Nurses vs EMT's in EMS

[VentMedic]

but I do think they are requiring unnecessary amounts of nursing specific education for ambulance professionals.

What part of nursing do you think is unnecessary? Community health is expanding and with the patient care experience a nurse has for the physical, psycho and social needs of the patient, their education is spot on. Also, remember that only a small percentage of EMS calls are codes and traumas. Most are medical, either chronic or acute, and not all require the EMS specific services of a Paramedic trained only in prehospital emergencies.

[Kiwiology]

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

That is most disturbing, especially considering the author is an MD

What part of nursing do you think is unnecessary? Community health is expanding and with the patient care experience a nurse has for the physical, psycho and social needs of the patient, their education is spot on. Also, remember that only a small percentage of EMS calls are codes and traumas. Most are medical, either chronic or acute, and not all require the EMS specific services of a Paramedic trained only in prehospital emergencies.

I agree Vent. The moves are being made for Paramedic's to become more emergent community health practitioners than the old day ways of "Paramedic" who only dealt with calls by taking everybody to the hospital. A good deal of our Degree is around non-emergent issues like psychosocial care and what to do for them as well as the emergent stuff. In the future it will only get bigger and better as Ambulance Officers get more referral pathways and options other than taking the patient to ED and as expanded scope roles (ECPs) are introduced more progressively.

Should you have to do a nursing degree to become a Paramedic? Whole-heartedly not! You should however get an appropriate amount of education in the things you speak of and not just the "emergency" stuff especially as the ability and need to do things other than take the patient to the hospital grows.

ER/ICU or even general medical nurses who have a good deal of experience and who are around patients 24/7 are very highly knowledgable and more than capable. I know one or two nurses who work in general medical and who I would have no problem with in the back of the ambulance if they had the appropriate time to get up to speed with the differences in modality.

We need to combine the best things that nursing can offer and what those systems with a very high level of Paramedic education are doing that seem to be working well. The Degree gives our Paramedics a strong base of A&P, pharm and patho and they spend a significant amount of time in the hospital and on the ambulance. A lot of the Degree is around chronic and non-emergent management of patients, not just about IVs and driving fast.

I can see what Melclin is saying in that Bachelor of Nursing graduates are not appropriate people to be used as Paramedics and they should not expected to be. The Bachelor of Nursing should not be the required Paramedic qualification but an appropriately educated and experienced ER or ICU nurse would make a great Paramedic if they are able to become familiar with the differences in operating modality.

That is why Australia/NZ are developing (I beleive Aus. already has them) a one year post graduate conversion program for RN to Paramedic (not Intensive Care (ALS) but our base level). Should they wish to do ALS (Intensive Care Paramedic) they would have to do additional Post Graduate ALS qualifications.

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.

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?

Edited April 5, 2010 by kiwimedic

[melclin]

VENT: Its important that to me that you and everyone else in this thread not think that I was having a go at nurses. In saying that I don't think they are educated to make certain kinds of decisions, I just mean that's not where I believe their expertise lays. As I say above. The critical care nursing you mention is quite different from intensive care nursing here as I understand it but I may be wrong. That's why I added the caveat about nursing appearing to be different here than in the states. Nurse in all fields do seem to have rather a lot more direct medical oversight here than they do in the states. But I'm no expert in nursing.

Also, I'm certainly not saying that its impossible for nurses to be able to made clinical decisions, from what I've seen of chbare's posts I'd prefer him/her (?) treating me than most paramedics, nurses or doctors I've met. So at the higher level of CCT nurses, that may be a different issue. What I'm getting at it that if you have a field that requires not just the best (you CCT nurses in this example) but all practitioners, straight out of uni, to be making these decisions, you have to ask yourself, do you want a person who has been taught from the word go how to make autonomous decisions in the prehospital environment, or someone who's education is very general, focused on observation, advocacy and carrying out treatments ordered by others? Eg: You take the ~300 paramedic grads at the end of this year and compare their ability to make sound autonomous decisions in the prehospital environment to that of a nurse graduate. If, after uni the graduates then complete equal postgraduate formal education, the Intensive care paramedic is still above the Intensive care nurse in terms of the percentage of their education and experience that is devoted to autonomous decision making in the prehospital environment.

