Going into EMS?

[TNViking]

Hey guys! So I'm an RN that currently works in my local ED. In a few months one of our local community colleges is offering an RN to EMT-B bridge course that I am very excited to take! Once I get my feet wet in this, if I find I like it, I'm considering going back to school to become a paramedic. To those of you that are RNs as well as EMS providers, what do you think about it? What are the pros and cons of working prehospital as opposed to working in the hospital?

[TNViking]

Wow, thank you all so much for all of your thoughts! It truly does help!

[Josh Runkle, RN, EMT-P]

One thing to remember about EMS is that it is not really standardized state-to-state the way that nursing (almost) is. If you look up what it takes to become a paramedic, you will find that it wildly varies state-to-state between about 1,000 hours of training beyond the EMT level to 14,000 hours beyond the EMT level. Some Paramedic courses can be completed in 6 months, and others are 1.5-2 years. For example, mine was relatively short (9 months), but I had to take Bio, Chem, A&P, Pharamcology, Physiology, MicroBio and Medical Terminology in addition to already becoming a certified EMT and taking a paramedic prep course (which covered the specifics from the pre-reqs into what would be needed for the Paramedic program). While my schooling was only 9 months long, my schedule was fairly intense:

Mon: 5am-5pm Hospital Clinical in ED; 6pm-10pm class

Tues: 8am-8pm Ambulance Ride Along

Wed: 5am-5pm Hospital Clinical in ED; 6pm-10pm class

Thurs: 4am-4pm Surigcal rotation (needed 50 intubation attempts) or 8am-8pm or noon-midnight other specialty clinical (like L&D)

Friday: 8am-8pm Ambulance Ride Along

Saturday: noon-8pm Study Group

Sunday: Study

While the INFORMATION was really easy for paramedic school, the schedule was not. Modules were often 1-2 weeks in length. The same information that I covered in a semester-long, 3 credit hour EKG course and a semester long, 3 credit hour Advanced EKG course was what I had to learn in 2 weeks in paramedic school. During a module, you would often read 100-150 pages of your textbook and 2-3 books that were 100-200 pages of supplemental material.

To sum up my EMS education:

EMT was super easy. It's basically an advanced lifeguard-type class (minus the pool). But, Paramedic was hard, not because of the material, but because of the limited time. Additionally, just about every state has completely different requirements, and many courses are entirely different lengths of time, so most people are going to have widely different Paramedic school experiences. My associate's degree, bachelor's degree and initial nursing school experiences have been stupid easy in comparison, simply because of the time differences and the ability to sleep.

I believe that EMS would be a lot better off if the material was spread out in a way that the information could be better retained. Unfortunately, that would have made my EMS schooling 3-4 years in length, and there is no way that fire departments want to pay Paramedics for the equivalent of a bachelor's degree.

TL;DR: EMS education widely varies state to state. Experiences and opinions will be quite different.

[PeeWeeQ, ADN, RN, EMT-B]

You guys want to fight over autonomy and critical thinking? Skills? Try being a lone combat medic, in the middle of nowhere, 2 hours until the helo gets there, with 2 critical, and 3 badly wounded patients, and one aid bag and a "trauma supply" bag. Combat lifesavers (think EMR on civilian side) are almost worthless because their buddies are dying. Wanna test your skills? Try doing an NCD on one PT, while you attempt to coach another soldier in giving respirations via BVM--on his best friend.

Become an infantry medic...

As also being an EMT-B and a nursing student, I can understand both sides. Instead of going back and forth, how about we just agree that ED nursing and Pre-hospital care are different. I'd take a nurse, with the knowledge they have, and turn them into an EMT-B any day. It can only enhance their knowledge (especially in the ER) and make them better, provided, they have the proper mind-set, and are willing to let go of a few things from the nursing side and understand that EMS protocols are different for GOOD, EVIDENCE-BASED REASONS. Like nursing, EMS changes too. Even EMT-Basics have to keep up good assessment skills, knowledge (there is a CEU requirement and a 24-hour refresher requirement for each renewal period), and be able to find their way around a scene.

