Replacing EMS with nursing revisited

[rook901]

Like I said in the last post on the previous page, the solution is not as simple as cutting out any one provider all together and replacing them with someone who has more education...we are in too deep for that.

If you read my initial response a few pages back, I'm on board with that same opinion. Handing EMS over to nursing is too cost-prohibitive and too dangerous (in regards to putting new RN's on the bus, as was suggested by the OP).

On top of that, you're putting all the current EMT's and medics out of a job if they're unwilling to go through a nursing program. One of the OP's points was that new nurses are having a hard time finding jobs, so we could just automagically put them in EMS positions and give them jobs. What does the medic with 20 years on the job do when he can't ride the bus and there aren't enough ED tech jobs to go around?

Handing EMS over to nursing just isn't the answer.

 

[Aidey]

I really have nothing but love for my RN colleagues, however, the BNE exerts a HUGE amount of leverage over what is considered safe and unsafe in regards to patient care, and most of what is considered unsafe has quite a bit to do with how no other profession can do certain tasks better than nurses.

An observation on that, I have noticed that there are problems with that within nursing. I've most commonly seen it as ED RNs vs the rest of the hospital RNs. Two examples I have personally witnessed are where IVs are started, and restarting ED IVs.

I know a couple of ED RNs that have been written up by non-ED RNs because they started IVs in "unauthorized" places. I know a lot of hospitals usually have policies on restarting field IVs within a certain amount of time. I know at least 2 hospitals here also restart ED IVs within the same 24 hour time frame as they restart field IVs.

I will probably catch crap for saying this, but it seems like RNs who work in more controlled environments tend to get more set on the rules than RNs who don't.

It has been demonstrated by some places like Seattle, Outside of DC (forgot the dept name) and even Oregon that the fire service has the capability to do EMS well. Unfortunately a majority of fire service EMS has chosen not to emulate them. I could advocate for such a universal system.

Say what? I'm not trying to be argumentative, but Seattle isn't as awesome as it seems from outside the system. Yes, the Medic One program is probably one of the most advanced Paramedic programs in the country, but that doesn't mean it is immune from the crap that FDs try and pull.

Common occurrence in the Seattle area; a BLS private transport agency responds along with the FD. The FD medic assesses the patient, starts an IV, pushes meds, discontinues the the IV and sends the patient to the hospital with the BLS ambulance (and not just locks the IV, takes it out completely). This happens with everything from pain meds to allergic reactions. I work with someone who used to work in Seattle, and the system allows the FD medics to cherry pick calls, and pawn off everything else to the BLS private agencies. She has some scary stories about complications that have come up after the FD takes off.

 

[WTEngel]

I consider myself "rubbed". As an EMT, I won't even think about asking to run a true code, or handle any patient best served by the skills and knowledge of a paramedic, but EMTs have their place in the back of an ambulance as a primary provider. Many many patients transported by EMS in the US need little more than a taxi ride to the hospital, and this gives the EMT the ability to practice assessment skills that they may use further down the line in their education as a paramedic, nurse, pa, or md. Remembering that I work in a system where all trucks have a medic, what is the harm in letting me take care of the kid with the broken arm, or even the woman having a panic attack? Who knows, at some point I may find myself alone providing care for a real medical emergency, and at that point, the last thing that needs to be going through my head is, "where is the medic". Although I agree that EMT-B should be considered an ephemeral position, a skin to be shed when one attains a higher level of training in the medical field, it is doing a disservice to EMTs to suggest that they cannot be primary providers. If all I am going to do is drive, my 180 hour class and 3+ months I will spend as a third rider to teach me proper assessment and treatment are totally wasted. They should just drop the EMT class down to 10 hours, teach you all the monkey skills, and then put you through a driving course.

