paramedic nursing - page 4

Hi, I'm a 2nd year nursing student and have an interest in paramedic nursing. Is there anybody involved in this area of nursing and would like to share some related information? For example what... Read More

  1. by   traumaRUs
    No Tammy...in some states (IL for one) we have what is called pre-hospital RN. It is an actual license that allows us to practice in the pre-hospital environment. For instance, I'm on a volunteer (rural) fire dept. I'm a pre-hospital RN certified at the ALS (advanced life support) level so I'm "equivalent" to a paramedic.
  2. by   Dr. Tammy, FNP/GNP-C
    Quote from traumaRUs
    No Tammy...in some states (IL for one) we have what is called pre-hospital RN. It is an actual license that allows us to practice in the pre-hospital environment. For instance, I'm on a volunteer (rural) fire dept. I'm a pre-hospital RN certified at the ALS (advanced life support) level so I'm "equivalent" to a paramedic.
    Wow, you live and learn. Never heard of that before. So who regulates--the BON or state EMSA? Just curious, can paramedics there perform ALS within the hospitals?
  3. by   GilaRRT
    The BON regulates the activities and SOP of nurses.
  4. by   CraigB-RN
    Quote from GilaRN
    The BON regulates the activities and SOP of nurses.
    Actually it depends on what state your in. In PA the State Office of EMS regulates what is done pre-hospital.
  5. by   GilaRRT
    I thought we were talking about a specific state?
  6. by   mwboswell
    Hi all, I was just re-reading some of the posts on this thread going back earlier this year. At one point someone asked the difference between Paramedics and Nurses; I don't think we ever went down that road. But I was intrigued by this and made me stop to think and I wanted to share my thoughts and see what you all think.

    I believe that the [WIKI]Paramedic[/WIKI] (or at least the intent) is just as the name implies "Para-Medicine". I have always considered the P-medic more of a "technician" as evidenced by a high degree of proficiencey required of certain skill sets.

    I believe the P-medic (as evidenced by their authority to practice "generally" eminating from some form of "medical control") is more of the medical model of patient care. Also to support this we know that most (if not all) EMS providers have a medical director, OR at the state regulatory level some form of medical directorship exists. You can usually then trace the lineage back to your states' board of medicine. In my thinking, the P-medic is like an "extension" of the medical diretor's arms into the field/pre-hospital; the medic is working in lieu of the physician being on scene.

    I also believe (again the technician theory) that the P-Medic is more in their realm to do technical skills/procedures; I refer you to the National Registry exams which include hands on skills testing as well as written...AND most states level renewal requirements will require some re-testing of skill sets.

    Finally, in my experience, most cases a P-medic is not a LICENSED practitioner, they are CERTIFIED. Other words, their ability to practice eminates from the LICENSED medical control (IE: Md, DO etc).

    Now for RN's.

    RN's are LICENSED. Which means that a legislative body (IE Board of Nursing) given authority by the State, issues a right to practice registered nursing. This is different from being CERTIFIED. Certifications are more of your specialty training, not part of your basic licensing requirements.

    The Board of Nursing can only authorize a licensed nurse to practice Nursing as defined in your BON documents. There are certain acts/skills that are "delegate" to nursing that are medical-like in nature; however, the focus of the nursing set is still nursing, not medical.

    When an RN is working Pre-hospital (MICN, HEMS) or in the field, they "may" be working under medical control, but that is for medical care only. Their nursing care is not regulated or directed by a medical director. for the most part, the RN (after having demonstrated competency in certain medical like skills) is given "policy and procedure" coverage by medical control to perform (IE: Intubation, needle deomp, central access etc)...Just like demonstrating ACLS competency and medical directorship authorzing the "use of a medical device" (IE defibrillator) to perform a medical act (defibrillation) ...legalistically both of which require a physician "prescription" (IE: order) to perform....

    I could probably go on comparing and contrasting a lot more, but I think it's understandable so far.

    So what then is the REAL difference?
    Some would say money.... a medic costs less than a nurse (generally) to keep on staff.
    (IE: Costs less to put medics in ambulances than two RNs), but a counterpoint here; there are more HEMS services going to dual RN crews (and a majority of them are dual RN/EMTs)....

    Some would say level of care...
    Odds are if it's a dedicated Neonatal/Peds Non emergent transfer (HEMS or ground) you're more likely to see RN's involved.
    Odds are if it's a scene call/trauma; there is a Medic involved.

