EMTs and Paramedics in the Hospitals

CWATT

Forum Lieutenant
176
49
28
Here in Canada, EMTs and Paramedics are starting to appear in Emergency Departments (EDs) in a few provinces — Nova Scotia, Saskatchewan, and British Columbia. No surprise, these are the provinces with the lowest paid medics and also have very rural areas and low populations. I can’t speak for their reasons in choosing medics to work in their emergency departments but I speculate it might include a cost-effective alternative to nurses in areas of difficult recruitment. That said, I am aware of paramedics working in downtown Halifax, NS EDs, so who knows.

In any regard, this is a new ‘thing’ but I’ve heard of EMTs and Paramedics working in hospitals throughout the USA for a while now. I’m curious to learn about their role (i.e., how they are utilized alongside but different than nurses), scope of practice (do the paramedics perform skills not within a RNs scope such as operate the ventilators and perform electrocardiographic interpretation), and what agency employs them (I’ve been told the Nova Scotia medics are not hospital employees, rather they are employees of the local EMS service (EHS) operating within the hospital).

My reason for asking is I am interested to see if we can apply this model to other parts of Canada and explore how that might look.


Thank you,
- C
 

DrParasite

The fire extinguisher is not just for show
4,811
1,159
113
One of my FB friends is an ER medic. She worked for several years on the truck, got hurt and moved to comms, and moved into the ER because comms drove her nuts. She loves it.

From what she tells me, she's essentially a super patient care tech. The nurses still run the hospitals, but she can do everything within her scope, except intubation. All drugs and procedures needs to be approved by the doctors first (either by online or offline medical direction), but she can interpret an EKG, and make requests for treatments, but it's still the docs call on how to treat. since the PCT isn't really a license level, their scope is pretty much up to the employer, and how they word the job description.

paramedics are def cheaper than nurses, but the only time I have seen local EMS paramedics working inside a hospital is when the local EMS system is owned and operated by the hospital. There are too many legal hurdles to jump through otherwise.
 

mgr22

Forum Asst. Chief
993
325
63
I worked as a paramedic in a U.S. hospital for many years. We were employees of the state, but were more closely identified with the county. We did IFT and 911 calls with medical direction and protocols separate (in most cases) from those used by other county paramedics. In the ED, we handled many of the same tasks as nurses. We were paid a lot less than them, but I found the atmosphere very cooperative and collegial.
 

TransportJockey

Forum Chief
8,620
1,667
113
I have worked both as a tech and an ER Paramedic since I got my medic license. As an ER Paramedic I had my own patient load, did assessments, passed meds, started lines and labs, and generally did most of the same thing as nurses plus kept our full medic scope (technically including intubation, but as it was a major teaching hospital, the chances of actually tubing someone were slim), and some new stuff like suturing.
As an ER Tech that's a medic, you just generally do general ER tech stuff, with maybe the ability to learn how to do a few more advanced things depending on the docs you work with
 

Summit

Critical Crazy
2,250
802
113
do the paramedics perform skills not within a RNs scope such as operate the ventilators and perform electrocardiographic interpretation
US RNs can operate ventilators and read EKGs if educated on it.

In US hospitals, it is frequently a RT that is running the vent while historically it was RNs.

There is no need for a full scope paramedic in the hospital IMHO. The point of a US paramedic's full scope (I mean that to be the whizbang skills of intubation, crics, vents, etc) is to have a cheaper lesser educated "hands of the doctor" to do high value interventions in an environment where it doesn't make economical sense to have many doctors and you may need advanced skills without the ability to get a doctor, much less a specialist: the prehospital environment.

The economic need of the prehospital environment is the only reason US paramedics are permitted such a broad scope with such a comparatively small amount of training. So why would you bring that economically forced compromise in education and training into the hospital where there are lots of doctors and specialists?

Honestly, it doesn't make sense to use paramedics as nurse replacements either. Paramedic school (in the US) is emergency specialist focused on short term care. It isn't nursing education: healthcare generalist with post graduate specialized training. Unless you are truly dealing with an inability to staff or are simply focused on saving $...

Definitely there is a use for paramedics in the hospital, but not as RN replacements and not as "full scope" paramedics.
 
