Replacing EMS with nursing revisited

[Journey]

I'm not saying this to be ugly, but it must be said. If I am working any job ambulance or otherwise where my official title is, "Registered Nurse" as opposed to "Paramedic", under no circumstance would I accept less than $25 an hour, which is almost laughable compared to what we as RN's can make, especially with credentials in emergency or critical care and equivalent experience.

As a Paramedic, $15 - $20 an hour sounds about right.

This is one thing to consider when talking about nurses replacing paramedics on the ambulance. The highest paying service I can think of pays $23 an hour for Critical Care Paramedic (which requires 2 years of experience in TN as a paramedic before being able to take the class, so about 3 years experience is the average). I know of no ambulance service that is going to pay anyone on their rigs anything above $26 an hour, especially not the $29+ an hour most RNs in emergency and critical care in metropolitan areas are accustomed too.

If you are going to compare wages with Critical Care Paramedics, what do the CCT and Flight RNs make in your state? I doubt if they take that much of a cut in pay. In California RNs are on many of the CCT trucks with EMT drivers. Some hospitals do own a share of an ambulance service and function under the company's emergency license to use lights and sirens. This also gives them more control over the training of those who do IFT of their patient.

It would be nice to see hospitals or health care districts take over the ambulances which would probably happen if more RNs were involved. One of issues discussed at the national EMS meetings was performance based transport. If RNs were involved, this would become a reality which would be recognized by the insurers much like specialty transports.

The system the U.K. has with the ECPs would be nice but again that would mean the Paramedics would have to advance their base education and then be expected to do some post grad work as well just like the nurses who are RCPs. RNs would be a more logical choice to do what Wake County is attempting. RNs would know the services of each hospital better for they appropriate facility. They may have a better insight on diversion status. They would also know the special needs of home bound patients that are labeled as frequent fliers because they have provided the care for these patients and have done the patient education. With their education, training and experience taking care of these patients on a daily basis, they would be much better qualified than the few extra hours of training a prehospital provider who has not provided care other then the emergent. There are too many things to consider and just scripted protocols don't always fit these patients. Some criticize RNs for calling doctors but RNs do recognize there are exceptions to the protocols and not every patient fits the protocol nor should you attempt to fit the patient to the protocol. It may be better to create a new plan of care rather than plod along with one that is not effective for the long haul even if it seems to be a quick fix now.

 

[medicRob]

If you are going to compare wages with Critical Care Paramedics, what do the CCT and Flight RNs make in your state? I doubt if they take that much of a cut in pay. In California RNs are on many of the CCT trucks with EMT drivers. Some hospitals do own a share of an ambulance service and function under the company's emergency license to use lights and sirens. This also gives them more control over the training of those who do IFT of their patient.

It would be nice to see hospitals or health care districts take over the ambulances which would probably happen if more RNs were involved. One of issues discussed at the national EMS meetings was performance based transport. If RNs were involved, this would become a reality which would be recognized by the insurers much like specialty transports.

The system the U.K. has with the ECPs would be nice but again that would mean the Paramedics would have to advance their base education and then be expected to do some post grad work as well just like the nurses who are RCPs. RNs would be a more logical choice to do what Wake County is attempting. RNs would know the services of each hospital better for they appropriate facility. They may have a better insight on diversion status. They would also know the special needs of home bound patients that are labeled as frequent fliers because they have provided the care for these patients and have done the patient education. With their education, training and experience taking care of these patients on a daily basis, they would be much better qualified than the few extra hours of training a prehospital provider who has not provided care other then the emergent. There are too many things to consider and just scripted protocols don't always fit these patients. Some criticize RNs for calling doctors but RNs do recognize there are exceptions to the protocols and not every patient fits the protocol nor should you attempt to fit the patient to the protocol. It may be better to create a new plan of care rather than plod along with one that is not effective for the long haul even if it seems to be a quick fix now.

I chose to focus on ground based transport services for one specific reason, I assumed this was the environment the OP was talking about putting RN's in instead of medics. Moreover, RNs have been in flight for quite some time, nothing new. Furthermore, you'd be surprised at what flight paramedics make, it is not what you are imagining, I am sure.. at least not here in TN, and yes I am talking about the choppers that are owned and operated by our major trauma I centers. I make more in the trauma unit than I do in flight.

