Paramedic to Paramedic handoff?

[truetiger]

That's how it is here. RNs are certified as EMS RNs.
They are the highest level of care. In cases of us landing and supposing it will be a cancel for whatever reason, usually we send the medic out to make contact... because once the RN makes patient contact they are unable to relinquish care to a ground medic.
Tradecraft

Where is this hierarchy documented?

 

[Carlos Danger]

I've seen it in the case of a no-go. I've seen a flight crew take a patient, and then land 20 seconds later because the aircraft was over on hours (big oops.) Or in the case in which the patient codes before the flight team could load, etc. I have yet to see or have anyone be able to cite anything that says a flight crew is a higher level of care. At least in MO, RN is not a higher license level. Now I could see why air medical agencies would push that as they get to bill if they go with ground.

Having RN behind your name doesn't necessarily make you a higher level of care than a ground paramedic. Nor does wearing a flight suit. However, HEMS crews almost always consist of two providers vs. the one that you normally find on a ground ambulance, which is a big deal when you are managing a really sick patient. The HEMS crew is also typically trained to a level considerably higher than your run-of-the-mill street paramedic. They also often transport a higher percentage of sick patients, and have a more expansive formulary and protocols than their counterparts on the ground. Certainly there are exceptions to these generalizations, but they are probably just that - exceptions, rather than the norm. If that doesn't all add up to reasonably higher clinical expectations - something we often refer to as "level of care" - then I don't know what does.

The HEMS programs themselves often have bedside-bedside policies for a combination of reasons that can include billing, liability, contractual, quality, and basic continuity of care considerations, and whether it is entirely accurate or not, I think they tend to refer to those collective responsibilities as maintaining their "level of care".

It isn't an insult to ground medics.

 

[VFlutter]

I've seen it in the case of a no-go. I've seen a flight crew take a patient, and then land 20 seconds later because the aircraft was over on hours (big oops.) Or in the case in which the patient codes before the flight team could load, etc. I have yet to see or have anyone be able to cite anything that says a flight crew is a higher level of care. At least in MO, RN is not a higher license level. Now I could see why air medical agencies would push that as they get to bill if they go with ground.

I am sure those situations do exist and I have heard of other flight programs bringing back patients and leaving for various reasons however the expectation of us is that we complete the transport by any means. If we have aircraft issues then we go by ground. If we establish patient contact and go back out to the aircraft and weather has changed then we go by ground. If the patient codes then we work it until we get ROSC and then fly or they call it. I am sure billing is part of it but as Remi stated there is much more that goes into it.

Whether it is technically defined as "higher level of care" or not on the referring hospital or agency is calling you because the patient needs something that they can not offer and many times it is the care provided not necessarily the quicker transport. I personally do not see many situations when I would be turning over care to anyone other than a hospital.

Also in many states the flight program may be licensed as "Critical Care" vs "ALS" which equates to a higher level of care.

 

[SandpitMedic]

Also in many states the flight program may be licensed as "Critical Care" vs "ALS" which equates to a higher level of care.

That's it.

Where is this hierarchy documented?

See above.
I'll look through our local protocols and try to post if they have it officially documented. While I sympathize and understand your position, the world views RNs as a higher level of care than a paramedic, regardless of whether that is true or not.

 

[SandpitMedic]

Unable to find it documented in the local EMS regulations or protocols.. other than that EMS-RNs and Critical Care Paramedics have advanced skill sets and procedures.

 

[truetiger]

In MO RN's are not automatically granted ALS privileges, they have to be given by the medical director. No offense to RN's but I don't think you're level of care is any higher than a paramedic's. If you believe differently, please explain. Nursing, as a course of study, is designed to teach a little about a lot and paramedic courses teach a lot about a little. Certainly there are those RN's that specialize, but that isn't commonplace. To say by default that RN is greater than EMT-P would be mistaken. There is nothing in the state statutes that designates RN's as a "higher level of care." In most cases I called for a bird for your mode of transportation, not your care. Please don't take offense to that statement but more often than not services are providing board certified critical care medics (FP-C, CCP-C, UMBC) with the equipment to match. Its becoming more and more popular to find Revel vents, IV pumps, etc on regular ALS ground trucks, combine that with the fact that MO is a medical director state and there are little limitations to ground care.

