Med control for Morphine?

[VentMedic]

You should not have to talk to anyone. You should be autonomous enough to be able to make a decision for that patient without outside interference.

In many areasa of California, they have a nurse (MICN) sitting at the radio to read the protocols to the Paramedics.

 

[FFMedic75]

Whatever man, the sky is blue!!! If you want someone to take care of your premature baby call a NICU Nurse, if you need someone to intubate call a CRNA, If someone is having an MI call a CCU Nurse. If you want someone who can deal with all of these problems effectively at your home in a blizzard or hurricane using a flashlight call for a Paramedic. Whether they be fire based, 3rd party or private, paramedics ability to think outside the box and adapt to the worst of situations is their specialty. Ya you can train people to specialize in all kinds of things but short of a flight nurse (who lets face is a very highly trained paramedic with lots of experience), you can't find anyone else who can function under the conditions that medics do with the same success. Is it perfect, absolutely not. Do we need to provide a higher level of training to all medics, sure. Will this bring validity to our profession, I hope so. The point I was trying to get across is the healthcare providers who understand what we do tend to respect us, the ignorant ones who think they are gods gift to their little world don't. The important side note to this is remember how you treat people. You will encounter home health aids, LPNs and CNAs who are thrust into emergency care not by choice, we shouldn't treat them poorly just as we shouldn't be treated poorly. If you can constructively teach them something about emergency care that is a good thing, the same can be said for nurses who choose to constructively help paramedics with an issue. I can't tell you how many times I've had a new medic who had trouble starting IVs, we would send them to the ER if the right nurses were working and they would get a world of experience. This is how it supposed to work. Not the Docs talk bad about the nurses, the nurses talk bad about the medics, the medics talk bad about the nursing home staff.

 

[RyanMidd]

My girlfriend of 4 years is a year way from completion of her RN, and we often have open-minded (albeit terse) discussions about differences in procedure, objective, protocol, and even A&P.

However, we always make it a point to remind people that we are never competing; the jobs themselves are much, much different despite both being in the medical field. Specifically, nurses are trained in a very broad spectrum of health & wellness, including socioeconomical factors, sensitivity to religion and ethnicity, and even improving access to healthcare for minorities. I respect how much training they receive and how different it was than mine. They are the manpower that allows First World Medicine to exist, and in some places, flourish.

Emergency medicine, on the other hand, has a different objective, and as such, different training. Yes, we are able to administer medications without a doctor's orders or 'scrip pad, including some narcotics. This is because it is impractical to train as many doctors as there are EMS personnel and shove them into ambulances. Additionally, the things we do are decided upon by a group of people, including many MDs, who determine that it is probably the safest course of action for the greatest number of patients. This is patently imperfect, but it works well enough that pre-hospital medicine is considered an essential service in most of the world.

I make it a point never to rub my scope of practice in another healthcare provider's nose, because they likely know and practice things every day that I would think inconceivable. Have I ever spent over 500 hours, unpaid, connecting with immigrants, low-income citizens, and the elderly and teaching them how to better access healthcare? How to read English? How to financially manage their health-related expenses? No, and I greatly respect that many nurses have similar experiences that are not relevant for pre-hospital medtechs.

I am grateful that medical direction puts their faith in our abilities, judgement, and skill, and if I encounter a catty nurse, or a specialist who thinks we are just IV-monkeys, I take it with a grain of salt, because I also know that I am often the first to deal with the family of the deceased, I am often the one speaking to a terrified 4-year-old who has just been in a car accident, and I am often the one who has mere seconds to decide whether to initiate a certain treatment or drug, and RNs and anesthesiologists are NOT trained to do THAT.

 

[downunderwunda]

In many areasa of California, they have a nurse (MICN) sitting at the radio to read the protocols to the Paramedics.

Vent,

shouldn't you know your protocol & pharmacology before you go out & start practicing?

 

[KELRAG]

Again you are expressing ideas from what sounds like a very poorly run hospital with nurses you believe to be inadequate.

Have you never seen a nurse run a code? Intubate? Put in central lines? Run a Rapid Response situation? And, nurses also must function outside of their hospital element every day to accompany a patient on an ER to ER transfer because the Paramedic is not allowed to take most medicated drips. They rise to occasion and go into whatever role required of them and if they have questions, they ask and seek out advice.