 

[Journey]

I chose to focus on ground based transport services for one specific reason, I assumed this was the environment the OP was talking about putting RN's in instead of medics. Moreover, RNs have been in flight for quite some time, nothing new. Furthermore, you'd be surprised at what flight paramedics make, it is not what you are imagining, I am sure.. at least not here in TN, and yes I am talking about the choppers that are owned and operated by our major trauma I centers. I make more in the trauma unit than I do in flight.

I was not just talking about flight either. I mentioned CCT which are commonly ground ambulances. In places where the private ambulances have a nurse full time on that truck, the truck will say NURSE UNIT. In some places like California, they are very prominent. Right now with the protocols being written by county, the RN would only be able to do what the Paramedics are doing in that county for 911 EMS. In California for CCT, they must also abide by the county but those protocols now take into consideration it is an RN and the scope is expanded. The same for some other states when the classification and regulations are changed to accomondate the professionals on that truck.

While the number of CCTs and RNs might be small now, it does show they filled a void which could not be filled by Paramedics in that area. As technology and medicine continues to advance, you will probably see more RNs doing high acuity IFTs officially and not just a throw on to get from one ED or ICU to the next. Hospitals are being more cautious now with EMTALA and making sure the transporting ambulances and teams are equipped to handle that patient. The days of RNs filling up the med pumps and trying to get the patient in a stable enough state for the Paramedics to drive real fast to the next hospital should have been a thing of the past decades ago. It is dangerous medicine but still practiced today in some places even with the CCT Paramedics who have little to no experience in Critical Care or even on the ambulanes and the CCT education is somewhat lacking in the U.S.

Also, as long as the U.S. EMS systems have set their expectations to the lowest denominator, there is no need for RN in the field for 911 calls right now responding along with fire departments and private ambulances and their bickering. However, the same is not true in the hospitals where the expectations are now higher and loved ones expect the hospitals to do the right thing for providing care that is more than just adequate. So, for now it will be CCT (ground), Flight and Specialty where the RNs will continue to grow in professional strength and numbers.

 

[BluesMedic]

Most of this seems to be entirely off subject that was intended by the OP. I understand the argument, but it is really going to happen? Probably not. Should it happen, not so sure. I think a re-evaluation of the education is the best place to start. But there is a myraid of problems concerning health care in general, paramedicine in specific.

I just do not see how a new grad student can function on an ambulance. I will use my area's Level I trauma center as an example. This is a huge facility that incoperates many specialties and is a nationally known medical school as well. The emergency department will not allow a new nursing grad to work in the ED, they must have at minimum one year experience. With one exception, if that new nurse was a paramedic before becoming a nurse, they will hire straight out and put said person to work in the ED. If a new nurse can't be allowed to work in the ED, how can they function out of hospital? Just to clarify, this is just the workings of one hospital, I mean no disrespect to any other facility or to nurses in general.

Another question I have for all those reading is this; I have seen a lot of comments concerning the education of nurses concerning pharmacology, A&P, etc. What about those paramedics that earned their medic through a nationally accredited college while obtaining an associates degree? These particular people went through the same exact college level courses on A&P, English, History, Psychology, Pharmacology, Patient Assessment and the like along with courses specific to pre-hospital medicine. Is a nurse any better at providing prehospital medicine than these people?

Until next time...

 

[Veneficus]

alas, somebody gets it

I just do not see how a new grad student can function on an ambulance. I will use my area's Level I trauma center as an example. This is a huge facility that incoperates many specialties and is a nationally known medical school as well. The emergency department will not allow a new nursing grad to work in the ED, they must have at minimum one year experience. With one exception, if that new nurse was a paramedic before becoming a nurse, they will hire straight out and put said person to work in the ED. If a new nurse can't be allowed to work in the ED, how can they function out of hospital?

At one time I understand it was a relatively standard practice that a nurse had to have 1 year of experience before being moved to an ICU, and one year in the ICU before being moved to the ED.

