Pre-Hospital Advanced Advanced Care

[RanchoEMT]

I've been infatuated with an uploaded video series on youtube about the HEMS Doctor's(http://www.youtube.com/watch?v=UP9ODcwr7ck) who work in the Pre-Hospital setting, operating much like 'Super Paramedics'. (Well there's nothing 'Para' about it) Dr.s in the field providing care within 10 minutes...
It's interesting how they have devised this system in London. The Doctor's actually do a Pre-hospital field Residency for 6 to 9 months or so. I think little ideas like this that can provide an EMS system with advanced Care outside the hospital are a very interesting proposition and I'm interested to know what you guys think or have already seen with regards to such "Advanced" Life Support in the field.

Maybe PA's, RN, etc. could also begin to emerge in field, maybe running 911 calls with a PA(under the Medical Director's License) and a Paramedic.... Instead of a Medic and an EMT.... No discredit to EMT's, I am one after all, but to be humble: I know damn well how little I know as one.

Possibly the ambulances could run from a hospital instead of a private "ride to the hospital" ambulance(like an extension of a specific hospital) and could bill like a hospital, with a "We came And Got You Charge" so that we could bill and pay for such advanced services.... Just some thoughts...

 

[medicRob]

Maybe PA's, RN, etc. could also begin to emerge in field, maybe running 911 calls with a PA(under the Medical Director's License) and a Paramedic.... Instead of a Medic and an EMT.... No discredit to EMT's, I am one after all, but to be humble: I know damn well how little I know as one..

We already are. I am a Critical Care Transport - RN. I have worked ground units as well as the chopper. As a matter of fact, most critical care transport services seek RN's over paramedic.

Here is one certification route for RN's wishing to participate in prehospital transport: http://www.ena.org/bcen/certified/ctrn/Pages/default.aspx

CTRN

 

[MrBrown]

It will never happen in the US because a 1000 hour wondermedic is as good as a Consultant Physician because they can do some of the same skills or so the psyche seems to be.

Senior Registrars in anaesthesia, intensive care or emergency medicine are seconded to HEMS for a period 6-12 months.

 

[RanchoEMT]

We already are. I am a Critical Care Transport - RN. I have worked ground units as well as the chopper. As a matter of fact, most critical care transport services seek RN's over paramedic.
CTRN

In San Bernardino, We don't have any Nurses in the PreHospital Emergency setting with exception to the Heli...(Pretty Sure) Are you a 911 responding nurse via ground?? I was under the belief that nurses required Direct Doctor's orders? as opposed to written (Medical Director's Protocols)??? This may be location specific or may be ignorance on my part. I would love to be enlightened.

Original 'Big Picture' Discussion: Providing a Higher, than Current, level of care outside of the hospital and into the field.

Pro's: A patient can receive advanced care in a shorter time frame.
Con's: Just that, "A" Patient. When a caregiver is giving care to a patient a mile east of the hospital he can't be giving care to another two miles West of the hospital....


-Should the Higher Level Providers, like Doctor's, stay in one spot as to provide a Place(Hospital) for the sick and injured to track to, or should they be mobile??? Do we have the resources for both?

I see problems/I see benefits...

 

[medicRob]

In San Bernardino, We don't have any Nurses in the PreHospital Emergency setting with exception to the Heli...(Pretty Sure) Are you a 911 responding nurse via ground?? I was under the belief that nurses required Direct Doctor's orders? as opposed to written (Medical Director's Protocols)??? This may be location specific or may be ignorance on my part. I would love to be enlightened.

Original 'Big Picture' Discussion: Providing a Higher, than Current, level of care outside of the hospital and into the field.

Pro's: A patient can receive advanced care in a shorter time frame.
Con's: Just that, "A" Patient. When a caregiver is giving care to a patient a mile east of the hospital he can't be giving care to another two miles West of the hospital....


-Should the Higher Level Providers, like Doctor's, stay in one spot as to provide a Place(Hospital) for the sick and injured to track to, or should they be mobile??? Do we have the resources for both?

I see problems/I see benefits...

I was required to have EMT-IV or Paramedic alongside my RN. Also, we can follow protocols just as EMS can, not to mention we have 10x the education.

 

[RanchoEMT]

not to mention we have 10x the education.

That being my point, do you feel more effective staying in one spot and being able to treat people as they come to you? or do you think it more effective to go to them? Making yourself out-of-service for others???

Once again the Big Picture: Should we have the big wig providers in the field or in the hospital?

 

[RanchoEMT]

It will never happen in the US because a 1000 hour wondermedic is as good as a Consultant Physician because they can do some of the same skills or so the psyche seems to be.

Does Brown feel it overkill?

Senior Registrars in anaesthesia, intensive care or emergency medicine are seconded to HEMS for a period 6-12 months.

"You must excuse my english and use smaller words, less dense in meaning."
What are/is "Senior Registrars"? What does it mean to be seconded to HEMS?

 

[BEorP]

Does Brown feel it overkill?


