Nurses vs. Paramedics

Nurses General Nursing

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I've recently learned more about the "turf war" going on between nurses and paramedics in emergency departments for hospitals around the country. The battle seems to be heavily focused on having paramedics become licensed instead of just certified and be able to supplement ED staffs when needed and to practice their skills in the case of an off duty emergency. The paramedics I have worked with have ample skill and knowledge to handle difficult and challenging emergency situations, why then are so many nurses opposed to advancing patient care in this regard? Isn't that what our career choices are all about in the first place?

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!

Most of the health care professions require many hours of clinicals which are usually structured although some better than others.

EMS lacks that structure and some of you may also have had the experience of EMS students showing up with a piece of paper for you to sign and no other intructions nor is their instructor onsite. Some EMS programs have students on ALS fire trucks without transporting the patient to the hospital. Some may get one "IV call" for the whole 24 hours for ALS experience and that might be their only call but the hours are still counted. Combine this with a weak education, you get bad "street medicine" where things get made up about how they think equipment or medications work. You also get "this is how we've always done it". In general that makes for a very bad Paramedic who is giving medications and doing skills because of how someone told them it once worked for them instead of understanding how and why. If you do not have the knowledge obtained from books, you will be a very scary practitioner in any profession. One should have an understanding or knowledge of what they are doing before just plowing into giving a medication or sticking a piece of plastic down someone's throat. This also starts to separate the technicians from the professionals.

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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

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 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.

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.

If I'm understanding you correctly, your concerns are primarly centered around critical care transport. I mentioned previously that I feel paramedics shouldn't be involved in this simple because, as we agree, their training program does not encompass critical care training, i.e. drugs, vents, etc.

That said, nurses don't get a lot of training on that either. Go to nursing school if you don't believe me. Nursing school is very generalized to the point of lacking in quite a bit of detail. I do feel that if you took both a brand new (no healthcare experience) paramedic and a brand new (no healthcare experience) registered nurse that the paramedic would hands down be better suited for critical care transport and emergency transport because paramedics are trained to operate autonomously while nurses are trained to work as a part of an immediate team and paramedics can at least implement ACLS. By this I mean someone who has graduated from their respective program and has not had any other continuing education or training pertinent to emergency or critical care.

A lot, if not most, nursing programs are not going to include ACLS, PALS, etc as paramedic programs must. This isn't to say that an RN couldn't easily take and pass the 16 hour course of instruction particular to any of those courses. I had to do at least 48, again clock hours, in the ICU as a part of my paramedic program. Many nursing programs won't spend even that much time in the ICU. I'd have to spend at least six days in the ICU to get that amount of experience in my RN/BSN program, and I know they're not going to give me six days of ICU coverage.

I do agree with you TraumaSurfer that when the nurse is experienced and acquires all the pertinent training that the person should, in theory, be hands down better suited for critical care transport and aeromedical transport than the typical paramedic. I've met a lot of flight nurses, and every one of them was an RN, NREMT-P. They didn't have to be paramedics, but they realized, along with their employers, that the indoctrination experienced by paramedics was suitable to their preferred line of work. We do see RNs placed in the back of ambulances everyday around the country to assist with critical care transport, and that's strictly for efficacy. Why would you not put an ICU nurse with a critical ICU patient when one is available? It'd be foolhearty not to. Here, however, the paramedic must attend to the patient and be in the patient compartment, or everyone involved is going to get in a lot of trouble if things go south for the patient. That's all stricly legislative. Change the law. Change the department of health regulations, and we'd be good to go.

To address emergency (911) service a nurse is going to have to pick up a lot of extra training. It's not at all anything difficult, but it's nothing included in nursing school. I had a five semester hour course called "traumatology" when I was in paramedic school. I really don't think my nursing program is going to address trauma at all. If they it'll be in the final course called "complex care." There's also the fundamental scene safety and EMS operational aspects that nurses would have to be trained including hazardous materials, vehicular extrication, etc etc. Sure, they could do it, but you're going to add at least a semester to their program.