However, as the amount of interested providers (aka nurses) declined and those with more advanced educations like a BSN were preferred over the ADN, in a recruiting enticement, orereqs were largely dropped in many areas. I even know traveling nurses who as thier first job out of school demanded ICU or ED appointments. (and got them)

Now I agree that in the hospital there is much more help to fall back on, but here is the rub. If a paramedic can be expected to follow rather narrow protocols (please people I don't want to hear about how your agency is somehow different, I recognize exceptions to the national norm) A nurse cannot possibly be any less capable than a new paramedic simply because the paramedic was probably educated using those protocols. (which is a failure of education to use local protocols, but that is for another thread.)

Now as I originally stated, there would have to be some additional training for the nurse. But how much? 9 months of medic school? I doubt it. Maybe 3, so call it a semester. Then I think their employer would give them the normal initiation and FTO time that the rest of the medics get.

Of course since you would have to pay the nurse more, you would have less "als" providers which of course in an emergency setting is beneficial. But then you also have providers who can and often do embrace preventative medicine that EMS only pays lip service to.

Visiting nurses, like visiting physicians are already paid for under the current reimbursement. Which adds to potential revenue sources. Less than an ALS ambulance? Sure, but quantity is sometimes a quality all of its own. Pls I would rather be stiffed out of 60% of the bill for a visiting nurse than 60% of the bill for an ALS transport ambulance.

It also has the benefit of getting paid for treatment instead of soley on transport. So while it would require some minor legal tweaking, which the nurses associations more than have the political clout to achieve, every treat and release instead of getting eaten as an RMA, now would get billed an reimbursed for a visiting nurse. (considerably cheaper than the ER bill) Better care, less money. Afterall, all that specialized emergency stuff paramedics are "trained for" are relatively a minor portion of the calls.

As for the patient, being able to recognize and treat or refer to the proper specialist for routine healthcare not only lowers the costs, but it also improves the health and quality of life. (the more I think about this nurse thing the better it looks)

Another question I have for all those reading is this; I have seen a lot of comments concerning the education of nurses concerning pharmacology, A&P, etc. What about those paramedics that earned their medic through a nationally accredited college while obtaining an associates degree?

Those medics are such a small percentage of the total workforce that it barely recognizes in percentile. It absolutely should be predominant if not the minimum, but right now they are outliers who barely factor in. Are they as capable? I gess that would depend on the nature of thier course. Afterall, if they have paramedic class, A&P, pharm, and a bunch of management classes, probably not. If they had 2 years+ of basic or clinical science, sure they should be more capable. But they are not right now.

These particular people went through the same exact college level courses on A&P, English, History, Psychology, Pharmacology, Patient Assessment and the like along with courses specific to pre-hospital medicine. Is a nurse any better at providing prehospital medicine than these people?

Certaily not, but again look at the numbers. I don't know for sure but I would wager a bet there are more vocational factory trained medics in systems like Houston, LA, or NYC than there are paramedics with EMS degrees in the whole nation. Especially if we factor in those who got degrees after starting as operational medics.

Like I said in my OP, it is nobody's fault but the EMS providers (both individual and organizational) that they are so lacking in education and marketability. They have had plenty of time to get their act together and failed, so a viable replacement should be sought.

As cold as it is, the primary function is being eaten away by less "true" emergencies, and the narrowness of their role is really making them obsolete with today's needs. No different from a blacksmith or a wheelwright, they are more novelty than useful.

 

[Journey]

After reading the last paragraph of Veneficus's post, I saw this comment in another thread.

Doing IFT for 8 months hurt my assessment skills. It hurt my ability to critically think. It hurt my manual skills. It hurt my ability to deal with acute situations. It hurt my ability to control a scene. It hurt my ability to interact with other agencies.

If many of the 911 calls are not emergent situations requiring the Paramedic to utilize their skills, how do they maintain their crtical thinking and skills? Although, I believe critical thinking is a process that can be applied to almost any medical situation even determining the best action to handle a nonemergent call. Would it be beneficial to either the patient or the Paramedic to expand EMS into community health or preventitive roles if the above statement is true for those in EMS?

Isn't there still an expectation for a Paramedic to be able to function as a Paramedic on an ALS truck? Hospitals do call ALS ambulances with Paramedics for patients who have the potential to need intervention requiring the skills and critical thinking of a Paramedic. Should hospitals be checking closer now to see how these Paramedics maintain competency when negotiating the contracts?

Veneficus, I apologize if I am off track on your thread.

 

[Veneficus]

Although, I believe critical thinking is a process that can be applied to almost any medical situation even determining the best action to handle a nonemergent call.

