Any other EMS professionals turned nurses having issues!

edogs334 · Oct 20, 2010

I love going to someones home, assessing them, and trying to figure out what is going on with them and how to treat it, if I can...

Which is why I would love to be a nurse in an EMS system- I'm also one of those people that got infected with the EMS bug and was never "cured." Being a nurse in a hospital (even in an ICU) just isn't the same as having the "office on wheels." As I've said before in another thread, if there was a nursing equivalent for positions such as the Advanced Practice Paramedic in Wake Co (Raleigh, NC) or the Emergency Care Practitioner (London Ambulance Service), then that would definitely be my dream job. Too bad most EMS systems in the U.S. don't officially involve nurses in prehospital care roles. RNs (especially Advanced Practice RNs) with specific prehospital care training could bring the same knowledge and skills used by medics plus the wealth of knowledge that comes with nursing education and experience. I'm sure some of you would say "well, that knowledge would be moot in the prehospital environment because the goal is to get the patient to the hospital anyways- so what difference would it make?" I would argue, however, that if RNs or APNs responded to 911 calls (esp the "BS" calls that some medics complain about) and actually did things such as facilitate referrals to alternate destinations/services (or provide definitive care such as suturing simple lacs), then everyone would benefit- especially the RNs in the ER who would be able to use that extra bed for more critical patients. In summary, transporting everyone to the ED (or having the patient sign a refusal form if they refuse to go) is legally nice, but it's far from efficient in use of resources; patients who keep calling EMS to go to the ED don't usually get better. So, RNs or APNs in prehospital care roles could definitely benefit EMS systems by providing more than just symptom management and transport to the ED. Here are the links to the aforementioned programs, if anyone's interested in reading about them:

http://www.wakegov.com/ems/staff/app.htm

London Ambulance Service - Ian Wilmer - emergency care practitioner

Granted the health care system in the UK is different from ours in many ways, but I still think RNs in EMS could benefit patients and the health care system alike.

hiddencatRN, BSN, RN · Oct 21, 2010

Hi all,
I am an RN also a paramedic, I was a paramedic first. I always dreamed of being a paramedic, since kindergarten to be exact... I will be honest, I went to nursing school really so I could make a better living, and not really because I had a desire to be a nurse. I know I am going to take a beating on here for that statement!!
Just wondering if any other EMS professionals are having problems making a tansition from emt/paramedic to RN... and if so how much time did you give it? (been a nurse for three years now, tried a new area, still love my office on wheels much better).
Any oppinions would be appreciated!
Happy

It's definitely a paradigm shift. I know the paramedics in my nursing class definitely were cranky about a lot of the fluffier nursing stuff, and DH, who is a paramedic and not a nurse, sometimes raises an eyebrow about things that aren't as hardcore-testosterony as paramedicine can be.

As an also-paramedic, can't you do transport, which would be very similar to what you're already used to?

GreyGull · Oct 21, 2010

As I've said before in another thread, if there was a nursing equivalent for positions such as the Advanced Practice Paramedic in Wake Co (Raleigh, NC)

For Wake County, their EMS system is not that much different except for the way it is funded and that it is not Fire Based. They use an extra Paramedic in a fly car who is trained to do RSI, initiate hypothermia and they must be proficient with intubation. They also tell the other Paramedics which hospital to take the patients to. Other than that they are an extra set of hands and do some welfare checks on residents. Checking on frequent callers or patients with special needs was something EMS used to do as a courtesy many years ago before some thought it was "BS" and a waste of time. Wake County really does not do anything which many Paramedics do in a little more progressive system. There is no special licensing or certification for APP. The extra inhouse training is also not that long. Still no degree, not even an Associates required. It is just a title the county gives the medics in the fly car much like some get if they ride in a truck that says CCT but the services vary widely.

Here is Wake County's protocols. They are really not that much different than many other EMS agencies.

http://www.wakegov.com/NR/rdonlyres/3BD4E0B0-1A9C-40FC-A73B-A622A332CCAD/0/WakeCounty2010ClinicalOperatingGuidelines.pdf

or the Emergency Care Practitioner (London Ambulance Service), then that would definitely be my dream job. Too bad most EMS systems in the U.S. don't officially involve nurses in prehospital care roles. RNs (especially Advanced Practice RNs) with specific prehospital care training could bring the same knowledge and skills used by medics plus the wealth of knowledge that comes with nursing education and experience.