All that said, if the law in Arkansas allowed for nurses to run a paramedic licensed ambulance and the RN was appropriately trained to do so then I'm all for it. I just don't get why they'd want to. If paramedic licensure here allowed for paramedics to work in the ER, or anywhere else, as a paramedic then I"m all for it, but again I don't get why they'd want to.

TraumaSurfer, I'm just curious. What is it that you do? What are you? A paramedic? Degree in anything? Firefighter? Trauma tech? I think I caught on that you're from Texas. By your arguments it's rather apparent that the Texas education of EMTs and Paramedics is much less than others around the country. Focus on Texas right now. Arkansas is extremely slow to adopt new elements into the scopes of practice for paramedic if not completely ten years behind urban areas of the U.S., but we at least seem to have very good educational programs for paramedics at least compared to Texas. Texas doesn't utilize the National Registry cognitive or skills exam does it?

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If I'm understanding you correctly, your concerns are primarly centered around critical care transport. I mentioned previously that I feel paramedics shouldn't be involved in this simple because, as we agree, their training program does not encompass critical care training, i.e. drugs, vents, etc.

That said, nurses don't get a lot of training on that either. Go to nursing school if you don't believe me. Nursing school is very generalized to the point of lacking in quite a bit of detail. I do feel that if you took both a brand new (no healthcare experience) paramedic and a brand new (no healthcare experience) registered nurse that the paramedic would hands down be better suited for critical care transport and emergency transport because paramedics are trained to operate autonomously while nurses are trained to work as a part of an immediate team and paramedics can at least implement ACLS. By this I mean someone who has graduated from their respective program and has not had any other continuing education or training pertinent to emergency or critical care.

A lot, if not most, nursing programs are not going to include ACLS, PALS, etc as paramedic programs must. This isn't to say that an RN couldn't easily take and pass the 16 hour course of instruction particular to any of those courses. I had to do at least 48, again clock hours, in the ICU as a part of my paramedic program. Many nursing programs won't spend even that much time in the ICU. I'd have to spend at least six days in the ICU to get that amount of experience in my RN/BSN program, and I know they're not going to give me six days of ICU coverage.

I just brought up the CCT part since you mentioned it and I was replying to your post.

I may not be a nurse but I do know if a patient codes inside a hospital the RNs on a code team do not just stand around waiting for a doctor to arrive to tell them to initiate CPR and ACLS protocols. I believe that is also true for the rapid response teams and the nurses working in the ICUs. Criticial care is also a lot more than just ACLS. A Paramedic functions by protocols and many are around ACLS. They are not that autonomous and do have contact with medical control and will divert to the nearest ED at the first sign of a problem on an IFT with the patient never reaching their destination. There are many, many critical care situations that require medications and equipment that are not covered in ACLS. You stated yourself how new drips and med pumps were when discussing the CCEMTP course. Most were never covered in a Paramedic program. So no, absolutely not should a Paramedic be given the responsibility of a critical care patient without extenseve extra education, training and experience just like what is expected for a nurse. Just knowing ACLS and PALS does NOT make someone critical care ready. If so, even the EMT-Bs could qualify since some have taken the class and passed with no problem.

A whole 48 hours in ICU with just the education and training of a Paramedic? You must think you are better than any RN who has the CCRN or who went through an ICU internship and preceptor process with your Paramedic patch and 48 hours in an ICU. The thing I like about RNs is even after their ADN or BSN and then a year in ICU, they still consider themselves or will be considered "new" with a lot more to learn. Most are not so cocky to believe they are ready for anything after a mere 48 hours in an ICU even with their education and patient experience. I am sorry but 48 hours in an ICU, especially as a Paramedic student, does not make you very well qualified for a lot of ICU patients as either a nurse or a Paramedic regardless of you having ACLS.

(I believe the nursing students do get 4 or 6 weeks inside an ICU here with 24 hours - 2/12 shifts. But, I believe it is told to them that is just an introduction and they are not "CCRNs" or ICU nurses after finishing the clinicial.)

