BR157

We will use the Respironics V60 Bipap machine in the ER, PICU and tele. Google "pediatrics v60 asthma". There is a good PPT by Julie...

There are very, very few teams which use Respiratory Therapists for transport. Most of the teams using RTs are for neonates and rarely for pediatrics or adults. Even some of the Neonatal and Pediatric teams which had used RTs in the past are now using Paramedics to partner with the RNs. Some teams are also RN/RN. The few teams which do use RTs may also require them to have the Paramedic certificate. Many times there are also Paramedics on a team along with the RT and RN to assist the RN with medications, IVs and intubation which usually are not within the scope of practice of an RT. Texas Dallas https://www.childrens.com/for-healthcare-professionals/departments-institutes-programs/nursing-services/our-nurses/transport-team Hermann Pediatric When Seconds Count Hermann Life Flight Life Flight in Houston, TX Here is one outside of Texas but is very well known. The RTs must be at least EMT and they do prefer Paramedics. https://www.nwmedstar.org/Flight-Respiratory-Therapist/ DHART used to use more RTs but now the teams are mostly RNs and Paramedics. Many of the RTs also got their Paramedic cert but still needed the prehospital experience. Notice RTs are at the bottom of the list on their website. DHART Crew | DHART | Dartmouth-Hitchcock Boston Children's has never used RTs and probably never will. RNs/Paramedic. http://www.childrenshospital.org/centers-and-services/department-of-critical-care-medicine/critical-care-transport-program Nicklaus Children's Hospital Miami uses only EMTs, Paramedics and RNs on the transport teams. I don't think RTs are even very active in any of the units there. http://www.mch.com/for-nurses/patient-care-units-and-departments.aspx In Oregon, Paramedics took the positions of the RTs on the flight teams. http://www.bendsource.com/Bent/archives/2012/04/02/st-charles-to-ground-airlink-texas-firm-will-take-over-medical-flights St. Louis Children's http://www.stlouischildrens.org/our-services/transport-services REACH used to use RTs but now RNs and Paramedics. http://reachair.com/join-our-team/clinical/ Notice REACH can do everything a team with an RT can do. If you get an Associates degree as a Paramedic to be licensed in Texas and then go on to BSN in nursing, you would be golden for most flight teams after a few years of experience. This looks interesting. I think you will find a few EMS to RN bridge programs in Texas. There aren't really any for RT to RN. Even Excelsior doesn't allow RTs to take their RN program. http://nah.southtexascollege.edu/adn/pdf/South%20Texas%20RN-to-BSN%20Transfer%20Guide.pdf

Did you know there are also Flight Paramedics? Do you know the protocols of all Paramedics in the US? You are basing all of your comments on one helicopter and one you don't work on as a crew member. I pointed out what is happening in flight programs and what has been done and still needs to be done to curb overuse of HEMS. Every one active in EMS has known someone who has called a helicopter to keep from driving a few more miles. If your helicopters are being used on calls just a few minutes away then I would say your system is part of or a victim of the situation I described. You, as CNA and EMT, are defending your ideal world which I hate to say has many flaws. Hiding your head in the sand and defending the issues of overuse is not keeping SAFETY in mind. Finish your Paramedic and get some experience on an ambulance before making anymore blanket statements. At the very least, read more about HEMS to learn of the issues of overuse. Some of these issues should be questioned by anyone seeking a career with a flight team.

