VentMedic

I initially did my OJT as an RT at the VA after several years as an EMT-P. Needless to say, if I thought I was good at intubating in the field, I achieved perfection at the VA. Esophageal placement was not an option.

IF they are HIRED as a Paramedic you can ASSUME that is correct. However, for many states the Paramedic license is strictly prehospital and not valid inside the hospital. If you are working under the title of ER Tech and not Paramedic inside the hospital, you may not be working under your Paramedic license. You do not have to be a Paramedic to be an ER Tech with advanced skills in the hospital. Many of the skills that a Paramedic possesses are used by many other trained personnel inside the hospital.

Report should be given to a licensed professional of equal or higher status who is working in the level of that license. If a paramedic is working as an ER Tech, they are functioning under the title the hospital has given them and not necessarily as a function of their certification or licensure. If they assume responsibilty for a patient while working in a nonlicensed position, there could be dire consequences if something happens to the patient later and the licensed person was not made aware of the patient or their condition. Florida already has case precedence for this in their court system unfortunately.

Just like they do it on TV! Or, is that the nasal cannula hooked up to the ventilator?

We used a football helmet to secure the Blakemore tube.

Did she take the Blakemore from the patient?

Novisen, What CPAP or PEEP valve are your using? Are you running all your patients at approximately an FiO2 of 0.30? High PaO2 is not the issue in the initial phase. High CPAP level can affect affect hemodynamics. Flow too high can increase expiratory work of breathing. Flow too low can increase inspiratory work of breathing. 1 bar = 14.5 psi 1 Cubic foot = 28.31 liters H tank is 56 inches in Height with a Diameter of 9 inches M tank is 47 inches in Height and 7 inches in diameter D tank is 20.25 inches in Height and 4.25 inches in diameter American tanks are usually filled to 2200 psi. Some composite tanks can hold up to 3000 psi. Respiratory equipment such as ventilators or the Whisperflow run off a working pressure of 50 psi. Size*** Factor *** Liters H **** 3.14 **** 6908 G **** 2.41 **** 5302 M**** 1.65 **** 3625 E **** 0.28 **** 616 D **** 0.16 **** 352 B **** 0.068 **** 150 A **** 0.035 **** 76 Number of liters available in a tank = (PSI)(Conversion Factor) For those that don't remember the conversion formula I mentioned earlier: minutes = (PSI)(Conversion factor)/liter flow

The O2 cylinders you have available and transport distance should be discussed prior to any service purchasing a CPAP device. I use the term device because very few prehospital CPAP gadgets qualify as a machine. The salesperson or clinical trainer for the CPAP device or machine should have thoroughly discussed all ups and downs to using that particular CPAP device. The manufacturers did do elaborate studies and do have all the information for O2 consumption of their product. If you know the flow required from your tank, you can do the math with the cylinder factor. The other thing to consider, which is dependent on the machine or device you are using, is what happens to total flow if you adjust the FiO2. Different systems will have different venturi type entrainment systems which can dramatically affect total flow to the patient by just changing the FiO2. Many systems are dependent on room air entrainment for total flow thus a higher FiO2 can actually decrease the total flow to a patient requiring more minute volume than the device can provide at the higher FiO2. A 15 liter flow is not much for someone in distress that wants 25 liters for MV. CPAP has been around for more than 50 years. I've used it for transport for almost 30 years through various ventilators and flow generators. Some of the ventilators were more gas efficient than some of the CPAP devices on the market now. Good article link listed below that shows some of the factors looked at when selecting CPAP units. These things should be asked of a clinical salesperson as they pertain to you patient population and transport time. Due to fatique from work of breathing for the patient, we would not consider using any of the prehospital devices in the ED for any longer than a switchover to a hospital machine or a quick post op recovery. http://www.cardinal.com/mps/focus/respirat...3%20Branson.asp