I also covered repeatedly the differences with nursing education and a specialized tech program like Paramedic. I also stated it should be unacceptable in any profession to put a very new grad into a situation they have had no specific experience or training for. This again is what makes us the butt of EMS jokes in other countries. Did you look at other countries' EMS systems including the Dutch system I linked?

I do agree with you TraumaSurfer that when the nurse is experienced and acquires all the pertinent training that the person should, in theory, be hands down better suited for critical care transport and aeromedical transport than the typical paramedic. I've met a lot of flight nurses, and every one of them was an RN, NREMT-P. They didn't have to be paramedics, but they realized, along with their employers, that the indoctrination experienced by paramedics was suitable to their preferred line of work.

I also know many who didn't have the Paramedic patch. Also, remember NREMT-P is just a certification test which isn't even used in all states. And, a nurse can get the NREMT-P and not the state license. A nurse can also challenge the Paramedic exam for patch collecting reasons as well. Taking training in prehospital medicine is great for a certification but that does not mean they give up their license, scope of practice or identity as an RN. Unless of course they want to if they think "Paramedic" sounds more glamorous than "Nurse".

We do see RNs placed in the back of ambulances everyday around the country to assist with critical care transport, and that's strictly for efficacy. Why would you not put an ICU nurse with a critical ICU patient when one is available? It'd be foolhearty not to. Here, however, the paramedic must attend to the patient and be in the patient compartment, or everyone involved is going to get in a lot of trouble if things go south for the patient. That's all stricly legislative. Change the law. Change the department of health regulations, and we'd be good to go.

The Paramedic is only there if it is not a dedicated Specialty or CCT team. If there is a full team, the Paramedic can drive, as they often do for neonatal and specialty teams, while two RNs or an RN and RT are in the back attending to the patient.

Not all hospitals have an extra ICU RN that can just leave his/her other patients to ride in an ambulance. But, if a team shows up that is obviously clueless about managing the patient, the hospital may have not choice. This should definitely be true in the ED with EMTALA but sometimes Paramedics don't alway know their own limitation or want to admit to them. The ego is a powerful thing and is often responsible for making the wrong decisions.

I already stated how states have changed their statutes by redefining emergency ambulances for CCT, specialty and flight to where a Paramedic is not necessary. I also stated about PHRNs or whatever terms some states are using for prehospital RNs have allowances in the statutes for them to function on an ambulance. I also stated previously that some states, especially with very rural areas, allow RNs to function under their own license in EMS with a scope designed by their medical director.

To address emergency (911) service a nurse is going to have to pick up a lot of extra training. It's not at all anything difficult, but it's nothing included in nursing school. I had a five semester hour course called "traumatology" when I was in paramedic school. I really don't think my nursing program is going to address trauma at all. If they it'll be in the final course called "complex care." There's also the fundamental scene safety and EMS operational aspects that nurses would have to be trained including hazardous materials, vehicular extrication, etc etc. Sure, they could do it, but you're going to add at least a semester to their program.

No one ever said nursing school was the same as Paraemedic training. However, nurses know they have to obtain more education and training for any area they go into. Fortunately the base education and over 1000 hours of clinical patient contact prepares them very well to expand their knowledge into emergency medicine. Good grief man! Do you think all RNs are so stupid to accept an assignment or a job that they are not prepared for? Try to get a SNF RN to accept a patient in the ICU on an IABP and ventilator. Yet, many Paramedics will even if they know nothing about either piece of equipment or the drips as long as someone sets it up for them and then they just "monitor" but will later have bragging rights.

If paramedic licensure here allowed for paramedics to work in the ER, or anywhere else, as a paramedic then I"m all for it, but again I don't get why they'd want to.

Somebody obviously didn't tell Paramedic students when they signed up for the class that it was prehospital medicine.