Now this is a great idea. The Emergency Care Practitioner can also be a nurse which I believe makes up almost 50% of the ECPs in the UK. However, you can not compare the Paramedic in the UK or any other country with the U.S. In the U.S. the Paramedic cert is measured in hours of training as other tech programs are and in the UK they are years or degrees. The UK ECP is essentially a graduate course.

http://www.nhscareers.nhs.uk/details/Default.aspx?Id=905

http://www.nhscareers.nhs.uk/details/Default.aspx?Id=414

http://www.plymouth.ac.uk/files/extranet/docs/HSW/ECP%20Study%20Report.pdf

Another system the utilizes RNs in prehosptial is the Dutch/Netherlands. Actually, it is called a nurse based EMS system.

http://www.jem-journal.com/article/S0736-4679(05)00386-0/abstract

http://www.ambulancezorg.nl/EN/Documents/General%20information%20ambulancecare%20in%20the%20Netherlands%202008.pdf

Spain also utilizes a nurse (and doctors) in their EMS system. Their Helicopter EMS is also an RN/MD crew.

PAs and NP should be utilized more. But, there is also a conflict in some EMS systems with contractual transport agreements where the ambulances are paid by the transport and where there is fire based EMS.

PMFB-RN, RN · Oct 21, 2010

Aren't there many, many things that an RN does which is also just as important? Don't write off the RN just because they don't intubate.

*** In my state (Wisconsin) RNs can and do intubate. All of our transport (flight and ground) service RNs do emergent intubations both in the field and in the hospital. Plus they do 30 intubations a year in the OR under the supervision of a CRNA to maintain competency.

ObtundedRN, BSN, RN · Oct 21, 2010

*** In my state (Wisconsin) RNs can and do intubate. All of our transport (flight and ground) service RNs do emergent intubations both in the field and in the hospital. Plus they do 30 intubations a year in the OR under the supervision of a CRNA to maintain competency.

In NC, an RN can intubate too. And of course the BON requires that the RN maintain competancy, but they don't give specific requirements, they leave that to be determined by the facility. So usually RN's don't intubate because that would be too many people to ensure competancy. Also, my understanding is they can't get reimbursement for it if an RN intubates, like they do if an MD intubates. But my hospital system does have some RN's that can intubate.

And to the statement about RN's not having to "think" as much as a medic. If you aren't thinking as much, then it sounds like you're not a very good nurse, imho. And please remember, I came from EMS, so i'm not an RN looking in from the outside. If I have a problem with my patient, I can make proper interventions, and get X-rays, 12-leads, and certain labs like an ABG (which are not available in the field, except the 12-lead). I then go to the MD with my situation, results of diagnostics, and make my suggestions. If you're an RN that just calls and reports something and wait for them to "order" you to do something, instead of "thinking" and working with the MD as a team, then you must have been asleep for most of your nursing school and now sell yourself short. And I don't give a medication just because it's "ordered." I give a medication if it is "prescribed" and appropriate for the patient. If its not appropriate, I can use my nursing judgement to hold a medication.

And yes, my assessment of a critical care patient is far more extensive then in EMS, and usually even more in depth then the MD. When is the last time you saw an MD go in and actually look at someone's urine output, wound, invasive line sites, edema, mental or pyschosocial status, etc?

