Replacing EMS with nursing revisited

[TraumaJunkie81004]

If nurses wanted to ride on an ambulance, they would have gone to paramedic school.

It won't work because I have a feeling the majority of them will not want to do it.

I am an advocate of nurses in the pre hospital setting, I have worked pre hospital with nurses before and continue to do so. I have nothing but respect for them and their knowledge, and I feel they respect me and my knowledge (granted I don't fall into the category of most average paramedics.)

In my opinion, the transition of paramedics to nursing (with the appropriate training) seems to be more successful than nurses transitioning to the paramedic role. Keep in mind, I am not just talking about the actual attainment of the certification, but also the practical application of the skills and abilities required for the position.

The thing that makes most nurses successful when they enter flight medicine of critical care transport is many years of experience and gradual increase in education beyond initial certification (the sa,e things that make a medic successful also.)

Taking all of this into consideration, putting GNs in the field is a bad idea. No experience, probable lack of desire, and lastly a real lack of relevant experience for the GNs who want to enter the clinical setting (except for ER and possibly ICU, which is a portion of the overall nursing workforce.)

Remember, we always talk about skills do not equal education. The opposite is also true, education does not equal skills.

I agree with all you said above. I strongly agree that all of levels of EMS provider need more education. I know I'm opening myself up to massive quantities of flack, but I think the the EMT-B level should either be eliminated or be changed. EMT-B's should have at least I-85 training and, continuing on, Intermediates should be trained closer to Paramedics. Paramedics training should be expanded/broadened. I have functioned as a B and as an I on an ambulance, in a construction setting, and in a casino. I cannot begin to tell you how frustrated I was at both levels. I felt lacking in skills and felt there had to be more I could have done to help my patients. I also have Paramedic friends who have experienced the same level of frustration. Guess the bottom line for me: I'm all for more training. I take what I can when it's available. I don't think that employing nurses in an ambulance setting, unless it's on a NICU/CCU designated rig, is the right move. Doctors/scientists, etc. are always coming up with new technology to be used in the field. Other than that I feel EMS has stagnated.

 

[Journey]

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.

There are still states with their own Paramedic and EMT exams.

CMEs are easy to obtain online and in your own living room. Refresher courses can be what you make of them good or bad and depends on how well they are done by the instructor.

Maintaining standards generally correlates to the medical oversight and what you have in place to monitor quality.

It is also not to difficult to teach one just to pass a test and unfortunately is being done rather than providing an education to go along with the memorization.

I encourage everyone, including those planning a family, to get first aid training that may even exceed what is taught in the EMT class depending on their situation. Many who have no interest in becoming an EMT can get as maybe more hours of training at the ARC. This can also include water safety and classes pertaining just to kids. Gun enthusiasts, hikers and rock climbers can also have first aid taught through their organizations to address their situations and some of these courses can be very extensive. Factory and construction workers, teachers and coal miners may all get a significant amount of training in first aid during their education or job skill set. So it doesn't have to be just health care professionals.

First aid as you know it in EMT class is not taught to those in the hospitals because there are other alternatives available. But, that does not mean they do not know how to control bleeding, recognize anaphylaxis or difficulty breathing and apply oxygen, identify diabetic emergencies, perform CPR, listen to breath (and heart) sounds, determine level of consciousness, log roll and do many different types of splints for immobilization. It is a different environment, a different focus and different tools that coincide with availablility and the situation. The EMT class taught just for the equipment and protocols used on an ambulance by an EMT-B may not be appropriate for inside the hospital.

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"

That is no understatement and that is provided the Paramedic had extensive clinical hours inside a hospital and LTC facilities to gain some experience.

Public Health and School RNs are recommended to have at least a Bachelors and many of them have a strong background in the ED for experience.

 

[TraumaJunkie81004]

There are still states with their own Paramedic and EMT exams.

CMEs are easy to obtain online and in your own living room. Refresher courses can be what you make of them good or bad and depends on how well they are done by the instructor.

Maintaining standards generally correlates to the medical oversight and what you have in place to monitor quality.

It is also not to difficult to teach one just to pass a test and unfortunately is being done rather than providing an education to go along with the memorization.

I encourage everyone, including those planning a family, to get first aid training that may even exceed what is taught in the EMT class depending on their situation. Many who have no interest in becoming an EMT can get as maybe more hours of training at the ARC. This can also include water safety and classes pertaining just to kids. Gun enthusiasts, hikers and rock climbers can also have first aid taught through their organizations to address their situations and some of these courses can be very extensive. Factory and construction workers, teachers and coal miners may all get a significant amount of training in first aid during their education or job skill set. So it doesn't have to be just health care professionals.

