Nurses vs EMT's in EMS

[VentMedic]

But if a Nurse/MICN/RN-Medic wants to be in the field, more power to them. But they have to go through the rescue and other areas of EMS, not just the class room.

Let me highlight the Dutch System Ambulance nurse education and training again:

In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment.

Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses.

In the U.S., some of those same requirements are expected of RNs who do HEMS, CCT and Specialty transport.

Imagine if the U.S. had the same requirements for education and experience for Paramedics before they were allowed to work on an ambulance. Imagine the scandal if some U.S. states increased the Paramedic cert to a minimum of 1 year fulltime college.

Edited April 4, 2010 by VentMedic

[firedoc5]

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......

[VentMedic]

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).

Three years to master a few EMT skills? Then go on to learn a couple more skills as EMT-I?

You gotta "pay your dues".

About the only one benefiting from your dues would be the union and that would probably be Fire. Longer does not always equal better if you do not have the education to know the "whys" of the skills you are doing.

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.

I would be more nervous with someone who took two - three years to master the 110 hours of EMT training.

At least other countries do emphasize education before specialty education/training and skills. Even in the U.S. other professions require a base education of anywhere from 2 - 6 years before specialty training. RNs must have a minimum of a two year college degree. If they want to get the CCRN cert, they must work for 18 months in the ICU of their preferred specialty to take the test. If they want to get another specialty cert, they must again work another 18 months in that area. For a Paramedic in the U.S. to be called a "Critical Care Parmedic", their employer usually just gives them the title. Their training might be as little as 1 hour in the backroom of the FD/ambulance service or a whole 80 hour course with no ICU experience required. Only about 5 states have the official level of Critical Care Paramedic. There is also a test for CCP which just requires you to pass the test with no other requirements other than a Paramedic cert.

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

I wouldn't say you have stepped on anyone's toes but rather you have highlighted how the U.S. has fostered the lower levels of training and placed no emphasis on education. Thus, it didn't matter if you knew why you were taking a BP for 3 years as an EMT.

I really do apologize for sidetracking a good thread about EMS in a country that emphasizes education.

I would like to know why the OP believes the Dutch system is not working to make him ask about changing it. If they go with the Paramedic what would be the education and training requirements? How long would this take to implement?

[Kiwiology]

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.

You're onto it mate. Our doctors are bloody excellent doctors but put them in the prehospital setting and they are useless!

They generally have little interest in what the Ambulance Officers do (although there are exceptions) and to that end they don't really have a lot of contact or understanding of what goes on in the prehospital world. Unless a patient is bought straight into resus they never really interact with AOs while the nurses on the other hand, man they are bloody fantastic.

While the military medics have to do 6 weeks of civillian Ambulance placements, a medical student does one weekend in thier second year and never sees inside a truck again.

The ambulance service themselves are also to blame in a way; up until recently it was possible to have up to seven different titles on your uniform patches and there has never really been a cohesive effort made to "brand" ambulance crews in a way that is easy to understand.

[melclin]

I have to say I don't like the idea of using nurses in the prehospital setting.

Here at least, a nurse and a paramedic are very different creatures. Paramedics have a greater scope and almost complete autonomy. They also have slightly more education than nurses although the more important point though is that it is different education.

Paramedics here tend to be taught along the lines of diagnosis. Critical thinkers who can problem solve and apply their knowledge appropriately to figure out whats wrong with a patient and treat accordingly. In this sense, our training in more in the spirit of medicine rather than nursing. It has to be that way, because we don't have medical control: we sort of have to be watered down doctors. Nurses are the educated eyes, ears and hands of doctors, and while in practice, they are much more, their training is still based entirely around the idea that they are part of a team that necessarily involves direct medical oversight. Take away a nurse's support structures, other nurses, doctors, fancy gear and I think you've got problems. I've often heard nurses saying, well the doctor should be doing this and that and the other thing, but I wonder how confident they would be if the decision to paralyze and intubate or thrombilyse over PCI, decide on the amount of fluids that post-severe haemorrhage pt should get, leaving a pt at home after deciding that they aren't sick, actually rested on their shoulders.

Most of my degree is about educated clinical decision making. When it comes down to (and correct me if I'm wrong), clinical decision making doesn't lay at the heart of nursing.

