UMSTUDENT

I'm torn on RSI, but typically believe it should be something that is part of the "universal paramedic toolbox." Why? I've watched so many dumb things happen to patients who truly needed it and where it wasn't available, e.g. head injured, clenched patient who has three paramedics desperately trying to nasally intubate as saturations drop below 80% with poor BVM compliance (with NPA placed). No matter which way you shake it, this patient is going to die if airway access is not achieved relatively quickly. We don't have RSI in my jurisdiction, but I have intubated both sedated (as part of routine clinicals) and non-sedated patients and can generally say that the paralyzed patient tends to be some of the easiest I've performed. It seems counterintuitive that we would ask our paramedics to intubate in a more difficult fashion and then hold them accountable for the success rates they receive in this austere, less than perfect situation. Then again, I don't personally see what all the "paramedics can't intubate" controversy is about. The advent of ETCO2 waveform capnography seems to have really limited the instances of unrecognized esophageal intubation and better education and fear mongering has really gotten most to realize the importance of confirming an airway. Really, in my opinion, every jurisdiction should have a robust airway training program which includes hospital time quarterly. The only way, in my opinion, to get good at intubation is to do it a lot, particularly as a new paramedic. I felt like I received this during my first job in a high call volume environment, but many paramedics never receive this exposure, particularly in a rural environment. I feel that where states should get involved in EMS is in things like this. States should pass legislation mandating hospital participation in EMS training programs and provide subsidized premiums for anesthesiologists who allow paramedic intubation. A paramedic should intubate four times quarterly or BAM-automatic OR time.

Is there anywhere I could read some good literature on New Zealand's system? Sounds pretty good.

First, thanks for searching. I'm sure plenty of people are privately commending you for using the feature. Second, my EMS system is not progressive. Where I work the protocols are statewide and widely considered "conservative." I used to say "not progressive at all," but recently the state has made some leaps towards accepted practices like CPAP, nitrates for acute pulmonary edema, and now corticosteroids for asthma. None of these things are cutting edge, in fact I'd say they're really just the accepted standard of care, but it's an improvement from even 5-6 years ago when no amount of literature could have convinced them to step toward the future. We're still flowing high flow oxygen on pretty much everything, rushing every cardiac arrest to the hospital, intubating everything under the sun, and just starting to pilot hypothermia (in limited ways). The protocols are restrictive, contradictory in many places, and long (over 300 pages). To avoid getting yourself in trouble, even for things that really are of no consequence, you need to have an encyclopedic knowledge of the protocols. So I'm not really sure I could help. I do have friends who work in what I would call "progressive" systems, but I think the word is pretty subjective. Places that I would consider progressive tend to have a few things in common: competitive hiring, better than average pay, an involved medical director(s), and local protocols. The last thing really seems to set these systems apart. I have yet to see what I would call a "progressive" system, or for that matter happy paramedics, in a state that has restrictive statewide, or even multi-regional, protocols. I have one buddy who works in Colorado. He constantly remarks about the general autonomy of the paramedics, short and sweet protocols, and close interaction with his multiple, yes multiple, medical directors. There is a general expectation that they are A) Qualified paramedics and Educated. The protocols do not dictate every tiny way, shape, or form of when a medication can be used, how to do intubate, etc. There is hands on training, a robust QA program, and a collegial culture. As for what direction EMS is headed I'd see the "Advanced Practice Paramedic" discussion to see a variety of opinions from many well qualified sources. This is a very contentious issue and very young discussion in our profession. It is probably many years away, if it happens at all, but I think the subject is at the very bleeding edge of what's coming.

