RN/firefighter policies and procedures

DanC · Aug 15, 2010

Check with the governing agency over EMS in your state in Texas it is the Dept. of Health. there is a medical director over the EMS area of the health department and each service/ area has their own medical controll,(MD/DO). As far as what you can do in the hospital that will depend on the hospital and your level of training as far as what you can do outside of the hospital I would check with your states board of nursing, you may want to look into becoming an EMT or paramedic in addition to your RN license.if you are wanting to function outside of the hospital setting. I was a flight nurse for many years and maintained paramedic status as well as being an RN. Hope this helps.

CrufflerJJ, BSN, RN, EMT-P · Aug 15, 2010

i'll try to keep this short. i am an rn who works in the emergency department. i am also a volunteer firefighter. while we don't run medical calls our district is along a very busy interstate and we run many many mva's. what can/can't i do without a medical director over the fire department? can i do anything? basically all the local ambulance company ever asks me to do is start iv's, assist with spinal immobilization, bag patients, splint fractures, and the like... the two that worry me are iv initiation and splinting. i am very capable of both tasks and the ambulance company always asks for my help (it's a small area and the medics know me well from the er). i don't mind helping them out but don't want to go out of my scope. with that said, what if a local doctor wrote standing orders and we had policies and procedures for me to do basic things like saline locks and place oral or nasal airways? thanks for the help.

hmmmm....difficult question....(i'm trying to balance "common sense" vs "the law").

i suspect that the law will win every time. even if you're trained to perform certain tasks (such as ivs) in a hospital setting, i'm not sure that you are legally allowed to perform then in a pre-hospital setting unless trained/certified as an emt or paramedic.

if you had a doc issue you standing orders, i think you'd be covered, but am not sure.

i ran as a volunteer emt & paramedic for 19 years before going into nursing. this taught me that being "capable" of something may be very different from being "authorized" to do something. common sense means nothing. all that truly matters is what the local prostituting attorney or state ems/nursing board believes to be the case.

thank you for being willing to help out. that being said, please be careful so you don't get an appendage caught in the wringer. you might also consider a rn to paramedic bridge program, if they are offered in your area. they're usually 1-2 quarters long, and would give you the emt-p certification that might be needed to cover you from a legal silliness standpoint.

ImThatGuy, BSN, RN · Aug 15, 2010

Unless/until you have a medical director authorizing all of that (perhaps the EMS service's that you operate with) I'd stick to BLS, first responder-type operations. You're covered with spinal immobilization. As a medic, I've directed bystanders to assist me with that before, and we're taught to do so if necessary. I know we all think it's reasonable and prudent to help when/where necessary, but that's not the case.

As an officer, I've been on scene and helped medics with BLS, spiked IV bags, etc, but I don't/won't perform ALS skills. I've actually directed what appeared to be an incompetent medic before on what he needed to do, and he did it, lol. Was that prudent? Probably not.

I remember back when I was in medic school, and often third riding with the local EMS, there was a S-10 pickup v. huge tree collision. Tree won. Middle passenger in the bench seat of the truck experienced bilateral femur fractures, fractured pevils, and I think some vertebral lumbar fractures. I think he actually died in the hospital, but at any rate, during a prolonged extrication I was there because I heard the collision at my house, plus I knew the VFD I was on would get paged so I was actually the first responder other than the person whose yard the tree was in.

This won't be grammatically correct, but...

I recall me, another basic EMT who happend to show up in addition to the ambulance service, a reserve deputy who was a medical technologist, and both members of the EMS crew trying to find veins on the guy. Adult IOs weren't in practice at the time. He'd lost enough internal blood that his veins were too small to find. Interestingly, it was the reserve deputy / MT that found a tiny little vein, and we all got access through there. Was he out of his scope? Yep. Did he do any harm? Nope. Could the guy's family have sued him, the sheriff, the medic, the ambulance service, the county, etc? Probably, lol.

ObtundedRN, BSN, RN · Aug 15, 2010

My understanding is that everything you mentioned is out of your scope in the field. Unless your board of nursing says otherwise. Where I'm at, the BON has a position statement regarding RNs working transport. Basically you fall under the rules set by the office of EMS, which require you to have a medical director. And chances are, if you had a medical director, it would be the one over the EMS agencies or first responders. And that medical director would probably either require you to obtain your EMT cert or limit you to practice at the level of EMT or medical responder.

Not to metion that nursing school doesn't teach how to properly splint or spinal a patient. I know it's easy, but you never received proper instruction on it. And the way my nurse practice act is written, requires the nurse to have proper education or it's put of their nursing scope of practice.

