RN/firefighter policies and procedures

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i'll try to keep this short. i am an rn who works in the emergency department. i am also a volunteer firefighter. while we don't run medical calls our district is along a very busy interstate and we run many many mva's. what can/can't i do without a medical director over the fire department? can i do anything? basically all the local ambulance company ever asks me to do is start iv's, assist with spinal immobilization, bag patients, splint fractures, and the like... the two that worry me are iv initiation and splinting. i am very capable of both tasks and the ambulance company always asks for my help (it's a small area and the medics know me well from the er). i don't mind helping them out but don't want to go out of my scope. with that said, what if a local doctor wrote standing orders and we had policies and procedures for me to do basic things like saline locks and place oral or nasal airways? thanks for the help.

12 Lead is still relatively new to EMS. I got into EMS in 2001, and 12 lead didn't come about here until 2005-06. I think 50% is an incredible number.

Also, emergency medical technicians aren't meant to have a large scope of knowledge. They're technicians. Procedures and algorithmic approaches to patient care serve that level of education / training well.

So many people want to "advance" EMS these days and make it some type of primary care organization which is ridiculous. Remember the "profession" was devised due to automobile collisions (emergencies), and rather than just scooping the bodies up off the pavement EMTs were given a basic set of skills to prolong their lives until they could get them to definitive care. Now we "stabilize." Later heart attacks (more emergencies) came in as being the leading cause of death so it was time for EMTs (now paramedics) to learn to do something about that as well. Ever seen the tv show Emergency? Squad 51! Paramedics were new at the time. The show took two rescue technicians / firefighters and put them through a hospital-based course of training that lasted all of like three weeks, lol. I think it's phenomenal that it takes about two years now to become a paramedic. I think all in all they're doing a good job. I wish all the people going to community college, etc to become paramedics would get at least an associate's degree out of the deal with courses in A&P and so forth. I favor educational classes too like English, social sciences, and others like those. More "understanding" would be great, but EMS doesn't pay enough to keep people that crave more understanding and education. The activists for the profession are a rare breed, and the people like you seen on here from EMS were those that craved more understanding (and possibly a change of atmosphere) so they studied more, got another degree out of it, and ended up with a job that paid more.

DOT establishes curricular guidelines for EMS, and I wish they were much more uniform.

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Ever read this little article? Many states, ambulance services and FDs still live by it. It gets passed around alot on the forums and has been used as a valid argument when the idea of more education gets mentioned.

http://www.fd-doc.com/2000Hours.htm

Freedom House ambulance service in Pittsburgh was around well before Emergency! hit the airwaves and had Paramedics. Miami FD also got their Paramedic program going in the mid 1960s to shock hearts and provide ETI.

12-lead ECGs have been around since the early 80s when prehospital thrombolytics were also trialed. Interesting times for EMS but the ball was already dropped for advancement. Also, the "stay and play" on scene seems to again be replaced with do what you can and do the rest enroute with very little emphasis on fluids and ETI. Of course if this was followed, the need for a life threatening ride with lights, sirens and speed could be avoided. Too many stay on scene messing around with multiple attempts at IVs and intubation or trying to get a BP with just fluids when they could have a comfortable ride during transport. Either way the providers probably won't be restrained in the back so I'd rather have a more controlled ride rather than a "hold the hell on" one.

EMS had every opportunity to pass up nursing with getting a degree established for entry while the diploma nurse was just starting to go to the curb in the 70s. Nursing also didn't start getting their professional recognition until they established their degree. Even now with just a mere 2 year for entry nurses are way behind the other professions. Their pays still is pathetically low in many areas especially for some of the nurse:patient ratio. This is when I got my start and it has been interesting to see EMS actually go backward in so many ways this it is almost destined to remain a certificate and an add-on for the FD. With the limited scope, protocols and skills for EMS, I am all for it remaining in the FDs but not for having 4 vehicles rushing to every scene. Fire should transport and dispatch centers should be able to screen calls like the nurse led systems being initiated.