I'm going for my RN. I'd like to spend some time in an ER, but, I'd really like to be on a helicopter some day. I plan on bridging/challenging for my paramedic cert eventually, because I see real value in it.

And yes, EMS protocols and training levels vary state to state. Here in WI, we are very progressive. EMRs here used to be more advanced than an EMT Basic in MN. I don't know if that still rings true...

Anyway, as I said, EMS and clinical experiences and, thus, protocols, are simply different...

[PeakRN]

You guys want to fight over autonomy and critical thinking? Skills? Try being a lone combat medic, in the middle of nowheret...

The military allows their medical personnel to perform skills well beyond that of their civilian equivalents. A combat medic is not the same as EMT. I knew a guy who was a retired 18D, he was a brilliant guy in almost any way but cardiac was not on his radar. To be fair, and his argument was, acute cardiac patients are never going to have a good outcome without significant resources that they simply did not have. Ironically he could identify malnutrition issues faster and with far fewer resources than any pediatric GI doc I have ever met. But acute cardiac is a huge part of stateside EMS and he struggled with his transition to civilian medicine.

I don't think that any of the 'argument' was about the ED and prehospital being the same, rather it was about whether prehospital nurses benefit from, or should be, paramedics. Personally I believe that a good critical care nurse who is invested in their education can function as the primary ALS provider without needing to become a paramedic. That being said I have met many flight nurses who are the shining example of the paralysis of indecision; I have met many medics who do the same thing but they seem to be fewer in proportion. Most medics also struggle with the whole patient oriented approach of nursing or medicine.

Some former EMS providers do not do well in the ED (or other nursing) environment, it took me a long time to change my thinking personally. They often go back to EMS and talk down all the ways the nursing is 'below' EMS, that 'EMS makes independent decisions,' and that 'I'm not a doctor's helper' or 'I don't need and order for...'. That does not equivocate to EMS being better than nurses, its an excuse for feeling unsatisfied or uncomfortable with nursing and returning to EMS.

If a nurse had the right mentality for EMS, I would far rather have them attend classes like TCAR, PCAR, ATLS, Neonatal resuscitation, STABLE, et cetera than go though medic school and learn what is predominately the exact same skills while missing out on a lot of the high level knowledge and skills that they could learn from other environments.

Long story short: Some nurses can be really good at prehospital, some medics become good at being nurses. Neither is 100%, but in the US nurses have a higher level of education and are more enabled to work in multiple environments.

[PeeWeeQ, ADN, RN, EMT-B]

The military allows their medical personnel to perform skills well beyond that of their civilian equivalents. A combat medic is not the same as EMT. I knew a guy who was a retired 18D, he was a brilliant guy in almost any way but cardiac was not on his radar.

A few bits of FYI--An Army Combat Medic (what I was--68W) is the result of combining the old combat medic MOS with LPN; the idea being that we could work in either the combat environment or the clinical. Also, 68Ws ARE EMTs--we have to obtain and maintain NREMT Basic status. Flight medics and Air Force PJs are NREMT-Ps. When I was trained, we trained for and passed NREMT-B in 3.5 weeks. I spent 3.5 more months learning additional tactical (assessment, TCCC, NCD, Surgical cric, advanced airways and intubation, IV therapy, etc) and clinical skills.

18Ds are LIGHTYEARS beyond 68Ws in training, experience, and skill. They aren't set up for cardiac, mainly because of the environments they work in. Its not that he wasn't trained, they just don't use it. Their own team members are in peak physical condition and the epitome of health. The populations they deal with and treat have primarily traumatic, orthopedic, and/or malnutrition issues. That's why he's likely so good at it. He's also trained in veterinary medicine. Also, considering the cardiac issues, PJs and flight medics that pick up the 18D's most critical patients are going to be well versed and experienced in dealing with those problems.

I don't think that any of the 'argument' was about the ED and prehospital being the same, rather it was about whether prehospital nurses benefit from, or should be, paramedics. Personally I believe that a good critical care nurse who is invested in their education can function as the primary ALS provider without needing to become a paramedic.

Some nurses can be really good at prehospital, some medics become good at being nurses. Neither is 100%, but in the US nurses have a higher level of education and are more enabled to work in multiple environments.