Esme12, ASN, BSN, RN · Oct 21, 2010

Respiratory Therapists work under a Medical Director just like all the other departments including PT, OT, and Radiology. AND, just like RNs who have protocols in placed signed by the Medical Director of their ICU or floor. Some hospitals have all the P&Ps posted on the intranet for all to see and others still have them in big manuals. Ask the Respiratory Therapists or any of the therapies if you can look at their P&Ps.
For nursing and RT (Respiratory Therapy) they may also have combined protocols such as sepsis, ARDS and sedation vacation.
Each Rapid Response Team and Code Team will also have protocols.
Who is going to start the IVs, push meds and get kits for other procedures setup? Aren't there many, many things that an RN does which is also just as important? Don't write off the RN just because they don't intubate. Without the RN, many intubations couldn't happen very easily.
How would you monitor 200 RNs on their skills and keep them competent in intubation? Paramedics are no longer intubating in the field in some places because that is an issue. There is also the follow through. Just sticking a piece of plastic through the cords is only one part of it.
Outside of NICU, there are only about 20 RRTs who intubate at my current hospital. They must do 10 intubations with a preceptor and then 25 per year. For transport they need at least 100 intubations to apply along with the years of experience and the education requirements.
However, there are many RRTs who do not intubate even though they have 2 or 4 (and 6) years of college specializing in Respiratory. But, that does not make them any less of an RRT. Most are busy getting set up for blood gases, A-lines, the ventilator, Nitric Oxide, heliox and whatever other meds and gases required. They are perfectly content to allow the physician to place the tube and move on with figuring out how to spare the patient's lungs and stabilize them for the long haul.
There is also this one little concept when working in the hospital called "teamwork". You can still be a jack of all trades but it is really great to have those who have serious expertise in their profession.
Abbreviations:
RT - Respiratory Therapy (or also used by Radiology professionals)
Credentials (state licensing may use same titles or sometimes RCP -Respiratory Care Practitioner)
RRT - Registered Respiratory Therapist
CRT - Certified Respiratory Therapist

YOu're a smart guy and it shows you care a lot about what you do. For the most part I agree with you 100% of the time. You obviously have a great understanding how to properly care for a patient with team work.....something greatly lacking these days. I think and that why there is so much posturing and bolstering my credential/degree is bigger than yours. I attempted to compliment you and it didn't translate well. YOu are obviously someone who does their job well and care very much that yo do iy well.......a rarity these days

KUDOS!

GreyGull · Oct 22, 2010

YOu're a smart guy and it shows you care a lot about what you do. For the most part I agree with you 100% of the time. You obviously have a great understanding how to properly care for a patient with team work.....something greatly lacking these days. I think and that why there is so much posturing and bolstering my credential/degree is bigger than yours. I attempted to compliment you and it didn't translate well. YOu are obviously someone who does their job well and care very much that yo do iy well.......a rarity these days
KUDOS!

I do thank you for your compliments but my knowledge is probably the same as many others with gray hair or for each strand of hair lost while being in health care.

I am going to ramble on a little more especially about intubation since that skill seems to be more of a member measurement or turf zone for some rather than a medical necessity.

Not all physicians are given the privilege of intubating even though it is within their scope of practice. All hospitals should have a privilege list for each physician. This also includes whether they can do RSI, order paralytics, insert A-lines and central lines.

For those who still hold a Paramedic credential, you must remember that in the hospital the immunity laws that you had with EMS are no longer applicable. You will feel the full impact of liability which all MDs, DOs, NPs, PAs, RNs and RRTs are made fully aware of when they are being checked off for intubation. This is also one reason why some RT departments are quite happy not doing the intubations even if they might be a good choice due to education, clinical intubations, small group and usually a medical director that expects above standard care and who is usually around to critique them.

A hospital and some flight teams are considered a higher level of care. You must be able to intubate the trachea. EMS has CombiTubes, King Airway and LMA along with the BVM. A flight team may also opt for leaving the supraglottic device in place if it is working well. Since some EMS agencies are starting with these rather than ETI, it is up to the hospital to intubate. Anyone who starts IVs also knows what its like to come along after multiple attempts have been made before you and you are looking at hamburger. The same for the airway. If multiple or even one attempt was done in the field, you may have cords that are in spasm or swollen and bloody soft tissue. The supra or extraglottic tubes can also create problems due to the size of the cuffs and the tube itself. The Combitube has a latex cuff which also can complicate things a little. We are seeing angioedema or tongue engorgement along with some cord damage (Combitube) and soft tissue damage even with these devices which are supposed to be so simple EMT-Basics are allowed to use them. We also see or get aspiration if the supraglottic tube is not carefully removed and the endotracheal tube placed.