(I have nothing at all against nurses, I'm just saying the fundamentals of their education are not suited to the requirements of autonomous care. I think it is also important to mention that nurses in American appear to have more education, a greater scope, and a slightly different role than nurses here).

Also, I think prehospital care is different enough for it to be its own qualification. It would be a pain in the arse if I had to do a nursing degree and, sit on a ward for 3 years, do my ICU grads, and then start learning about prehospital care. You don't have to be a nurse first to be physio, or an OT or a midwife, because while they are related in some ways, they are different enough to have separate qualifications - so is paramedicine.

[chbare]

However, the discussion is not necessarily revolving around your specific system or experience, therefore your views regarding nurses may not even apply to the situation at hand. While we do not know what system we are dealing with definitively, would you continue to have the same opinion assuming we are in fact dealing with the Dutch system?

Take care,

chbare.

[Kiwiology]

I sort of agree with what Melclin is saying; however the main reason nurses are used is I believe because civillian Paramedics do not exist in the nations where they are used. Israel for example uses MICN/doctor/ and a civillian paramedic on thier MICUs whereas (and WM can correct me) but in the Dutch system they do not have civillian Paramedics.

My opinion is that if we take the best of nursing education and the best of Paramedic education and combine the two then you're on the right track to not requiring a nurse on the ambulance.

[VentMedic]

but I wonder how confident they would be if the decision to paralyze and intubate or thrombilyse over PCI, decide on the amount of fluids that post-severe haemorrhage pt should get, leaving a pt at home after deciding that they aren't sick, actually rested on their shoulders.

This is where the Paramedic really doesn't understand "critical care nursing" since most have never been around the ICUs in the hospitals. I also found from reading a couple of posts on the other forum that some EMT(P)s can only relate to nurses in nursing homes. The nurses I work with have no problem using paralytics. Infact, most ICU RNs will have assisted in probably well over 100 RSIs before they make the decision to do CCT. They are also in control by protocols of paralytics and sedation for the long haul. RNs in ICUs also have protocols to follow when there is a code or any emergent situation. Hospital Rapid Response Teams (different from code teams) have a very long list of protocols to initiate and way more than any Paramedic since they do have lab values available. If I need to intubate a patient in the hospital with RSI, the RN will have a protocol to get the job done without waiting, while bagging a patient, for an hour until a doctor calls back. Working a critical infant, pedi or adult has also not been a problem for Flight, CCT and Specialty RNs who may be a thousand miles away from their base hospital. An experienced ICU RN may work a couple hundred codes to where it is second nature. RNs are also very capable of intubating and doing central lines as well as chest tubes if given the training. If you had read the article I posted, you will see that thrombolytics are not an issue with the Dutch Ambulance nurses.

How many Paramedics (at least in the U.S.) can actually determine if a patient is sick enough for ICU unless they are coding? There are studies that state most will under estimate how sick a patient is because they don't fit the text book "emergency". And, due to the lack of a strong background in the sciences such as A&P, pharmacology and pathophysiology, the U.S. Paramedic is very weak in many medical issues. On the other hand, the RN is responsible for determining which patient is sick enough to be moved to a higher level of care or tossed out of the unit to make room for another patient. Even though a doctor's order may be needed to make the actual move, the RNs are constantly triaging and retriaging their patients.

The RN would also be a better judge about chronic patients. How many Paramedics would even consider taking a patient's temperature or turning over a quad to check for a decubitus ulcer? How many remove the shoes and socks off of diabetics or street people? How many would ask about their nutrition, urine or bowel moverments? How many Paramedics are well versed with insulin or even some of the common asthma medications? How many Paramedics in the U.S. know about the various venous access devices or could check their patency? How many Paramedics are familiar with the various forms of dialysis and the issues with each? Yet, some transport these patients everyday and only know "renal failure" as the reason for the dialysis and have no clue about what caused the renal failure.

Very few EMS calls are "trauma" or "codes" and the other 98% of the patients are brought into the hospital by Paramedics who have done very little for the patient except for a taxi ride. Some even miss very important issues with the patients because it "doesn't appear to be an emergency" because it was not in the one Paramedic text book.

Considering this Dutch system has an experienced ICU RN who then gets another years training/education in EMS appears to a good situation. Our Flight, CCT and Specialty RNs go that route. Our NICU RNs get a couple years of experience outside of the NICU and then get 2 more years in the NICU before they can apply or be invited to the transport team. They then spend another year getting intubations, central lines and chest tube skills along with more intense transport education before they are actually put into that situation. I don't know many Paramedics that are that well prepared for transport except perhaps those in Canada.

