Texas ENA position paper against EMS

[TransportJockey]

http://unwiredmedic.com/2015/04/24/texas-enas-unprofessional-attack-on-ems/

I posted a blog with a rebuttal, but the original letter by the president of the ENA is there too.

 

[Carlos Danger]

Never been a fan of the ENA, even when I briefly worked as an ED nurse, or the years that I worked as a flight nurse. I am well aware of times that the ENA has unfairly attacked and frankly been quite insulting to paramedics.

But I didn't see any paramedic-bashing in this ENA letter. I would agree that the ENA overstates the differences in educational preparation between nurses and paramedics and also the ability of nurses to practice "autonomously" vs. a paramedic, but I wouldn't call that "fear mongering", or an attempt to "hold their siblings down in mediocrity" or "attack their intelligence", as the blog post says. In fact there's much more hyperbole in the blog post than in the ENA letter.

I'm generally not a fan of protectionism (using the law or politics to keep your competition at bay), but nor am I a fan the reverse of that, where profession A uses politics to crowd into profession B's territory when there is really no market demand for profession A there. I don't know if that's what is trying to be accomplished by the bills in question, but unless there is a real shortage of ER nurses and techs in Texas, it would appear that this is more a case of paramedics attacking RN's than the other way around.

What would Texas paramedics say about a bill that allows RN's to work EMS with no EMS training or certification? They would oppose it, of course, writing letters to each other stressing and exaggerating how much more highly prepared they are for the prehospital environment than nurses, and how nurses shouldn't be allowed on ambulances. And they'd be right.

 

[DrParasite]

the ENA is probably just like the IAFF... they support only their point of view (and omitting any facts that they disagree with), support only their members, and do whatever they can to put forth their agenda, even if it is at the expense of other providers who their line staff work side by side with day in and day out.

If you are in the ENA, you probably want them to do what they can, as you will probably benefit from what they are trying to do.

if you aren't in the ENA, you should probably work on creating a unified voice to advocate what you do, why you should get paid well to do it, and why people should listen to you, and not those idiots at the ENA who aren't looking out for your interests one bit.

BTW, if you were to write a response, I would start off with saying "a nurse can't fart without getting approval from a doctor; on the other hand, a paramedic can initiate care, establish IV access, put a tube down a person's throat, interpret a cardiac monitor and give medications based on what they see, establish a treatment plan, activate a trauma team, and only needs to call a doctor if they need to consult about a patient. So who do you think is the autonomous provider?"

But then I would be just as one sided as the person who wrote the ENA letter.

 

[OnceAnEMT]

I am very confused by this article, but perhaps I am just missing something. Everything stated can already be done, as long as there are standing orders or a verbal order given. Paramedics in the ED I am at push meds (a higher scope than "normal", but slightly less than RN, I do not know specifics). They can defibrilate.

"The Texas Board of Nursing rules limits what tasks can be delegated to others. This restricts paramedics from administering medications and intravenous fluids in the hospital setting." Maybe the word "specific" is missing in here.

Sounds like an RN is getting butt hurt over the fact that some paper says a Paramedic could intubate in the ED. I started a thread before about licensing and standing orders, and this thread seems to beg the same question. As long as a doc is giving the green light, they can do anything. Unless of course that doc has order restrictions from the hospital protocols, saying you can't order a Paramedic to intubate.

But again, all of the above is already happening. So what is the fuss?

 

[Carlos Danger]

BTW, if you were to write a response, I would start off with saying "a nurse can't fart without getting approval from a doctor; on the other hand, a paramedic can initiate care, establish IV access, put a tube down a person's throat, interpret a cardiac monitor and give medications based on what they see, establish a treatment plan, activate a trauma team, and only needs to call a doctor if they need to consult about a patient. So who do you think is the autonomous provider?"

Where in the US can a paramedic provide ALS-level care without a physicians' permission? RN's do every one of those things, too, and much more - with standing orders - just like paramedics do.
RN's and paramedics are actually almost identical in this way. It is an absolute myth perpetuated by ignorant paramedics that RN's in the hospital aren't allowed to do anything with a patient until a doctor comes by and tells them what to do.