I find your comments to be very naïve. Since you are a CNA working in the ICU only maybe you have never been in the ER where the patient transported by a helicopter was released before the helicopter could get back to base. Attitudes like yours are what keep some air ambulance companies flying and sometimes very unsafely. They want everyone like you to believe every call for a helicopter is a life threatening situation. This puts not only the patient but also the crew members at great risk when inappropriate flights are taken. Maybe you aren't aware of the risks a flight team takes every time they are dispatched or the problems with over utilization of a medical helicopter. Not one thing I stated is out of line with what has been stated before by others and many with MD behind their name as well as numerous state and Federal investigators. I have to ask, how long do you think a patient should lay around at scene waiting for a helicopter if the hospital is only 20 minutes by ground? It may take 5 - 10 minutes for a ground EMS crew to decide the patient needs to fly and another 2 - 5 minutes to dispatch the helicopter depending on protocols. It will take maybe 5 - 10 minutes to get the crew in the helicopter and to get the flight started. It may take another 15 minutes to fly to the scene. It will take several minutes to get a report and the patient packaged into the helicopter. The flight may then take another 15 to flight back to the hospital. How much time beyond a 20 minute ambulance ride does that add up to? You are actually knocking prehospital Paramedics by believing they are not capable of taking care of a critically ill or injured patient for 20 minutes in an ambulance. You would have to be totally removed from any aspect of EMS to not have heard about these issues in HEMS. Reduce Inappropriate Helicopter Utilization in EMS - Journal of Emergency Medical Services Be sure to look at the references used in this article. The

Calling the RTs ventilator jockeys are your words, not mine. At no point did I say RTs were uneducated and lacked indepth knowledge of the respiratory system. Do you really have your RTs hanging all your IV antibiotics or would you like to clarify that to RTs giving nebulized antibiotics which come in a plastic vial like albuterol? EKGs and IVs can also be done by EMTs and ER Techs in the ER. RNs can also do those skills and in most hospitals, especially in the units and on telemetry floors, the RNs don't have to wait for an RT. Most RTs will also tell you they hate doing EKGs and have gladly turned them over to nursing. The issue here is that other health care professionals have advanced their education and knowledge of the respiratory system. An RN should be able to assess the respiratory system and determine the correct action without always calling respiratory. RNs on flight and CCT teams do this all the time. The RNs working in ERs, CVICUs and PACUs (other than yours it seems) have been assessing and determining the correct action for the respiratory part of their job for years. The people who write the regulations for Critical Access hospitals and long term facilities have determined there is no need for RT to be in house even with ventilators. These changes in health care were NOT the decisions made by me or Paramedics. Medicine changes and professions evolve. RTs have not increased their value in the eyes of the insurers. When reimbursement goes away, often so does much of that profession. Unless RT can show an increase in their value to those who control the reimbursement, their positions will become fewer. This is not new especially in the ER, long term care and on the hospital floors. But, if a profession does not grow or step up to the new demands of health care, don't fault others for creating opportunities for their own profession. My suggestion to you is to increase your own knowledge of the respiratory system and what to do besides just calling RT. Things are changing in health care and at some point it might be up to you to determine if a patient needs an albuterol treatment or oxygen. You might even have to start doing all of the treatments RTs do routinely just like other RNs have. Paramedics also don't call RT when they are on an emergency call. You can also look up the fact that the US and only a few areas in Canada use RTs. Nurses in Australia, NZ, UK, France and all the other countries do not have