paramedics in the ER

[blufoxtrot]

Do any of you have paramedics in your ER? If so what do they do?

[cmarn]

:redpinkheWow! I realize the original post was not intended to illicit such an opionated response; however, I do think it's a touchy subject for many. There seems to be a lack of respect on the part of both professions for one another. I think each profession has its place in the area of their specialized training. I have had personal experience working in an ER and office setting with EMTs/Paramedics. EMTs/Paramedics are trained in a very focused area of care. Thank God for them....they make split second decisions stablilizing our patients for transport to the hospital. They are accustomed to operating independently under a certain protocol.

As nurses we are responsible for holistic care of patients and their families. We are trained to help stabilize patients, recognize contributing factors, long term care issues, education, working WITH physicians, coordinating care..etc. It seems like when EMTs/paramedics are introduced to care outside of the truck there is a struggle for power. I have dealt with many who do not want to take orders from nurses or physicians. They function outside of their scope of practice acting independently in an environment that is not conducive for them to do so. Once again, I appreciate their aggressive, focused care but the focus broadens after patients are stabilized and we have to be willing to appreciate that other disiplines are needed for continued care. As a nurse, I have never felt offended that repiratory therapy draws ABGs, or bags my patient in a code just because I can do these things myself. I welcome them and try to learn from their knowledge when they are willing to share. I have not met an EMT/Paramedic who exhibits this same attitude toward nurses.

A few examples from the last few months....

Today: We had a code. EMTs brought patient in performing CPR. The patient was found unresponsive. We were told the patient had a pulse of 30. When the nurse asked why the patient did not have an IV, was not on the monitor, and had not had a FSBS, the EMT filed a formal complaint. I'll let you form your own opinion. (the patient's actual rate was above 100 and how did the EMTs know what the patients rhythm was?)

As a Home Health Nurse I called rescue for a patient having abdominal and chest pain. The patient was bedbound and several co morbidities. He was requesting to go to the hospital. Rescue came and tried to convince the patient not to go to the hospital explaining that it was probably GERD. As nurses, paramedics, techs, etc....our job is never, NEVER to diagnose. They finally took the patient but never reported the abdominal pain to the ER. The patient was admitted to telemetry, discharged days later only to end up dying from a small bowel obstruction.

Last, I worked in an office. Patient came in with chest pain. I had orders from the doctor to start saline lock, no fluids..send patient to ED. Paramedic came in took over disregarding MD orders, getting in the way of the IV start, hung fluids and delayed the patient's transport.

I don't understand why anyone has to feel threatend, challenge other disciplines, or argue that we all have an area of expertise. Just because I don't want EMTs/Paramedics in the ER doesn't mean I don't think they are incredible at what they do.

[Lunah, MSN, RN]

While I enjoy working with Paramedics in the ER, and I've worked in several ERs that employ them, my only "beef" is that they get paid the same as the nurses and do far less work.

Wow, where is this? Usually the reason ERs use medics to augment staff is because they are paid less.

[RBlucky]

Wow, where is this? Usually the reason ERs use medics to augment staff is because they are paid less.

I'm in Florida, and the PRN medics get between $20 - $25 an hr, where as I make $24.81!

[ER_JEN_RN]

So, I totally agree that medics and EMTs are a HUGE asset to the ER. However, one poster commented that he has been hired as a medic to write orders, prescribe meds, etc and he cant wait to "see the face on the RN's" when they find this out? Sounds like someone is on a power trip here......

EMTs kick butt and are a huge help in our ER. They start IV's, do 12 leads, hang fluids, splinting, wound care, transport, etc. This is wonderful especially when things get hectic. However, we all have a scope of practice regardless of our title, and have been trained to work within that scope. Its for the safety of everyone involved.

[TraumaSurfer]

Old thread but unfortunately in the U.S., EMS education changes very little.

There seems to be some misconceptions about the education and training of the Paramedic. The DOT curriculum only provides a general list of things that should be covered. Essentially, if one just went down the list, which some schools do, it doesn't take that much time which is why we get "hours of training". The minimum amount of hours varies from state to state with as few as 600 (Texas) with 800 to 1000 hours being the average for the total which includes classroom and clinicals. Some schools may only do the bare minimun and some may offer a few more. There are schools that teach the Paramedic in 3 months and leave the students to find a place to do clinicals with very little oversight. At this time only one state (Oregon) requires an Associates degree and there may be loopholes around that. Texas offers the title of Licensed Paramedic to someone who holds a degree but it can be in anything including majors that are non-science or non-medical. The EMT is still 110 hours in most of the states.

The colleges that do offer a degree program for the Paramedic will also have a certificate which most will obtain and never return to finish the degree. The Anatomy, Physiology and Pharmacology classes may also be vastly different than what the nursing and other health care programs require. Generally they are watered down and cover only a few basic concepts and meds for the EMS provider. If a Paramedic wants to transfer to a nursing program, the A&Ps with lab must be taken.

As far accreditation, only about 50% of the Paramedic programs are accredited by CoAEMSP/CAAHEP. Some states, like Michigan, are fighting accreditation which will be required in a few years to test by the NREMT for the Paramedic. Many programs are private votechs or medic mills. Some Paramedic programs are still taught in the backrooms of FDs and private ambulances with the warm body mentality for mass production. Several FDs want all of their FFs to be Paramedics which they do become and have few to no problems with the Paramedic program or the NREMT exam even if they have no interest in medicine.

This brings us to the "nurses must follow orders" comments made by the Paramedics posting. Paramedics follow orders called protocols which are written by their Medical Director. The protocols may be written very conservatively. Many must follow these protocols to the letter and may even work in a "mother may I" system where they must call Med Control to initiate the orders.