We could also use the Paramedic (U.S.) who might be lucky to get 1 ETI or IV chance per year and misses either because he/she is one of 7 Paramedics at each scene or because of laziness. There are also those who work ALS/CCT and only move a patient from one facility to another with the RNs at the facilities doing the packaging, pump and whatever other equipment setup. If the patient is really sick or "critical care" the RN will probably have to accompany the patient. How many tubes and IVs do these Paramedics get? These are nice jobs for Paramedics who like a "CCEMT-P" patch and very little to do. Of course there are exceptions but harder to find them in the U.S.

Melclin, I do know some very good RNs from your country and I can say they are not incompetent and can definitely manage themselves in an emergent situation. They have also made great transport nurses. Maybe they were the last good RNs from your country. It would be truly sad to know nursing now sucks where you are that nurses are incapable of learning more than what their basic program taught them. At least here in the U.S. RNs can learn new things and work in many different units while continuing their education. From the Dutch article, it seems those nurses can as well. RNs must also adapt to many different situations since hospitals love to float their nurses throughout every floor and unit when given the chance. Maybe if you had the opportunity to work with critical care nurses in a progressive hospital, you might have a different opinion.

However, it is good to see your EMS education is advanced. As hard as it is trying to explain what RNs are capable of, it is equally difficult for those in EMS in the U.S. to understand a Paramedic that comes from a system that requires a solid education. We have EMT-Bs arguing that book learning is of little use and trying to hold the standard for EMS.

Let me leave you with this little article which some seem to go by in the U.S.

2,000 Hours to train a Paramedic?

http://www.fd-doc.com/2000Hours.htm

Edited April 5, 2010 by VentMedic

[DwayneEMTP]

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......

No toes stepped on from my point of view, but you have once again shown your ignorance here. In thread after thread of scenarios you've shown to have a weak grasp of medicine and a very poor logic tree as it applies to EMS. Yet under your name, once again, you state that you're here to teach. Each of your posts shows how much you have to learn, how much you fail to "get" yet you continue to hold yourself out as a teacher instead of a student.

This opinion of yours is, unfortunately the one we've come to expect from those fire based. "Don't judge me on what I do today, how well I've performed my job, what effort I've made to bring additional tools to the table, instead judge me on how long I've been willing to 'pay dues', to be treated second rate." It's unfortunate brother, but I'm guessing most will see the truth in it.

I do believe the one thing that the vast majority can agree on here is that whatever the new system the OP ends up with, it should not be fire based. Once again you've proved that to be a healthy sentiment.

Dwayne

[melclin]

However, the discussion is not necessarily revolving around your specific system or experience, therefore your views regarding nurses may not even apply to the situation at hand. While we do not know what system we are dealing with definitively, would you continue to have the same opinion assuming we are in fact dealing with the Dutch system?

Take care,

chbare.

Well, no, but what else have I got? There seemed to be a 'paramedics aren't educated enough, so using nurses would obviously be better' vibe going on and I thought I'd present a view from a place where your average paramedic actually has slightly more education than the average nurse, not to mention that the entry requirement for a paramedic degree are much higher.

Specific to the dutch system, they clearly have a system that works well, but I do think they are requiring unnecessary amounts of nursing specific education for ambulance professionals. If you go back to the question of should I have a nurse or EMT based service and you live in the Netherlands, then it would make more sense to have nurses given they don't appear to have paramedics in the same sense we do. I was commenting on what I thought to be the ideal, rather than what was practically the best idea for someone for example wanting to staff ambulances because I think the conversation has moved significantly beyond giving advice to a general discussion of pathways to EMS.

I would say though that I can't really make these assertions with any confidence without knowing the educational systems intimately. I do, however, know a little about the Australian bachelor of nursing degree, and I know what its students/graduates are like, I go to school along side them after all, and while they may have many talents I don't, I wouldn't want to see them in the back of an ambulance. Its by no means derogatory. I couldn't be a nurse with a paramedic degree, and I don't think you can be a paramedic with a nursing degree, and I especially don't think you need to have nursing degree and experience before gaining paramedic qualifications.