Anyone who refuses to recognize that the future of EMS is in preventative healthcare, treat and release, referral to alternate destinations, etc lacks vision. It is a matter of time before someone in this country realizes that there is this preexisting universal public tool to screen and filter out unnecessary medical cost: EMS. The real way to decrease health care cost is to stop people from using the service, or at least the most expensive services. Not accounting tricks, not raising the age for Medicare from 65 to 67, and certainly not Ryancare where we pawn one of the most successful social safety nets over to private insurance companies. The fact of the matter is that private insurance premiums have risen, when adjusted for inflation, 700% over the last 40 years compared to 400% for Medicare (spending per beneficiary). When common statistics show that anywhere from 60-80% of admissions to a hospital originate in the 9-1-1 system, someone should be looking at this and saying, "Gee, what could we do to stop this?" Other countries have; many with outstanding results. You're right, the Wake County model is really just a giant PR campaign and feigned way to spend tax payer dollars. It provides essentially the same supervisory or support role (with a twist) popular in many EMS systems around the country. It doesn't have nearly the teeth to make an appreciable dent, but it has attracted the attention of people around the country. A generation of U.S. paramedics is growing up to learn about a concept that has otherwise been successful elsewhere. Really, the U.S. needs to look to the U.K and South Africa where the Emergency Care Practitioner program is being lauded as largely successful. These programs are looking to expand the roles of these providers given the preliminary results in the communities they serve. Movements like the one in Wake, and the Community Paramedic initiative, should be commended in what they've done and are doing to lead the field into the future. There is no reason why, given the proper education and very small leaps in technology, that a well trained ECP could not treat and discharge a vast majority of the lower level complaints seen by the 9-1-1 system. Create a market and someone will scale down and democratize the basic diagnostic tools needed. X-Rays, basic lab work, etc. No one is going to create a portable X-Ray machine that can be used in the field without a market when they can produce a larger, less complex product with higher margins. Look at the research into metmaterials. What about the research into holographic recognition of bacteria? These are all developments that could bring a level of diagnostic capabilities to the field. I don't think anyone is saying that paramedics should be discharging chest pain patients, but what about the basic diabetic, the COPDer or kid with asthma who responds well to a single breathing treatment and/or steroids? What if these providers could provide daily checks on the noncompliant diabetic? I have patients routinely who ask, "Can't you just give me the medicine. Why do I have to go to the hospital?" I think the reality is that we like to overcomplicate some limited aspects of medicine. We look for complicated answers when simpler ones may exist. Even if at the end of the day we say, "Hey this is a nurses job" I think I'd be ok with that, so long as we insist those nurses intervene at the point of contact to stop wasteful spending. Providing immediate lifesaving care will always be part of our job, but stopping it from happening is the future. We need to insist that our profession be more than a glorified taxi cab. Paramedics need to get a basic college education. We need to insist as a profession that a 4% national cardiac arrest survival rate is unacceptable. If we want the public to place trust in us and invest billions (yes,billions) into an actual robust EMS system capable of the things above, then we need to provide more than a college try on cardiac arrests by supporting, or even putting forth our own, research into how better save people from SCA. Even if that answer is better public education, then we should be the ones out doing it! We should insist on progressive protocols that allow us to provide appreciable changes to our patients before arrival in the ED. We should insist that we are a health care organization separate and unique from fire suppression. My $0.02.

Big news, especially when it comes to parsing through future qualified medical directors. Very good news.

More in Pennsylvania is messed up besides EMS. Everything is pretty much locally controlled. No economies of scale to provide adequate services. With the exception of a few large municipalities, most Pennsylvanians live in rural "Pennsyl-tuckey." Counties provide very few services with the exception of tax assessments, sheriff's departments (typically warrant serving agencies with little law enforcement responsibilities), and jails. Everything else is typically handled by local boroughs, townships, cities, etc. Most basic law originates in local magistrates, who like ALL justices (including their Supreme Court), are elected. The local UPS driver might be your magistrate so long as they take a course... Schools, police, fire, EMS, etc is typically handled by the local jurisdiction. This leads to tons of individual school districts, dinky (sometimes unprofessional) police departments, and borderline, sometimes barely existent fire & EMS. You can also imagine the small town mentality that sets in when locals have access to millions of dollars in tax funds (paid for largely on the backs of property owners- PA has relatively high property taxes-for everything). For EMS this has big disadvantages and now lost advantages. For one, funding is non-existent. It does allow the jurisdictions to have purview over how, and to what extent, they want to provide service. Unfortunately this typically doesn't end up being the advantage it could be. Up until a few years ago, ALS protocols were largely jurisdictional. They're now statewide-something I find a big letdown. This is why so many people who know Pennsylvania had a huge problem with Wang's intubation study. It was done statewide in a state that is VERY rural. ALS is provided by a variety of different delivery models.