I once Heard Dr. Thomas Scalea say that "critical care is not a place, it is a mindset."

I think that sums it up rather well.

 

[medicRob]

I once Heard Dr. Thomas Scalea say that "critical care is not a place, it is a mindset."

I think that sums it up rather well.

Dr. Scalea is one of my personal heroes, and I hope to visit the R adams cowley, Shock Trauma center in Baltimore at some point in the near future.

/derail

 

[Akulahawk]

I once Heard Dr. Thomas Scalea say that "critical care is not a place, it is a mindset."

I think that sums it up rather well.

I think the same can be said for Paramedics/Prehospital medicine as well. It's not so much a place as it is a mind-set. Education being equal, some people would do well in the less controlled environment of the street and some people would do well in the clinical environment. Many of my instructors and co-workers have been RNs that work in the transport environment (prehospital and IFT). In effect, they had to learn to "think like a medic" in order to be able to function well in that prehospital arena. It's not that they didn't have the skills or the knowledge, but they had to develop the right mind-set to use them in a more independent manner. More than one Chief Flight RN has told me that it takes significantly longer to train an RN that only has a clinical background that it does to train one that also has a Paramedic background, when getting that new RN ready for "scene" work.

Education being equal... mind-set also becomes an issue. Even in the Pre-hospital arena, plug-n-play won't work.

 

[Shishkabob]

If many of the 911 calls are not emergent situations requiring the Paramedic to utilize their skills, how do they maintain their crtical thinking and skills? Although, I believe critical thinking is a process that can be applied to almost any medical situation even determining the best action to handle a nonemergent call. Would it be beneficial to either the patient or the Paramedic to expand EMS into community health or preventitive roles if the above statement is true for those in EMS?

Isn't there still an expectation for a Paramedic to be able to function as a Paramedic on an ALS truck? Hospitals do call ALS ambulances with Paramedics for patients who have the potential to need intervention requiring the skills and critical thinking of a Paramedic. Should hospitals be checking closer now to see how these Paramedics maintain competency when negotiating the contracts?

You've either misintrepreted what I said, or misrepresented it to suit your need... either way you're incorrect.

Barring something going oddly wrong:

Tell me the amount of assessment skills needed for your everyday BLS discharge? The patient has already been diagnosed.

The amount of critical thinking required to bring a patient to dialysis for the day? Minimal.

The amount of scene management required to, well, non-scene responses? Again, minimal if any.



Pre-hospital (i.e. NOT IFT) you have to come up with a working diagnosis for the patient, you have to figure out what plan of action to implement, how to implement it with the minimal resources and personnel at hand, and how to control what could potentially be an uncontrolled scene.





Sorry, Vene, for continuing to go off topic, but I couldn't let her post that without a rebuttle.

 

[Journey]

You've either misintrepreted what I said, or misrepresented it to suit your need... either way you're incorrect.

Barring something going oddly wrong:

Tell me the amount of assessment skills needed for your everyday BLS discharge? The patient has already been diagnosed.

The amount of critical thinking required to bring a patient to dialysis for the day? Minimal.

The amount of scene management required to, well, non-scene responses? Again, minimal if any.



Pre-hospital (i.e. NOT IFT) you have to come up with a working diagnosis for the patient, you have to figure out what plan of action to implement, how to implement it with the minimal resources and personnel at hand, and how to control what could potentially be an uncontrolled scene.





Sorry, Vene, for continuing to go off topic, but I couldn't let her post that without a rebuttle.

I did misunderstand you. I thought you were a Paramedic working on an ALS transfer truck since you stated you had 70 meds. On an ALS transfer truck a Paramedic or RN will have both unknowns and knowns with more factors to consider.

However, complacency with dialysis patients can lead to disaster. If you don't do some assessment and note changes, you will be caught off guard when you arrive with a very sick patient who can not go on dialysis and probably should have been taken to an ED at a hospital which also has dialysis.

Hospitals are also discharging patients earlier than some probably should and you shouldn't take it for granted that the patient is perfectly healthy. Labeling a patient as BLS shouldn't excuse you from still assessing a patient. It is no unheard of for a truck to turn around and bring a patient back to the hospital whether it is BLS or ALS or whatever label you want to use.
.

