Nurses vs EMT's in EMS

[Harold1]

In my country a choice has to be made whether to continue with a nurse-based ambulanceservice or to start with a EMT/paramedic-based EMS-system. Can anyone give me good arguments why EMT/paramedics would be better than nurses (with ED or ICU-background)?

[JTpaintball70]

I'd say go with the Nurses unless you are planning on having your medics trained to the level of medics in places like Australia or New Zealand. The system we have in the US is very flawed and I'd say do not go with anything like it.

[Timmy]

To become a Registered Nurse or Paramedic in Australia you need to complete a 3 year degree, the training standards between a paramedic and nursing degree is pretty similar but obviously it’s industry specific.

You can’t expect a Registered Nurse to jump into an ambulance and be expected to perform at an advanced level of pre hospital care with out appropriate specialised training in that area, just as you can’t expect a paramedic to perform at an optimal level in say a surgical environment or in the nursing intra hospital environment.

I’ll draw you a little flow chart which demonstrates how a Registered Nurse can become a paramedic in Victoria, Australia.

Bachelor of Nursing (3 years)

^

Graduate Year (One year of mentoring in a hospital)

^

Registered Nurse, Grade Two (Base Line Nurse)

^

Graduate Diploma in Emergency Care or Intensive Care (One year)

^

Graduate Diploma in Paramedic Care (One year)

^

Graduate Paramedic

^

Advanced Life Support Paramedic

Unfortunately there’s no bridging program for a Paramedic to become a Registered Nurse.

While it’s all well and good to have RN’s running around on the ambulance your company needs to have a bridging program to ensure a smooth transition.

[Richard B the EMT]

Sounds to me like somebody attempting to "protect their territory", and it is going both ways.

[VentMedic]

Spain and other countries require the nurse to have post grad work similar to the U.S. NPs which puts them more inline with a public or community health model that gives them more field opportunities for providing the best care. Thus the nurse would be the more appropriate provider. If the Paramedic has training/education as the equivalent of a 4 year degree with expanded education for community health needs, then that could be argued as well.

But, the RN who has no less than 3 years (5 preferred) experience in med-surg, ED and the ICU, I would say they would be extremely valuable in the community on an ambulance. I included med-surg because those are the nurses that do much of the teaching for diabetics, asthmatics, wound care and other chronic conditions. This is where the Paramedic may be lacking.

Edited April 4, 2010 by VentMedic

[Kiwiology]

It all depends on what level of education you are going to give your Technicians and Paramedics.

While we are it, just call them Paramedic and Intensive Care Paramedic, it's much simpler do not make the mistake of using the "Technician" verbage as it will do you no favours whatsoever.

Civillian Paramedics (if properly educated and trained) are comparable to nurse based ambulances (which are still used in the majority of Europe and some Mid East nationss far as I know). I cannot stress how important proper education is!

To give you an idea of how New Zealand works:

- Paramedic: Three year Bachelor of Health Science in Paramediicine plus one year graduate internship

- Paramedic scope of practice: Manual defibrillation, cardioversion, 12 lead ECG interpretation (mainly around ST changes), laryngeal mask airway, IV fluid, adrenaline, amiodarone for cardiac arrest, ondansetron, naloxone, ceftriaxone, fentanyl, salbutamol, GTN, aspirin, glucagon and glucose, methoxyflurane

- Intensive Care Paramedic: Paramedic + two years experience + Post Graduate Certificate + one year internship

- Intensive Care Paramedic scope of practice: Paramedic + advanced 12 lead interpretation, thromolysis, intubation, rapid sequence intubation, atropine, midazolam, amiodarone for wide complex arrythmaias, ketamine, hydrocortisone, salbutamol IV, mag sulfate IV, frusemide (probably going to be withdrawn)

Links to our Paramedic Degrees:

http://www.aut.ac.nz/study-at-aut/study-areas/health-sciences/undergraduate-courses/bachelor-of-health-science-paramedic

http://www.whitireia.ac.nz/courses/Pages/BachelorofHealthScience(Paramedic).aspx

If you have any questions please, you are more than welcome to ask!