Like I mentioned I try to maintain the 5 foot rule even with family when they are coughing and sneezing. In the late 1980s a large county hospital had 10 RTs contract an atypical strain of TB. That was a life altering event for all of them. Since that time we have gone to great lengths in improved masks and room filtering systems. Luckily, those same precautions could be used for many infectious diseases. What we have found is that patients who are at risk for TB may also be harboring many other diseases such as Hep C, MRSA and pseudomonas. Pertussis Here is a pertussis website that offers a good overview. http://www.pertussis.com/ Pertussis or Whooping Cough is bacterial spread by droplets. Adults, especially seniors or immunosuppressed by chemo or disease, can be gravely affected. For members of these groups, contracting any disease that should be left in childhood can become deadly or require lengthy medical treatment. The problem with bacterial infections is that they may require big gun antibiotics which then makes the body open for another infection requiring even stronger antibiotics. These antibiotics may then weaken or damage various organs which then creates more problems. A good example of the perils of antibiotic therapy is a nurse who was treated for a nasal MRSA infection. The antibiotics given created the opportunity for another bacterial infection called Clostridium Difficile or C. Diff as you will hear the term in nursing homes. This required more treatment and at 6 months out, he is still in antibiotic hell. We usually see a rise in childhood diseases when politicians start to make illegal immigration an issue and the members of that population are fearful to take their kids to the county clinics for immunizations. When it comes to healthcare for kids I believe the acts of the adults should not be held against the kids. Varicella can offer a deadly potential for adults especially in the form of PNA. My varicella titer was definitely positive until I turned 40. I then had two negative titer tests. Of course, I then was given the vaccine to continue working with kids in the hospital. I also change clothes at work. My work shoes are left by (not in) my locker. My stethoscope is wiped down and left in my locker. I change the rings/diaphragm on the stethoscope often and use protective covers or the isolation stethoscopes whenever available. I try not to take my work home with me especially in the form of bacteria or viruses.