GreyGull · Aug 15, 2010

Not to metion that nursing school doesn't teach how to properly splint or spinal a patient. I know it's easy, but you never received proper instruction on it. And the way my nurse practice act is written, requires the nurse to have proper education or it's put of their nursing scope of practice.

Nick, I would hope that you don't believe just having the title of RN behind one's name makes one incapable of learning how to splint or spinal(?) a patient. A nurse (and CNAs, PCTs, PTs, OTs and RTs) working in an ED, ICU or many other areas of the hospital would be able to learn the proper technique and probably would be required to know such things. I couldn't imagine having ortho, surgical or trauma patients without getting some of these basics while working in those areas. Education doesn't stop with the diploma. These are not skills limited only to EMS and some in EMS would be amazed by what type of patients and their spinal accessories RNs do work with, most of which EMTs or Paramedics will never see.

But, back to the topic, prehospital is a very different situation. Unless the RN is in one of the few states which extends privileges through both the BON and EMS state department, the RN would be restricted to providing little more than a first responder. However, if the EMT or Paramedic is obtained, the RN may be restricted to functioning only within that scope of practice under an EMS Medical Director and no more. This was one of the positions that ENA took on dual certifications and has supported prehospital credentials under the BON for nurses to avoid conflicts.

The OP may have to choose to be only an EMT and leave the RN license alone. However, if working as an EMT or Paramedic, should the OP decide to participate in titrating meds or doing a procedure in the field as he would while working as an RN, he may find himself out of his scope as a Paramedic. This could include something like starting an IV or administering an Epi-pen which the EMT may or may not be able to do under their Medical Director. Thus, trouble from the EMS board as well as the state's BON.

The safest thing is to contact the state's BON and the EMS state agency.

This is an interesting link I saw in another discussion on this forum. It is a survey about which professionals can challenge the Paramedic and which states allow other than those who are EMS certified to work on ambulances.

http://www.nasemso.org/NewsAndPublications/News/documents/NASEMSOsurvey051208.pdf

kcochrane · Aug 15, 2010

We had several RNs riding as EMTs (basic) on our ambulance. There were only allowed to perform tasks as an EMT. As others have mentioned, check with your state protocols for EMS.

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Aug 15, 2010

RN's work on the doctors orders in the hospital. EMS has a physician medical director with standing orders and radio contact with a doctor. These orders are ONLY for appropriately licensed EMS personel. You're operating without physicians orders in the field and are on your own. I've done ER-RN and volunteer Basic EMT and this was always an issue. That said, I'd rather face a jury having done what's best for my patient, than for withholding skills allowed in the ER but not as a Basic EMT. I'd brake protocol to save a life anytime, but it's entirely my own liability.

ObtundedRN, BSN, RN · Aug 16, 2010

Nick, I would hope that you don't believe just having the title of RN behind one's name makes one incapable of learning how to splint or spinal(?) a patient. A nurse (and CNAs, PCTs, PTs, OTs and RTs) working in an ED, ICU or many other areas of the hospital would be able to learn the proper technique and probably would be required to know such things. I couldn't imagine having ortho, surgical or trauma patients without getting some of these basics while working in those areas. Education doesn't stop with the diploma. These are not skills limited only to EMS and some in EMS would be amazed by what type of patients and their spinal accessories RNs do work with, most of which EMTs or Paramedics will never see.

I think you missed the point of my earlier statement. What I was trying to say, is that my practice act states that the RN must have proper education, and show proficiency. Nursing school doesn't teach those skills. As I said before, I know these are very easy skills to learn. What I meant by the proper education is that without some type of proof that they learned those skills and showed proficiency, one could say they are out of their scope. Something as small as someone showing them, and then watching and getting "checked off" would probably work. I never meant that an RN couldn't learn to do it. I'm sure that OTs and PTs could learn it as well. I don't think that UAPs like CNAs and PCTs would be able to though, considering it requires ongoing assessment, planning, and implementation. And it can require modification for each patient. This would go against every "rule" of delegation. At least that is my opinion.

GreyGull · Aug 16, 2010

I think you missed the point of my earlier statement. What I was trying to say, is that my practice act states that the RN must have proper education, and show proficiency. Nursing school doesn't teach those skills. As I said before, I know these are very easy skills to learn. What I meant by the proper education is that without some type of proof that they learned those skills and showed proficiency, one could say they are out of their scope. Something as small as someone showing them, and then watching and getting "checked off" would probably work. I never meant that an RN couldn't learn to do it. I'm sure that OTs and PTs could learn it as well. I don't think that UAPs like CNAs and PCTs would be able to though, considering it requires ongoing assessment, planning, and implementation. And it can require modification for each patient. This would go against every "rule" of delegation. At least that is my opinion.

