RN's challenging the Paramedic and/or EMT-Intermediate Exam in MA

happystudent, RN · Jul 1, 2004

Kool!

Thanks for the info!

Im thinkin' bout being a RN/Medic myself.

:)

GracefulRN · Jul 1, 2004

I have never heard of an RN/medic. What would you do as an RN/medic? It seems to me that your either one or the other? What advantages does it have? I mean what do medics know that nurses don't?

Again, I apologize for my ignorance, but I would really like to know.

Trauma Columnist · Jul 1, 2004

In Illinois - its called a pre-hospital RN and I'm one! Love the pre-hospital environment. I volunteer on my rural EMS/fire dept and have been doing it for five years. I get a lot of satisfaction knowing I've really helped people. Sometimes in the hospital - you don't always get feedback. For me, I had to challenge the written exam (paramedic) and then do 12 hours ride time. However, I'm an experienced level one trauma center RN otherwise the med director was going to make me do more ride time. Good luck - the sirens and lights are too cool!

PaulMedik · Jul 1, 2004

I have never heard of an RN/medic. What would you do as an RN/medic? It seems to me that your either one or the other? What advantages does it have? I mean what do medics know that nurses don't?
Again, I apologize for my ignorance, but I would really like to know.

GracefulRN:

I am a Paramedic so I can say this without concern for backlash; Paramedics do not yet have the level of professional practice that RNs have. In some areas of the country EMS systems are decades ahead of other areas in terms of procedures and professional requirements, and until the profession becomes a nationwide licensed profession, it will remain a technical 'blue collar' occupation.

As for what Paramedics can do that RNs can't; Paramedics are expected to perform all of the skills covered in ACLS, BTLS, PALS and perform in depth rapid assessment of any and all medical emergencies and respond accordingly. Paramedics are expected to perform these skills in every inclement weather condition day and night and normally are working 24 hour shifts. As an RN you can think of a few clients that didn't smell too good, but you don't know just how bad those people can smell until you smell them in their own home. You also can't imagine just how much you can lift until you have to lift someone up and carry them out of a basement or down a dozen flights of stairs while trying to resuscitate them.

The differences between an RN and Paramedic are few on any given day, but over a years time, an RN and a Paramedic will travel VERY different paths and experience VERY different things. I will have RN after my name soon but I'll always be a Paramedic first and an RN second.

Trauma Columnist · Jul 1, 2004

Paul - thanks for your reply! Working both pre-hospital and ER - I know many medics...love a few, like a lot and as you've said there are differences between medic and RN. However, the roles aren't at odds with each other - just different disciplines and both just as needed in an EMS system. Thanks again for your viewpoint...

edogs334 · Jul 1, 2004

Don't worry about being ignorant about something. Everyone, including me, is ignorant about something in this world (I'm far from being one of those "all-knowing" types). Even though I am only an EMT-Basic right now, I've been involved in EMS for almost three years now and have worked with Paramedics on a fairly regular basis to know a good deal about what they can/cannot do. I love educating people about what EMT's and Paramedics do, because it seems like so many people in the public (and in other health care professions) don't know what we actually do and what the extent of our training is.

Since I haven't even started nursing school yet (although I want to starting in Fall '05), I'll admit my knowledge of nursing is only cursory. Since I've only heard from various sources (including RN's themselves) about what nurses can/cannot do, maybe some of you on this forum can enlighten me about what you are allowed to do in your area(s) of practice.

Anyways, just in case anyone doesn't know this already, there are basically three levels of prehospital care providers who work in ambulances and medical helicopters: EMT-Basics, EMT-Intermediates, and EMT-Paramedics. Basics and Intermediates usually don't work in the choppers- you usually have to be at least a medic (or RD or MD) to work on those things. EMT-Basics go through a 120-150 hour course which teaches them basic assesment techniques (i.e., techniques pertaining to Airway, Breathing, Circulation), bandaging, splinting, oxygen administration, CPR, automated external defibrillation, spinal and fracture immobilization, and administration of certain drugs (Glucose, Activated Charcoal, Aspirin, Patient prescribed Nitroglycerin, Epi-Pens, Albuterol (in some states)). EMT's at all levels also have to pass a state or national certification exam once they pass the course.