RTs. They might have someone who is a specialist in the respiratory/CV systems but they are usually educated at a Masters level or at least a Bachelors degree. Some of the RTs in the US do have Bachelors degrees but if their profession as a group has failed to push for recognition with the insurers and advance the profession as a whole, it is unfortunate for those RTs who do want higher standards. This link pretty much sums up my points. These are the reasons some RTs have moved on to be RNs or even Paramedics. Egan's Author Disappointed With AARC's Stance On 2015 This is a small quote: Calling the RTs ventilator jockeys are your words, not mine. At no point did I say RTs were uneducated and lacked indepth knowledge of the respiratory system. Do you really have your RTs giving your IV antibiotics or would you like to clarify that to RTs giving nebulized antibiotics which come in a plastic vial like albuterol? RTs can also give morphine by a nebulizer, not IV. EKGs and IVs can also be done by EMTs and ER Techs in the ER. RNs can also do those skills and in most hospitals, especially in the units and on telemetry floors, the RNs don't have to wait for an RT. Most RTs will also tell you they hate doing EKGs and have gladly turned them over to nursing. The issue here is that other health care professionals have advanced their education and knowledge of the respiratory system. An RN should be able to assess the respiratory system and determine the correct action without always calling respiratory. RNs on flight and CCT teams do this all the time. The RNs working in ERs, CVICUs and PACUs (other than yours it seems) have been assessing and determining the correct action for the respiratory part of their job for years. The people who write the regulations for Critical Access hospitals and long term facilities have determined there is no need for RT to be in house even with ventilators. These changes in health care were NOT the decisions made by me or Paramedics. Medicine changes and professions evolve. RTs have not increased their value in the eyes of the insurers. When reimbursement goes away, often so does much of that profession. Unless RT can show an increase in their value to those who control the reimbursement, their positions will become fewer. This is not new especially in the ER, long term care and on the hospital floors. But, if a profession does not grow or step up to the new demands of health care, don't fault others for creating opportunities for their own profession. My suggestion to you is to increase your own knowledge of the respiratory system and what to do besides just calling RT. Things are changing in health care and at some point it might be up to you to determine if a patient needs an albuterol treatment or oxygen. You might even have to start doing all of the treatments RTs do routinely just like other RNs have. Paramedics also don't call RT when they are on an emergency call. You can also look up the fact that the US and only a few areas in Canada use RTs. Nurses in Australia, NZ, UK, France and all the other countries do not have RTs. They might have someone who is a specialist in the respiratory/CV systems but they are usually educated at a Masters level or at least a Bachelors degree. Some of the RTs in the US do have Bachelors degrees but if their profession as a group has failed to push for recognition with the insurers and advance the profession as a whole, it is unfortunate for those RTs who do want higher standards. This link pretty much sums up my points. Lack of support for the profession is one of the reasons some RTs have moved on to be RNs or even Paramedics. Egan's Author Disappointed With AARC's Stance On 2015 http://rtfocus.com/wp-content/uploads/2015/06/Kacmarek-Presentation.pdf The whole presentation summing up their profession is pretty impressive. But, if very little of it is supported by the current RTs through their professional association, nothing will change and the profession stagnates. Right now Paramedics growing stronger in pushing through their legislation at least for Community Paramedics and CCT. I think nursing has had many of the same arguments in their history and still continue with the BSN debate. The message here is move forward or move over. I think nursing has had many of the same arguments in their history and still continue with the BSN debate. The message here is move forward or move over.