Last edited:

johnrsemt

Forum Deputy Chief
1,303
153
63
I worked in a hospital as a medic for the 1st year out of medic school. It was a new hospital (we opened it). We could do everything that we did in the street plus a lot more: I intubated, numbed people for suturing (didn't actually suture) etc.
We sat down with the nurses and charge nurse and medical director for the ED before we opened and went through the list of things that we were allowed to do or not do: the only thing on the list that the medics stated we were not allowed to do was Digital did-impaction (double glove and manually dig out a lower bowel blockage). I told the charge nurse that medics were not allowed to do that, and gave the other medics a dirty look to stay quiet. Later the charge nurse found out we could do that too, and asked me why I said we couldn't: I told her because we were smart.

I loved what I did and what I learned, hated the politics. If a nurse made a medication error or a patient error they were told "no no, don't do that again" medics were demoted or fired for smaller mistakes, and if the nurses covered up a mistake it was ok, but we would get in trouble for reporting our mistakes (even when it was a guarantee that you wouldn't get in trouble for reporting errors).
 

Summit

Critical Crazy
2,250
802
113
I loved what I did and what I learned, hated the politics. If a nurse made a medication error or a patient error they were told "no no, don't do that again" medics were demoted or fired for smaller mistakes, and if the nurses covered up a mistake it was ok, but we would get in trouble for reporting our mistakes (even when it was a guarantee that you wouldn't get in trouble for reporting errors).
Sounds like you worked in a dysfunctional culture... but that you weren't exactly trying to be a beacon of collegiality and change either:

I told the charge nurse that medics were not allowed to do that, and gave the other medics a dirty look to stay quiet. Later the charge nurse found out we could do that too, and asked me why I said we couldn't: I told her because we were smart.
 

CWATT

Forum Lieutenant
176
49
28
@TransportJockey — in your experience and opinion, what are the primary benefits to Paramedics in the hospitals? What settings do you think would most greatly benefit from Paramedics? What settings do you think Paramedics would not provide any benefit?


US RNs can operate ventilators and read EKGs if educated on it.

In US hospitals, it is frequently a RT that is running the vent while historically it was RNs.
I need to issue a correction so I don’t insult an entire profession. RNs in Canada receive training for ECG acquisition and interpretation, however -to the best of my knowledge- they are unable to initiate treatment as per their assessment and the acquisition is most commonly done by a tech then -most often- passed directly to the physician for interpretation and treatment.

I am not aware of nurses receiving training in mechanical ventilation. They may receive employer orientation.

From your post, there appears no reason to integrate paramedics into hospitals, so why in your opinion are they utilized in the US system?



@Johnrsemt — were you employed directly by the hospital? Did they also operate the ambulances for the area as well? If so, were you expected to work on the ambulance as well?
 
Last edited:

Summit

Critical Crazy
2,250
802
113
I need to issue a correction so I don’t insult an entire profession. RNs in Canada receive training for ECG acquisition and interpretation, however -to the best of my knowledge- they are unable to initiate treatment as per their assessment and the acquisition is most commonly done by a tech then -most often- passed directly to the physician for interpretation and treatment.
In the US it depends on the setting/facility and protocol. Most of the ICUs I workd at, if the doc isn't there and it's an emergency, I can interpret and follow my protocol for treatment. I almost always acquire my own 12 leads.

I am not aware of nurses receiving training in mechanical ventilation. They may receive employer orientation.
Not in most US RN schools: again, remember, broad education as a generalist, then specialization post-graduation. Although some schools now offer a crit care elective. Otherwise it is crit care edu after grad when going into crit care specialty, eg residency program.

From your post, there appears no reason to integrate paramedics into hospitals, so why in your opinion are they utilized in the US system?
Most US hospital use paramedics as super-ER techs. I think that is a great use.

There are some others where they are used to save $ over RNs.
 
Last edited:

johnrsemt

Forum Deputy Chief
1,303
153
63
Another problem that the ED I worked at had with nurses vs medics was on call pay: we could both sign up to be on call.
Medics got $4.00 an hour to be on call; we had to be able to get the the ED within 30 minutes of getting called, and we got time and half (1.5) for anything we worked, guaranteed 3 hours blocks. So if we came in and only had 24 hours that week we got paid time and a half, and if we worked 90 minutes we got paid for 3 hours which equaled 4.5 hours of pay. If we worked 3 hours and 5 minutes we got paid for 6 hours.
1st 2 months we thought it was a good deal. Then one of the nurses told us what they got for on call pay.
They got straight time to be on call; they had an hour to get there; and got two and 1 half pay (2.5); and got paid in 12 hour blocks. So if they came in and worked 1 hour they got paid for working 12 hours which equaled 30 hours of pay.
After the 2nd month medics stopped signed up for on call hours.
 