The professions that have raised their education levels to higher degrees eventually saw their pay increase as they were able to lobby with their education and how it could benefit the patient.

This was an interesting thread. PTs, OTs and SLPs with high minimum education levels are having no problems with being recognized as professionals and finding employment. RTs are also moving up to the Bachelors in some areas of healthcare if their Bills pass for Medicare.

https://allnurses.com/general-nursing-discussion/health-care-jobs-498173-new.html

Now for EMS, raising the pay will not increase professionalism. It will just give more money to an already flooded industry which delights in having a low entry to an exciting profession. The turnover comes from disillusioned EMTs/Paramedics who find out patient care is not all about glamorous saves. There are still many volunteer agencies that could be argued as more professional than the paid. The states that have RNs in the EMS statutes also have many volunteer services. Placing a nurse on what would otherwise be a very basic BLS truck can have its advantages to provide at least some advanced care in the middle of nowhere.

There are a couple of posts in other sections on this forum such as Emergency and Flight that are interesting and restate what is known about EMS.

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Just because 12 lead has been around since the 80s doesn't mean EMS had it. Heck, in the 80s our EMS didn't have any kind of cardiac monitoring capability, and I'm from a city of about 27,000 in population. The hospital probably had one or two monitors. There's one remaining captain in the hometown PD where I started out in LE who remembers when the police department ran the ambulance service. Two officers would get radioed to return to the station, get in the station wagon complete with first aid kit and oxygen bottle, and leave there to pickup whatever poor, mistaken person called for the ambulance.

I think paramedic school could've been shortened a lot too. I had a sciencey background before going into it so a lot of the concepts could've been rushed. However, for the many others that had been out of school for 20-30 years the extra time was necessary. I think if EMS only did what EMS started out to do then it'd be ok to minimize the training down from what it is today. I think interfacility transports personally should be left to nurses. With IV pumps, meds that medics don't know squat about, ventilators, etc it's a nurse's field. I had to transport a woman once that required nearly a ream of paper to report everything she had going on with her. All kinds of stuff was hooked up to her, and the only instructions I got was "don't touch her belly or she'll pop." She looked like a drowned person before they rupture, but she hadn't drowned. Thank you bacteria.

I've never been a "stay and play" kind of guy. I can't stand watching medics sit parked in the ambulance trying to get IVs, etc when they could've driven to the hospital and back in that time period.

Personally, I like the idea of FDs having EMS as well, but if that were the case all the time then I wouldn't have ever worked as a medic. Thinking back...maybe that wouldn't have been so bad, lol. ;) However, I know several firefighters who hate doing EMS stuff. I grew up in a town where every fireman had to be an EMT, and a percentage of them had to become medics with all of a 50 cent hourly wage increase.

I don't like PTs moving to a DPT, and I don't like NPs moving to a DNP particularly this latter one. I don't understand what was wrong with the five year B.S. for pharmacists. Increase the education to increase the salary, but you've got to increase billing for that so the patient pays more...or doesn't and then there's even more to write off.

Oh, I didn't say Johnny and Roy were the first medics. I just noted that the field was new when they got on board.

The reason I don't work in EMS anymore is because I actually don't like riding in the back of ambulances, lol. Go figure. ;)

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Just because 12 lead has been around since the 80s doesn't mean EMS had it.

I was referring to 12-lead ECGs and thrombolytic trial in EMS.

Heck, in the 80s our EMS didn't have any kind of cardiac monitoring capability, and I'm from a city of about 27,000 in population.

Now that is a little behind for the times even for some of the rural areas. LifePak 2 was around by 1972.

Alabama had Automatic defibrillators by the mid 80s and were training LEOs to use them..

I think paramedic school could've been shortened a lot too. I had a sciencey background before going into it so a lot of the concepts could've been rushed. However, for the many others that had been out of school for 20-30 years the extra time was necessary.

I think 600 hours is short enough. Even 1000 is very short when there is not a college level A&P class as a prerequisite.