TraumaSurfer, I'm just curious. What is it that you do? What are you? A paramedic? Degree in anything? Firefighter? Trauma tech? I think I caught on that you're from Texas. By your arguments it's rather apparent that the Texas education of EMTs and Paramedics is much less than others around the country. Focus on Texas right now. Arkansas is extremely slow to adopt new elements into the scopes of practice for paramedic if not completely ten years behind urban areas of the U.S., but we at least seem to have very good educational programs for paramedics at least compared to Texas. Texas doesn't utilize the National Registry cognitive or skills exam does it?

I already told you about myself in previous discussions. But yes FD and educator with a college system are part of my background. I've become very accustomed to debating those (which can include you also based on some, no all, of your statements) who say nurses don't know how to act without doctor holding their hand or that Paramedics can do it all. I've also seen bad, bad situations concerning the Paramedics who took their "autonomus" status too far and have lost their license. The protocols, medical director and med control are there for a reason. We have built EMS up to believe that their limited education, training and scope of practice can do it all and are above the rest so no need to any more book learnin'. You can find fault with every education system like for nursing especially if you keep reflecting only on a couple of good things you remember when you were a Paramedic. If you really want to be a nurse maybe you should stop putting down that profession and see the good things you are learning. Not every patient will be an emergency and the long term is important also just as some of the minor illnesses. You might be trying to see everything as an emergency and are disappointing yourself doing the comparisons.

Texas doesn't utilize the National Registry cognitive or skills exam does it?

Yes Texas uses the National Registry which is not a very difficult test but at least it gives some resemblance of a national exam. Texas also has two distinctions for Paramedics with "Licensed Paramedic" for those holding an Associates degree. I would say about 25 - 30% are licensed with almost 20,000 Paramedic in TX and between 5 - 6000 with LP patches.

Some criticize California but maybe they have it right by having their scope of practice set more appropriately for 1000 hours of training. I believe Arkansas requires a little over 1000 hours for Paramedic as a minimun.

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Specializes in Emergency & Trauma/Adult ICU.

I completely agree that in an emergent situation, particularly one outside of a hospital unit, I'd welcome the help of a brand new medic over a brand new nurse, hands down. A first-day-on-the-job medic has been trained to respond to emergencies. A first-day-on-the-job nurse has been trained to assume ongoing care of a patient after receiving report on that patient and assessing the patient head to toe.

In terms of EMS/scene response, there is quite frankly a limit to the value of, say, a critical care nurse's experience because there's only so much you can do outside the hospital setting anyway. Individual states' departments of health tweak the list of approved meds/procedures/equipment now and then, but there is definitely a practical limit to what can or should be done outside of the hospital.

I was fortunate that my diploma nursing program did cover critical care concepts in some depth, and that an entire semester of clinicals were spent in an ICU setting. To this day I use my critical care instructor's verbage when explaining some things to my preceptees. But again, this had limited value in preparing me to deal with emergent situations until I had gained some experience as a new nurse. And by the way, in my region, paramedic programs (whether diploma programs, associates degree programs, or bachelor's degree program) utilize hospital ICUs and EDs for substantial portions of their clinical time. And supervised intubations are practiced first on mannequins, then in cadaver labs, then in the OR.

TraumaSurfer, I am also curious about your background. Whether you are a medic or EMT who has experienced a bad situation which you attribute to substandard training, or a patient/family member of a patient who had a bad outcome which you attribute to substandard EMS training ... by all means, concentrate your efforts in raising the bar for paramedic education in your home state. I think states need to realize that they don't have to reinvent the wheel -- the National Registry curriculum and practical/cognitive exams are the result of extensive research into best practices.

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I am also a little heavy handed on this thread because I believe the OP is an EMT-Basic considering or just starting a Paramedic program judging by the posts made on EMS forums.

We trying to discourage the nurse bashing the first day of Paramedic school emphasizing professionalism. We also emphasize the importance and differences in education.