TB: very much alive and active in specific populations but can also be found in all economic types. Tuberculosis, TB, is caused by bacteria called Mycobacterium tuberculosis. Multi-drug resistant tuberculosis called MDR-TB is also prevalent in some areas. The smaller community hospitals may only have one or two inpatients with active TB. Some large county hospitals in the major cities may have easily 5 - 10 active cases as inpatient. The hospital Pulmonary Labs may do 2 - 4 sputum testings per day for AFB, Acid-fast bacilli indicating the presence of Mycobacteria. The clinics may do many more in some regions of the city. Many people can be treated outpatient if they have a home and can be restricted for a few days to that home. The family members are also tested but do not always test positive provided they are healthy and the person infected isn't coughing in the usual "Consumption" manner. In the hospital, if someone is coughing and I am going to have to be in the potential line of droplet fire, I will be wearing a mask and goggles since there are also many other things that can be in the sputum besides TB that I don't want in my eyes or sinuses. This is especially true when giving a nebulizer and I can not get at least 5 foot between us even with kids. Pertussis is still out there along with a wide variety of viruses. A mask is still advised when in the same room with patients who are coughing forcefully, in a risk group or will be tested for AFB. Florida still has a state hospital, "sanitarium", for TB for the patients that need confinement during treatment. The links on its website can give you more information about TB. http://www.doh.state.fl.us/AGHolley/index.html BCG, or bacille Calmette-Guérin, is used in many countries with a high prevalence of TB to prevent childhood tuberculous meningitis. However, BCG is not generally recommended for use in the United States because of the low risk of infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against adult pulmonary TB, and the vaccine’s potential interference with tuberculin skin test reactivity. Since HIV is again in a resurgence in the U.S. there are still many populations at risk for TB. HIV is now found again in the 20somethings of all economic groups that were born in the 80s and missed the massive public eduation done in the late 80s and early 90s. I do recommend that you keep the usual vaccinations up to date such as MMR, Tetnas, Hep B and Varicella if your titer is low or not existent. I also recommend following the guidelines for Hep B titer testing. Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV) are viruses. HCV can live outside the body on surfaces for several days. HIV is a very fragile virus and does not survive long outside the body. Now for the very common bacteria; MRSA and VRE. However there are many others including MSSA and MSSE that are not resistant yet but can still be deadly to some patients and is still difficult to treat. Methicillin-Resistant Staphylococcus Aureus (MRSA) Mode of Transmission - MRSA is transmitted primarily by contact with a person who either has a purulent site of infection, a clinical infection of the respiratory tract or urinary tract, or is colonized with the organism. Hands of personnel appear to be the most likely mode of transmission of MRSA from patient-to-patient. MRSA can be present on the hands of personnel after performing such activities as wound debridement, dressing changes, tracheal suctioning, and catheter care. Infection refers to invasion of bacteria into tissue with replication of the organism. Infection is characterized by isolation of the organism accompanied by clinical signs of illness such as either fever, elevated white blood count, purulence (pus), pneumonia, inflammation (warmth, redness, swelling), etc. Colonization is the presence, growth, and multiplication of the organism without observable clinical symptoms or immune reaction. MRSA - Colonization may occur in the nares, axillae, chronic wounds or decubitus ulcer surface, perineum, around gastrostomy and tracheostomy sites, in the sputum or urine. One of the most common sites of colonization in both patients and employees is the nose (anterior nares). While personnel may become colonized with MRSA (as they may with susceptible S. aureus), they rarely develop infections. Reservoirs for MRSA - Colonized and infected patients are the major reservoir of MRSA. MRSA has been isolated from environmental surfaces including floors, sinks, and work areas, tourniquets used for blood drawing, and blood pressure cuffs. Evironmental surfaces should be routinely disfected to reduce the bacterial load. Healthcare workers can have skin lesions infected with MRSA and should be treated. Decolonization should be considered for those employees with persistent MRSA nasal carriage (ex. chronic sinusitis), especially if the healthcare worker had contact with patients who were subsequently found to be positive for the same strains. Vancomycin-Resistant Enterococci (VRE) Enterococci are normally found in the bowel and the female genital tract. When exposed to antibiotics for any reason, the drug-resistant bacteria may survive and multiply, resulting in an overgrowth of drug-resistant enterococci in the bowel, referred to as colonization. Reservoirs of VRE - Enterococci are part of the normal flora of the gastrointestinal tract and female genitourinary tracts. Most infections with these microorganisms have been attributed to the patient's endogenous flora. However, a recent study found VRE is capable of prolonged survival on hands, gloves, and environmental surfaces. E. faecalis was recovered from countertops for 5 days; the E. faecium persisted for 7 days. Thus environmental surfaces may serve as potential reservoirs for nosocomial transmission of VRE and need to be considered when cleaning equipment. Most of the bacteria and viruses mentioned may not affect a healthy individual but can be deadly to the next patient you transport if you do not take a few simple precautions. Patients trust you and it is up to you to see that you do them no harm. That means learning about and diligently practicing good infection control. Hand washing and cleaning your equipment between patients should be always be done. Too often I see ambulance crews toss the gloves after patient care and go back to their truck or to the caferteria touching many surfaces along the way. There's plenty of information in the EMS journals and on some of the EMS websites. The community colleges and various agencies that do healthcare continuing education for nurses and allied health professionals should at least have the mandatory infection control classes which they may be required to show proof of for some employers that do not offer the education such as agencies for contract workers. Some healthcare licenses also require some of the classes. This question has been asked many times on several EMS forums. It does make one wonder what type of continuing education is being done for people working in EMS. The same goes for HIPAA education. Are any of these things being mentioned in the refresher courses which would be a perfect opportunity instead of reviewing basic anatomy or procedures that the services' training officers should be testing competencies?

North Carolina Paramedic Saved by Juniors http://www.emsresponder.com/article/articl...n=1&id=6935 Story by wsoctv.com LINCOLNTON, N.C. -- 17 year old Ethan Parker, captain of the Lincoln County Junior Rescue Squad remembers thinking it had to be a joke when told their mentor and captain, 39 year old Ken Morrison had collapsed Friday night. "One of the juniors said Ethan there's something wrong with Ken. And I was like are they playing another joke on me? I walked in and found him and he was blue and wasn't breathing and didn't have a pulse," he says. But it was no joke and the teens immediately began CPR. They say they had to shock Captain Morrison's heart three different times before he responded. Fellow junior Michelle Ward doesn't want to think about what might have happened had they decided not to stop by after seeing a movie that fateful night. She says, "we talked about going back to a friend's house instead of coming here but we came here. So maybe there was a reason." Others squad members like candy walker believe there was a reason saying, "thank the lord that they did because i think god puts people in places where they need to be and we've got some very awesome kids here." It's those very accolades the teens say their not comfortable receiving because they were simply doing what they'd been trained to do. We really weren't thinking about the fact that it was ken. It was more of a hits you later sort of thing," says Ward. She adds, "we kind of owe it to ken because he's one of the main people responsible for our training so its just kind of paid off for him." Morrison, a ten year veteran of the squad, is still in critical condition at Carolinas Medical Center in Charlotte. His co-workers tell us doctors still don't know what caused him to collapse. http://www.emsresponder.com/article/articl...n=1&id=6935