    Some would say regulatory influences...
    Especially for Hospital Owned HEMS, the same JCAHO standards apply in as much as requiring some involvement of "professional nursing" care for the pt (IE: RN)

    When it comes down to the patient care I can only make one set of statements on the differences....
    I think the Medics are great at the technical skills and things that are procedural driven.
    I think the RNs are good a managing the total patient.
    -this does NOT mean that I think medics can't/dont give high quality pt care,
    -nor does it mean that I think the RNs give BETTER pt care
    -It means I think the two work TOGETHER for the best outcomes;

    I have taught in both nursing and paramedic programs and have noticed differences as well there...but that's another discussion altogether.

    Everyone feel free to reply/respond with YOUR thoughts, I'm interested to hear any counterpoints based on experience and knowledge.

    Oh By the way, my background...
    9 years first responder/fire department
    6 years "street medic"
    1 year flight/transport nurse/medic
    3 years ICU/CCU/MICU
    7 years ER Staff RN (Certified)
    8 years ER Nurse practitioner
    ...and STILL working as Part time medic "on the street" in my spare time

    -Be safe everyone!
    -Mark
  7. by   bat3fingers
    I'm a nurse, soon to be paramedic. My nursing degree took me around the world. I am hoping that having both will get me flying. I think being both is great, the 2 compliment each other and have different mind sets to bring to any situation.
  8. by   GilaRRT
    Quote from mwboswell
    Hi all, I was just re-reading some of the posts on this thread going back earlier this year. At one point someone asked the difference between Paramedics and Nurses; I don't think we ever went down that road. But I was intrigued by this and made me stop to think and I wanted to share my thoughts and see what you all think.

    I believe that the [WIKI]Paramedic[/WIKI] (or at least the intent) is just as the name implies "Para-Medicine". I have always considered the P-medic more of a "technician" as evidenced by a high degree of proficiencey required of certain skill sets.

    I believe the P-medic (as evidenced by their authority to practice "generally" eminating from some form of "medical control") is more of the medical model of patient care. Also to support this we know that most (if not all) EMS providers have a medical director, OR at the state regulatory level some form of medical directorship exists. You can usually then trace the lineage back to your states' board of medicine. In my thinking, the P-medic is like an "extension" of the medical diretor's arms into the field/pre-hospital; the medic is working in lieu of the physician being on scene.

    I also believe (again the technician theory) that the P-Medic is more in their realm to do technical skills/procedures; I refer you to the National Registry exams which include hands on skills testing as well as written...AND most states level renewal requirements will require some re-testing of skill sets.

    Finally, in my experience, most cases a P-medic is not a LICENSED practitioner, they are CERTIFIED. Other words, their ability to practice eminates from the LICENSED medical control (IE: Md, DO etc).

    Now for RN's.

    RN's are LICENSED. Which means that a legislative body (IE Board of Nursing) given authority by the State, issues a right to practice registered nursing. This is different from being CERTIFIED. Certifications are more of your specialty training, not part of your basic licensing requirements.

    The Board of Nursing can only authorize a licensed nurse to practice Nursing as defined in your BON documents. There are certain acts/skills that are "delegate" to nursing that are medical-like in nature; however, the focus of the nursing set is still nursing, not medical.

    When an RN is working Pre-hospital (MICN, HEMS) or in the field, they "may" be working under medical control, but that is for medical care only. Their nursing care is not regulated or directed by a medical director. for the most part, the RN (after having demonstrated competency in certain medical like skills) is given "policy and procedure" coverage by medical control to perform (IE: Intubation, needle deomp, central access etc)...Just like demonstrating ACLS competency and medical directorship authorzing the "use of a medical device" (IE defibrillator) to perform a medical act (defibrillation) ...legalistically both of which require a physician "prescription" (IE: order) to perform....

    I could probably go on comparing and contrasting a lot more, but I think it's understandable so far.

    So what then is the REAL difference?
    Some would say money.... a medic costs less than a nurse (generally) to keep on staff.
    (IE: Costs less to put medics in ambulances than two RNs), but a counterpoint here; there are more HEMS services going to dual RN crews (and a majority of them are dual RN/EMTs)....

    Some would say level of care...
    Odds are if it's a dedicated Neonatal/Peds Non emergent transfer (HEMS or ground) you're more likely to see RN's involved.
    Odds are if it's a scene call/trauma; there is a Medic involved.

    Some would say regulatory influences...
    Especially for Hospital Owned HEMS, the same JCAHO standards apply in as much as requiring some involvement of "professional nursing" care for the pt (IE: RN)

    When it comes down to the patient care I can only make one set of statements on the differences....
    I think the Medics are great at the technical skills and things that are procedural driven.
    I think the RNs are good a managing the total patient.
    -this does NOT mean that I think medics can't/dont give high quality pt care,
    -nor does it mean that I think the RNs give BETTER pt care
    -It means I think the two work TOGETHER for the best outcomes;

    I have taught in both nursing and paramedic programs and have noticed differences as well there...but that's another discussion altogether.