 

[CowboyMedic]

I read about half way through this and skipped to the last three pages so excuse me if this has already been stated/answered.

the CORE of the argument is that it would be beneficial for the EMS community to staff RNs on their rigs. Yes? But the benefits stated is that the RNs could treat and refer pts to other facilities that are more adequate for their diagnosis instead of an ER. So from what I understand the pts are already diagnosed cause RNs dont diagnose and Paramedics/EMTs "possible" diagnose. Doctors are the only ones that diagnose.

If these pts are already diagnosed then they already qualify for in home nurse care which is covered. There are already private companies for in home RN visits set up for this. Many nursing homes and hospice care facilities have a list of staff that they can send for this service. What do they need my ambulance for then?

The IDEA behind 911 is that it is suppose to be used for an emergency. Is it always an emergency? Hell no. If they are just asking for a ride to the doctors office or they stubbed their big toe they may get 'no ride' written. this is where the private ambulances pick up that slack. Again do they need to go to the ER? No. But they will. I dont see the benefit to bogging down a crew that has a RN staffed so they can treat someone who already knows they need treatment at such and such time.

For emergency purposes the RN idea doesnt work as far as I see it. As far as bogging down ERs with pts that is why the CDC has a triage system in place and there are hospitals with different trauma levels. If you live in the sticks you may only have one choice besides air lift.

Education wise I hope to see alot of change. I would like to see an LP with some much greater difference in skill set and education than what it has now. A LP has as much teeth as a newborn right now. I think education is the big elephant that need some attention right now. You cant force ever Paramedic to retake a higher level of training to maintain their paramedic but you can increase the quality of education in CE programs and initial Paramedic courses and effectively elevate the quality of a certified Paramedic and some of those old school paramedics. Granted this has to be done gradually but I think it is the most effect way of approaching the EMS system. Yeah you will still have people who shock Asystole but over time they should either educate them self or be forced out of the profession.

 

[JPINFV]

So from what I understand the pts are already diagnosed cause RNs dont diagnose and Paramedics/EMTs "possible" diagnose. Doctors are the only ones that diagnose.

Call it what you'd like, but anyone who makes a conclusion on a patient's condition based on a history and physical, augmented by medical testing as available, including point of care testing such as EKGs and blood glucose, and builds a treatment plan based on that conclusion has engaged in the process of making a diagnosis. If calling it a "possible" (differential) or working diagnosis helps you to sleep better at night, then so be it. However, it is still a diagnosis.

More on my thoughts about this:
http://emtmedicalstudent.wordpress.com/2010/11/09/ems-and-diagnosis/

The IDEA behind 911 is that it is suppose to be used for an emergency. Is it always an emergency? Hell no. If they are just asking for a ride to the doctors office or they stubbed their big toe they may get 'no ride' written. this is where the private ambulances pick up that slack. Again do they need to go to the ER? No. But they will. I dont see the benefit to bogging down a crew that has a RN staffed so they can treat someone who already knows they need treatment at such and such time.

Yes, the idea behind 911 is that it is for emergencies. The question now is, "Has the role of EMS evolved past just a ride to the hospital? If not, should it? If still no, can EMS survive as a government function as such a limited service?" The fire department is no longer just about putting out fires. The police department is no longer just about catching criminals. A large part of those departments are also about prevention. Why is it OK for EMS to sit back and ignore the effect it could have both on efficiency for the entire health care system as well as the possible role it has on prevention?

 

[Veneficus]

the CORE of the argument is that it would be beneficial for the EMS community to staff RNs on their rigs. Yes? But the benefits stated is that the RNs could treat and refer pts to other facilities that are more adequate.

The argument is that because what society needs from EMS as demonstrated by other civilized nations as well as the inefficencies of US EMS, that a nurse is better positioned (though not perfect) to provide such level of service in the US.

Because of the hyperspecialization of sociological roles as well as the lack of adequete education among a majority of US citizens, there is a definate need for healthcare providers who reach out to the community for the purposes of taking care of minor problems that do not need a healthcare facility, refering patients to the appropriate source of care when they need something other than the ED, prevention of illness, and health maintenence.

