What can the prehospital crews do in your area?

[nfdfiremedic]

In my region, I find that the paramedics really have their hands tied. Before returning to nursing school, I was a firefighter/medic for years (as my screen name suggests... I've used the same SN since the 90's and never changed it.) I relocated to this region (midatlantic) after graduating nursing school, and the prehospital crews here operate under a different set of protocols than I used when I was working on the road. I am quite taken aback by how limited they seem to be here!

Paramedics here can give pretty much all of the ACLS drugs. They can not pace. They can not perform RSI and thus carry no drugs that could be used for this purpose. They carry Morphine but can only administer it with an order from the Med Control doc. They carry Valium (not Ativan) and can give one dose to patients only if actively seizing. They are not allowed to carry McGill's forceps to facilitate removal of visualized foreign bodies in the airway. They are not allowed to perform nasal intubations.

One of the ED docs I work with is on the committee that decides their protocols and, when asked about this says that he "Does everything in his power to limit what they are allowed to do" because of "the quality of paramedics around here." I'm a bit baffled by this answer. I would think that any such problems would be easily remedied by reforms to the paramedic curriculum and teaching methodology, not by severely limiting the scope of practice of this very important group of professionals.

What is within the scope of practice of the prehospital providers in your areas?

[usalsfyre]

The Paramedic scope of practice used to be a lot larger and several more advanced procedures were taught in the Paramedic class. If you look in the earlier editions of Nancy Caroline's book you will find pericardiocentesis, chest tube placement, retrograde intubation and subclavian central lines. You will also notice the drug boxes were quite heavy for all the ACLS meds and NaHCO3 was given when in doubt for everything.

Most of this was disproven by EBM/easiser methods became available. For instance, adult IO has nearly completely eliminated the need for prehospital central lines, pericardiocentisis is really just a shot in the dark prehospitally, bicarb and antidysrhythmics aren't all that useful in the short term and if your going to cut a throat to put a wire in, why not just perform a cric while your there?

But as more hospitals, trauma centers and HEMS programs developed, most of these advanced procedures were found to be unnecessary for every Paramedic service.

Don't get me started on the oversaturation of HEMS and trauma centers.

Lasix is another drug that is no longer considered necessary for every patient with crackles.

Even ED physicians aren't that great at determining when fuorsemide is needed, I wholeheartedly agree with it getting pulled off EMS units.

So, it may not be that your scope is being limited but rather all the skills and meds done by one service in rural nowhere, like Ada county, may not be appropriate who for an ALS truck which has a hospital within 10 blocks from anywhere in their area. Medicine also evolves to where some medications or procedures may no longer be considered as appropriate but for some in EMS who do not keep up with the current trends, they may just think their Medical Director is picking on them. We could also get into a discussion as to how much is too much on scene and when you have the point of diminishing returns come about.

Absolutely great points. Far too many medics seem to think that the end of medic school was the end of theri education.

[ImThatGuy, BSN, RN]

Could not caring enough to even read the protocols be a reason why some MDs don't trust their Paramedics? Some in TX thought they were above reading the protocols for RSI and ended up with some bad results especially for the patient.

Textbooks can vary and so can the instruction by the schools. Also, just because your state scope of practice says you can does not always mean you should. A Paramedic who might get one intubation attempt per year, either successful or unsuccessful, probably should not be allowed to do RSI. A Paramedic who has never intubated a child or done a cric but just read about these procedures 10 years ago in a textbook without any additional retraining probably shouldn't be bragging about how they can do everything either.

We used Brady texts. I didn't read them BECAUSE the class instructor (the only instructor) OWNED the ambulance services I worked for. He taught out of the books which was the way he paid his medical director to write the protocols.

FWIW, I wondered when you'd reply to that. I had you partially in mind when I wrote that first reply to the OP.

[TraumaSurfer]

We used Brady texts. I didn't read them BECAUSE the class instructor (the only instructor) OWNED the ambulance services I worked for. He taught out of the books which was the way he paid his medical director to write the protocols.

Now that is scary...

Your Medical Director seems to be a name only with no original thoughts.

Medicine evolves and the textbooks should be a starting foundation and not the protocol book. This is how recipe Paramedics function. Only one instructor which means you probably attended a trade school or a backroom at the ambulance company rather than a college. And, the owner of the ambulance service? This means: "his way or no way and this is the only way because I ain't never did it any other way which no way works better than my way" mentality. I can smell the 1980s.

By not reading the books and only relying on this ONE instructor's interpretation of the material, do you think there might be a chance you missed something?

[ImThatGuy, BSN, RN]

Now that is scary...

Your Medical Director seems to be a name only with no original thoughts.

Medicine evolves and the textbooks should be a starting foundation and not the protocol book. This is how recipe Paramedics function. Only one instructor which means you probably attended a trade school or a backroom at the ambulance company rather than a college. And, the owner of the ambulance service? This means: "his way or no way and this is the only way because I ain't never did it any other way which no way works better than my way" mentality. I can smell the 1980s.

By not reading the books and only relying on this ONE instructor's interpretation of the material, do you think there might be a chance you missed something?

Yep, in a rural area it's hard to find qualified people to make decisions. That's why I think you should move to Arkansas. We'd like you.

The guy was pretty sharp. He was on the governor's EMS advisory council and held some other seats. Was up for something with National Registry once I believe.

ETA: Who said I didn't read the books? I didn't read the protocol binder. I loved the text books.

[classicdame, MSN, EdD]

In my area they may do whatever they are licensed to do in the field, but the license stops at the hospital door. Do not know if States have varying scopes of practice. I have learned that EMTs/Paramedics have difficult in nursing school accepting the fact that they are limited BY LAW to perform tasks they know. Nursing philosophy is different that first responders. Just keep reminding yourself that once you have that nurse's license you will be a very valuable nurse.

