Paramedic to RN bridge….. options?

[akflightmedic]

I am feeling you have just chosen to take a stand and not be persuaded or convinced otherwise. Too late to back down...cause it is NOT just where I am that this is occurring, and with your stated level of experience, then any of this should have been instant no brainer for you to comprehend. Unless you are not currently practicing anywhere and have retired or been on hiatus.

As for use of Provider...and Midlevel, they have all referenced themselves as that within all my personal experiences.

But again, you seemingly do not want to dismount the high horse apparently and realize what is taking place quite commonly in many, many places is the current reality.

 

[MonkeyArrow]

Why isn't it the same thing? Pared down, your stance is that a doctor must evaluate a patient before a nurse can make a decision, but not a paramedic.

You're missing a little nuance that makes a world of difference. My stance is that a doctor should evaluate a critically ill (ergo, time sensitive) patient when available. The key distinction is that in an ER, a doctor is always (I guess technically almost always) available. Prehospitally, a doctor is almost never physically available, at least in the US, hence the need for protocols. Yes, you can call a doctor on the phone for OLMC, but that is not the same as the physician being at the bedside and seeing the patient personally.

 

[MonkeyArrow]

I am feeling you have just chosen to take a stand and not be persuaded or convinced otherwise. Too late to back down...cause it is NOT just where I am that this is occurring, and with your stated level of experience, then any of this should have been instant no brainer for you to comprehend. Unless you are not currently practicing anywhere and have retired or been on hiatus.

As for use of Provider...and Midlevel, they have all referenced themselves as that within all my personal experiences.

But again, you seemingly do not want to dismount the high horse apparently and realize what is taking place quite commonly in many, many places is the current reality.

You are completely correct that I am unconvinced the situation that you describe is happening regularly. I am not saying that it cannot happen; of course it can, but that is the unusual exception to the rule, not routine. Fundamentally, the question I propose you ask is: who is the sickest patient in the department at this time? In the overwhelming majority of cases, the patient you described is the sickest, and so the provider should be with that patient. I do not think having more peri-arrest patients simultaneously appearing than you have providers is at all a common occurrence anywhere in this country, and I think it is a mischaracterization to assert as such. (Sure, there are probably some centers that at least not rarely have multiple resuscitations going on at once, but those are also typically urban knife-and-gun club departments that are decidedly not single coverage, so the point is moot).

 

[akflightmedic]

Wow...you are simply deluded and choose to remain ignorant then. Not much more to say here as you have your opinion based on dialogue with peers, and I have mine based on personal real time experience.

 

[Akulahawk]

I used to work in a 16 bed ED that was at a Critical Access Hospital. We usually had 1 Physician and 1 PA on duty MOST of the time. Most of the time, all the beds were full. Our scope of practice before a provider saw a new patient was basically what the Paramedics had, along with the authority to order some imaging and most labs by standing order. Notice I didn't indicate if the patient was initially seen at triage or brought in by EMS. This all starts because of my assessment. The labs and basic imaging could be already cooking before a provider is ready to see the patient. In more than a few instances, the provider wouldn't have to see the patient but once or twice (for MSE and discharge). It wasn't unheard of (actually relatively common) to have a code going when another would arrive so we'd get going on our own, under standing orders. Exactly as it's done in the field. This was well before COVID, we were seeing 70 patients/day so we had to have EVERYTHING going quickly for maximum throughput or the ED flow would grind to a halt because the providers would get completely buried.

Where I work now, I'm in a 29 bed ED that's in an urban/suburban environment and we usually have 3-4 providers on and while the providers do lean on the nurse doing the triage to get some things done, they're able see patients very quickly, they've got scribes, and they can get orders in very quickly. My hospital system wants most of the orders entered by a provider and wants "verbal orders" to be used as infrequently as possible. If we've got 60-ish or 85-ish patients in our 29 bed ED and one of my patients needs something, I just ask for it, provider puts in the order, and I go do it. The providers I work with trust my judgment. It's been that way for several years... long before COVID. While I'd like to have the authority level I had at the CAH at my current job, our providers are able to get going on things fast enough most of the time that I'd only beat them by a couple minutes in getting that stuff ordered. Incidentally, we're usually seeing upwards of 160 patients per day with effectively a 10 bed (or less) ED because how many holds (psych, tele, ICU) we have. Our process isn't the greatest, but it works reasonably well for our circumstances.