This is the article link from your first post. Why paramedics are qualified emergency care providers This is the first paragraph of that article so you can NOT say that article has nothing to do with the bills in Texas. You argued against the education and comments of the other Paramedic (Medic_5) who posted here. Most of the others posting have been EMT-Bs (like yourself) and nurses. You already posted this on an EMT forum and didn't get the responses you hoped for. You figured this would be a great place to stir up comments against Paramedics especially when many people will only read the headlines and not the actual article. So carry on with your mission against Paramedics who have gotten and education and who are trying to better their profession. Increase the divide between RNs and Paramedics when it should be coming closer together.

You make a statement but don't offer much else in support of RTs. I do know what they do from working on flight teams, orientating in the ICUs and working in the ER. Our Paramedic students are also required to shadow them for a day. That is where much is learned about how limited they are in some hospitals even though a few might want to do more. In the ER there are also a few RNs who had been RTs but moved on to BSN to have more opportunities, more money and be more involved in patient care. There are also many discussions on this forum which provide tons of info about what RTs and RNs do. Some of the comments and links are provided by those claiming to be RTs. One of the RNs and former RT still has an AARC membership and will show the discussions on that website which show frustration in that profession. The discussions on LinkedIn and RT FB pages also paint a troubling picture for that profession. There probably are RTs out there who still do a lot but health care is changing. RTs are being left out of the money for reimbursement. In Community Paramedic class, it is mentioned about RTs not being reimbursed for their time which is why only 1 or 2 RTs might cover a huge area for a DME. Let's just look at a few things learned by reading RTs websites, this forum and then checking with national sites like CMS. RTs are rarely in the ER except to set up equipment. RNs, Paramedics, Lab, EMTs (with phlebotomy cert) can draw ABGs. Paramedics, RNs and Lab can analyze them. RNs and Paramedics can assist with intubation by giving the medications and securing the tube. RTs will set up the ventilator if they are in house. C ritical Access Hospitals (small rural hospitals) may not have any RTs in house even with ventilators or BIPAPs in their tiny ICUs. RNs and Paramedics manage the setup and changes. RNs, Paramedics and EMTs can do all MDI and nebulized medications in the ER including the continuous ones. RNs and Paramedics can do the patient respiratory education in the ER. It is rare to see an RT in a free standing ER. This has been a big discussion on the AARC and LinkedIn websites especially after the KentuckyOne layoff of all RTs in that free standing ER. In the ICUs, RNs can draw the ABGs, talk to the doctor and then maybe call the RT for a ventilator change. Rarely are RTs required to be in the ICU. They usually just do a vent check twice a shift or every 6 hours. In some post op heart units, the RT will set up the ventilator but the RN will do the actual ABGs, iSTAT and ventilator management up to and including extubation. The same for some PACUs. RNs can do the retaping and manage the subglottic suction devices. Many of the ER RNs are Asthma and COPD Educators. Very few RTs bother to get the certificate since most of the hospital Asthma and COPD certs since the education is done by RN educators. Smoking Cessation will also fall to RNs since they usually will have the CTTS in their group. RTs are not always required to take ACLS, PALS or NRP. It is sometimes embarrassing to see some of the RTs who do take it struggle especially with the assessment and meds even though they attend a lot of codes. Many just focus on bagging and not what else is going on around them. RNs and Paramedics focus on the whole process. Very few RTs can tell you very much about the medications being given to a patient except for the RT meds even if their patient is being intubated and on a ventilator. Very few RTs are on transport teams and almost none on the adult teams. Even some of the big name transport teams are using less RTs now. If they do use RTs, they usually go through the Paramedic course and get their certs and licenses. Some of the Pediatric and Neonatal teams also have Paramedics to provide the intubation and assist the RN with the meds while the RT only does the ventilator setup. The RN and Paramedic may also do the iSTAT. Note I am using the word SOME. There are probably some RT departments who are managing to stay well staffed and keep the budget balanced but times are changing and RT seems to be one profession which seems to have stagnated. There was even a letter from a well know physician who blasted the AARC (the RT professional association) for doing too little to keep the profession alive. Most of my observations have been for the ER and clinics since that is where the most opportunities are for Paramedics. RTs have failed to get any bills passed to advance their profession. The telemedicine bill will probably help the RNs and Paramedics much more than RTs since RTs are limited for what they can do in outpatient settings. It is really easy to get to know another profession when it presents with lots of opportunities for yours. RNs have taken notes on what is happening in the RT world. Now Paramedics are seeing this. Too bad some RTs did not see some of this also. It is not personal. It is just the health care business and the survival of those who take the initiative to advance their profession. If you really insist I can link you to the AARC, LinkedIn and some FB RT discussions to confirm my statements. If you know any RTs, if they are members of their association, they can probably log you in for you to read the discussions on their forum. You can also use the search feature on this forum for RT vs nursing discussions where they compare what each do or overlap. Credit: I will give credit to the RTs, RNs and RN/RTs who helped me list some of the things on this post.

