Should nurses be required to complete ride alongs with FD

[Summit]

haha wow, what med/surg is this? The BSN nursing staff that I was attached to where not allowed to start IV's, they called an "IV team" for that. They did not do any NG tubes while I was there, and to be honest it would be surprising if anyone could do such a thing on this floor.

Again, I'm on your side from the "not the best use of limited time" point of view. However, I'll tell you that your m/s experience is very atypical. RNs not allowed to start IVs? What cockamamy crap is that?

I'll contrast it to my first m/s rotation was on what was considered the lowest acuity inpatient floor in the hospital, which itself was not particularly acute: non-trauma center literally across the street from a level IV and down the road from a level I with its only standouts being a top notch OB/NICU and arthroplasty/surg. Nevertheless, I started NGs, IVs, and took patients down to interventional radiology and watched 2 procedures, etc.

You have provided a good example on how skewed of a view one can get in just two shifts. I'll compare it back to EMT clinicals. We had 2 hospital shifts and one ambulance. The ambulance shift: zero calls. The "hospital," a rural level IV "ER" attached to an outpatient surgery center, 2 patients all day so they sent me to watch an Achilles tendon repair. While waiting for my one shift in an urban Level I, I was concerned about my non-experiences and begged for more clinicals, not permitted, but they relented and gave me two or three shifts in a Level 5 standalone "ER" that was more of an urgent care... at least I had about 15 pt contacts. Then I drove off for my shift at the Urban Level 1 ED and saw more patients than my other 5 clinical shifts combined and as much acuity in one shift as I did in my first year on a 911 ambulance. Actually, that sounds like a good argument for m/s rotations for EMT students instead of low volume rural services/clinics. Obviously Level 1 trauma center placements are the best, but harder to get.

 

[ExpatMedic0]

Again, I'm on your side from the "not the best use of limited time" point of view. However, I'll tell you that your m/s experience is very atypical. RNs not allowed to start IVs? What cockamamy crap is that?

SW Washington medical center, Vancouver, WA, med/surg policy when I was there 2005, I shucks you not! ;-) I was also very surprised.

Regarding the rest of your statement, maybe it was just a bad luck shift, the same an EMT student could have on a ride along. I feel I learned a lot from Nurses and Doctors in the ED and the ICU... even OBGYN, I just can not say the same regarding my med/surg rotation and in retrospect it seemed to be a misuse of the students time and resources, which are extremely limited and focused.

 

[Carlos Danger]

RNs not allowed to start IVs? What cockamamy crap is that?

It's actually not all that uncommon in large hospitals.

I've been a couple places where the only nurses in the hospital allowed to start IV's were ED, ICU, and IV team staff.

 

[ExpatMedic0]

However, before we roam to far off topic.... I mentioned this because I thought it was a relevant comparison to the nurse riding with a transporting FD.

 

[Summit]

^Ah, not in CO... the state where everyone gets to do IVs. EMTs, LPNs, and Medical Assistants can take a 32 hour class with an 8 hour clinical and get their State IV Approval certificate.

We have a daytime PICC/IV team staffed by ICU nurses who are called in for hard sticks with repeated failed starts. At night, they just call the ICU. Sometimes, a RN will be lazy and call without trying... drama ensues.

 

[Carlos Danger]

Clipper1 I must say every post you make is trying to showcase how much education and superiority you think you hold in this forum full of sheep. If you are such an astute ICU scholar why not produce a strong conducive argument to support your stance with facts without resorting to attacks? This only makes you look foolish and anything substantial you had to say is nullified by such statement:

"Chances are the average EMS Paramedic will not be managing ICU ventilators, IABPs or multiple IV drips." I have some news for you, as long as there are community hospitals, small rural hospitals, clinics and the MD deems so appropriate (see MD.... makes decisions) that the patient needs to be transported and (RN.... records notes for discharge) to a regional center via ground or air there will be EMT's and Paramedics doing said job. I know this may cause you a great deal of pain to read that, but it's the reality.