Also, nurses are still awesome, but have a totally different role from paramedics. Though both operate under standing and written orders, the nurses training can't be simply patched with a 2 month course to make them a paramedic, nor can the medic's training be easily patched to make them a nurse. There is a huge difference between operating under standing orders when the doctor is 10ft away and 10 miles away. You are trying to climb a huge hill here. Most nurses sign up to be nurses, which means that they wanted to take care of people, both physically and mentally, but what they aren't signing up for is diagnosing and treating emergent patients. This is what medics sign up for. Arguing that they can easily take each other's place is like arguing that a duck could replace a swan. Its just silly.

On a practical note, I think it is possible to train nurses for EMS, but I think it would require a year of specialty emergency training, and selection for nurses that honestly desired to work in EMS. This is the heart of the issue. Every medic wanted to work in EMS, but few nurses do, or they would be paramedics.

I understand why you are rubbed and I would have been rubbed also earlier in my career (I am not accusing you of being early in your career, I am simply pointing out that at the beginning of my career is when I would have been rubbed by such a comment.)

In order to increase the professionalism of EMS, BLS roles in the field need to be limited to non transporting roles. As long as there are provisions for BLS providers to transport patients, employers will find creative ways to justify the use of BLS providers in as many transports as possible as a cost saving measure. I am not saying that BLS providers can not be competent caregivers, I have met many a good basic in my days, and I will admit that i have had a good basic save me a time or two early on in my career. What I am saying is that if people are truly passionate about EMS as a profession, then they need to bite the bullet and go all in.

Do you think that ADNs and BSNs both being considered RNs is a coincidence? Absolutely not. The ANA and other associations supporting nursing understand that if there is a difference in skill set, there will always be a push by employers to hire the least expensive provider who can provide the bare minimum skills necessary. With EMS recognizing three and in some places four or more different levels of provider able to transport patients, we are allowing employers to come up with creative ways to decrease pay rates for all certification levels!

 

[JPINFV]

If you read my initial response a few pages back, I'm on board with that same opinion. Handing EMS over to nursing is too cost-prohibitive and too dangerous (in regards to putting new RN's on the bus, as was suggested by the OP).

Too dangerous? Really? Compared to a new paramedic? Any service that takes a fresh from school paramedic, EMT, or RN and just hands them the keys and drug box with a, "Have at it," is putting the public at risk.

Cost-prohibitive? Sure, if all EMS is is a ride to the hospital.

On top of that, you're putting all the current EMT's and medics out of a job if they're unwilling to go through a nursing program.

Can't that be said about any increase in education requirements?

Handing EMS over to nursing just isn't the answer.

While I agree with the statement, I disagree with the reasoning. It takes time to train a generalist to practice in any specialty, regardless of what the generalist is. A generalist that specializes is not necessarily better or worse at providing a specific service than a pure specialist, but the mobility of the pure specialist is limited and, depending on the education and training requirements, it can be harder to expand services. The solution for EMS is not to hand it over to nurses, but for paramedics to up their proverbial game.

 

[Aidey]

Because there is very little wrong with what they are doing. It is EMS that can't seem to educate or advance itself.

Compare the standard requirements of those providers to that of EMS on a national scale.

Like I said, EMS has failed to keep up with the body of medical knowledge applicable to it. It has failed to develop value outside of transport. Many patients are not properly served by the ED, which in the US with less than a handful of exceptions is the only option for patients. (at a terrible waste of money) The services exemplifying the role of EMS in the future are not being emlulated. There has been a failure of standard in EMS. No matter what state (or country) you are from the requirements to take the NCLEX are standard. You can get a paramedic card in places and not take national registry. Ever.

You ever see a nurse patch factory? A rad tech patch factory? An RT patch factory?

I agree with most everything you said, but I see a problem with where you place the blame.

EMTs and Paramedics can advocate all they want for more education, expanded scope etc, but when it comes down to it the DOT and the individual medical directors control what happens.

Yes, it is a bit of a catch 22. Bad providers lead MDs to reduce the scope, leading to frustrated providers who feel they are nothing but taxi drivers. Since the MDs honestly have little to no control over keeping a person from practicing, they change the protocols for everyone because of the actions of one person.