I think that EMS should have long ago been defined as a health care profession. Dust is right. True unification is impossible. There is a small contingent of our profession who adamantly opposes any other direction for the profession, and they're right. Those who agree with this vision need to step up to the plate. I feel that it is really going to take two things to make true progress: A) An organization that is well organized by smart, charismatic leaders who can clearly articulate the points we all know to be true. This organization may need to be borderline militant, choosing to directly obstruct and oppose those organizations (IAFF, etc) that choose to keep our profession behind. The central tenant of this organization's advocacy should be around increased education standards. B ) A true leader. I've always seen this person as a prominent, well educated physician/academic who is willing to politic a bit. We have our share of advocates, but no one who has really been willing to challenge the status quo about the future of the profession. We're seeing more and more studies that seem to be diverging on two separate paths: 1) EMS personnel are inherently incapable of doing anything resembling complex medical procedures (intubation, refusing of care) vs. 2) These studies are flawed and performed on biased cohorts (municipal fire systems, rural Pennsylvania-Wang). EMS has really made great strides and could probably play a more prominent healthcare role if providers were properly educated and utilized. Someone needs to step up and push us into higher education and more prominent roles in preventive health and primary, community care. Even still there is professional disagreement among people on the "enlightened" side. I compare myself to Dust, whom despite agreeing with me on virtually every argument regarding higher education, has seemingly always disagreed with my vision of eventual advanced practice. Dust brings up important questions about being good at what we already do, before biting off more challenging endeavors. I argue that higher education will only be mandated once the market, in this case healthcare, sees a reason for anything short of certificate trained, paramedic mill firefighters. Its a good argument to have and I have always appreciated the opportunity to forge my opinions on this essential question. Regardless, someone needs to first step-up to the plate and vehemently disagree with organizations that continue to push us towards the predominantly public safety realm and not healthcare.

My prayers are with them and their families. GOD be with them.

Jwade, You're probably from one of the following: University of Maryland, Baltimore County-UMBC UPitt (my second choice) GW's old program before they cut the clinical portion. Western Carolina-WCU (excellent program. Buddy of mine graduate from here) Eastern Kentucky University of New Mexico University of Southern Alabama University of Texas Health Sciences University Central Washington University Loma Linda University Western Carolina and UMBC bicker back-and-forth about who started the first program, but there is some historical evidence to suggest that UMBC's started in 1980. Founded by the late R Adams Cowley. Both WCU and UMBC have fairly elaborate alumni networks. The above are the only bachelor's programs in the country that aware degrees for clinical purposes. There are other programs that focus on management and healthcare economics. Sort-of disappointed though. The year after I graduated the university made the department lower the entry credit requirements due to too many credits required for graduation. Typically students had to complete almost 150 credits (instead of the typical 120) to finish the program. The university had them remove the chemistry requirement to bring it down to a more manageable course load. Students typically handled a load of at least 15-19 per semester, or took summer and winter classes, to exit within four years prior to the change. The current prerequisite requirements, prior to applying for application to the major at my school, are: Introduction to Biology (6 credits w/ lab) Anatomy and Physiology I & II (8 credits w/ lab) Finite Mathematics OR Completion of College Algebra and Statistics for the Sciences (4 or 8 credits respectively) Introduction to Psychology (4 credits) Introduction to Sociology (3 credits) Abnormal Psychology (3 credits) Introduction to EMS (history class) (3 credits) English Composition (3 credits) 16 Elective Credits. It's my understanding that the department highly encourages competitive applicants to use these to complete at least inorganic or biochemistry prior to application. Prior to my graduation this was a requirement ALONG with 16 elective credits. The school requires a foreign language profiency that eats a lot of those up. Many students choose to add microbiology or other sciences courses. Large subsets of students are premedical or pre-physician assistant so they extend their science education as needed.