For those who do not know what these tubes are:

Combitube

http://www.armstrongmedical.com/itm_img/lg.combitube.jpg

King

http://1.bp.blogspot.com/_-p7DcK-ba74/SoRMwh6Uu9I/AAAAAAAAAk8/8NA4nYckCHQ/s400/KINg.jpg

The other issue facing health care providers who intubate is obesity. Patients are coming in with fat necks.

Not only should you be familiar with direct laryngoscopy with the standard laryngoscope, you had better have plans B, C, D and even E in your mind if not already set up. You should also KNOW who your backup is be it the ED doctor, anesthesiology, Pulmonologist, ENT, the Intensivist or RRT. You shouldn't wait until you realize you are in over your head to be shouting "who's on call for ...?" while bagging frantically with a BVM and no artificial airway as well as losing the natural one. Good RRTs will generally have these numbers on speed dial or memorized. They will also know who's in house and where as well as where all the advanced intubation equipment is along with the difficult airway cart.

Not only should you know how to do intubation by a couple different methods, you should also know what to do when things go very, very wrong. But, above all one should know if you shouldn't attempt the tube or without the specialized equipment. Ego and inexperience (or inflated experience) are the two most common reasons for botched airways.

The other thing stressed when you are learning to intubate and take that responsibility is the fact the patient could die and the death could be placed directly on your shoulders regardless of blame. You must be able to deal with that maturely. Of course you may critique yourself and be critiqued by others whether you have the necessary skills and are competent.

A few years ago I was moonlighting at a hospital which had a L&D and small nursery. The RNs were taught NRP and intubation on an infant head which then gave them the privilege of intubation. It was very rare for there to be an emergency in L&D. One night a baby was born with thick meconium. This was gong to be the RN on duty's first intubation on a live baby. She was never quite sure if she put the tube into the belly or through the cords due to all the meconium present. The RRT arrived and the baby was intubated for the long haul, transported to a Level 3 and placed on ECMO. The baby died a few days later. The RN beat herself up more than the hospital inquiry and she left to work at a doctor's office. She got dealt a bad situation and still feels responsible for that baby's death.

Now for some more very serious examples.

Here I just typed intubation and liability into Google Scholar (great search engine for legal and medical)

http://scholar.google.com/scholar?hl=en&q=intubation+liability+&as_sdt=2002&as_ylo=&as_vis=0

This case has the flight medicine community relied to know the RNs were cleared.

http://www.emsflightcrew.com/content/calstar-flight-nurse-cleared-all-charges-2008-yolo-county-incident

Below is the actual case summary. The Paramedic's statements were a little disheartening and apparently there was some friction between the ambulance and flight crews noted on scene.

http://rn.ca.gov/public/rn528232.pdf

Here's an incident involving RRTs. It is probably not a good feeling to be labeled as incompetent.

http://www4.va.gov/oig/54/reports/VAOIG-09-03815-170.pdf

For those who also want to intubate, along with all the liability issues there might be a job requirement. If RRTs are required to intubate, they must fulfill that requirement or can be terminated or lose unit status. If this was a requirement for all trauma RNs, the same might apply regardless of how good you are with other aspects of nursing. This has also happened to flight and specialty RNs who can't get their tubes.

Anybody get the Sentinel Events alerts? After airways, ventilators are next on the attorney attraction list for $$$$.

http://www.jointcommission.org/sentinelevents/

From another discussion, you can also Google Scholar trach lawsuits and see how easy it is to screw up with these airways.

Another thing to consider is when ED physicians take it upon themselves to allow EMS Paramedics or even an ED RN/Paramedic practice. The physician may want you as the RN and RRT to document that he/she performed the intubation since the hospital probably does not cover anyone but designated staff intubating and the doctor may be coding (billing) as "procedure performed" rather than "procedure supervised" as what might be done in a teaching situation or when flight RNs get their tubes done in the ED. CHART TRUTHFULLY and tell the physician...too bad. If something happens to that patient later and you are questioned about the events, I can guarantee not everyone in that ED will have the same story. Not too long ago we had a patient that was difficult to wean off the ventilator in ICU because of no leak around the tube. When ENT visualized the patient had a significant mass forming near the cords. The Intensivists were puzzled because the ED physician didn't document this in his intubation record. During questioning he admitted he did not do the intubation but has allowed one of the EMS Paramedics perform it but documented it a if he had done it. Not only did this create problems for the ED physician, it complicated the patient's course of treatment.