Almost every healthcare profession, except for a few that are still considered "techs or assistants" and many of them have more than 1000 hours of training, require a minimum of a two year degree. I got my EMS degree in 1979 in Florida where most of the community colleges already had 2 year Paramedic degrees established. Back then being a female with a paramedic certificate and able to pass the fitness test was all that I needed to get a job with almost any FD. Speaking Spanish was also worth a few points. I would have been even more perfect if I had gotten a degree in Fire Science to go with the degree in EMS. At that time EMS was still relatively new and really had a good chance to keep up with the other professions, including nursing, that were just getting their start at being recognized with professional status. Many people thought the Paramedic would also be required to have a two year degree by 1985. There are now more degrees at all levels for Fire Science than EMS today. Actually, I do have a lot more respect for the FF or anyone that takes their profession serious enough to continue their education. At least in the FDs there is an education motivation with a career ladder for promotions. Unfortunately the "hero" thing has been creating problems in the past 5 years as there are many applying to the EMS and FF services that want to be a hero and not a medical or FF professional.

And, running like the devil is chasing them with both the L/S thing back to the hospital and running them into the ED entrance has led to many a patient being "dumped" at the door. A few months ago a hospital had this happen twice. The "shortness of breath" patients quickly turned into trauma also with one suffering a head injury and the other with clavicle/humerus fxs. I remember one other pt that had cancer with bone metastasis who suffered bone fxs from being dumped. Those breaks will probably not heal. I also believe that was a routine transport from a SNF for a port-a-cath placement.

Been there, done that myself on a bad day in the ICU.

My favorite for O2 related mishap is the flow dial says 6 and the pressure guage says 0 either because the tank is empty or not cranked open. Worst is when the BLS/ALS team fails to recognize the empty tank is the reason the patient is still short of breath and tries to get a NRBM to work on the same tank. Or, the Paramedic wants to intubate. I also see ALS teams trying to trouble shoot their vents or CPAPs with an empty tank. And then you have the NRBM let in place on the face from the ambulance to the ED stretcher without a tank attached. Unfortunately this lack of attention is too common place and just accepted as "oh well".

Too bad for the name of the service in more ways than one.

This is a non medical shopping comparison but it does give a good idea about what is available and the new price range. http://www0.shopping.com/xGS-Finger_Pulse_...nkin_id-8006946 Nonin 9500 Onyx Digital Finger Pulse Oximeter - the most popular finger pulse used in the hospitals. It has a middle of the road price. BCI is also a good brand. http://www0.shopping.com/xPC-Nonin_9500_On..._Pulse_Oximeter If you buy new, make sure at least a 1 year warranty is with it. You can compare the accuracy with the one at the hospital or MD's office. The accuracy can depend on anything from the circulation/temperature of your finger to if you are wearing acrylic nails with dark polish. http://www.pulseox.info/ As a Respiratory Therapist I am now seeing adult onset CF more frequently. SpO2 can be deceiving in many respiratory disorders. Hopefully you have some access to a good Pulmonologist and Respiratory Therapists to answer your questions and give you the best advice to help you understand what your body will be experiencing. CF is not something you want to manage by yourself.

That's too bad when someone loses a job because other regulations prevent an industry from making equipment safer to prevent such errors. Hopefully the doctor was able to channel his need to hit an employee to someone who needed to bag the patient until the ventilator reset to ventilating. I've had way too many doctors, some repeat offenders, unplug the ventilator when they were setting up for a procedure but I have not felt like hitting them. That type of anger does no one any good. You deal with it for the pt's sake and educate the person even if you have to do it over and over. Possibly being restricted from the critical care area for awhile if possibe would be a better option for the Radiology Technician. Or, a nurse, RRT or physician could be present to assist maneuvering through the equipment would be an easier and safer option.