What part of nursing do you think is unnecessary? Community health is expanding and with the patient care experience a nurse has for the physical, psycho and social needs of the patient, their education is spot on. Also, remember that only a small percentage of EMS calls are codes and traumas. Most are medical, either chronic or acute, and not all require the EMS specific services of a Paramedic trained only in prehospital emergencies.

Absolutely they are not mostly trauma and codes, but you asume the paramedic degree is predominantly about that, when in fact it is not (we have returned to our old problem of the difference between the American and Australian systems). One out of twenty of my units was trauma based, and code related components have been spread across about 3-4 of those units. The others are very much about community health and well ballanced understandings of many medical and psychosocial problems. Far more so than the nursing degree I believe. For example, among other things, this semester, I have to evaluate a community based disability support project using our previous book learnins in public health and using techniques for health project evaluation, I also have to design an education package regarding a issue of special needs in the geriatric population along with a plan for its implementation and target audience using our established knowledge of public health and epidemiological fundamentals. Unless you chose to undertake subjects of that nature, the nursing degree tends to be quite specific and it is fifty percent on the job experience, which, while useful, does not help you get a broad and formal education in way that a university subject does. Compare that to the wide range of community, ambulance, hospital (obstets, emerg, psych, ICU, theatre) and disability placements we have to do on top of actual three years of formal education. In our degree, roughly 45% people already have degrees, often in health fields (AnP, human movement, nursing, one girl even has a masters in public health).

I wouldn't consider any skills learned in the nursing degree to be useless per se, but they focus on particular ideas more than others, while ignoring many issues that are important to prehospital care, let alone ignoring the much discussed skills portion of being a paramedic. Many nursing grads man learn to identify breath sounds only if they are in streams that are emerg specific, none can perform a patient assessment in the same way a paramedic can. The average nursing graduate cannot, for example, cannulate , its not part of the degree. I hope this just gives you a bit of an idea of why our nursing degree is less than you would be familiar with and why our paramedic degree is much more than you may have in the states. I have to qualify this all by saying, I'm not an expert in the nursing eduation system, I go by what I hear from double degree students who are undertaking both degree simulatneously over an extended time frame, from what I've read, and the classes I've shared.

Here are some links to the nursing, paramedic and nursing/paramedic bachelors, that might be more informative (and accurate) than me.

http://www.monash.ed...urses/0727.html - nursing

http://www.monash.ed...urses/3892.html - nur/medic

http://www.med.monas.../structure.html - medic

Should you have to do a nursing degree to become a Paramedic? Whole-heartedly not! You should however get an appropriate amount of education in the things you speak of and not just the "emergency" stuff especially as the ability and need to do things other than take the patient to the hospital grows.

I can see what Melclin is saying in that Bachelor of Nursing graduates are not appropriate people to be used as Paramedics and they should not expected to be. The Bachelor of Nursing should not be the required Paramedic qualification but an appropriately educated and experienced ER or ICU nurse would make a great Paramedic if they are able to become familiar with the differences in operating modality.

Precisely. I do think most ICU and ED nurses would make great paramedics with a little top up to their educations as far as prehospital specific stuff goes. I do not however, agree that this is the best or only pathway.

That is why Australia/NZ are developing (I beleive Aus. already has them) a one year post graduate conversion program for RN to Paramedic (not Intensive Care (ALS) but our base level). Should they wish to do ALS (Intensive Care Paramedic) they would have to do additional Post Graduate ALS qualifications.

Depends where you go. I think ACU have a one year course. At Monash, all nurses are required to go through the accelerated entry program which is two years, although depending on their nursing speciatly, they may gain recognised prior learning for some of the subjects in that two year block, but it still takes two years.

[Timmy]

I sense a little naiveness here. I don’t think a Registered Nurse is any more or less educated than a paramedic, merely you’re provided with industry specific education.

