing during the 24 hours for the written test.
The State of MN then sends out our State certification. We can use that Cert. and document 40 hours of continuing education related to BLS and renew the National Registry Certificate.
One would have to carry that certificate in Mn to teach in the EMS field. it is mostly an imitative kind of thing, But required.
But through it all, one is still just an EMT-Basic!


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## triemal04 (Sep 26, 2007)

VentMedic said:


> The dual paramedics units are in the EMS systems. Florida cities cover a lot of territory with high concentration of condos. They don't have a medic on every corner. There are still plenty of BLS and ALS transport companies to do the routine calls.
> 
> I personally am in favor of the PHRN.  It might raise the bar a little on prehospital providers. RNs are already utilized in many areas out of the hospital and are very autonomous in their protocols. Plus, they if they are ICU, CVICU, NICU or PICU, they have many, many more protocols than most paramedics. Intubation and central lines for RNs that are involved in transport is actually less of a problem than trying to get paramedics some extra tube time.  Many RNs involved in interfacility transport or HEMS provide advanced skills and are comfortable with ICU patients and their specialized equipment.  Many of the interfacility transports are fresh trauma. If at scene the FD usually provides extrication and packaging.
> 
> ...


Forgot this thread even existed.  Oh well.  Don't get me wrong, I love dual medic ambulances, for me, that's the way to go.  Your other posts made it sound like the only people to transport were ALS units, something I think is ridiculous.  If that's not the case then I feel much better.  

I think you're missing my point about prehospital RN's.  While they may have applications, like in an industry setting where a lot of their work may be more clinical than our standard call, I don't want to see them become widespread on ambulances.  If paramediciene is taken seriously and taught at a higher level, there wouldn't be a need for a RN to be on a car.  The medic would be fine taking pt's from the street, or from an ICU.  (really, exactly what specialized equipment are you talking about?  I've done transfers like that and never had a problem.)  I can see how some areas might want to utilize PHRN's because the medic's are being trained to a piss-poor standard, and then never being tested on their skills.  <shudder>  That shouldn't happen.  

I guess that's a long way of saying that if paramedics are trained to a higher level on a national scale, act like true medical professionals on a national scale, and stop letting EMS get dumbed down, there is no need for a PHRN.  'Course that means there is a lot of work to be done, but really, EMS is still in it's infancy, so I've still got hope.


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## disassociative (Sep 26, 2007)

TN requires National Registry Licensure to receive state licensure. 

The only TRUE advantage I see to being NREMT-B, NREMT-I, NREMT-P is simply being able to move out of your state and getting a license in the new state without going through the process of state testing, etc. The NR shows that you have met NATIONAL standards of competency at your level. I will tell you like my nursing professor told me: titles are not indicative of competency. Do not just assume that someone is always right and always knows what to do just because someone has RN, CCRN, EMT-P, NREMT-P, CEN, abc, 123 past their name(sorry ridryder911). However, in person(s) like ridryder for example; these titles are backed up with the appropriate knowledge and experience. That my friend, is something you can't buy. I hope to one day be an old flight medic with 30+ years of experience under my belt, well informed, and still eager to learn more. We should all be so lucky.


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## VentMedic (Sep 26, 2007)

triemal04 said:


> I think you're missing my point about prehospital RN's.  While they may have applications, like in an industry setting where a lot of their work may be more clinical than our standard call, I don't want to see them become widespread on ambulances.  If paramediciene is taken seriously and taught at a higher level, there wouldn't be a need for a RN to be on a car.  The medic would be fine taking pt's from the street, or from an ICU.  (really, exactly what specialized equipment are you talking about?  I've done transfers like that and never had a problem.)  I can see how some areas might want to utilize PHRN's because the medic's are being trained to a piss-poor standard, and then never being tested on their skills.  <shudder>  That shouldn't happen.
> 
> I guess that's a long way of saying that if paramedics are trained to a higher level on a national scale, act like true medical professionals on a national scale, and stop letting EMS get dumbed down, there is no need for a PHRN.  'Course that means there is a lot of work to be done, but really, EMS is still in it's infancy, so I've still got hope.



There's a possibility that a specialized team may have transported the more critical patients for some of the interfacility transports that you as a paramedic may not get to see.