 

[VFlutter]

In MO RN's are not automatically granted ALS privileges, they have to be given by the medical director. No offense to RN's but I don't think you're level of care is any higher than a paramedic's. If you believe differently, please explain. Nursing, as a course of study, is designed to teach a little about a lot and paramedic courses teach a lot about a little. Certainly there are those RN's that specialize, but that isn't commonplace. To say by default that RN is greater than EMT-P would be mistaken. There is nothing in the state statutes that designates RN's as a "higher level of care." In most cases I called for a bird for your mode of transportation, not your care. Please don't take offense to that statement but more often than not services are providing board certified critical care medics (FP-C, CCP-C, UMBC) with the equipment to match. Its becoming more and more popular to find Revel vents, IV pumps, etc on regular ALS ground trucks, combine that with the fact that MO is a medical director state and there are little limitations to ground care.

I agree that RN should not automatically equal higher level of care.

I respectfully have to disagree. More services are implementing critical care trucks with similar equipment and protocols but that does not necessarily make them equal to the care provided by an experienced flight crew. Your program may be an exception however there are many that are churning out Critical Care paramedics / trucks with very limited experience and knowledge base. Just because a service has a Revel and a 1 year medic turned CCP-C does mean they expert critical care clinicians. Having said that there are many great ground critical care programs and many horrible flight programs. But there is still a large majority of EMS services and hospitals that do call us for the level/quality of care we provide.

I could take a group of floor nurses and put on a critical care course to get them to pass the CFRN but that does not mean they could transport critically ill patients.

 

[truetiger]

I agree that RN should not automatically equal higher level of care.

I respectfully have to disagree. More services are implementing critical care trucks with similar equipment and protocols but that does not necessarily make them equal to the care provided by an experienced flight crew. Your program may be an exception however there are many that are churning out Critical Care paramedics / trucks with very limited experience and knowledge base. Just because a service has a Revel and a 1 year medic turned CCP-C does mean they expert critical care clinicians. Having said that there are many great ground critical care programs and many horrible flight programs. But there is still a large majority of EMS services and hospitals that do call us for the level/quality of care we provide.

I could take a group of floor nurses and put on a critical care course to get them to pass the CFRN but that does not mean they could transport critically ill patients.

We'll have to agree to disagree then. Being part of a "flight crew" does not qualify ones experience. Being that EMS is a small field, I know many people that fly or have flown. Most air programs are a revolving door. People leave the ground to fly and then come back to the ground. I've always been curious as to how things are done in the air medical arena. From what I've been told, by a few different people, from a few different companies is that its mostly the same, with the obvious difference in transportation and the longer charts required by air services. I've also been able to work around these clinicians on the ground and in-hospital. They put their pants on the same way we do. They do the same interventions, think the same thoughts, etc. A paramedic or nurse working for an air service may run higher acuity calls more often; obviously if a helicopter is involved it is more than likely a high acuity case. But ya know what? Busy rural services run a lot of high acuity calls that don't utilize air services. We get a lot of "touches" as well with those high acuity patients. MI's, strokes, trauma, etc. Might be due to weather, or just proximity to the hospital, but there's a lot of calls air craft aren't dispatched on. To make a blanket statement that a crew is a "higher level of care" due to its mode of transportation is just false. It's all propaganda in my opinion. Of course the air medical companies want everyone to think that. It's good for business.