I believe all medical personnel can benefit from broadening their horizons. Who are we to tell individuals what they should or shouldn't be? As far as functioning as an ALS provider--maybe, but, it's not just the technical training. Its that there is a certain way EMS does things, whether you are BLS or ALS that is DIFFERENT than the clinical, "whole patient oriented approach"--its more focused on the "right now."

It may be good to have those long-term, nurse-minded things in your head, but that's why being trained as an EMT, in EMS operations, (not just ACLS, PHTLS, TCAT, PCAR, PALS) can make a difference. EMS operates in a different, constantly changing environment.

We CAN and need to learn to think differently, and, that's my point. One has to accept that in-hospital and pre-hospital care are different, with different goals and focus, in order to be able to transition from one to the other or between the two. Sure, it might be a struggle, but, to say one way or the other is a bad idea, all depends on the versatility of the individual, not the concept itself.

As for indecision you said you saw in flight nurses--EMS isn't for everybody. Hopefully these individuals are evaluated honestly for such things. As the Battalion Sr Medic, I was responsible for all aid station and field combat medics. I had to move several from the field to the aid station because they weren't equipped to handle some of the more intense situations. They may have had issues with indecision, assertiveness, or dealing with authority (the people you have to advocate for your patients to).

[Lunah, MSN, RN]

Just to clarify, 68W is not the LPN MOS - that is a 68C, formerly 68WM6. My husband was a 68W, and I was a 66M5 nurse (now 66T). I just don't want people to get the wrong idea that 68Ws are actually LPNs. But a 68W certainly goes beyond EMT-B.

Regarding 18Ds, I spent my entire FST deployment attached to an ODA team. Those guys are fabulous, and they loved to get out of the "med shed" and hang out in our plywood ER/OR/ICU palace. I worked with four different 18Ds during my time there, and all seemed competent in just about everything.

[PeeWeeQ, ADN, RN, EMT-B]

AAMED took a bunch of the tasks that LPNs do and added them to the 68W curriculum to prep them for a clinical setting. They also took SOME of the clinical tasks from the old 91B and threw them out as well. I used to be an AAMED 68W instructor. In the interest of brevity, I worded my 68W description poorly in my post. Thanks, Pixie.RN, for clarifying.

I like to say a 68W is more closely related, civilian-wise, to an EMT-A (Formerly EMT-I, IV tech). Plus the TCCC and some other trauma related tricks...At the advanced NCO levels, we also learn things like basic suturing, chest tubes, etc...

[EMTPJean]

Hi SummitRN!!! Paramedic school was by no means easy for me. I had to study very hard and perform mega codes for the EMS medical director. As a EMT-P, you have to know what you're doing out in the field because it's just you, your partner, and the patient out there.

[PeeWeeQ, ADN, RN, EMT-B]

The biggest hurdle is to learn to think in an ems mentality, which is more difficult than most people think. Most nurses that I know that went to P school for whatever reason still think like nurses anyway, and as a result their scene management is poor to say the least.

Well, I'm almost done with my second semester (of four) of nursing school and, coming from an EMS and infantry medic background, I have struggled with trying to shake my EMS mentality for the nursing mentality. I always new that they were different, but, the EMS mentality is much more focused and mechanical while nursing is total patient.

I kick butt at taking vitals (I think I'm better without the machine) and doing head-to-toe and focused assessments, but, it's all of the other things (nursing assessments) that I have to keep in mind as well. There is a bigger (deeper is probably a better word) picture that we just don't get much opportunity to deal with on the EMS side.

I'm still considering taking the Paramedic course once I'm done with nursing, but, that will depend largely on what my wife thinks about it. She's as burnt out on school as I am and I still have my BSN to think about when I'm done with my ADN. All that said, I can see why nurse's who just bridge to EMT-P could have an issue getting lost in the weeds with a more "big picture" approach. Knowing what I know now, I'd stick to what I said previously in this thread--I'm not sure that bridge idea is a good one. It's hard to shake a certain mentality for another, no matter which way you're going...

Just my .02...