Replacing EMS with nursing revisited

[Shishkabob]

I didn't figure so, Bro, I just never knew what your plan was.

It was always a secret!

The exception, not the rule.

Yet the exception is steadily becoming the rule... atleast in the areas I see.

Plus, notice how many of the areas I named were in Texas? Where the individual MC is allowed to choose what their medics do instead of beaurocrats that limit it to thing like "You need to call a nurse"?

Maybe if places like Cali and Florida actually, you know, treated EMS in a better light, they'd get better medics?

 

[terrible one]

My first mission is to find a college that will give me life credit for my Paramedic cert so I can finish my EMS degree, to which I've found a few, then move on to either my BA or do an RN bridge.

What degree? Is there an actual EMS degree? or do you mean something else?

 

[Sasha]

It was always a secret!




Yet the exception is steadily becoming the rule... atleast in the areas I see.

Plus, notice how many of the areas I named were in Texas? Where the individual MC is allowed to choose what their medics do instead of beaurocrats that limit it to thing like "You need to call a nurse"?

Maybe if places like Cali and Florida actually, you know, treated EMS in a better light, they'd get better medics?

Florida doesn't treat EMS poorly, it recognizes the need for more trained professionals beyond the Basic level and requires a medic on every truck. Unfortunately the IAFF is a big beast and convince the public that Fire EMS is better than third service EMS.

 

[Shishkabob]

What degree? Is there an actual EMS degree? or do you mean something else?

Depending on the school, there's degrees in Paramedicine or degrees in Emergency Medical Serives / Emergency Medicine.

 

[Shishkabob]

Florida doesn't treat EMS poorly, it recognizes the need for more trained professionals beyond the Basic level and requires a medic on every truck. Unfortunately the IAFF is a big beast and convince the public that Fire EMS is better than third service EMS.

I'd rather have less that care, than more that don't.

 

[Aidey]

I think the idea would be met with too much resistance all the way around honestly. Some people would support it, but the big players wouldn't.

Given the current political climate in the US, just the money involved would prevent the idea from gaining widespread traction. No one is going to want to pay for a RN. Not the private companies, fire based EMS agencies, or the insurance companies. As someone pointed out the average RN wage in a hospital can easily be twice what a Paramedic makes working for a private agency.

No service (private or fire based) is going to be willing to absorb that kind of increase in overhead costs. They will try and make up for it by increasing billing rates. Insurance companies will never go for it, arguing that it isn't necessary to have a RN on the ambulance, and they won't reimburse at a higher rate. The only way I can see insurance companies getting behind it is if there is a clear benefit to them.

The fire unions will do everything within their power to fight it, as everyone in fire knows the only reason FDs are maintaining their funding and staffing levels is because of EMS calls. We can't even get them to support any sort of educational increase, I can't imagine their reaction to a takeover.

I'm not trying to be a pessimist here, but I envision a lot of resistance from all sides.

 

[Veneficus]

But what about the highly motiated people who want an education and want to get on the truck?

It just makes nursing a prereq to be a paramedic. It also has the additional bonus of offering easy transitions to other nursing environments like the ICU when a provider is getting older, injured, or burnt out. Because of the fractured nature and nonportability of EMS, there are relatively few positions for a street medic to transition into comparitively to nursing.

Nursing also has the portability to work in multiple areas at once, where again the medic is severely limited in that. A vast majority of medics cannot work in a public health clinic one shift, home health the next, an occasional ICU rotation and answer emergency calls.

Most who work in EMS do not have your background. Like in many professions EMS is judged by the lowest common denominator. Like I said, it is much easier to teach a nurse skills than a medic knowledge. It also requires less lead time and less radical system change.

2/3 covered by government non fire and private is absolutely laughable, considering the amount of paid EMS that is controlled by fire, look at the major departments covering EMS, From FDNY to LAFD, Chicago, Houston, Philly, Soon to be Cleveland, Memphis, San Diego, and the list goes on and on With a trend towards fire based. Even the nation's Capital is a fire service EMS model. 3rd service really is a minimal exception. Private also a rather small part comparitively when you eliminate IFT only agencies.

Just because a few places in Texas can get intelligent design in their textbooks or rewrite history does not make it a major competitor for nation wide fire based EMS or even a trend.

Now I know many people are proud of being a paramedic. I am still a paramedic. I plan on keeping my certification. I understand people fearing for their jobs in a nursing take over. But the hard truth is that EMS has been unable to unite into an educated valuable and viable profession. It has failed to increase it's value by providing service outside a taxi ride to the ED. It has failed to demonstrate its value as something other than an add on technical cert for fire. It continues to fail by every measure of both healthcare and public safety with the exception of a very few unique services.