An example of this is the situation in Florida. Don't agree with the MDs rules? Get a new MD. MD revokes sponsorship of a particular person because they keep screwing up? Find a new sponsor. Have a medic who gives a patient a 200mcg dose of Fentanyl all at once and then forgets that narcan exists? Change the protocol limiting everyone to .5mcg/kg doses.

Any meaningful change is going to necessitate re-educating the physicians who ultimately control the application of the system. I will always advocate for more education, but it isn't going to get us very far if things still get bottle necked at the MDs. This is also going to mean that something would have to be done about the unions that fight to keep bad providers in their jobs.

 

[rook901]

Too dangerous? Really? Compared to a new paramedic? Any service that takes a fresh from school paramedic, EMT, or RN and just hands them the keys and drug box with a, "Have at it," is putting the public at risk.

Yes, compared to a new paramedic, a new RN is more dangerous on the unit. The entire paramedic program is geared toward prehospital. Adding a 3 or 6-credit prehospital course to the RN program is not going to prepare the RN for prehospital. Orienting a new paramedic to prehospital operations is not going to be the same as orienting a new RN.

Cost-prohibitive? Sure, if all EMS is is a ride to the hospital.

What percentage of EMS calls would you say is NOT just a ride to the hospital? I work for a private company that has the contract for county EMS, which covers a broad range of settings, from strictly rural to very urban. Throughout our coverage area, I'd say roughly 5% of our calls require anything more than oxygen, reassurance, and a very expensive taxi ride.

To put you back on point, the cost-prohibitive aspect was in regards to the personnel cost of having two RN's on an ambulance versus having a medic and a basic, not the cost to the patient.

Can't that be said about any increase in education requirements?

No. If you increase education requirements within one hierarchy, anyone already in the hierarchy is going to be grandfathered in. Ex: There are FNP's and PA's out there who still only have a Bachelor's degree, even though a Master's is now required in most (if not all) states. However, if you change the requirements so that you have to belong to a totally new hierarchy, you're not going to get grandfathered in. Paramedics will not be grandfathered into nursing.

 

[JPINFV]

Yes, compared to a new paramedic, a new RN is more dangerous on the unit. The entire paramedic program is geared toward emergency. Adding a 3 or 6-credit EMS course to the RN program is not going to prepare the RN for prehospital. Orienting a new paramedic is not going to be the same as orienting a new RN.

True, a 3 or 6 hour EMS course isn't going to make an RN into a paramedic, but it should be a heck of a lot less time than to go from EMT to paramedic. So, what exactly is a RN missing then? The ability to do an assessment? The ability to start an IV? Or is it the "the doctor isn't right behind me in the ER" safety net that will arguable put the RN into a different mind set than a paramedic. Alternatively, is it the handful of interventions such as intubation? I'd argue that the actual skill itself isn't hard, especially if there's already a solid anatomical and physiological foundation to build off of. Everything else is just psychomotor.

What percentage of EMS calls would you say is NOT just a ride to the hospital? I work for a private company that has the contract for county EMS, which covers a broad range of settings, from strictly rural to very urban. Throughout our coverage area, I'd say roughly 5% of our calls require anything more than oxygen, reassurance, and a very expensive taxi ride.

How many of those could be handled as an outpatient on scene provided that the provider has an appropriate level of education, oversight, and authorization to do a quick on scene workup and refer?

How many of those can go to an alternative destination besides the ER?

Not all patients need a huge workup, and while arguable, EMS should be reserved for life threatening emergencies, reality is vastly different and I don't see it completely changing. You play the hand your dealt, not the hand you want, and sometimes the best way to play that hand is to treat and release on scene. However that's not appropriate when the top level of EMS provider is 1000 hours of training, if that.

No. If you increase education requirements within one hierarchy, anyone already in the hierarchy is going to be grandfathered in. Ex: There are FNP's and PA's out there who still only have a Bachelor's degree, even though a Master's is now required in most (if not all) states. However, if you change the requirements so that you have to belong to a totally new hierarchy, you're not going to get grandfathered in. Paramedics will not be grandfathered into nursing.