This post was very clear in its message about Paramedics in the ED. A Licensed Paramedic in Texas has a degree in Emergency Medicine. Very few nurses enter the ED with education or training in EM. Much of what Paramedics do in the field is also done in the ED. I don't see how you can say they are not appropriate for the ER. I will say again, READ the actual Bill in its final version which I posted tonight. Learn what a Paramedic is and what they can do within their scope of practice. This shouldn't be new to any of the RNs who are in TX and several other states either. I have utilized the search function on this website. There are many positive comments made by RNs about working in the ER with Paramedics especially when they can work at their full scope. But, if I was to use your argument, maybe all Flight RNs and CCT RNs should stay in the hospital and leave all of the transport situations to the Paramedics. Canada rarely has any nurses on transport and that includes the NICU. At some point you have to see how a team approach might actually benefit the patients.

I do like to present the facts which were not given by the OP in his initial post. Had some bothered to read the Bills which I linked at the beginning of this discussion, they would have known what was actually being discussed. The Bills presented were real. I fail to see how you can say that is irrational. I also work in the ER with nurses. I know what they can and can not do just like they know my job description for the ER. I am also proud to say almost all of them know what Paramedics do everyday for patients in prehospital and CCT. It seems some commenting here are taking a lot out of context because they do not know what a Paramedic actually does.

Are you saying you have no protocols in place to initiate anything before a doctor is contacted with your observations? Don't you have any protocols to titrate drips or get labs if you think they are needed? Giving oxygen? Do you have to call the doctor for all "orders"? If a patient came into the ER with chest pain or shortness of breath, can't you start some treatment under standing orders or protocols? Protocols can be used as guidelines and not merely recipes. The state scope of practice for a nurse can be extensive including intubation and initiating central lines but that does not mean YOU can do those in your hospital. Physicians rely heavily on Paramedics to assess and initiate appropriate treatment for a prehospital patient or the patient they want taken to another hospital who is in critical condition. Paramedics do not have labs, xrays and other professionals in the field. They must rely on their assessment and if they must call for medical direction, that physician relies on the Paramedic's assessment. Not all patient's are found within a few blocks of an ER and might be as far as an hour away. Now that the Community Paramedic is making house calls, the physician is also very reliant on their assessment to provide the correct continued care.

For an update on the legislation, this was posted on the Association of Texas EMS Professionals' website.

Summit is the OP but he has his own agenda to continue something which the ENA has already apologized for. I already posted a link to Carol Twombly's letter who represented the Texas (San Antonio Chapter) ENA. But here it is again. An Urgent Call To Texas EMS Professionals - Ambulance Driver Files I posted the links to the actual bills (Texas HB 2020 and SB 1989) earlier and you can see who the has sponsored the bill. This is really no different than those passed in other states where Paramedics can use their knowledge and scope of practice in the ER. It really is not that uncommon for Paramedics to start IVs, intubate and given medications when working in the ER. Paramedics should not be limited to just clerking as one nurse (nurseactivist BSN) here wants Paramedics to do. Read the links to the Bill and find out more detail. My state and the neighboring state, as I mentioned earlier, already allows Paramedics to work in the ER with their scope of practice. The ENA did apologize for Carol Twombly's letter and have worked with EMS to come up with wording agreeable to both. Ms. Twombly's strong words of opposition against Paramedics actually helped propel the Bill forward by bringing out such strong support (and from nurses) for the Paramedics after her letter was published nationally. Anatomy of a grassroots EMS movement The wording is nothing new and it is what Paramedics already do in other states in their ERs. One thing Summit's discussion did prove is that so few nurses are aware of what is happening in their world when it comes to pending legislation and then get an emotional knee jerk reaction if it is not to their liking. Carol Twombly's letter was sent to the members of the Texas ENA. I also posted the link to this legislation a few weeks before Summit started this discussion. Join your professional associations and find out what is going on in your part of the nursing world. You shouldn't have to hear about it from the EMS world first.

