Nurses vs. Paramedics

TraumaSurfer · Jan 16, 2011

You, as a non-nurse, do not need to educate me, a nurse with 25 years of experience, about my profession. Your presumptuousness is offensive. You need to know your audience before you speak.
BTW, I am more than familiar with where to find my BON website.

Almost every post I did was concerning EMS education. The only time I mentioned nursing education was in a supportive manner for RNs' role in EMS and to show examples of the differences between the education of the RN and the Paramedic. How on earth did you confuse a certificate for Paramedic with the education for a nurse? You took my advice to search you own licensure website as being directed at you personally? Why? Did you not see my comments to the OP?

I don't know what ever misconceptions you may have presumed from my posts but you need to reread them and see that my information was purely directed at EMS education and in no way was directed at nurses (except for good examples of education) nor did I make any statement at you personally attacking your abilities as an RN.

hiddencatRN, BSN, RN · Jan 16, 2011

The other poster was saying after her husband obtained a cert as a Paramedic he continued learning through continuing education or CEUs.

No, I said nothing about the education of any kind he has pursued AFTER his paramedic cert, CEU or otherwise- you implied that he was against education and was one of those making excuses about not furthering his education, and I asked you to point out where I said anything about his views on education. When one paraphrase another's posts, it's really bad form to change their argument or insert arguments that they have not made.

caliotter3 · Jan 16, 2011

Again with the ignorant and uninformed comments. Utah Valley University offers a 4 year paramedic degree, with a one year branch program offered to become an RN. University of Utah has also begun a 4 year degree program in EMS and prehospital care. No one is discrediting nurses, no one is seeking their jobs this is about the ANA stop throwing a temper tantrum and work with paramedics in requiring more for prehospital care. It seems like nurses are the one who want to ride the hero train and not allow paramedics more freedom because then nurses like yourself won't get the "saves"

There are no appropriate EMT/paramedic websites to post this? Your negative attitude toward nurses on a nursing website causes one to wonder what the real problem is.

ImThatGuy, BSN, RN · Jan 16, 2011

Would the primary arguers on this thread like to summarize and bullet their issues with EMS and/or nursing so the readers, including myself, could fully understand why you're all so stirred up?

TraumaSurfer · Jan 16, 2011

per your request.

repeat of post #43

however, it wouldn't be controversial if some would know a little bit about each profession their are trying to discuss.
for ems (and nurses also):
look at the state website. it will list the different levels and what the minimum education requirements are for each level. just because one college in your state offers a bachelors degree in ems does not mean that is the entry level requirement.
there may be wording in the licensure definition that clearly states "license for prehospital". this can be interpreted into legal terms and why in many states hospitals have the title of ed tech with a very defined job description rather than paramedic. however, there are also a couple of states that have recently amended their statutes to allow paramedics function under their own title in the ed with an expanded scope.
this wording also extends to the definition of an emergency vehicle as far an rns are concerned. a paramedic on every ambulance licensed for emergencies was and still is the wording in many states. however, there are states that allow rns to function in ems under their own license under a medical director such as in very rural areas. there are also a couple of states with phrns. sct, cct and flight fall into a different category and the statutes may have been written to be more specific to scene response.
also, just because your state scope of practice says you can do certain things does not mean you can in the field. the medical director will determine what your protocols will be in the field.
you should watch the websites of state and national associations to see exactly what is happening in your profession.
ems providers must also take responsibility for their own profession and stop blaminng the nursing profession for the shortcomings of their own.
if you don't know the minimum requirements for entry or what the state statutes for your own profession state about specific working situations, it is very difficult to present a valid argument.

and a copy of the response that pretty much sums up the intent of the op;

originally posted by adwilcox28

again with the ignorant and uninformed comments. utah valley university offers a 4 year paramedic degree, with a one year branch program offered to become an

rn

. university of utah has also begun a 4 year degree program in ems and prehospital care. no one is discrediting nurses, no one is seeking their jobs. this is about the ana stop throwing a temper tantrum and work with paramedics in requiring more for prehospital care. it seems like nurses are the one who want to ride the hero train and not allow paramedics more freedom because then nurses like yourself won't get the "saves"

it is way too easy for some in ems to say it is the nurses fault for them not getting a job in the ed or advancing the profession. but, when you don't know what the minimum requirements are for your state and use one bachelors degree program as an example, which would be nice but it is definitely not the entry for the paramedic, does not lead to a valid argument.