Hopefully not fired. This is a very common occurrence in the ICUs made by physicians, nurses or anybody using any type of electrical technology. RTs complain on their forums and at national meetings that they are not able to get the manufacturers to make the electrical plug a different color. There are some regulations in the electrical industry that prohibits that. Only extension cords can be differently colored. Luckily most ventilators have loud alarms when unplugged. Unluckily, many ventilators will go through a self test which can take them up to a minute to start ventilating again. The true error comes when you don't recognize what you did and/or the people who are supposed to recognize a high alert alarm do not respond. With medical errors, the worst ones involving loss of life are handled swiftly amongst the receiving hospital, EMS agency and/or governmental agency, the lawyers, the insurance companies and the pt's family. The healthcare workers themselves are told not to talk about the patient or anything concerning the patient amongst their peers. Violation of that can mean serious consequences for their job. The media and the public will not usually hear of these incidents. In the hosptial the incidents are reported as a sentinel event to the Federal agencies monitoring hospitals. Government and municipal entities also have a different system for handling medical lawsuits involving their agencies for they do have some protection. Thus, those "mishaps" may be squashed quickly by the court system. I have seen many medical errors throughout the years and will only discuss incidents to those that are required to know or for internal teaching purposes. This is to protect the patient, family members and the person(s) involved. It is a tough time for all when someone you know may have made a fatal error. Of course, I too a guilty of posting other peoples' incidents that make the news that I, my agency or hospital are not involved in. I figure it is in the news now and can be used as an awareness that errors can happen. I did mention the combitube incident because I have a firm stance on proper education and training on medical devices for all levels including the Paramedic even if the device is somethings represented as BLS. The consequences can be very bad for the pt and a bad career breaker for the EMS provider.

As an RRT I had to give a deposition for a Combitube vs Larynx on a 20 y/o who just had a little too much alcohol to drink and was brought to the ED by ALS. It was placed by a Paramedic who thought the Combitube would prevent aspiration better if the patient vomited. (??!!?) The poor kid will not be using his own larynx to speak again. I'm sure the Floridians remember this fairly recent incident. Florida Woman: Paramedic's Error Caused Loss of Arm http://www.emsresponder.com/article/articl...p;siteSection=1 Rebecca Mahoney, Sentinel Staff Writer Orlando Sentinel (Florida) SOUTH DAYTONA -- A violent stomachache prompted 84-year-old Marie Caschetta to call 911 in January 2006. She expected to end up in a doctor's care. Instead, according to a lawsuit, she wound up losing most of her right arm. Caschetta says a paramedic with Volusia County's ambulance service, EVAC, wrongly gave her a drug that can cause gangrene when improperly injected. The South Daytona woman has since undergone three amputations, each time losing a different portion of her right arm, and she may face a fourth amputation that would take her elbow. "I lost my whole life that day," said Caschetta, who is suing for an undisclosed amount of money. "I went in for a tummy-ache and came out without a hand. I'm an invalid." The lawyer representing EVAC, Barbara Flanagan, declined to comment on the case. According to court records, however, Flanagan has argued that Volusia County, not EVAC, is legally responsible because its medical director sets the protocol for ambulance responses. County attorney Dan Eckert did not immediately return a call seeking comment Monday. At issue is the paramedic's use of a medication called Phenergan or promethazine, used to quell nausea. If it is accidentally injected into an artery instead of a vein or a muscle, it can make arteries shut down and cause gangrene.

Not all CNA programs are 2 weeks. Although, that is 80 hours of mostly clinical experience with CPR being additional. The EMT is 110 hours with 20 hrs of ride time which may not have much patient contact and only 10 hours ED time. Some of the CNA programs are closer to 3 to 4 weeks which makes it between 120 to 160 hours depending on the program and specialty. Many CNAs get a basic education/training to get certified prior to applying and then another 40 - 80 hours once hired for their specialty; psych, rehab, ED, acute or long term care. The Florida CNA test is both a written and performance. They are also required to have CEUs. The CNA is required to have 1.0 hours of in-service per each calendar month or a total of 12 hours for a full calendar year. Every 2 years, in-service hours shall include: HIV/AIDS, Infection Control; Domestic Violence; Documentation & Legal Aspects for CNAs; Resident Rights; Communication with impaired clients; CPR skills; and Medical Error Prevention/Safety. Specific agencies may have in-service requirements in addition to these. http://www.doh.state.fl.us/mqa/cna/index.html Of course, not all states, training programs or employers are equal. In the hospital I also rely more on the CNAs than RNs on the med-surg/SNF/Rehab floors and make myself available to give inservices either formal or impromtu at their request. I have tried to encourage many CNAs to advance to nursing but most are very happy doing what they do. That is, if they have a good employer and working environment. Some NHs as well as hospitals can be slave mills for them.