There are times also when the sending ICU over estimates the skills of the paramedic and sends a patient assuming the paramedic is familiar with advanced modes of ventilation, cardiac mechanical assist devices, ICP monitors, PA catheters and monitoring equipment, balloon pumps and various venous access catheters. Unfortunately, the paramedic may take the patient assuming a catheter is a catheter....that is until they need it.  ECMO, some dialysis, and high frequency vent patients will not be transported solely by paramedics. There will be RNs and/or RTs present.  

I mentioned just some of the equipment attached to the patient. I could also list many meds (including some of the thrombolytics and anesthetic agents such as Diprivan) used in the ICU/ED that a paramedic will not be familiar will.  There are times when the ICU will temporarily discontinue a med for the patient to be transported and hope for the best. Flolan and Iloprost are meds we routinely discontinue for transport by a paramedic unit. There is not that much to them, but if one is not familiar with it, reading about them while preparing for transport is the best time. 

It all depends on your area and the type of ICUs your hospitals have. Some ICUs are little more than med-surg with monitors. 

It is much easier for the nurse to acquire knowledge and experience about extrication and scene response through various agencies than to try to get a paramedic 5 years of experience working in direct patient care with balloon pumps, ventilators, CVVH and surgical patients inside an ICU. Many paramedics even detest transporting a patient from a subacute vent facility and absolutely cringe at the thought of anything involving dialysis. Knowing more about these patients can only help when learning ICU techniques and the reasoning behind many ICU protocols to spare the lungs and kidneys. 

The "critical care" cert programs for paramedics are introductory at best. 

My position for PHRN (or MICN for some states) is it is senseless for a nurse to take the paramedic program 70% redundant in A&P, basic acid base, cardiology and an over simplification of many advanced protocols that nurses who have ED or ICU experience already practice. Nurses are already part of many systems and their numbers are growing.  Currently they are more concentrated in high acuity specialty transport areas such as CV, Neo, Pedi and HEMS.  Some private companies may find it is easier to utilize a PHRN/EMT-P driver than have a nurse on call and explain response delays to their customers (hospitals and doctor offices).  Hospitals will also be much happier if they do not have to send one of their staff to accompany a patient.  The nurses who usually get stuck going on a truck with a crew they do not know with equipment that may or may not be adequate, would be much happier also. 

In all fairness, I have seen some very well trained paramedics. But, we are now saving sicker patients that require more expertise which the inhospital employees must continuously educate and train to stay current. EMS is still trying to get the prehospital stuff standardized.

For scene response, HEMS still employs a large amount of nurses. There are also ground EMS systems that employ Trauma RNs as "Trauma Officers" who determine where the patient goes and how.

I may sound very critical but when I think back on some of the inter-facility patients I cockily transported as a paramedic without ICU experience, "ignorance is bliss" is not a good defense in court.  Sometimes, you don't know what you don't know.

I apologize again for being off the topic. Guess a new thread should be started soon if this conversation is continued.


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## Arkymedic (Sep 27, 2007)

VentMedic said:


> There's a possibility that a specialized team may have transported the more critical patients for some of the interfacility transports that you as a paramedic may not get to see.
> 
> There are times also when the sending ICU over estimates the skills of the paramedic and sends a patient assuming the paramedic is familiar with advanced modes of ventilation, cardiac mechanical assist devices, ICP monitors, PA catheters and monitoring equipment, balloon pumps and various venous access catheters. Unfortunately, the paramedic may take the patient assuming a catheter is a catheter....that is until they need it.  ECMO, some dialysis, and high frequency vent patients will not be transported solely by paramedics. There will be RNs and/or RTs present.
> 
> ...



Vent I believe you truly are on the mark with this. I have transported some patients when weather was bad enough they could not fly that I was almost sure was going to die in my truck. I took care of the pt and the nurse I took with me took care of pumps, meds, etc. I too believe that PHRN has a definate place and use. For those Paramedics bridging to nursing this would also be a unique situation where they might be of the most use.


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## Ridryder911 (Sep 27, 2007)

I believe some clarification is needed. I much prefer to see the PHRN be labeled as a Specialty Transport or Critical Care Transport. In fact in the nursing world, Emergency Nurses Association has a new board certification labeled Certified Transport Registered Nurse (CTRN). Most nurses (that possess integrity) should realize they are not properly educated in field treatment regime, however; critical care and emergency medicine is NOT the same. Like others, I do believe there is a place for speciality. 

R/r 911


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## VentMedic (Sep 27, 2007)

True Rid, but the training programs are pretty impressive in the states that spell out the requirements. It gives the nurse a chance to broaden his/her knowledge base from the nurse education level and institute the skills for prehospital. This has already been accomplished in the specialty teams. For hospital based services that do interfacility and EMS, this could be a nice marriage without the need to pull staff or run trucks crowded with various professionals.  