Strange. If I recall correctly with the current realignment from EMT-B/EMT-I85/EMT-I99/EMT-P to EMT/AEMT/paramedic, the rule is either take additional course work at recert time or drop to a lower level. That doesn't sound much like grandfathering people in to me. Additionally, I'd argue that there's a vast difference between going from patch mill to an actual education and going from one degree level to another in terms of changes in education.

 

[Aidey]

How many of those could be handled as an outpatient on scene provided that the provider has an appropriate level of education, oversight, and authorization to do a quick on scene workup and refer?

How many of those can go to an alternative destination besides the ER?

Not all patients need a huge workup, and while arguable, EMS should be reserved for life threatening emergencies, reality is vastly different and I don't see it completely changing. You play the hand your dealt, not the hand you want, and sometimes the best way to play that hand is to treat and release on scene. However that's not appropriate when the top level of EMS provider is 1000 hours of training, if that.

Out of curiosity, do you think anyone without the ability to prescribe medications will be able to significantly impact the number of non-transports by either treating on scene or redirecting to a more appropriate place than the ER?

I'm just thinking of the high number of people who demand to go, no matter what, and/or don't have other means of transport.

 

[rook901]

True, a 3 or 6 hour EMS course isn't going to make an RN into a paramedic, but it should be a heck of a lot less time than to go from EMT to paramedic. So, what exactly is a RN missing then? The ability to do an assessment? The ability to start an IV? Or is it the "the doctor isn't right behind me in the ER" safety net that will arguable put the RN into a different mind set than a paramedic. Alternatively, is it the handful of interventions such as intubation? I'd argue that the actual skill itself isn't hard, especially if there's already a solid anatomical and physiological foundation to build off of. Everything else is just psychomotor.

None of the above. The RN is lacking the specialty education that the paramedic gets for the entire length of his/her program. The larger majority of what the RN learns simply does not apply to prehospital scenarios. Yes, an RN can be trained to do prehospital. An RN has the prerequisite knowledge and will be teachable. But in the context of the OP's suggestions, taking a new RN, who has a general medical education (let's not get into nursing vs medical here) and giving them a little prehospital education does not prepare them as well as the paramedic who has spent a huge portion of their program riding the bus, spending time in the hospital doing intubations, getting their 50 patient contacts as team leader, etc. It's just not a realistic expectation to assume that a new RN with a little prehospital training is going to be as good as a new medic. Period. Now, give me an RN who's been working in critical care for a couple of years, can identify rhythms and do ACLS as easily as nuking a Hot Pocket, etc. and I can see giving them a brief prehospital course and putting them on the bus.

How many of those could be handled as an outpatient on scene provided that the provider has an appropriate level of education, oversight, and authorization to do a quick on scene workup and refer?

How many of those can go to an alternative destination besides the ER?

Not all patients need a huge workup, and while arguable, EMS should be reserved for life threatening emergencies, reality is vastly different and I don't see it completely changing. You play the hand your dealt, not the hand you want, and sometimes the best way to play that hand is to treat and release on scene. However that's not appropriate when the top level of EMS provider is 1000 hours of training, if that.

You're right. Many of these could be treat and release on scene, but they're not going to be. As I mentioned earlier, your truly sick patients need to go to the ED or at least an urgent care. Your folks who call 911 because they have had a toothache for two weeks and it's 2am and they can't get to sleep -- those folks are going to demand to go to the ED anyway, simply because they either don't have a car, don't want to drive, don't have a PCP or insurance, or they think that coming in by ambulance is going to get them seen faster. As I said, the number of people who will benefit from a community health model, with RN's riding the bus, is nominal at best.

Strange. If I recall correctly with the current realignment from EMT-B/EMT-I85/EMT-I99/EMT-P to EMT/AEMT/paramedic, the rule is either take additional course work at recert time or drop to a lower level. That doesn't sound much like grandfathering people in to me. Additionally, I'd argue that there's a vast difference between going from patch mill to an actual education and going from one degree level to another in terms of changes in education.