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TraumaSurfer, I am also curious about your background. Whether you are a medic or EMT who has experienced a bad situation which you attribute to substandard training, or a patient/family member of a patient who had a bad outcome which you attribute to substandard EMS training ... by all means, concentrate your efforts in raising the bar for paramedic education in your home state. I think states need to realize that they don't have to reinvent the wheel -- the National Registry curriculum and practical/cognitive exams are the result of extensive research into best practices.

I've already repeatedly stated my credentials on this forum.

You do not need to accuse me of being some disgruntled EMT. I have not done any name calling or bashing of EMTs or Paramedics or nurses. So stop that that attempt to discredit everything I have stated. You may not want to read about any of the problems of EMS which leads me to wonder why you would even waste the time. However, by your comments, you probably didn't read any of my posts but just picked out what you wanted to make assumptions. Everything I have posted can be verified through state EMS websites for education standards. Stop with the personal attacks and do some GOOGLE searches.

After almost 37 years in EMS, I have been active at local, state and national levels. It took 15 years for the current changes in the NREMT to come about and even those are getting resistance from all levels including the accreditation part as I have already described over and over. The arguments a few statements have for not using the NREMT are valid. Also, through reciprocity, even if one state did raise its education, someone could take a 6 month course across the state border, get their NREMT and come back over. This is one of the loopholes in Oregon.

Altra, I have no idea if you are an RN or an EMT so if I asked if the education of an LVN or MA is adequate to take care of a heart transplant patient would be okay you may not know the answer or you may have an opinion. I do know LVNs were once in the ICUs so I could assume they have more than enough education. Isn't that what some are assuming about Paramedics? If they have ACLS, they should be great in the ED or ICU for any situation.

I am just tired of EMS providers starting threads like this to get nurses in a fuss and then linking it to their own nurse bash thread on another forum. At least this time they will get to read my posts about EMS education with only a few putting nurses in a bad light.

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Specializes in Emergency & Trauma/Adult ICU.
I've already repeatedly stated my credentials on this forum.

You do not need to accuse me of being some disgruntled EMT. I have not done any name calling or bashing of EMTs or Paramedics or nurses. So stop that that attempt to discredit everything I have stated. You may not want to read about any of the problems of EMS which leads me to wonder why you would even waste the time. However, by your comments, you probably didn't read any of my posts but just picked out what you wanted to make assumptions. Everything I have posted can be verified through state EMS websites for education standards. Stop with the personal attacks and do some GOOGLE searches.

I have not accused, attacked, bashed, attempted to discredit or name called. What I have done, repeatedly, is to offer support to what I believe to be your desire to see paramedic education upgraded and standardized nationally.

And ... about a page & a half ago I asked if we could be drinking buddies. ;) So I am unsure where your hostility is coming from.

Altra, I have no idea if you are an RN or an EMT so if I asked if the education of an LVN or MA is adequate to take care of a heart transplant patient would be okay you may not know the answer or you may have an opinion. I do know LVNs were once in the ICUs so I could assume they have more enough education. Isn't that what some are assuming about Paramedics? If they have ACLS, they should be great in the ED or ICU for any situation.

My credentials are listed on the "about me" section of my profile, but if you are unable to click that, I will list them here: I am an RN. My basic nursing education was a diploma program. I have since completed my BSN. I am both a CEN and CCRN. My EMS experience is limited to ride-alongs as a new nurse and some precepted time when I was pursuing my state's PHRN designation. I learned a great deal, including that I personally do not have enough of a burning desire to work outside the hospital setting. So I am no longer pursuing that. I work closely with medics, PHRNs and flight nurses though, and repeatedly attend ACLS, PALS, ATLS and other conferences with EMS colleagues, so at least through classroom discussion and casual conversation I have frequent exposure to at least some EMS/prehospital issues.

I split my time between the ED and ICU, and am relatively content with that arrangement for now.

I am just tired of EMS providers starting threads like this to get nurses in a fuss and then linking it to their own nurse bash thread on another forum. At least this time they will get to read my posts about EMS education with only a few putting nurses in a bad light.

Then ... your beef is with the OP, and not with me, right?