and of course this conversation is all too familiar on the ems forums when they want a nurse bash thread. although lately there have been more of us trying to stop this and getting some to actually look at their education and "list of skills" to see where their own backyard needs to be cleaned up before throwing blame toward the nurses or trying to compare that profession as inferior just because not every

rn

can do the one "skill" of intubation.

TraumaSurfer · Jan 17, 2011

altra canesdukegirl flyingscot

are there any specific questions you want cleared up?

ImThatGuy, BSN, RN · Jan 17, 2011

Here, to become a paramedic, you'd have to complete an approved paramedic educational program and pass both the National Registry "psychomotor skills" and "cognitive" evaluations.

There are no bachelor's degree programs in Arkansas for paramedics, but I've read of the curriculum in states that do have them. An associate's degree is not required either nor any other college diploma but rather passage of an approved, thus accredited paramedic program, all of which are offered by community colleges or universities. You can also take the assorted liberal arts components such as English, math, science, social studies, and receive an associate's degree. I elected not to fill out an application for an A.A.S. paramedic degree since I already held a B.S. degree when I completed the paramedic program.

Even nurses have not yet fully clarified their educational requirements. You can become an RN after completing a diploma program, an associate's degree program, and a bachelor's degree program. You can complete a nursing program online. You can also pick your RN credentials up along the way in a direct-entry MSN program. However, all programs will require the student to pass the very same NCLEX examination regardless of the educational path. Research the very large bone of contention among those in favor of requiring advanced practice nurses to hold a doctorate degree rather than a master's degree, yet that's an entirely different argument - I know.

The NCLEX would be very much akin to the National Registry examination. I think it'd be great if all states adopted the the NR exam rather than using a state examination. Arkansas has long done away with a state examination at all EMT levels in favor of the National Registry. I will suggest that National Registry goes a step further in testing the abilities of its professional area by requiring the skills examination. Nurses don't get that. They get checked off in school just like EMS students do before going off to clinicals, but they're never tested again on the material.

True, the scope of practice for paramedics varies among states just as it does for registered nurses. As an example, we'll examine a practical, procedural skill. Paramedics here used to could insert a central line. They can't now. I know two medics that have done it. Registered nurses can't do it here either. At one time they probably could too. I'm sure in one of the 50 states somewhere a RN can still do it. A paramedic may can as well somewhere I'm willing to bed.

Things aren't as cut and dried for nurses as they may appear to be. I can't count the times I've taken a patient to the ER on supplemental oxygen only to have the nurse detach the tubing and not re-attach it to the hospital's oxygen supply. Apparently, they're not allowed to put the patient on oxygen. They usually turn off my IV too. Obviously, this would be different in a code-type situation. It may very well be because the patient didn't need those interventions, but the protocols approved by the physician medical director obviously found some use for them or they wouldn't have been in the protocols. The paramedic uses his or her professional judgement and selects the appropriate "diagnosis" and implements a series of interventions as delineated in the corresponding protocol. Nurses have standing orders for some interventions and not so for others. There are independent nursing interventions, many of which don't require a lot of training to implement, but the bulk of nursing requires a physician or midlevel order for interventions such as oxygen, cardiac monitoring, medication administration, etc.