We're talking about a relatively brief bridge course vs several years of school. Apples and oranges, my friend.

 

[rook901]

Out of curiosity, do you think anyone without the ability to prescribe medications will be able to significantly impact the number of non-transports by either treating on scene or redirecting to a more appropriate place than the ER?

I'm just thinking of the high number of people who demand to go, no matter what, and/or don't have other means of transport.

^^^ +1 for this.

 

[JPINFV]

Out of curiosity, do you think anyone without the ability to prescribe medications will be able to significantly impact the number of non-transports by either treating on scene or redirecting to a more appropriate place than the ER?

I'm just thinking of the high number of people who demand to go, no matter what, and/or don't have other means of transport.

As long as we're talking hypothetical future directions, why would EMS providers always lack the ability to furnish prescriptions within a specific set of rules as laid down by their medical director?

 

[JPINFV]

You're right. Many of these could be treat and release on scene, but they're not going to be. As I mentioned earlier, your truly sick patients need to go to the ED or at least an urgent care. Your folks who call 911 because they have had a toothache for two weeks and it's 2am and they can't get to sleep -- those folks are going to demand to go to the ED anyway, simply because they either don't have a car, don't want to drive, don't have a PCP or insurance, or they think that coming in by ambulance is going to get them seen faster. As I said, the number of people who will benefit from a community health model, with RN's riding the bus, is nominal at best.

...but here's the problem with something like that. You see a tooth ache, and I see everything from a cavity or bad gingivitis to something that can be life threatening. The question is, and this is where education in total comes into play, when is a tooth ache just a tooth ache and when is it something more? However just going off of a chief complaint, the "what if" game can be played for eternity with DDxs placed anywhere on the non-emergent to emergent scale. However this is where a community health program can come into play. You don't have to have a RN or community health paramedic on every ambulance. If the complaint is, "It burns when I pee," then you can send the community health paramedic or RN, essentially doing a reverse triage. If, based on an assessment and including additional POC testing (for the 'burns when I pee' patient, you could do a urine dipstick), it's either something that can be successfully refereed and treated based off of a clinical diagnosis ("Here's a script for Bactrim, get it filled in the AM and make an appointment in three days with the clinic for follow up." Uncomplicated UTIs make a great example for this), then do it.

Additionally, who says every patient needs to be treated from now until forever? Yes, given the current standards, this all is a pipe dream. However why not change the current standards besides the fact that 'it's hard.'

 

[rook901]

...but here's the problem with something like that. You see a tooth ache, and I see everything from a cavity or bad gingivitis to something that can be life threatening. The question is, and this is where education in total comes into play, when is a tooth ache just a tooth ache and when is it something more? However just going off of a chief complaint, the "what if" game can be played for eternity with DDxs placed anywhere on the non-emergent to emergent scale. However this is where a community health program can come into play. You don't have to have a RN or community health paramedic on every ambulance. If the complaint is, "It burns when I pee," then you can send the community health paramedic or RN, essentially doing a reverse triage. If, based on an assessment and including additional POC testing (for the 'burns when I pee' patient, you could do a urine dipstick), it's either something that can be successfully refereed and treated based off of a clinical diagnosis ("Here's a script for Bactrim, get it filled in the AM and make an appointment in three days with the clinic for follow up." Uncomplicated UTIs make a great example for this), then do it.

Additionally, who says every patient needs to be treated from now until forever? Yes, given the current standards, this all is a pipe dream. However why not change the current standards besides the fact that 'it's hard.'

In all reality, for someone who's had a toothache for the past two weeks, the toothache is probably just a toothache. Unless there's an abscess, there probably isn't any emergent condition going on. But this person is going to demand to go to the ED, unless you're able to write and fill a script for Lortab and Amoxicillin in the field. (not saying they will get the script filled at the ED, but they will get some pain meds while there and probably some Rocephin to get them started)

On the subject of writing scripts in the field, it's not going to happen unless there's a Master's-prepared provider on the bus. An MD cannot authorize a medic or RN in the field to write a prescription, so the medic/RN will need to have prescriptive authority. In order for the state to give prescriptive authority, the state is likely going to require an education level on par with other providers that have prescriptive authority. In all cases, these are Master's level or above, so I doubt that the state would be willing to grant prescriptive authority to another class of provider with a lower education level.