Now for one of my biggest pet peeves which is when people say they are "certified" to intubate because they have had ACLS.

Even though I have also referred intubation to be just placing a plastic tube through the cords which is a "skill", the whole process surrounding intubation can be very complex especially if you do not have all your plans for althernative or backup in order.

dixiebelleRN · Oct 22, 2010

I can feel your pain on that, been an EMT for 6 years. ICU tech for 3 years and nurse for a few months, nothing gets me going like a good car accident or being first on scene!!

What about pre-hosp. RN?

edogs334 · Oct 22, 2010

=
I am going to ramble on a little more especially about intubation since that skill seems to be more of a member measurement or turf zone for some rather than a medical necessity.
Not all physicians are given the privilege of intubating even though it is within their scope of practice. All hospitals should have a privilege list for each physician. This also includes whether they can do RSI, order paralytics, insert A-lines and central lines.
Not only should you be familiar with direct laryngoscopy with the standard laryngoscope, you had better have plans B, C, D and even E in your mind if not already set up. You should also KNOW who your backup is be it the ED doctor, anesthesiology, Pulmonologist, ENT, the Intensivist or RRT. You shouldn't wait until you realize you are in over your head to be shouting "who's on call for ...?" while bagging frantically with a BVM and no artificial airway as well as losing the natural one. Good RRTs will generally have these numbers on speed dial or memorized. They will also know who's in house and where as well as where all the advanced intubation equipment is along with the difficult airway cart.
Not only should you know how to do intubation by a couple different methods, you should also know what to do when things go very, very wrong. But, above all one should know if you shouldn't attempt the tube or without the specialized equipment. Ego and inexperience (or inflated experience) are the two most common reasons for botched airways.

Exactly! One of supervising anesthesiologists at my hospital conveyed a similar message to us during out airway lecture in orientation- that he would rather anesthesia be stat-paged preemptively and eventually not be needed than being stat-paged after 3 unsuccessful intubation attempts.

edogs334 · Oct 22, 2010

=
I am going to ramble on a little more especially about intubation since that skill seems to be more of a member measurement or turf zone for some rather than a medical necessity.
Not all physicians are given the privilege of intubating even though it is within their scope of practice. All hospitals should have a privilege list for each physician. This also includes whether they can do RSI, order paralytics, insert A-lines and central lines.
Not only should you be familiar with direct laryngoscopy with the standard laryngoscope, you had better have plans B, C, D and even E in your mind if not already set up. You should also KNOW who your backup is be it the ED doctor, anesthesiology, Pulmonologist, ENT, the Intensivist or RRT. You shouldn't wait until you realize you are in over your head to be shouting "who's on call for ...?" while bagging frantically with a BVM and no artificial airway as well as losing the natural one. Good RRTs will generally have these numbers on speed dial or memorized. They will also know who's in house and where as well as where all the advanced intubation equipment is along with the difficult airway cart.
Not only should you know how to do intubation by a couple different methods, you should also know what to do when things go very, very wrong. But, above all one should know if you shouldn't attempt the tube or without the specialized equipment. Ego and inexperience (or inflated experience) are the two most common reasons for botched airways.

Exactly! One of the supervising anesthesiologists at my hospital conveyed a similar message to us during our airway lecture in orientation- that he would rather anesthesia be stat-paged preemptively and eventually not be needed than being stat-paged after 3 unsuccessful intubation attempts. AND he said that nursing has the full support of MDA chiefs and NMs to stat-page anesthesia if we think they are needed- even if the ICU attending or resident says otherwise.

linearthinker, DNP, RN · Oct 22, 2010

I didn't read the whole thing, but years ago when I was a flight nurse, I worked with a lot of flighties that were dual RN/paramedics. So look into flying, might be a good niche for you.

AnnieOaklyRN, BSN, RN, EMT-P · Oct 26, 2010

I have been thinking for a long time about flight, now I just have to quit my ice cream addiction, easier said than done..