First aid as you know it in EMT class is not taught to those in the hospitals because there are other alternatives available. But, that does not mean they do not know how to control bleeding, recognize anaphylaxis or difficulty breathing and apply oxygen, identify diabetic emergencies, perform CPR, listen to breath (and heart) sounds, determine level of consciousness, log roll and do many different types of splints for immobilization. It is a different environment, a different focus and different tools that coincide with availablility and the situation. The EMT class taught just for the equipment and protocols used on an ambulance by an EMT-B may not be appropriate for inside the hospital.

Journey: thanks for the insight. I guess I'm just a blind-hearted fool. I believe that all education is what you make of it. You can memorize just to take a test and become a EMT (and believe me I've met plenty of those people who work in a confined setting like a casino), but I choose to believe that most of us took the education to heart and got into EMS to help others. All I can do is continue to further my education and pray that EMS evolves to the point where those who just want the pay (ha ha) drop out. I would really like to see EMS become a place where all responders were focused on the patient and not grousing because they just heard a call on the radio about an overturned vehicle or structure fire - because in their world EMS is a distraction not an attraction. PLEASE NOTE: I AM NOT SAYING ALL FIREFIGHTERS ARE LIKE THIS. THIS IS BASED SOLELY ON MY INTERACTIONS WITH THE COUNTY FIRE DEPARTMENT IN LAS VEGAS, NEVADA.

 

[Journey]

My comments were not toward any particular group either. The scandals in Massachusetts and New Hampshire didn't pertain to just one group. Hopefully that is not the norm but I would bet there are other in different states who have gotten away with something similar. This could also include other professions but I would not want to piss off the BON and risk losing several years of hard work. But, the years of education part can not be taken away and could be applied to another career.

 

[Veneficus]

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:

That is precisely why you need a nurse. They actually are responsible for patient education.

As for who pays for it, it is already being payed for. An an extremely inflated cost. Anyone who seeks help must be seen in the ED. Tests must be run, ultimately some federal agency will pay part of the bill or it will be eaten by the hospital. By removing the need to take everyone to the ED, the cost that is already being paid is reduced.

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.:

If you are not aware, only the most common life threatening situations are taught in paramedic class. It doesn't include 1/2 of them. So having an EMS vehicle show up and rule things out is not only an unneeded redundancy, it can miss a considerable amount. Have you ever seen a kid with Kwashiorkor? How serious is that? In today's economic climes and within certain populations of the US, it is quite possible you may run across it. Would you know it if you saw it? Do you think it is an emergency?

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

Not in the least. Kid has a fever, calls 911, nurse is sent, decides it is not an emergency, gives antipyretic educates family on what to do, how to tell if kid is getting worse or better, creates followup. Emergency abated. Parents thought it was an emergency and their needs were met.

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..

The reason it is important to branch out in value is so the job is there tomorrow, next year, and next decade. US EMS as a whole does not see the value in this.

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...

You are comparing EMS basic education to tweaking a few procedures and adding some gadgets? So what do you do when those gadgets are not available and you still have to treat patients, perhaps without the benefit of transport?

EMS claims to be useful in a disaster, but in the US, once you take away rapid transport, EMS falls on its *** in a big way.

 

[Veneficus]

i would really love to continue this discussion but

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

In the interest of what is best for the patients and the public, since EMS has failed to increase its education or update its functions to the demands of today, finding a suitable alternative is a legitimate discourse.

It is about finding a solution to the needs. If EMS was making progress, or even effort, nobody would bother discussing it. But I am not the only one and this is not the only place this topic has been raised.

 

[vquintessence]

The horse is long since dead; the cadaver is beyond tender, yet the wolves continue to bark and fight amongst one another.

 

[Journey]

The horse is long since dead; the cadaver is beyond tender, yet the wolves continue to bark and fight amongst one another.

True. There is probably not enough interest in improving EMS beyond what it is now so it is basically a dead horse. The two representatitves that have introduced a bill into the House are just wasting their time.

Other professions wouldn't have achieved what they have if they hadn't kept the interest alive and not calling advancement a dead horse. Some people just don't want to hear times are chaniging.

Some good ideas can come out of even an open EMT forum on the internet.

