Clinical preceptors

[Veneficus]

I was reading the thread about why nurses hate paramedics that was based on a clinical experience and I didn't want to hijack it.

Before starting, I would like to give credit to the 2 specific ER nurses who were among my many preceptors in paramedic school for being instrumental to my success in all of my medical pursuits.

I would like to discuss who should be responsible for paramedic students during their clinicals.

In the early days of EMS, it was physicians who were responsible for the clinical time of EMS providers. During my initital EMT class, my 16 hours of hospital time was with a doctor.

Some years later in paramedic school, I had preceptors who were RTs, Nurses, doctors, and probably a few other providers I forgot.

Now I am not picking on anyone, but from my perspective, it seems to me like nursing is very routine driven. There is definately value in that. When it comes to learning procedures, routine brings the best results. Think about it. Starting an IV, intubating, stroke checklists, they all work better when following the routine without deviation.

Now with some exceptions, doctors are by far some of the worst people I have ever seen try to start an IV. So it stands to reason as one of the fundamental EMS skills, it be taught by a nurse.

But because EMS is best served by learning various skills from various providers, how did that default into nursing largely being responsible for EMS students?

When people don't understand what a paramedic is I use the analogy of Star Wars to explain it. If the doctor is the Emperor, a paramedic is like Darth Vader. Think about it, they are both pursuing the same knowledge. One is in charge and takes care of the big picture. One is sent out into the field to make sure it gets done. There is some overlap but not that much.

Wouldn't it be more helpful if we went back to having doctors be the primary preceptors for paramedics?

I am not nor ever will be a nurse, but it seems to me from my observations, the thought process of a paramedic is more like a doctor than a nurse. (especially when it comes to charting)

I left out other paramedics intentionally because there is a great discrepancy in paramedic providers. In the same agency you could get the finest prehospital provider ever one shift and a skills monkey the next. US paramedics are not at the level they need to be to exclusively train their own.

What do you think?

 

[mgr22]

Like you, I had nurses, doctors, and medics as preceptors. I learned from their different perspectives (even what not to do, occasionally). I vote for variety.

 

[Veneficus]

Like you, I had nurses, doctors, and medics as preceptors. I learned from their different perspectives (even what not to do, occasionally). I vote for variety.

But primary responsibility?

 

[usalsfyre]

I thought for a long time our jobs a far closer to what a mid-level provider does than a bedside nurse per say (how's THAT "typical paramedic arrogance"? Exceptions exist of course, there's some uncovered community ICUs where the staff at night pretty well flies solo...). As such, to me it would make far more sense to me to be educated by mid-levels and physicians vs bedside nursing staff in the later stages of practium.

Like you said, for learning IVs, med pushes and other psychomotor skills early in your education then bedside nursing is the best place to be. However once you leave that realm and enter into true diagnosis and forming a treatment plan then your better served by being educated by the people who do this daily.

The issue here? Cost for one. These providers are unlikely to volunteer their time (nor should they). As such someone's got to pay them, and schools are unlikely to eat the cost/cut into their profit margin. And EMS education is about moving people through as cheaply as possible, not quality (hence the number of mills around). Secondly, students have got to have the base education to understand what the heck is being taught. Which is rare in EMS education right now.

 

[Aidey]

I think the way mine were done was pretty good, even if there were a few problems.

We were precepted by RNs for most of our clinicials. We also spent time specifically with RTs. Often, in the ER we would be assigned to both an RN and an MD. The RN would supervise us doing vitals, giving meds, starting IVs etc. We would go in with the MD on their assessments and when they did more advanced procedures.

I feel that being precepted by an RN in most settings is appropriate. In places like peds, geriatrics, post surgery recovery etc the RNs are the ones who are there all the time, and it is possible that the MD will only be there for a couple of hours out of a 12 hour shift. The majority of what we end up doing in those areas are the ongoing assessments on the already admitted patients. I think these areas also allow the student to be exposed to different disease processes and symptoms that they might not otherwise see, for which having an RN precept is fine.

When it comes to the ER and ICU, I think spending time with both the MD and the RN is the optimal situation. That way the student can see the MDs assessment and decision process, and then with the RN carry out those decisions and reassess the patient.

Like I said we did have some problems, and when I say "we" I mean students at my school in general, no just my class.

