Nurses vs EMT's in EMS

[Eydawn]

There are midwives who practice who are not RN's. There's a difference between a midwife and a certified nurse midwife... come to think of it, there's certified midwives (not RN), direct entry midwives (not RN), certified professional midwives (may or may not be RN) and certified nurse midwives.

Just thought I'd throw that out there... This is some really excellent discussion!

I would definitely agree that a lot of the misperception of nursing vs paramedicine comes from the attitudes that have developed within each specialty, with each disdaining the other through ignorance. Nurses are definitely independent thinkers (maybe not some of the SNF drones, but fortunately most of the ones I've met in that field so far have been very intelligent and good at what they do)and have to be in order to perform their job appropriately. Standing orders are standing orders, no matter what title you may happen to hold. I have standing orders to NOT EVER do CPR in my facility, because we're not a "skilled" facility. I also have standing orders to provide basic wound care since I have no nurse at night. Does that take all my thinking out of the equation? Certainly not, and if that holds true for me at the flunky level, it definitely holds true at higher levels.

I think the perception that you are "autonomous" as a paramedic is one of the dumbest things I've encountered... it's where a lot of the cowboy medicine that is practiced without solid foundation comes from. Of *course* you need to make autonomous decisions based on the situation you are presented with... but at the end of the day you answer to the doc and if you gooned it up, the doctor will take away your ability to practice. Same holds true for nurses... you have to make critical decisions based on the information in front of you.

Has anyone here been sick recently? What was your experience- who did you see? Who did the majority of your care? In my experience and that of close friends recently, it's been the nurse who does 90% of the care. The doctor may pop in to provide some of the puzzle pieces, but the nurse is providing care. That's autonomy if I've ever seen it... just autonomy with the awareness of physician involvement at the forefront instead of hidden away in the subconscious.

Wendy

CO EMT-B

[Kiwiology]

No, I'm refering to those who go from basic class, Intermediate class, to Paramedic class with TWO years. With very little field experience in between classes.

If you count the years of how it use to be when I went through the whole process, it was a total of at least four years.

I saw the question of what nurses learn that Paramedics do not need to know. The one's that came to my mind I thought of of patient care plans, long term observation and treatment, giving sponge baths (I know, that's something RN's rarely do, but it is part of a nurses training). There were some more that I can't think of right now.

I do not think a nurse learns anything that a Paramedic does not need to know. While some of the things you touch on such as long term care plans may not be of the same relevance to a Paramedic who may only see that petient once as opposed to multiple times in the LTC/community nurse environment it is still relevant. Many patients with end of life care plans for example are seen by Ambulance Officers and these plans are often referred to in the context of giving the most appropriate treatment and care when called to that patient.

As for your counting years, our Paramedics spend three years in school full time (with a minimum of 1,200 hours clinical placements) then do another full intern year ontop to become a Paramedic. Remember that this is not advanced life support, to reach that level (Intensive Care Paramedic) you must do at least another two full years on the road, then the Intensive Care course, and then another intern period. While your folks might take four years to reach Paramedic (ALS) level as an example, they are in reality only getting probably just over a year of actual education (and that is likely a generous estimate, most Basic/Intermediate classes I have seen that are full time run for a number of weeks, whereas Paramedic classes tend to be nine to twelve months).

[melclin]

Paramedics have a different scope but not necessarily broader. For instance, how many can insert foleys, NGT's, titrate inotropes, infuse blood products, administer antibiotics, set up, start, run and discontinue dialysis (including CRRT), access central lines, insert PICC lines, initiate ventilator weaning protocols, manage invasive pacemakers, manage invasive monitoring lines (arterial, Swan Ganz etc)? Just to name a few "skills" beyond intubation. The majority of the aforementioned activities require some degree of "critical thinking" abilities.

2) If as a nurse you are unable to do this you won't last long in an intensive care or high acuity ER environment. Nurses don't stand around and wait for the doctor to come when a patient is coding.