EMS was designed to respond to motor vehicle accidents. Later, the overwhelming number of prehospital cardiac arrests led to paramedics be granted the privilege of using an array of drugs, cardiac monitors, etc. In time other elements were added. EMS is meant to be a pre-hospital profession. I fully support paramedics being better at their job and giving them the tools, knowledge, and experiences to make them better at their jobs. However, I firmly feel that paramedics are pre-hospital providers and shouldn't become intertwined with critical care, interfacility transports. Sure, that's a lot of bread and butter for private EMS, but paramedics aren't widely trained for it. I know I hated taking IV pumps and hanging drips with meds I knew nothing about on the ambulance for three hour rides. CCEMT-P is a forifice. It's a weekend course. In this instance, it would be great to put registered nurses on the ambulance because their educational program entails more of that element. However, being a current RN student I don't know when that part of the curriculum will come in. Thus far, the program has been fairly shallow and light on details so a new graduate nurse probably would not be well suited for critical care transport and certainly not emergency (911) service. Personally, I feel like a brand new paramedic would probably be better off than a brand new paramedic in either emergency transport or critical care transport, but after pertinent experience in those areas the nurse would probably be better suited for the critical care and the paramedic still for emergency service. Nurses could learn the pre-hospital elements easy enough, and paramedics could learn the critical care elements easy enough. However, both programs leave those elements out because it's not part of their professional role.

Why not let paramedics be paramedics and nurses be nurses?

Altra, BSN, RN · Jan 17, 2011

altra canesdukegirl flyingscot
are there any specific questions you want cleared up?

i don't have any specific questions for you, traumasurfer, though thanks for asking.

i had a very hard time figuring out what your purpose or intent was through much of this thread. however, i now believe i can conclude that you feel that ems gets disrespected because of inconsistency in educational preparation and the use of confusingly different titles in different states. (hmm ... where have i heard this before ... it sounds familiar ... oohh, i know - in nursing! ) you may feel particularly strongly about this if your state, texas, has a particularly low minimum requirement for paramedic education (640 hours). and no, i am not bashing the state of texas.

if i am drawing the correct conclusion, and you're advocating for uniformity in the educational preparation of emts and paramedics, i'm with ya 100%. i personally feel that nursing education should be standardized at the bsn level as well.

so, can we be drinking buds now? :smokin:

ObtundedRN, BSN, RN · Jan 17, 2011

CCEMT-P is a forifice. It's a weekend course. In this instance, it would be great to put registered nurses on the ambulance because their educational program entails more of that element. However, being a current RN student I don't know when that part of the curriculum will come in. Thus far, the program has been fairly shallow and light on details so a new graduate nurse probably would not be well suited for critical care transport and certainly not emergency (911) service.

I hate to disappoint, but it won't be in the curriculum. I too waited for the "critical care" level of education to come into the curriculum in nursing school, and very little of it actually is taught. Critical care education is taught to the RN when they start working in the ICU. And various hospitals use different ways to teach this information. It may be classes, online work, or just orientation with a preceptor and picking it up with experience. My hospital makes all new ICU nurses do an online program developed by the AACN, worth 70 hours of CEUs. It is very detailed and give lots more information then ever taught in nursing school. In addition, my hospital makes all new grad nurses going into the ICU do that online program as well as a very rigorous orientation program that has lots of classroom lectures and 8 months of orientation with a preceptor.

Nursing school teaches you how to be a med/surg nurse, and gives small samples of a few specialty areas. Period. That's why the NCLEX is mostly med/surg questions, with a few questions regarding ped's, OB, and psych.

ImThatGuy, BSN, RN · Jan 17, 2011

I hate to disappoint, but it won't be in the curriculum. I too waited for the "critical care" level of education to come into the curriculum in nursing school, and very little of it actually is taught. Critical care education is taught to the RN when they start working in the ICU. And various hospitals use different ways to teach this information. It may be classes, online work, or just orientation with a preceptor and picking it up with experience. My hospital makes all new ICU nurses do an online program developed by the AACN, worth 70 hours of CEUs. It is very detailed and give lots more information then ever taught in nursing school. In addition, my hospital makes all new grad nurses going into the ICU do that online program as well as a very rigorous orientation program that has lots of classroom lectures and 8 months of orientation with a preceptor.
Nursing school teaches you how to be a med/surg nurse, and gives small samples of a few specialty areas. Period. That's why the NCLEX is mostly med/surg questions, with a few questions regarding ped's, OB, and psych.