One of the main issues we ran into was with the anesthesiologists and scope of practice. Basically they thought the Paramedic curriculum wasn't good enough, and took it upon themselves to expand it. This was not well received by the students who were arriving at clinicals and being told they had to learn about drugs and equipment that were rarely if ever used in the field. The preceptors went so far as to say the students couldn't intubate without knowing the info. By the time my class started we had switched our OR time to a different facility where they were more willing to understand the Paramedic scope and teach at that level.

The other problem we had was with some of the ER RNs. There was a problem between the state BON and the board that supervises Paramedics. It was mostly stupid semantics stuff, involving the fact that Paramedics are considered practitioners and RNs are not, and how could a non-practitioner supervise a practitioner. All of the ER MDs and a good number of the ER RNs thought the whole thing was stupid. Once someone complained to the BON though, all RNs were told they were not allowed to precept us until it got sorted out, which they did after a few weeks.

 

[8jimi8]

I think everyone has pretty much hit the nail on the head. EMS clinicals need to be precepted by a mixture of the allied health professions AS WELL AS physicians.

EMS skills are most closely aligned with nursing, so the psychomotor skills, i agree are best learned with them; however for those specialty skills (RT for cpap/nebs, a sticks) and MDs for invasive procedures as well as assessments and differentials.

Will we ever get this mix of top notch educators? Will we ever pay $10,000 for classes? i just don't see it happening in the US. I mean look at the state we keep our mainstream educators in.



Many cultures REVERE education and educators. The US does not.



Even i've fallen victim to... get in and get it done as fast as possible. Hell i'm cramming EMT-P and a BSN into the same year.

Fast Food Nation: I'll take my education with a side of fries and 32oz of heart attack please. Yah, Biggee Size me.

 

[Shishkabob]

The other problem we had was with some of the ER RNs. There was a problem between the state BON and the board that supervises Paramedics. It was mostly stupid semantics stuff, involving the fact that Paramedics are considered practitioners and RNs are not, and how could a non-practitioner supervise a practitioner.

Heh, seems the exact opposite here. The BON, in it's "infinite wisdom", labels Paramedics as technicians because we have "technician" in our name, and per the BON, RNs can't delegate RN tasks to technicians.

Funny how out of a hospital I can start IVs, flush, give all the fluid I want, give any drug I deem I should give, all without any direct supervisions, but the moment I step foot in an ER, I lose any and all ability to make rational decisions and can't even do a saline flush after I start an IV? How in the hell does it make sense to have a "tech" start an IV, but only a nurse can do a saline flush?

EMS skills are most closely aligned with nursing, so the psychomotor skills, i agree are best learned with them; however for those specialty skills (RT for cpap/nebs, a sticks) and MDs for invasive procedures as well as assessments and differentials.

Meh, the Paramedic model is much more closely aligned to physicians than nurses, from skills to decision making. The only real 'skills' we share with nursing are IVs and foleys. Everything from intubation to advanced airway control to IOs to pacing to cardioversion to CPAP to needle thoracotomy, etc etc etc, is generally out of most RNs scope.



Might be why I see many more PAs and MDs who are former Paramedics than nurses.





During my clinicals, much of my ER time was spent 'assigned' to a nurse, but off on my own roaming the ED doing everything from DDX with the doc to IV starts to other skills and being sent to the "cool" patients.

In other places such as the ICU, OR, or cath lab, we were always with an RT or MD, never a nurse.

 

[Outbac1]

Well I had a mix of Rns and Drs for preceptors. For my ER shifts I asked the Dept head (a Dr.), if he would be my precepter. Not that the ER nurses weren't good or willing but I wanted to follow the Drs assessments. I wanted to know what was leading them down a certain path with a pts illness. The nurses certainly kept me busy with IVs and meds in between. I think I had the best of both worlds. I also had some great anethesists as preceptors for my OR time. I also had a Dr for my ortho rotation and got to follow the chief surgeon for a day in his OR outpatients & minor procedures clinic. Otherwise it was mostly nurses for my other rotations in ICU, Peds, L&D, Mental health, PACU, NICU and Respiratory.
Here our education is better and many Paramedics have worked very hard in the last 15 years to raise our profile among doctors and nurses so that we have some hard won mutual respect. As a student it is important that you go in with a willingness to learn. A willingness to work with your precptors and others, to get your hands dirty with the not so fun tasks. When people see you willing to work they tend to make sure you get in on the good stuff.
We as paramedics have such a broad area of responsibility I feel it is important we have a broad mix of education as well. No one person or type of person is going to give us the mix of education we need.
It is also important that we as students insist that we are placed with competent preceptors that want students. It is a waste of time to be with someone who doesn't want you.