I don't like PTs moving to a DPT, and I don't like NPs moving to a DNP particularly this latter one. I don't understand what was wrong with the five year B.S. for pharmacists. Increase the education to increase the salary, but you've got to increase billing for that so the patient pays more...or doesn't and then there's even more to write off.

Don't be so anti-education.

If you knew how broad the field of PT is and the material they cover, even a Masters or DPT is not much.

Their contribution to getting the patient out of the hospital and into a more independent living situation is invaluable. The tech mentality did nothing to move patients through a system faster or to get a goal for decreasing level of care. That decreases medical costs tremendulously if the patient can become productive again and doesn't need a nursing home. RTs also have proven their stance for higher education from the tech to therapist in reducing vent days and protocols for patients on the floors for teaching and transition. However, with just an Associates degree, their knowledge is limited. The Bachelors will give them a broader stance in the professonal world and a chance to expand into other areas. Again, techs serve a very limited purpose in medicine. Medicine is constantly changing and NPs saw this many years ago and knew they had to advance their education. The DNP has been around for over 15 years. Now that it is about to become official for entry, people are just now noticing. Higher education is not new for clinical specialists or those in academia. EMS might be able to stay the same for 45 years but other professions don't.

Also, when all the other professional services that are non-medical require at least a Bachelors or Masters, why shouldn't the medical professions have that level for entry. I would never consider having my taxes or major legal matters taken care of by someone with a 600 hour cert or even a two year degree. I want an Accountant who has a degree and credentials of higher education for professional certification.

The reason I don't work in EMS anymore is because I actually don't like riding in the back of ambulances, lol. Go figure.

Unfortunately many RNs get stuck in the back of an ambulance from the ICUs or EDs without being part of a transport team. They are tossed in there because the Paramedics can not take critical patients and the meds or technology. The Paramedics or the MDs insist on RNs accompanying the patient. Thus, to get the patient safely from point A to point B, the RN must go and make the best of it. For those situations it is perfectly fine for an RN to be placed in an unfamiliar truck and take responsibility of the patient. But, for simple first aid they are considered to be out of their league.

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I'm not anti-education, but there are fields where I don't believe a doctorate should be required to do something. I also don't feel like most EMTs that I know are people interested in higher education. After leaving the fire academy here one could easily get an associate's in fire science with a few liberal arts courses, and then they could go on and get a bachelor's degree from somewhere. However, few are interested. The police academy is the same way. They're all important technical jobs that operate under similar instances. I don't think requiring a myriad of degrees for them serves the purpose. I never worked as a medic or cop without a bachelor's degree. I went to college because I wanted to, and I got into those jobs because I wanted to. Each and to their own.

I read what you said about the thrombolytics trial and simply pointed out that just because 12 leads existed on the earth doesn't mean EMS had them.

As for the rest, I'm not sure what your stance is regarding EMS education. You seem to favor more education and yet a shorter training period as well.

It's sad that the RNs get stuck there. I've been stuck there too. Interfacility transports aren't fun. I think hospitals should have a transport team specifically for that purpose with staff that come on the job willing and able to ride around in the back of an ambulance from hospital to hospital. They wouldn't be on the road all the time so they could stay in the ER or ICU. Just a thought of mine.

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Specializes in ICU.
Ever read this little article? Many states, ambulance services and FDs still live by it. It gets passed around alot on the forums and has been used as a valid argument when the idea of more education gets mentioned.

http://www.fd-doc.com/2000Hours.htm

I've not seen that article before - thanks!

After reading the article, I firmly agree with the author. I was a chemical engineer for 22 years, and a volunteer EMT/Paramedic for 19 years (in my "copious free time"), before going through a carefree, relaxing (?!?) Accelerated BSN program.

I don't recall how many hours were required for my medic certification (back in 1991 or thereabouts), but I think it was ~1000 hours. I believe that some states (such as CA or TX) require many more hours than OH. I'm not convinced that the subject matter covered during the additional hours of training REALLY matters during EMS practice on the street.