FWIW, the reason nursing organizations talk about RN's being "autonomous providers" is because traditional nursing (not in the ICU or ED) is autonomous. Most nursing actions do not require a physician order. This is not really relevant to the discussion at hand, so it shouldn't have been even mentioned in the ENA email, but that is why they say it.

Sounds like an RN is getting butt hurt over the fact that some paper says a Paramedic could intubate in the ED.

I have no idea what prompted the email from the TENA, but I doubt it was over a paramedic intubating in the ED. Nurses tend not to get all worked up over individual skills like paramedics do.

As I said before, if a bill were presented that called for RN's to be able to work on ambulances, the EMS community's response would be very similar.

 

[OnceAnEMT]

As I said before, if a bill were presented that called for RN's to be able to work on ambulances, the EMS community's response would be very similar.

But what is the point of the bills presented? What would change if they became law? It really seems like a formality, just recognition of reality.

 

[DrParasite]

Where in the US can a paramedic provide ALS-level care without a physicians' permission? RN's do every one of those things, too, and much more - with standing orders - just like paramedics do.
RN's and paramedics are actually almost identical in this way. It is an absolute myth perpetuated by ignorant paramedics that RN's in the hospital aren't allowed to do anything with a patient until a doctor comes by and tells them what to do.
...
FWIW, the reason nursing organizations talk about RN's being "autonomous providers" is because traditional nursing (not in the ICU or ED) is autonomous. Most nursing actions do not require a physician order. This is not really relevant to the discussion at hand, so it shouldn't have been even mentioned in the ENA email, but that is why they say it.

See, this is exactly what the ENA is doing.... putting information that isn't relevant to the situation to support their case.

The author in question is an EMERGENCY ROOM nurse. As you stated, an ER nurse is not autonomous, and I'm pretty sure the issue in question involves EMERGENCY situations. So the fact that traditional nursing is autonomous isn't relevant to the topic at hand, because the bill primarily deals with ER paramedics.

I didn't say a paramedic could provide care without a paramedics permission; what I said was a paramedic doesn't need to speak to a doctor before they treat a patient, and can perform all those interventions before they speak to a doctor, especially in an emergency situation. I'm sure RNs have standing orders, just like paramedics; however, in an emergency setting, an RN still needs to get a doctors order to do something (see your statement about the ER and ICU, I didn't say that), while a paramedic can perform interventions (if they fall under their standing orders) and then consult with the doctor after if they want to do more or something else.

The exact quote from the author in question states "This bill allows EMTs and EMT-Paramedics the authority to provide healthcare services including advanced life support in hospital emergency rooms and freestanding emergency medical care facilities under a physician delegation." So what nurses do in healthcare doesn't apply; the bill says it's only in a hospital ER or a freestanding ER, and in this case, a nurse needs to get a doctors approval (your words, not mine).

 

[SandpitMedic]

See, this is exactly what the ENA is doing.... putting information that isn't relevant to the situation to support their case.

The author in question is an EMERGENCY ROOM nurse. As you stated, an ER nurse is not autonomous, and I'm pretty sure the issue in question involves EMERGENCY situations. So the fact that traditional nursing is autonomous isn't relevant to the topic at hand, because the bill primarily deals with ER paramedics.

I didn't say a paramedic could provide care without a paramedics permission; what I said was a paramedic doesn't need to speak to a doctor before they treat a patient, and can perform all those interventions before they speak to a doctor, especially in an emergency situation. I'm sure RNs have standing orders, just like paramedics; however, in an emergency setting, an RN still needs to get a doctors order to do something (see your statement about the ER and ICU, I didn't say that), while a paramedic can perform interventions (if they fall under their standing orders) and then consult with the doctor after if they want to do more or something else.

The exact quote from the author in question states "This bill allows EMTs and EMT-Paramedics the authority to provide healthcare services including advanced life support in hospital emergency rooms and freestanding emergency medical care facilities under a physician delegation." So what nurses do in healthcare doesn't apply; the bill says it's only in a hospital ER or a freestanding ER, and in this case, a nurse needs to get a doctors approval (your words, not mine).

This!

I love it when the RNs get all worked up about how they can do things autonomously too. (Like Remi's post, for example.)