Have you also considered what protocols for the Paramedic in that area? Maybe they are like Washington DC where their Paramedics would never think of giving morphine with or without a doctor's order. It just isn't done and they are not the only EMS system in this country like that. I can also think of a couple FDs in Florida that got their meds taken away and weren't allowed that many to begin with.

Thus, unless you actually know this system personally, since the OP is only a student and is not working as a Paramedic, you can not say for certain if that nurse is right or wrong.

During my clinicals i've experienced this attitude before and I believe OP's underlying statment is the somewhat rare but existing resentment between RNs and medics.

I'm really not trying to belittle you as is a common theme on this forum. You seem to have knowledge and experience.

However, you did contridict yourself with the "poorly run hospital" and "DC's limited protocal" arguement using the extremes as generalizations, the norms. Generalization automatically debunks an argument but lets run with this. The insinuation of ur statment is; unless a hospital allows RNs to work independently, then it is a poorly run insitution. Furhter by extension, nurses are fully capable and competent to perform advanced procedures and if not the hospital sucks. In my experience only, this is a rarity. I've worked in a cath lab, a level 1 pediatric trauma center, a level 2 trauma center and I date a RN, she agrees. Personally only seen one RN intubate and that was because the DR knew she was a medic previously. A Level 2 in Washington (state) allows medics to practice all skills including intubations and not RN's... Im sure they are capable but this is what we are extensively trained in, not just a run through on a manikin and pig which is what the girlfriend did. She went to Baylor Nursing.

Im def not saying it doesnt happen, just to answer your question, no.. i've never seen it.

You also generalized protocals prohibiting medics from taking certain drips. Ive never been told I cant take a pt based on their medications. Also, only once have I taken a nurse on a critical transfer and that was bc my :censored::censored::censored::censored:ty service didnt want to give me another set of hands so I had to ask the hospital.

Then you used as an example an EMS system with the most limited scope of practice i've heard of as the norm to justify an instance where a Medical Director has no faith in competence of Medics. When in reality, many systems allow medics to give stabilizing drugs as well as begin infusions that will only be beneficial awhile after we get them on ya'lls bed. IV steriods and terb for example.

Nurses and Medics' training differ in specialty. Nurses are trained in mixing drips and long term care while medics are used to doing more tactile, emergent procedures like running initial ACLS drugs and airway. There is no reason a nurse should be taught about extrications just as no reason medics need to know how to give a Foley and moniter a SICU pt. The exception is obviously Flight.

In refrence to flight jobs, the RN/medic combination is merging the skills of both, as a result each grows familiar with the others' expertise and allows for greater comprehensive care. I only have experience with one flight program and they do not differentiate between RN/medic in the protocals. Each is allowed to do any procedure. No one person is in charge. Often the medic runs the scene calls and nurses do the CC transfers. However, this is a progressive system requiring ATLS.

You wont like this but many RN-medics have agreed, the trainng is in objectivity

 

[KELRAG]

Education is highly irrelevant

In reference to your snide, passive-aggresive remark about "trade schools." The community college where i got my medic from also has a same length Resp tech and RN program. The top 10% school where i got my biochem from def doesn't have a resp tech. Stop trying generalize about paramedics' lack of education, more than a few of the people I work with get their medic as a stepping stone to PA and med school because of the autonomy required. I dont know any DRs or PAs that were nurses first. Askin a doc about whether he would rather hire a PA or NP he went with PA. He explained PAs are taught differential diagnosis and how to be independant from the beginning while nurses only start that when they begin their NP program.

Some of the best medics I know only have their cert and they are much better than I am. RNs and LVNs at the trauma center in mycoverage area do the exact same job, but im sure thats because its a poorly run hospital. Ap

I completely respect nurses and their capabilities. There are nurses, medics, and DRs, good and bad. In end... FFmedic and Ryan, feel free to push meds, intubate and decompres my chest. Ventmedic, relax and when I need some albuterol... go find OP

 

[VentMedic]

In reference to your snide, passive-aggresive remark about "trade schools." The community college where i got my medic from also has a same length Resp tech and RN program.

Looks like we have a noobie to EMS and the world of medicine here as noted from the above two posts who also doesn't do his homework before spouting off things he knows little about.

I date a RN, she agrees.