I don't get why you don't think you need a license. Granted it might only be a measure that you completed all the required testing and paid your fees to the state but it also defines your state scope of practice. In some way or another a physician is involved in your job as an RN. The hospital and the medical staff (physicians and nurse administrators) will then determine which of that scope of practice you will utilize in a hospital. The doctor designated as the medical director of that unit will then sign your protocols. This also works for every allied health department in the hospital. Each and every one of them has a medical director (physician) who determines their protocols and scope of practice for that hospital. You can find this paragraph in just about every nursing SOP manual. The protocol must be signed by the delegating physician and must be on file and available to the nursing staff. If the tasks or functions ordered fall outside the scope of the protocol, the extender must consult with the physician to obtain a verbal order before the RN may carry out the order. Regardless if you work in an ICU, ER or nursing home you will have a medical director who signs the protocols for that unit. Go to your protocols right now and see the name and title on them.

The only one calling RTs incompetent and useless is you. RTs have been vanishing from the ERs, transport and some other areas of the hospital for a long time now. They are great at ventilator management but they are specialists and with a very limited scope of practice when it comes to helping out in the ER except for the ventilators. RTs are stretched very thin in the hospital and for them to come to the ER, they must leave other patients. Many RTs would rather not have the ER as part of their assignment. It is also not fair to their other patients to have their treatments missed totally because the RT is tied up in the ER babysitting a ventilator. I will again tell you that Paramedics are not as uneducated as you make them out to be. I have quoted the Licensed requirement for Texas with the Associates degree in EMS required. A hospital can also require whatever higher education they want for a job. I have already made an issue about the skills thing when others tried going that route. Why is it so difficult for you to believe a Paramedic can have an education? An ambulance may only carry 30 medications and some carry more. CCPs and FP-C do carry more. But, if a Flight RN only has access to 40 meds on a helicopter, is that person less of an RN? Paramedics may only carry a few meds but that does not mean their education has been limited to only those medications. I would hope the ER doctors can do a FAST. US Techs usually work M-F 8 - 4. A CT Scan can be done if no US is available. But then there are small hospitals where the Radiology Tech is also the US Tech and is also on call after hours. Yes, Paramedics can be trained and educated to do US and Texas has had US on some ambulances for almost 10 years. I think your experience is very limited when it comes to EMS and the many different hospital settings. You started this discussion but you failed to address the real bill involved in Texas. You came to the nursing forum wanting to ruffle some emotions rather than addressing the real bill you referred to. You are trying what the ENA chapter president did in Texas and the ENA ended up apologizing for her. Now your post is more about name calling and personal attacks. You have no valid arguments. Paramedics have been in the ERs for decades and a few places allow them to practice to their full scope of practice and beyond in the ER. Texas just wants to give that a chance if there is a need in the ERs.

Do you have RTs just in the ER? What do they do? From your post it seems you still have to call them every time you want them. They still have to come to you which means they have to leave their other patients. Yeah, Paramedic students have to spend a day or two shadowing RTs in the hospital and get to hear all about this. I actually do know what happens to a patient after they are intubated in the ER and in the ICUs and in transport. Paramedics on flight teams do spend a lot of time in the hospitals. RTs are great at ventilator management in the ICUs but they are very limited in what they can do beyond that. Even on this forum the nurses have talked about doing all of their own RT procedures. I am not saying anything new. For the ER, and only in the ER, why have another healthcare professional with such a limited scope just hanging out or waiting to be called which could take 20 minutes to get to a critically ill patient in respiratory distress in the ER? You can't really say a Paramedic is replacing an RT in the ER when they are not there anyway. RTs will still be around in the ICUs. Do you see the RTs as an "EQUAL"? If you do, why can you not see a Paramedic as an equal team member? The bill in Texas is not about replacing RNs in any way. It is about allowing Paramedics to work in the ER with the same scope of practice they have on the ambulances instead of just being a tech do EKGs and cleaning patients. Is that really so hard for some to accept? How about a team player who can actually help the nurses? Doesn't anyone work with Paramedics now in the ER? Why do some think this it is so strange? Some hospitals like Vanderbilt have had Paramedics in their ER work to their full scope of practice for many years. Giving nebs and doing labs, including blood gases, are a huge part of a Paramedic's job in the ER already in some states. Texas just wants to get their state up to speed with others.