Summit

Critical Crazy
2,250
802
113
Was that hospital union or something? Or did they just have imbeciles running the place? @johnrsemt
 

Peak

ED/Prehospital Registered Nurse
347
186
43
I'll start off by saying that I'm not really a fan of paramedics in the ED. I have never seen a time where paramedics were hired for their skills and experience, but rather as a cost saving measure over hiring nurses. I don't necessarily understand why someone would want to do a job because they were hired as the cheaper option instead of the value they bring to the team. While it generally isn't sold this way during interviews I think it is generally understood what is happening.

We used to have paramedics in our ED, but the value over EMTs was marginal and their scope was far below that of nursing staff. We only allowed medics to practice within the scope of nursing and their paramedic scope, although policy did explicitly prohibit medic from performing certain skills that (some of) the RNs could like EJs or intubation. We had a less than stellar medic who make a very serious medication error and that kind of put the end to us using medics in the ED. I don't think that it was a fair opportunity from the get go, but that preceded when I started.

The competing pediatric system used paramedics for a few winters as mini-RTs; essentially giving nebs, suctioning, and a few other basic tasks. I know that most of the medics that took the job were fairly disatisfied and I don't believe that they still have that position.

Quite a few of the other local EDs hire medics with various scopes of practice, though typically acting as an expanded scope tech.

Paramedic programs are focused on the very short term emergent management of patients. Though deep in the subject matter it is very narrow, and is not an adequate preparation for the breath of care in the hospital.

Nursing, like @Summit said, is a very generalist education. Nursing school also doesn't adequtly prepare nurses for critical care, but it is much easier to build upon the wide base that new grads have.

In the ED we require about 2 months of didactic education in the class room (not including basic classes like ACLS, PALS, ENPC, or TNCC), three or more months of direct preceptorship, and about another six months before they are considered independent.

Likewise our inpatient critical care units typically require three to six months of direct preceptorship and many hours of additional unit-specific education.

With time and experience we will then add on things like learning to place EJs, intubate, manage vents/NIPPV/HHF, ultrasound guided interventions, chest tube placement, suturing, digital and nerve blocks, drawing ABGs, and so on.

Some new hires will come with more experience and therefore sometimes advance down this pathway much more quickly, but we still verify that they can safely practice before letting them have an full independent scope. Many nurses never get to this scope of practice even after years in their unit, but as charge nurses we know who has what skills and how we can best run the unit.
 

Bishop2047

Forum Probie
22
9
3
I am a Canadian medic who worked part time in a rural ED in Saskatchewan, and now work remote flight (ED when we are not flying).

The sites chosen for EMS involvement are call CEC or Collaborative Emergency Centers. Many of these site including my first ED job where EDs that had been shut down due to doctor shortages. I would work with an ER and function within my scope having the option to call med control for anything outside of my scope. These were all small facilities so you did do any and all airways management, lab draws (and often running them), ECG interpretation, meds, slabs, and typical nurse duties. it was certainly a cost savings, but they also liked having medics who had standing orders for treatment. Most patients that walked through the door did not warrant OLMC calls, or could be scheduled for follow up in clinic.

This model was for the most part poached from the Nova Scotia model.

Other spots around the province have interesting in hospital/traditional EMS models where they do both prehospital care and in hospital care. These seem mostly on the West side of the province in small centers. Many of these towns don't actually have EDs so the medics work in the LTC units during the day and still are on call for EMS calls.
 

DrParasite

The fire extinguisher is not just for show
4,811
1,159
113
I'll start off by saying that I'm not really a fan of paramedics in the ED. I have never seen a time where paramedics were hired for their skills and experience, but rather as a cost saving measure over hiring nurses. I don't necessarily understand why someone would want to do a job because they were hired as the cheaper option instead of the value they bring to the team. While it generally isn't sold this way during interviews I think it is generally understood what is happening.
That was pretty much my opinion.
We had a less than stellar medic who make a very serious medication error and that kind of put the end to us using medics in the ED. I don't think that it was a fair opportunity from the get go, but that preceded when I started.
That's a pretty unfair action consequence, one that shows how little the hospital thinks of paramedics. If a less than steller nurse made a very serious medication error, would you get rid of all nurses form that unit? would they even get fired, or just sent for "retraining?"

Based on my limited observations, 80% of the skills that a nurse does in an ER a paramedic can do. the other 20% the medic can be taught to do, (just like a newbie RN would need to be taught how to do stuff that wasn't covered in nursing school that their facility does or equipment they use). They can be good in the ER, but not so on the rest of the floors.