There is a stark difference between the autonomous nature of what an ER RN can do and what a paramedic can do.

To ask where a paramedic can provide ALS procedures without a doctor's say so or over watch is like watching paint dry. It is a boring question with no real purpose. It's a spin. Sure, I have a protocol soup written by a doctor... However, those protocols are very fluid. They are broad and wide, and I can pick and choose what I want to and don't want to do based on what I find in my assessment. Without any "permission" on the scene, nor a doctor looking over my shoulder.

As a paramedic I am an extension of the doctor, with 99% authority to act autonomously. As a an ER RN you are not an extension of the physicia- you are a Registered Nurse. You can only go so far as to do what the doctor says, when he says to do it - period. (Not withstanding simple procedures like IV ACCESS, and CPR INITIALLY.) Even to draw blood and get a bag of NS takes an order.

(That's not even to mention the advanced skills that RNs aren't even practiced or trained in: EJs, EKGs, needle decompressions, intubations, IOs, etc.)

Rediculous to say otherwise... As a nurse or anyone else.

I am not discounting RNs. They play a vital role in the healthcare system, and an even more vital role in the ER. They are great at what they do. But there is no comparing the autonomy of each, it's apples to oranges.

 

[SandpitMedic]

Also, I can deviate from those protocols, and notify a doctor via telemetry.
And then fill out a .... Protocol deviation form.

At least in my AO we have that ability.

 

[OnceAnEMT]

This!

I love it when the RNs get all worked up about how they can do things autonomously too. (Like Remi's post, for example.)

There is a stark difference between the autonomous nature of what an ER RN can do and what a paramedic can do.

To ask where a paramedic can provide ALS procedures without a doctor's say so or over watch is like watching paint dry. It is a boring question with no real purpose. It's a spin. Sure, I have a protocol soup written by a doctor... However, those protocols are very fluid. They are broad and wide, and I can pick and choose what I want to and don't want to do based on what I find in my assessment. Without any "permission" on the scene, nor a doctor looking over my shoulder.

As a paramedic I am an extension of the doctor, with 99% authority to act autonomously. As a an ER RN you are not an extension of the physicia- you are a Registered Nurse. You can only go so far as to do what the doctor says, when he says to do it - period. (Not withstanding simple procedures like IV ACCESS, and CPR INITIALLY.) Even to draw blood and get a bag of NS takes an order.

(That's not even to mention the advanced skills that RNs aren't even practiced or trained in: EJs, EKGs, needle decompressions, intubations, IOs, etc.)

Rediculous to say otherwise... As a nurse or anyone else.

I am not discounting RNs. They play a vital role in the healthcare system, and an even more vital role in the ER. They are great at what they do. But there is no comparing the autonomy of each, it's apples to oranges.

...unless a physician provides standing orders. Or is that not a thing for RNs? I understand that yes, at some point a unique order will have to be given to be that bit of "definitive care", but is it simply too much to have standing orders? For instance, triage EKGs. An order may show up eventually, but we are preforming that EKG before the Pt is even in our system. I assume this is because in some dusty book somewhere in our director's office protocols are provided to physicians from the Chief Medical Officer of the hospital, and then a separate book defining standing orders for RNs and paramedics in the department.

 

[SandpitMedic]

No, not standing orders in the EMS sense. (Besides like an I/V, O2, etc) Read- not invasive. Essentially, the answer is no, but folks will argue that because they don't like the ideology behind that little factoid.

ERs here run stat EKGs on arrival here too- they print it and run the doctor with it. They have EKG techs. No one interprets it but the doc... Or a nearby medic (who has usually already done their own.) I've met few RNs who know about EKGs and even less that know anything other than ST elevation (only.)

 

[Carlos Danger]

I love it when the RNs get all worked up about how they can do things autonomously too. (Like Remi's post, for example.)

I'm not sure if you are just trying to bait me or what. The only folks I see getting worked up about anything here are the paramedics who get hysterical because of some stupid email sent out by some stupid state ENA chapter. I do not nor do I ever plan to live or work in Texas in any capacity. If I did move there for some reason, I would not likely work as either a paramedic or an RN. So frankly, I don't care in the least what happens there.