Since many if not most EMS providers think thier only role is a a ride to the ED for the critically ill, which is such a small minority of patients, even smaller when you consider viable ones, that they may be removing the need for themselves and therefore eliminating them from the marketplace.

for their diagnosis instead of an ER. So from what I understand the pts are already diagnosed cause RNs dont diagnose and Paramedics/EMTs "possible" diagnose. Doctors are the only ones that diagnose.

I do not agree that only doctors diagnose. While a specific doctor may have the most accurate diagnosis, it is certainly not exclusive.

A person who is having an ACS, can also be having an MI, an anterior decending MI, and infarct at the ramus intermedius.

All of these are diagnosis, for the same patient for the same complaint.

If these pts are already diagnosed then they already qualify for in home nurse care which is covered..

What if they are not? Does An ED help a 5 year old with a temperature of 38.1? Is it cost effective? Does the trauma of the many tests outweigh the benefits? Because the parent is afraid and didn't know what if anything to give their first kid, didn't know what to do is it not an emergency to them? Who do they call? Could this be evaluated by a nurse, treated, and refered to follow up with a peds doc instead of the ED?

There are already private companies for in home RN visits set up for this. Many nursing homes and hospice care facilities have a list of staff that they can send for this service. What do they need my ambulance for then?

THe point is nobody may need your ambulance, because what they get doesn't match their needs, for what they are expected to pay.

The IDEA behind 911 is that it is suppose to be used for an emergency. Is it always an emergency?

Emergency is a truly subjective term. Ask a 15 y/o female if her months of missed menses is an emergency. Ask a 70 year old who cannot get to dialysis because of the snow if it is an emergency. Ask a mother if the blood coming from their kids head is an emergency?

What about the 45 year old man who denies he is having a heart attack because he is too young, or just doesn't want to admit the possibility and doesn't think that he has an emergency?

Emergency is defined by the consumer, not by the provider.

If they are just asking for a ride to the doctors office or they stubbed their big toe they may get 'no ride' written. this is where the private ambulances pick up that slack. Again do they need to go to the ER? No. But they will.

You don't see that as a failure and a waste?

It may come as a surprise to some, but all doctors are not equal. All facilities are not equal because there is a doctor there. The ED costs a lot and may not be able to help the person. What exactly is the point of that? It is like going to a fast food place when your car needs repaired.

I dont see the benefit to bogging down a crew that has a RN staffed so they can treat someone who already knows they need treatment at such and such time.

KNowing a person needs treatment and getting to it are completely different animals. By having a more educated person on a unit, you can reduce transports, give patients what they need, instead of what is convienent for the provider, lower the costs, and improve the outcomes.

Basically you reduce the inefficent waste EMS has become.

For emergency purposes the RN idea doesnt work as far as I see it. As far as bogging down ERs with pts that is why the CDC has a triage system in place and there are hospitals with different trauma levels. If you live in the sticks you may only have one choice besides air lift.

There are not enough characters in the post for me to address this, but I see a serious deficency of knowledge from this post.

Education wise I hope to see alot of change. I would like to see an LP with some much greater difference in skill set and education than what it has now. A LP has as much teeth as a newborn right now. I think education is the big elephant that need some attention right now. You cant force ever Paramedic to retake a higher level of training to maintain their paramedic but you can increase the quality of education in CE programs and initial Paramedic courses and effectively elevate the quality of a certified Paramedic and some of those old school paramedics. Granted this has to be done gradually but I think it is the most effect way of approaching the EMS system. Yeah you will still have people who shock Asystole but over time they should either educate them self or be forced out of the profession.

There hasn't been an effective change for EMS education in at least 22 years. You can wish all you want, but until you can enact change by provider will or force, you will have people who not only perform poor patient care directly, but whose knowledge of the system and patients needs lead to poor patient care indirectly by serving the providers instead of the patients.

 

[CowboyMedic]

Because of the hyperspecialization of sociological roles as well as the lack of adequete education among a majority of US citizens, there is a definate need for healthcare providers who reach out to the community for the purposes of taking care of minor problems that do not need a healthcare facility, refering patients to the appropriate source of care when they need something other than the ED, prevention of illness, and health maintenence.

There is a definitive need for referring pts to other facilities and yes it does generally fall on the ED. For illness prevention and health maintenance you are right to chalk that up to poor education. But who is going to pay for that? When I was putting a pulse oximeter on a pt and explaining to him what it was for one time his girlfriend replied see thats what I told you it was for in which the pt quickly replied man you should have became a doctor. Good luck educating and tackling that beast.:unsure:

THe point is nobody may need your ambulance, because what they get doesn't match their needs, for what they are expected to pay.