So, now we're talking about putting Master's-prepared medics or RN's on the bus for this community health EMS model. This is even more unrealistic than having RN's take over EMS.

Granted, each state has the authority to determine who they give prescriptive authority to and what education requirements they want. Even still, the AMA and ANA will fight against giving prescriptive authority to a lesser-educated provider.

On top of that quagmire, we'll STILL have the people who just want you to take them to the ED no matter what. The field provider will not realistically be able to fill prescriptions on scene. So, it's 2AM, this person is in pain, we give them a nice piece of paper with some pretty writing and a fancy signature, and it's useless to them.

Yes, some people will take the script and go on with their life. This is going to be a minority. The majority will still either truly need to go to the ED or will demand it, and we end up being a Master's-prepared taxi driver anyway.

 

[Aidey]

As long as we're talking hypothetical future directions, why would EMS providers always lack the ability to furnish prescriptions within a specific set of rules as laid down by their medical director?

I don't think it would, look at the Oz model of EMS. Or even some unique US models.*

I was specifically referring to Vene's idea of replacing Paramedics with RNs, without making any major changes to the Paramedic of RN curriculum. As things are now, I don't know that an RN would make that much of a difference, even if they had a significantly expanded scope.

JP, what you describe is the only way in my head I could think of the system working. In which case, why use RNs as the person who responds? Why not use NPs and PAs since they are already set up to do exactly what would be needed? I'm just thinking of how this could be implemented now, rather than in 5-8 years.

As someone pointed out too, how would any of this work for uninsured patients? If they couldn't pay out of pocket, would they be refused the expanded services?


* I used to work remote medical, waaaaay remote. I had a fairly long list of meds I could give, including a few antibiotics and prednisone. I had urine dips, rapid strep tests etc, and could use the antibiotics accordingly. The protocol was that I had to call the doc within 24 hours of giving the antibiotics if I couldn't get a hold of them at the time. That wasn't even a firm rule, but if you didn't call you better have a good reason, like communications were down (which could/did happen).

 

[JPINFV]

I don't think it would, look at the Oz model of EMS. Or even some unique US models.*

I was specifically referring to Vene's idea of replacing Paramedics with RNs, without making any major changes to the Paramedic of RN curriculum. As things are now, I don't know that an RN would make that much of a difference, even if they had a significantly expanded scope.

JP, what you describe is the only way in my head I could think of the system working. In which case, why use RNs as the person who responds? Why not use NPs and PAs since they are already set up to do exactly what would be needed? I'm just thinking of how this could be implemented now, rather than in 5-8 years.

Using a current mid-level is definitely a valid concept, and truthfully, more so than trying to elevate another level to a mid-level type position.

As someone pointed out too, how would any of this work for uninsured patients? If they couldn't pay out of pocket, would they be refused the expanded services?

To an extent, maybe. The problem with the uninsured is that they're likely to be seen and treated (especially if it's communicable) in the ED anyways. So the big question is, since they're already accessing the emergency medical system at some point, is there a cheaper way of treating them if they're going to be treated anyways?

 

[Veneficus]

I go to bed for a few hours and look at this place

Pages of medic>nurse, nurse>medic with a handful of skills arguments.

Not exactly the intelligent debate I was looking for.

I did see some stuff about mindset or personality type that I found interesting.

The ever popular pay disparity was mentioned. But it was the usual short sighted "I am cheap labor, I want a pay raise and respect before I get an education or do anything else to earn it."

But here is a few points that I took away from it all.

Medics are extremely short sighted. What is probably the same ADD that draws them to the emergency field also stops them from any forward looking or thinking. How can anyone ever hope to build a profession or respect on that?

