Paramedic triage

Neveranurseagain, RN · May 6, 2009

Ivan, I respect the fact that you were a paramedic prior to becoming a nurse. RN's, as well as paramedics, are no more ready fresh out of school to work in the ER as paramedics are ready to quickly intubate in the field. I would never suggest a newly graduated RN to start in the ER, even if they feel they are able and ready. They are not."
Having been a RN as well as a Paramedic I have to disagree with that statement. Paramedics have a high level of diverse skill training and experience, much more so than RN students, along with their classroom training and must be able to perform all skills quickly in the field, right after graduation. They hit the ground running, vs new grad RN's that need preceptorship as they do to not have enough high quality clinical time. My first call as a Paramedic was a full code that was worked with just a basic EMT. The pt. was successfully resuscitated and DC from the hospital 9 days later. Working a full code by myself was possible due to the training I received as a medic.
The difference between medic school and RN school is that in medic school, all the BS is cut out and critical thinking and skills are taught in a high pressure, competitive environment which quickly weeds out students that are not up to par.
That being said, while I do feel paramedics can appropriately triage, I do not feel they should as RN's again are being replaced by cheaper staff, jeopardizing our future. With the use of medication aides, and non RN's triaging, pt. care tech's that start IV's and cath., we are eliminating our position and jeopardizing pt. care with semiskilled personnel who can not assess the big picture as an RN can.

MassED, BSN, RN · May 6, 2009

Ivan, I respect the fact that you were a paramedic prior to becoming a nurse. RN's, as well as paramedics, are no more ready fresh out of school to work in the ER as paramedics are ready to quickly intubate in the field. I would never suggest a newly graduated RN to start in the ER, even if they feel they are able and ready. They are not."
Having been a RN as well as a Paramedic I have to disagree with that statement. Paramedics have a high level of diverse skill training and experience, much more so than RN students, along with their classroom training and must be able to perform all skills quickly in the field, right after graduation. They hit the ground running, vs new grad RN's that need preceptorship as they do to not have enough high quality clinical time. My first call as a Paramedic was a full code that was worked with just a basic EMT. The pt. was successfully resuscitated and DC from the hospital 9 days later. Working a full code by myself was possible due to the training I received as a medic.
The difference between medic school and RN school is that in medic school, all the BS is cut out and critical thinking and skills are taught in a high pressure, competitive environment which quickly weeds out students that are not up to par.
That being said, while I do feel paramedics can appropriately triage, I do not feel they should as RN's again are being replaced by cheaper staff, jeopardizing our future. With the use of medication aides, and non RN's triaging, pt. care tech's that start IV's and cath., we are eliminating our position and jeopardizing pt. care with semiskilled personnel who can not assess the big picture as an RN can.
I have to disagree with you. Where I went to nursing school (Washington state) was extremely competitive and difficult, with an emphasis on clinical time. Critical thinking is not BS, nor is nursing school. I hated it at the time, but hindsight is 20/20. It was absolutely essential - all of it. You seem bent on making it out that new nurses are not ready in any way to function independently. This is not true. RN's are as different in skill and competency as Paramedics are... it's difficult to make a blanket statement and generalize. We KNOW all nurses are not created equal, just as Paramedics are not. You, I'm sure, will disagree. So I see on your credentials that you are now an RN. If being a Paramedic was adequate, then why did you move on (or up?) to obtaining your RN??

