Paramedics in the ER

ernurse16 · Jun 28, 2007

Paramedics should only be relegated tech duties in the ER, stocking, splinting,ekgs,vitals,transport.
In the ER IVs, meds,everything else is nurses realm..

Why should well trained well qualified medics be relegated to tech duties? I have worked in places that use medics like you described and I think it's a waste. We are short staffed and have excellent resources and are not able to utilize the medics as the assets that they are. More and more ED's are beginning to evolve and get a bit smarter. Medics in those facilities are able to do in the Ed what is in their scope of practice. They are allowed to push meds if it's in their scope, ie, morphine etc. They are not allowed to hang antibiotics since it's not in their scope. They start IV's, intubate when the docs can't get it, push ACLS meds (generally are better at knowing when and what to give than many of the nurses), assess pts... anything they can do in the field. Why would you want to limit them? Nothing like cutting off your nose to spite your face. Nurses are so territorial at times, so much so they shoot themselves in the foot!

vamedic4, EMT-P · Jun 28, 2007

Why should well trained well qualified medics be relegated to tech duties? I have worked in places that use medics like you described and I think it's a waste. We are short staffed and have excellent resources and are not able to utilize the medics as the assets that they are. More and more ED's are beginning to evolve and get a bit smarter. Medics in those facilities are able to do in the Ed what is in their scope of practice. They are allowed to push meds if it's in their scope, ie, morphine etc. They are not allowed to hang antibiotics since it's not in their scope. They start IV's, intubate when the docs can't get it, push ACLS meds (generally are better at knowing when and what to give than many of the nurses), assess pts... anything they can do in the field. Why would you want to limit them? Nothing like cutting off your nose to spite your face. Nurses are so territorial at times, so much so they shoot themselves in the foot!

This is so very true. I think Tom was a medic long before they allowed medics to have protocols the likes that they have these days. EMS and field care is light years ahead of what it was even when I began working in the field in 1986, and medics are much more highly trained than they were at any time in the past...they have to be. And I totally agree that pigeonholing these trained and willing people keeps nurses working harder.

If you want to be territorial - that's fine, it's more work for you. I'm just here to help.

But there are so many more things they could be doing to assist in the care than restocking and cleaning the room after the patient gets sent to surgery or to the floor.

Please understant by my post above that I mean no disrespect to anyone's background or experience...just my observations.

vamedic4

littleRNthatcould · Jul 5, 2007

Like many of the above posters my ED hires medics into a "tech" position. They can start IV's, draw blood, EKGs etc. No meds are given, ever and no charting outisde of vitals and the like. I think some of our medics are a great asset to the department.

Here's the problem, I think that a few are resentful about being "pigeon-holed" into a tech position (and rightfully so in some cases). So the problem develops when after developing a good rapport with the doctors and nurses, they slowly expect to creep out of thier scope of practice and into what is considered the "nurses role" or some even the "physician role" ie assessments, meds in life-threatening circumstances.

All of these things I personally don't have a problem with, but when one of them comes up to me and says, "hey I just assessed patient x and here is what's going on" and they expect me to sign off on it. Or things like: as a patient is crashing I enter the room with meds in hand and the medic happens to be on the same side as the IV and says, "hand it to me" . You know, I can't do that!! It's my license, my signature attached to that med!

It comes then to questioning ability and education which is so not the issue with me but a point I can never convey. I trust my medics assessments and ability moreso than some of the RN's but legally I can't allow them to do things that the hospital has deemed outside of the scope of practice.

I don't know why it has to be so difficult to define what this set of initials can do and this one can't. But unfortunatley my ego (or lack thereof) doesn't set the precedent for the law.

stayseerrn · Jul 7, 2007

I have worked in "all licensed units." And that has meant anywhere from all RNs only to RNs AND Paramedics. Because, let's face it, EMTs and Paramedics are licensed (at least in the 5 states I have worked in). So my one argumentative point, to say that they are Unlicensed Personnel, does "chap my hide."

