RN/firefighter policies and procedures

[ERRN324]

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.

[GreyGull]

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."

You might be surprised as to what Paramedics could do in the 80s and it wasn't just limited to one town.

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.

Physical Therapists are not considered technicians. The reason the education has advanced is to get placed into a professional category which can only benefit their future existence. Techs can be replaced and eliminated rather easily. We've already seen that in health care with LVNs, Respiratory Techs and ECG techs along with many others who didn't advance when their profession did.

Career Police Officers may not share your opinion about education being of any use either. Report writing and being able to express oneself in a courtroom as well as on the street in a professional manner are important. It also discourages those who just want the job for the uniform, badge and a paycheck. I can definitely tell the difference since a college degree has been encouraged for the local Police and Correctional Officiers.

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 don't know how much clearer I can state that I believe 600 hours of training is not enough unless they have some college level A&P and Pharmacology to go along with it.

I continue to feel that EMTs of all levels are learning enough for their scope. As I said much earlier, algorithmic health care 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.

You want the EMT and Paramedic to remain as techs who follow their recipes. That part is clear. Other professions, including nursing and a few Paramedics, do practice with guidelines rather than just follow the numbers.

If more in EMS did get an education, they might see where EMS got lost when it had such a great start to becoming a respected profession back in the 70s just like nursing, Radiology and Respiratory. There may have been less Fire vs everyone else debates.

Part of me wants to agree with you that Paramedics should remain as first aid techs with a little training and a few advanced skills but another part of me would like to see them become part of the health care professions. There are some very talented Paramedics and progressive departments that are better than the average. If you are in a very small town with very limited resources, you may not have seen a more progressive EMS agency.

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.

In your area this might be true. But, in other areas, the closest facility thing is only true for BLS units which are only transfer trucks in most situations. The more appropriate facility has been advocated in EMS for over 20 years. If the patient is a trauma and the patient meets trauma criteria, they are taken to a trauma center or a helicopter might be activated. If it is a STEMI, the Paramedics can usually decide to go to a facility that is a cardiac center. If the patient is having stroke symptoms, the Paramedics can also go to the Stroke Center facility. If you only have one hospital like in your area, I can see why you have never known Paramedics to be able to make decisions. But, not every area is like yours.

However, why should the RN be brought down to the level you are describing and must work under a lessor certification? Why not just allow protocols within the RN scope of practice written by a Medical Director or have state prehospital credentials using their educational foundation and whatever extra they need to work outside of the hospital? It beats just having a BLS truck with with only EMTs. If you believe EMS does not need education, most states will agree with you as do the Fire and EMS unions. However, does that mean every Paramedic in every area must be so limited especially in parts of the country where there is not a fire station and hospital on each block?

I also see in your profile "nursing education" listed. Is this a turf protecting issue for you which is why you don't advocate education for any other profession? I personally enjoy working with well educated professionals. The ICUs here have mostly BSNs and MSNs as well as a multidisciplinary team consisting of at the minimum of a Bachelors degree. It is really impressive since we can be in the cutting edge of new technology, evidenced based medicine and do some of our own research. Many of the Paramedics have their Associates in EMS and are working on their Bachelors. Yes, it might be for a promotion with the FD but it still makes for a much more professional group to deal with.

[CrufflerJJ, BSN, RN, EMT-P]

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.

Yup, I work in a nice hospital, in a relatively safe area of the country. MUCH nicer than when I was running as a street medic. I have yet to feel the need to wear a Level II or IIA concealed vest in my ICU, carry a folding blade knife (just to open things), a metal flashlight (purely for lighting purposes), or a 3oz canister of OC (just to spice up my food). This was my environment as a street medic, however.

Field EMS versus in-hospital treatment is different. Not better, but just different. A RN could certainly be a valuable addition to an ambulance crew, especially in long transport time areas of the country. I can also see how a RN given additional training on interventions (surgical cric, chest tubes, and the like...) might be beneficial I would just hope that any RN running with an ambulance crew would receive sufficient training to recognize the hazards present in what might appear to the untrained as a "secure" scene.