 

[VFlutter]

We'll have to agree to disagree then. Being part of a "flight crew" does not qualify ones experience. Being that EMS is a small field, I know many people that fly or have flown. Most air programs are a revolving door. People leave the ground to fly and then come back to the ground. I've always been curious as to how things are done in the air medical arena. From what I've been told, by a few different people, from a few different companies is that its mostly the same, with the obvious difference in transportation and the longer charts required by air services. I've also been able to work around these clinicians on the ground and in-hospital. They put their pants on the same way we do. They do the same interventions, think the same thoughts, etc. A paramedic or nurse working for an air service may run higher acuity calls more often; obviously if a helicopter is involved it is more than likely a high acuity case. But ya know what? Busy rural services run a lot of high acuity calls that don't utilize air services. We get a lot of "touches" as well with those high acuity patients. MI's, strokes, trauma, etc. Might be due to weather, or just proximity to the hospital, but there's a lot of calls air craft aren't dispatched on. To make a blanket statement that a crew is a "higher level of care" due to its mode of transportation is just false. It's all propaganda in my opinion. Of course the air medical companies want everyone to think that. It's good for business.

I won't argue too much since it is likely neither of our opinions will change however to make a few points. I would not say that "most" air programs are a revolving door. Some programs and bases have issues more so than others and there are many reasons why that would be. Some of it is bad management or practices, some are justifiably weeded out, and some are just constantly moving on to advance their career. However to get a job at a CAMTS program candidates must have 3-5 years of experience and usually with the competitive applicant pool must have a pretty impressive resume to go along with it. That is not to say all of these people end up being highly successful at the job but at if you are a fight crew member even on day 1 you been a competent, probably above average, clinician for a number of years and have a lot of education behind you.

I am not implying flight crews are superheroes or that they do anything extraordinary I do however believe on average they do the critical care stuff pretty damn well. That is not to say that ground critical care units can not. But average to average i think flight teams have more exposure and experience and do have something to offer. I guess I should clarify I speak mostly about my colleagues since there are many air programs I do no think do it well, especially in Missouri.

Objectively, our company presents our intubation and procedural statistics at transport conferences and usually we are towards, if not at, the top of the list. I think that is a testament to our education/training and crews experience. Again, that is not to say that ground programs can't do this but on average we do a great job.

To some it up I am not trying to make a blanket statement that every flight crew is by virtue a higher level of care, because I know that is not the case. I will admit that for some ground programs with great protocols and equipment you may be calling HEMS solely for the mode of transport and that is fine but that is not the norm. However I think its a disservice, and a fallacy, to say flight crews do not have anything to offer besides their mode of transportation and that it is nothing more than "propaganda".

And of course all of this is referring to HEMS for EMS which I can concede your argument may have some merit. However in regards to Critical Care IFT I think it is abundantly clear that HEMS has value from a "level of care" perspective.

 

[VentMonkey]

You know what? In my region we are considered the highest level of prehospital care because of my partner, the flight nurse.

And you know what else? So what. I don't care that I "need a nurse" to do an RSI, it doesn't define my clinical prowess.

Apparently if I want to do all of these "cool things" that so apparently defines our profession even at this "level" I need to leave my home state. I'm kind of over the pissing matches, the "we have this, you don't", "we can do this just as good as you because of XYZ".

My ego is not so fragile that I feel "less than" because my partners expanded scope allows me clinical opportunities not all that common elsewhere within my system. I don't measure any providers competence by any of their levels of service. It's all ******** semantics plain and simple. I feel bad for anyone that ego driven. Arrogance inhibits infallibility.

FWIW, our QA utilization form requires us to circle "specialty team" only when we carry a specialist (e.g., perfusionist, NICU team, etc.) along for the transport. Our program is the "basic" level of specialty/ critical care (basic expanded airway scope, invasive line monitoring, and your run of the mill ICU patient).

None of this makes me any better, or worse than the 20 year CCP that takes the same approach to CME that I pride myself on. Who really cares?!!!

 

[SandpitMedic]

There are a lot of great points in this thread, on both sides of the coin.

I would just offer my opinion that where I am at a HEMS flight team is considered the highest level of care (prehospital and IFT, save for a true specialty team like NICU or an MD).

It is also denoted in our protocols, and the transporting RNs have a special a EMS credential which makes them the defacto highest level of care, although there is no written diagram with them at the top. Their scope is the most broad.

I certainly don't feel or think I am better than any other clinician, but I do have expanded training, a wider scope of practice, critical care equipment, and an expanded formulary.