air transport staffing position statement (Pg 1 of 2)

[niko327]

Interesting reading............

EMERGENCY NURSES ASSOCIATION AIR
&
SURFACE TRANSPORT NURSES ASSOCIATION JOINT POSITION STATEMENT
STAFFING OF CRITICAL CARE AIR MEDICAL TRANSPORT SERVICES

STATEMENT OF PROBLEM

There are no nationally supported minimum standards for the qualifications of health care providers actively participating in the air ambulance transport of critically ill and/or injured patients.

SIGNIFICANCE

Currently, resources are available to all geographic areas of the United States for the provision of air ambulance transport, either helicopter and/or fixed wing, of critically ill or injured patients. Each air medical transport program provides services to a large geographic area usually encompassing multiple counties and often several states. Policies and regulations regarding the provision of patient care may vary significantly from one political area to another. Air medical transport of critical patients requires highly sophisticated, specialized, medical and nursing knowledge and clinical skills to assure the provision of an adequate level of care. Medical care providers referring and receiving patients and also public consumers utilizing air transport services should be able to expect a nationally consistent level of care.

The number of air medical transport services throughout the country establishes a significant need to develop minimum standards for the qualifications of air medical care providers that will be nationally endorsed and supported. To assure the provision of appropriate aeromedical care to the consumers of these services, the skill and training of the personnel must be commensurate with the rapidly advancing sophistication of methodologies and equipment for providing critical care in the complex environment of air transport.

BACKGROUND

The initial use of helicopter and fixed-wing transport of critically ill and/or injured patients in the modern sense can be traced primarily to the military experience during the Korean and Vietnam conflicts. Helicopters were utilized to rapidly transport wounded soldiers from the battlefield to field hospitals. Although physicians were occasionally used on an experimental basis in these settings, military medics were the principal care providers on the evacuation helicopters. Once initially treated at field hospitals, some patients were later transferred to larger facilities in Southeast Asia and the U.S. with military flight nurses on large fixed-wing aircraft.

Civilian use of this concept in the U.S. began in the mid to late 1960's with the informal initiation of several private and public service operated fixed-wing and helicopter transport services. These early services utilized a variety of medical crew members including physicians, nurses and prehospital personnel.

The first formal hospital-based helicopter transport service was initiated in October of 1972 at St. Anthony’s Hospital in Denver, Colorado. By June 1986, there were approximately 140 hospital-based helicopter transport services (HBHTS) in operation throughout the United States. Most HBHTS provide services within a 130-mile radius from the base facility. For those programs also providing hospital-based fixed-wing transport services (HBFWTS), the primary service area is usually extended to approximately 500 miles from the base facility. Several HBFWTS services also routinely provide transport to all areas of the continental U.S. and to international and intercontinental locations.

The growing demand for highly sophisticated air medical transport services has, in part, been the result of the rapidly growing technological complexity of medical care for critically ill and injured patients. The most sophisticated and technologically advanced treatments are only available at regional referral centers usually located in large metropolitan areas. A need was created, therefore, to transfer those patients requiring such care to the regional referral centers. Because of the distance and time involved and because of a need to maintain a comparable level of care during transport, critical care air

medical transport services were found to be best suited to accomplish the patient transfer.

In 1984, the National Flight Nurses Association (NFNA) now the Air & Surface Transport Nurses Association (ASTNA) conducted a survey of all 103 hospital-based air medical transport services in operation at that time. Of the 83 services that responded, 46% provided both fixed wing and helicopter transport services. It is important to note that 97% of the responding 83 services utilized registered professional nurses as routine members of the medical flight crew. The medical crew configurations were reported as follows:

One RN 20%

Two RN 15%

One RN/One Staff MD 14%

One RN/One Resident 7%

One RN/One Paramedic 27%

One RN/One Physician Assistant 3%

One RN/One Respiratory Therapist 5%

Paramedics Only 3%

The 2000 Medical Crew Survey published in the September/October 2000 addition of

the AIRMED Journal surveyed 358 air medical service providers worldwide. Of those, 119 U.S.-based programs and one international program completed the survey, a 33.5% response. In both helicopter and fixed-winged aircraft staffing missions with two medical attendants (97 %) remains the standard and 97% have an RN as part of the medical crew make-up. The Medical crew configurations were reported as follows:

Staffing Helicopter Fixed Wing

One Attendant: 3% 3%


Two Attendants: 96% 97%


One Supplemental Staff 1% 0%

RN/Paramedic 71% 61%

RN/RN 8% 8%

RN/Physician 3% 3%

RN/EMT 1% 5%

RN/other (RRT/PA) 10% 18%


Paramedic/Paramedic 5% 0%


Other 2% 5%


Paralleling the development of air medical transport systems in the U.S., ground

emergency medical services (EMS) systems were developed to provide pre-hospital

care with an emphasis on providing initial stabilization of ill and injured patients in the field and during transport to more definitive care facilities. These services primarily utilize Emergency Medical Technicians (EMT) of various levels including basic (EMT-A) and the intermediate level EMT (EMT-I) as well as the highest level of EMT, the paramedic (EMT-P). The educational preparation for the basic EMT is a 110-hour course as outlined by standards promulgated by the U.S. Department of Transportation (DOT). This course focuses on basic, initial pre-hospital care. The EMT-I has basic EMT training and receives additional instruction in performance of specified advanced pre-hospital skills. EMT-P's receive additional training and certification focusing on more advanced

pre-hospital care skills including airway management, intravenous fluid administration and administration of limited medications for initial stabilization of ill and injured patients. Several recent courses have focused on certification for the Critical Care Transport EMT-P.

With the explosion of sophisticated techniques, the medical and nursing professions have developed the ability to monitor and maintain the physiologic requirements of the body in situations of extreme stress and compromise. Use and understanding of equipment and techniques such as mechanical ventilators, central venous catheters and monitors, arterial catheters and monitors, intra-aortic balloon pumps, and cardiac assist pumps have made significant improvements in the morbidity and mortality of critically ill and injured patients. In addition to highly sophisticated equipment and techniques, an ever-increasing variety of medications are being utilized in emergency and critical care settings. The use of such equipment, techniques and medications depends on specialized training and a complex theoretical understanding of normal and abnormal physiologic functioning. Currently in the hospital setting, this advanced level of care is being provided by highly skilled physicians and nurses.

To adequately consider the type of medical crew members best suited to provide care for patients being transported by air medical services, it is important to understand the type of patients transported and the environment from which they are transported (whether directly from the scene of the accident or from another hospital). Based on the 1984 NFNA survey, patients with traumatic injuries and medical-cardiac conditions were the most frequent types of patients transferred by the 83 air-medical services responding. Other types of patients frequently transferred were critical neonates, burn patients, high-risk obstetrical patients and other critical surgical and medical patients.

The 1984 NFNA survey further found that the 83 responding services transported an average of 4,700 patients per month or approximately 56,000 patients per year. Seventy five percent of all patients transported by these services were inter-hospital transfers rather than scene responses. The number of patients transported per month by individual programs varied from 8 to 350. Although the percentage of patients transferred directly from the scene also varied among the responding programs (0% to 85%), 60% of these programs transferred 25% or less of their patients from the scene while 86% of these programs transferred 50% or less of their patients from the scene.

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Members don't see this ad.

 

[niko327]

When responding to transfer patients directly from the scene, HBHTS services are rarely the first or sole responder. A ground EMS ambulance almost always precedes them. The role of ground EMS responders is to assess the patient and request the response of the HBHTS if, according to specified criteria:

The patient requires a higher level of care than can be provided by the ground EMS crew, or
If the patient requires rapid transfer to a regional referral center for specialized critical care not available at the local resource hospital.

The air medical transport service providing critical care has become a functional extension of hospital emergency and critical care services. In the hospital setting, physicians and nurses are the primary care providers for patients requiring the most advanced medical technology and care. They are highly trained and skilled at caring for unstable neonates, high-risk obstetrical patients, and seriously ill and injured adults and children. In flights made directly to the scene of accidents, the medical crew's primary

responsibility is to bring to the patient the highly regional referral services.

If specially trained physicians are not utilized for these sophisticated care and experience of the hospital's emergency and critical care transports, the sophistication of care required can only be provided by specially trained flight nurses who have a variety of critical care experience and training. In addition, these flight crew members must, at a minimum, have training and experience in altitude physiology, management of patients in the pre-hospital setting, and flight communications and safety. They must also have the ability and training to function autonomously in a variety of settings with treatment protocols if

immediate communication with a physician is not possible or if immediate life-saving actions are required.

A major advantage to the use of critical care air medical transport services is the ability to provide care prior to and during transport at a level of sophistication previously available only in a regional referral center's emergency and critical care units. The use of any level of EMT as the principle medical crew member for the air transport of critically ill and injured patients from the scenes of accidents cannot provide a level of care commensurate with hospital emergency and critical care services; thus removing a major advantage

to its use. The use of any level of EMT as the principal medical crew member for

critical air medical transports between hospitals significantly reduces the level of care already established by the referring hospital.