MassED, BSN, RN · May 6, 2009

you ask the question and then you answer it: what stops hospitals? nursing political bodies/lobbyists. i find it ironic that you would quote a 17 year old ana statement. it was wrong then. it is wrong now. paramedics are not unlicensed. all working paramedics are licensed. they were licensed in 1992. they are licensed now. there is no study, not one, that shows that patient outcomes with hospital based paramedics are less (or more) favorable. that makes me wonder about the motivation behind statements like that. are they truly about patient safety or is job security the issue? i expect it is somewhere in between. it is wrong for groups like these to lump paramedics in with nursing assistants/patient care techs.
i am not putting paramedics above rns. so let me be clear about what i am saying. i am saying that with the current state of both nursing and emt education, that either of these two pools of talent can equally succeed in the hospital setting given the same type of new grad or transition training. now this is based only on my experience, but i can't find a single reason to think that i am wrong, and no one has been able to demonstrate to me anything other than position statements which do not seem to backed with any study either.

no one has been able to "demonstrate to you." hmph. interesting. i do think there is a place for experienced rn's and paramedics to work collaboratively in an er, with clear roles within a team.

here's ena's more up to date information on this issue - this is only one example of a wisconsin hospital on their policy for hiring paramedics in the er.

http://www.ena.org/document_share/documents/draftpolicyparamedicroleined.doc

Neveranurseagain, RN · May 6, 2009

Maybe it was the nursing school I went to but I never got a chance to start 15 IV's in one day, nor defibrillate 3 different pts, on the same day, or give multiple IVP's or hang many piggybacks on the same day as I did when I was a paramedic student. I was also an LPN when I was a medic. I felt paramedic school placed a bigger emphasis on skills as well as classroom. There were nurses in my class that graduated that had only started on or two IV's, and a few that did not get the opportunity to cath or insert an NG tube. The reason I became a paramedic as our area did not have one, despite the fire dept sending 3 people through paramedic training, only to have them not pass their boards. It got old after a while watching the EMT's bring in pt's to the ER I worked at BLS. I felt our community deserved better care and went to medic school. I also taught as a paramedic instructor at a community college, precepted medic students in the ER and out in the field.

I finished my RN when I got tired of the snow chains falling off the rig and having to reapply them several times, arriving at a call soaking wet. Being a medic is somewhat a young person's job, and I was getting older and had kids. I was also the only paramedic in my area, and it got a little old being on call 24 hrs a day/7 days a week for many years. And pay as an RN was a big motivator as I could do many of the same things as a medic but in the comfort of a hospital (air conditioning and heat!), with scheduled hours!!!!!

MassED, BSN, RN · May 6, 2009

Maybe it was the nursing school I went to but I never got a chance to start 15 IV's in one day, nor defibrillate 3 different pts, on the same day, or give multiple IVP's or hang many piggybacks on the same day as I did when I was a paramedic student. I was also an LPN when I was a medic. I felt paramedic school placed a bigger emphasis on skills as well as classroom. There were nurses in my class that graduated that had only started on or two IV's, and a few that did not get the opportunity to cath or insert an NG tube. The reason I became a paramedic as our area did not have one, despite the fire dept sending 3 people through paramedic training, only to have them not pass their boards. It got old after a while watching the EMT's bring in pt's to the ER I worked at BLS. I felt our community deserved better care and went to medic school. I also taught as a paramedic instructor at a community college, precepted medic students in the ER and out in the field.
I finished my RN when I got tired of the snow chains falling off the rig and having to reapply them several times, arriving at a call soaking wet. Being a medic is somewhat a young person's job, and I was getting older and had kids. I was also the only paramedic in my area, and it got a little old being on call 24 hrs a day/7 days a week for many years. And pay as an RN was a big motivator as I could do many of the same things as a medic but in the comfort of a hospital (air conditioning and heat!), with scheduled hours!!!!!

I recall starting in the ER and was freaked out with the thought of starting a line on a patient quickly. I think back and wonder why I was so intimidated. On the floor, most patients have lines in place and if you do need a restart, you can usually page the IV nurse. I did work on a floor that was mainly dialysis, sickle cell and cancer patients, so I learned some tricks with the most "difficult" population. Again, I think it goes back to training and experience. Not every patient will have those gusher veins that we all love. Those difficult veins were great practice for starting lines on peds. I can see your rationale for moving on from Paramedic, after what you were put through - what about flight nursing as an option to have the best of both worlds? That's my goal - would be great fun, I think.