Vent, I've obviously struck a chord. You've shown what you really think of the profession in general. You used my "sit in a room" figure of speech as an indication of what I believe nurses do. You talk about the "kid gloves" treatment of paramedic students. You yourself have no idea what you're talking about. Your experiences are from what? Late 80's...early 90's? Do you live in the Deep South or some impoverished area of this country where paramedic education is completed in trailers? Jeez man. Symbiotic and symbolic also have nothing to do with each other. Interesting as symbiosis is a biological term that should be well understood by a nurse. You talk about how paramedics gripe about nursing home patients and how "B.S." the care is in these places. Common Vent. If the pinnacle of nursing education is to ship out patients to conduct borderline Medicare fraud (to readmit after X number of days) or because they've noticed a mild change in mental status, you've got to be kidding me. Most of these nurses couldn't tell you what the patient's normal mental status is (They don't care. Too busy gabbing at the nursing station). Doesn't help that there is a huge influx of non-English speaking, Caribbean nurses because of the artificial nursing shortage. Remove yourself from flight RN/RRT/whatever badge you’ve collected and think about the typical nurse right out of school. Not so many are spectacular. I’ll also say it again: I’m not saying nursing is useless. They’re just not that different than us. All I’ve heard is a bunch of stuff about compassion and “total care” that seems to have come from a Johnson & Johnson nursing commercial. You talk about following patients? What practical skills are you talking about? That a human being, a nurse (they’re super special and empowered with special skills of reason), is capable of realizing that there are multiple facets to healing? Are you implying that paramedics can't feel for another? That we're all cold, heartless idiots? “I’m sorry sir. You’re a traumatic brain injury patient who needs to go to Cat Scan. Unfortunately I’m incapable of finding the room. For that matter sir I have no idea what a Cat Scan is. But why am I talking to you? I probably don’t even realize that you have severe, long lasting neurologic deficits because I’m a stupid paramedic and not an awesome nurse.” “Miss I can’t empty your urine because I’m incapable of understanding the implications of urine output and overall renal function. I’m just a big dumb paramedic.” “Well sir. The doctor finished that in situ pinning. Your femur should be all better now. Here’s five dollars and a cane. Have fun! Oh, what is that? You need physical therapy? Ah, I’m sorry sir. I’m just a paramedic. I thought you’d be all set!”

Still a lot of nothing. Honestly Vent I'm not saying that a paramedic is even remotely qualified to be a nurse-there are obvious differences in roles and responsibilities. I'm saying that the educational deficits seem small to me. You've still failed to give me specific examples of when and where, in the entry level educational process, this occurs. I'm of the opinion that much of it is on-the-job or clinical related. Again, something I believe could be easily integrated into a quality paramedic education. I think your on the defense when I'm more on your side than you see. You seem to advocate compartmentalizing healthcare professions, which I'm not necessarily against. But what I don't agree with is a paramedic being clueless about what happens to their patient once they leave their hands, or not knowing how the continuity of care affects patient outcomes. A well educated paramedic should be capable of sitting in a room and not only understanding the job a nurse performs but vise versa. That isn't how it works in this country. Paramedics are often left out of overall healthcare considerations for exactly this reason. "Oh, those poor things don't know any better." I worked on a hospital floor for almost two years prior to college. Of the over 1200 hours (yes) I did for clinical rotations, at least half or more were in hospital environents (and no not all in the ED). I've been in ICUs, flight environments, progressive care units, PICUs, etc. There were very few instances where I watched a nurse engage in anything that I didn't feel I had a very strong grasp of (w/ neonates and some aspects of LDRP the exceptions). Yes, I learned a lot. But it wasn't fundementals-ussually more procedural. Some of my best education on vents came from nurses. ECMO, IABP, and LVAD orientation was also done by nurses. In fact, the experience was often symbiotic. We didn't fight nor puff our chest at how different the professions were. I distinctly got the impression that we each learned something from the other. In fact, the only place I have ever encountered a nurse who was brazen enough to insult the paramedic profession was in the ED. The rest seemed to genuinely get that the profession had its values and distinct specialities. So, yes I have been there. That is why I'm confident when I assert these questions. Healthcare is no different than any other service. There is a large propensity for fraud and waste. As Chbare said, a lot of it is political. It's creating a need for something from nothing.

