Nurses vs EMT's in EMS

[Timmy]

Melclin - for sure, there’s heaps of courses RNs can do to increase there scope of practise in the ED. As I said, it completely depends on what standing orders are in place and what the facilities policy is regarding what nurses can do. At a rural hospital I work at the senior nurses have an individualised scope of practise which is signed off by the hospital chief medical officer that if X situation arises then X nurse can perform X task without medical direction. Just look at the RFDS, they sometimes send nurses out on emergency missions without a doctor and can perform to a similar level as MICA in remote situations. I know this is a little off track and maybe a little basic but St John have a standing order for any volunteer RN (including grad nurses) to independently administer and carry methoxyflurane, GTN, paracetamol, salbutamol, ant acids and acetylsalicylic acid (soon to add adrenaline and IM glucose) with out any medical direction what so ever and it's more than likly they can not administer these medications at there workplace without an order, I know these are basic drugs but it's just a little example to support my cause on facility standing orders lol.

The base line course that is offered around Victoria for any RN is called Front Line Emergency Care, this course encumbers basic emergency education but only allows slight increase in scope.

We have a Remote Area Nursing course which includes X ray interpretation, ECG interpretation, initiation of first line emergency medications, suturing, back slabs etc.

There’s also a course accredited by the Royal Australian College of Nursing which encumbers a number of ALS skills such as airway management including LMAs, ETs and Crics, IVC and venous cut downs, head injury assessment, splinting and spinal immobilisation using collars, spine boards, KEDs and traction splinting, chest tubes, burns management and fluid balance, managing shock and so on.

There’s heaps of courses based around the concept of ALS/PALS/ILS/ACLS and the list goes on and on.

As I said, the standard nurse can not perform any of these but certainly a Grade 5 Nurse who has under gone this further education can with approval from there employing facility.

Just so we don’t have our wires crossed here, I do not support any RN to work on ambulance without the relevant paramedic training.

[Dustdevil]

Can anyone give me good arguments why EMT/paramedics would be better than nurses (with ED or ICU-background)?

Biggest plus to staffing with under educated emt's is they work cheap.

That about says it all.

[BushyFromOz]

Answer for me is easy, which one benefits the patient the most, and if the Netherlands system or Ambulance Nurses is superior to traditional Paramedic / Ambulance Officer model of delivery, then that's what they should retain.

[VentMedic]

Answer for me is easy, which one benefits the patient the most, and if the Netherlands system or Ambulance Nurses is superior to traditional Paramedic / Ambulance Officer model of delivery, then that's what they should retain.

That depends on which country you compare the Paramedic/Ambulance officer.

The Dutch system:

A major difference between a Dutch ambulance crew and those in other countries is the strict separation in the scope of duties. Every ambulance includes a crew of two. One is the nurse, skilled and trained in medical issues, procedures and performances. The other crew member is the driver, trained in vehicle operations for all circumstances. The driver also assists the nurse but does not interfere with any medical issues.

If the Paramedic is also little more than someone from tech programs which do only a minimum of 600 hours while an RN is expected to have a year of additional training along with their RN, then that could be another argument.

Of course, if it is only money then the "ambulance driver" system with just providing a speedy taxi ride to the hospital might be the cheapest. But it would also burden the ED with patients someone similar to an NP or Ambulance RN could have triaged to another facility or offer some form of on scene treatment. They could also follow the U.S. and train all of their FFs to be "Paramedics" and just merge the systems.

Edited April 5, 2010 by VentMedic

[Kiwiology]

I dislike having the "driver only" concept as it limits you to having only one Paramedic who can treat the patient.

[VentMedic]

Just so we don’t have our wires crossed here, I do not support any RN to work on ambulance without the relevant paramedic training.