That makes you an expert? Is that like sleeping at the Holiday Inn ad? Tell your girlfriend to get out more and see what her profession is all about so she can educate you better. You must be stifling her career. Jealous of her maybe?

I expect you are not from Oregon but from a state like Washington that has 8 different "cert" levels all based on one skill. Also, if you are in Washington state you should know who is on the Flight teams there and who does the intubating. Majority of your flight teams are RN/RN or RN/RRT. Even if they hold a Paramedic cert, it is their RN or RRT license they work under since it supersedes a Paramedic certification. RNs can also challenge the Paramedic test in some states. Other states have the RNs and RRTs just take a few weeks of things that might pertain to EMS but rarely to they have to take the 10th grade pharmacology or A&P when they have had college level courses. Nor do they have to do ED rotations to learn IVs and most are already ACLS, NRP, PALS etc plus many other specialty certs that require actual experience and not just a weekend no fail course. In fact, most RNs that do prehospital will have worked more codes in the hospital in one year, including leading them, than some Paramedics will work their entire career.

How many "hours of training" does you state require to be a Paramedic? Also, at that college, was the Associates degree MANDATORY or OPTIONAL with a "cert" program offered? I just checked the Washington website and their Paramedic "hours of training" requirement is no longer than most other states in the U.S.

Guess what? Both the RT and the RN licenses require no less than an Associates degree. It is not an OPTION.

no reason medics need to know how to give a Foley and moniter a SICU pt.

At least you are correct here. Most IFTs are out of the scope of care for a Paramedic and that includes the majority of nursing home calls since they involve complex medical conditions that many Paramedics have little to no understanding.

BTW, you "insert" a Foley and not give it. The Foley catheter is not a medication. It is a tube that is passed through the urethra and into the bladder to drain urine.

The difference between RNs, RRTs and Paramedics is that the RN and RRT gets a solid educational foundation to build on for whatever specialization they desire. Thus, when the job calls for learning how to run a code or rapid response team in the hospital or do CCT/Specialty/Flight or become a prehospital RN, it is not that big of a stretch. On the other hand, the Paramedic learns a few technical skills without a lot of whys behind it and very little A&P or pharmacology, thus, they should not be allowed to touch a critical care patient on any IFT until they have finished a minimum of a two year degree. In fact, allowing them expanded scope of practice of any type, especially CCT, is probably not advisable for some Paramedics.

The other difference between RRTs, RNs and Paramedics is that RT and nursing saw what their weakest links were and did something about it. Thus, for that reason you will rarely see an LVN and the "Respiraty tech" is no more which means your information is very outdated. Both professions raised their educational standards after evaluating their bargaining and value in the world of medicine. They also realized medicine is constantly evolving and a "tech" cert is no longer good enough. EMS still has yet to embrace that concept. But, it is good that you at least got your degree.

Often the medic runs the scene calls and nurses do the CC transfers. However, this is a progressive system requiring ATLS.

And here's a news flash for you, Paramedics can not be certified in ATLS. They may audit the class but not participate in most of the skills labs and the audit is allowed only if the program has space to allow it.

Im sure they are capable but this is what we are extensively trained in, not just a run through on a manikin and pig which is what the girlfriend did. She went to Baylor Nursing.

Define extensively. Some Paramedic programs only require 5 successful passes on a manikin. Was your nurse girlfriend in training for MICN or PHRN? If not it was probably just a demo. Once she decides she wants to do transport, she will be trained by the doctors and given the opportunity to do many live intubations. And, she'll have the advantage of having seen many intubations prior to that time and probably would have participated in RSI many times. Thus, all she will have to do is learn the "skill" since she will already know the hows and whys of intubation. Some new Paramedics are put out on the street without any live intubation experience and may not even have seen one done except on a manikin. Sad but true. Thus, EMS then wonders why the statistics for unsuccessful Paramedic intubations are getting noticed.

There is one other little thing about the U.S. Paramedic that is now particularly annoying. It has be dumbed down to where every FF can become a Paramedic in just a few short months whether they want to or not. Most will do it for the extra few dollars of pay and "attempt" their one intubation per year while on an ALS engine.

You also generalized protocals prohibiting medics from taking certain drips. Ive never been told I cant take a pt based on their medications.