Vent, "Unless you have been through the RN or even RT program and have worked in that profession, you may not fully understand what they do or know." I'm still seeing a lot of "you wouldn't understand." I refuse to accept this excuse. Other professions have to justify why they exist and what it is they provide that is valuable. Nutrition? Maybe impliment a nutritionist guidelines, but you seriously want me to believe this? I have never encountered a patient in the hospital environment that didn't have a detailed nutritional plan developed by a registered dietitian for a specific type of patient. Those with specific nutritional needs may have prompted a nurse/dietitian interaction, but that was rare. Speech class? Most of this thread still reeks of a lack of understanding. A speech class? English comp? You think I completed a reputable Bachelor's Degree without these same classes? Decision Making You want me to seriously believe that nurses are empowered solely with the ability to make cost benefit analysis of "quick" vs. "longterm" actions? Common Vent. You're doing exactly what I didn't ask for. I want precise measures of how these things are different in the nursing realm. Again, I consider this protectionism. I'm not saying that paramedics should be nurses, but I am questioning the reported huge differences in scope of understanding. Even the things you address (insulin, nutritional needs) could be addressed by simply rearranging some of the curriculum (at least mine). The base education is there. Where I will agree is that, in general, the paramedic (not EMS) profession is ill equipped to handle these changes on a wide scale basis. Even if it functionally did not change what we do I would welcome an identical scope of education to the nursing profession to abate precisely this argument.

Vent, Good response. I still feel like it comes with a bit of predetermined bias about what is and isn't taught in a good paramedic programs. My patient assessment class was almost 6 months long, Monday-Thursday. The majority of the class was taught by a combination of PAs and physicians. We were taught to do entire assessments of the entire body, not just from an EMS standpoint. There was a realization that many of our graduates may work in industrial settings or overseas. So yes, I do have training in recognizing and classifying ulcers. Yes, I was required to memorize cranial nerve exams (right down to corneal reflexes-cotton ball included). We had individual exams on every major system. I had to know Kehr's sign, Cullen's Sign, Grey Turner's, etc. Normal lab values, etc. I’m just pulling some of the things you mentioned. Respiratory standpoint? Yes, I know and can describe in detail a V:Q mismatch, shunting, partial pressures, anatomical vs. physiologic dead space. Communicating adequately with a patient? Yep. Mental health, including death, dying, and disability, was a major portion of my education. So when you write about these things I get frustrated. I'm not one of those paramedics. As for the DNP, trust me when I say I see the value in a terminal degree (I attended a Carnegie Research Extensive University), but I was writing specifically about the DNP as an entry point to advanced practice. It is my understanding that this is being considered, though not currently required. When will the nursing profession simply come out and say it. They want an entry pathway to independent medical practice separate of traditional medical education.

My prayers are with him and the family.

These programs really are the infancy of what I think will inevitably become a standard career route for paramedics. The reality is that EMS education standards need to increase dramatically. Some political things need to happen too. One of the brightest, and I think future telling, developments I recently saw came from a proposed bill that was shot down in Maryland last year (I know, really). In an attempt to reign in the monopoly that is MSP aviation, a state senator introduced a bill that simultaneously created the first State Board of Paramedics. The bill specifically required that the board serve as a self-regulating professional body that was separate of the nursing and physician boards. Like the state nursing board it required some collaboration, but was mainly self regulating. The bill got shot down by, surprise, the state volunteer firefighting association. I think these things are the two most important steps our profession can take. Become self-regulating and make stringent entry requirements to the profession. Advanced practice would surely follow within a decade. This was a particularly interesting development for Maryland because the state has a well oiled statewide system of EMS oversight that is conveniently close to D.C. It also has the educational resources, including a university program, which could easily pilot some of these proposed programs. Maryland also has diverse demographics, ranging from dense urban environments to vastly rural areas in the east and west. This part of the bill was not well read by most people due to the political hysteria surrounding loosing the vaunted trooper program (ugh). Some observers, especially knowledgeable professionals, were closely watching the development of the state board concept. That particular clause was very well written and researched, to the dismay of certain well entrenched career politicians at MIEMSS. It died in the senate due to extremely heavy lobbying from fire organizations which are in MSP's pocket. BUT it pioneered the concept, at least in Maryland. I look to see it in the future. This is especially as MSP has become increasingly expensive and resistant to meaningful change and oversight. I've heard that it may be introduced again during the next legislative session. EVERY paramedic in the country should write and support these changes.

chbare, We essentially agree. Thank you for your honesty. Your emphasis on politics is exactly what I'm getting at. I also completely agree with you about EMS and taking advantage home healthcare opportunities. I hate to say it, but nursing is a profession that has created its existence in the current rendition. Smart, really. Also, I've read about the DNP issues. Education creep is something of a side interest of mine; something of which I think the nursing profession is slightly guilty of in regards to the DNP. Again, good for the nursing profession. I know that if we were even half as organized we'd do the exact same thing. I'd just like some acknowledgement of the truth.