Editorial Team / Moderator · May 6, 2009

If being a Paramedic was adequate, then why did you move on (or up?) to obtaining your RN??

I know you weren't asking me, but I have a big mouth. I am still a paramedic, as well as an ER RN. I volunteer prehospital, and get paid in hospital. Put simply, the pay for RNs is much better. But I love being on both sides of that ER door! I feel that being a paramedic has made me a better ER nurse, and vice-versa. The roles are different, but there is overlap.

I love being a paramedic. I have always been volunteer, never paid. I volunteer weekly with the same partner I've had for nearly 7 years (since I was an EMT-B, before becoming an EMT-Paramedic), and I don't see myself giving it up anytime soon. My partner and I joke that this is the longest relationship either of us has ever had.

My medic program was great -- my instructor was sooooo passionate about A&P, pathophysiology, etc. ... we had a great mix of classroom and clinical. My clinical preceptor was a trauma nurse, and she was the first person who put the idea of becoming a nurse into my head -- during my last semester of clinicals, she told me I'd make a great nurse. I hope to prove her right.

Neveranurseagain, RN · May 6, 2009

No, flight nursing is not an option (but heck! Them choppers don't need snow chains!) as I don't work in nursing anymore...read my post Husband Died of Medical Incident and you will see why. Nursing and working in the medical field will always be in my blood, and posting on allnurses lets me stay involved but at a distance. https://allnurses.com/california-nurses/my-love-nursing-224330.html

I also was a full time volunteer medic for my community except when I worked as a paid medic for a rural ambulance company that covered a hugh area--it would take up up to 2 hr to get to some of our calls and those fancy helicopters don't fly when it's snowing or icy!

And had some GREAT partners!!!! And lots of fun times!!!

Displaced · May 6, 2009

I have flown to many hospitals around my area that use medics for the RN role. I always saw them in the more rural areas, never in more populated places. Even in Aeromedical you have RN and Medic switch off who is primary on every other flight.

I know there will forever be a Rn vs. Medic debate here, for many reasons, but we can't forget where nursing started, where it is now and best of all, where it is going. You now have Docs worried about nurses taking their jobs and I don't think it will be too long before Medics unite/come together and start challenging some of the nursing positions. It all comes down to education and competency.

NSR_0_Ectopy · May 7, 2009

RN's, as well as paramedics, are no more ready fresh out of school to work in the ER as paramedics are ready to quickly intubate in the field.

I have to disagree with this. My first week as a paramedic I did an rsi in the field with the assistance of my emt-b partner and the fire department. I was prepared for this in school where I competed 10 intubations in the or with crna's and 5 in the field. The fact is that medic school prepares a new medic to operate 100% within their scope of practice day one.

I too agree that I learned more in paramedic school in regards to a&p, pharmocology , and management of medical problems and trauma than I did in nursing school. I found that nursing school pretty much explained theories and gave you a basic understanding of nursing. I learned how to be a nurse during my orientation program at my hospital, not in nursing school.

cjcsoon2bnp, MSN, RN, NP · May 7, 2009

I don't work in the ER but my friend is a CNA in a peds. ER and she said that the triage system goes something like this...

A patient comes in the ER and they first see the CNA who takes their name, some quick basic information and their chief complaint. Next they move to a CNA/RN triage team where the CNA will take vital signs while the RN begins the assessment. If an EKG or blood work is needed ASAP then the CNA can do that while the RN continues the assessment. The patient is then prioritized and either goes into the ER or back to the waiting room (to fill out any forms or registration if necessary.) I think that you have some EMTs working in the ER as techs. but they basically do the same things CNAs do which is assist the nurses or physicians.

