FF894
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Do you know if the medics can use their standing protocols or are limited to just "helper" work?
Can an EMT B become an ER tech?
- Thread starter CardiacJunkie23
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Do you know if the medics can use their standing protocols or are limited to just "helper" work?
JPINFV
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The protocols and standing orders inside the hospital bear no relation to the protocols and standing orders outside of the hospital.
FF894
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Some hosptials do carry over the pre-hospital standing orders, maybe with procedure changes. Thats one of the advantages to having an EMTP in the hospital setting though - if needed, a medic can act immediatly, caring out life saving interventions that otherwise may have needed to wait for a MD, PA, etc depending on which unit you are in and specific protocols etc.
JPINFV
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^
Still, at that point you are not relying on the EMS medical director for orders, but the hosital's physicians/insurance to determine what you can/can't do.
I'm also not 100% clear on the second part. Short of stationing a paramedic in every unit, an emergency situation is still going to have to wait for a paramedic to respond. Since I doubt that a hospital is going to want to spring for a paramedic on every floor, the wait might as well be for a code (generally comprised of RT, critical care nurse/s, and physician) or rapid response team (RT, CC nurses with a direct line to a physician) to respond since these providers are already on site and can be used for more routine care.
Still, at that point you are not relying on the EMS medical director for orders, but the hosital's physicians/insurance to determine what you can/can't do.
I'm also not 100% clear on the second part. Short of stationing a paramedic in every unit, an emergency situation is still going to have to wait for a paramedic to respond. Since I doubt that a hospital is going to want to spring for a paramedic on every floor, the wait might as well be for a code (generally comprised of RT, critical care nurse/s, and physician) or rapid response team (RT, CC nurses with a direct line to a physician) to respond since these providers are already on site and can be used for more routine care.
FF894
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The hospitals I know of the chief of the department is the "medical director" for standing orders although if you are carrying out MD orders its whoever asked for them - 2mg of MS in room 14 is whoever saw that pt, signed the chart.
As far as a code- it really depends on the hospital because I have heard of all different scenarios. Most of the time the medic is on the code team to respond to any codes in the hospital. As far as he unit they are working in (I know of ED more than anything else) the EMTP can push the ACLS drugs and intubate patient, etc without waiting for anyone to tell him he needs to. Yes, some hospitals allow the nurses to push drugs in an arrest without waiting for orders. Medcis also are responsible for admin and interpretation of ECGs and and appropriate protocol. On the other hand many hospitals who have medics use them as any other tech although they can maybe start lines.
Not sure if any of that made sense...
As far as a code- it really depends on the hospital because I have heard of all different scenarios. Most of the time the medic is on the code team to respond to any codes in the hospital. As far as he unit they are working in (I know of ED more than anything else) the EMTP can push the ACLS drugs and intubate patient, etc without waiting for anyone to tell him he needs to. Yes, some hospitals allow the nurses to push drugs in an arrest without waiting for orders. Medcis also are responsible for admin and interpretation of ECGs and and appropriate protocol. On the other hand many hospitals who have medics use them as any other tech although they can maybe start lines.
Not sure if any of that made sense...
The "skills" of a Paramedic are very limiting in the hospital setting. Other practitioners may have many years of critical care experience to quickly identify specific situations. We often will stabilize NOT according to the simplified EMS protocols which are meant for a blanket treatment but with a set of treatments, as well as a whole pharmacy of medications, to be more specific to the patient. The critical care medicine physicians write the protocols and train the experienced providers. Hospitals are now encouraged to develop programs to be compliant with JCAHO recommendations and those from the Institute for Healthcare Improvement which has established the plans for inhospital Rapid Response Teams.
In other words, you may be able to intubate or start an IV, but then what? Your intubation and IV skills may also have to be fine tuned to prevent infections. These "skills" are just one small part of the equation. It might fly in some rural middle of nowhere hospital but with all eyes on quality and education to prevent screwups that lose Medicare reimbursement, it could be very risky for the hospitals. Many states also do not allow the recognition of the EMT-P inside the walls of the hospital. That is the way EMS wrote the statutes.
NO RN or RRT on a code or Rapid Response Team in most hospitals needs permission to initiate and carry through care in an emergency situation.