Have you actually read your protocols or are you just shooting from the hip here? "Taking" a drip and "managing" one are two very different things. Yes the RN can get the drip all set up for you to watch on your drive inbetween hospitals and hopefully you are not one that just shuts the IV pump off when it goes beep, beep.

RNs and LVNs at the trauma center in mycoverage area do the exact same job, but im sure thats because its a poorly run hospital.

A trauma center using LVNs? As CNAs I hope and not as actual nurses. I haven't seen an LVN in an acute hospital in well over 20 years? Where did you say you were from?

Askin a doc about whether he would rather hire a PA or NP he went with PA. He explained PAs are taught differential diagnosis and how to be independant from the beginning while nurses only start that when they begin their NP program.

Wow! You really have a very closed view of the world of medicine and of nurses. Is this a personal issue with your nurse girlfriend?

Let me explain the world of NPs and PAs to you. A PA now requires a Masters degree in many states and soon that will be their entry standard. They first get an undergraduate degree which could be anything from Biology, Art history (as long as the sciences are present), RT, or a BSN. Following the 4 year degree they enter another 2 years of training.

The NP has a lot more advancement ability and practice opportunities than the PA which is actually rather limited in some ways. Also, the NP is raising their educational standard to doctorate in a couple of years. Trauma Nurse Specialist, Neuro NPs, Pedi NPs and Neo NPs are a great asset to their field. The PA also has their place but the NPs have already organized their field and scope. I do have faith the PA will catch up as both of their organizations are also working together for improved patient care quality.

It sounds like you will never match my 30 years in EMS because you have too many low opinions of other health care professionals. You also believe the Paramedic is perfect and needs no improvement even when "hours of training" is still the standard. It also appears you don't believe the EMS degree is necessary even though you got one. No education is a waste of time. Until those in EMS realize the shortcomings of their profession, it will not advance. Take notes from what the RN, RRT, OT, SLP, PT etc have accomplished.

BTW, since you are new, I will just give you some friendly advice. There is a spell check feature on this forum.

 

[rhan101277]

My program is certainly not dumbed down, I am sure there are some that are though. We have to do 5 "live" intubations, those are mostly done in the OR. Some are done on dead people that have only been dead a short period of time 10-15 minutes or whatnot.

Anyhow paramedics need to be recognized as professionals in their field and that is what the program that I attend is trying to do. We are taught above and beyond what is required, which is minimum. No one wants a "minimum level" trained paramedic. There needs to be a lot less "cookbook" medics out there.

 

[reaper]

My program is certainly not dumbed down, I am sure there are some that are though. We have to do 5 "live" intubations, those are mostly done in the OR. Some are done on dead people that have only been dead a short period of time 10-15 minutes or whatnot.

Anyhow paramedics need to be recognized as professionals in their field and that is what the program that I attend is trying to do. We are taught above and beyond what is required, which is minimum. No one wants a "minimum level" trained paramedic. There needs to be a lot less "cookbook" medics out there.

No offense here, but a school that only requires 5 live intubation's, is kinda dumbed down!

You should have no less then 10 and preferably 20-30!

 

[Jon]

In PA, I have several protocols that let me give 50-100 mcg Fentanyl or 2-5mg of Morphine before calling the doc. Off the top of my head, the protocols are for suspected cardiac chest pain, serious burns, and isolated extremity trauma. The protocols specify additional doses, but medical command contact is supposed to be made before giving additional doses.

And yes, we have a protocol to allow us to follow the protocol options/suggestions below the "command line" if we truly feel they are in the best intrest of the patient, and we have no way to communicate with medical command. Never seen this happen in 8 years around here... but as was mentioned in another thread, Rule 34 of EMS - If you can think of a scenario, it's happened.

 

[wyoskibum]

There are a lot of services who can administer Morphine without contacting the "Online Medical Control" via "Standing Orders". But you can't administer it without those standing orders from your "Medical Control".

 

[Smash]

There are a lot of services who can administer Morphine without contacting the "Online Medical Control" via "Standing Orders". But you can't administer it without those standing orders from your "Medical Control".

Indeed. What many seem to forget is that we ALL have medical control in some form. Be it offline, or online, we all act under certain protocols and the authority to do so is typically delegated by an MD. The only real difference is that some need permission for each instance, others have a broader remit.
In my service I can administer as much or as little morphine as I see fit for the patient's presentation, and I have no upper limit on how much I can give.
This works where I am, but may not work everywhere for a wide range of reasons.