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I just brought up the CCT part since you mentioned it and I was replying to your post.

I may not be a nurse but I do know if a patient codes inside a hospital the RNs on a code team do not just stand around waiting for a doctor to arrive to tell them to initiate CPR and ACLS protocols. I believe that is also true for the rapid response teams and the nurses working in the ICUs. Criticial care is also a lot more than just ACLS. A Paramedic functions by protocols and many are around ACLS. They are not that autonomous and do have contact with medical control and will divert to the nearest ED at the first sign of a problem on an IFT with the patient never reaching their destination. There are many, many critical care situations that require medications and equipment that are not covered in ACLS. You stated yourself how new drips and med pumps were when discussing the CCEMTP course. Most were never covered in a Paramedic program. So no, absolutely not should a Paramedic be given the responsibility of a critical care patient without extenseve extra education, training and experience just like what is expected for a nurse. Just knowing ACLS and PALS does NOT make someone critical care ready. If so, even the EMT-Bs could qualify since some have taken the class and passed with no problem.

A whole 48 hours in ICU with just the education and training of a Paramedic? You must think you are better than any RN who has the CCRN or who went through an ICU internship and preceptor process with your Paramedic patch and 48 hours in an ICU. The thing I like about RNs is even after their ADN or BSN and then a year in ICU, they still consider themselves or will be considered "new" with a lot more to learn. Most are not so cocky to believe they are ready for anything after a mere 48 hours in an ICU even with their education and patient experience. I am sorry but 48 hours in an ICU, especially as a Paramedic student, does not make you very well qualified for a lot of ICU patients as either a nurse or a Paramedic regardless of you having ACLS.

(I believe the nursing students do get 4 or 6 weeks inside an ICU here with 24 hours - 2/12 shifts. But, I believe it is told to them that is just an introduction and they are not "CCRNs" or ICU nurses after finishing the clinicial.)

I also covered repeatedly the differences with nursing education and a specialized tech program like Paramedic. I also stated it should be unacceptable in any profession to put a very new grad into a situation they have had no specific experience or training for. This again is what makes us the butt of EMS jokes in other countries. Did you look at other countries' EMS systems including the Dutch system I linked?

I also know many who didn't have the Paramedic patch. Also, remember NREMT-P is just a certification test which isn't even used in all states. And, a nurse can get the NREMT-P and not the state license. A nurse can also challenge the Paramedic exam for patch collecting reasons as well. Taking training in prehospital medicine is great for a certification but that does not mean they give up their license, scope of practice or identity as an RN. Unless of course they want to if they think "Paramedic" sounds more glamorous than "Nurse".

The Paramedic is only there if it is not a dedicated Specialty or CCT team. If there is a full team, the Paramedic can drive, as they often do for neonatal and specialty teams, while two RNs or an RN and RT are in the back attending to the patient.

Not all hospitals have an extra ICU RN that can just leave his/her other patients to ride in an ambulance. But, if a team shows up that is obviously clueless about managing the patient, the hospital may have not choice. This should definitely be true in the ED with EMTALA but sometimes Paramedics don't alway know their own limitation or want to admit to them. The ego is a powerful thing and is often responsible for making the wrong decisions.

I already stated how states have changed their statutes by redefining emergency ambulances for CCT, specialty and flight to where a Paramedic is not necessary. I also stated about PHRNs or whatever terms some states are using for prehospital RNs have allowances in the statutes for them to function on an ambulance. I also stated previously that some states, especially with very rural areas, allow RNs to function under their own license in EMS with a scope designed by their medical director.

No one ever said nursing school was the same as Paraemedic training. However, nurses know they have to obtain more education and training for any area they go into. Fortunately the base education and over 1000 hours of clinical patient contact prepares them very well to expand their knowledge into emergency medicine. Good grief man! Do you think all RNs are so stupid to accept an assignment or a job that they are not prepared for? Try to get a SNF RN to accept a patient in the ICU on an IABP and ventilator. Yet, many Paramedics will even if they know nothing about either piece of equipment or the drips as long as someone sets it up for them and then they just "monitor" but will later have bragging rights.