You're not disappointing me. I actually never expected to learn a lot of interesting material in nursing school. I can read about whatever I want and learn from it, but one of the reasons I got into the program was to learn more about assessment, pharmacology and pathophysiology in a proctored atmosphere. I am, however, hoping that I pick up some interesting nuggets along the way in the core nursing courses. I learned a few things in foundations, but none of it was really anything I was excited to know about.

To get back on track, the last semester of the program we'll have a course called "complex care." Supposedly, the complex care course will focus largely on emergency and critical care nursing with our rotations devoted to those arenas. Our only med/surg course is called acute care, and honestly there seems to be no focus in it. Of our four instructors, one was largely CCU and one was largely ICU in career choice, and thus far they are obviously more excited when teaching about cardiology, pulmonology, and related topics over say tube feedings or bed sores. I'm hoping their focus stays with card and pulm and patho because that's what interests me most as well probably because I was indoctrinated into healthcare as a paramedic, and those are the areas (card and pulm) that paramedics primarily treat aside from trauma which I don't envision being covered at all in nursing school. It wasn't last semester and doesn't look like it will be this semester. It won't be next semster either because that's OB/Peds and Public Health.

Katie5 · Jan 17, 2011

I do agree they don't go to school for as long as an RN does, but they come out with a wealth of knowledge, lets not discount that.

As with all other careers, they read the book and did what they had to, to pass- that does not give them " a wealth of knowledge". The knowledge comes from the job itself, hands-on!

TraumaSurfer · Jan 17, 2011

the tools, knowledge, and experiences to make them better at their jobs. However, I firmly feel that paramedics are pre-hospital providers and shouldn't become intertwined with critical care, interfacility transports. Sure, that's a lot of bread and butter for private EMS, but paramedics aren't widely trained for it. I know I hated taking IV pumps and hanging drips with meds I knew nothing about on the ambulance for three hour rides. CCEMT-P is a forifice. It's a weekend course. In this instance, it would be great to put registered nurses on the ambulance because their educational program entails more of that element. However, being a current RN student I don't know when that part of the curriculum will come in. Thus far, the program has been fairly shallow and light on details so a new graduate nurse probably would not be well suited for critical care transport and certainly not emergency (911) service. Personally, I feel like a brand new paramedic would probably be better off than a brand new paramedic in either emergency transport or critical care transport, but after pertinent experience in those areas the nurse would probably be better suited for the critical care and the paramedic still for emergency service. Nurses could learn the pre-hospital elements easy enough, and paramedics could learn the critical care elements easy enough. However, both programs leave those elements out because it's not part of their professional role.
Why not let paramedics be paramedics and nurses be nurses?

The one thing that usually makes the CCT RN different from the Paramedic is critical care experience. The "easily" part is not that easy if you have never been inside an ICU. In their training Paramedics may only get to see the inside of an ICU for one day and probably would not have much hands on. I had heard of one program in Georgia that was attempting to incorporate ICU experience into it Bachelors EMS program but I have heard no more about it since the director made his proposal. Nursing will at least train the RN in an ICU to them to get the experience. It would be rare for a new grad RN to be given an assignment in ICU without some type of preceptor mentoring. However, it would not be uncommon for an EMS company to assume a Paramedic is ready for everything, including CCT after a weekend course, for critical care transfers. Flight and CCTs teams that do use RNs require extensive "experience" as it should be.

But, everyday throughout this country RNs are placed on ambulances to accompany Paramedics for ED and ICU transports without ever having the ambulance experience, transport training or even the desire to leave the hospital setting for even a short time. If the patient requires a higher level of care and there is not a more appropriate transport team available, they must go. They do however have the education and experience to take care of the patient and hopefully the EMT or Paramedic can assist them with the rest. In California, almost all CCTs and Flight are staffed by RNs and not Paramedics. EMTs are used to assist with equipment carrying and driving. There is no way their scope of practice would allow them to do much of anything that an ICU patient might require nor what many ED to ED transfers require. In many places Paramedics still do not use IV pumps on their truck so for an ALS or CCT transfer that does use Paramedics, the RN at the hospital will be responsible for setting up all equipment and giving as many meds as possible to get the patient from point A to point B. Some states have also set up special transport regulations in their statutes that set specific requirements for pediatric and neonatal transport. This can also include an experienced NICU or ED RN to accompany the child or infant if a dedicated pedi or neonatal team is not used.