[TraumaSurfer]

Yep, in a rural area it's hard to find qualified people to make decisions. That's why I think you should move to Arkansas. We'd like you.

The guy was pretty sharp. He was on the governor's EMS advisory council and held some other seats. Was up for something with National Registry once I believe.

No thanks. I prefer a Medical Director who is not in name only and who actually cares about the quality of care he is putting his name to.

Regardless of how many appointed positions the ambulance company owner has by the Governor (who is not a medical specialist of any type), he is not a doctor.

ETA: Who said I didn't read the books? I didn't read the protocol binder. I loved the text books.

You said you didn't read the books:

We used Brady texts. I didn't read them BECAUSE the class instructor (the only instructor) OWNED the ambulance services I worked for.

I take "them" to be in reference to the textbooks.

[TraumaSurfer]

In my area they may do whatever they are licensed to do in the field, but the license stops at the hospital door. Do not know if States have varying scopes of practice. I have learned that EMTs/Paramedics have difficult in nursing school accepting the fact that they are limited BY LAW to perform tasks they know. Nursing philosophy is different that first responders. Just keep reminding yourself that once you have that nurse's license you will be a very valuable nurse.

Every state has a different scope of practice and every county or EMS agency can have their protocols within that scope of practice but does not have to include everything. Medical Directors can limit them as they see fit.

Paramedics usually do not know how broad the scope of practice for nursing is. RNs in the hospitals have their own set of protocols from which they can act in emergent situations. Most states also allow RNs to intubate and place central lines as well as many other advanced procedures as their job description dictates. You have RNs placing PICCs in the hospital everyday in almost every state. You have L&D RNs intubating babies. You have flight and CCT nurses doing every skill a Paramedic can plus utilizing everything they have learned from their years of working in the ICUs. In an emergency, an RN also responds but with the equipment, medications and skills they possess. RNs also can work with medications that Paramedics can not and they can work in areas that Paramedics will probably never see. Chemotherapy, ECMO, post op cardiac, OR and many, many other places with unique skills and knowledge with many protocols are all within reach of the RN. Do not sell the RN short when it comes to knowledge and skills.

What a Paramedic who becomes a nurse must understand is that he or she will be part of a team. You can not just drop getting IV access to push a doctor or Respiratory Therapist out of the way to intubate because you once could. If they can not disassociate themselves for identifying their sense of worth or value with "a skill" then they probably should have stayed in EMS.

[ImThatGuy, BSN, RN]

No thanks. I prefer a Medical Director who is not in name only and who actually cares about the quality of care he is putting his name to.

Regardless of how many appointed positions the ambulance company owner has by the Governor (who is not a medical specialist of any type), he is not a doctor.

You said you didn't read the books:

I take "them" to be in reference to the textbooks.

No. Focus, son. Earlier you hounded me about not reading the protocols. Read through the posts again if you need to refresh yourself. The reference was again made to the protocols which were binded books and not the textbooks that you'd buy at the campus store.

Say, if you've got instant messenger I get bored a lot. I'd love to sit around and argue with you about random, meaningless stuff on Yahoo. The AllNurses folks kinda get bent out of shape with our constant bickering.

[TraumaSurfer]

about random, meaningless stuff on Yahoo.

I don't care to waste anymore time than the few occasional posts I do here with thinks minimal education and a no show doc are good enough for EMS.

[ImThatGuy, BSN, RN]

I don't care to waste anymore time than the few occasional posts I do here with thinks minimal education and a no show doc are good enough for EMS.

Well, I guess you sure told me.

[AnnieOaklyRN, BSN, RN, EMT-P]

Is this for specialized neonatal teams, which do have expanded scope of practice?

Or, is this for the field Paramedic? If so, what size lines do you carry and what meds can be given without X-Ray confirmation?

Cannulation with an IV catheter is discussed as an option for IV access but by no means is it the same as the long umbilical lines placed by neonatal teams.

No, this is for the regular 911 ambulance at the ALS level, UVC is at the paramedic level only of course, and no you do not have to be a paramedic on a specialized neontal team to do it. We can carry either umbilical catheters or use an IV catheter, it is up to the individual service to decide what they want to carry.

Fluids and whatever medications are needed, whoch for the most part would be Epi... If a neonate needs epi, I would guess that a hospital isn't gonna wait for xray confirmation either before pushing the med!

Happy

[TraumaSurfer]

No, this is for the regular 911 ambulance at the ALS level, UVC is at the paramedic level only of course, and no you do not have to be a paramedic on a specialized neontal team to do it. We can carry either umbilical catheters or use an IV catheter, it is up to the individual service to decide what they want to carry.

Fluids and whatever medications are needed, whoch for the most part would be Epi... If a neonate needs epi, I would guess that a hospital isn't gonna wait for xray confirmation either before pushing the med!

Happy

Before ever attempting to do this procedure, please review your protocol with someone who is very, very experienced with neonates. There are some very fundamental priniciples you are missing or you are just too cocky to realize the need for training for specialized procedures. Even if it is in your scope of practice, it may not mean you should do it when you do not know much about it. If you have never done one, when was the last time you reviewed the procedure? The same for doing a cric. Too many cause more problems because they rely solely on the training they has in Paramedic school 10 years prior and hadn't reviewed the procedure since.

As I mentioned before, UVC cannulation was taught in PALS and NALS (which still exists as a hospital version and not to be confused with NRP) for emergency use. However, the location of the tip of the UVC must be taken into consideration for what can be infused. The location of the UVC determines what can be delivered.