 

[MonkeyArrow]

Wow...you are simply deluded and choose to remain ignorant then. Not much more to say here as you have your opinion based on dialogue with peers, and I have mine based on personal real time experience.

It's ironic that you think my personal experiences are worth less than yours, but ignoring that. Let's approach this from a different perspective.

National data shows that there are between 300,000 and 400,000 out of hospital cardiac arrests annually in the U.S. I chose cardiac arrest because it is a patient population with well-reported data and who clearly needs resuscitation; I obviously recognize that there are may be other patients, not in cardiac arrest, but who are still critically ill. I believe the general principle displayed by this assumption holds for my larger point, however. Another source puts it at 111 per 100,000 people. With a U.S. population of 330,000,000, that means there are 366,300 OHCAs every year. Divided by 365 days a year, that comes out to 1003.56 arrests a day. There are ~4000 hospitals in the US. That means, on average, each hospital is expected to see 0.25 arrests a day.

(Now, this "model" makes significant simplifying assumptions, but which I think are appropriate for a back-of-napkin calculation like this. For example, these numbers are reliant on every OHCA being transported to an ER. Additionally, we assume that each ER sees an equivalent number of arrests each day, which we know is not accurate, since higher volume centers will see a larger absolute number of arrests, by definition. However, because we're interested in a smaller-than-average sized ER, my calculation will actually overestimate the true event rate, which is fine.)

We can model the number of cardiac arrests seen in an ER by a Poisson distribution. Again, a Poisson distribution is not perfect, but it is a good enough approximation. The average rate is 0.25, and our random variable is 2 (that is, we are interested in how often any given ER should see >=2 OHCAs a day). The probability of X>=x (or of seeing at least 2 arrests a day) is 0.02650, or 2.65%. However, remember that this is over a full 24 hour period; the likelihood of seeing 2 (or more) arrests within one hour, where the single provider would already be tied up and unavailable to come see the new patient, is much much lower.

To summarize:
Do I think that having more critically unstable patients than you have providers is theoretically possible? Yes.
Do I think that having more critically unstable patients than you have providers actually happens? Of course it does.
Do I think that having more critically unstable patients than you have providers happens regularly? Or is commonplace? Or is "taking place quite commonly in many, many places [and] is the current reality"? No.

I'm not saying that you aren't seeing more critically unstable patients than you have providers available to see in a timely manner, or that you aren't overwhelmed with patients, or even that this isn't an infrequent occurrence in your experience. Most things in the real world follow a distribution, and distributions have tails that hold outliers and extreme values, and due to unique geography/patient factors/happenstance/luck, you could work at ER(s) that see an unexpectedly large number of critically unstable patients. Who am I to say whether you do or not? You work there, I don't. However, it is not true that this experience is generalizable or largely applicable to most other ERs, who do fall closer to average values.

 

[CCCSD]

Backpedaling: an American art.

 

[FiremanMike]

It's ironic that you think my personal experiences are worth less than yours, but ignoring that. Let's approach this from a different perspective.

National data shows that there are between 300,000 and 400,000 out of hospital cardiac arrests annually in the U.S. I chose cardiac arrest because it is a patient population with well-reported data and who clearly needs resuscitation; I obviously recognize that there are may be other patients, not in cardiac arrest, but who are still critically ill. I believe the general principle displayed by this assumption holds for my larger point, however. Another source puts it at 111 per 100,000 people. With a U.S. population of 330,000,000, that means there are 366,300 OHCAs every year. Divided by 365 days a year, that comes out to 1003.56 arrests a day. There are ~4000 hospitals in the US. That means, on average, each hospital is expected to see 0.25 arrests a day.

