Medics vs Nurses in the ER

[fire_911medic]

I know this is a topic which has probably been hashed to death, but I am curious to find out nurse's views on this. Before starting, let me say please read the whole post as I do see both sides of the picture. I am an experienced medic who works for a busy fire/ems service and frequently do critical care transports (including long distance as we are located an hour from any major trauma centers and frequently have difficulty getting helicopters to fly due to weather). I have applied for several positions within hospitals to work and the only position they have been willing to give is the equivalent to a tech/aide in the ER with enhanced privledges. Many of the medics I know have made the transition from the street to the hospital in search of better pay, and while the pay does increase, the ability to perform procedures and use all of our training is severely restricted. Most have had their wings clipped to the point of being reduced to nothing more than doing a nurse's scut work and starting IV's. There is also a major arguement between the nurses and medics as to who is better suited to a hospital. Here's my thoughts on it for all it's worth. Medics are trained to the emergency environment more so than nurses are. We are trained to complete difficult procedures above what a nurse is as well as function completely independent of a physician under most circumstances (though we have ability to contact med control as needed, we work mostly under a physician's standing orders). Also, we perform procedures in the worst of environments (it's one thing to intubate or start an iv in a well lit room, another to do it in a crunched up car, in a creek at midnight). Many medics find out they aren't cut out for the job after realizing this, I can't imagine the terror of even an experienced nurse who is used to functioning in a hospital being presented with that situation. That being said, here is my thoughts for you nurses. I will be the first to say when it comes to care for a special needs patient or one with a chronic disease, you all stand far and above what any medic knows, I don't care what they say. In my transports, if it is something that I am not familiar with, or a nurse knows a patient's history particularly well, I'm all for her/him accompanying me on the transport. I can always appreciate the second set of experienced hands. I will even ask for a nurse to accompany me many times even if one is not given for this reason. I am trained to deal with emergencies, not chronic patients. My job is to keep them alive until you all can perform whatever surgery, medical treatments, etc they need. I am NOT a long term care provider on any level, therefore, I don't know a patient's history as well as you may as you have cared for them for several days many times before I transfer them out and can provide me with valuable information. During my clinicals, I was well educated by great nurses who really took the time to teach me, but also showed me the differences in the care they give and we do. I have tremendous respect for the nursing profession, but while they do have different focuses, I believe BOTH have a place in a hospital. Hear me, I am not saying that nurses should be removed from the ER, simply trained differently, more like a medic. Is why so many flight services require your paramedic or at least the EMT-basic in addition to a nursing degree is to manage the the on scene difficulties one encounters. I believe a medic is not experienced enough in care to be placed anywhere except the ER in a hospital. However, I feel in addition to a nurse, if treated equally, a medic has a definite place there. What are your all's thoughts? You've heard mine, now let me know yours ! Thanks so much.

[jlbns]

I have worked for many years as a tech (EMT-B) in an ER that currently sees about 40,000 patients. I also volunteer as an EMT for my local township squad. I am in my third semester in an ADN program. Before I started nursing school, I erroneously believed that I was entitled to more responsibility and respect than I was given. I, too, thought that I got all of the scut work. Well, I was WRONG! There is a significant difference of the emphasis of training between EMT's and nurses. Nurses are trained to be critical thinkers and to treat the whole patient, not just the illness/injury. Perhaps it should not be Medics vs. Nurses in the ER, but rather Medics and nurses in the ER collaborating together to properly treat and serve the patient.

Let's also keep in perspective the type of pt generally treated in a typical ER: the majority are medical patients, not trauma.

jlbns

[purplemania, BSN, RN]

In my opinion it is not a training issue so much as a legal one. The nurse and the paramedic both should have complete understanding of their own scope of practice and the standards under which they are obligated to practice. In Texas, the RN is required to do the assessment and plan of care (including planning the patient education). This cannot be delegated by the nurse nor can it be assumed by another discipline. Ability is not the issue. Licensure is the issue. What does your license allow you to do and what does your malpractice insurance cover?

