Replacing EMS with nursing revisited

[Medic2409]

IMHO, RN's and Medics are both highly trained, but from different standpoints.

Medics are trained to deal with emergency care and treatment. Primarily, "what can we do to keep this person who is at the point of death alive until we get him to the ED?" Typically, short term care, with oftentimes highly important interventions that must be done rapidly and correctly.

RN's are trained from the opposite standpoint. "What do I need to do to make sure this person will continue to improve until s/he can go home?" Longer term care, highly important interventions, which must be done correctly, however, not always interventions that must be done rapidly.

 

[jjesusfreak01]

Question. In the entirety of the nursing profession, what percentage of nurses would you (anyone may answer) say have ever had to observe, assess, and diagnose an emergent patient, followed by immediately creating a treatment plan based on medical knowledge and evidence based guidelines?

ACLS doesn't count, that's pure cookbook medicine.

PS: The Wake County protocols were adopted almost in their entirely as the new North Carolina protocols for 2010, though individual medical directors have discretion to change them. My 180hr EMT class is followed by 3+ months of time as third rider under the watchful eyes of FTOs before I can be solely responsible for any patient. This is the minimum level of any working provider in the county. ALS competency testing is done by the medical director himself, and any increase in provider level requires entry into the FTEP training program (yeah, just like law enforcement) to ensure there are no weak links in the system.

 

[WTEngel]

Do you know what Magnet Status consists of? Unless you are working in that envirionment and evaluating it, you may only be judging it by the snacks left in the EMS breakroom or the cafeteria. It is amazing how some do put the label of "prestigious" on something when more requirements are made which also involve patient care. Do you know some of the 65 standards minimum that must be met? Is nurse to patient ratio of any importance? What about career advancement for the employees? How about consultation of other professionals? Ongoing education? So many, many factors go into achieving magnet status that you may not know about or take for granted.

Many in nursing will also argue that the ADN is too short to provide a well rounded education complete with all the reading, writing and arithmetic skills as well as the appropriate sciences to advance beyond the tech level which it is still largely considered with nursing now and rapidly becoming one of the least educated professions in the hospital.

But, I see your point and by your arguement, the 6 month cert in the U.S. may not be any better than a degree so EMS should stay right where they are for education.

I am quite well versed in how Magnet designation is achieved. I was employed by one of the largest pediatric level 1 trauma centers in the nation during our push to achieve Magnet designation, and was involved at various levels and on multiple committees. That was the SECOND Magnet facility that I had the pleasure to work at, so yes, you could say I have more than just a "general" idea of what is involved in obtaining Magnet status. Please don't assume that because I am not a RN that I speak about these things without knowing what I am talking about.

My point was that all Magnet institutions are not created equal, and just because a facility met Magnet requirements during their evaluation does not mean they can't backslide and lose their designation on their next evaluation. It has happened before...

Also, how you stacked assumptions in order to come to the conclusion that I feel a 6 month paramedic certification is adequate is beyond me. You can follow my posts in any thread related to education and see that my opinion is pretty clear on EMS degree programs are the only way to achieve professionalism in the industry.

 

[rook901]

I know I'm late coming into this, but I thought I'd throw in my two cents. LPN since 2006, EMT-IV since 2008, and new RN as of this year, so my opinion may not carry as much weight as the more experienced folks.

In the matter of taking new RN's and putting them on the bus, I'd have to say... not no... but, #&$% NO! With no other medical background, a new RN only knows enough to get themselves in trouble. Any good hospital will put a new RN into at least a 3-month orientation, following a preceptor around and not even thinking about looking at a patient funny without the preceptor weighing in. Even when they're out of orientation, they have LOTS of other nursing staff on the unit to help out if the SHTF. When you're out in the field, it's just the medic and the EMT. The only way that I would support putting an RN onto a unit is if you're riding two RN's, with the senior RN having at least a few years of experience.