Now some states have a differentiation. There are EMTBasics, EMT-IV, and Paramedics. EMT Basics cannot give meds and, please forgive me if this phrase sounds demeaning to the EMT Basics, function as a tech role in the prehospital setting. That is, they can place pt on monitors, assist with VS, perform chest compressions, and assist the paramedics. Then there are the EMT-IVs. They can do all of the things an EMT can do, but they can start IVs, but DO NOT give meds or intubate. So, their practice is broadened a bit. And of course, there are the Paramedics. These are the guys who are the overall directors of the prehospital care. They can do all of the other things the other two can do, plus give the meds, interpret EKGs, and receive additional orders from medical control for meds outside of ACLS drugs (drugs like morphine for pain control on a fx, valium for a seizing pt). In my home community (because it is the largest city in the state), all of these trained individuals are stationed out of the local fire departments, not an individual hospital or employed by a private company. They are true "first responders."

In my personal experiencs and opinion, EMT-IVs and Paramedics are an invaluable tool in the new paradigm of most EDs. Because we are getting slammed as more people are using the ED like a PMD office, our volumes have dramatically increased over the years. This means there is more work, with little hands to do the job. And because of the lack of healthcare coverage in the US, we have less money to do these tasks. One means of answering this call is to move to "all licensed units." This means that those involved in pt care hold licenses, and units are no longer using CNAs or Nurse Techs whose scope of practice is severly limited by many states and institutions.

As far as what Prehospital Professionals can do in each ED should be left to the leaders of the unit, as well as state guidelines. Fortunately, I have worked in a unit which has an EMT-IV or Paramedic paired with a nurse in providing pt care to those pts who are placed in the rooms assigned to that team for the day. And it has been such a lifesaver for both the pts, nurses, and the ED MDs.

Some of the tasks which my home hospital allows:

For EMT-IVs (we don't hire EMT Basics): IV starts, blood draws, nasal sxn, EKGs, Splinting, ALL wound care - including suturing (after going through an extensive suturing course and being checked off by MDs on their first 25 wound closures), splinting, running the fluoro for our ortho team when they come to the ED for fx reductions, repeat or routine assessments, in & out caths, and obtain VS when assisting the nurse in triage.

Paramedics: all of the above plus administration of po meds, starting IV fluids which contain no additives (so only NS or LR), and can perform bedside glucose checks.

BOTH the RN and the EMT-IV and/or Paramedic are responsible for pt transport to the floor and can give report to the receiving nurse on the floor (my home hospital went back to face to face reporting instead of telephone or fax reporting). BOTH are responsible for cleaning rooms and putting pts in them. And BOTH are responsible for charting their respective interventions. If any pt goes to the ICU, the hospital requires that TWO CPR trained individuals must take the pt, so BOTH the Prehospital Professional and the RN have to go to ICU.

RN only: give blood (duh), ALL IV meds, receive verbal orders from ED MDs or admitting MDs via telephone, IV fluids with additives and all IV drips, initial assessment of any kind on a pt, discharge assessment of pts but Prehospital Professionals can do the discharge teaching (especially if they did the wound care or splinting), conscious sedation and sedation monitoring, and there are other things that my mind can't recall at the moment. But you get the big picture.

The reception the unit had to this - an outstanding addition to our ED team. By doing this, pt flow has improved and turn-around times have decreased. Now, we don't have to wait for the MD to get "unbusy" and then get tied up suturing a lac. So decreased presentation to MD time. Pts don't have to wait for a nurse to get "unbusy" for an order to be executed. Therefore decreased turnaround time because orders are executed in a timely fashion. Pts are able to have assessments done on a regular basis, so they don't feel like they are being ignored. That helps improve pt sastifaction scores. So, teaming an EMT-IV or a Paramedic with an RN to provide care to their patients is an invaluable assest for both the unit and the pts. I don't want to go back to a unit without Prehospital Professionals.