Many cannot see that econimics will be forcing the system to change in the very near future. They do not want to change, if they put their head in the sand, it will all get better.

But really, paramedics are not upward mobile. Or sideways mobile, or mobile at all. The hyperspecialized training (not to be confused with education) that even I have carried the banner for is not applicable to todays needs and knowledge. Most calls are not emergencies. Most of the training is for emergencies that never happen. Even a lot of the treatments are in question.

Responding with ever growing fleets to take people who don't need an ED to an ED is really not worth :censored::censored::censored::censored:. Policy makers are figuring that out too.

Medics cannot argue education so they instead resort to the old standby of "there I was saving the patient from untold suffering and death with my device and skills."

There is a philosophy at least in European medicine that a provider must first be a generalist before a specialist. I agree with this thinking, otherwise, you never know when you are in over your head. Sometimes you still don't.

From the nursing side, I saw a missed opportunity. I could argue that it is that sort of indecision that makes then unsuited to EMS except as an armchair QB. I only recall one post where a nursing representative said something to the effect of "this is why we are better."

So let me help. Nursing is portable. Within the profession you can specialize, you can increase your education and thereby practice capabilities. Medics simply can't. No matter what branch they go to it essentially becomes a "do over."

Also missing was one of the foundations of nursing. That everyday care leads to healthier lives. Healthier means less medical spending. Less suffering.

There was also the miss of coordination of care, something many US nurses I work with are proud of. They talk to the 3 different specialists not talking to each other. They know when they need to refer the pt up. There is a reason there are camp nurses and school nurses. (I worked as an EMT at a summer camp, I totally ripped those people off, looking back I had no idea what I didn't know, it was mostly just me guessing at stuff except when somebody needed a splint or bandaid)

Only JP put forth an argument of how the future might look with various providers in the role of EMS.

Has it occured to anyone if patients had a viable alternative to the ED, they wouldn't go as much? Every other civilized country seems to.

If I called the ambulance for a toothache, and it persisted for a while, causing pain and discomfort, which didn't progress to bacteremia/septic shock, or endocarditis/cardiac arrest, and the ambulance showed up, gave me some pain medications and made me an appointment at the local charity dental clinic, and found/offered me a ride that I might not need to go to the ED by emergency ambulance for the same thing?

If the ambulance showed up and gave my kid some tylenol, I wouldn't have to wait with her screaming and generally uncomfortable in a hospital waiting room for hours upon hours to get some cool aid and a tylenol.

Simple math,

lets compare an economy car, gas and maintenence, adose of tylenol, zofran, some nasal spray and caugh syrup plus the cost of the RN/hour to A medium or light duty truck responding lights and sirens, a couple of paramedics, driving everyone to and from the hospital every 8 minutes.

Savings, even if you pay double than what you would for the medics.

Now you could even add a bunch of ALS gear, priority dispatch, and a cell phone to the nurse, and use her (I used the feminine unless you want me to start calling the guys "sister" ) as the ALS intercept with a couple of basics driving around in much cheaper ambulances.

I keep trying to impress upon the ALS providers, it is not a need, it is a want.

Truthfully, if you guys want to keep your jobs, you better quit whining about the pay and start educating yourselves and branching out to be more valuable. As it stands, in a major cost cutting effort, replacing EMS providers with nurses is going to be a lot easier than EMS providers figuring out they need to be more valuable by society's standards, not by their own.

 

[MrBrown]

EMTs and Paramedics can advocate all they want for more education, expanded scope etc, but when it comes down to it the DOT and the individual medical directors control what happens.

Wrong. It is the providers themselves who will ultimately determine the direction of the system.

It seems to Brown in the US there is no incentive for increased education, most Paramedics are ignorant to its benefits and would resist it, the evolution of EMS seems to have stopped at the "Paratechnician" level and never gone much beyond it.

Brown blames the lack of national unity, the Fire Service, volunteers, Parathinktheyare's, New World Order, public taxation, the media and American healthcare system.