The only reason I even commented here was, quite honestly, to help you guys out. There is a lot of misunderstanding among paramedics about what nurses do, what their scope of practice is, and what there motivations may be for sending out communication like the one the TENA did. And your post here proves that perfectly; it's exactly the type of ignorance that keeps you guys chasing your tail about this stuff.

"But....but.....we can INTUBATE, and they can't!!!"

There is a stark difference between the autonomous nature of what an ER RN can do and what a paramedic can do.

No, there really isn't. Ask me how I know.

There is a stark difference in practice environment, obviously, and the out-of-hospital environment clearly lends itself to performing with less direct physician oversight. But that does not mean what you think it does.

Again, ask me how I know.

...unless a physician provides standing orders. Or is that not a thing for RNs?

Yes, it is a thing. Nurses start IV's, draw labs, treat labs, get EKG's, place foleys, start drips, titrate drips, D/C drips, run vents, run codes, call alerts, deviate from protocols, etc. - plus much more - all day long on standing orders, just like paramedics do. I've had many busy days in the ICU where I worked my *** off with a sick patient (or two) without ever seeing their physicians other than rounds first thing in the morning.

Paramedics cannot legally do anything other than simple BLS without a physician's order. Neither can RN's. There is no difference.[/QUOTE]

 

[SandpitMedic]

Once again- we are not talking about ICU nurses, Remi.

Irrelevant.

Also, there is a little more to it than intubating. And as I said, my orders are fluid and encompass a whoooole lot, of which I can pick & choose what is appropriate for each patient. Not to mention, the protocol deviation. ER RNs do not have the same practice.

Next.

 

[SandpitMedic]

Also, paramedics get all "spun up" because it is us that are constantly trying to defend ourselves from all angles... Corporate, government, the public, clinical, and the guy writing the checks.

We are treated like step children. And we're ****ing sick of it.

If the shoe were on the other foot, it would be the nurses getting all fired up. But it isn't.

 

[Carlos Danger]

Once again- we are not talking about ICU nurses, Remi.

Irrelevant.

Also, there is a little more to it than intubating. And as I said, my orders are fluid and encompass a whoooole lot, of which I can pick & choose what is appropriate for each patient. Not to mention, the protocol deviation. ER RNs do not have the same practice.

Next.

This attitude is a large part of the reason why you see so many people who move on from EMS fail to stay involved, even though they loved EMS and swore they'd never leave comepletely.

Keep believing these myths and wallowing in your own ignorance. No skin off my back.

 

[SandpitMedic]

What am I talking about?!

I'm just a garbage man....right?

 

[DrParasite]

The only reason I even commented here was, quite honestly, to help you guys out. There is a lot of misunderstanding among paramedics about what nurses do, what their scope of practice is, and what there motivations may be for sending out communication like the one the TENA did. And your post here proves that perfectly; it's exactly the type of ignorance that keeps you guys chasing your tail about this stuff.

"But....but.....we can INTUBATE, and they can't!!!"

Ummmm I'm quite clear on what a nurse can do.... In an emergency situation (or any unplanned event), a paramedic can do more without asking for online medical control. yes, both RN and paramedics have standing orders, but paramedics have a lot more autonomy than nurses. In fact, the letter the Texas ENA president is sending out is spewing ignorance about paramedics, to a politician, and she is hoping to advance her profession at the expense of EMS professionals.

Quite honestly, they are acting like bullies; they feel threatened by paramedics so they are telling half truths to an important person, trying to say how awesome they are at the expense of another profession. And if the roles were reversed, we both know that the nursing associations would be up in arms over it.

Yes, it is a thing. Nurses start IV's, draw labs, treat labs, get EKG's, place foleys, start drips, titrate drips, D/C drips, run vents, run codes, call alerts, deviate from protocols, etc. - plus much more - all day long on standing orders, just like paramedics do. I've had many busy days in the ICU where I worked my *** off with a sick patient (or two) without ever seeing their physicians other than rounds first thing in the morning.

Paramedics cannot legally do anything other than simple BLS without a physician's order. Neither can RN's. There is no difference.