The Bachelor of Nursing degree in Victoria is not based around emergency or pre hospital care, while it has some elements of life support and basic emergency care this is not its intended content. The aim of the graduate nurse from this degree is to be a competent practitioner in holistic nursing care, I see the nursing degree as the fundamental or baseline level of nursing with hundreds of educational opportunities and courses in the specific area of nursing I enjoy and dabble in after I graduate.

If I want to work in an Emergency Department I can go off and study my Graduate Diploma of Emergency Care or Master of Nursing (Emergency Care), if I want to work in the Cardiac Unit I can go off and do further education in this field, same with community nursing, continence care, intensive care, acute nursing, diabetes and the list is endless.

I’m sure you’re fully aware of how a Registered Nurse becomes a paramedic in Victoria. One must hold a Bachelor of Nursing, Graduate Diploma in Emergency or Intensive Care then complete the Graduate Diploma of Paramedicine. That’s 5 years of tertiary education plus experience compared to a undergraduate paramedic who has 3 years education.

I’m not sure how much rural exposure you’ve had but we have a doctor shortage out in the sticks, in smaller rural facilities were there are limited/no doctors, nurses are often the only health professionals present during an emergency and depending on what level of training the RN has depends on what can be done for the patient. Depending on the facilities standing orders specific RNs can RSI, thrombosing, perform needle chest decompression, give front line medications and take any measure to sustain life within their scope of practice with out a medical order. We have an excellent relationship with the paramedics which is an essential part of the multi disciplinary team which ultimately contributes to a positive patient outcome.

I’m merely a RN Endorsed Division 2 (shock, horror what would I know). I work casually in a small rural setting as well a regional hospital to support my way through my degree and I can tell you it’s no walk in the park. I mostly work weekends and nights were we have limited contact with a doctor. Sure I need to have a doctor’s order (direct or indirect) to give a medication or perform an invasive procedure but I can assure you the young intern/resident who has no interest in general medicine or surgery because they’ve been shoved out in the sticks as part of there rural cohort training and mope around all shift grumbling about not being at the Alfred or RMH, they makes quiet a number of mistakes and I need to know what’s going on in order to prevent being dragged in front of the coroners court. Most of the time they just okaying what I’ve suggested is best for the patient based on my clinical observation through out a shift, 9 times out of 10 they wont even come back to the ward to R/V the patient because there too busy waiting around for the next MET call.

In certain ways nurses have a greater scope of practice, even though doctors must prescribe a medication I’m still responsible and accountable for giving it, this means I must be aware of the pharmacokinetics, pharmacodynamics, adverse reactions, interactions, contraindications – equally must a paramedic. The difference being you guys have… 40?? Drugs in your bag of tricks but we have a whole room full of medications. We can catheterise, deal with central/PICC lines etc etc were a paramedic would not know were to start. But on the other hand, as you say paramedics have greater flexibility in prescribing your own medications and doing what you like, per say.

In conclusion please don’t short sell nurses because we all have our place and our speciality, I have great respect for ambos, your knowledge and skills and one day I hope to become a paramedic as well. But with a appropriate bridging program and education in the relevant specialist area I see no problem in a RN becoming and ambo or vise versa

[Kiwiology]

...with a appropriate bridging program and education in the relevant specialist area I see no problem in a RN becoming and ambo or vise versa

Well said Timmah! Mmmm Tim Tam's

[Timmy]

Well said Timmah! Mmmm Tim Tam's

You and your damn Tim Tams Ben, poor kiwis your missing out on the good stuff. I acutally have a Tim Tam Easter Egg sitting in my room, collecting dust lol Anywho, back to the topic.

[WelshMedic]

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.

I do, indeed, agree. The paramedic role that has developed in anglo-saxon countries (for want of a better term) never really took off in mainland europe. I think the OP was looking for arguments in favor of changing the system, although I can't be sure due to the lack of reply.

One thing we must recognize is that it's not about titles but education and experience. With these comes extended scope of practice and more autonomy. I am sure that a degree trained paramedic is more than capable of doing the job in EMS very competently. However, when you get into community-based paramedicine like we do, it may fall somewhat short.