True, but I think your missing my point about the fundamental focus of the paramedic vs nursing undergraduate education, which was really my original point. Most of those skills listed their are quite advanced and are not predominantly things that graduate nurses do. I keep saying, I'm not having a go at nurses and people list skills and talk about how wonderful nurses are. I concede that I was unaware of the extent of the scope of advanced practice nurses in some settings, however, that is not terribly relevant to my main point which was basically if you are looking for an affective way to educate prehospital professionals, the best way to do that is begin with prehospital qualification, because of the specific skill set required. I happily agree that good ICU/ED nurses would make great paramedics, but as I said, to require prehospital professional to be great ICU nurses before they can step onto an ambulance is an overly round about and unnecessarily long pathway to EMS (with the corollary being that a nursing undergraduate degree by itself is by no means equivalent or superior to a paramedic degree when it comes to prehospital care, which is a common argument in the states where the prehospital qualifications are inferior, and I wanted to provide a picture of a system where that was not the case).

Some of the things I said "dissing" the average grad nurse was my attempt to explain to the Americans that a BSN in Australia is not equivalent to an American BSN which is a higher qualification as far as I can tell.

3) Pretty bold statement to make based on hearsay and your own very minimal experience and limited knowledge. It actually only shows your ignorance of what it involves to be a nurse especially in a critical care unit or ER. I can guarantee you that there are many Doctors who have ignored a nurse's advice and caused harm to a patient or on the other hand listened to what a nurse said and prevented a serious event as a result. Do you think Doctors aren't human and don't make mistakes or write orders incorrectly?

Of course not, but to be far I didn't really suggest that. I have obviously touched on the a nerve that many nurses and paramedics have (students like me included) that involves raising ones temper when people assume a much lower level of practice that you actually have. It appears some of what I have said has been the equivalent of calling you an ambulance driver, and I do apologise for not being more familiar with the extent of higher levels of nursing practice. However, again, this was not fundamental to my point about the fundamentals of the undergrad education.

Also, importantly, I often make a point of the fact that I'm a student. I don't claim to be coming from a position of any particular expertise and my point was primarily about something that I am familiar with, which is the nature of the paramedic and nursing undergrad education. I do however, maintain that almost every nurse, some of them quite highly qualified and experienced, that are now doing my degree have said that it is a much different ball game - that it is much harder than they thought when its all on them and them alone, especially without the support structure of the hospital. You can take or leave my undereducated and under-experienced opinion, but that is a pretty common sentiment from people who have actually made the switch. I was also on placement with two experienced paramedics, who were originally ICU nurses and wanted to return to nursing, who were complaining angrily of the re-certification requirement on the grounds that they do more as paramedics than they ever could do as nurse. So I feel my opinions are not totally baseless, but your're right, I know very little about the nursing field, but I never really said I did beyond the graduate component.

4) Another example of ignorance since "educated clinical decision" making is the foundation of nursing. It is obvious that your whole perception of what a nurse is and does it to mindlessly follow Doctor's orders.

No it isn't. But I can see how you would think that looking back on some of my posts. I apologise for my obtuse use of language and broad generalizations.

6) I agree with Ventmedic about Paramedics having a false idea of autonomy. They all operate under standing orders or protocols (Doctor's orders! Every program has a Medical Director for that very reason). Many different units have their own version of standing orders and protocols just the same that nurses can initiate and use without having to ask the Doctor for each specific order. Autonomy exactly the same. The Doctors are not always readily available in the units either. How many medic programs have to call for online medical control to give an extra dose of Morphine over the protocol amount (just for example!). Really no difference just looking at it from a different perspective. Doctors orders and the protocols that paramedics follow are really the same thing except in the hospital they are individualized to a patient and not a broad disease category. Nurses in the ER will often triage and start treatment with standing orders before a doctor has even seen the pt. (For example with chest pain). Is that not exactly the same thing that a paramedic does? That is just one example.

Yes it is that way in America, but things are a little different here. I take your's and Vent's point about a false sense of autonomy, but I do think that depending on the extent to which you are willing to defend your decisions, we have more autonomy here than perhaps you realise. I think the point here is the difference between guidelines and protocols, while some here argue the difference is only the name, others feel that they can basically do whatever they want if they can justify it, and that is different to a lot of American systems, which is what you appear to describe. I don't of course want to start a pissing match about who can do more because it is evident that, one, I already did that without intending to and I don't want to continue it, and two, I obviously don't know enough about nursing to do it. What I will say however, is that I think the above paragraph shows a bit of a misunderstanding about some of the aspects of a lot of Australian paramedic practice. I don't know your background, so I obviously can't say for sure, but the above does sound like an odd interpretation of Australian practice if you are aware of its specifics, so I'd like to humbly and tentatively suggest the possibility that you may be more unfamiliar with modern paramedic practice here than you realise. Forgive me if I have misinterpreted your words, and that you are actually the CEO of Ambulance Victoria, which could be somewhat embarrassing on my part .