EMT-Intermediates can do all of the above plus a number of other skills that are considered to be in the "Advanced Life Support" realm of care. In Massachusetts (the state I live in) they are only allowed to do all of the above plus start IV's, give fluid (i.e., NS) boluses, intubate, and give D5 via IV solution.

EMT-Paramedics are considered the highest level of providers in prehospital (ambulance) care. They go through about 800-1000 hours of didactic, clinical, and field education. They can do ALL of the above skills plus give various drugs (including sedatives such as versed and ativan) via IV solution, IM, IV push, and IV suspension, Intraosseous (into the bone), Down an ET tube and other routes under the sun that I can't think of right now. They also intubate, manually defibrillate, do transcutaneous pacing, cardioversion, surgical airways (although not in all states), and needle-chest decompressions (for pneumothoraxes). They can also interpret cardiac rhythms and can interpret 12-lead tracings (sp?). If there's anything I forgot about, anyone can feel free to add in.

Correct me if I'm wrong, but from what I've been told (by both RN's and non-RN's), RN's cannot do a lot of things without a direct order from a physician. In contrast, Paramedics have a lot of autonomy in the patient care they practice because they do not need direct medical control orders for everything they do. Instead, they have a whole set of treatment protocols with "standing orders" already written in by qualified docs. In other words, a bunch of docs have already dictated what kinds of treatments a paramedic can and cannot perform in certain medical and trauma situations. Don't get me wrong, though. Good paramedics, just like good RN's, actively use their noodle to determine what the best course of treatment is for every patient. They aren't just "cookbook providers" who follow protocols blindly. Paramedics also have to call a physician at the ER in order to perform certain procedures and give certain medications. Also, I've been told that RN's cannot do a number of procedures (such as intubation, surgical airways, and needle-chest decompressions) either at all or not without a doc's supervision.

So why would I want to become an RN AND a paramedic? Well, I think it's because EMS is already in my veins, I love working outside, I love the autonomy, and the occasional excitement (80-90% of our calls aren't so exciting, but that's all good). Plus, becoming a paramedic is something I've always wanted to do. So why not just become a paramedic and skip nursing? Well, there are a few reasons. For one thing, RN's have MUCH better pay (but that's all relative). When I first became an EMT, I started out at $9.50/hr. I know people who do EMS full time for a living and have to pull 50-80 hrs a week just to make ends meet (esp. if they have families). On the other hand, I've seen advertisements for RN salaries starting at $30-$34/hr. Now that still might be considered "underpaid," but it's A LOT better than $9.50/hr. Moreover, I've been told (and have read) that the career/specialty mobility in nursing is phenomenal. I mean, if I complete my BSN and get my RN, there are lots of specialty areas that I can choose from, and I could go on to get an advanced practice degree if I wanted to. Plus I could be a flight or Critical Care Transport RN with the right amount of experience and the right credentials. Being a paramedic, I could basically chose from one of two routes- staying on an ambulance and/or going onto a helicopter or going into management and having almost no patient contact at all. I'm not just going into nursing for the money, though. I want to increase my knowledge of medicine so that I can have more theoretical and practical tools to help my patients. As long as I don't get injured (fingers crossed- I should be excercising more), I can still be an EMT (and hopefully a medic in the future) on a part-time basis. So I can be both. I would probably just have to work full time in a hospital and part-time on an ambulance.

edogs334 · Jul 1, 2004

Plus, challenging the EMT-P as an RN (after I've had enough ER or Critical Care experience, of course) will save me about $6000-$7000 that I would have to pay for a medic course IN ADDITION to paying off the crapload of student loans that I will be paying off after BSN school. No offense to people who took the medic course and went to RN school- I have a lot of respect for those people.