BVFD 333 · Jul 7, 2007

I have worked in "all licensed units." And that has meant anywhere from all RNs only to RNs AND Paramedics. Because, let's face it, EMTs and Paramedics are licensed (at least in the 5 states I have worked in). So my one argumentative point, to say that they are Unlicensed Personnel, does "chap my hide."
Now my some state have a differentiation. There are EMTBasics, EMT-IV, and Paramedics. EMT Basics cannot give meds and, please forgive me if this phrase sounds demeaning to the EMTs, function as a tech role in the prehospital setting. That is, they can place pt on monitors, assist with VS, perform chest compressions, and assist the paramedics. Then there are the EMT-IVs. They can do all of the things an EMT can do, but they can start IVs, but DO NOT give meds or intubate. So, their practice is broadened a bit. And of course, there are the Paramedics. These are the guys who are the overall directors of the prehospital care. They can do all of the other things the other two can do, plus give the meds, interpret EKGs, and receive additional orders from medical control for meds outside of ACLS drugs (drugs like morphine for pain control on a fx, valium for a seizing pt). In my community (because it is the largest city in the state), all of these trained individuals are stationed out of the local fire departments, not an individual hospital or employed by a private company. They are true "first responders."
In my personal experiencs and opinion, EMT-IVs and Paramedics are an invaluable tool in the new paradigm of most EDs. Because we are getting slammed as more people are using the ED like a PMD office, our volumes have dramatically increased over the years. This means there is more work, with little hands to do the job. One means of answering this call is to move to "all licensed units." This means that those involved in pt care hold licenses, and units are no longer using CNAs or Nurse Techs.
As far as what they can do in each ED should be left to the leaders of the unit, as well as state guidelines. Fortunately, I have worked in a unit which has an EMT-IV or Paramedic paired with a nurse in providing pt care to those pts who are placed in the rooms assigned to that team for the day. And it has been such a lifesaver for both the pts, nurses, and the ED MDs.
Some of the tasks which my home hospital allows:
For EMT-IVs (we don't hire EMT Basics): IV starts, blood draws, nasal sxn, EKGs, Splinting, ALL wound care - including suturing (after going through an extensive suturing course and being checked off by MDs on their first 25 wound closures), splinting, running the fluoro for our ortho team when they come to the ED for fx reductions, repeat or routine assessments, in & out caths, and obtain VS when assisting the nurse in triage.
Paramedics: all of the above plus administration of po meds, starting IV fluids which contain no additives (so only NS or LR), and can perform bedside glucose checks.
BOTH the RN and the EMT-IV and/or Paramedic are responsible for pt transport to the floor and can give report to the receiving nurse on the floor (our hospital went back to face to face reporting instead of telephone or fax reporting). BOTH are responsible for cleaning rooms and putting pts in them. And BOTH are responsible for charting their respective interventions. If any pt goes to the ICU, you are required to take TWO CPR trained individulas, so BOTH the Prehospital Professional and the RN have to go to ICU.
RN only: give blood (duh), ALL IV meds, receive verbal orders from ED MDs or admitting MDs via telephone, IV fluids with additives and all IV drips, initial assessment of any kind on a pt, discharge assessment of pts - they can do the discharge teaching (especially if they did the wound care or splinting), conscious sedation and sedation monitoring, and there are other things that my mind can't recall at the moment. But you get the big picture.
The reception of this - an outstanding addition to our ED team. By doing this it, pt flow has improved and turn-around times have decreased. Now, we don't have to wait for the MD to get unbusy and then get tied up suturing a lac. Pts don't have to wait for a nurse to get unbusy or because the nurse is busy placing a splint and doing crutch teaching. Pts are able to have assessments done on a regular basis, so they don't feel like they are being ignored. I don't want to go back to a unit without them.

Thank you, Thank you, Thank you! ...most people do not know the difference between EMT EMTI (85 and 99) and Paramedics. I work every day on this problem! Radmedic in the above post takes about EMT's not Medics. Have a great weekend!

ernurse16 · Jul 7, 2007

I completely agree with you. I wish more ER's would utilize the medic as resources and the territorial nurses would open their eyes and not see medics as a threat. I love it when medics in the ER are allowed to work within their scope... makes my life a lot easier... my hat is off to the medics!!!!