Bearing in mind here that we are talking about the Dutch system, which is unique and doesn't necessarily translate well in other settings. There are just 1600 ambulance CCRN's in the whole of the country.

WM

WM

Edited April 5, 2010 by WelshMedic

[melclin]

I sense a little naiveness here. I don't think a Registered Nurse is any more or less educated than a paramedic, merely you're provided with industry specific education.

When I say slightly more education, here's what Im getting at: The BN is 3 years and roughly 50% on the job training, where as the B. Emerg Hlth is actually three years of classes learning theory. While you may argue about the validity of class room learning and on the jobs learning, the fact still remains, that paramedics have, for better or worse, a little more classroom time to add to their on the job experience.

The Bachelor of Nursing degree in Victoria is not based around emergency or pre hospital care,

Thats entirely the point. No arguments there. That's why I argue that while its not necessarily time wasted if its added to prehospital education, but nursing in itself is not an adequate substitute for prehospital specific learning. An ICU/ experience crit-care ED RN with added relevant training in prehospital care would be a good paramedic, but the five years of formal education plus the experience required to go and do ICU grad dips etc is an unnecessarily extensive pathway for prehospital care when it could be covered in a field specific sense in 3-4 years, so I don't believe it should be the only pathway as it is in the netherlands.

Depending on the facilities standing orders specific RNs can RSI, thrombosing, perform needle chest decompression, give front line medications and take any measure to sustain life within their scope of practice with out a medical order.

I am certainly surprised about that. I was not aware that any nurse could RSI with or without a physicians orders. I feel skeptical about it, given that metro nurses are often not even allowed to give OTC medications without orders. To be clear you're saying, pt comes in head injured, GCS 9, poor O2 saturation, and a nurse can cannulate, setup, order fluids, sux, atropine, midaz/propofol/fent, intubate, and start infusions of pancuroinium/morphine/fent/midazolam and begin a ventilation plan, all without a doctors orders? I apologise profusely if I have led everyone down the garden path on this issue.

I'm merely a RN Endorsed Division 2 (shock, horror what would I know). I work casually in a small rural setting as well a regional hospital to support my way through my degree and I can tell you it's no walk in the park. I mostly work weekends and nights were we have limited contact with a doctor. Sure I need to have a doctor's order (direct or indirect) to give a medication or perform an invasive procedure but I can assure you the young intern/resident who has no interest in general medicine or surgery because they've been shoved out in the sticks as part of there rural cohort training and mope around all shift grumbling about not being at the Alfred or RMH, they makes quiet a number of mistakes and I need to know what's going on in order to prevent being dragged in front of the coroners court. Most of the time they just okaying what I've suggested is best for the patient based on my clinical observation through out a shift, 9 times out of 10 they wont even come back to the ward to R/V the patient because there too busy waiting around for the next MET call.

All the nurses in my degree including crit-care qualified ones all say that its a whole other ball game when you actually have to take responsibility for it yourself. Obviously I've never been in their shoes, and I'm only a student and all, but I'm hearing this off nurses who have become paramedics: the difference between, knowing what you need, asking for it, and having it okayed, all in a controlled environment is a lot different to being presented with a pt lying on the ground and going from knowing absolutely nothing about them to performing some of the interventions we've talked about, all on your own back. I really can't say anymore, because I don't have the experience or knowledge to be making any further claims, so we'll have to just leave it at that I think. That's just what I've heard. I will go an talk to one of the ICU nurses at uni about their scope, because I may have been mistaken about their scope of practice.

In certain ways nurses have a greater scope of practice, even though doctors must prescribe a medication I'm still responsible and accountable for giving it, this means I must be aware of the pharmacokinetics, pharmacodynamics, adverse reactions, interactions, contraindications – equally must a paramedic. The difference being you guys have… 40?? Drugs in your bag of tricks but we have a whole room full of medications. We can catheterise, deal with central/PICC lines etc etc were a paramedic would not know were to start. But on the other hand, as you say paramedics have greater flexibility in prescribing your own medications and doing what you like, per say.