In other words, you may be able to intubate or start an IV, but then what? Your intubation and IV skills may also have to be fine tuned to prevent infections. These "skills" are just one small part of the equation. It might fly in some rural middle of nowhere hospital but with all eyes on quality and education to prevent screwups that lose Medicare reimbursement, it could be very risky for the hospitals. Many states also do not allow the recognition of the EMT-P inside the walls of the hospital. That is the way EMS wrote the statutes.
NO RN or RRT on a code or Rapid Response Team in most hospitals needs permission to initiate and carry through care in an emergency situation.
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JPINFV
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You know, I could make the same statement about paramedics. Maybe we should staff ambulances with a rapid response team since they rely on standing orders with a wider selection of interventions while the local EMS has their paramedics call a hospital for virtually all orders and rely on a 12 lead ECG machine's interpretation for when to call a STEMI alert.
FF894
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So what I am hearing is that EMTPs are taught specific skills and cant possible be expected to expand those skills with the proper education and guidance? By that concept, how can RNs start IVs? They never learn that in their initial education - it is on the job training and is usually one of the most used skills in ED settings. You are saying that paramedics are just monkeys that can intubate but then have no idea how to manage the patient after that?
FF894
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What system are you working in that you have to call the hospital to ask for orders based on your ECG interpretation? I agree MA is a little behind and could never be called "agressive" with their protocols, but you are making it sound like you can't do anything.
JPINFV
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I used to work in Southern California.
http://ochealthinfo.com/docs/medical/ems/treatment_guidelines/c15.pdf
On a side note, I noticed that Orange County finally got around to writing BLS protocols (there weren't any when I worked there). Thanks for telling me that I need to put a patient on oxygen and take some vital signs.
FF894
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Interesting, and I thought MA was behind. Cal does get 10mg more MS than MA though...
SoCal to Boston eh? HOws the weather treating you?
SoCal to Boston eh? HOws the weather treating you?
JPINFV
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Let's just say it took me 30 minutes longer than I though to get to work on Saturday (I budgeted an hour) with most of that spent just getting out of my driveway.
How many pressors do you use in the field? How familiar are you with line and drug compatibility? Various vascular access devices? Do you know what labs to order? When was the last time you messed with an ICU ventilator...legally? Initiated a Sepsis protocol? VAP protocol? How many cardiac conditions are your familiar with enough to identify on an EKG besides STEMI? Knowledge of the many Pacemakers? Can you administer blood products? Thrombolytics? Dosed Heparin? Hung an insulin drip? Lasix or Bumex drip?
How much time do you have in the ICU as a primary care giver being responsible for the care of a patient?
Do you have at least an Associates degrees in EMS or some allied health profession? Many hospitals long ago did away with the LVN or Resp Tech who only had a mere 1 year of training.
Who writes your inhospital protocols? Who is responsible for your QA? Training? Who do you directly report to for orders and who is your immediate supervisor. An ER tech normally works under the nursing department.
All of our student RNs get a chance to start IVs and a whole host of other invasive procedures.
Our CCT RNs also intubate along with many other providers in the hospital. It is skill that can be learned rather easily especially if the Pulmonologists are mentoring. However, learning all the things that make up critical care knowledge requires a solid foundation of education and experience. Thus, RNs and RRTs are not so cocky to believe their 2 - 4 years of college prepared them for the ED or ICU. However, it gives them the foundation to now be trained for just about anything. Unfortunately, paramedics believe their 700 hours of training has prepared them for everything.
It is a lot harder to start from scratch with a person who has no formal A&P, Pharmacology, Microbiology, Psychology, Pathophysiology etc and attempt to get them up to speed on the many different disease processes and protocols that apply to them.
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Regardless of a Medic or Emt b, ER techs are assitants to the RN's and physicians in the ED. They work under the RN at every hospital actually that I've notice look it up. And another thing RN's are trained in IVs and Phlebotomy so I don't know where the source says that they aren't when they really are.
JPINFV
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Originally Posted by FF894 
I forgot to comment on this.
You run to the ICU for an unstable patient. Do you know which of the drips you may need to discontinue or add to initiate your prehospital protocols? Usually an ICU patient may be on 2 different pressors, neither of which is used in prehospital. Have you titrated Diprivan? Continuous paralytic? Worked a patient that is now at 33 degrees on a hypothermia protocol? Do you know if all of your ACLS drugs will be compatible with what is hanging and what line to use? If something goes wrong, will your license protect an RN "working under your orders"? Or, will you just work the code by yourself?