7) Actually a midwife is a nurse with further education. You can't be a midwife without being a nurse first.

I am not attacking you personally here. I am just a tad offended at the statements made when you obviously don't really know what you are talking about.

Midwives absolutely do not need to be nurses first - http://www.med.monas....au/bmidwifery/

I can see that I have offended you and, as I said, I do apologise. I was wrong about a number of points but I also think you misinterpreted the main point of my post perhaps because of its inadvertently offensive nature....This feels familiar .

Oh and the creatures remark...I just assumed that all health care professionals ate noisily from horse troughs and made abhorrent noises and gestures when displeased. Is that not the case of nurses?

[Timmy]

There’s no need to apologies, this is a forum of adult education were mature and up standing citizens voice there educated opinions and receive constructive criticism in a professional and well educational environment.

Nah, it’s all good. I once was a Student Paramedic back in the day and made the switch to Nursing as we were constantly told that undergraduate high school leavers would never be accepted into the graduate program with AV because we had no ‘life experience’ and we’d be better doing nursing first then coming back to paramedics. I was also a little uneasy about the shear volume of first year students they accepted into the paramedic degree.

(Not to mention the better pay, hours and work conditions compared to being a paramedic, have you seen what a RN Div One can earn on agency? It’s not to shabby at all)

So I moved back to the country, found my self a hospital that paid for my training, paid me a full time wage, were crazy enough to pass me then gave me a scholarship to bridge into the nursing degree… I know deep down that I immensely want to be a paramedic but for the time being I enjoy nursing, it’s fun, challenging and I’m learning a lot.

Anywho, enough about my life story…

As I said in my previous posts, there two different courses. After all, what’s the point of having the same course for two different industries?

Someone posed a question in a previous post what defining relevant paramedic education. I have no direct answer to that as I’m not a health sciences teacher nor am I a paramedic but like anything you need to assesses what previous qualifications, skills, education and experience these people have, you then need to implement a plan of action to over come these gaps in knowledge by both theoretical and practical education and possibly assess them on what there new scope of practise maybe as a paramedic with the aim of producing safe and competent partitioners.

There was mention that Nursing and Paramedics are very different in regards to clinical environment, approach and support mechanisms – this is very true. How do we overcome this? More than likely with clinical supervision and guidance from an experienced practitioner in that particular speciality but at the end it all comes down to time and experience.

[WelshMedic]

There was mention that Nursing and Paramedics are very different in regards to clinical environment, approach and support mechanisms – this is very true. How do we overcome this? More than likely with clinical supervision and guidance from an experienced practitioner in that particular speciality but at the end it all comes down to time and experience.

Hi Timmy (and everyone else of course),

You make a good point here.

I am one of the EMS clinical supervisors you mention above. I have been mentoring new colleagues for the past 10 years. Apart from the obvious aspects that need to been taught like scene management and safety, what also strikes me is that, although most of these people are already reasonably experienced CCRN's, they still need to be helped in certain areas. Not about which drug to give or how much but whether or not it's clinically safe to leave a pt. at home with an alternative care pathway. If that is the case with this level of student, what will it be like with young paramedic students without the necessary experience.

I agree that a degree trained medic is more than up to the job of treating and transporting. I do, however, have my doubts about accepting the level of autonomy and responsilbilty with Dutch EMS in it's present form.

WM

Edited April 6, 2010 by WelshMedic

[Harold1]

We are talking about one of the Dutch-Antillian islands, were we do believe that the Dutch nurse-based system for pre-hospital care is among the best in the world, to be preffered above the American paramedic-model. However I don't think we can afford the Dutch system.

And untill we can afford it, we have nurses on the bus, without any specific ambulance-training.

Maybe it's about time that we start thinking about alternative (and indeed cheaper) options to upgrade this system to ILS- and ALS-level.

[ccmedoc]

I'd be for a full year of class room/ ride time to become a Paramedic. One of my biggest pet peeves is how an EMT-A or B can go to the next level then to Paramedic, boom, boom, boom now in many areas.