    Everyone feel free to reply/respond with YOUR thoughts, I'm interested to hear any counterpoints based on experience and knowledge.

    Oh By the way, my background...
    9 years first responder/fire department
    6 years "street medic"
    1 year flight/transport nurse/medic
    3 years ICU/CCU/MICU
    7 years ER Staff RN (Certified)
    8 years ER Nurse practitioner
    ...and STILL working as Part time medic "on the street" in my spare time

    -Be safe everyone!
    -Mark

    However, the definition of "paramedic" in the United States is changing. The Nationsl Scope of Practice is being instituted over the next few years and a paramedic will no longer be considered a technician. In addition, the NREMT will be changing the testing procedures to reflect these changes. EMT and AEMT are considered technicinas, while a paramedic will be considered a paramedic. In addition, changes will require a paramedic to graduate from an "accredited" program. Hopefully, we will get to the point where all paramedics graduate from two year program as required for entry into practice.

    Of course, this will begin to deflate all of the "nursing" arguments against paramedic presence in the hospital. This could force us to take a look at our educational standards and push for changes. Win, win situation, hopefully.
  9. by   CraigB-RN
    No chance of improving anything. EMS is just repeating the same mistakes nursing made. No has yet proved that ALS actually makes a difference. we know that there are a few specific areas and problems that benifit from ALS care, but on the whole, who knows.

    I was a medic for over 20 years. I've worked in places were Paramedics only had 500 hours of training and in places were they had 2000. Each had it's own good medica and each had it's bad one. I'm all for accredidation and closing the paramedic mills, but how exactly is having a 2 year degree going to change how EMS providers are percieved in a hospital setting. They are still being tought the exact same thing. I'ts just going to take 2-3 years to get there now.
  10. by   GilaRRT
    Quote from CraigB-RN
    ...but how exactly is having a 2 year degree going to change how EMS providers are percieved in a hospital setting. They are still being tought the exact same thing. I'ts just going to take 2-3 years to get there now.
    Simple, the "typical paramedic is an uneducated UAP" argument will no longer be valid. In fact, the PM would have the same degree for entry into practice as an RN. Nurses can no longer use the education argument to keep PM's out of the hospital.

    I disagree, the same things are not being taught. You can go through a "shake and bake" school, rush through the required 1,000 total hours, and pop out a medic. These providers have little exposure to A&P (other than the chapter integrated into their medic classes), little exposure to English and compesition skills, little exposure to biological studies, little exposure to math, and little exposure to any humanities or social science courses such as psychology. While you can argue these courses are trivial, they in fact provide the student with a solid foundation of knowledge that can be used to build their house of paramedic studies upon.

    You could most likely condense the "core" nursing courses of an AD program into a few months as well without all of the pre-requisite and co-requisite material; however, you stand the good chance of having an impotent provider who has no real understanding of their profession because they lack the foundational knowledge that allows them to understand and utilize the knowledge of their profession.

    As far as the ALS argument, this depends on your definition of ALS does it not? You see, when somebody gives lifesaving IV dextrose to a diabetic with a critically low blood sugar, I call that ALS. However, many people call that BLS or ILS. The later may simply be a basic with a few hours of IV training who is told to push an amp of D50 if the sugar is below "x." Providing interventions without adequate education is potentially harmful IMHO. Even educated" providers can screw this up. Just look at the six million dollar arm judgment for that proof. Or perhaps we cold go to the pain argument? Sure, a limited amount of data supports improved outcomes between BLS and ALS in trauma patients. However, if your femur is sticking out of your foot, you would most likely want somebody to manage your pain? Not going to happen at the BLS level. Of course the ultimate outcome may be the same; however, at that moment, how important is having an ALS provider capable of safely and effectively managing your pain? Again, it comes dow to your definition of a "positive" outcome.
  11. by   CraigB-RN
    First I want to make it very clear that I am very pro education, and that education is never wasted. What I was trying to point out is that just makeing the associate degree the solution to all EMS problems is way to simplistic, and it's not going to solve any problems. The problem is way to complex for that. There are many factors that have to be addresses and untill they are, you could have a PhD and still not looked at as anything but an ambulance driver. There are many factors, political, econonim, ego's and perception that have to be addresed first.