BTW... all you that think only nurses can save lives... I hope a nurse doesn't show up at your door next time you call 911... unless of course... they were trained medics first!

srmedic · Jul 10, 2007

i am one of radmedics, medics and we are in desperate need of help with the rules and regulations on medics working in the e.r. you see our nurses want us there, but dont want us to do anything but change the beds and take vitals. well that's pretty much an insult and our administrator is willing to allow us to help out if we can come up with something that shows that it is legal for us to work in the e.r. without a dr. present. any help would be appreciated.

stayseerrn · Jul 10, 2007

Check both your state and institution regarding what a medic can do in the hospital. My home base is in Memphis, TN and that is where we were using EMT-IVs and Paramedics. There was also a children's hospital in Texas, I think it may have been Cook (i forget the name) that we used to model the all licensed unit from.

I worked at another hospital in Memphis which opened after the first hospital went to all licensed. They were using EMTs, mostly basics but a couple of EMT-IVs, and they did some of the things that the other ones did: draw blood, start ivs, vs, reassessments, wound care (no suturing), splints, crutch teaching, foleys, run the defibrillator, but no meds of any kind. Then again, there were no paramedics in that second unit. If you want to know the names of the hospitals, then let me know. Just PM me.

vamedic4, EMT-P · Jul 11, 2007

The hospital you speak of is Methodist Hospital, in Downtown Dallas.

PM me for names and phone numbers of people who may be able to help you.

vamedic4

stayseerrn · Jul 11, 2007

I do have the names of the hospitals that are using Paramedics and nurses as the care team for patients:

Cook Children's, Fort Worth, TX (the model used for the hospital in Memphis)

LeBonheur Children's Medical Center, Memphis, TN (uses both EMT-IVs and Paramedics, but not EMT Basics)

St. Francis Hospital - Bartlett, Bartlett, TN (uses EMTs, mostly basics)

To get these started, I do know that medical control for the paramedics, the ER physicians, the ER nursing directors, and state boards all had to sit down to establish what they would deem was in the scope of practice for prehospital professional in the ER setting. So, start with these people, as they are the ones who will be the ultimate determining factor.

troop742 · Nov 13, 2008

In our area, paramedics can earn an associate's degree, from the local community college, same as an RN, although AAS not required for licensure as paramedic. Funny thing, though, the registry pay rates are more than double for RN as they are for paramedic to work as tech in ED. And, as someone who works both sides of that fence, my paramedic IV skills can beat RN IV skills any day. I do understand the meds angle, the only meds we can give in the field are from the standing orders. That comment reminds me of the old days, and sometimes still being called "ambulance driver"

allnurses Guide · Nov 14, 2008

Our paramedics are basically glorified techs. They can start IVs but not give meds. Triage and write the initial assessment (which I questioned but was told their training was all about assessment); when my LPNs are supposed to have an RN cosign. I do not agree with that at all, triage yes but there should be a nurse doing a full assessment. The rest are commonly shared duties with our techs (who are supposed to be crosstrained in being secretaries as well).

They can do Foleys but not NGs (possible because of the many folks with varices?). They do not take a patient load (can't do meds).

I was orienting one paramedic who was angry that he could not "practice medicine". Ah, reality check here, you don't get to practice medicine anyway, you have specific medical protocols that you follow based on your field assessments that allow you to give certain meds (ACLS) under certain circumstances, but you are practicing under your medical directors license and P&Ps.

The lines are very difficult to determine between the 2 scopes of practice. Several studies I looked at on whether to allow paramedics to refuse transport (trying to cut down on amublance calls for bogus reasons) found that up to 10% of critical cases would have been dismissed wrongly. The studies attributed this to the limited and very focused assessments done in the field, concentrating on immediate medical needs or trauma, but not being taught the wider and supposedly more in depth assessments that nurses do.

I have enormous respect for all of our EMS, and the field work they do. Prehospital care is tough and takes special people to do it. I appreciate having help in the ER when we need lines put in, etc. But my license is on the line when I delegate such things, nurses are held accountable for knowing the person (CNA, tech, EMS) they are delegating to is capable and performing within their scope, when I brought this up I was told I was able to direct their activities as charge, but they were under our medical directors license, not mine. Don't think that will stand up in court.