Some EDs may be required to initiate ICU protocols while holding a patient in the ED if it is for an extended period of time. This is also where it is difficult to use a Paramedic as a Paramedic in the ED and rely on them as a primary care giver. The Paramedic is not qualified to administer many of the meds that are used in the ICU or manage an ICU ventilator. If they are counted in staffing the same as an RN, it may make them short-staffed when ICU patients need to be taken care and you as a Paramedic still rely on RNs to hang blood products or provide other care to your patients that you can not do by your state's scope of practice.
If a Paramedic does go on to get a degree in another Health profession such as RN or RRT, they will soon see how vastly different the professions are and yet very similiar. Critical Care medicine is the common thread.
I forgot to comment on this.
You run to the ICU for an unstable patient. Do you know which of the drips you may need to discontinue or add to initiate your prehospital protocols? Usually an ICU patient may be on 2 different pressors, neither of which is used in prehospital. Have you titrated Diprivan? Continuous paralytic? Worked a patient that is now at 33 degrees on a hypothermia protocol? Do you know if all of your ACLS drugs will be compatible with what is hanging and what line to use? If something goes wrong, will your license protect an RN "working under your orders"? Or, will you just work the code by yourself?
Some EDs may be required to initiate ICU protocols while holding a patient in the ED if it is for an extended period of time. This is also where it is difficult to use a Paramedic as a Paramedic in the ED and rely on them as a primary care giver. The Paramedic is not qualified to administer many of the meds that are used in the ICU or manage an ICU ventilator. If they are counted in staffing the same as an RN, it may make them short-staffed when ICU patients need to be taken care and you as a Paramedic still rely on RNs to hang blood products or provide other care to your patients that you can not do by your state's scope of practice.
If a Paramedic does go on to get a degree in another Health profession such as RN or RRT, they will soon see how vastly different the professions are and yet very similiar. Critical Care medicine is the common thread.
It's interesting that you'd use an example like that. Let's really look at that, shall we? Now, while I have no doubt that there are many RN's out there that have the autonomy to start the above med's without consulting with a doc, for the vast majority, that will not be the case. (just like there will be many paramedics who are able to do various procedures/administer various meds that the vast majority will not) No, what they'll be doing is getting an order from a doc for an amount of the med to be given over a certain time. Do a bit of math, set the IV pump, and you're done. Not that complicated. Even starting it autonomously, still not that complicated, although more knowledge is definetly required. Why did I bring this up? Because I really don't like hypocrisy, and saying the above is no different that someone saying how much better paramedics are because we can intubate and most RN's can't.
If you're going to point out why it might not be beneficial to have the average paramedic working in an ICU setting (just like the average RN for that matter) you should probably stick to valid arguements; there are plenty out there, which I'm sure you know.
JPINFV
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That is true, but most RNs are not going to be a member of a rapid response team either. What FF894 was proposing was essentially hiring paramedics on AS the rapid response team.
Sure, I got that. My issue was, and is, the reasons that Ventmedic gave for WHY a paramedic should not be in that role. While she did much better a couple posts later, that first bit is just a wee bit hypocritical on her part.
Times are changing. Inhouse teams are providing a need that was lacking in your mother's or grandmother's day.
I take it you have no progressive hospitals in your area. They need to get with the program because Medicare and many other agencies have spoken. Unlike EMS, hospitals do have various organizations pushing them to improve and provide better care.
Every thing is a "skill" mentality with the Paramedic? Just plug in the numbers on the pump and who cares what the drug is? Guess what? Doctors make mistakes and that is why RNs are now required to have more education and UNDERSTAND all the meds they are giving. A doctor that is not right there may not see the full patient and may need to be reminded about other patient conditions that make giving that med unwise. The same can apply for RRTs who should NOT take ventilator orders via the phone for a Pressure setting. More often not, they have their own protocols from their medical director for vent management.
Also, why do you think so many hospitals have established their own CCTs with RNs? The Paramedic scope, education and experience varies so widely that it is difficult for find any consistency between the services or even within the same service. What one ambulance service considers to be a Critical Care Transport Paramedic may be totally different than another service.
RNs at least have some consistency for their foundation education for the hospital to work with. At this time that can not be said for the Paramedic.
Again, comparing a "skill" such as intubation which by the time the CCT RNs start intubating they have probably seen it done well over a 100 times at the very least and have probably already done RSI for the majority of those as well as all the meds for maintenance. They will have their ICU experience and foundation education to better understand the "skill".