US EMS is a failure. Both in system design and value to patients. Paramedics today are no more or less responsible for its failures than those of yesterday. But since EMS cannot seem to fix itself, then it should be fixed from outside, now and before, the best solution as I see it is nursing.

If people who want to work in the prehospital environment are forced to get a nursing degree to continue to be a "paramedic" or EMS provider, I have no sympathy for them. They should have made more effort to developing the trade to begin with.

As for the pay, I have said it before, so I guess one more time. The current amounts paid to EMS for what they provide is unsustainable. It will change because money will dictate it. To maintain value it will have to move into out of hospital care. Some progressive services like Wake county have figured this out. Most have not. They stick their heads in the sand hoping not to see the coming tide. It will not save them.

Paying a nurse to keep people out of the hospital, directing them to the proper care, helping them avoid the need for emergency care with preventative care, and responding to the occasional "emergency" is worth every penny that is spent on it. It will also reduce the amount of pennies needed to be spent on it.

 

[Sasha]

I'd rather have less that care, than more that don't.

I'd rather have someone equipped to deal with my emergency. Basics normally aren't.

 

[Journey]

So, what say you about places like NZ, UK, AU that have Paramedics, and I use this term gritting my teeth, "on par" with nurses? Should the nurses 'take over' EMS there as well?

The U.K. already utilizes nurses as Emergency Care Practitioners along with Paramedics. The ECP utilizes the skills of both and it is not entry level.

As long as you're open to Paramedics replacing nurses in the trauma room... or cardiology... or respiratory.

As long as the Paramedic has 2 - 3 years of college concentrating on that specialty in addition to their Paramedic cert that could be done. The idea of replacing other professions that specialize in something and with another specialty profession makes about as much sense as Physicial Therapists replacing Cardiovascular Technologists in the cath lab. There will also be things done in other specialties and nursing that will exceed the Paramedic scope of practice which creates a problems with the RN or other professional cross covering a patient the Paramedic might have in the ED which can lead to confusion for charting and changing of assignments mid treatment.

Every profession can have a few skills and knowledge that overlaps but if you have something that requires a specialist, someone with a few extra skills and a week's worth of training in that specialty will not do. A nurse or a Paramedic can ambulate a patient in the hallway but a Physical Therapist would be more likely to know how to rehabilitate that person to regain close to full function without causing other problems. A Paramedic might be able to do a few skills like a nurse in the ED but not every patient in the ED requires only emergent skills or the few medications the Paramedic is trained for. There are also other assessments that must be carried out to identify problems for preventitive and long term care.

It seems some may choose a profession like being a Paramedic and then they think the grass is greener on the other side. But, instead of going back to school to be properly trained for that profession, they try to compare skills and some training to the other profession but without really knowing what is involved or seeing the whole picture of their education and training.

 

[Veneficus]

The only way I can see insurance companies getting behind it is if there is a clear benefit to them.

There is a clear benefit to them. Compare the price of sending a home healthcare nurse to a residence to make sure the patient is med complaint compared to the cost of an ALS response to a toxicity problem followed by an ED visit and an ICU stay.

Then compare the cost of treat and release to same said ambulance ride to the ED and workup and discharge.

The fire unions will do everything within their power to fight it, as everyone in fire knows the only reason FDs are maintaining their funding and staffing levels is because of EMS calls. We can't even get them to support any sort of educational increase, I can't imagine their reaction to a takeover.

Just wait till reimbursement is cut to the point that they lose more money than they make. They will drop it in 1/2 a heartbeat.

I'm not trying to be a pessimist here, but I envision a lot of resistance from all sides.

No change is ever without resistance.

 

[Melclin]

I've gotten into trouble regarding my thoughts on nurses in the prehospital environment before (unfairly I think). Before anyone has a go at me, I'm not having a shot at nurses and I'm not saying paramedics are better than nurses full stop or anything stupid like that. I'm essentially saying that the two roles are different enough to require significant cross training if you wanted to swap roles.

I quite like the idea of paramedic practice being a nursing specialty, however, we have a pretty good system that is moving towards being an even better system as it stands so I don't know that, practically speaking, another change would be good.