But a paramedic doesn't replace a nurse, and if you a paramedic wants to be a nurse, they should go to nursing school and pass their nursing boards. Even hospital based paramedics that help out in the ER when their ambulance is slow, they are just extra people, because they can be pulled for an ambulance call at any time.
 

Peak

ED/Prehospital Registered Nurse
347
186
43
That's a pretty unfair action consequence, one that shows how little the hospital thinks of paramedics. If a less than steller nurse made a very serious medication error, would you get rid of all nurses form that unit? would they even get fired, or just sent for "retraining?"
Nobody got fired. The timing was such that we were losing our current paramedic staffing in the next few months for various reasons anyway (med school, getting on fire, moving out of state, et cetera), so we simply didn't hire back into the position. The medication issue was largely that it was fully allowed under the state paramedic scope of practice but also was something not really educated on. It really brought into light the risk of using prehospital providers in the ED and the difference in education. Unfortunately since the error would have been deadly had it not been realized shortly after by another staff member there was a very strong reaction by hospital leadership. I'm not entirely sure it was unfair since the state was allowing medics to practice in a way they really weren't educated in.

Had a nurse made the same error there would have been very serious disciplinary action. In fact we actually had an agency nurse make essentially the same error, we no longer allowed her or anyone from that agency (they defended her and didn't acknowledge the serious nature of the error) to work in our ED. I'm not sure what we would do if a staff nurse made that error, we would probably put them on an improvement plan but I'm not really sure if we would allow them to practice at the bedside even on a floor. For the medic it was a training issue, for a nurse it would be negligent care.

Based on my limited observations, 80% of the skills that a nurse does in an ER a paramedic can do. the other 20% the medic can be taught to do, (just like a newbie RN would need to be taught how to do stuff that wasn't covered in nursing school that their facility does or equipment they use). They can be good in the ER, but not so on the rest of the floors.
A paramedic may be able to do 80% of the tasks for ED patients, but the knowledge behind it is very different.

Part of the problem is that the background knowledge and experience of nursing in a big part of keeping the department functioning. I can't expect a medic to understand how to prioritize treatments based on the nature of hospital medicine. I can't have them give off label meds. I can't have them admit patients upstairs. I can't have them make complex discharges.

For example in medic school I had rotations in the ED, it was focused on training for interventions (intubations, starting IVs, reading EKGs, etc) and assessing patients which I then discussed the the docs what I thought could be wrong, if it needed ED evaluation, what field treatments I would give, and so on. In nursing school we teach how to manage the patient's hospital course, how to balance a full load of patients (I've had up to 9 at a time, many of whom we an ESI 2 and the rest 3s, though typically we have far fewer sick patients), and the risks and benefits of the treatments we are giving. I'm not responsible for making medical decisions, but I am responsible for intervening if there is an unsafe decision or one not being made.

Just to emphasize the point I'll compare a few other clinical areas, I do very much realize that it is not the same as the ED.

In L&D as a paramedic student I went from room to room watching and participating with deliveries. In nursing school I took two patients and cared for them for 12 hours through all four phases of labor, or in the perioperative environment when getting a cesarean.

In the ICU and PICU as a paramedic we went around assessing for the various life threatening conditions that landed them in the unit. As an nursing student we did all of their care for 12 hours for 1-2 patients.

In the OR in medic school I went from room to room getting tubes, and watching a few cool procedures. In nursing school we stayed and observed the entire process from preop to pacu.

Psych rotations in both medic school and nursing were equally watch and don't do a whole lot of anything else, although in nursing school we were forced to practice our 'therapeutic communication'.

In paramedic school I never had rotations in community health, school nursing, med/surg or the peds floor. Our pharmacology classes had different emphasis, so did our physical exam classes. Our programs emphasized different patient management goals, and taught two very different ways to view patient care.

From the opposite side of the argument an RN can do 80% of a paramedic straight out of school or with minimal training (with the assumption that they have ACLS and PALS). They take a basic history, perform a physical exam, assess for a medical emergency, place IVs, follow protocol orders for treatment, contact a physician for orders when a presentation is not adequately covered by the protocol, and so on. At least in my state with additional training there isn't actually any paramedic skills that cannot be performed by an RN who has additional didactic and hands on training. RNs can intubate, place EJs, interpret EKGs, et cetera. That doesn't make them paramedics. The training isn't the same, they don't have field internships, and generally would be pretty disastrous.