In conclusion please don't short sell nurses because we all have our place and our speciality,

Like I said, I really wasn't having a go at nurses, and maybe things are that dramatically different out in the country, but in my (admittedly limited experience, including rurally) I have never seen or heard of anything like the level of scope. You certainly must have one special deal going on.

[Dustdevil]

Is there any shortage of qualified nurses in Holland who would like to be ambulance nurses?

[VentMedic]

I've been reading more about the Dutch Ambulance nurses and it seems they are indeed very similiar to the Nurse Practitioner here in the U.S. which definitely gives them an advantage. The NP (and PA) in the U.S. has been going into the community, outside of clinics for several years to help people in shelters. Several major cities have them in roaming vans so they can go to the people who need them and arrange for the patient to be taken to the appropriate facility. Sometimes EMS personnel don't realize how many patients they could actually be called far if it wasn't for these professionals getting to them first. We also have numerous other healthcare professionals that see patients in their homes who also can get the patient by nonemergent transportation to the appropriate facility before EMS is required.

However, the NP has the advantage of an autonomous scope of practic to where it would take years if not a couple of decades at least in the U.S. for the Paramedic to come close to that in education and being able to obtain a DEA number which requires a Masters degree in many states.

If the Dutch Ambulance RN is even close to being like the NP, then their system is truly very advanced and it would be a shame if it went backward to something like the U.S. system even for a short while.

The Bachelor of Nursing degree in Victoria is not based around emergency or pre hospital care,

Few entry level professional degrees specialize. Nursing generaly realizes their entry level education is just that and they can choose the path they want through more education. Even RT, PT, OT and SLP realize their degrees are entry level at Bachelors and Masters. If they want to work with neonates, emergency med, TBI or SCI patients they will need additional education and maybe a higher degree as well as specialized training in that unit.

Unfortunately, too often it is the Paramedic that fails to see the limitations of their trainning. Some are fed this line about "critical thinking" which is magically supposed to appear with their cert and very little education or experience. They also believe their few "skills" entitle them to the title of critical care or that an 80 hour course makes them a "CCEMT-P". Thus, most get in over their heads and what is the most frightening part is that they don't realize it because they don't know what they don't know. At least other countries recognize this for their Paramedics and do ensure more education and experience is obtained.

From reading about the Dutch Ambulance nurse, they have education, experience and then more education. In an ideal world, this is world this is how EMS should be. Unfortunately some believe it is by considering the EMT-B to be the "experience" part which has little to no education in the U.S.

I feel skeptical about it, given that metro nurses are often not even allowed to give OTC medications without orders.

There is a difference betweening treating and dispensing medications.

To be clear you're saying, pt comes in head injured, GCS 9, poor O2 saturation, and a nurse can cannulate, setup, order fluids, sux, atropine, midaz/propofol/fent, intubate, and start infusions of pancuroinium/morphine/fent/midazolam and begin a ventilation plan, all without a doctors orders?

Our Flight and Specialty RNs (and RRTs) do this quite often outside of the hospital even without having NP behind their name.

That's just what I've heard. I will go an talk to one of the ICU nurses at uni about their scope, because I may have been mistaken about their scope of practice.

In the U.S. RNs (and RRTs) have a large scope of practice which makes them ideal for CCT, Flight and Specialty. Just because you don't see someone with that title intubate every day may not mean it is not within their scope of practice. Not every facility will have a need for all the skills one professional may legally be allowed to do. If you have 1000 RNs working in a hospital, is it really feasible to teach everyone to intubate? It is no more practical than having 2000 FFs in on FD be Paramedics and do few to no tubes each year on an ALS engine.

That is most disturbing, especially considering the author is an MD

Fortunately the states settled for somewhere between 500 and 1200 hours of training instead of just 200. However, this doctor was a consultant for many FDs in the U.S. so this crap will be around for a long time.

Edited April 5, 2010 by VentMedic