As I've said before, this is the future. The lack of interest in this thread shows a unfortunate theme. No paramedic wants to be out "preventing" disease and taking care of minor ailments. Too bad. If only more policy makers read these success stories.

I took the time to go back read all the posts in this thread. One thing I've noticed among the old timers is their ancient notions of current paramedic education. Yes, when referencing paramedic certificate mills, they're definitely right (and these definitely do still exist). A lot of the comments; however, are grossly inaccurate about legitimate community college programs and flat wrong about the really superb programs that I'm familiar with. Granted, I'm not knowledgeable about the entire country. I guess some of you live in areas with some sorry excuses for paramedic education.

Do enlighten me Dust. Really. I've seriously considered bridging to RN (a job I have little desire to do) just so I don't have to hear this completely illogical argument. I hear this all the time from nurses. "Well, you'll never understand because you didn't take our incredibly hard (yawn!) curriculum and succumb to our pat ourselves on the back mentality." Sense my sarcasm? I've sat in plenty of classes with nurses (my prerequisite curriculum was nearly identical) to know that a bunch of twenty something, settle on a gender appropriate profession, college chicks were not surpassing me in intelligence (I'm not sexist, but the reality is true. At least 75-80% of all nursing majors I met in school were female. Few had any real interest in healthcare). What value does the nursing profession add to the healthcare environment? When you address this question, please do so from the perspective of a new graduate, floor nurse. Let me also reiterate that I've spent enough time with nurses in hospitals. In an employment atmosphere, and as a paramedic student. I'll know better when you're spewing BS. Give me clear, concise examples of "what" the nursing profession does. Oh, and don't use a paramedic as a comparison. As I stated in response to VentMedic, I'm more than well aware that 60% of our profession is full of charlatan, cook book paramedics. We're definitely not an example of how best to defend your existence. Also, don't use small technical examples that a monkey could learn in a week (this is no better than me accusing nurses of being idiots when it comes to ECG analysis). I want you to provide me examples of far reaching, critical medical concepts that are achieved solely by the nursing profession and could not be duplicated by any other group of professionals. If these don’t exist (I can think of but a few) then cite me examples of economic pressures that make nursing a valuable profession. My real belief is this: nurses (a basic RN, don't use this globally) constitute the worker bees of the hospital environment. The majority of their day-to-day interactions with patients could be duplicated by a different group of professionals; perhaps (gasp!) with less education! Don't get me wrong, the profession is needed and useful. I greatly admire the profession's push for higher education standards, increased pay, respect, and more autonomy. Bravo! I just believe that if you had to rank EMS' problems in order they would go in this order: A) Poor, fragmented education standards. Low barriers to entry. B ) No standard definition of "what" EMS is. No professional standards. C) Lobbying efforts of the IAFF. The firefighting profession in general. D) Lobbying efforts of the nursing profession. I'm being serious. All I really want is a well written, believable manifesto of what I'm missing. No smart a$$ snipets of my writing and twisting it for a nice gut jab (Dust!). Answer my question. I'll read it. I promise. Also, if you provide studies, please try to get them from something other than a nursing journal, for which I believe there is more than questionable bias (talk about a celebration of how awesome you all are).

Vent, I agree with 100% of what you say. I realize these things too. I understand nursing does "more" than specialize in emergency treatment and also understand the educational things they've done right. Your last paragraph adequately sums up my disgust with our profession. A lot of my arguments are rhetorical, because I know better. Our problems, in my opinion, come from the fact that we are not a homogenous group. We have "healthcare" practitioners and firemonkeys forced to become paramedics. One side wants one thing (progress) and the other wants the status quo. As for the PA thing? I can speak for myself in that I think the Physician Assistant profession would be a viable option if I ever decided to pursue that direction, but I'm not addressing what PAs do. Be it PAs, NPs, advanced practice EMS providers, or physicians themselves I feel that much of healthcare, especially emergent care, could be completed in the home. I think EMS, or a component of EMS, is in a good position to accomplish this mission if we could get out sh!t together.