So more along the lines of EMS shows up on scene and decides this is a no ride situation and isnt really constituted as an emergency and decides to call the RN unit to follow up and educate the individual provide any minor care needed and referrals. I can go with that aslong as paramedics are first on scene and decide if it is an emergency or not. If you can get that into legislature and have insurance pay for it I would definately be on board for that. I can also see that being an additional source of income for FDs that use EMS to float their budget.

Emergency is defined by the consumer, not by the provider.

This quote kinda contradicts the entire purpose of using RNs to refer persons to other facilities because it is not judged as an emergency.

You don't see that as a failure and a waste?

Yes I do. That is why I wrote it. Im not on one side of the fence or another really. But that waste is my job right now.

There hasn't been an effective change for EMS education in at least 22 years. You can wish all you want, but until you can enact change by provider will or force, you will have people who not only perform poor patient care directly, but whose knowledge of the system and patients needs lead to poor patient care indirectly by serving the providers instead of the patients.

I disagree the educate and knowledge of EMS has changed drastically. Just look at the evolution of equipment and tools over the years. Our understanding of the human body and the changes in CPR procedures. We are constantly getting better and finding ways of being more efficient at our jobs. It just takes time. Granted you are going to have people who perform poorly in any industry. In EMS that is generally in my opinion due to the patch factories that pass students who do not posses the skills or aptitude to be an EMT/Paramedic so therefore again we come full circle back to education.

More on my thoughts about this:
http://emtmedicalstudent.wordpress.com/2010/11/09/ems-and-diagnosis/

Very good read and very well written. Differential was the word I was looking for. Thank you.

 

[CodyHolt83]

Interesting topic! Is this a reality in the future?

 

[TraumaJunkie81004]

We already have that autonomy in ICU. Our protocols and guidelines function very much like standing orders. Open heart starts flagging and pacer wires are still in place. you can bet your hiney i'm going to start that pacer before I make the phone call. Isn't that close to what the situation in California is? Critical Care nurses giving orders to medics over dispatch?


Vene i think this idea is outstanding. Seriously you killed two birds with one stone on that one. It has long been a notion I have endorsed that all RNs get at least an EMT-B.

Linuss (i'm not trying to call you out and be a ****) part of the proof is patch factory medics. For being one of the strongest advocates for education and autonomy of Medics, i can't see why you haven't gone back to school. For arguing so much of the equality of the two professions, wouldn't you agree you need more school to be the equivalent that you defend?

Patch factory medics?! I disagree whole-heartedly. There are reasons why ALL EMS PERSONNEL MUST pass National testing and maintain those standards along with incorporated CMEs. If I had my way all health care professionals would have at least basic level EMT training.

 

[Journey]

I disagree the educate and knowledge of EMS has changed drastically. Just look at the evolution of equipment and tools over the years. Our understanding of the human body and the changes in CPR procedures. We are constantly getting better and finding ways of being more efficient at our jobs. It just takes time. Granted you are going to have people who perform poorly in any industry. In EMS that is generally in my opinion due to the patch factories that pass students who do not posses the skills or aptitude to be an EMT/Paramedic so therefore again we come full circle back to education.

The Paramedic course in many states still does not require any more anatomy, physiology, pharmacology or hours of training than it did over 30 years ago. It is the ones who have taken these extra courses at the college level that might see or recognize changes but for their own knowledge and not necessarily in their EMS protocols which is the frustrating part for them. CPR procedures are also taught to the layperson and they are now simple enough for almost all to understand and perform. 12 Lead ECGs have been available to EMS for almost 30 years but according to the AHA, only half of the ALS EMS trucks have them and those that do may rely on machine interpretation. The same for ETCO2 which is also not on many trucks now. CPAP is another example of it being not available to that many EMS systems and neither is the IO. Evidence based medicine is still not prominent when it comes to EMS. Some in EMS also don't care about the EBM and may see it as if they are being penalized if a medication or skill is removed from their truck rather than if it was best for the patient.