FWIW, Clipper1 was not wrong here. The average paramedic does not manage ICU vents, IABP's, or multiple drips. They aren't even taught those things in school.

Even among those who do flight or CCT, most will never transport an IABP, and true ICU ventilators are almost never used in transport (an LTV1200 is not an ICU ventilator).

True, a few paramedics do these things - but definitely not the average paramedic.

Not really trying to make a point, I'm just sayin'.....

 

[VFlutter]

I not going to lie, I never held nurses as someone I go check in with for differentials or diagnosis. Nor did I care for what were nursing interventions , because to me this was not medicine. You alluded in another post "If you want to be the best in ICU care you should become a nurse" no if you want to be the best in ICU care you would become a physician do 3 years IM residency and a fellowship in Pul/CC and be called an Intensivist that is what the best is.

And how much time have you spent in an ICU? Or even a hospital for that matter.

Many people do not realize how much input nursing has on medical care. It is a collaborative effort not just a Doctor giving an order and the nurses blindly following it. Many times a Doctor will give me options and ask me what I think would work best in the situation, other times I will ask for orders that they have not thought but think is a great idea. If my patient is in A fib RVR I don't run up to the doctor cluelessly but rather ask for a specific drip or bolus and they either agree or recommend something different. If someone can't maintain their pressure on a diltizem drip I will ask if we can switch to amino. I don't sit there and wait for the doctor to tell me.

And during any given time I can guarantee the nurse knows more about the patients status, test results, etc then the multiple consults or sometimes even the attending.

I am not claiming an ICU nurse is more of an expert than a Doctor or that a Doctor is not the final decision maker but to view the nurse as not worthy of consulting because they do not "practice medicine" is a bit ignorant.

Ask a pulm/cc about their residency and you may be suprised how much they learned from nurses during that time. In a teaching hospitals ICU the nurses and residents usually have great interactions.

As for nursing intervnetions. I will agree some may look dumb but many make a huge impact on the patients outcomes, discharge, and possible readmit. Doctors don't write orders to turn patients or skin wound care. If nursing did not do "nursing interventions" many of our patients would be septic from decubitus ulcers.

 

[JPINFV]

A disgruntled med student. What does it matter for this discussion who your chain of command is as a med student? Did the mean nurses pick on you again?

I generally get along fine with the nursing staff. However, that comes from simply expecting them to do their job (nursing) and not my teams job (medicine). This includes me doing my job. If I'm writing my progress notes at 6am and notice that the 4 am vital signs includes something like an SpO2 of 88%, that means that I grab a vital signs machine and get a new number for my own documentation. Of course it also makes me wonder why they heck no one was called, since "MD notified, no new orders" is more common than radiologists adding "clinical correlation required" (I guess I hate radiologists now too, right?). For all of the "nursing should be done by nurses" propaganda, it's amazing how much medicine the average nurse wants to practice.

Are you just mad that I don't bow down to the altar of Florance Nightingale?

I will only comment on a couple of things out of all that stuff you wrote since you want to resort to insults on nurses again.

What insults? Seriously, point them out? When did pointing out that nurses not being 100% perfect angelic beings means that it's an insult? If that's the definition of "insult" than can you stop being a hypocrite and insulting paramedics?

You might read more documentation from nurses because they do a heck of a lot of documentation per patient. There are also a heck of a lot of nurses. Some of the larger hospital will employee over 1000 - 2000 RNs easily. We have over 200 in just our Neonatal units. Since you have not been a Paramedic, you may only have read a few of the Paramedic charts which happen to be on the patients admitted. The important thing is "what did you do about the errors you found"? Do you know the regulations for the state and facilities you are in for reporting errors? Do you report only the errors of the nurses and not the Paramedics?