What is really important though, is that we are doing the right thing for our patient. We all want more autonomy, and I certainly think that it is an admirable cause to back (including the education to allow it), however it is not really about who has to ask for pain relief and who doesn't so long as the patient who needs pain relief gets it.

Of course there are issues with contacting med control in that the Dr or RN on the other end of the line cannot see you patient, so is entirely reliant on what you tell them, and of course it would be foolish to think that personal bias doesn't ever come into play either. This is one of the reasons I support having offline medical control in the form of protocols, and in most instances the more liberal the better (with certain caveats of course).

 

[rhan101277]

We can give up to 10mg morphine here. Any more call med control.

 

[downunderwunda]

The issue is not how much or little you can give. The issue is the amount of autonomy you, the person with the patient, the person who can see the patient has.

Yes, we act withing guideline, usually referred to as protocols, but they, if written properly, should give you enough discretion to apply them as you see fit.

 

[NomadicMedic]

The issue is not how much or little you can give. The issue is the amount of autonomy you, the person with the patient, the person who can see the patient has.

Yes, we act withing guideline, usually referred to as protocols, but they, if written properly, should give you enough discretion to apply them as you see fit.

Exactly!!!!

When you ask a medic why he gave Morphine, there are some who will say, "He had chest pain so I gave 2+2 up to 10. That's what I'm allowed to do". That's not good patient care. That's just following the cookbook.

Instead, A prudent medic will know that eliminating pain will reduce stress which will reduce those catecholamines the the patient is pumping out and help to stabilize heart rate and blood pressure. I know I answer the question by saying, "I gave the patient the appropriate dose of MS04 to drive his pain level as close to zero as possible." That's what my protocols allow.

 

[rhan101277]

Exactly!!!!

When you ask a medic why he gave Morphine, there are some who will say, "He had chest pain so I gave 2+2 up to 10. That's what I'm allowed to do". That's not good patient care. That's just following the cookbook.

Instead, A prudent medic will know that eliminating pain will reduce stress which will reduce those catecholamines the the patient is pumping out and help to stabilize heart rate and blood pressure. I know I answer the question by saying, "I gave the patient the appropriate dose of MS04 to drive his pain level as close to zero as possible." That's what my protocols allow.

Oh I agree entirely, we are being taught not to be cookbook paramedics. People die under cookbook paramedic care. Not saying that others don't die, but those we just can't help. You need to be able to think outside the box and if there is a better treatment call med control. All of our protocols say "consider" which encourages independent thinking. Know how everything works full circle will help you a lot. I am trying to develop these skills in school and during clinicals. Because when people see you come through the door they expect the best and most will think everything is great now, the ambulance is here. I just want to to my best to not let them down. To not do anything stupid to worsen the situation and give the best patient care that I am trained and educated to give.

 

[downunderwunda]

There are times when 'cookbook' is to a degree appropriate. The example given was for chest pain. Most protocols call for the administration of ASA, Nitro & morphine as well as hi flow O2.

We know this regimin has an effect in preventing thrombus formation, dilation of the vascular bed & Morphine has dilation properties for the coronary arteries, but its most dramatic effect is reducing the pain, therfore reducing the anxiety level of the patient.

This is variable for all patients & needs to be administers based on the presentation of the patient at the time. We use nitro in a sub lingual for & can administer up to 3 dependent on systolic BP & morphine dependent on perfusion. Posture also plays a role & it is impossible to write a protocol based on a generic presentation as most differ in some way.

To have the ability to adjust your treatment, acording to the presentation of the patient is vital. Can med control see the patient? No they cant. I have had patients who, even with pain, have had Morphine withheld because I felt the patients perfusion levels were not acceptable, my call. My protocol calls for a BP to be greater than or equal to 100mmHg, with a pt at 102 mmHg, I have with held nitro but given morphine, again, my call.

What gives me that ability, knowledge of the drugs, their actions & the pathophysiology of the illness. No, I am not a specialist cardiologist, & I admit my knowledge will never be as detailed as a Cardiologist, but the knowledge I have is more than adequate for pre hospital care.