Somebody obviously didn't tell Paramedic students when they signed up for the class that it was prehospital medicine.

I already told you about myself in previous discussions. But yes FD and educator with a college system are part of my background. I've become very accustomed to debating those (which can include you also based on some, no all, of your statements) who say nurses don't know how to act without doctor holding their hand or that Paramedics can do it all. I've also seen bad, bad situations concerning the Paramedics who took their "autonomus" status too far and have lost their license. The protocols, medical director and med control are there for a reason. We have built EMS up to believe that their limited education, training and scope of practice can do it all and are above the rest so no need to any more book learnin'. You can find fault with every education system like for nursing especially if you keep reflecting only on a couple of good things you remember when you were a Paramedic. If you really want to be a nurse maybe you should stop putting down that profession and see the good things you are learning. Not every patient will be an emergency and the long term is important also just as some of the minor illnesses. You might be trying to see everything as an emergency and are disappointing yourself doing the comparisons.

Yes Texas uses the National Registry which is not a very difficult test but at least it gives some resemblance of a national exam. Texas also has two distinctions for Paramedics with "Licensed Paramedic" for those holding an Associates degree. I would say about 25 - 30% are licensed with almost 20,000 Paramedic in TX and between 5 - 6000 with LP patches.

Some criticize California but maybe they have it right by having their scope of practice set more appropriately for 1000 hours of training. I believe Arkansas requires a little over 1000 hours for Paramedic as a minimun.

So what are you trying to sell me on? I can't even read this crap anymore.

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Specializes in Spinal Cord injuries, Emergency+EMS.
As with nursing education, there are various educational routes to becoming a paramedic. A major university in my region offers a 4-year bachelors degree in emergency medicine, something that might shock those of you who seem to have a vested interest in viewing paramedics as technicians with 3 months of training.

But until that is the level of entry it's irrelevant ...

Until paramedics have their own professional regulation and registration and their scope of practice is on that basis rather than the by seeking permission from other Health care professionals ( whether that's via the Medical Director's approval of protocols, or the US only 'mother may i' model of medical control where permission to carry out skills or interventions has to be requested from a remote supervising Doctor or Nurse or any combination of model vs the situation elsewhere in the world where health professional Paramedics work to Paramedic ( as part of a multi disciplinary team) generated clinical guidelines ... and have their own registration and legal mechanisms to obtain, hold and adminster / supply the Prescription medications used in the course of their work.

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Specializes in pcu/stepdown/telemetry.

yawn.. this is the hardest post I have ever looked through and most I had to skip. They are different professions.

I highly respect paramedics and they respect us as RN's. I can't intubate a pt and likewise there are things they cant do that RN can. So what. You cannot interchange the two. To me no one is above or below the other. The ER is different than being on the field. RN and paramedic should not be compared this way. Each brings something to the table and that's why hospital flight crews are usually paramedic and RN. As far as having paramedics help out in the ER which I think is what the OP was asking, I am in ny and I have not seen it yet. Not sure if it has to do with policy or what but I know any help is good help as long as it's following hospital policy

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I have not accused, attacked, bashed, attempted to discredit or name called. What I have done, repeatedly, is to offer support to what I believe to be your desire to see paramedic education upgraded and standardized nationally.

And ... about a page & a half ago I asked if we could be drinking buddies. ;) So I am unsure where your hostility is coming from.

My credentials are listed on the "about me" section of my profile, but if you are unable to click that, I will list them here: I am an RN. My basic nursing education was a diploma program. I have since completed my BSN. I am both a CEN and CCRN. My EMS experience is limited to ride-alongs as a new nurse and some precepted time when I was pursuing my state's PHRN designation. I learned a great deal, including that I personally do not have enough of a burning desire to work outside the hospital setting. So I am no longer pursuing that. I work closely with medics, PHRNs and flight nurses though, and repeatedly attend ACLS, PALS, ATLS and other conferences with EMS colleagues, so at least through classroom discussion and casual conversation I have frequent exposure to at least some EMS/prehospital issues.