Did I say that I reported errors? Should I start reporting errors when there's something obviously wrong, like physical exam findings that haven't been present in 2-3 days, but keeps being put in the shift assessment documentation? Should I report every time something is off? As I'm concerned, the best course of action is generally to just recheck it myself, but I guess I can start getting the nursing board involved. Do you call the EMS authority/board every time you notice bad paramedic documentation?

I guess by your reasoning, Paramedic students really should not doing much interaction at all in the hospital since they will have to encounter nurses at some time. Nurses also should not ride on with the fire department either if it is only to be for a superiority pissing match.

...because, somehow, the basic med-surg unit is the only unit in the hospital? Also, where have I advocated nurses ridding along with the fire department?

You know what I wouldn't be fully adverse doing, though? I'll pull a couple 8 hour shifts with the nursing team, the nurses can pull a couple 30 hour shifts with the IM on call admitting team or surgical call team.

Maybe we should have more physicians on the ambulances in the US. Why is it that when of the advantages of certain clinical situations like in med surg are pointed out EMTs and Paramedics feel insulted?

Pointing out that there's more appropriate places isn't an insult. It's simply pointing out that there's more appropriate places for them to be. Why is your ego so fragile?

Maybe an EMT or Paramedic student might get some ideas about what to ask for in clinicals or do something to take the initiative rather than just stand around waiting for someone to tell them to do something or for something cool to come into the ED. I bet a lot of Paramedic students never knew what all they could see and maybe do in the hospital.

...because hospitals as a whole are large intimidating places where unless you understand intimately how it works, you end up walking on egg shells. Unless the paramedic is going to spend at least week working in the hospital full time, than it's fully understandable.

 

[JPINFV]

I am not claiming an ICU nurse is more of an expert than a Doctor or that a Doctor is not the final decision maker but to view the nurse as not worthy of consulting because they do not "practice medicine" is a bit ignorant.

I think it depends on the expectations on both sides. I won't argue that nurses spend a vast majority more time with individual patients than physicians (for a variety of reasons, including the fact that the physician can have 3-4 times the patients as the nurse). I think the problem comes when the nursing staff starts either demanding something inappropriate medically (i.e. sedating patients with delirium. Sure, it's easier for the nursing staff, but it's still bad medicine), is inappropriate for the time of day (unless it's an emergency or urgent situation, the overnight coverage team shouldn't be handling it), or simply ignores the medical orders for what ever reason and doesn't even bother notifying the primary medical team.

 

[Ecgg]

FWIW, Clipper1 was not wrong here. The average paramedic does not manage ICU vents, IABP's, or multiple drips. They aren't even taught those things in school.

Even among those who do flight or CCT, most will never transport an IABP, and true ICU ventilators are almost never used in transport (an LTV1200 is not an ICU ventilator).

True, a few paramedics do these things - but definitely not the average paramedic.

Not really trying to make a point, I'm just sayin'.....

The difference here is what "manage" actually entails. In CCT environment we work darn hard in the sending facility to make sure the patient and crew have an unadventurous trip.

If however patient condition deteriorates we don't have the luxury of recruiting higher trained members to gives us hands on assistance. In reality RN facade of management is calling the doctor or paging code "insert color of what your facility uses" and waiting for their response.

If the patient goes in to cardiac arrest on your floor is RN allowed to initiate CPR? By that I mean prompt initiation of chest compression on your own accord? Because that is what this patient currently needs. Or you call the doctor? Or page/broadcast/announce/call response team?

If the IABP malfunctions, there is a timing error or patient sustains an arrhythmia is RN adjusting the IABP control and controlling the arrhythmia or the correct answer is one again call the doctor?

Any nursing exam if there is a choice “call the doctor” it’s usually the correct answer.

Medics are not taught those things in school you are 100% correct. In addition if you don’t work for a hospital with today’s rules and laws you can’t even gain entry to ICU (to which you bring patients to constantly) for clinical time. Even though the Intensivist allowed you to come, but the charge admin RN’s think it’s highly inappropriate for a Medic to do an ICU rotation with the MD.