"You must excuse my english and use smaller words, less dense in meaning."
What are/is "Senior Registrars"? What does it mean to be seconded to HEMS?

Senior Registrars are what Americans would call Senior Residents (resident physicians). Seconded to HEMS means that they spend a period of their residency working on the air ambulance and then return to their normal in-hospital stuff.

 

[MrBrown]

"You must excuse my english and use smaller words, less dense in meaning."
What are/is "Senior Registrars"? What does it mean to be seconded to HEMS?

A Registrar is a Physician undertaking specialist training. For example, an emergency medicine trainee spends five years in "residency" as you call it, two as a Junior Reg and three as a Senior Reg. They can take a leave of absence and work on HEMS then go back to their training.

Outside North America a graduate doctor who is undertakes general rotation before choosing a speciality is called a Graduate Medical Officer or a House Officer, a specialist trainee is called a Registrar (i.e. seeking registration) and a Consultant is a qualified specialist physician with whom the Reg consults.

Brown believes you call them Interns, Residents and Attendings

 

[Aidey]

I was under the belief that nurses required Direct Doctor's orders? as opposed to written (Medical Director's Protocols)??? This may be location specific or may be ignorance on my part. I would love to be enlightened.

The only difference between an EMS protocol book and the orders an MD writes on a chart is how long ago they are written, and the MD may have seen the patient before writing the orders.

In many settings RNs have standing orders, including most parts of the hospital and many out of hospital settings like dialysis clinics and nursing homes.

Some of the standing orders I see most often are for O2, nebulizers, antipyretics, antibiotics, pain meds and insulin. At SNFs it also isn't uncommon to see them for tests, like doing urine dips on anyone that has a fever greater than a certain amount.

 

[medicsb]

I've been infatuated with an uploaded video series on youtube about the HEMS Doctor's(http://www.youtube.com/watch?v=UP9ODcwr7ck) who work in the Pre-Hospital setting, operating much like 'Super Paramedics'. (Well there's nothing 'Para' about it) Dr.s in the field providing care within 10 minutes...
It's interesting how they have devised this system in London. The Doctor's actually do a Pre-hospital field Residency for 6 to 9 months or so. I think little ideas like this that can provide an EMS system with advanced Care outside the hospital are a very interesting proposition and I'm interested to know what you guys think or have already seen with regards to such "Advanced" Life Support in the field.

Maybe PA's, RN, etc. could also begin to emerge in field, maybe running 911 calls with a PA(under the Medical Director's License) and a Paramedic.... Instead of a Medic and an EMT.... No discredit to EMT's, I am one after all, but to be humble: I know damn well how little I know as one.

Possibly the ambulances could run from a hospital instead of a private "ride to the hospital" ambulance(like an extension of a specific hospital) and could bill like a hospital, with a "We came And Got You Charge" so that we could bill and pay for such advanced services.... Just some thoughts...

Role for physician? Sure. I hope that physicians will become more involved with prehospital care. In NJ, there are two physician response vehicles. One in New Brunswick and one in Patterson. They are staffed by EMS fellows and other physicians. UMASS in Worcester requires resident EM physicians to staff their helicopter. I believe physicians also respond in Pittsburgh and out Lehigh Valley Hospital in PA. I'm sure there are plenty more, especially with EMS fellowships becoming more prevalent. Also, most, if not all EM residencies require that residents do at least a 2 week block with EMS. However, this is usually along the lines of an observer-ship (in my experience), though most can perform medic level procedures if they would like to.

I do not think there is ANY role for RNs or PAs in the prehospital/911 setting. We should be advancing the paramedic profession, not that of nurses and PAs. For IFT work, the use of RNs make sense as the care delivered is a continuation of that which is done inside a hospital. RNs are undoubtedly going to be more familiar with balloon pumps, VADs, ECMO, advanced ventilators, etc. than most paramedics. However, I expect that for RNs (except those with previous or subsequent paramedic experience) are not adapted to the prehospital setting. No nurse should work a prehospital/911 ambulance, chase-care, etc. unless they are actually certified as a paramedic. Of course, this is my opinion.

Basically, we should advance the education of paramedics, and not supplant medics with nurses and/or PAs.

---

For medicrob where do you get the '10x the education' from? I know that even a standard AS level RN has more education, it is certainly not 10x the typical 1100 medic course. Even for DNP that seems particularly high.

 

[WTEngel]

A Registrar is a Physician undertaking specialist training.

Brown believes you call them Interns, Residents and Attendings

Interns, Residents, FELLOWS, Attendings.

Here in the US, once the residency is completed, many physicians end up doing a fellowship to specialize.

For example, someone who wants to be a pediatric emergency physician will either do a general peds residency or a general emergency medicine residency, and then complete a 1 or 2 year pediatric emergency fellowship.

 

[WTEngel]

I would have to disagree with this. I think a mid level provider such as a PA is the perfect addition to the pre hospital care environment.