The one thing we found with our nurses doing HEMS and interfacility, they must still pull some hours in ICU to stay current with knowledge and hands-on for trouble shooting equipment. This is also one reason why RTs have a difficult time specializing in a free standing transport team. They are behind the times in skills and knowledge in a very short time.  Neo and Pedi teams running at a level 3 (and now 4) levels are usually unit based to keep competencies current. When on the neo transport team I had to tube 3 babies per month regardless.  For the specialty teams the standards are high with little room for error. You have to demonstrate both the knowledge and the skills to back up the "certification".

Arkymedic,
You're right in that until you've been with an ICU patient and their full complement of accessories, it's easy to think one can handle it all.


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## triemal04 (Oct 3, 2007)

VentMedic said:


> There's a possibility that a specialized team may have transported the more critical patients for some of the interfacility transports that you as a paramedic may not get to see.
> 
> There are times also when the sending ICU over estimates the skills of the paramedic and sends a patient assuming the paramedic is familiar with advanced modes of ventilation, cardiac mechanical assist devices, ICP monitors, PA catheters and monitoring equipment, balloon pumps and various venous access catheters. Unfortunately, the paramedic may take the patient assuming a catheter is a catheter....that is until they need it.  ECMO, some dialysis, and high frequency vent patients will not be transported solely by paramedics. There will be RNs and/or RTs present.
> 
> ...


Start with the rebuttals...with the exception of certain pediatric pt's (which I am all to happy to let a specialty crew take) or the rare pt that goes by helicopter, no, the more critical pt's don't get a differnt crew than your average transfer would (here that means a dual medic ambulance, maybe with a third if the transfer warrants it).  There are times when an RN will go, again, fine with me, but we'll get to that in a minute.  But for monitorring the "specialized" equipment...ventilators are old hat.  Worst comes to worst they get switched to mine.  For monitorring ICP probes...again, it's not that horrible difficult.  For PA catheters, sure I'll admit I have no clue, which is why an RN would be riding along.  As for extra meds...part of doing my job correctly means that I get the info about my pt and what they're taking before I get there if possible, and damn sure before I leave.  Generally the med will be continued under a doc's orders, depending on the distance of transport, state of pt, type of med, and how I (or any medic) feels about it.  Taking a bit of time to get some info on what is going into the pt is mandatory, as is finding out how it could adversly affect them.

Now, I'm not sure about something.  Are you just argueing that RN's should be doing interfacility transfers?  If so, then I'm actually all for it.  Despite what I said above, I'm not an expert in all the equipment that some of my pt's have had; I can generally keep it running, stop it if neccasary and try something else, but that's not perfect.  Having someone who uses that on a regular/semi-regular basis is a fine idea, as is sending the RN who has been treating the pt for (sometimes) a very extended time; they'll know a hell of a lot more than what is in the pt's chart.  Like I've said, there is a place for RN's outside the hospital, that's another one.

But, if you're argueing that RN's should be used pre-hospital to answer emergency/non-emergency calls instead of a paramedic...sorry.  Hell no.  For the reasons allready listed.  Emergency mediciene is a field that not everyone is suited for, and paramediciene is (or was, still is to some extent) based around keeping people alive in the field in adeverse conditions for sometimes extended periods.  Some things we get taught RN's don't.  Don't need to.  We use some things in different ways or at different times.  Emergency mediciene is what your normal nurse knows, and this includes some ICU nurses (I'll tell you about a code I watched in a very well run Trauma 2 ICU sometime  ^_^).  Keep nurses working in the hospital, it's where they're taught to work, and keep medics in the field, it's where we are taught to work.  And if the training of those medics makes RN's look better...well...like I've said, that is a damn shame, and something that needs to be fixed on a national level.  But to arbitrarily decide that RN's should take over instead of fixing the problem...it's shocking to hear anyone who still calls themself a medic say that.  I can understand people wanting to get out of EMS, either as RN's, RT's, some docs, or something non-medical, but damn...don't ever forget where you started.  To just turn your back on a system instead of looking for ways to improve it is pretty shameful.  Now, if that's not what you're doing then I apologize, but that is how it comes across.