Spending thousands of dollars out of my own pocket (because medics are rich) to take critical care, NRP, Stable, AHA, Airway Management classes etc. in hospitals to improve my patient care vs RNs who’s employer paid them to attend and they complain how early they had to wake up. Getting dirty stares from all the nurses when I am the only medic in the room after we do the introductions, with witty comments to ensue like we didn’t know ambulance drivers needed this.

This topic is of seldom use because in reality everyone has their own prejudices either through life experience, on the job experience, plain ignorance, lack of education and various combinations of their off. I don’t expect RN’s to change their minds about ambulance drivers even though there are outliers and I don’t expect Paramedics to change their minds about nurses even though there are outliers. Will see if my outlook will change when I am in the medical student role, although honestly I think it will be worse.

 

[Summit]

Clipper1 would do well to realize that his/her good points would be appreciated if some more tact was used. Bludgeoning your opponent will not convince them and at some point turns off the audience to what you have to say. I do my best to take the good info from Clippers posts while annoying the vitriol. I too would like to know Clippers credentials.

Should I start reporting errors when there's something obviously wrong, like physical exam findings that haven't been present in 2-3 days, but keeps being put in the shift assessment documentation?

IMO it would be quite appropriate to report that to their manager.
I've seen it and mentioned it within nursing... although I don't do it when I see physicians copying each others notes. It is funny because I recently read an article on this in the Journal of Critical Care Medicine:
Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes
"Measurements and Main Results: EIghty-two percent of all residents and 74% of all attending notes contained greater than or equal to 20% copied information (p = 0.001)."

You know what I wouldn't be fully adverse doing, though? I'll pull a couple 8 hour shifts with the nursing team, the nurses can pull a couple 30 hour shifts with the IM on call admitting team or surgical call team.

Frankly, I think that would be awesome. Where do I sign up? I think I'd learn a ton; I know I do when I use my lunch break to attend grand rounds. (FYI most acute care RNs work 12+).

 

[Tigger]

Bring this thread back on track or it's done.

 

[JPINFV]

Bring this thread back on track or it's done.

 

[VFlutter]

If the patient goes in to cardiac arrest on your floor is RN allowed to initiate CPR? By that I mean prompt initiation of chest compression on your own accord? Because that is what this patient currently needs. Or you call the doctor? Or page/broadcast/announce/call response

Uh, what? I do not know any hospital in the country that does not allow floor RNs to start CPR. Even techs will start CPR if a patient arrests. When I code a patient I am usually through the first few rounds of ACLS before the code team even gets there. I don't sit there and wait for the doctor to show up before I start compressions.

Actually, "call the doctor" is almost never the correct answer on standardized nursing exams.

 

[ExpatMedic0]

haha, ya how does this all tie in with the topic of nurses riding on FD transport ambulances?

 

[Summit]

In reality RN facade of management is calling the doctor or paging code "insert color of what your facility uses" and waiting for their response.

If the patient goes in to cardiac arrest on your floor is RN allowed to initiate CPR? By that I mean prompt initiation of chest compression on your own accord? Because that is what this patient currently needs. Or you call the doctor? Or page/broadcast/announce/call response team?

If the IABP malfunctions, there is a timing error or patient sustains an arrhythmia is RN adjusting the IABP control and controlling the arrhythmia or the correct answer is one again call the doctor?

Any nursing exam if there is a choice “call the doctor” it’s usually the correct answer.

Well, I think we have gone to the heart of the matter hear. Frankly, you are operating under either some completely incorrect assumptions, or your perspective has been limited to an unusually restrictive facility and you are extrapolating it to the rest of the world.