This is all relative. What exactly is "Paramedic" training? Intubation is not exclusive to Paramedics and other professions have been intubating long before Paramedics got started. The same with IVs. Spinal immobilization is also nothing new and many professions have to be familiar with it in the hospital for the numerous SCIs and surgical patients we do. The medications are also nothing new. The major difference is the environment but then RNs and many other professionals are accustomed to following the protocols for whatever unit they are working in. The onocolgy unit is very different than ED and ED is different from ICU. This is also why we must have ICU trained/educated RNs in the ED for hold overs to do the ICU protocols since the ED doctor will no longer be covering the patient and the ICU doctor does not hover but expects certain things to be initiated. If the RN to be trained for another environment, it should also be at their professional level. They should not have to go through 10th grade A&P or read about Sidney Sinus node. They also shouldn't have to cast aside their nursing knowledge about infection control for IV starts and "do it like a medic" either. Weekend certs like PHTLS are also available to many different health care professionals. RNs can get just as much out of it as an EMT(P). RNs should also be able to function at their level of education and expertise. RNs are often paired with Paramedics on CCTs and Flight because the Paramedic's scope of practice is very limited. Some RNs get the "exciting Paramedic cert" only to find they can no longer titrate meds or access certain vasuclar devices because it is not within their scope. Thus, a person should be trained/educated to a level that places them at a higher level of expertise and not a cert that might take away from what they already have. But again, for many professions, the Paramedic cert in the U.S. is just that...an additional cert much like some of the other certs they must obtain and maintain. It is not considered a profession and should not trump their existing license that allows them an extended scope of practice. And for the U.S. Paramedics that believe they are autonomous, you do have a medical director. You do have protocols which are signed by your medical director. Like it or not, those are your written orders. Also, for some services, if you lined up all of your protocols side by side, you will find most of them are very similar just like the doctor stated in the 2000 vs 200 hours of training article. Some paramedic services do not have a choice of multiple pathways or guidelines as other professionals have which includes RNs work in and out of the hospital.

There are also reasons why RNs do call for certain orders. There are more variables known to the RN and if a med that is nephrotoxic is about to be given, the RN will defer that choice to the higher license. If that situation arises with a Paramedic, they may not know the kidneys are failing either by training or lack of information. Their medical director has already weighed the odds when writing their protocols and has taken the responsibility. It is not uncommon for an ALS/CCT with Paramedics to transport a patient for a CT Scan procedure with contrast who has a high BUN/Creatine number. Even if they have the lab work in their hands, they may not know enough to put the info together. Thus, it will fall on the Radiology Technologist's license to double check what should have be caught by the RN and MD. The RN can also not claim ignorance if he/she acknowledged those lab values before sending the patient.

[Richard B the EMT]

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?

After you've been here a while, you'll follow up with the information that some countries will call anyone, with the local minimal level of training for working on an ambulance, a Paramedic.

My level of training is EMT-B. Basic instruction in New York State, USA, is at least 125 hours, and Paramedics go above and beyond that by, easily, an additional 1000 hours (I may be underestimating the number).

Refresher (every 3 years) is, for BLS, 45 hours, and for ALS, is at least 125 hours.

There are some countries represented here in the city who tell me that basic for being on the ambulance is a 2 year college degree in medicine.

[Kiwiology]

It varies by state; in Texas you can get away with 600 hours (literal clock hours) over twelve weeks whereas Oregon requires a two year Degree and then there is everything inbetween.

By contrast Australia and New Zealand require several thousand hours in school plus a graduate internship for Paramedic (which is not advanced life support although pretty close) and several more years plus more schooling and internship for Intensive Care Paramedic, which is advanced life support. The UK requires a Bachelors Degree for Paramedic (advanced life support) from 2012.

The nations mentioned also offer Post Graduate, Masters and/or PhD in Paramedicine. I know of at least one ambo ere who has a PhD, so we still do have "Doctor" based ambulances

[firedoc5]

I guess our Paramedics who have four years of education and experience and our Intensive Care Paramedics who have a minimum of six are doing something wrong then?

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.

Edited April 6, 2010 by firedoc5

[Aussieaid]

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.

1) 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)

Critical thinkers who can problem solve and apply their knowledge appropriately to figure out whats wrong with a patient and treat accordingly.

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.

3)

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.

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?

4)

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.

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.

5)

(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).

So following this philosophy I should not be able to be a Flight nurse as I was educated and trained in Australia? (Don't tell my bosses that, I have them bluffed!!! )

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.

7)

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.

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.

Oh and p.s......Paramedics might be "creatures" but nurses aren't!!!

Edited April 6, 2010 by Aussieaid