I'm going to say something kinda inflammatory. This is an educated response, I think. Since it involves the comparison between paramedic education and nursing education let me preface it by saying I have an education beyong basic paramedic training. Many of the deficits I note below I see in others in my field, not neccesarily in my own background. Dust and others are familar with my posting (I've been busy with life and such). Having been a paramedic for almost three years I am still having a problem finding huge differences between an RN and a well educated paramedic. I came out of school thinking, and truly believing, that there really was a big deficit in certain areas of practice. Outside of the nursing profession's focus on in-hospital processes, I honestly believed they received more in depth training in pharmacology, basic disease processes, and other long term care issues. I've discovered that at the community college (ADN, associates, etc) level that this really isn't the case. I recently had the opportunity to engage in some educational opportunities with nursing students. Some of my newer clinical exposures have led to some newer perspectives as well. Can someone who is a nurse please educate me on what I'm missing? Yes, there are some differences. Nurses have a detailed knowledge of in-hospital politics and patient progression through the healthcare system. I learn something here on a fairly regular basis, but nothing that couldn't be taught me in less than a week. Yes, I had little exposure regarding wound care. Got me there. Pediatrics? Some differences, but mostly from a developmental aspect. My largest observation? Nursing and paramedic involves VAST cultural differences in providing care. Paramedics are told every day in school that disease processes are out literally hunting down their patients. They're fed a bunch of BS about the golden hour, rushing from the scene, etc. Every ailment has to be treated immediately with some mind-blowing process? Chest pain? Every patient's going to get PCI. The slightest ST elevation? STEMI (regardless of statistical improbability). Back pain? AAA. I think a lot of this comes from the lack of prerequisite education that EMS providers get. I bet fully 2/3rds of this nation's paramedics have undergone dubious education in the basic sciences. Microbiology and infectious disease training is lacking in the majority of paramedic programs. Paramedic educators have no real standard to meet and they themselves have little knowledge of in-hospital treatment. Nurses seem to be taught to approach patients from a more cautious diagnostic perspective. For the nurse, diseases are a process. The patient, as a person, should be supported. Disease prevented and monitored. Patient advocacy is better emphasized. Still, I feel like I encounter at least one nurse a week in my different clinical exposures who is harmful to their patient. Just as the average paramedic is not fit for the hospital setting, many nurses are typically horrible for the urgently sick patient. Lack of basic knowledge regarding ECG analysis (even among the CENs), poor intuition about overall patient condition, lack of decisiveness, acquired clinical practices or assumptions that are false or improper, etc. Minimizing even the obviously sick. Even things that you would assume are privy to nursing expertise like aseptic procedures and general infection control seem to go to the wayside. EXTREMELY poor understanding of patient living conditions or human events that precipitate common ailments. Poor understanding regarding the immediate evolution of emergency conditions. I'm a big proponent of a pretty controversial idea. That in reality, the two professions have minimal differences that amount to huge clinical differences. The difference is in easily correctable educational problems. Either A) All paramedics go through nursing school and receive specialty training in EMS OR B ) Paramedic education mimic, or exceed, those differences present in nursing schools and actively compete with the traditional nurse for survival in certain aspects of the healthcare field. The last is probably unrealistic. I understand the argument that not every nurse wants to bop around in the back of a gut box. BUT, I have always, and still do, believe that the future of our profession is in more definitive in-home care. Prevention and treatment of common medical ailments. The word no one wants to hear: advanced practice. Many steps need to happen. First, our profession has to get out of these certificate programs. Minimal entry has to be an associates degree with some adequate barriers to entry. Meaningful bachelors programs that emphasize research and managerial programs with proven methods. Eventually Masters programs that mimic and exceed the standards practiced in current mid-level practioners. I even foresee no real need to reinvent the wheel. Offer adequately educated paramedics entry into already established professions (NP, PA) with later subspecialty training in in-home diagnosis and training. Of course some technologies will need to advance, but they will in time. We need to be prepared to meet these challenges or be relegated to being replaced or forgotten.