I guess we'll just need to agree to disagree re: the need/benefit for more extensive paramedic training prior to certification or licensure. Yes, a medic might recognize that an elevated WBC count is a potential indication for sepsis or infection. Unless their local protocol permits it, however, they are not going to give the pt loads of fluids in anticipation of septic shock, nor would they start a broad spectrum antibiotic. IF the pt presents with signs of shock, then the medic might start running fluids (we didn't carry Levophed on the ambulance, but some areas might). My old protocol, however, only had fluid boluses permitted in the case of shock (unless the medic contacted medical control first).

[GreyGull]

I guess we'll just need to agree to disagree re: the need/benefit for more extensive paramedic training prior to certification or licensure. Yes, a medic might recognize that an elevated WBC count is a potential indication for sepsis or infection. Unless their local protocol permits it, however, they are not going to give the pt loads of fluids in anticipation of septic shock, nor would they start a broad spectrum antibiotic. IF the pt presents with signs of shock, then the medic might start running fluids (we didn't carry Levophed on the ambulance, but some areas might). My old protocol, however, only had fluid boluses permitted in the case of shock (unless the medic contacted medical control first).

Thank you.

You have just provided the examples I needed to illustrate the difference between "trained" and "educated" Paramedics.

Without the additional education and retraining, there is no reason to increase the med list or protocols for a Paramedic.

I guess our EDs and hospitals are very different from yours. We even take the patients that the "street medics" bring in who they consider unsafe. We take prisoners. We take spouse beaters and we take gang members. We must be prepared for whoever wants our medical assistance.

[ImThatGuy, BSN, RN]

You might be surprised as to what Paramedics could do in the 80s and it wasn't just limited to one town.

Physical Therapists are not considered technicians. The reason the education has advanced is to get placed into a professional category which can only benefit their future existence. Techs can be replaced and eliminated rather easily. We've already seen that in health care with LVNs, Respiratory Techs and ECG techs along with many others who didn't advance when their profession did.

Career Police Officers may not share your opinion about education being of any use either. Report writing and being able to express oneself in a courtroom as well as on the street in a professional manner are important. It also discourages those who just want the job for the uniform, badge and a paycheck. I can definitely tell the difference since a college degree has been encouraged for the local Police and Correctional Officiers.

I don't know how much clearer I can state that I believe 600 hours of training is not enough unless they have some college level A&P and Pharmacology to go along with it.

You want the EMT and Paramedic to remain as techs who follow their recipes. That part is clear. Other professions, including nursing and a few Paramedics, do practice with guidelines rather than just follow the numbers.

If more in EMS did get an education, they might see where EMS got lost when it had such a great start to becoming a respected profession back in the 70s just like nursing, Radiology and Respiratory. There may have been less Fire vs everyone else debates.

Part of me wants to agree with you that Paramedics should remain as first aid techs with a little training and a few advanced skills but another part of me would like to see them become part of the health care professions. There are some very talented Paramedics and progressive departments that are better than the average. If you are in a very small town with very limited resources, you may not have seen a more progressive EMS agency.

In your area this might be true. But, in other areas, the closest facility thing is only true for BLS units which are only transfer trucks in most situations. The more appropriate facility has been advocated in EMS for over 20 years. If the patient is a trauma and the patient meets trauma criteria, they are taken to a trauma center or a helicopter might be activated. If it is a STEMI, the Paramedics can usually decide to go to a facility that is a cardiac center. If the patient is having stroke symptoms, the Paramedics can also go to the Stroke Center facility. If you only have one hospital like in your area, I can see why you have never known Paramedics to be able to make decisions. But, not every area is like yours.

However, why should the RN be brought down to the level you are describing and must work under a lessor certification? Why not just allow protocols within the RN scope of practice written by a Medical Director or have state prehospital credentials using their educational foundation and whatever extra they need to work outside of the hospital? It beats just having a BLS truck with with only EMTs. If you believe EMS does not need education, most states will agree with you as do the Fire and EMS unions. However, does that mean every Paramedic in every area must be so limited especially in parts of the country where there is not a fire station and hospital on each block?

I also see in your profile "nursing education" listed. Is this a turf protecting issue for you which is why you don't advocate education for any other profession? I personally enjoy working with well educated professionals. The ICUs here have mostly BSNs and MSNs as well as a multidisciplinary team consisting of at the minimum of a Bachelors degree. It is really impressive since we can be in the cutting edge of new technology, evidenced based medicine and do some of our own research. Many of the Paramedics have their Associates in EMS and are working on their Bachelors. Yes, it might be for a promotion with the FD but it still makes for a much more professional group to deal with.