Waaaay back when, we had to have been an active EMT-A for a min. of three years before moving on to the EMT-I class (having to pass an entrance exam of course). Then be a certified EMT-I for one a min. of one year before taking an entrance exam to get into the EMT-Paramedic program. You HAVE to be experienced and proficiant at a certain level before moving on.

I know there are a lot here have been on the fast track to Paramedic, but I don't think it's right. You gotta "pay your dues". I know I would be nervous if a Paramedic with less than two years in the field was going to treat me for something serious.

Sorry if I stepped on some toes, but, oh welllll......

With all due respect, this is very old school thinking and has no merit. Any evidence that being a basic for three years makes a better medic? Does being an intermediate first make a better medic? I never worked as a basic, and I think it is very individual as the the benefits of working as a basic or EMT-I for a number of years first. I , for one, think it is a waste of time.

As far as the Paramedic/Nurse thing, This is an argument that doesn't need to be going on. CCRN as a Paramedic is as perfect as you can get without going NP or Physician IMHO. With the requirements to attain this certification, the individual/critical thinking and practical skills are a given. Couple that with the additional bit of pre-hospital and transport education and it is a beautiful thing..

To say a (almost any U.S.) paramedic is more educated than these ICU practitioners is, well, misinformed to be sure. Certainly from my Point of View as being licensed as both and having advanced certs and experience as both..

As usual....Just my opinion.

[Dustdevil]

However I don't think we can afford the Dutch system.

And untill we can afford it, we have nurses on the bus, without any specific ambulance-training.

Maybe it's about time that we start thinking about alternative (and indeed cheaper) options to upgrade this system to ILS- and ALS-level.

Well that's easy enough. It takes a month or less of ambulance-specific training to make a nurse a competent pre-hospital practitioner. Learning to use ambulance-specific devices, like portable respirators, portable suction, stretchers, extrication boards and collars, etc... as well as the situational awareness to recognise your surroundings and how they contribute to the patient's condition and your care. Beyond that, ALS training is ALS training, and is really no different pre-hospital than in-hospital. Nurses already have the foundation to build upon, unlike any other lay person you could drag into the job to use instead.

By not being able to afford it, I assume you are talking about the costs of the educational system, and not administration of the actual EMS system itself? Obviously, setting up an education system from the ground up is no small task. Do you have medical and nursing schools there, or do your physicians and nurses come from the mainland or other countries?

[WelshMedic]

Well that's easy enough. It takes a month or less of ambulance-specific training to make a nurse a competent pre-hospital practitioner. Learning to use ambulance-specific devices, like portable respirators, portable suction, stretchers, extrication boards and collars, etc... as well as the situational awareness to recognise your surroundings and how they contribute to the patient's condition and your care. Beyond that, ALS training is ALS training, and is really no different pre-hospital than in-hospital. Nurses already have the foundation to build upon, unlike any other lay person you could drag into the job to use instead.

By not being able to afford it, I assume you are talking about the costs of the educational system, and not administration of the actual EMS system itself? Obviously, setting up an education system from the ground up is no small task. Do you have medical and nursing schools there, or do your physicians and nurses come from the mainland or other countries?

Dust,

I think Harold is talking about nursing graduates without critical care qualifications, making the transition into ALS somewhat more difficult. (Correct me if i'm wrong, Harold..)

WM

[VentMedic]

Dust,

I think Harold is talking about nursing graduates without critical care qualifications, making the transition into ALS somewhat more difficult. (Correct me if i'm wrong, Harold..)

WM

Is it any more difficult than a Paramedic who has very little A&P and only has the minimum required hours to complete a Paramedic course? (speaking of the U.S.) Many of these new grads come out of the programs with very little live patient experience for even their skills such as IVs and intubation which is the meat and potatoes of theri profession. Working as an EMT-B only gives them very limited patient care experience. As it stands now, many Paramedic programs have too few clinical hours. After certification they are then given a couple of shifts with a preceptor and made "lead" medic with an EMT as a Partner. Of course we do have some EMS schools and companies much better but still, in many areas the expectations are low.

For Harold's country it would depend on the long term plans for patient care outside of the hospital with serious consideration as to how much nurses can save in the long run with their broader knowledge of medical problems and not just the emergent. One issue in the U.S. as studies have shown is that the Paramedics underestimate the seriousness of some medical problems as well as some trauma especially in the elderly.