I know that the NREMT has updated their exam since I graduated, many moons ago. As a NREMT skill station examiner for the paramedic certification over umpteen years, I regularly spoke with former instructors & people who had recently gone through the program.

I see ZERO value in some of the stuff being taught (for an Associates degree in EMS) to paramedic students. Why should a street medic be required to know the various flavors of white blood cells, for example?

The author of the referenced article is 100% correct that street medics need to KNOW :

1. Advanced Airway management; 2. Intravenous access; 3. Cardiac monitoring; 4. Medications.

To this, I would add Scene Size-Up (AKA - how to keep from getting killed).

This knowledge should be oriented towards a reality based system, rather than any sort of "pie in the sky" cutesy, "nice to know" system.

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Specializes in Nephrology, Cardiology, ER, ICU.

I live in IL and am both an advanced practice nurse as well as a pre-hospital RN (a true license in IL) and a volunteer FF/EMT.

I would suggest consulting with your EMS director. In order to be legally covered (at least in IL), you need something in writing. Otherwise, you might find yourself practicing outside the scope of practice of a FF.

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Specializes in ICU.
The Paramedics or the MDs insist on RNs accompanying the patient. Thus, to get the patient safely from point A to point B, the RN must go and make the best of it. For those situations it is perfectly fine for an RN to be placed in an unfamiliar truck and take responsibility of the patient. But, for simple first aid they are considered to be out of their league.

Unfortunately, "simple first aid" is not always just simple first aid. For facility-to-facility transports, what you see may be what you get. For on-scene care, a head lac is not always just a simple head lac. It might be the result of an accident, an assault, or a domestic violence (DV) situation.

As you may know, there's a world of difference between how you might manage a DV situation in a well staffed, nicely lit, safe & secure (hopefully!) ER, versus in the back bedroom at the end of a hallway of a gungy house out on the west side.

There's a world of difference between how you'd manage the driver involved in a motor vehicle crash when the person is pinned in the wreckage versus nicely packaged with a backboard/KED/CID, laying on a hospital bed. Yes, an ER RN might know how to avoid/minimize c-spine manipulation, but what about your regular ICU or med-surg RN?

There's a world of difference between how you'd manage the victim of penetrating trauma in the ER versus on the street.

Care of the patients themselves may not be all that different. How you as a street medic handle the environment (& bystanders), however, can make the difference between going home at the end of your shift...or not.

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I'm not anti-education, but there are fields where I don't believe a doctorate should be required to do something. I also don't feel like most EMTs that I know are people interested in higher education. After leaving the fire academy here one could easily get an associate's in fire science with a few liberal arts courses, and then they could go on and get a bachelor's degree from somewhere. However, few are interested. The police academy is the same way. They're all important technical jobs that operate under similar instances. I don't think requiring a myriad of degrees for them serves the purpose. I never worked as a medic or cop without a bachelor's degree. I went to college because I wanted to, and I got into those jobs because I wanted to. Each and to their own.

Until you've seen what highly educated professionals like PTs can do for rehab patients, I wouldn't complain about their education level. Their DPT is not much different than a lawyer's education where at least a Bachelor's is required to enter the program. However, the difference in professionalism and the results for the patients is noticable. They've also expanded themselves out of the hospital which makes them even more attractive to insurers and of greater benefit to patients. I can definitely see a need for many of the classes most believe to be useless because of their extensive documentation they must do for insurers. The sooner they can also justify their position with starting rehab early in the ICUs and even while the patient is still on an ICU ventilator, the more progress that patient can make for a shorter stay. The sooner SLPs can evaluate and start working with patients, the faster they may get decannulated from a trach or be prevented from having one. I can't stress enough the importance of having a highly educated multi-disciplinary team working with patients and reducing their disability and length of stay.

Several PDs are now requiring at least an Associates degree for entry. FDs want a Bachelors for promotion. Education is still viewed as value even in this so-called technical skilled professions.

I read what you said about the thrombolytics trial and simply pointed out that just because 12 leads existed on the earth doesn't mean EMS had them.