Also, as it stands now with the way nursing education is here, you couldn't put a nurse on an ambulance. University wise, the paramedic degree requires a much higher entry score than nursing, so it attracts a higher academic standard. There are a lot of people in the paramedic degree who wanted to do medicine and didn't quite make the cut, where as there are a lot of people doing nursing who are lucky to have gotten into university (I'm just talking about what I see around me at my own uni in terms of university entrance scores). Additionally, in the three years nurses spend at school, they don't ever seem to do a subject related entirely to proper patient assessment, Hx & Physical, and the idea of the primary survey being something more than a CPR checklist. Sure they do "obs", but there is a difference. For nurses in roles like the ED, they get taught later, mostly on the job and in the subsequent crit care qualifications as far as I can tell.

I'd also like to add that there are a lot of RNs doing the paramedic degree and they have all been surprised at how much different it is working in less controlled environments, with less time, hands and advice.

This will be an unpopular idea, but they have also commented on the difficulty of making clinical decisions when it is actually your decision (nurses words, not mine). Nurses often comment that they know what to do, they just need a doctor to sign off on it, but its a bit different when it really all falls to you (keeping in mind we don't have online medical control). Similar to the idea JP suggested in another thread the other day. I know nurses in America seem to have a more extensive scope than they do here and I know even here rural nurses, nurse practitioners and ICU nurses often have a lot of autonomy, but its an unfair comparison. They are nurses at the top of their game and I don't doubt their ability. But every paramedic out of uni has to be able to make these decisions, where as nurses have many years to learn, grow and gain experience in clinical judgment in environments that require less autonomous decision making. Those who are not suited to that sort of practice can excel in other areas. When you compare apples with apples and oranges with oranges: Paramedic grad to Nursing grad, Intensive Care Paramedic with Intensive Care Nurse; paramedics at each stage have a greater burden of extensive and focused patient assessment as well as autonomous clinical decision making (this is not to say paramedics are better or necessarily smarter, just that the focus of their role is fundamentally different). I think that the fundamentals of our respective educations need to reflect that.

Like I said, I like the idea in theory, because the most educational experiences I've had in my degree were my hospital placements. I think a year or two of doing rotations through various kinds of nursing before becoming a paramedic would be very beneficial. However, as I've said, you'd have to dramatically change the structure of nursing education if you were to do so.

 

[Shishkabob]

So, Vene, why the push to replace just Medics with RNs? Why not replace RTs with RNs? Sonograpghers with RNs? Rad-techs with RNs?

 

[Journey]

So, Vene, why the push to replace just Medics with RNs? Why not replace RTs with RNs? Sonograpghers with RNs? Rad-techs with RNs?

Not vene but RNs did all of those specialties at one time to some degree. Each profession you just mentioned such as RT, Sonographers and Radiology Technologists are relatively new professions that grew when it was realized these were specialties that required much more than just the performance of a few skills and a brief overview of the principles.

 

[Veneficus]

So, Vene, why the push to replace just Medics with RNs? Why not replace RTs with RNs? Sonograpghers with RNs? Rad-techs with RNs?

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?

 

[8jimi8]

So, Vene, why the push to replace just Medics with RNs? Why not replace RTs with RNs? Sonograpghers with RNs? Rad-techs with RNs?

You didn't realize that nurses used to do all of these jobs until they evolved into their specialized roles?

 

[Shishkabob]

You didn't realize that nurses used to do all of these jobs until they evolved into their specialized roles?

And EMS isn't specialized? Only difference between RT and Paramedic is one currently requires a degree nationally, other only in certain states.

Again, a problem that needs to be remedied, but not a problem that did not exist in other allied health professions at one time or another, either.

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

Yes, actually.


It's not like people in other professions don't try to find easy ways to certification too.

 

[usalsfyre]

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

Actually, if you talk to nurse educators many of the new nursing schools that have sprung up and contributed to the surplus of new grads are the equivilent of "patch factories". And according to my wife, 9 to 10 month non-degree rad-tech programs exist.

EMS failed when we let other people (the government, the fire service, private services) set the standards for entry. Until a committed group of career paramedics seizes control and raises the entry standards (yeah right) then EMS will continue in the crapper.

 

[8jimi8]

And EMS isn't specialized?

Those other professions that you listed evolved out of nursing. Evolved out of the generalist education base.

EMS did not evolve out of a standard body of education.

 

[usalsfyre]

The problem with EMS being involved in dispositioning patients to areas other than the ED is....

...MONEY. Plain and simple.

When EMS gets paid for something other than transport, then paramedics will do more than transport. If this requires more medical knowledge, then they will be forced to obtain it if the services they work for wish to stay in business. At some point the burden of obtaining that knowledge will be shifted to the employee before hire rather than the employer through CE.

However, fixing the reimbursment structure is abour as easy as fixing the educational requirements.

 

[WTEngel]

Actually RTs and paramedics are quite different....