[JMBM]

I am an RN in an ER, and I am an EMT-Intermediate. In past lives, I have worked in both urban and rural EMS. First, I agree that nursing schools could take a page from EMS training, especially in the area of assessments in an ER context. The TNCC training partially addresses this. I also agree with the writer that EMS providers and nurses most often work together, not in opposition. That being said, I do find that many people, including some EMS providers, have a fundamental misperception of the work in an ER. The vast majority of the work does not involve emergencies. Any ER nurse can tell you that she/he spends most of the time caring for non-emergency cases involving people that just may not have any other care options. For every few minutes handling a major trauma, there are hours and hours of care for the stroke patient, the child with CF, the CHF patient, etc, etc, etc. This work is incredibly difficult and challenging, but it does not involve the emergency medical procedures learned by some levels of EMS providers. While many advanced EMS providers have accumulated the knowledge and experience to deal with these patients under these circumstances, many have not and do not care to. It is not their field. On the other hand, there are obviously times when we do have to intubate someone. However, it will not be a paramedic (or nurse) who does it. it is not a matter of "clipping wings". Physicians and well-lit rooms are available in an ER (or they should be). If you have an argument with who should be performing these procedures in a hospital setting, it might better be taken up with your state medical board, not on a nursing chat line. ... I have done medical work in the field, in crushed cars, on mountainsides, etc and I truly admire the folks who continue to do it, probably much better than I ever did. However, as critical as those skills may be, it is not what is done in the ER. While some of those advanced skills are used in some trauma cases in the ER, doctors do them ..So, I do agree that the training of nurses could be improved. I do agree that EMS providers do a critical job. Some EMS providers could work as nurses in an ER. Some nurses could step right onto an ambulance. However, EMS services really don't need most of the broad skills possessed by nurses, and most ERs don't really need people who specialize in advanced skills already provided by doctors. That all being said, I am proud to work with the EMS professionals in my community. We are part of a team that hopefully delivers the best possible medical care to patients.

[WVUturtle514]

:yeahthat: Bravo to the above post!!! I could not agree more with the majority of what you said. Medics and EMTs are undoubtedly a vital part of the medical system. However, you hit the nail on the head when you said that a large majority of ER patients ae not trauma and/or patients with injuries. I worked in a very large level 1 trauma center at a university hospital and I can guarantee that almost 90% of our patients were not trauma patients, but in fact, medical patients. On a daily basis my patients generally consisted of CHF, chest pain, respiratory failure, psych (big one), OB/GYN, sickle cell, etc....all of which require a fairly strong med-surg or ICU background. You were correct in saying that while a medic may be able to intubate in a car in the dark, that we would never have that situation arise in the ER. In addition, there are always physicians and residents around to do that job (I'm sure in some rural hospitals this may not be the case, however). I am not saying that medics do not have a place in the ER, but ER nurses definitely have a wider scope of practice in the hospital setting due to their educational background and training. If you feel that your wings are "being clipped" and you still desire to work in the hospital setting, your only choice might be to go back and get your nursing degree. Best of luck to you!!!

[Victoriakem]

I am an RN in an ER, and I am an EMT-Intermediate. In past lives, I have worked in both urban and rural EMS. First, I agree that nursing schools could take a page from EMS training, especially in the area of assessments in an ER context. The TNCC training partially addresses this. I also agree with the writer that EMS providers and nurses most often work together, not in opposition. That being said, I do find that many people, including some EMS providers, have a fundamental misperception of the work in an ER. The vast majority of the work does not involve emergencies. Any ER nurse can tell you that she/he spends most of the time caring for non-emergency cases involving people that just may not have any other care options. For every few minutes handling a major trauma, there are hours and hours of care for the stroke patient, the child with CF, the CHF patient, etc, etc, etc. This work is incredibly difficult and challenging, but it does not involve the emergency medical procedures learned by some levels of EMS providers. While many advanced EMS providers have accumulated the knowledge and experience to deal with these patients under these circumstances, many have not and do not care to. It is not their field. On the other hand, there are obviously times when we do have to intubate someone. However, it will not be a paramedic (or nurse) who does it. it is not a matter of "clipping wings". Physicians and well-lit rooms are available in an ER (or they should be). If you have an argument with who should be performing these procedures in a hospital setting, it might better be taken up with your state medical board, not on a nursing chat line. ... I have done medical work in the field, in crushed cars, on mountainsides, etc and I truly admire the folks who continue to do it, probably much better than I ever did. However, as critical as those skills may be, it is not what is done in the ER. While some of those advanced skills are used in some trauma cases in the ER, doctors do them ..So, I do agree that the training of nurses could be improved. I do agree that EMS providers do a critical job. Some EMS providers could work as nurses in an ER. Some nurses could step right onto an ambulance. However, EMS services really don't need most of the broad skills possessed by nurses, and most ERs don't really need people who specialize in advanced skills already provided by doctors. That all being said, I am proud to work with the EMS professionals in my community. We are part of a team that hopefully delivers the best possible medical care to patients.