Which leads to the next problem - money. No way is an RN spending anywhere from three to five years getting an ADN or BSN (counting pre-req's) only to get a job on the bus making $14/hr. I just don't see it happening, especially in the numbers that you would need to cover double-RN units across the whole of EMS. Of course, if it were mandated that ambulances had to be staffed by RN's, the pay scale may have to come up to whatever the market demanded. This would put the vast majority of privates out of business and would significantly increase taxes as government services would have to step in where the privates left off.

I'm not sure what the answer is, but I don't think this is it, simply based on cost. Unfortunately, EMS in the United States is what it is. It's a way to get people into the ED. Attempting to change EMS into some sort of community health service just isn't going to work, as much as I would like it to. Your truly sick patients need to go to the ED regardless of what you can offer them in the field. Your not-so-sick, attention-whoring, drug-seeking type patients are going to demand to go to the ED anyway. I think the number of patients that you would be able to keep out of the ED with a community health model would be nominal, and wouldn't justify the increased expense.

 

[rook901]

On another note, if I were able to make one suggestion that would be a huge improvement for EMS, it would be to disassociate EMS with Fire. EMS has always been and will always be nothing more than a way to increase call numbers for the FD to get more money to buy more shiny red engines. If the FD spent their money proportionately to the number of fire calls vs EMS calls, fire-based EMS would be something to marvel at. As it stands now, you have too many folks getting their medic just to get a ride on the engine and too many FD's sending engine companies along with their units on nosebleed calls just to chalk up another engine response.

Knock fire down to the first responder level, put EMS in the hands of the local Dept of Health, and go from there.

 

[Medic2409]

On another note, if I were able to make one suggestion that would be a huge improvement for EMS, it would be to disassociate EMS with Fire. EMS has always been and will always be nothing more than a way to increase call numbers for the FD to get more money to buy more shiny red engines. If the FD spent their money proportionately to the number of fire calls vs EMS calls, fire-based EMS would be something to marvel at. As it stands now, you have too many folks getting their medic just to get a ride on the engine.

Knock fire down to the first responder level, put EMS in the hands of the local Dept of Health, and go from there.

Amen Brutha!

I think the ATC EMS or Williamson Co. model are the best things going.

Third service, preferably County wide, and do it up right!

Prob is, and I know we're getting a bit off topic, how many counties are willing to spend the amount of money required to do it right?

 

[abckidsmom]

IMHO, RN's and Medics are both highly trained, but from different standpoints.

Medics are trained to deal with emergency care and treatment. Primarily, "what can we do to keep this person who is at the point of death alive until we get him to the ED?" Typically, short term care, with oftentimes highly important interventions that must be done rapidly and correctly.

RN's are trained from the opposite standpoint. "What do I need to do to make sure this person will continue to improve until s/he can go home?" Longer term care, highly important interventions, which must be done correctly, however, not always interventions that must be done rapidly.

I disagree with this notion. As a medic, I seldom encounter a situation that is a true, life-threatening emergency. And every single intervention we take, every decision we make- should be based on that long-term perspective. Making decisions based on the needs of only the next hour is a way to engage tunnel vision.

 

[abckidsmom]

Question. In the entirety of the nursing profession, what percentage of nurses would you (anyone may answer) say have ever had to observe, assess, and diagnose an emergent patient, followed by immediately creating a treatment plan based on medical knowledge and evidence based guidelines?

ACLS doesn't count, that's pure cookbook medicine.

ACLS isn't exactly cookbook medicine. The algorithms all go to "consider the causes" and that's where the patients are actually fixed.

In the entirety of the nursing profession, not many nurses observe, assess and diagnose an emergent patient, but nurses CAN totally do this. Not all nurses, I will definitely grant that most nurses wouldn't even want to function outside the hospital, but we've had flight nurses for a long time and they are typically pretty handy on scenes.

I don't realistically see this fix for the education problem happening, but if we had a magic switch date by which we could implement the paranurse system, I think it could work.

The real trouble is in the transition. The IAFF will never let it happen, and I'd really doubt the ANA would either.

 

[Aidey]

When it comes to consider the causes though a RN can't do anything more than a Paramedic though.