But, if you consider the amount of patients each CNA is responsible for when it comes to cleaning, feeding and monitoring each day especially in the NHs, that money is not nearly enough. Usually the CNA has 15 - 25 patients to look after per shift and is expected to keep track of all of them to keep them from falling and safe. It is a difficult job and turnover is high. You have some EMTs/Paramedics complaining when they have to transport more than 3 patients 1:1 (or actually 2:1) per 24 hour shift in some threads. Then, you get all the people who don't understand the job complaining about lousy care in the NHs. If you think a job is so easy a caveman can do it, then don't complain about the care in the NH when they do hire the equivalent of a caveman to do it. The CNA must put up with stressed patients, family members and "know it all" EMTs/Paramedics who all take out their frustrations about anything from poor care or missing the football game on whoever happens to be nearby. At least the CNA education is specific to the job and that is what may be what is needed to take care of the patient. Hiring someone who does not know how to feed an elderly patient or how to safely bathe them in a shower chair or how keep a patient from getting pressure sores just because they think they are just as good doesn't cut it. People should have an understanding that what they are trained for and what they may think they can do are not necessarily the same. One little point to clarify about wages and unions. CNAs are not represented by nursing organizations or nursing unions. If they belong to any union if it the same one as housekeepers and dietary workers. Florida is a Right to Work state so it is doubtful they belong to a union. In California, it is usually SEIU (Service Employees International Union) that represents them.

Quotes by WANTYNU What amazes me most about the EMS profession is the total isolation from the rest of the medical field. Yet, I know every day on BLS/ALS transfer trucks and in the ED they see/meet many people. I also have made suggestions that EMTs and Paramedics venture into some of the many classes that the hospital offers on various clinical things like assessing different central line ports, pacemakers and new medications on the market. More often than not, I get a screech from them like I asked them to venture into enemy territory. Other health care professionals have evolved over the last 30 years because they saw the need to provide a higher level of care as patient needs, technology and the inadequacies of the healthcare system changed. Medicine and roles are changing. RNs and RRTs have greatly expanded their roles. Rapid Response Teams, teams to intervene in providing emergent care when physicians are not available or don't "call back", have been around for almost 20 years. However, it has been just within the last 5 that a national awareness has been made of them in terms of their success with promoting these teams throughout the country. This are well educated RNs/RRT who have an entensive set of protocols to work with as established by a medical director. Also inside every progressive (and even those that aren't) hospital, RNs/RRTs can have impressive protocols to where calling a physician is not necessary. Yes, some are diagnosis driven and some fall into critical care medicine to which there are many different pathways to take. If you actually look at the Paramedic protocols, many of them are generic. They can be applied to many different situations. Inside the hospital, we do use different information to guide the protocols. Different vasopressors are used for different problems such as sepsis. Sometimes we have a lactate level and sometimes we don't but may initiate the sepsis protocol based on assessment. RRTs (and RNs) don't wait for a physician to intubate or give meds in a code or respiratory failure situation. Nor do they need to wait to initiate their own specific ARDSnet protocol which involves both RNs and RRTs. In CVICUs/CCUs/MSICUs/NICUs/PICUs there are extensive protocols for almost any situation that arises even when we don't have "definitive" diagnoses. Yes, there are emergencies in the hospital also. A doctor is still the only professional that can make a medical diagnosis. Paramedics and other professionals make a working diagnosis for their own scope of practice. RNs/RRTs can in may situations make a more specific working diagnosis due to the clinical data available to them which also allows access to many different protocols. Usually a patient is admitted to the hospital under many diagnoses until more clinical data is available or because in adults it is rare if only one body part affected. Inside the hospital, many different aspects of care and the long haul must also be taken into consideration. And then, you have the many specialty teams inside the hospital and the specialized transport teams. The professionals, RNs and RRTs, on these teams have extensive education, training and skills that are truly impressive. They definitely do not fit under the "palliative care" blanket statement. One of the reasons I chose to get another degree in another medical profession was to expand upon the education I had an a Paramedic. In my early years as a Paramedic, I also thought nurses were just hand holders who had to call a doctor for everything. I definitely got an education on how wrong my stereotyped view of these professionals were when I started to pay attention to what was going on around me when I did a transport into the hospital or an RN/RRT accompanied a patient on my ambulance. Once I began working in the hospital, I realized just have many healthcare professionals there were and how each played an important role with their own protocols and scope of practice. Maybe because people in EMS consider themselves different and isolated is also why other professionals don't always recognize what EMTs and Paramedics do. By stereotyping other professionals, EMS workers have built their own wall and have also allowed their profession to become stereotyped. There are also many Paramedics who are licensed but don't work on a rescue truck. I know many that haven't intubated or done an IV in 10 years. Many that hold Paramedic certificates may never run a code. If they are the paramedics another healthcare professional knows then there might be a misconception about what a paramedic can do. If you do not truly know another profession's capabilities, don't stereotype all the professionals within that profession. If you do make blanket statements about some other profession then don't get upset when the same is done to your own profession. WANTYNU, please don't take offense to my statements. Your comments gave me fuel for a little rant that also goes along with a couple of other recent threads on the forum.