 

[PenguiNet]

Not in the least. Kid has a fever, calls 911, nurse is sent, decides it is not an emergency, gives antipyretic educates family on what to do, how to tell if kid is getting worse or better, creates followup. Emergency abated. Parents thought it was an emergency and their needs were met.

a nurse has absolutely no authority or training to undertake a field-based, provider-initiated refusal. you would need at LEAST a NP or PA for that. you are forgetting that we live in a litigious society. there is not a snowflake's chance in hell that a county EMS agency/fire department/private provider/etc would accept the liability for someone who is just a RN to, in essence, deny transport without online MD control. guess what? paramedics already have that.

and kwashiorkor? you are really grasping at straws here. what is the definitive treatment for severe malnutrition? something a nurse can fix in the field? what's that? that's precisely what i thought. i'm sure we'll all be stocking NG tubes and cans of Ensure just to prepare for this sort of contingency lol.

admittedly, if i lived in some sort of EMS hell like you seem to...where silly, dumb, uneducated paramedics have NO IDEA that someone with kwashiorkor is "big sick", then of course i would push for someone with just a RN license to jump on the box and take over...RNs who magically went to medical school and have the training, expertise, and level of care of a MD to initiate transport denials masquerading as patient education.

you have simply not sufficiently qualified what it is that a RN can do in the field that a paramedic can't. what kinds of medications can they push that paramedics can't? i've never encountered a scenario where i opened up my medication bag and said to myself, "well, :censored::censored::censored::censored:...i sure wish i had <blank>".

i posit that an EMS service with at least a modicum of progressive attitude has all the tools necessary to meet the demands of their constituency. adding a RN simply does not increase the standard of care in the field in any appreciable way.

 

[Chimpie]

Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).

Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?

 

[SerumK]

Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).

Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?

Arguably both?
1. The RN can provide expanded and more appropriate treatment due to increased educational depth.
2. The RN can be made to fit the roll of the mythical "Community Paramedic" idea that cannot come to pass because of the lack of educational breadth in US Paramedicine.

 

[Veneficus]

Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).

Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?

yes to the better care.

Not primarily to reduce ED traffic, but that would be a side effect. The goal is to give patients an avenue of nonacute care and that directs them to the appropriate resource, medical or social to handle their problems that cannot be adequetly addressed by the ED.

It also adds a prevention component that can reduce the frequency of 911 calls because patient education is a primary function of nursing.

I think the future of EMS is less responding to "emergencies" and offering transport to an often ineffective and expensive ED, and more as a provider that is part of the community rather than secluded from it.

 

[uhbt420]

well here's my reasoning behind promoting medic education as opposed to transitioning to nursing.

to be a nurse, one obtains a four-year degree. the advantages of this compared to a 2,000 hour medic course are numerous-- more experience, more education, etc. however, an rn does not necessarily have a higher scope of practice in the context of emergencies. for example, nurses can't cric AFAIK.

so here we have our RN's who would like to work on ambulances. now they need an EMT-B course for first aid and operating in a prehospital setting, and afterwards a paramedic skills seminar to peform advanced treatments like crics.

would it not be simpler to build a 4-year medic degree? no emt courses, no skill seminars, and the same body of knowledge that a BSN would have, though more in the context of emergencies.

am i making sense?

ninja edit: i am in no way opposed to education. i'm hoping for an AAS in paramedic one day, maybe even working my way towards a BSN.

 

[usalsfyre]

to be a nurse, one obtains a four-year degree. the advantages of this compared to a 2,000 hour medic course are numerous-- more experience, more education, etc. however, an rn does not necessarily have a higher scope of practice in the context of emergencies. for example, nurses can't cric AFAIK.

so here we have our RN's who would like to work on ambulances. now they need an EMT-B course for first aid and operating in a prehospital setting, and afterwards a paramedic skills seminar to peform advanced treatments like crics.

Why do people keep focusing on monkey skills? I'm fairly certain I could teach anyone who's able to identify the landmarks how to perform a cric.

would it not be simpler to build a 4-year medic degree?

Honestly no, the procedures needed to operate in the prehospital environment could be taught is about a month, far, far better than many medic schools teach them.

Veneficus, as much as I hate to admit this, maybe your right...