 

[Medic2409]

I disagree with this notion. As a medic, I seldom encounter a situation that is a true, life-threatening emergency. And every single intervention we take, every decision we make- should be based on that long-term perspective. Making decisions based on the needs of only the next hour is a way to engage tunnel vision.

I didn't say we always have to make rapid life/death decisions. We are, however, trained to do so should the need arise.

Case in point, and only a possible example, most RN's aren't trained in how to extricate a patient in an MVC. If not done right, further harm can be caused to the patient. We have to know how to get the pt. properly extricated, packaged, stabilized, and transported. Like I said, only an example.

I can, however, provide another example. At a local ER a pt. arrived POV c/o pain in his leg/thigh, he was placed in the car by a friend, was unable to ambulate, and in pain. The only Medic working in the ED that day was the one who told me about this. He and several RN's went out to the car to assist the pt. Upon making pt. contact it was discovered the pt. had classic shortening and rotation of his LLE, pointing to a?? Yep...fx. femur. The Medic had to locate a Traction splint, and then teach the RN's how to apply it and get the pt. in the ER without causing further harm. I'm not knocking the RN staff, but none of them knew how to do this, and could only assist the Medic as he did the job.

The practice of Medicine is a Team concept, far too many have forgotten this.

 

[rook901]

When it comes to consider the causes though a RN can't do anything more than a Paramedic though.

Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?

 

[rook901]

Prob is, and I know we're getting a bit off topic, how many counties are willing to spend the amount of money required to do it right?

Well, you take the portion of money that Fire is getting for their bloated call volume and dump it into DoH-run EMS, and I think you have your money right there.

But that's not going to happen as long as the IAFF is around, as others have pointed out.

 

[abckidsmom]

I didn't say we always have to make rapid life/death decisions. We are, however, trained to do so should the need arise.

Case in point, and only a possible example, most RN's aren't trained in how to extricate a patient in an MVC. If not done right, further harm can be caused to the patient. We have to know how to get the pt. properly extricated, packaged, stabilized, and transported. Like I said, only an example.

I can, however, provide another example. At a local ER a pt. arrived POV c/o pain in his leg/thigh, he was placed in the car by a friend, was unable to ambulate, and in pain. The only Medic working in the ED that day was the one who told me about this. He and several RN's went out to the car to assist the pt. Upon making pt. contact it was discovered the pt. had classic shortening and rotation of his LLE, pointing to a?? Yep...fx. femur. The Medic had to locate a Traction splint, and then teach the RN's how to apply it and get the pt. in the ER without causing further harm. I'm not knocking the RN staff, but none of them knew how to do this, and could only assist the Medic as he did the job.

The practice of Medicine is a Team concept, far too many have forgotten this.

RN/EMT-P team...champions!

Seriously, though...both of those can be taught to the motivated provider in a completely reasonably-taught class of less than a couple of months.

 

[Medic2409]

Well, you take the portion of money that Fire is getting for their bloated call volume and dump it into DoH-run EMS, and I think you have your money right there.

But that's not going to happen as long as the IAFF is around, as others have pointed out.

Agreed. Firefighters have pretty much worked themselves out of a job. Kinda funny if you think about it, though, just a coupla decades ago FD's didn't have ANYTHING to do with Medical.

 

[WTEngel]

Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?

Yes, multiple times.

 

[jjesusfreak01]

In the entirety of the nursing profession, not many nurses observe, assess and diagnose an emergent patient, but nurses CAN totally do this. Not all nurses, I will definitely grant that most nurses wouldn't even want to function outside the hospital, but we've had flight nurses for a long time and they are typically pretty handy on scenes.

Maybe they can, maybe they can't, but in most states you don't get out of medic school (much less get a job anywhere) unless you can do this. For a medic, every skill they learn in class is a base skill. They have to be able to do every one at any point or someone dies. Sure, some nurses would make great paramedics, but its a totally different mindset. I neither fault them nor expect them to want to work in EMS, it isn't what most of them signed up for.