I split my time between the ED and ICU, and am relatively content with that arrangement for now.

Read your posts and you'll see why I made my statement. I took your "drinking buddies comment to be sarcasm. You have given agreed with everything by way of kudos even to those who made nurses out to be incapable of making any patient care decisions unless a physician was right there beside them. For that reason I also suspected you to not be a nurse if that is how you perceive all nurses. I do know there are some nurses who do fit that description but I was also giving the profession the benefit of the doubt since it does afford opportunities for growth from that general base education.

Originally Posted by TraumaSurfer viewpost.gif

I am just tired of EMS providers
starting threads like this
to get nurses in a fuss and then
linking it to their own nurse bash thread on another forum.
At least this time they will get to read my posts about EMS education with only a few putting nurses in a bad light.

Then ... your beef is with the OP, and not with me, right?

Does anything in my statement pertain to you?

Originally Posted by Altra viewpost.gif

As with nursing education
, there are various educational routes to becoming a paramedic.

It is difficult to argue with someone who believes because there are a few programs that offer a 4 year EMS degree that must be the minimun or most common route even though I have repeatedly asked you to check the state EMS websites to verify what I have stated. I doubt if any volunteer organization, Fire or EMS, Fire department or ambulance service is going to wait or pay for 4 years for their new hire to finish Paramedic school. Those who do go through a 4 year degree will usually move away from the street, where those with the 6 month cert will be critical of them, to become PAs, RNs and managers. It seems nursing has a similar situation where the ADNs downplay the importance of a BSN or MSN on this forum. But until even a 2 year degree becomes mandatory in EMS, I don't see it becoming the norm any time soon since not many finish the Assoicates degree even if they get their cert from a college. However, I believe a sizable percentage of the total RNs in the U.S. hold a BSN degree which is impressive given the number of RNs.

There are many impressive Paramedics who do have either an Associates or Bachelors degree but for the most part they will still be judged by the minimum standards for entry. By giving those who want entry into an area that normally would require a higher education such as the RN, just pushes back the EMS drive for higher standards. Their argument would be "Why?" when I can do all this with just a tech cert. Some hospitals have raised the bar on their inhospital techs suchs as for Radiology, PT, OT, and RT long before their own profession increased minimum education standards. You even have hospitals preferring BSNs and I believe LVNs had to upgrade or be displaced in some places. So why would you want someone whose minimal education standards per the state is less than what most of you hospital techs or licensed professionals have? My goal would be to reward those who do have at least an Associates degree which TX does sorta. But, I would rather have the statutes changed to allow them more opportunities in prehospital first. But, the minimal standards would have to be changed across the U.S. for EMS to gain professional recognition by the insurers.

I have been attempting to give the OP a better explanation other than just "nurses won't let us" which he/she has probably heard on the truck and in Paramedic school.

Maybe we are on the same page on some things Altra but I do want you to check the EMS websites. If your state is PA, I have already posted the links and protocols.

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Specializes in FNP.

I admit, i didn't read the whole thread. I just want to say that like nurses, there has been a huge difference in the calibre of EMT-Ps I have worked with across the state. When I lived and worked in a metro area the paramedics were outstanding. I can only assume that the education programs in the area were top notch. Here, they are terrible. I mean unbelievably ignorant and borderline incompetent. Scary scary bad. They have no idea what they don't know. I can't believe they passed the same exam as the medics I knew a few hundred miles east. Those people were professionals of the highest order, and I have trusted any of them With the lives of my own children without hesitation. The ones here, I wouldn't let babysit. I mention this, b/c on the first few pages I did read there was a big argument about level of preparedness, etc and I just wanted to mention that I have seen a huge, huge difference in then quality and calibre regionally.

I have seen a similar dichotomy in nurses,ut it seems just to vary more person by person, with a mix of good and bad everywhere.

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