First I'll admit my perspective is limited to my first hand experience as an EMT, a nursing student, an ICU nurse, and to what my colleagues have related to me in other states and hospitals. I hope that I can share some perspective with you:

Yes, the ICU nurse is going to IABP controls (at many facilities at least, I know of one where it could be RT flying the IABP). I'm guess you also think RNs have to ask mother may I before giving O2.

Yes, the nurse is going to initiate CPR without being told to do so, but not before hitting the code blue button and/or yelling "Bring the Code Cart NOW!!!" That is expected of a CNA, EMT, Paramedic, RN, or MD. At my facility, the RN is expected to have CPR in effect, the lifepack pads on and, if appropriate, to initiate the first shock all before the code team arrives. In the ICU, we will push atropine for symptomatic bradycardia if it is appropriate, and there are plenty of other RN practice policy privileges (something akin to protocols). When we run codes, we use a pilot/copilot model with the resident as the pilot and an ICU RN as the co-pilot.

Next, I'll share with you some information. Let's start with nursing exams: the answer is not always "call the doctor." Nursing is expected to assess, investigate, and problem solve as appropriate. In fact, turning off your brain and calling the doc for everything will get your reamed and fired. When you do call the physician, you are expected to be able to explain the situation, give the background and unnecessary findings, your assessment of the situation, and your recommendations on what should be done. SBAR (or ISBARR if you prefer).

For example: I see PVCs in my patient who was otherwise in ST and the MAP is starting to drop. I adjust some vasoactive drips, assess, and elected to send scheduled coag and CBC labs early, and tacked on an ABG and lytes panel. I receive the results, THEN I called the resident, which went something like this:

Me: "Hey Doc, this is Summit taking care of MICU bed X. There is some new ectopy and hemodynamics are requiring more aggressive use of pressors apparently from worsened coagulation and worsened hemorrhage with a continued acidosis. I saw some new polymorphic PVCs and so I sent the labs early, the H&H has now dropped to 6.5/20 and the PT/PTT/INR is now 70/85/8.9 and fibrinogen is less than 60. The iCa is 1.09 and Mg is 1.4. Also, we the profound acidosis continues and changing vent settings further is unlikely to help an uncompensated metabolic acidosis of 7.14, 20, 114, and 8.5. Can we please start a bicarb drip? It will help my pressors work too... and do some FFP, cryo, platelets, and PRBCs, and replete the Ca and Mg?"

Dr. So and So: "Crap. Yea. I'll order the blood products. Go ahead and push a gram of Ca and I'll write for the Mg. I like the bicarb idea, but I want to check with pulm first."

Me: "Sweet. I will push 1 gram of Ca, I'll look for the Mag bag, and I'll call blood bank to let them know the paperwork is forthcoming."

(and later there was a bicarb drip)

Even though the Intensivist allowed you to come, but the charge admin RN’s think it’s highly inappropriate for a Medic to do an ICU rotation with the MD.

That is ridiculous. I am sorry that happened to you. It sounds like that facility was not very pro-education.

RNs who’s employer paid them to attend and they complain how early they had to wake up. Getting dirty stares from all the nurses when I am the only medic in the room after we do the introductions

I don’t expect RN’s to change their minds about ambulance drivers even though there are outliers and I don’t expect Paramedics to change their minds about nurses even though there are outliers. Will see if my outlook will change when I am in the medical student role, although honestly I think it will be worse.

It really sounds like you have an axe to grind here... I hope you can gain some perspective and peace on this issue. Perhaps you should try setting the example. If you go through medical school with disdain for nurses, it will not be to your advantage. Our chief of medicine never walks out of a patient room without asking for nursing input and constantly reminds residents to listen to and respect nurses.

Nursing isn't always right, but we are all on the same team, just with different jobs.

One thing I've learned as I've gone on is how much more there is to know and be an expert at than virtually any person can master, even within their own subfield. You realize that when dealing with complex problems in complex systems, the human element can muddy the waters. It is readily apparent when you see renowned cardiologists disagreeing among themselves, or the cardiothoracic surgeons going at it with the cardiologists, or the pulm/cc fellow ranting that if the medical attending would only listen to them then things would right.