I am trying to tell you EMS had 12-lead ECG when they did the thrombolytic studies back in the early 80s in EMS. 12 lead ECGs were on ambulances in the 80s. Thrombolytics were also trialed on ambulances in the 80s.

As for the rest, I'm not sure what your stance is regarding EMS education. You seem to favor more education and yet a shorter training period as well.

If you read my posts, I clearly stated 600 hours is not enough but then if EMS remains as it is, then it may be more than enough. However, at the very least a college level A&P class (2 would probably be too much to ask) should be the prerequisite to those 600 hours.

It's sad that the RNs get stuck there. I've been stuck there too. Interfacility transports aren't fun. I think hospitals should have a transport team specifically for that purpose with staff that come on the job willing and able to ride around in the back of an ambulance from hospital to hospital. They wouldn't be on the road all the time so they could stay in the ER or ICU. Just a thought of mine.

Agree. But the patients the RNs here must go on are those that EMS brought to the closest facility's ED rather than the more appropriate facility a half mile away. An IV with a med or two might be started quickly and then the RN must go. For most ICU transfers, many of the larger facilities do have their own staff of RNs that do the transports from the smaller hospitals.

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Unfortunately, "simple first aid" is not always just simple first aid. For facility-to-facility transports, what you see may be what you get. For on-scene care, a head lac is not always just a simple head lac. It might be the result of an accident, an assault, or a domestic violence (DV) situation.

Aren't RNs now dealing with domestic violence and assaults in the hospital? In fact with the large number of patients they are responsible for and without the Police present at all times, they are at high risk. Just because someone is an RN doesn't make them incapable of learning a few basic first aid procedures. However, I do see it as a conflict of license to be forced to work under a low level cert such as an EMT. If you break down an EMT course, how much time is actually spent on heavy extrication or even each skill? Their ride time on an ambulance is only about 8 - 10 hours and the same for the ED. By the time they take the CPR portion, do a little classroom work on very basic anatomy and rules, there is not much time spent on even the skills like taking a pulse and BP.

As you may know, there's a world of difference between how you might manage a DV situation in a well staffed, nicely lit, safe & secure (hopefully!) ER, versus in the back bedroom at the end of a hallway of a gungy house out on the west side.

You must work in a very nice hospital. Not all are like that. Those in a hospital will also not always have the Police Officers who will enter the room first with their guns to make sure the scene is safe. In many areas, PD is dispatched with the ambulance to certain locations and types of calls. EMTs also will not have to deal with a patient or several in DTs for 12 hours or the combative patient they brought in after just 15 minutes of being with them. The patient doesn't all of a sudden become a gentleman once in the ED. Generally their behavior will continue to esculate. When was the last time an EMT had to deal with several abusive patients at one time for many hours and many shifts? And do the charting to prove they were well cared for? That patient may be in the hospital for several days with his charming personality abusing the staff verbally and physicially. In a hospital, the patients have more rights than the staff and will be treated with kid gloves.

There's a world of difference between how you'd manage the driver involved in a motor vehicle crash when the person is pinned in the wreckage versus nicely packaged with a backboard/KED/CID, laying on a hospital bed. Yes, an ER RN might know how to avoid/minimize c-spine manipulation, but what about your regular ICU or med-surg RN?

Where do you think those patients with C-spine injuries go to after they leave the ambulance? The C-spine doesn't magically heal itself. That patient may be on spinal and mobility precautions for days to months in many areas of the hospital and SNF.

There's a world of difference between how you'd manage the victim of penetrating trauma in the ER versus on the street.

Care of the patients themselves may not be all that different. How you as a street medic handle the environment (& bystanders), however, can make the difference between going home at the end of your shift...or not.

It is medicine. Some in EMS either never learned that or forget it. Do you not think nurses don't have situations with angry bystanders and family members as well as the patients?

Nurses are very capable of learning a few new skills and adapting to a different environment.