    I'll get the biggest hurdle out of the way first, Ego's. You know as well as I do that the nursing community isn't going to care, what the degree is, if it's not nursing, then it's not the same and can't do the job as well. Now I know for a fact that a good paramedic, can do the job of an RN in a busy setting. I work in an ER that see's 122k pt's a year, some night, I"m to busy to be anything but a technician.

    The second biggest hurdle is economic. How are you going to change the reimbursment patterns? Again I have to go back to nursing as an example. No matter how hard nursing tried to change the perception of the hand maiden to the MD, as long as everything we do is included in the basic room rate, the perception is never going to change. Untill reimbursment changes, it will be hard to break out of the ambulance driver pidgenhole.

    State practice acts have to change. Now this prob had the potential to change the fastest, sur to the way that some of the state EMS acts are worded. But there are way to many fingers in the pot, and if you've ever sat in on a board of ems meeting, thre are some docs in postitions of power that don't think the average paramedic can fing the toilet papper inteh AM without a step by step protocol. Then you have the hospital board. Most people don't know, that it isnt'e the EMS board that says paramedics can't work in hospital environments, it's the hospital licensing boards in a number of cases.

    Fire deparments. As long as Paramedics are attacheed to fire departments, it's going to be to easy to remember the Jonny and Roy days of Emergency. Being part of the Fire dept also froces EMS into an strange situation, were there is to many Paramedics. Having one in every station, spreads the calles out. Politically gret for patients, but not so good for proffesional development. I know medics that have never dropped a tube in a crisis situation. Not to spend to much time on the old days, because they had their problems, but back when there was only a few medic untis in every city, we were over worked and dangerous in that sense, but I'd drop a tube or two every day. In 1987, i actualy dropped exactly 365 tubes. that averaged 1 a day. That's how you get good at something. This falls into the same catagory as limiting intern and resident hours though, there is good and bad to both sides of the argument. Telling a community that is used to having a paramedic no more than a few blocks away that they dont' need them there. Not a political move many politicians are going to make. (Do you know of any stats on how many paramedics work for companies that actually do 911 calls, vs transport? I haven't had time to look, and don't know. If so I'ld like to see them)

    My statement about ALS wasn't meant to be so generalized. Yes there is some invasive interventions that do save lives, but a two year education vs a certification isn't going to make that much difference. Just look at that errors and maltpractive against CRNA's. Look at how many medicaion errors have been made by 4 year nurses.

    I have to end this with Ego's again. As long as statements made out of frustration are made, like "they will have to take us seriously" it's always going to look like ego. It's not about patient care, it's about me. Look at the fights going in the medical and nursing community now about the Doctorate of Nursing practice. After the fist 5 min of discusion, is stops being about providing the best care possible to a patient population, and becomes a battle of egos.

    EMS has come a long way over the years. I can rember the first time I heard a medical command call in Sacramento, with a nurse telling the EMT-I to give one amp of the blue box, I just about died. There are places that are have fantastic protocols now that let EMS workers do what they do best. But it is always someone else directing what they are doing.

    Shotting for the moon is important! If you set you sights to low, you might just get what your aiming at, even if it just mediocraty. But somewhere, people have to be reilistic. What will bring EMS out of the dark ages, not a piece of paper from you local community college. It will be politically active community, a research and evidence based community, and a community that has solidarity.

    Personally, I'd like to see the Paramedic become a nurse position, with specialized training and certification. Might add to the oportunities for prehospital providers, when they become to old or fat to fit into what passes for aircraft around here. But that is another topic and I forgot to put on my fireproof underwear this AM.

    Accredidation is the first step and it's an important one, but its only the first step.

    Ok now that I've completly hijacked this topic.
  12. by   core0
    Interesting post. You correctly identified one area - reimbursement. However, in my opinion, the problem isn't reimbursement but what we are reimbursing for. In EMS you are reimbursed if you transport the patient. You are not reimbursed if you don't. Therefore the impetus is to transport.

    In the UK they are experimenting with another model which for a lack of better terms they are calling advanced paramedic practitioner. Its outlined here:
    http://www.jephc.com/uploads/Woollard990156.pdf

    The key to this is the ability to triage and treat the patient in the field. They are authorized to treat minor issues such as lacerations in the field. They also have the ability to triage and decide that the patient does not need to go to the ER (A&E there) but instead can follow up with their PCP in the morning. If you consider how much this would unburden the US system its rather amazing. The issue here is that since its a national health system there is no reimbursement pressure to transport. Instead there is pressure not to transfer since it saves the system money.

    David Carpenter, PA-C
  13. by   CraigB-RN
    Again David takes my posts and makes them clearer. And I was so hoping that Grad school would help he state my thoughts clearer.

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