So a nurse can administer morphine before a doctor tells them to do it? they can interpret EKGs and initiate treatment based on it, correct? The only time I have ever seen a nurse run a code is until a doctor arrives to take over. Paramedics can place foleys too, just in case you were wondering.

BTW, a nurse can do more than a paramedic. a nurse can administer blood products. and can administer more medications. and are much better trained to deal with long term care. and end of life care. and a bunch of other stuff. This I completely understand, and I think most do too.

But in an emergency situation (whether it be an ER, a new patient and the urgent care, or a 911 call), a paramedic operates with more autonomy, and can treat a patient without a verbal consultation from a doctor on how the patient will be treated.

This attitude is a large part of the reason why you see so many people who move on from EMS fail to stay involved, even though they loved EMS and swore they'd never leave comepletely.

Keep believing these myths and wallowing in your own ignorance. No skin off my back.

actually, it's usually because of the low pay for EMS, poor chances for advancement, lack of things to do besides be on an ambulance, and once your blow your back, you are pretty much screwed. If you think otherwise, than you are "believing these myths and wallowing in your own ignorance."

Oh yeah, and the fact that there isn't any large scale group who can convince politicians that EMS is worth funding, at least compared to other jobs that do similar functions.

It isn't ignorance, but if you want to keep putting down your current profession (you are a paramedic right?), and keep drinking the nursing kool aid..... Maybe one day EMS will have their own organizations to convince the politicians to drink the EMS Kool aid...

Signed,
An ambulance driver.

Also, paramedics get all "spun up" because it is us that are constantly trying to defend ourselves from all angles... Corporate, government, the public, clinical, and the guy writing the checks.

We are treated like step children. And we're ****ing sick of it.

If the shoe were on the other foot, it would be the nurses getting all fired up. But it isn't.

Well said. We, as an industry, are underpaid, under staffed, and no one wants to do anything for EMS until they need EMS.

Remi, I understand that everyone is looking out for themselves, but if you expect me to sit quietly while another healthcare professional tells half truths and lies to a politician about my industry, so they can advance their agenda, well, then maybe you should go back to nursing. If you want to help out EMS, why don't you write a letter to a politician saying how as a credentialed nurse, a paramedics can do a whole lot more than the president of the Texas ENA chapter is claiming. I mean, you are a supporter of EMS right?

 

[Handsome Robb]

Pretty sure Remi was a Paramedic, ER/ICU/Flight Nurse and is now a CRNA.

I really don't want to get involved in this but what I will say is while the letter is inflammatory we do have less education.

They put us down in the letter, that's pretty obvious and some of the information is incorrect however we do operate similarly when it comes to standing orders, that's exactly what protocols are. Some systems allow deviation from protocol while others do not. Some systems allow a lot of autonomy while others require OLMC contact for damn near everything outside of an ALS assessment.

What I don't understand is what are we accomplishing Pickering about semantics on an online forum?

Yes, ICU nurses operate under a rather comprehensive set of standing orders. Some ER nurses have a wide set of standing orders while others do not.

 

[Tigger]

Yet another reason why paramedic certificates need to die. While I don't necessarily believe that having an associates or bachelor's degree in EMS would necessarily result in a drastic betterment in care, it would do a lot when this sort of crap comes up. At the end of the day, the "nursing voice" will win out over EMS's because they have the education that the healthcare community deems necessary. For the most part, EMS doesn't.

If you want a seat at the big kid's table you have to earn it. We can stomp our feet all we want about how it's not fair, but that's not going to change the outcomes. All this arguing about skills and standing orders is a waste in the scheme of things. The rest of healthcare has moved far beyond this.

 

[04_edge]

I don't understand what the big deal is about all of this. A single nurse wrote a letter on behalf of the ENA promoting her own agenda. As someone else said, we would be just as emotional about this subject if it was being pushed for nurses to begin providing prehospital care. I have worked part time as a tech in the ER and I enjoyed it. It was easy money and good learning experience that i wouldn't have been able to get anywhere else. However, not once did i ever have the desire to perform at the same scope of practice as i do pre-hospital.

If we want to be treated as professionals, we must first act as professionals. Belittling nurses because "they can't intubate and we can," is not proactive and is exactly the mindset that has caused us be looked upon as less than professionals to begin with.