I never said nurses are out to replace EMTs and Paramedics. However, I do believe their skills and knowledge can be utilized in some areas by protocols from a Medical Director to allow them to be useful. Not every EMS system consists of hundreds of Paramedics.

The rural regions of this country could definitely be benefited by having an RN respond instead of just EMT-Basics. Fortunately a few states have realized this.

I believe that some states (such as CA or TX) require many more hours than OH.

TX is only about 600 hours and CA is about 1000. CA probably is the one state that limits the scope of practice of their Paramedics to what it should be for someone with that little education and training.

I see ZERO value in some of the stuff being taught (for an Associates degree in EMS) to paramedic students. Why should a street medic be required to know the various flavors of white blood cells, for example?

Why shouldn't they know college level anatomy? As far as the WBCs, if a nursing home is saying the elevated WBCs are the reason for transport, a Paramedic could then know that an infection or sepsis might be an issue and actually initiate some type of treatment for the ride into the ED.

Although, the more I read these posts, EMS should probably just give the patients a fast ride to the hospital and perform the few interventions they might have for just the obvious. The list of things they can do also seems to be getting shorter. I remember when Paramedics could do a lot more.

I am all in favor of more states changing their statutes to allow RNs get their own prehospital credential through training that doesn't assume they have never touched a patient before. Then there might even be the basis for Emergency Care Practitioner like in the U.K. although at that level it would be closer to the NP.

I do not believe an RN should have to forget their license to work as an EMT-Basic. Will the EMT cert actually protect them or will a court see the RN license and education as "should've known better" regardless of the EMT protocol?

I don't like being argumentative but I also don't like RNs to be stereotyped as all helpless weak females who couldn't possibly work outside of a sterile environment.

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The author of the referenced article is 100% correct that street medics need to KNOW :

1. Advanced Airway management; 2. Intravenous access; 3. Cardiac monitoring; 4. Medications.

Texas does model some of its programs after the less is better theory although for some reason they offer the title of Licensed rather than certified to a Paramedic who has an Associates degree in almost anything but science or medicine.

This is an example of the TX Paramedic program.

http://www.teex.org/teex.cfm?pageid=training&area=TEEX&templateid=14&Division=ESTI&Course=EMS135

The total hours for each class are 624 hours and are divided into 240 didactic/lecture, 192 hospital clinical, and 192 ambulance internship.

The prerequisite is EMT-B. No college level A&P or Pharmacology required. No English or Math.

All the time spent on the ambulance rotation might be of little value if they only see a couple of patients. Their experience in the ED may also vary from doing a few patient care things to waiting in the nurses' lounge for a trauma.

Now I must figure out how to disable the email notification so I don't spend so much time here.

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Until you've seen what highly educated professionals like PTs can do for rehab patients, I wouldn't complain about their education level. \

What makes you think I don't know?

I know the difference between preferred and required education for technical professions. You're not the only one who can read. I've hired enough people to gauge required and preferred. Police officers don't need college degrees. I'd love for them all to have them, and many do, but like EMS it's a field where academic types don't tend to gravitate.

I continue to understand what you're trying to tell me about 12 lead, lol. I'm just making a sweeping statement along the lines of "it may have existed in a town near you but not everywhere else."

I've read your posts and can keep this up through the weekend if you like. Nonetheless, your position on requisite education for EMS hasn't been obvious.

I continue to feel that EMTs of all levels are learning enough for their scope. As I said much earlier, algorithmic healthcare suits the occupation. There's a lot of nice to know information they could learn. I love knowing that type of thing, but it's not for everyone. There are certain essentials. I do believe one should understand a drug and its effects rather than simply pushing it because it's next on the ACLS list. Unfortunately, there are many out there, at all levels of healthcare actually, that just go through the steps. Knowledge is great, but lengthening the education period for EMS isn't a great solution for changing the field.

Down here it's rare for an EMS agency to have more than one hospital to take a patient to. That said, it's usually policy to take someone to the closest facility. That's a policy issue and not that of the EMS staff. Likely, you'll need to contact their medical direction for change in that regards.

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