 

[MEDIC802]

Alot of experience on this thread(old guy's). Do you remember when ACLS was a real course and it was just you and 3 doctors in your mega code. those were the good ole stressful days

 

[mgr22]

But primary responsibility?

I guess I don't see preceptor responsibility being delegated more to one group than another. Medic students will spend the most time with medic preceptors because of all those ambulance hours, but that doesn't make medic preceptors more responsible than, say, ER docs, for providing educational opportunities.

 

[usalsfyre]

Alot of experience on this thread(old guy's). Do you remember when ACLS was a real course and it was just you and 3 doctors in your mega code. those were the good ole stressful days

I never had three doctors, but I do remember when for your final mega code you were alone actually had to be able to interpret rhythms and remember medication doses.

Come on, we can't do that anymore! Feelings might get hurt if anyone "fails"!

Although, considering how useless ACLS really is for cardiac arrest it probably doesn't matter. ACLS needs to be far more about peri-arrest rather than running the code.

 

[Veneficus]

Alot of experience on this thread(old guy's). Do you remember when ACLS was a real course and it was just you and 3 doctors in your mega code. those were the good ole stressful days

Never had 3 docs, only the medical director by himself.

 

[MEDIC802]

always had our Medical Director, an ER doc, and a cardiologist, they threw every strip that they could generate on a MD3 at ya and expected you to actually know drug doses and actions.

Dr Campbell the author of BTLS now ITLS was our medical director, he always was an evaluator for ACLS and BTLS, that was back when those courses actually ment something.

 

[Veneficus]

always had our Medical Director, an ER doc, and a cardiologist, they threw every strip that they could generate on a MD3 at ya and expected you to actually know drug doses and actions

You make that sound like a bad thing?

 

[STXmedic]

always had our Medical Director, an ER doc, and a cardiologist, they threw every strip that they could generate on a MD3 at ya and expected you to actually know drug doses and actions.

Sounds like fun! I would live to have resources like that easily available

 

[MEDIC802]

Not a bad thing at all, just wanted to be absolutely perfect, they never gave any indication if you were doing good or bad, Guess I did good because I aways passed the first time, question, do ya'll have nurses rush to partner with medics during the New and Improved ACLS mega code( maby I'll just call it student friendly)

 

[Veneficus]

do ya'll have nurses rush to partner with medics during the New and Improved ACLS mega code( maby I'll just call it student friendly)

No, when I teach for a hospital, the groups are usually homogenous and assigned by us. Everyone has to demonstrate being in charge anyway, so partnering up doesn't help.

 

[johnrsemt]

Great to follow the docs, but the nurses are the best for teaching IV's and drug pushes etc.

 

[Shishkabob]

Great to follow the docs, but the nurses are the best for teaching IV's and drug pushes etc.

While yes, we do many IVs and push a fair amount of drugs, our thought process is more in line with physicians. Nurses, generally, don't have to make the decision what drug to push when unilaterally. We do. Therefor it's a lot more beneficial to be with the doc when he decides what drugs to give than it is to be with the nurse when she goes "Here, push this very slowly".



Like I said, most of what we do is a lot more in line with the physician model of thinking than the nursing model. EMS shares very little with nursing, which is where a lot of our friction stems from. They think they're above us, when realistically, we're equal in level, just as an NP is equal to a PA in most instances. Just different models of thinking.

 

[Aidey]

Alot of experience on this thread(old guy's). Do you remember when ACLS was a real course and it was just you and 3 doctors in your mega code. those were the good ole stressful days

I did my first ACLS and PALS recerts at the local hospital, and I was grouped in the "Providers" class with MDs, PAs and ARNPs. I was terrified I was going to totally bugger it all up and look like a complete fool.

I found out later someone had told the director of the Paramedic program I was a credit to the program. Who would have thunk it. It was definitely a different class with that lot.