 

[Achromatic]

I expect you are not from Oregon but from a state like Washington ... Other states have the RNs and RRTs just take a few weeks of things that might pertain to EMS but rarely to they have to take the 10th grade pharmacology or A&P when they have had college level courses. Nor do they have to do ED rotations to learn IVs and most are already ACLS, NRP, PALS etc plus many other specialty certs that require actual experience and not just a weekend no fail course.

And here's a news flash for you, Paramedics can not be certified in ATLS. They may audit the class but not participate in most of the skills labs and the audit is allowed only if the program has space to allow it.

Apropos of anything else, I found it amusing your denigration of some courses as "weekend no fail courses". The longest ATLS course I saw on the FACS site was a two day course. Interestingly, some were listed as being available to physician extenders, some to RN, some open.

Define extensively. Some Paramedic programs only require 5 successful passes on a manikin. Was your nurse girlfriend in training for MICN or PHRN? If not it was probably just a demo. Once she decides she wants to do transport, she will be trained by the doctors and given the opportunity to do many live intubations. And, she'll have the advantage of having seen many intubations prior to that time and probably would have participated in RSI many times. Thus, all she will have to do is learn the "skill" since she will already know the hows and whys of intubation. Some new Paramedics are put out on the street without any live intubation experience and may not even have seen one done except on a manikin. Sad but true. Thus, EMS then wonders why the statistics for unsuccessful Paramedic intubations are getting noticed.

This, if true (and I am not pretending it is not - sadly, I recognize it to be true) is an utterly sad state of affairs. I can say, happily, that I know that EMT-Ps in our county, whose training is "arranged" by the county, get by mandate of our MPD, at least FIFTY live intubations in ED/OR before being unleashed on the world.

There is one other little thing about the U.S. Paramedic that is now particularly annoying. It has be dumbed down to where every FF can become a Paramedic in just a few short months whether they want to or not. Most will do it for the extra few dollars of pay and "attempt" their one intubation per year while on an ALS engine.

Hear, hear. I have zero interest in fighting fire. More power to those who do. I am stuck in a system whereby I will almost definitely need a firefighter cert to do ALS 911. Nothing pisses me off more than seeing FFs who view 'medic' as a patch needed to do their job, and who hold zero interest in doing it. I can appreciate their pain but I cannot and will not tolerate any that I interact with (big words for a student) half-assing a patient because they don't want to deal with medic calls, any more than I would expect them to tolerate me standing around scratching my *** on a structural fire. Every patient deserves 100%, even the "BLS tweeker" type calls that cause everyone involved to roll their eyes, even if only on the inside.

Let me explain the world of NPs and PAs to you. A PA now requires a Masters degree in many states and soon that will be their entry standard. They first get an undergraduate degree which could be anything from Biology, Art history (as long as the sciences are present), RT, or a BSN. Following the 4 year degree they enter another 2 years of training.

Not to denigrate either NP or PA, as I think both are valuable, and both know a lot about their worlds, but to rephrase what you say, a student could conceivably become a PA with as "little" as some entry level maths, some gen chem and bio, and a year of upper division science (I am watching someone do O-chem, microbiol, and cell biol) who will have enough credits to enter a PA course, 2 years (though she will be doing a DVM). i.e. some foundational sciences, a year (though an intense year) of upper science, then 2 years to come out as a PA.

 

[Shishkabob]

Meh, I chuck it off as some nurses not knwoing what medics/EMTs do, and vice versa.

I had a new grad RN (less then 6 months employment) go in a 5min explanation of what sedatives were and what they were used for... I didn't feel like telling her we have a handful of sedatives on our rig, and that I already knew what they were used for.

She probably thought I was an EMT student, and not a medic student 90% done with his course.

 

[Achromatic]

Meh, I chuck it off as some nurses not knwoing what medics/EMTs do, and vice versa.

I had a new grad RN (less then 6 months employment) go in a 5min explanation of what sedatives were and what they were used for... I didn't feel like telling her we have a handful of sedatives on our rig, and that I already knew what they were used for.

She probably thought I was an EMT student, and not a medic student 90% done with his course.

Makes me feel lucky... our county MPD is on the board of directors at our regional trauma center, and is a senior attending in its ED, so by virtue of that, and some great nursing staff in said ED, everyone is very much aware of everyone else's capabilities and knowledge.