For nursing, the equivalent of a 2 year degree is required. For the paramedic, it is not. Except for a couple of states where the 2 year paramedic degree is required, there is usually the certificate option for the paramedic in the colleges. This also allows the colleges to be competitive in attracting students in areas that have many medic mills. There are those that do find college general education and sciences easier than patient care classes. Patient care can be difficult to learn especially if you did not know what what to expect. When you sign up for a math class, math is what you expect. Patient care can be more difficult to grasp when dealing with the complexity of the human body outside of a textbook and when human behavior is involved. Until the education field is leveled, it will be very difficult to petition and position for the same salary. Other healthcare professionals recognized this quickly and spent less time trying to identify with other professionals and more time developing their own identity through education. Have you ever seen the standing orders for RNs inside an ICU, CVICU or even med-surg floor? They can be very impressive. That's not even mentioning the nurses that are on specialty teams both inside and outside of the hospital. Even for in hospital codes or rapid response calls, a physician is not always there. RRTs and RNs get things started with "standing orders or protocols". Almost every licensed healthcare professional inside the hospital has standing orders or protocols written by their medical director to follow whether it is RT, PT or RN. Yes, RNs work under protocols and standing orders written by the Medical Director for their unit. Paramedics are also not independent contractors and still work under a medical director. The skills that paramedics possess are not that unique. The out of hospital scene makes the paramedic unique. Nurses are there for the patient for the long haul. There will be many RN/MD exchange of information during one 12 hr shift and for several days for many patients. Due to the broad range of information and planning of care, it is necessary for MDs to know a little about their patients' primary inhospital caregivers.

CNA is a certification with a few more hours than EMT with a very different focus as Dustdevil stated. CNAs must be trained extensively in infection control and long term prevention of skin integrity breakdown/recognition. Proper ambulation techniques, fall prevention and personal hygiene are some things that an EMT is not trained to do. They must also be trained with communication skills/special needs for long term care of pts with dementia and alzheimer's. That in itself is not an easy task everyday and all day. CNAs that work in long term facilities must also be well versed on the rights of "residents". The same for hospitals. CNAs are often used for suicide watches. For an 8 or 12 hour shift, this bears some serious responsibility especially when it comes to restraints and allowing pt to still have personal hygiene time. In many places they are very well trained in CPR and get the party started while the licensed personnel are arriving or setting up. In some states the CNA certification allows them to advance to Medication Aide or Pt Care Tech which can be 700 hours easily. This gives people a good idea if they want to go on to be an RN and accepting more patient care responsibility. In other words, they know what the patient care thing is all about before signing up for a long term education commitment. States recognized the need for the CNA specialty within facilities with many states initiating certification over 30 years ago. EDIT: Yes, an EMT-B should be trained and Certified as a CNA since you are no longer prehospital and must be trained to the requirements of a job within a facility. CNAs that work EDs may have similar if not more experience/training in some things than an EMT-B but would still be required to have EMT-B training and certification to work prehospital. Hospital trained ER technicians with many skills definitely may fall into that category but still need an EMT-B cert to work on an ambulance.