ETA: While I was typing all that, Tigger posted.

 

[Carlos Danger]

The difference here is what "manage" actually entails. In CCT environment we work darn hard in the sending facility to make sure the patient and crew have an unadventurous trip.

If however patient condition deteriorates we don't have the luxury of recruiting higher trained members to gives us hands on assistance. In reality RN facade of management is calling the doctor or paging code "insert color of what your facility uses" and waiting for their response.

If the patient goes in to cardiac arrest on your floor is RN allowed to initiate CPR? By that I mean prompt initiation of chest compression on your own accord? Because that is what this patient currently needs. Or you call the doctor? Or page/broadcast/announce/call response team?

If the IABP malfunctions, there is a timing error or patient sustains an arrhythmia is RN adjusting the IABP control and controlling the arrhythmia or the correct answer is one again call the doctor?

Any nursing exam if there is a choice “call the doctor” it’s usually the correct answer.

Medics are not taught those things in school you are 100% correct. In addition if you don’t work for a hospital with today’s rules and laws you can’t even gain entry to ICU (to which you bring patients to constantly) for clinical time. Even though the Intensivist allowed you to come, but the charge admin RN’s think it’s highly inappropriate for a Medic to do an ICU rotation with the MD.

Spending thousands of dollars out of my own pocket (because medics are rich) to take critical care, NRP, Stable, AHA, Airway Management classes etc. in hospitals to improve my patient care vs RNs who’s employer paid them to attend and they complain how early they had to wake up. Getting dirty stares from all the nurses when I am the only medic in the room after we do the introductions, with witty comments to ensue like we didn’t know ambulance drivers needed this.

This topic is of seldom use because in reality everyone has their own prejudices either through life experience, on the job experience, plain ignorance, lack of education and various combinations of their off. I don’t expect RN’s to change their minds about ambulance drivers even though there are outliers and I don’t expect Paramedics to change their minds about nurses even though there are outliers. Will see if my outlook will change when I am in the medical student role, although honestly I think it will be worse.

It is always amusing to see people try to speak with authority on things with which they obviously have very little, if any, actual experience. :rofl:

 

[Fish]

Medics and EMTs have to do shifts in the ER and we're not really learning anything new in there

I have been in EMS for 8yrs, I like to think I have seen a lot, done a lot and know a thing or two. And I would sure benefit even now from a clinical in an ER or OR. There is SOOOOOOOOOO much a Medic student does not know, the clinical time should be expanding your mind. And as you move on in your career and become a more experienced provider the things you want to know, the questions you have they never stop, they just change and a lot of the time the answers are found in the ER. Saying a nurse can't teach you anything is like saying a Medic cannot teach a nurse anything, it is not true.



But to answer the original question of this thread, I think ER nurses benefit greatly from 2-3 ride outs. Infact 1 hosp out here does not require it, but has it as an option for all new er nurses....... And usually they take advantage of it and they have a good time and learn a few things.

 

[Akulahawk]

Over the years, the nurses that I've met that bash the paramedics usually have no idea what they do or the training they actually do receive. From what I've seen during my nursing training is that they're given absolutely zero education about what other care providers are capable of and their general scopes of practice. RN's are taught about appropriate delegation to CNA and LVN staff... but not to EMT / AEMT / Paramedic personnel, which they lump into unlicensed personnel.

Requiring a Nurse to ride on a Paramedic unit for a couple shifts and become familiar with prehospital protocols should at least give the Nurse a very basic understanding about an area they have little understanding of. Later on down the road, it'll also help them determine if the transfer/discharge via ambulance is actually appropriate, for instance.

 

[chaz90]

My old hospital based service often had ED nurses and other floor RNs ride along. It did seem to give them a bit of appreciation into what field work is like and what we do.