I think that if we suggested using nurses to cover the ALS shortage that paramedics would be much quicker to point out the difference between paramedicine and nursing.
 
Last edited:

rescue1

Forum Asst. Chief
580
128
43
Just out of curiosity, what kind of places are having a medic or an RN intubate in the ED? The only non-doctors I've ever seen intubate in the ER have been APPs (CRNAs, and rarely NPs and PAs), but admittedly all my experience is in more urban areas.


I agree with @Peak that paramedic education does not really prepare you for the care of a hospitalized patient. It is designed to have you recognize a number of emergent/serious medical conditions and be able to intervene with a handful of specialized skills. In the hospital, this skill is completely overlapped by the emergency doctor or APP. Conversely, none of these people have the skill of actually managing the care/executing orders on a hospitalized patient, which is what nurses are specifically trained to do.

Anecdotally, my coworkers who did ED work as a paramedic operated on the level of a super PCT, the only skill they really used on a daily basis was starting peripheral IVs (they were usually the best person in the department at this). Most ended up going back to 911 unless the money difference was significant--most medics value the clinical independence of being on the street and even if you were "operating at your full scope" you were still doing it under the direct orders of the provider staffing the patient.

I have heard of very rural departments using medics like a "PA-lite". I'm not really sure I see the point of this--you're either having the paramedic see very low acuity patients, which they are completely untrained to do, or having them try to manage the very ill patients by themselves, and at least in my opinion, if an ALS ambulance takes a patient to an ER where they will transfer care to a second paramedic with the same scope and education, they probably should have just kept driving to a bigger hospital. But I suppose in very remote areas you have to take what you can get.
 

GMCmedic

Forum Asst. Chief
695
333
63
About the only time I've ever seen it is when our flight crews were hospital employees (before my time). They could do anything within their scope, on any unit in the hospital. Were no longer hospital employees after a vendor change but we still have privileges, the hospital has just learned to operate without us.
 

Peak

ED/Prehospital Registered Nurse
347
186
43
Just out of curiosity, what kind of places are having a medic or an RN intubate in the ED? The only non-doctors I've ever seen intubate in the ER have been APPs (CRNAs, and rarely NPs and PAs), but admittedly all my experience is in more urban areas.
I think allow may be a better word for most hospitals. Depending on the situation it isn't uncommon for RTs, RNs, or Medics to intubate in some EDs and units either because they want to keep up their skills or it allows the medical provider to continue organizing care. Other than weird code situations I haven't seen a non-medical provider tube without an APRN/PA/Doc present (and those are typically when multiple code situations are occurring far beyond what is normal in the ED or house).

Of course in large teaching facilities this is far less common as every resident and APP are trying to capture every opportunity they can get.
 

Bishop2047

Forum Probie
22
9
3
I have heard of very rural departments using medics like a "PA-lite". I'm not really sure I see the point of this--you're either having the paramedic see very low acuity patients, which they are completely untrained to do, or having them try to manage the very ill patients by themselves, and at least in my opinion, if an ALS ambulance takes a patient to an ER where they will transfer care to a second paramedic with the same scope and education, they probably should have just kept driving to a bigger hospital. But I suppose in very remote areas you have to take what you can get.
This is a nice way of describing Paramedic involvement in hospital where I am. I live and work in Canada and the physicians assistant is a rare sight in any province (prominent in the military). Critical Care paramedics or Advanced Care Paramedics often fill this role to some extent. This is seen both in urban and rural settings. Often seeing the less acute and assisting with the very ill.

You will also frequently see a Primary Care paramedic at triage when stole into these EDs. I dont know of medics working in other departments and don't really think we have a lot of value in other faculties. That is unless you are on a Code team/IV team or something similar.

In the ultra rural we often are there to keep the doors open and function entirely by OLMC with an RN partner. One place I worked had a giant smart board that the Doc could skype in on. Made it look like the Wizard of Oz projection.

wizard-of-oz-w24.jpg
 

rescue1

Forum Asst. Chief
580
128
43
Makes sense. All my experience is very Northeast based, and from what I've heard having a high concentration of doctors like the NE tends to mean less stuff gets done by APPs/medics. Also critical access hospitals are less of a thing round these parts, especially given that I can see the Empire State Building on my commute back from the hospital.

@Bishop2047 , do Canadian medics have training with that kind of less acute care? Are they staffing these patients independently? I don't have any experience with Canadian training, but I would have been pretty out of my depth in an ED fast track back in the day. However, I know that the Canadian educational standards are more rigorous than they are here.
 
Top