It is true there have been many, many changes in medicine but just how many of those are EMS providers aware of and are constantly changing to would be a more appropriate question. In some ICUs, changes are occuring at least weekly. New protocols and policies are constantly being written for the many new meds, technology and procedures being introduced. There are countless more in Europe and Canada that have yet to hit the U.S. which are being anticipated for the moment someone gains approval to start their own research with or they are officially approved by the FDA. It is also very easy for an RN who works only on a nonhospital based Flight team to get behind on the latest advancements in just a short time. The RN may have to also work in the ICUs to stay current on all the latest meds, equipment and protocols. Sepsis, burns, trauma and ARDS protocols are just a few examples. To effectively continue care from one hospital to the next, they must know what, how and why the patient is being treated as they are and should not just be trying to match numbers on the machines and pumps to get from point A to pont B.

You also can not just blame the patch factories if the state standards are low. Texas requires only about 600 hours to become a Paramedic and there are no prerequisistes mentioned. So of course so, even the better colleges or universities might take advantage of that and produce grads with a 3 - 4month program especially if they are also catering to the local FDs and ambulances. If the need perceived by those in the industry to extend the education is not there and certificate with the minimum hours is enough, then chances are that is what will be provided. Any other education will be optional.

There is a definitive need for referring pts to other facilities and yes it does generally fall on the ED. For illness prevention and health maintenance you are right to chalk that up to poor education. When I was putting a pulse oximeter on a pt and explaining to him what it was for one time his girlfriend replied see thats what I told you it was for in which the pt quickly replied man you should have became a doctor. Good luck educating and tackling that beast.

I don't get the point you are making here. If you mean educating the layperson about pulse oximetry, RNs and LPNs do that everyday in the hospitals, clinics and home care. That same patient who thinks you are a doctor can learn the skill of pulse oximetry well enough to monitor her own child at home if necessary. Also, pulse oximetry can be well reimbursed for different situations. Many, many patients, regardless of their education, have been taught to manage their diabetes, COPD, asthma, consequences of cancer such as a colostomy, a tracheostomy or a laryngectomy, home oxygen and even ventilators.

So more along the lines of EMS shows up on scene and decides this is a no ride situation and isnt really constituted as an emergency and decides to call the RN unit to follow up and educate the individual provide any minor care needed and referrals. I can go with that aslong as paramedics are first on scene and decide if it is an emergency or not.

Actually there should not be a need for EMS to show up. Some cities now have nurses in their dispatch centers who could send the most appropriate and this would be ideal for areas with high call volumes. Paramedics at this time are also not educated, trained or have the appropriate experience to recognize the many needs of a patient that are not immediately emergent but can be if not dealt with so actually an RN doing the initial determination might be the more approrpriate. If it is an emergency, that can be handled also.

Patient education is also not something a Paramedic is well versed or experienced in when it comes to the long term. If you use the pulse oximetry which you gave as an example, you can not always talk like a doctor when explaining a procedure for the layperson to comprehend. There was recently a post somewhere on this forum where someone was trying, unsuccessfully, to convince a person they needed to go to the hospital by saying the patient was having an MI and their heart was ischemic. It may sound nice to impress the girlfriend but doesn't give an adequate explanation of what is happening.

 

[8jimi8]

As for a Degree, it needs to be a proper speciality University degree not some two year flout that includes basked weaving, computers 101 and art history as well as the DOT cirricula which has been massaged into a barely qualifying community college course.

My associates degree required no electives. There is something to be said about taking a focused curriculae versus a 130 hour $50,000 dollar degree. (My RN cost $5,000. With my psych degree I never earned more than 28,500/yr which was nearly doubled by my ASN) My degree plan over 2 years was 50 clinical hours less than the 4 year University plan. The clinical competence of ASNs is evidenced by their preferential marketability here in Austin. Hospitas hire from the Community college grads preferentially because the ACC grads are more prepared to begin working out of school.

This harkens back to specialty versus general education.

Personally, I will complete my BSN and go on for a masters. because while the associates allowed me entry into the profession, I'm not stopping at the entry level. If you want paramedics doing community healthcare, they will need a masters to be competent. Maybe that will be your "community health fly-car"

 

[uhbt420]

i would really love to continue this discussion but

a) increasing medic education should be our focus, not putting nurses on ambulances, and

b) you are ventmedic