PaulMedik · Jul 1, 2004

........However, the roles aren't at odds with each other - just different disciplines ......

traumaRUs:

Different disciplines. You can say that again!

My Paramedic instructor, way back when, was a Paramedic/RN with an MSN, and he maintained a 100% pass rate for his classes on the NREMT-P exam. His style of teaching and his course work requirements, were exactly like those of my nursing instructors. I think it would be ideal to have his style of Paramedic training required nationwide, along with requiring completion of an AS degree in EMS. The holdback is funding for such a program as well as EMS reimbursement levels by insurance companies. Hopefully the day will come when Paramedics can more easily triage a 911 call and divert would be ER visitors to more appropriate care centers or to their primary physicians. In the long run, such triaging will result in lower health care costs and improved efficiency all around.

Professionalism is what it all boils down to. RNs have it and Paramedics are working towards it. We'll get there but it's going to take time. :)

GracefulRN · Jul 1, 2004

Sounds like you guys are adrenalin junkies after my own heart. WoW, I had no idea. Very interesting and informative posts. Thank you traumaRUS,PaulMedik, and edogs334.

GracefulRN · Jul 1, 2004

Sounds like you guys are adrenalin junkies after my own heart. WoW, I had no idea. Very interesting and informative posts. Thank you traumaRUS,PaulMedik, and edogs334.

redsquareblack · Jul 30, 2004

I have never heard of an RN/medic. What would you do as an RN/medic? It seems to me that your either one or the other? What advantages does it have? I mean what do medics know that nurses don't?
Again, I apologize for my ignorance, but I would really like to know.

As far as knowledge base is concerned, there is no question that an RN's knowledge base is far wider than that of most paramedics. Most paramedic didactic hours are concentrated mostly on emergency pathophysiology and pharmacology, and some factors of disease processes (common meds, common complications, etc.) that are more chronic are picked up through experience.

Scope of practice, on the other hand, can sometimes be very different. Paramedics practice under the medical license of an MD, and so I think of paramedics as an extension, as it were, of an MD; we play the role of the MD's eyes, ears, and sometimes hands, out in the field. We can intubate on standing orders, which in my experience, at least in New York, RN's typically do not. We defibrillate and pace on standing orders, and administer several medications on standing orders, as well (epi, atropine, albuterol/atrovent, D50, narcan, sodium bicarb, etc). We can take verbal orders for controlled substances. Given clear signs of pneumothoraces, we can perform needle decompression. I know that in some regions, paramedics perform RSI, cricothyroidotomies, sternal IO lines, NG tubes and foleys, and external jugular IV access, and in some more metropolitan areas, some emergency surgical techniques are being piloted as we speak.

I personally feel that paramedics and advanced EMTs provide a vital and necessary service to the community, and many, if not most, of the medics and AEMTs with whom I have worked are very competent with their skills. A complication comes in to play, however, when medics and AEMTs are introduced into the ER setting. As a Critical Care AEMT in New York, working in a rural hospital, the door to the ambulance bay marks a transition into a very different world. Whereas in the field I am able to perform many of the abovementioned skills, once I hit the door, I practice as a UAP, and my skills are limited to EKGs, phlebotomy, patient transport, and bedpan service.

Now, I understand that in many cases, it is inappropriate for a UAP to perform more invasive skills. OJT is simply not sufficient to perform something such as foley catheter insertion or IV therapy. But does it make sense to limit the scope of practice of someone who is qualified to perform many of these skills? I understand that bean counters would pray for the day that they could replace RNs with something cheaper, but wouldn't it make more sense to lobby for regulations on staffing proportions, and not on the skills of those qualified?

Sorry to turn this into a rant, but I merely wanted to express frustration over the fact that a certain group of UAPs, namely hospital-based medics and EMTs, could really come in handy in an emergency. We aren't enemies. And we of course recognize that when it comes to comprehensive patient care, an RN can't be beat. But that doesn't mean we are not capable and trained to do a little more.