I also fail to see the logic that is often used by EMS with the "Brand new Paramedic would be better than a brand new nurse for an emergency or critical care". This is the most backwards thinking possible. As I stated before, I would hope a brand new RN get some additional education and training in the ICU. Only EMS with its tech style training believes in putting brand new Paramedics into situations they are often not prepared for even in EMS. A two shift orientation is often all some get before being on their own and may have never intubated anything but a manikin. But EMS continues to believe their comparison. Other countries laugh at the U.S. not only for its lacking EMS education but also for its reasoning to justify these low requirements.

Take the Dutch system for an example:

http://www.jems.com/article/operations-protcols/ems-netherlands-dutch-treat

the main medical care provider on an ambulance is a nurse. In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anaesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body. Main objectives of the program include legal issues and working in the prehospital environment.
Previous clinical experience and the required educational program guarantee a high level of medical knowledge and wide range of skills in the nurses.

I believe Spain is similar and so is the ECP for the U.K. The Paramedics in other countries have 3 - 4 year diplomas or degrees. Why must those in U.S EMS make such ridiculously absurd comparisons of brand new grads for either professions when it comes to emergencies or critical care. The U.S. Paramedic education pales totally when compared to other countries. Have those in the U.S. just gotten so accustomed to such low standards that we expect inexperienced minimally educated and trained to be a norm for a valid comparison?

As far as titles, isn't the term "Registered Nurse" used in all 50 states? In the U.S., some states like Hawaii and Kansas, use MICT (Mobile Intensive Care Technician) instead of Paramedic. Also for "ALS", the EMT-Intermediate might be used which also has had a could of different steps. There are also other psuedo ALS terms such as EMT-Cardiac Care, EMT-IV and EMT-Intubator. So the public get something called an ALS vehicle but without a Paramedic. At least Washington state cleaned up their 7 or 8 different levels to become consistent with the NREMT. If and when the new NREMT levels go through the the EMT-I will become AEMT or Advanced EMT. Also, with the accreditation situation for Paramedic schools with only half be accredited in some states, there have been a couple of states that are challenging the requirement and stating they will go back to having their own state exams. States that are using their own exams probably will not change to the NREMT.

I also do know of nursing diploma schools since a friend graduated from one in Pennsylvania. I was told they are articulated with a college so all of the basic education requirements are still met. She also had not problem just finishing a BSN after the diploma. The program still has the same college classes such as A&P as the ADN and BSN programs. There should also not be any problem with getting a degree higher than what is required such as a BSN. Other professions also have that option. Some just prefer to get their Bachelors, Masters or doctorate first before entering the job market. EMS, however, is based on the cert and "maybe" going back for the Associates someday. Right now not many Paramedic programs require college level A&P and even the college programs will use a watered down A&P for the Paramedic which is a 2 semester credit course with a very thin textbook which is basically just an overview. When Paramedics want to become RNs they find they must take the regular college level A&P courses along with all the other prerequisites.

The paramedic uses his or her professional judgement and selects the appropriate "diagnosis" and implements a series of interventions as delineated in the corresponding protocol. Nurses have standing orders for some interventions and not so for others. There are independent nursing interventions, many of which don't require a lot of training to implement, but the bulk of nursing requires a physician or midlevel order for interventions such as oxygen, cardiac monitoring, medication administration, etc.

The Paramedic has protocols written by a medical director and online medical control for all else. In some places, the Paramedic must still call med control for things that are in their protocols to initiate them. Protocols are written in very broad terms with fluids and meds that can be beneficial and do the least harm. Some meds such as lasix and solumedrol have been removed from several EMS agencies since there was a potential for overuse and most diagnostic tests may be required. When a patient arrives at a hospital, the standing orders for a hospital situation can be initiated quickly with their fluids. It is also not uncommon for a hospital to only want to use their medications and fluids. Also, sedation meds and protocols are limiiting. Med control often must be called and physicians are sometimes reluctant to extend any orders.