The scope of practice varies from state to state, county to county and agency to agency. The Medical director of an agency does not have to allow a Paramedic to perform everything listed in the state's scope of practice.

In no way is a Paramedic a "Physician Extender". They do not have the privilege of script writing nor do they have any of the professional privileges recognized by CMS. Until the Paramedic can increase the education standards to at least a two year degree in the U.S., they will still considered to be a vocational tech much like the LVN was considered to be. Until then, those who do hold a two or four year degree in EMS will still be brought down to the weakest link or the lowest trained Paramedic when it comes to professional recognition unless they advance from the ranks.

The skills that someone mentioned such as chest tube insertion, pericardiocentesis and central lines are rare except in a few very rural or Flight services. Even endotracheal intubation is debated as to whether it should remain in protocols for some agencies. One should not be blinded by a couple of impressive "skills" when assessing a potential candidate for hire. Anyone can be trained to do a skill but it is the education and knowledge behind it that makes a difference. Some of the Paramedics who work in the ED brag about "skills" and codes. They rarely talk about the detailed assessments, patient/family education, routine care, infection control, LTC issues, chronic disease management, diagnostics, lab values and care plans.

The title of "Paramedic" is not even used in all states. Some use MICT. The NREMT is also not the credentialing exam for Paramedics in all 50 states. A few states use their own exam. In a couple of years the NREMT will institute 4 new levels but it still does very little to raise the education level of the Paramedic. This may or may not affect the states that do not utilize the NREMT for their exam. The same goes for the accreditation requirement by the NREMT.

Combine the title or cert confusion with the many variations from state to state for "hours of training", credentialing exam and scope of practice, it is difficult to even assess what the basic standard for the Paramedic is. Some can do 12-lead EKGs and some can not. Some can titrate medicated drips but many can not. Some states allow for RSI and some limit the drugs for DAI. In many areas, RNs must accompany ALS IFTs because the Paramedics can not do the meds or the technology. For this reason RNs are on Flight and CCT teams.

The LVN was practically eliminated in some areas because of their limited training. Those that are still around are represented by tech unions and not the same professional union as the RNs. Their total hours of training is almost 2x that of a Paramedic and they are familar with patient care inside of a hospital and often have extended scopes. Yet, it is rare to find one working as an LVN in the ED. They are considered ED Techs which is how the Paramedic should remain also. Until the Paramedic can be defined by education with some standard for licensing across the board, it would be difficult to allow them the same working privileges and scope as the RN in the ED.

[ImThatGuy, BSN, RN]

In a hospital where paramedics are utilized if a person were an RN and a medic could the person operate in a dual role? Just curious. I've never figured out why nurses can't do some procedural things.

[TraumaSurfer]

In several states the Paramedic cert is not recognized inside the walls of the hospital. There are many RNs who are also EMT-Ps. The RN is considered to be a higher license which is the one they will work under and often affords a broader scope especially when it comes to medications and incorporating new procedure or protocols. In most states an RN can do all the "cool skills" that a Paramedic depending on where they work. The RN can intubate and many do in the L&D or NICU, on Specialty and Flight teams. It is also not uncommon to see these RNs gaining their intubation experience in the ICUs and EDs of the hospitals. The same goes for central lines and even chest tubes depending on their Specialty or Flight team. RNs are also the ones who place PICCs in most hospitals for patients of all ages. If you actually go through the list of "skills" that a Paramedic considers to be their own trademark, you will find there are many different healthcare practitioners that can do those same skills plus many more. They don't need to become a Paramedic. Some RNs who have become Paramedics to leave the hospital for something that appears to be more exciting end up frustrated because they can not do what they could as an RN since they must work under the Paramedic scope.

Inside the hospital there are such things as teamwork and the RN has his/her responsibilities as does an ER Tech (Paramedic). Each position of responsibility is based on much more than just one or two skills. In a hospital, it is not necessary for 1500 RNs to do intubation. They already have their own responsibilities and most have fantastic careers without ever performing an intubation. Unfortunately for some Paramedics, if intubation is taken away you might as well have cut off their right arm. They believe their whole identity is tied up in that one skill.

[Hagabel]

Wow, what a bunch of responses to having Paramedics in the ER. I personally agree that Paramedics in the ER are an excellent choice. I personally believe that Paramedics are trained to critically think and most nurses are trained to ask for orders from the doctor.

I agree with this statement to a point but would also like to state that there are plenty us nurses out there who also know how to 'critically think'. 16 yrs of ICU taught me that without 'paramedic' after my name. And don't get me wrong I love the Paramedics.

[Lunah, MSN, RN]

I don't think any one profession owns the rights to "critical thinking."

[gardengal1, ASN, RN]

We have one paramedic in our ER per each 12 hour shift. Because we are a rural area and many ambulance services have no staff with advanced skills, our paramedic has a SUV fully equipped and goes and meets ambulances that are enroute to our hospital and can then start IV's and give meds and have the patient stabilized before arriving in our ER. When not on calls, our paramedics start IV's and give medications and transport patients to ICU. They cannot hang antibiotics or start blood infusions but can monitor blood infusions once they have been started by a RN. They cannot do triages and operate under the RN direction. They can chart any cares that they provide. And, if needed, they do emergency intubations, IO's and other paramedic skills when needed in the ER setting. I believe each state has rules as to what paramedics can and cannot do in any given state. Ours can do almost everything except for those things I have listed. And, they cannot do foley insertions - probably only because they have not been specifically trained to do this skill. We consider them an asset to our team.

[ImThatGuy, BSN, RN]

And, they cannot do foley insertions - probably only because they have not been specifically trained to do this skill. We consider them an asset to our team.

Medics aren't going to want to do foleys either, lol.