I also believe that the pre hospital PA would be an excellent terminal career path for a paramedic who went and got their Bachelor's in biology or some other science.

So I think requiring paramedics to complete initially a 2 year degree and then offer a 4 year degree that could lead to a specialized PA certification specifically for a prehospital environment.

 

[mycrofft]

Tiered response, starting at EMT-B, then dispersed clinics.

The clinics would be able to treat cases needing differentiation and sometimes stabilization before or instead of hospitalization. Staff the clinics with MD or PA or FNP, RN, two MA's, three clerks, and assorted techs (radiological, lab).

 

[STXmedic]

I would have to disagree with this. I think a mid level provider such as a PA is the perfect addition to the pre hospital care environment.

I also believe that the pre hospital PA would be an excellent terminal career path for a paramedic who went and got their Bachelor's in biology or some other science.

So I think requiring paramedics to complete initially a 2 year degree and then offer a 4 year degree that could lead to a specialized PA certification specifically for a prehospital environment.

I completely agree. PAs seem perfectly suited for a "Prehospital Advanced Provider". The physiology, pathophys, pharm, etc knowledge base along with the ability to diagnose and write scripts would make them the perfect addition to an EMS system. ACNPs would fit this position well, too.

And to those who say "It's a completely different animal in the field" or whatever, it did not take very long for us to learn it in our short curriculum, so I'm sure a mid-level provider could learn it pretty quick, as well.

 

[mycrofft]

Rolls for PA, RN, FNP prehospital facilities or in mobile clinics.

Keep paramediocs and EMT-B's in ambulances, put nurses and other higher level practitioners (hahhahaa I hear the response now) where they can see more patients in a given time and thereby disperse the noncriticals and nonemergents. If the setting is frontier or rural, then maybe, if the patients will need to be cared for or stabilized on scene over time before transport.
Actually, I have no qualms about working cheek to jowl with parameds or EMT's in a non-ambulance setting as long as they can follow the standardized procedures or protocols assigned them. A nurse or PA or brain surgeon cold work field stuff if they have the chops andf the attitude. Not very cost effective though.

As a matter of fact, after having tried to land a job in a little doc in the box or six, it seems they don't even use RN's anymore, too expensive. Just a MD ordering around some medical assistants.

If my drift isn't apparent, the "call 911--ambulance arrives--emergency,go to ER" food chain is not as frequent as the "call 911--ambuance arives--nonemergency goes to ER" deal. Part of prehospital care should be a lower level of care but good diagnostic provider service. Free up the vehicles and crews and take the load off the ER's.

 

[CANMAN]

I was required to have EMT-IV or Paramedic alongside my RN. Also, we can follow protocols just as EMS can, not to mention we have 10x the education.

Come on man, I will give credit where credit is due but 10x the school give me a break MSN sure, BSN not so much. There are BS Paramedic programs out there and while I agree that RN's obtain more focused patho and such there are certainly things that P's get educated in that RN's have never even discussed.

I agree PA's would be an excellent addition to pre-hospital EMS. I currently work full-time pre-hospital and did critical care transport for 6+ years for one of the nation's leading hospitals. In working along side of nurses for years I value a good ICU RN in the transport setting but personally would rather have an experienced EMT-B or another ALS provider over a RN in the field.

I know I will get flamed for this post h34r:, but this is my opinion, based on my experience.

 

[medicsb]

PoeticInjustice and WTEngel:
Why not establish a different level of paramedic, instead; one that requires more training and a degree? This could be a way to not only advance/broaden the role of EMS, but better establish it as a health profession and component within the overall healthcare system.

To me, it seems that to fall back on RNs or PAs in order to expand prehospital EM services is a step backwards when we should be moving forward. Bringing in PAs and/or RNs only helps those professions. It's a fine option only if paramedics collectively decide that they don't want to do it.

 

[usalsfyre]

. In working along side of nurses for years I value a good ICU RN in the transport setting but personally would rather have an experienced EMT-B or another ALS provider over a RN in the field.

Sorry, every former ICU RN I flew scene flights with was a great deal more useful than the average EMT, Paramedic or even ED RN I run calls with on a day in, day out basis. They brought a level of background knowledge most of the others listed don't seem to have.

I know I will get flamed for this post h34r:, but this is my opinion, based on my experience.

Not flaming, but did you ever do scene work with an experienced ICU RN? I think you'd be surprised.

 

[usalsfyre]

PoeticInjustice and WTEngel:
Why not establish a different level of paramedic, instead; one that requires more training and a degree? This could be a way to not only advance/broaden the role of EMS, but better establish it as a health profession and component within the overall healthcare system.

To me, it seems that to fall back on RNs or PAs in order to expand prehospital EM services is a step backwards when we should be moving forward. Bringing in PAs and/or RNs only helps those professions. It's a fine option only if paramedics collectively decide that they don't want to do it.

medicsb, I agree with this 100%...but we can't even get an associates degree mandated. How much progress do you think we're going to make here?