That was well said! It comes down to licensure & who's covering who. We have some EMT's working as techs in the ED, who are finding out the other side of care, & how labour intensive it is & how you need to have critical thinking & training to care for these patients. Do EMTs & medics know that inserting a f/c can help bring down a patient's BP? What about diet & CHF? Nurses are taught these things & many more for a more encompassing view of patient care & not just getting someone stable enough to take to the hospital. I am glad for all aspects of caring for the patient, whether coming from a medic, emt, nurses or whatever, as long as we view each other as a team member & not get into a contest to see who's bigger & badder & knows more & who should be doing what.

[WVUturtle514]

Medics are trained to the emergency environment more so than nurses are.

One more thing.....I completely disagree with this statement. Medics may have more "field" experience than ER nurses do, but that does not mean that RNs are not properly trained just as much or more so in an emergency environment than a medic. In addition, I know very few ER's that will hire a brand new nurse right out of school b/c they feel that the nurse should get experience elsewhere (med-surg, ICU, etc...) before transitioning to the emergency environment. I did a complete semester of leadership in the ER during my senior year in nursing school and then I worked in the ICU for over a year before I was able to transfer to the ER. I just feel that the statement should perhaps be reworded to say, "Medics are trained in a different emergency environment than nurses are."

[vamedic4, EMT-P]

One more thing.....I completely disagree with this statement. Medics may have more "field" experience than ER nurses do, but that does not mean that RNs are not properly trained just as much or more so in an emergency environment than a medic. In addition, I know very few ER's that will hire a brand new nurse right out of school b/c they feel that the nurse should get experience elsewhere (med-surg, ICU, etc...) before transitioning to the emergency environment. I did a complete semester of leadership in the ER during my senior year in nursing school and then I worked in the ICU for over a year before I was able to transfer to the ER. I just feel that the statement should perhaps be reworded to say, "Medics are trained in a different emergency environment than nurses are."

I so love this dialogue!!!

Okay,

As a medic I completely understand where the OP is coming from, having worked as a field medic and now work in critical care peds. And I completely agree with the above statement "Medics are trained in a different emergency environment than nurses are."

What boggles my mind is this: As a paramedic, you are the eyes, ears and hands of the physician - outside of the hospital. This is why they are trained in the manner that they are. But once INSIDE the hospital - all the rules change.

The issue IS that of licensure - yes, but moreso it is the issue of "who wants to take responsibility for these medics while they're in the ER." Unfortunately, we're not independent practitioners - and that's both a good and a bad thing. As medics we HAVE to have medical director OK to perform up to our skill level inside the hospital. And (at least where I work), medical direction is...just not there. Medical direction for medics in the hospital is lacking perhaps because hospitals think that nurses can do the work, so why provide medical direction to a bunch of paramedics? The answer lies in training and experience. As medics we are SPECIFICALLY TRAINED to deal with a variety of emergent conditions, something nurses don't get unless they have some form of class outside of the realm of nursing school.

The difference between nurse care and care provided by a paramedic are subtle but VERY different. A nurse's care is patient focused. My care as a medic has to deal with the situation at hand. Having worked in the field and here in the hospital setting I can tell you : Even my worst night in the hospital is better than my worst day in the field. Why? Because I'm the one who arrives to the house at 0227 and finds your 22 month old unresponsive and apneic and bleeding from his left ear. I have to deal with screaming parents/ hysterical family members and try to get this patient to the nearest hospital ASAP while employing all of the skills at my disposal to do so. IF my assessment reveals he needs advanced airway management - he gets an ET tube. IVs? Done. Meds? You bet. If I have questions, I call the doc and inform him of my assessment findings and HE makes the decisions about how to proceed. But I'm the one who's responsibility it is to accurately inform the doc about what is happening with the patient. That's a huge responsibility.

Inside the hospital, I'm more than happy to relinquish some responsibility for "emergent" care of patients. But only if you can do it better than I can. And in most cases, that's just not the case. Then they tie my hands and tell me "that's not in your job description." OUCH.

I definitely think that we'd make a great addition to the health care "team" inside the hospital, if only someone had the balls to help us achieve that dream. As I said before, I'll take a bad night in a hospital over a bad night in the field ANY DAY. You think a code blue is stressful? Try working one after having to pull someone from an icy river, or in the 110 degree heat in Texas. Or having 3 codes in 5 calls. Ouch.

I take that back, Methodist Hospital here in Dallas does allow paramedics to practice to their full skill level, but not here as of yet. We just don't have the doctors behind us. Bummer.