If we were to use your logic, Paramedics would also be at a great disadvantage since ETCO2 and 12-Lead ECGs are not part of many Paramedic programs. Also, if someone was trained by the 2000 AHA ACLS standards, how would you expect them to function with the 2005 guidelines? How on earth can Paramedics ever be expected to do such things since they didn't learn them in school?

I am finding a lot of good information in other threads and some good links. Here is one from the emergency section about ENA and ASTNA's position on prehospital RNs.

http://www.astna.org/PDF/HOSPENV.pdf

Also, the EMT-B class is essentially a "check off" of skills with very little education since 110 hours of training is not very much time.

ObtundedRN, BSN, RN · Aug 17, 2010

If we were to use your logic, Paramedics would also be at a great disadvantage since ETCO2 and 12-Lead ECGs are not part of many Paramedic programs. Also, if someone was trained by the 2000 AHA ACLS standards, how would you expect them to function with the 2005 guidelines? How on earth can Paramedics ever be expected to do such things since they didn't learn them in school?
I am finding a lot of good information in other threads and some good links. Here is one from the emergency section about ENA and ASTNA's position on prehospital RNs.
http://www.astna.org/PDF/HOSPENV.pdf
Also, the EMT-B class is essentially a "check off" of skills with very little education since 110 hours of training is not very much time.

All of the paramedic programs in my area teach ETCO2 and 12-lead. If their program didn't teach them these things, then they would need to be taught it after their formal classroom learning before they can do it in the field. I'll try to explain what I was trying to say again. According to MY practice act, If a nurse didn't learn a skill in school, then they would need to have adequate training and show proficiency on it before they practice it. I wasn't saying that if they didnt' learn it in school, then its out of scope. Only that they require further education and continueing education. Besides, EMS and nursing function under different rules. I was only stating what MY nursing practice act states to define the scope of practice of an RN. I wasn't trying to get into an argument with you. EMS scope of practice clearly states exactly what skills and medications are in their scope, MY nursing scope gives more guidelines since it would be way too hard to list every skill since nurses work in so many areas. Take an RN who inserts PICC lines for example. They are never taught to do this in school, so as a new grad, you could say its out of scope. But, if they receive proper training and show proficiency, then by my nurse practice act, it is in their scope. And in my area, RNs do place PICC lines.

And you're right, EMTs are pretty much just taught how to do a skill and checked off. They are not taught much of the "why" behind it. That's why they are a certified technician, and not a licensed professional. But I wouldn't say they don't get much education. 110 hours isn't much, but they do manage to cram a lot of information into it. I personally think they should increase the classroom hour requirement. They definitely need to take more time learning what they are taught.

GreyGull, I'm sorry if you took my last reply or this one as an argument. I'm only trying to have a professional conversation.

GreyGull · Aug 17, 2010

GreyGull, I'm sorry if you took my last reply or this one as an argument. I'm only trying to have a professional conversation.

It is great that your area actually teaches 12-lead since according to the AHA less than 50% of the EMS agencies utilize them. Do they teach interpretation also or just placement? How indepth is their ETCO2 class? Do they actually teach the interpretation of the waveforms or just how to get one for tube placement? You can send me a private message if you wish so we don't sidetrack this thread. Many Paramedic programs seem to be too short to offer much more than the standard curriculum.

But again, every state a different set of statutes and guidelines for each profession. EMS just happens to be the more fragmented profession with too many inconsistencies in training and education. At least with nursing there is some basic consistency to build from.

I didn't mean to offend you as an EMT but it is a very limited cert and whether nurses realize it or not, they do many of the same procedures that are taught in basic first aid and EMT classes but they are just not thought of as an "emergency" even when in the ED. Log rolling, c-spine, c-collars, direct pressure, splinting, bandaging, airway clearance, aspiration precautions (definitely more indepth than EMT), recognizing diabetic emergencies, administering O2, using a glucometer and CPR are all part of nursing but with different applications. Nurses also have the lead on vitals and sepsis which is often missed by those in EMS.

Not trying to argue but rather to give you a different perspective to how an RN could adapt to EMS. Just like in other discussions, I doubt if a medical director would take responsibility for any provider regardless of title be it EMT or RN unless he/she knew what they are capable of. If you look up a couple of the states that allow RNs to work under their title of RN, the statutes make allowances for IVs, fluids and certain medications.

Also, did you read the ASTNA and ENA position on RNs being mandated to get dual credentials and be expected to work under something as limited as the EMT scope of practice especially with the RNs knowledge about assessment and diseases which are not even thought of at that level of EMS?

Again, I am not trying to be argumentative or disrespectful to you but merely pointing out the conflicts of working with a lessor cert when holding a valid professional license.