Your scope is very narrow, and I don't understand your defensive posture. We're obviously not communicating here as I don't understand where many of the points in your last reply came from so I'm tired of bantering back and forth now.

Btw, if my profile says nursing education then my mistake. I probably clicked on something and then scrolled down and the box landed on that. I'm not even a nurse, lol.

[CrufflerJJ, BSN, RN, EMT-P]

Thank you.

You have just provided the examples I needed to illustrate the difference between "trained" and "educated" Paramedics.

Without the additional education and retraining, there is no reason to increase the med list or protocols for a Paramedic.

I guess our EDs and hospitals are very different from yours. We even take the patients that the "street medics" bring in who they consider unsafe. We take prisoners. We take spouse beaters and we take gang members. We must be prepared for whoever wants our medical assistance.

You're quite welcome! Always glad to help provide examples. As to trained vs educated, don't forget to include "permitted by protocol" versus "get your tukas handed to you if you exceed the allowed limits of protocol." Please don't confuse operating under a narrow scope of practice/protocol versus being uneducated.

I'm not quite sure where you got the idea that my hospital doesn't accept prisoners, spouse beaters, gang members,.... My hospital ICU is definitely a safer environment for the caregivers than my prior environment, but it's not utopia.

You had briefly mentioned in a prior post about how to stop getting notifications each time there's a reply to your posts. In case anybody else hasn't let you know, this can be done by:

- click on "My Account" (top left of the screen, to the right of your username)

- click on "Edit Options"

- under "Default Thread Subscription Mode", change this to whatever your heart desires

If you're logged on & want to see if there have been any replies, just click on My Account, then My Posts. Any post with a reply will have a green icon next to it.

[GreyGull]

Your scope is very narrow, and I don't understand your defensive posture. We're obviously not communicating here as I don't understand where many of the points in your last reply came from so I'm tired of bantering back and forth now.

My scope narrow? Not near as narrow as what you have described. It sounds like EMT-B is the highest level in EMS for you. Here we utilize mostly Paramedics and RNs with very liberal protocols.

Btw, if my profile says nursing education then my mistake. I probably clicked on something and then scrolled down and the box landed on that. I'm not even a nurse, lol.

No kidding?

If you want me to clarify any of the points I made in the previous posts, just ask. Not knowing any of your background I can see where the different titles and protocols might be confusing.

[GreyGull]

You're quite welcome! Always glad to help provide examples. As to trained vs educated, don't forget to include "permitted by protocol" versus "get your tukas handed to you if you exceed the allowed limits of protocol." Please don't confuse operating under a narrow scope of practice/protocol versus being uneducated.

Unfortunately the protocols will be set for the least educated or training. If the minimum required is 600 hours from a 10th grade Paramedic text, that is the level the Medical Director will have to adjust his/her protocols to even if several Paramedics might hold degrees. If the Medical Director tries to set higher standards, opposition from the FD or EMS unions may become a limiting factor. EMS has become too fragmented in education for many reasons including the agendas of the special interest groups.

With nursing, there are certain classes that will be common to all within the 2 year degree. That is at least a decent foundation for the nurse to use and gives managers a starting point to build from where more education is needed. Generally the nurse will have a recommended path to follow if they want to be successful in a specialized unit. For the states that have prehospital credentials for RNs, there are specific requirements. The same goes for the states that allow RNs to function under their own license on an ambulance with some EMS protocols from a Medical Director.

[ImThatGuy, BSN, RN]

Thanks for trying to make yourself look better. :)

[GreyGull]

Thanks for trying to make yourself look better. :)

Do you have anything constructive to offer or a rebuttal that says something different? You have made it clear about how limited EMS is in your area and you seem to be fine with that. Don't restrict others to what you view to be "good enough".

[NurseGizmo]

I have spoke with the California RN board regarding RN's working in a lower lisc. position but with an RN lisc. I have an Lisc. RN working as an LVN. According to the Bon. The scope she must work under is the lvn. However she will be held accountable as an RN is any issue arises.