(Now, this "model" makes significant simplifying assumptions, but which I think are appropriate for a back-of-napkin calculation like this. For example, these numbers are reliant on every OHCA being transported to an ER. Additionally, we assume that each ER sees an equivalent number of arrests each day, which we know is not accurate, since higher volume centers will see a larger absolute number of arrests, by definition. However, because we're interested in a smaller-than-average sized ER, my calculation will actually overestimate the true event rate, which is fine.)

We can model the number of cardiac arrests seen in an ER by a Poisson distribution. Again, a Poisson distribution is not perfect, but it is a good enough approximation. The average rate is 0.25, and our random variable is 2 (that is, we are interested in how often any given ER should see >=2 OHCAs a day). The probability of X>=x (or of seeing at least 2 arrests a day) is 0.02650, or 2.65%. However, remember that this is over a full 24 hour period; the likelihood of seeing 2 (or more) arrests within one hour, where the single provider would already be tied up and unavailable to come see the new patient, is much much lower.

To summarize:
Do I think that having more critically unstable patients than you have providers is theoretically possible? Yes.
Do I think that having more critically unstable patients than you have providers actually happens? Of course it does.
Do I think that having more critically unstable patients than you have providers happens regularly? Or is commonplace? Or is "taking place quite commonly in many, many places [and] is the current reality"? No.

I'm not saying that you aren't seeing more critically unstable patients than you have providers available to see in a timely manner, or that you aren't overwhelmed with patients, or even that this isn't an infrequent occurrence in your experience. Most things in the real world follow a distribution, and distributions have tails that hold outliers and extreme values, and due to unique geography/patient factors/happenstance/luck, you could work at ER(s) that see an unexpectedly large number of critically unstable patients. Who am I to say whether you do or not? You work there, I don't. However, it is not true that this experience is generalizable or largely applicable to most other ERs, who do fall closer to average values.

None of this has anything to do with your assertion throughout this entire thread that paramedics are capable of evaluating and making decisions based on protocols and experience without direct physician input, but nurses are not.

 

[MonkeyArrow]

None of this has anything to do with your assertion throughout this entire thread that paramedics are capable of evaluating and making decisions based on protocols and experience without direct physician input, but nurses are not.

Where did I say this?

 

[mgr22]

To those who've been both nurses and medics: If you were to make a list of traits and talents most important for nurses and a second list of traits and talents most important for medics, are there any items that wouldn't be on both lists?

 

[CCCSD]

Where did I say this?

Everywhere.

 

[FiremanMike]

To those who've been both nurses and medics: If you were to make a list of traits and talents most important for nurses and a second list of traits and talents most important for medics, are there any items that wouldn't be on both lists?

I saw this - going to answer tomorrow with my opinion as an almost nurse lol

 

[Carlos Danger]

None of this has anything to do with your assertion throughout this entire thread that paramedics are capable of evaluating and making decisions based on protocols and experience without direct physician input, but nurses are not.

Everywhere.

Quotes?

 

[CCCSD]

Quotes?

Read the lines. It’s pretty obvious.

 

[Carlos Danger]

Read the lines. It’s pretty obvious.

I’ve read it all. I don’t necessarily agree with all of it, but I also don’t recall examples of what you and FiremanMike are asserting. I’d like you to post quotes so I know what comments you are referring to.

 

[akflightmedic]

You wrote a nice dissertation there on cardiac arrests and stats...not once did I mention working cardiac arrests. Unsure how those stats even apply to the subject being discussed.

Anyways, ironically, I did just get home due to being held over 1.5 hours due to the fact among the many holds in the ED, the usual gamut of ER patients, we had an urgent appendicitis, a tension pneumo, and then a cardiac arrest. All within an hour's time...very quickly overwhelms this FSER, however it is what it is. One provider, bouncing for those three criticals, while myself and the others do what we do. You know, the stuff you simply think does not happen all that often, yet it does. As we were wrapping up the chest tube patient, the transfer ambulance arrived to take the nSTEMI to another facility, after sitting in our ER for about 36 hours, lo and behold she decides to code. Glad the crew stayed to play, and you know what....the doc was NOT in the room the entire time (gasp!).