Have a good night all!!

vamedic4

Licensed Paramedic

Children's Medical Center Dallas

[Zachary2011]

I also am an EMT inter and now an RN, In the ER,,,,,,,,,,,, Heres some differences......... As an EMT, there BP goes low you bolus, regardless of pt illness, IE: CHF......and you just cont. with transport...... as a nurse you have many options one is educated on...... ie: Dopamine, Levophed,and the calculation of these gtts. etc. As an EMT you place Nonrebreathers on all pts. with low SpO2, In ER, if they have COPD or known to be a C02 retainer you take off the nonrebreather, .... You give Ntg SL for chest pain, in the ER we will do same but also heparin, morphine, and ASAP EKG, for if they are having a Right Ventricular Infarct nitro is usually contraindicated, and hope the cath lab is available or perhaps give throbolytics. As an EMT you do just what the original post stated, you keep them alive for transport........... I am not saying thats a bad thing, for I have a lot of respect for my past job. and many times the pt. is asymptomatic by the time they hit the ER and many times in part to the care the EMTs provided. Also in a busy ER as a nurse you do often treat as you feel is needed , its not as if a DR. is there to watch over you or write an order for your every move. You often determine which pts. get to a room while others wait in the waiting room (the pts. you dont see as an EMT), and if this sounds simple enough just wait untill you have your first code in the ER waiting room. You learn to read lab values, not just surveys but Enzymes, ABG's, lactate levels, etc. You learn to identify the warm stages of sepsis and treatright away so when the go into the cold stage they dont crash. I greatly agree EMTs are way underpaid, and we are all in this together, for the greater good of the pt. I also know of many EMTs who believe they have been demoted by working in an ER.................... but the fact is ,just doing vitals sign , helping to clean up a pt, getting them a blanket, is the basics of nursing care, and if someone believes they are above that, they have no business in the ER. People are EMTs and ride the trucks because they love it, and if thats what you love......... do that, and I thank you for doing that.

[Zachary2011]

Its a shame how some people are speaking about the other profession on here, "Try intubating on a hill with coyotes and bears chasing you on skateboards"...................... We as nurses speak to the pts. family when one passes, yes even the 10 day old babies, in fact I would say 90% of our pedi codes are brought in by mom and dad and not the Ambulance. If you want to work in the hospital and want more respons. goto school, get you liscence, hell the way some are talking get your MD cause evidently you are all that and more already , and I am speaking about a few posts on here........ sounds to me like your above all the rest but unlucky for you noone else knows that. I was an EMT for 8 yrs. before I got my RN I have been on both sides of the fence......... and the one thing I hear from most EMTs that get there liscence....... "I had no idea"..... and I am sure nurses would say much of the same with a few shifts on the truck......

[LoriAlabamaRN]

"Try intubating on a hill with coyotes and bears chasing you on skateboards.

:lol2:

[vamedic4, EMT-P]

Now Zach..don't get all bent outta shape. When I made the reference you referred to "Try intubating on a hill with coyotes and bears chasing you on skateboards"... I meant...

It's a different KIND of stress, and it requires a different response. And the physical demands are different. And as I may or may not have stated before, it's not that anyone harbors resentment for nursing staff..duh, it simply states that we all have something to offer, and we all have things that we're particularly good at. Nurses in the ER and EVERYWHERE else in the hospital are wonderful, and I love my nurses very much. Hospitals don't run without nurses....

"If you want to work in the hospital and want more respons. goto school, get you liscence, hell the way some are talking get your MD cause evidently you are all that and more already"... - ouch...are your feelings hurt? Now that wasn't necessary. We do what we do because we enjoy it. Perhaps if you had not taken the postings so personally you would see that. We're just, again, pointing out that we have things to offer that will benefit the organization. I work in a teaching hospital, and, as I'm sure you know, the doc who responds may not be the best in the world. But we're there to support.

"sounds to me like your above all the rest but unlucky for you noone else knows that. I was an EMT for 8 yrs. before I got my RN I have been on both sides of the fence......... and the one thing I hear from most EMTs that get there liscence....... "I had no idea"..... "

Wrong again. And it's license, BTW.

No...on the contrary I have a very good idea. Having been an EMT since 1986 and a medic since 1992. Worked for more than 10 years in the field, worked in critical care peds/peds ER/peds cardiology for 12 years, I have a very good idea. Perhaps, and I may be wrong, but if you had advanced your training beyond the EMT level, you would know that.

AND WE'RE ALL THERE FOR THE SAME REASON ...So we're all on the same team. Stop throwing rocks in my pudding and just sit and have lunch with me.

Have a good night, all.

vamedic4