I also have never seen an RN in the ED wait for a doctor's order to initiate oxygen or a cardiac monitor. However, don't confuse waiting for an order with an order being required. Almost everything done in a hospital right up to a glass of water in some situations will need an order for reimbursement and quality control. If you have standing orders in a protocol, you may still need to officially place a specific order to state which of your many standing orders you did for documentation and so all the other staff members in various units are on the same page. EMS does not have that issue since they have only one set of protocols for one patient. Also, if you read through EMS protocols or lay them side by side, you will find almost all of them are essentially the same except for a couple of different interventions. This simplifies things greatly especially when there are not lab values or other testing to be concerning with. New grad Paramedics will usually have no problem changing EMS companies and memorizing new material since the protocols are basically the same with only a few exceptions.

Here is an example of what a Paramedic can do in California which also varies by each county.

http://www.emsa.ca.gov/paramedic/files/scopechart.pdf

Their optional scope of practice is equally interesting.

http://www.emsa.ca.gov/paramedic/files/LOSOP-Chart101210.pdf

Here is the Paramedic IFT guideline. Note the words monitoring and adjusting when reading these guidelines.

http://www.emsa.ca.gov/pubs/pdf/emsa152.pdf

Here's a checklist of Ohio's EMS scope of practice:

http://www.publicsafety.ohio.gov/links/ems_scope_practice0608.pdf

What is listed is what can be done and that is it. There are a few exceptions but very few without a title change or petitioning the state. In Texas, the scope of practice is determined by the medical director but that has had its share of problems when too much is extended with too little training and education.

I already posted Pennsylvania's protocols where the PHRN can do more medications or RSI which the Paramedic can not.

Imagine if every skill and medication for an RN was listed such as what is done here for EMS. I challenge the RNs here to list every skill done and medication they give right down to a finger stick and aspirin just as the Paramedics have. Just like the Paramedics have listed you can include every piece of O2 equipment, ways to take a temperature, drains, types of IV lines and vascular access devices. There are of course some meds and skills RN can and cannot do by their work unit but usually these are the exceptions and not the general expectations of their job. I believe only certain units or floors can do some drips and not others or some nurses can give chemo or conscious sedation meds in one area but not another. But, it still can be done by transferring and training in that area as an RN. Imagine if hospitals had to go through what EMS does everytime a new med or piece of equipment was introduced. Usually for EMS approval must be made at the state level and then with each medical director deciding whether his or her EMS agency is ready for it. That might take years for even one med or the introducation of a new piece of equipment such as CPAP.

True, the scope of practice for paramedics varies among states just as it does for registered nurses. As an example, we'll examine a practical, procedural skill. Paramedics here used to could insert a central line. They can't now. I know two medics that have done it. Registered nurses can't do it here either.

The reason central lines are no longer done in the field is because of the IO and the risk of infection from a central line placed in a less than ideal situation. This is also another difference between EMS and other professions. When something is not done or is removed from the scope of practice, some in EMS view it as a bad thing without understanding the reasons behind it. Lasix is now viewed like this as some in EMS are complaining it is being removed from their protocols. Medicine and the way things are done change as more EBM is introduced. You have to look at the reasons before just saying "I can do this and they can't". Central lines can still be done by RNs on Specialty and Flight teams. They will often be done in the hospital by these teams if necessary befor e being transported. Trained RNs can also insert PICC lines in the hospital. RNs can also do more things with a central line than a Paramedic which all of those can also be added to the list they can make of their skills.

This isn't about us vs them but a reality check of the limitations of the education, training and specialization for each profession. Physical Therapists can have a doctorate degree but do not hold themselves out to be "like a doctor" or like an NP or like a nurse or whatever else even though some skills and assessments may overlap. They hold higher education in a very specialized field. They also know if they want to be an RN later, they will have to go back to college for more education and training. RNs get a very broad knowledge base for a very broad profession that offers them the opportunity to specialize in whatever area of medicine they want to. Paramedics get specialized technical training for specific emergency situations in a prehospital environment where the goal is to quickly get the patient to the hospital.