In my county, On-scene "Command" NORMALLY goes from MD -> EMT-P -> MICN/RN/EMT. Most of the time, there's no MD on scene... RN's, including MICN's function at the discretion of the Paramedic, and may provide BLS care only. MICN's may assist with ALS care and provide suggestions, but can not provide medical control on scene. Flight RN's are a higher level of Pre-Hospital care that's provided for under a separate policy. CCT RN's would be treated the same as an RN. They're not generally considered Pre-Hospital personnel.
Yes, there's a lot. Some states allow a wider scope of practice for Paramedics than California does. Politics and fear of liability plays a large part in this. A lot of that restriction comes from Medical Directors that are afraid of too much liability on their part if a Medic screws up. A lot of that comes from the RN lobby that doesn't want Paramedics to gain more skills and scope of practice. That would just kill the CCT-RN programs out there if Paramedics could provide most of those services... As it turns out, CCT-P programs actually make it easier for CCT-RN programs to do well because their time isn't wasted on transporting someone on a NTG drip or a K+ drip that's out of scope for a local medic.But then, for some scenes, the command does not necessarily need a medical title. It all depends on the scene. For clarification (or for confusion) to the OP, most of the statements in this thread are only about the medical personnel and the actual scene command may be very different.
Yes, for large incidents, the actual scene command structure might the ICS system and as such, overall command may be fairly high ranking LEO or FD person.
As broke as CA is, are they using RNs (or MICNs) for 911 response especially with it being largely fire based EMS and 6 Paramedics showing up at each scene?
No. There's protocols for "Physician/RN at scene". Most of the time, these personnel know to NOT get in the way of the field specialists.
I also thought that Sacremento still had an MICN at the base hospital that could give an order to the Paramedic? Aren't there also MICNs or liason RNs that assist the Medical Director and supervise the Paramedics in that area?
Sacramento DOES have MICN's at the Base Hospital. They're required do one or two rides as part of their MICN renewal. They may NOT provide control while in the field, and while in the field, they can assist the Paramedic. Once back in the Hospital, they can provide the BHO that allows a Paramedic to utilize those portions of the protocols that require a BHO to proceed. Most of the time, those orders are not needed as MOST of the transports don't exceed 20-30 minutes and you just don't get to that point in the protocols. IFT Paramedics often do NOT have that restriction. You get to the point where you'd need to ask for permission normally, and you just keep going.
Even the CCTs in many parts of CA just use one CCT RN and 2 EMT-Bs. Then there is the thing with Paramedics not being able to work in some counties unless they are with a 911 EMS. Of course the very limited scope of practice for Paramedics in CA is the reason RNs have been on the CCT trucks for so long. It is also a good reason as to why most of the flight programs in CA use RN teams. And let us not forget the reason the ED RN (or CCT RN) must ride with the ALS truck to get a patient a few more blocks with a patient that needs a cath lab when the Paramedics drop at the nearest facility. Once almost any medicated drip is hanging and/or an ETT is established, the RN must go. If a second RN or RRT goes, the Paramedic may ride up front and not in the patient compartment.
The 911 Medic Only thing is starting to go by the wayside. In Santa Clara County, it has. They now allow for EMT-P IFT's. Santa Clara and Alameda County also utilize CCT-P in addition to CCT-RN. As far as having an RN ride with the patient, the only time I've seen THAT happen is when the patient has meds hanging that are outside the scope of practice. With an intubated patient, if I have a vent on board that I'm authorized to use, no problem. The RN is often there for the facility's liability. When there's other personnel in the back of my ambulance, I'm going to be there too. I know where everything is in the back. They don't.
And, in CA as in some other states, all the RN has to do is challenge the Paramedic test and that can solve some issues about who is what. Or it can muddy the waters even more. Yes, in California, an RN can challenge the Paramedic test, but they MUST complete the 480 hour internship. The only thing that the challenge gets them out of is the didactic portion of the training. Some of them fail because they can't figure out how to be an EMT... No pass the internship, no get EMT-P.
Yes, in California, an RN can challenge the Paramedic test, but they MUST complete the 480 hour internship. The only thing that the challenge gets them out of is the didactic portion of the training. Some of them fail because they can't figure out how to be an EMT... No pass the internship, no get EMT-P.
VADs, IABPs, ventilator beyond the ATV (most ICU patients), Diprivan (Propofol), transvenous pacemakers...to name a few more.They also use them because some of the meds and procedures that they can provide are out of scope for California Paramedics. Escharotomy and Surgical Cric come to mind... as does use of Sux, Roc, Vec...
Blaming RNs for the state of California's EMS is a cheap shot.A lot of that comes from the RN lobby that doesn't want Paramedics to gain more skills and scope of practice.