Edited April 4, 2010 by kiwimedic

[DwayneEMTP]

In my country a choice has to be made whether to continue with a nurse-based ambulanceservice or to start with a EMT/paramedic-based EMS-system. Can anyone give me good arguments why EMT/paramedics would be better than nurses (with ED or ICU-background)?

There are a lot of variables, but in the US you'd be better off to go with a medic/medic system as opposed to a nurse/nurse truck as prehospital EMS is a very different animal than in-hospital EMS. The scope of practice and skill sets are much more finite and well defined, as well as the autonomous work environment. Am I, as a paramedic, the better choice to work an accident scene or significant acute medical in the field than an ER trained nurse? In my experience, yes, very much so. Is that because I'm smarter than the ER trained nurse? Not in any significant way. What I do bring as a significant advantage is a finite toolbox that I have practiced over and over bringing an efficiency of movement and confidence with not only pt management but the management of the scene and the resources available there.

Now of course if you take a nurse that has been trained in these skills as well, then my whole point becomes moot, as we see often with flight nurses in the US. There is nothing magical about a medic cert that endows one with the skills mentioned above, only that here, that certification focuses on those skills throughout the education process as well as puts us in an environment to practice them endlessly.

If your system is looking at simply staffing ambulances with hospital trained nurses over traditionally trained paramedics, then I'd say that that is not a good thing. In Kandahar I worked with a driver, a KIWI doc and an Aussie nurse. The doc was useless as he couldn't seem to get the point that he had hands of his own and that on an ambulance he was expected to use them. He also could either work a pt on scene, or load and run to the hospital, but seemed unable to come to understand that there are ways to do both at the same time. (THIS NZ doc, please don't extrapolate this to ALL NZ docs, or even docs in general, he just happens to be my only experience in this arena.) The Aussie nurse was awesome, but coming from Australia she already had a healthy respect for prehospital medicine and was simply a sponge when exposed to those concepts. But despite the fact that she was wicked smart and competent, she originally had almost none of the tools necessary to work prehospital, by her own admission I might add. The flip side of course is that given those tools and additional education specific to prehospital EMS her intelligence, commitment and common sense would have made many, many of the medics I've been exposed to look like a bunch of monkeys humping a like number of footballs. She was an inferior provider to me because she'd been dropped in my environment. Had I instead been put into hers I would have, and often did, feel like a complete poser, medically speaking. Two different worlds.

Prehospital EMS is a pretty specific skill/education set. If those that will man ambulances are not trained/educated in it then I believe that system will suffer because of it.

Dwayne

[KosherMedic]

Belonging to this discussion group is helping to open my eyes. I had no idea that paramedic training in other parts of the world is so different. I have heard that some paramedic programs in the USA are only 90 hours. Is that really true?

I was reading what KiwiMedic said about their training in New Zealand and their Intensive Care Paramedic is comparable to the training I received here in Alberta, Canada. Though, our program is a two year technologist diploma that follows a one year technician diploma. Also, our training focuses on the actual skills and knowledge needed for critically injured patients and doesn't include the professional courses like:

Psychology and Lifespan Development

Knowledge, Enquiry and Communication

Health and Environment

Professional Practice and Ethics

Health Law & Policy

Disaster Theory

Emergency Planning

We do have four year degree programs that cover that material for people who want a professional degree. However, most get their Emergency Medical Technician (year one) and then go back for their Emergency Medical Technologist - Paramedic (years two and three) after getting some experience.

Would I think that a nurse/EMT crew would be better than a paramedic/EMT team? Not unless that nurse was also a paramedic. There are things you need to know about working on an ambulance that you cannot learn from a book. And, unless that nurse is allowed to perform the same kinds of advanced airway techniques a Paramedic can then what's the point of them trying to take a paramedic spot?