Bottom line:  if there is a RN that wants to work on an ambulance running emergency responces, then let them get certified as a paramedic.  If there is a way they can challenge that, that's fine (as long as the process is sound).  But to certify someone as a "prehospital registered nurse" makes me shudder.  It just sounds like a death knell for EMS.


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## VentMedic (Oct 3, 2007)

triemal04 said:


> But for monitorring the "specialized" equipment...*ventilators are old hat*.  *Worst comes to worst they get switched to *mine. * For monitorring ICP probes...again, it's not that horrible difficult.* *For PA catheters, sure I'll admit I have no clue, *which is why an RN would be riding along.  As for extra meds...part of doing my job correctly means that I get the info about my pt and what they're taking before I get there if possible, and damn sure before I leave.  Generally the med will be continued under a doc's orders, depending on the distance of transport, state of pt, type of med, and how I (or any medic) feels about it.  Taking a bit of time to get some info on what is going into the pt is mandatory, as is finding out how it could adversly affect them.



I don't even want to respond to your view of the ICU environment as just a set of "skills" and not as a whole patient.   How much time do you want to delay transporting the patient while you learn some of the meds which may be the reason the patient is transferring?  How much do you want to risk harming the patient and/or your license on a medication error?   




triemal04 said:


> Bottom line:  if there is a RN that wants to work on an ambulance running emergency responces, then let them get certified as a paramedic.  If there is a way they can challenge that, that's fine (as long as the process is sound).  But to certify someone as a "prehospital registered nurse" makes me shudder.  It just sounds like a death knell for EMS.



Again, why should a nurse waste time repeating basic A&P and how to start an IV. The certification course for PHRN is longer than most EMS certification courses for skills.   Nursing and the allied health professions are constantly evolving in their knowledge, skills and leadership.  Professions and technology are changing.  

I started in EMS in the 70s and have been involved either on slave trucks in the private industry to ground EMS and HEMS as well as education.  EMS is stuck in a skills mentality as you desribed by your desription of ICU transport. 

I mean you no disrepect, but there is so much to learn. Maybe it will take nurses and other professionals to start the ball rolling before EMS wakes up to the fact they have to change their perspective as a profession and strive for better industry standards.  

Maybe I am getting tired of betting on the underdog. Over the years I've seen so many professions that weren't even a bleep on the radar mature quickly into well educated and repected members of the health care community. If this was a horse race, in many ways EMS would be headed for the glue factory.


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## triemal04 (Oct 3, 2007)

VentMedic said:


> I don't even want to respond to your view of the ICU environment as just a set of "skills" and not as a whole patient.   How much time do you want to delay transporting the patient while you learn some of the meds which may be the reason the patient is transferring?  How much do you want to risk harming the patient and/or your license on a medication error?
> 
> Again, why should a nurse waste time repeating basic A&P and how to start an IV. The certification course for PHRN is longer than most EMS certification courses for skills.   Nursing and the allied health professions are constantly evolving in their knowledge, skills and leadership.  Professions and technology are changing.
> 
> ...


ICU being only skills related?  Not sure how you reached that conclusion, but ok, if that's how you want to play, go for it.  As for the meds...if Iget notified in advance of a transfer I (and any competant medic) will be finding everything I can about the pt, this includes the drugs they're currently being given and how they'll effect them.  If I can't do that before I arrive, it doesn't take that long to get a quick overview of the possible complications.  Now, I allready said an RN may do that better and may be better suited to...ahh...you don't want to see that I sguess.

The point, which you apparently missed is that in the last 30 years EMS has progressed, and certain equipment that is used in the ICU is used in the field, and medics are now being taught how to handle/understand/treat/use a lot more things and illnesses than they were in the beginning, or even 10 years ago.  That's not to say that more shouldn't be taught or that there isn't a ways to go to get EMS where it should be; there is without a doubt.  It's not to say that other professions aren't getting more knowledge than medics and may be better suited to some interfacility work; they are.  I recognize that, and it's something I want to change (the training part I mean).  Unfortunately, it seems like you don't.  Instead of wanting nurses to work prehospital, why not advocate for advancing EMS training?  Wouldn't that be a better route?  Why go down a path that could mean the death of EMS instead of working to change it?  I understand that you now work as a respiratory therapist in a more clinical setting, but that doesn't mean that you have to disregard what is happening in the EMS world.  

EMS needs improvement, oh hell yeah, but competition isn't always the best way to make something improve.


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## VentMedic (Oct 3, 2007)

This is a good conversation triemal04. But lets start a new thread to get more opinions.


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