I disagree with this notion. As a medic, I seldom encounter a situation that is a true, life-threatening emergency. And every single intervention we take, every decision we make- should be based on that long-term perspective. Making decisions based on the needs of only the next hour is a way to engage tunnel vision.

Two calls yesterday.
1. Pulmonary Embolism showing as a STEMI
2. VT (with pulses, but on the edge of falling into Vfib) on a patient that was FTD when we arrived on scene (shocky as anything you've seen before). This patient would have been dead within a few minutes if a medic unit (on which I was riding) hadn't arrived to cardiovert.

No decision made by the medics should be taken entirely without thought of long term effect. Long term consequences mean nothing if the patient dies, but evidenced based medicine in EMS strives to protect both the current and future well being of the patient. No protocol is going to prescribe a treatment that keeps a patient alive for 5 minutes if it guarantees they die in 10.

Really? Just off the top of my head... ever set up a KCl drip as a medic?

Ever do that as a nurse without explicit doctor's orders? That's a silly example, pick something that a medic can't do because of their scope of practice, not something they can't do because they don't carry the drug on the truck.

 

[abckidsmom]

Two calls yesterday.
1. Pulmonary Embolism showing as a STEMI
2. VT (with pulses, but on the edge of falling into Vfib) on a patient that was FTD when we arrived on scene (shocky as anything you've seen before). This patient would have been dead within a few minutes if a medic unit (on which I was riding) hadn't arrived to cardiovert.

Good day at work! If all you did was drive the PE patient to the hospital, do you think the outcome would have changed?

Ever do that as a nurse without explicit doctor's orders? That's a silly example, pick something that a medic can't do because of their scope of practice, not something they can't do because they don't carry the drug on the truck.

Nurses hang K all the time because the K is low. No MD involved at all.

 

[Aidey]

Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?

No, but that isn't saying that medics can't.

Here is my problem with that example, in most cases an RN is doing that because a MD ordered it after reviewing lab tests. The exceptions I can think of are CCT teams that have I-Stat capabilities, and in those cases the team could have either an RN or a Paramedic on it.

Edit: Or the RN hung it because there are standing orders that if the patient's K is a certain number they get a drip at whatever appropriate rate.

 

[Medic2409]

Really? Just off the top of my head... ever set up a KCl drip as a medic? Ever hung blood products as a medic?

Who gives a rat's ***? C'mon now, want another real life example?

Young male, football player, bad hit, significant neck pain with numbness and tingling in all 4 extremities.

Medic crew arrives to find the pt. supine, pads removed, helmet left on.:blink::blink:

What do you do at this time?

Personally, I was taught they either both stay on, or they both are removed. Never do you remove one without removing the other.

As the Medic crew began to properly remove the helmet, a RN on scene began to shriek at the crew, "No, you WILL NOT remove that helmet!"

Once it was proven that the RN was not a parent of the child, she was properly removed at EMS request.

Once the pt. was heli-evacuated the local FD (all vollies) stated to the EMS crew that the RN had taken over the scene, and removed the pads. This occurred in an extremely small town where everyone knows everyone else, and since the RN worked in a Trauma Center in the big city, they thought she knew what she was doing.

Hmmmmm................... makes ya wonder, now don't it!

 

[rook901]

Ever do that as a nurse without explicit doctor's orders? That's a silly example, pick something that a medic can't do because of their scope of practice, not something they can't do because they don't carry the drug on the truck.

It's not on the truck because... *drumroll*... it's not within scope of practice.

Don't pull the "nurses just wait around for doctors to give them orders" nonsense. ER and ICU nurses have standing orders that allow them to operate without MD handholding. Medics do not practice medicine independent of MD supervision. Protocols are explicit doctor's orders. Online medical direction is the same.

Granted, a nurse will not hang blood without an order, but the statement I responded to was that RN's cannot do any more than a medic as far as ACLS goes (I would argue that hanging drugs/blood product is a component of addressing the causes in the scope of ACLS). Hanging KCl could be a standing order based on the labs. While the standing order is an explicit MD order, it is not handholding.