I think the inevitable change from a transport model to advanced practice, in-field triaging of care and treatment will come at the request of either A) Government B)Insurance Companies or C)Academic public health and emergency medicine experts. This is sad, because we as a profession are paralyzed by so many competing lobbies. The issue of EMS Advanced Practice is a purely (almost) political one. At this point in 2009 there is plenty of evidence, both anecdotally and from actual trials/active programs, to show that a well educated, independently practicing paramedic can inflict huge cost savings on the health care system. I read recently that the Nova Scotia Community Health Paramedic trials have, in some cases, produced a 40% drop in ED admissions. Add to the above problem a generation of currently practicing paramedics who obtained their training through the simplest means possible (certificate programs) and you rapidly see the aversion to "higher education." The key will be to develop adequate bridge programs to bring most current paramedics up to speed. Make education accessible through an industry sponsored campaign. Make it necessary for current employers to make education a priority and develop funding options to assist with that education. I guarantee if Medicare or the insurance companies said that they wouldn't pay out claims to paramedics w/o associates degree you'd see a massive national push to make formal higher education a priority-overnight. More likely, you'll just see a decrease in certificate paramedics through years of future attrition (unfortunately). Once the NREMT and other organizations get the gumption to end certification w/o formal education you'll slowly see older paramedics get on board, retire, or be priced out of the market as their higher educated peers advance in leaps and bounds (as in nursing now). Very simply: A master's trained practitioner with some degree of independent practice with limited physician oversight. Require all paramedics to license at a minimum of an associate's degree. Critical care or paramedic supervisors should be obtaining Bachelor's level education. Similar to nursing. This is an issue that I take seriously. I know many paramedics whose years of experience have made them excellent providers. I know people who were priced out of education or grew up in locations where the idea of getting a degree to work in a fire department was just ludicrous. These people need an option. The critical problem is for our profession to buck up, establish new standards, and then come up with innovative solutions to bring the rest up to speed. Every single paramedic should be shouting from the hilltops. "Education!" - "Higher Pay" - "Advanced Practice." Every paramedic should spend some personal thinking time with the possibility of a well respected, self regulated profession. They should seriously think about what that means and how badly we deserve it. It doesn't happen by being complacent or accepting the status quo.

Actually, one of the things Delaware does right is ALS...and no sales taxes. In Delaware, ALS is regulated by the state. Under state law a qualified "ALS unit" must have two paramedics. Almost universally ALS care is provided by chase cars. Some nice things about Delaware's system: 1) Almost exclusively ALS is provided by professional paramedics. No volunteers. It is provided by the three county systems. 2) Care is pretty progressive. Sussex County has every medic performing RSI with a comprehensive system in place to insure skills retention (OR time, etc). Hiring is extremely competitive. 3) There is little call dilution. Each county has maybe 6-8 ALS units that cover pretty decent sized areas. Providers get plenty of experience while serving in a semi-rural atmosphere (higher acuity, less BS). 4) State law requires all EMS units to have ventillators on board. If I remember correctly, it was originaly supposed to be some pandemic flu thing (I guess someone assumed there would be a need for field hospitals...?). Interestingly enough this has expanded to everyday clinical applications. 5) Pretty open drug boxes w/ regional protocols. 6) Paramedics do split (if one is following behind and another call comes out they go to that call), but they run cover units in a similar fashion to police officers. The idea is to have two paramedics on the call, or atleast severe calls. 7) Decent starting pay for the regions. County jobs, county retirement, good benefits. I have two friends who worked in Delaware. One for Sussex and one for New Castle. Both said the systems were great and very oriented towards progressive ALS care. The one now works at a renowned flight service and credits his experience in NC with getting him that job. Con: Delaware is boring. Hope that helps.

The NREMT testing is stressful enough. Being in the military with the threat of being shipped back home adds even more stress. It sounds like she had a rough couple of years to add to the stress. As someone else mentioned, the military has shown it is poorly equipped to handle stress (combat or otherwise). God Bless her for the dedication.

Get a lawyer. Now. I've had an exposure before and I know how worrying it can be. Time is of the essence in these types of events. Even if the possibility of transmission if low, employers are bound by most state's Occupational Health Service/Departments to provide an adequate infection control policy. Your safety is top priority! At the very least make sure your objections are well documented so you have recourse if something happens. You'll be able to show that your infection was caused at work and hopefully get worker's compensation to pay for any future care.