 

[FiremanMike]

Quotes?

This is absolutely NOT what should be happening, and I will die on this hill. This patient, as described, is critically ill and needs to have a physician at the bedside immediately. Playing hero and doing all this stuff without notifying a physician to come to the bedside is poor practice and not in the patient's best interest.

You know how its fundamentally different, because in the back of an ambulance, you don't have a doctor there, but in an ER, you do? (Or at least a "provider" as ak keeps saying.)

It's pretty much this and the continued theme of "nurses shouldn't do anything before the doc sees the patient".

Did I oversimplify his point with my summary of "medics can but nurses can't?" maybe.. but at it's core, it's really what he's saying.

Lest we forget, we pretty much all felt that way about nurses at least some point in our lives as paramedics..

 

[FiremanMike]

To those who've been both nurses and medics: If you were to make a list of traits and talents most important for nurses and a second list of traits and talents most important for medics, are there any items that wouldn't be on both lists?

In my opinion, the traits and talents should be the same between a good nurse and a good medic.

In practice, it's different.

I think paramedics must be more decisive than nurses, because if I nurse gets stuck they have other people immediately available they can lean on, whereas the paramedic is generally going to be the highest level of care in the room.

Nurses must be better at multitasking than medics, because it's pretty rare for a medic to be juggling more than 1 patient, and they almost never have more than 2.

In practice, medics don't generally need to consider all the nuances of how various disease processes work together, medics are mostly focused on the immediate problem and mitigating it, whereas nurses think a few more steps down the line at any given moment.

 

[MonkeyArrow]

You wrote a nice dissertation there on cardiac arrests and stats...not once did I mention working cardiac arrests. Unsure how those stats even apply to the subject being discussed.

Anyways, ironically, I did just get home due to being held over 1.5 hours due to the fact among the many holds in the ED, the usual gamut of ER patients, we had an urgent appendicitis, a tension pneumo, and then a cardiac arrest. All within an hour's time...very quickly overwhelms this FSER, however it is what it is. One provider, bouncing for those three criticals, while myself and the others do what we do. You know, the stuff you simply think does not happen all that often, yet it does. As we were wrapping up the chest tube patient, the transfer ambulance arrived to take the nSTEMI to another facility, after sitting in our ER for about 36 hours, lo and behold she decides to code. Glad the crew stayed to play, and you know what....the doc was NOT in the room the entire time (gasp!).

Ah, so the story unravels. Those three patients are not the same level of "critical". The principle I will again espouse is that the physician must attend to the sickest patient in the department first, at least until stabilization has begun. Let me remind you, that this all started when I said it was inappropriate for a complete workup and medication administration to be done without the physician ever assessing a critically unstable patient. I never opined on what should happen with stable patients or that the physician has to stay in the room the whole time.

Unless the appendicitis was in fulminant septic shock, they can wait. By definition, a tension pneumo causes hemodynamic compromise. However, we both know that there is a little bit of wiggle room with what that means. If they are tachy to 110 and have an spo2 of 94, they can wait. If not, a crash chest tube should take 5 minutes at most, and that is being generous. No need to use lidocaine when the patient is peri-arrest. And that frees the physician up to attend to the code.

I will let you go back and re-read why I chose to use cardiac arrests above as my example. Without knowledge of your patient volume and arrival times and clinical course, I won't be able to model probabilities for any one specific hospital anyways.

 

[MonkeyArrow]

It's pretty much this and the continued theme of "nurses shouldn't do anything before the doc sees the patient".

Did I oversimplify his point with my summary of "medics can but nurses can't?" maybe.. but at it's core, it's really what he's saying.

Lest we forget, we pretty much all felt that way about nurses at least some point in our lives as paramedics..

Again, where did I say that "nurses shouldn't do anything before the doc sees the patient"?

I have been very clear and very particular with the claims I have made in this thread. Your "oversimplification" is wrong. I never commented on anything beyond what should happen with a critically unstable patient in an ER.

I never compared nurses' ability to think independently vs. paramedics', because they are not directly comparable in my opinion. They work in very different environments.