 

[uhbt420]

Why do people keep focusing on monkey skills? I'm fairly certain I could teach anyone who's able to identify the landmarks how to perform a cric.

crics, starting IVs, EKG interpretation, etc are actually not monkey skills, but its nice to see you sticking up for your profession

 

[usalsfyre]

crics, starting IVs, EKG interpretation, etc are actually not monkey skills, but its nice to see you sticking up for your profession

Horsesh!t. Crics, IV's, ect ARE nothing but monkey skills. I can teach nearly anyone ANY of these skills. I can teach anyone where to put the leads and to read off "ACUTE MI SUSPECTED" an an EKG. Intubation is taught in 4 hours in many EMT-I classes, IV's are taught to non-medical military personnel daily. I can actually teach most folks to go through the motions of a very through assessment as well. If this is what you equate paramedicine with, than YOUR part of the problem.

Knowing when to use these things and how to correlate them clinically is where the value lies. Do you think medical school spends four years on how to start central lines? Management of a presenting medical condition relies on recognition and understanding.

I stick up for my profession on a regular basis, to see it urinated on by people who value "cool skills" over the inate knowledge needed to back those "cool skills" up. I like to think of myself as a paramedic because of the knowledge contained above my shoulders and the proper way to apply it. I also work very, very hard to retain and increase that knowledge, to the point I consider what myself and many of my coworkers do to be far closer to what a mid-level does than what many ED nurses do. If you think because you can do a cric your special, I suggest you look at military medicine. Medics in the sandbox are doing them frequently, with only an EMT-B card. When you define yourself by a unique knowledge set, and not "skills" then you can puff your chest out at me about "standing up for your profession".

 

[Shishkabob]

This thread is silly / pointless.



Just laying that out there.

 

[usalsfyre]

This thread is silly / pointless.



Just laying that out there.

Agree, completely. We're just mentally pleasuring ourselves at this point. :unsure:

 

[Shishkabob]

Agree, completely. We're just mentally pleasuring ourselves at this point. :unsure:

The thing is, the BIGGEST complaint that this thread raises is a Paramedic's apparent inability to understand anything medical outside of emergency medicine. (Which is a stupid fallacy in and of itself)


Truthfully, this isn't a problem of EMS and any supposed lack of education, but of the civilian population who utilize 911 for non-emergencies and primary healthcare. If EMS / 911 were utilized only for true emergencies, I'd venture to guess this thread would not exist aside from people WANTING us to get in to community Paramedicine.


And don't bring up that "The patient defines the emergency, not us" crap. No. A stubbed toe is not an emergency.

 

[Journey]

Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?

I am surprised someone from Florida would as this. Florida has for decades be a leading in Community and Public health programs which include RNs. They also play a significant role in disaster preparedness and management since there is no way EMS could ever cover all the bases for the many health care and shelter needs in the community which includes medical patients and the homeless. If these RNs did not go out into the community at senior citizen centers and homeless shelters, which includes under the bridges, to identify and get these people the necessary care, there is no way even the best EMS systems in the area could handle all the calls.

Community and Public Health RNs, Social Workers and Case Managers (also could be RNs) have played a role in preventitive community medicine for investigating situations and providing them with the needed services which may involve calling the physicians associated with their agency for advise. There is absolutely nothing wrong with calling "med control". A few hours of training or even 2 or 4 years do not make anyone a doctor. This thing where Paramedics in the U.S. feel like it is bad to call a doctor just shows how little some might know about the many illnesses there are and may not realize their limitations. These Community and Public Health RNs are involved in so many projects around the country which also includes child and elder abuse as well as identifying and caring for medical problems of the homeless under the bridge. Many times they are called to investigate a person whose neighbor has seen EMS at the home many times but each time a "refusal form" is signed and EMS has cleared because the patient was okay since they know their name and place or didn't have any obvious trauma or illness. Unfortunately just knowing your name and where you are does not mean you can't be in need of some medical care or a different living situation. But, for many in EMS, "not my job to be a social worker, I just do the emergencies" is often the response. Is this just the lack of training or is it just "not my job" that prevents them from expanding their sight into preventitive care?

In San Francisco there is a Paramedic, Niels Tangherlini, who started an outreach program for frequent 911 users including the poor, homeless, mentally ill, elderly, disabled, and alcoholics and drug abusers. Prior to starting this program he got a degree from UC Berkeley in Social Welfare and formed an alliance with the Department of Public Health. He also enlisted the assistance of RNs and RRT as well as many others involved in the health care systems to cover the medical needs he did not have expertise in. I would say Mr. Tangherlini had the foresight to know the limits of his Paramedic training and the limitations of the EMS system to see the bigger picture to provide the needed services.