!Chris :specs:

ivanh3 · May 7, 2009

I have to disagree with this. My first week as a paramedic I did an rsi in the field with the assistance of my emt-b partner and the fire department. I was prepared for this in school where I competed 10 intubations in the or with crna's and 5 in the field. The fact is that medic school prepares a new medic to operate 100% within their scope of practice day one.
I too agree that I learned more in paramedic school in regards to a&p, pharmocology , and management of medical problems and trauma than I did in nursing school. I found that nursing school pretty much explained theories and gave you a basic understanding of nursing. I learned how to be a nurse during my orientation program at my hospital, not in nursing school.

This is similar to my experience as well. In paramedic school during my "putting it all together" ride time, I participated in many codes/intubations (this is prior to graduation). Obviously we studied trauma and emergencies, but we also extensively studied medical complaints and non emergencies. Diabetes, cardiopulmonary/vascular, GI, oncology, mental health/psych, and neuro were some of the topics covered in as much depth or more as nursing school. We also covered OB as well. I have delivered several times (Some prior to graduation). In short paramedics deal with anything from the minor (cough/cold) to the dire (traumatic arrest, MIs, etc). I do feel that I learned more about OB and mental health in nursing school, but that is really about it.

Paramedics are hammered in critical thinking, patient assessment, documentation, medicolegal, pharm, etc. I can't even recall how many IVs I started, EKGs I read, manual blood pressures taken, lung fields auscultated or medications given (IM, SQ, PO, IV, SL, PR, Inhaled) during my medic training. Paramedics learn surgical crichs, needle thoracentesis, splinting, how to move/lift patients. Of course this list is not complete, but it is more than the hands on training that nursing students receive that I am aware of. Even if there are nursing students that get to do this they are the exception. For paramedics it is the rule. Not only do we learn how to do all of this, we learn why/when we do all of this or said in another way: we learn the rationale behind all of this and more. Paramedics learn sick vs. not sick (good for triage eh?). As a paramedic I was trained by paramedics, doctors, and yes, RNs. In fact, the co-instructor of my program at the Chicago Fire Academy was an ER nurse.

Paramedics learn how to talk to patients/families in times of duress. Again, this is all before graduation. Please don't forget this: 99.9 percent of paramedics started out as EMT basics. Many paramedic programs (but not all) require a certain amount of time as an EMT basic. So most paramedics already have a fundamental grasp of basic patient assessment before they begin paramedic training. Additionally, most paramedics students as current EMT basics are already comfortable just talking with patients, family, instructors and hospital staff. That means they are less likely to have "stage fright" during their paramedic training. They can focus better on the material at hand. I can't find the stats, but many nursing students do not have this type of background as there is no state requirement to be an LPN or CNA first.

So back to the OP. With all of this in mind I feel that a paramedic can do just as well as an RN in triage, given the same additional on the job time and training that a triage RN should get (sadly, not all do). For the posters here who want to poo poo paramedic training you should really get involved with it and learn what it is about. In fact, offer to help with paramedic training at local community colleges. Don't take my word for it. See for yourself.

Ivan

Neveranurseagain, RN · May 7, 2009

I suggest to all the ER nurses out there: Go take an EMT Basic Course! Yes, I can feel the indignation that many of you have that you are already an RN but you will be amazed at how much you would learn in this basic class. Even better, sign up a go on a ride along with the Fire Dept/Ambulance company in your area! It will give you a more accurate outlook on what paramedics really do and under what conditions they perform them under. And you might even have fun, too!

I had several ER nurses who knew they wanted to be a paramedic. But once they rode with me several times, they decided it was not for them. It was too difficult for them to break away from the security of the hospital, knowing they had unlimited help and MD's to make decisions. The autonomy you work under is challenging. Believe me, it is a lot different out in the trenches when all heck breaks loose, multiple pt's and you are the only ALS person.

Should paramedics replace RN's in triaging? Absolutely not! It it a form of outsourcing-using a lower paid employees to replace an RN. We need to protect our job or will end up with one RN supervising 3 medication aides, 10 pt. care techs that perform all the skilled nursing and the RN having ultimate responsibility for 100 pts.