Any meaningful change is going to necessitate re-educating the physicians who ultimately control the application of the system. I will always advocate for more education, but it isn't going to get us very far if things still get bottle necked at the MDs.

Wrong. It is going to mean re-educating the providers themselves. When Paramedics prove they can be trusted with more than they have at the moment (thanks to those barely homeostasasing Parathinktheyare's who may or may not be Medicfighters) the medical director will listen.

Our medical director and regional medical advisors trust our Ambulance Officers with near total clinical autonomy (in line with reason and good clinical support) because they have proven capable of being trusted with it.

This is also going to mean that something would have to be done about the unions that fight to keep bad providers in their jobs.

Man that is going to be almost as difficult as defeating the New World Order

 

[MusicMedic]

So i kinda skimmed the whole thread sorry if i repeat anything that has been said...

What do you guys think of Doctors on Ambulances like they have in parts of Europe?... at least in Turkey (where my fam is from) they have a Doctor AND Paramedic on the rig... the Medic usually Drives, but also helps the Doctor with advanced on scene care..

Why cant we have a system with RN's and Medics on the rigs? i think that would up the standard of care quite dramatically.. or Hell Physicians and Medics!!

what about people in situations like me... I want the Education of an RN, but i want to work on a rig... once i become an RN, the only way i could work on a rig is either CCT (critical care transports) or Work as a Medic with a serious paycut and my scope limited... why does it have to be that way?

and honestly who thinks that 6 months of schooling is adequate enough education to be a paramedic? why are the only Pre-Reqs for Medic school A&P, while for RN school its A&P/Microbio/English (this is the local pre reqs for ASN Program)

I think Medics should still stick around, i just believe the education standards should be raised...

 

[MrBrown]

Brown thinks the use of Doctors in prehospital medicine should be restricted to the helicopter or a rapid repsonder model like HEMS/BASICS in the UK

Now, a history lesson ....

1969: Miami, Seattle and Los Angeles get "Paramedics"
1971: Melbourne (Australia) launches MICA (mobile intensive care ambulance) and MICOs (mobile intensive care officers)
1973: New Zealand introduces Paramedic staffed mobile life support units (LSU)
1983: Ontario, Canada introduces ALS Paramedics in Oshawa, ON
1990: Paramedic training is introduced in the UK ....

... sad to see the rest of the world started later and has overtaken the US :sad:

 

[Journey]

Okay, RNs are in Flight, CCT, Specialty and can have PHRN or MICN certs to work in various out of hospital situations.

However, since we have now ventured to PAs and NPs, there is a large group of nurses, Public Health, who do work the streets with a variety of outreach services providing medical care. They may have NPs and PAs with them or they may be based out of clinics to see patients can be taken there. They don't drive around in flashy ambulances or wear a uniform and most in EMS will never know they are there. But, they are out there in many cities and they do prevent many calls to EMS and unnecessary deaths. The Public Health nurse will see many patients each day that need immediate medical attention and those who can be prevented from being a 911 call through maintenance of their diseases. They also work with a health care team of many different professionals to see the patients get the proper ongoing care including housing, meds and psycho/social services. Public Healh nurses have been around for over a century at least and probably assisted with some of the early ambulances. NPs, PAs and Public Health nurses do try to address these issues at a national level while EMS is still trying to figure out what to call its providers and who can start an IV and who can not.

RNs in hospitals also become very familiar with many, many different patient needs and not just the emergent ones. Probably the med-surg RN is the better suited than someone who had done only critical care for long term maintenance, recongizing and preventing problems, understanding psycho/social needs, helps with arrangements if a Case Manager is not around and does extensive education. They had to expand their education to keep up with the demands of the patient care and there is also a specialization certification in Med-surg. Certs may not seem like a big deal espeically if some want compare it to the weekend courses offered in EMS which RNs can also take, but the prep work for nursing specialty certs is extensive and do require documented experience.

In San Francisco, one Paramedic did go back to college to get a degree in Social Work/Public Health to start making a difference and worked along those who made up the Public Health Services. His also recognized the need to advance his education to achieve his goal.