I've worked in remote nursing stations where the nurses thought they could be the local ambulance people too. The vast majority of nurses just don't have the skill sets and experience with pre-hospital patient care they need to function in a prehospital environment - but, you try telling them that. If they want to be ambulance personnel then they should go to school and learn how to do it properly. If a nurse wants to learn how to board a patient in a ditch, goes to the OR and learns how to intubate, and passes a full ALS practicum on ambulance then they've earned the right to take a paramedic spot.

[VentMedic]

Now of course if you take a nurse that has been trained in these skills as well, then my whole point becomes moot, as we see often with flight nurses in the US. There is nothing magical about a medic cert that endows one with the skills mentioned above, only that here, that certification focuses on those skills throughout the education process as well as puts us in an environment to practice them endlessly.

If you look at the systems in other countries that utilize RNs in prehospital, their education AND patient care experience is extensive and advanced by the ED/ICU before they can apply for an ambulance job. That is similar to what some U.S. flight and specialty teams expect of their nurses. It would not be a stretch for them do a post grad ( 1- 2 years) and become proficient in pre hospital. Also, if the RN is working in EMS, aren't they exposed to the everyday experiences the same as the newly minted U.S. Paramedic? Many U.S. Paramedics may only have a year working as an EMT-B on a BLS truck or an ALS truck as a driver. Others may have their time in with the FD on an engine while getting their patch. Many U.S. Paramedic programs only teach the bare minimun with a couple of shifts as orientation once they are hired. Even for intubation, in some areas it may be only recommended that 5 intubations be done and a manikin can be substituted for human patients. The RN is also less likely to be limited for scope of practice when it comes to skills and medications with states allowing extended practice to those who are in out of hospital situations. The truck can also easily double for CCT transport. Hospitals are also more accepting of allowing RNs to enter the hospitals to maintain their critical care knowledge (IABP, ventilator, hemodynamics and medications/drips) and "skills" (intubation, IVs, central lines and chest tubes). The U.S. Paramedic may be limited only to what they get a chance to see and do in the field. Thus, we have Paramedics who haven't intubated or even started an IV in months with the way some systems are set up and few opportunities to get additional experience in a hospital setting.

The U.S. Paramedic is just not a good model to argue against systems in other countries where both the Paramedic and the RN are well educated and have higher expectations to enter and function in the prehospital environment. The U.S. system in many places also promotes Paramedic/EMT rather than Paramedic/Paramedic. U.S. Flight, CCTs and Specialty teams generally will utilize an RN(s). The U.S. Paramedic has not kept up and has become limited to a few skills and a small section of emergency medicine. Times are changing and those who have a broader education and more patient care experience may be the better choice to provide the role some have been dreaming about as the Advanced Practice Paramedic. Right now the way that title is loosely used in the U.S. is for Paramedics in fly cars to assist other Paramedics in "advanced skills" like intubation or the complicated RSI meds and telling them what facility to take the patient to. In other words, a patch to fill in the missing gaps in the present Paramedic education and training or oversight.

I apologize for the rant but the OP posed the same question on another forum right under a thread with a 10 week Paramedic program listed. I now have to change from saying 3 month wonders to 10 week..."blank"...haven't found the right word yet.

[WelshMedic]

Hi all,

Although I can't be absolutely sure, I have a hunch that the OP is here in Holland. There is a discussion going on here whether CCRN's on all ambulances aren't a very expensive option (and in short supply). One of the iniatives is a feasibility study into a 4 year Bachelor's degree that has a 2 yr common core followed by either 2 years in either ER or EMS. The problem is that the practitioner that rolls out of this programme would, not yet, have a recognized title. They are neither nurses or medics.

Whilst we recognize that change isn't necessarily a bad thing, our concern is that the programme will not prepare the student for the broad role that they will fulfill in EMS here. We are far more community based than the US. We treat and refer patients ourselves rather than necessarily transporting everyone.

Anyway, there's a bit more background info for you...

WM

Edited April 4, 2010 by WelshMedic