Currently there are no nationally supported policies regarding the staffing of air medical transport services. Several professional organizations and others have developed or are developing standards for staffing of critical care air medical transport services. At present, however, none of these standards have been uniformly adopted and implemented throughout the United States.

The Commission on Accreditation of Medical Transport Systems (CAMTS) in their Fourth Edition of Accreditation Standards, October, 1999 lists the following standards for critical care transport staffing. A critical care mission is defined as the transport of a patient whose condition warrants care commensurate with the scope of practice of a physician or registered nurse. The medical team must, at a minimum, consist of a specially trained physician or registered nurse, as the primary care provider.

The Association of Air Medical Services (AAMS) has developed minimum standards,

which must be met by member organizations to receive full membership. Greater than 394 of the current hospital-based air medical services subscribe to these standards and are full members of AAMS. The AAMS standard regarding staffing as adopted in December 1985, is as follows:

"Staffing the aircraft shall be commensurate with the advanced life support environment afforded by the airborne emergency care facility. The aircraft in fact, by virtue of critical care staffing and medical retrofitting, becomes a special care unit. The medical flight crew must, at a minimum, consist of at least one specially trained registered nurse."

In June 1986, The American College of Surgeons Board of Regents approved standards for critical care air ambulance services as Appendix D to their document, "Hospital and Prehospital Resources for Optimal Care of the Injured Patient." These standards recommend, "If only one medical crew member is present, this should be a specially trained flight nurse."

Numerous states have also developed standards or regulations regarding the staffing of air medical transport services in operation within their jurisdiction. These staffing standards/regulations vary widely from state to state.

ASSOCIATION POSITION

The Emergency Nurses Association (ENA) and the Air & Surface Transport Nurses

Association (ASTNA) believe that services providing air transport of the critically ill and injured are functional extensions of hospital emergency and critical care services. The ENA and ASTNA further believe that staffing for these air medical services must minimally consist of at least one specially trained registered professional nurse who has extensive experience and expertise in caring for critically ill and injured patients.

BIBLIOGRAPHY

American College of Surgeons Committee on Trauma: Appendix D to Hospital Resources Document. Critical Care Air Ambulance Service. Approved June 8, 1986

by the American College of Surgeons Board of Regents. Publication Pending.

Association of Air Medical Services (AAMS): Rotorcraft Standards. Adopted at 6th

Annual Conference; Reno, Nevada; December 1985

Baxt WG, Moody P, Cleveland HC, et al: Hospital-Based Rotorcraft Aeromedical

Emergency Care Services and Trauma Mortality: A Multicenter Study. Ann Emerg Med; 1985; 14:859-864.

Cleveland HC, Miller JA: An Air Emergency Service: The Extension of the

Emergency Department. Top Emerq Med; 1979; 1:47 54.

Commission on Accreditation of Medical Transport Systems (CAMTS); Accreditation

Standards of CAMTS, Fourth Edition, October 1999

Kyes FN: National Flight Nurses Association: Liaison Committee Flight Programs

Data Report. Unpublished Raw Data: 1984.

Neel SH: Helicopter Evacuation in Korea. USAF Med J ; 1955: 6:691-702.

Neel SH: Army Aeromedical Evacuation Procedures in Vietnam. JAMA ; 1968;

204:99-103.

Rau W: 2000 Medical Crew Survey. AIRMED; Sept/Oct 2000; Vol. 6, No. 5; 17-22

Scheib BT, Foust J, Mueller W, et al: MAST: Military Assistance to Safety and

Traffic, A Decade of Service. JEMS; November, 1983; 38-45.

Shea, D: The Role of Nurses and Paramedics on EMS Rotorcraft. Trauma Quarterly;

May, 1985; 1:33-37.

U.S. Department of Health, Education and Welfare: Essentials and Guidelines for

the Education and Training of the Emergency Medical Technician - Paramedic .

Washington, D.C. U.S Department of Health, Education and Welfare, 1999.

U.S. Department of Transportation: National training course: Emergency Medical

Technician - Paramedic . (Module I and Course Guide). National Highway Traffic

Safety Administration. Washington, D.C.: U.S. Government Printing Office, 1999.

Approved by the Board of Directors of the Emergency Nurses Association, July 27,

1986, and by the Board of Directors of the Air & Surface Transport Nurses

Association, July 29, 1986

Revision Approved by ASTNA Board of Directors

 

[southerndoc]

I think a critical care/certified flight nurse should be on every flight. Personally, I like CFRN NREMT-P's on every flight in addition to a physician (usually a resident). I'm not a fan of the RN/RT combo, but I think if a physician cannot be on the helicopter, I much prefer an RN-medic combination team instead of an RN-RN team.

 

[Doczilla]

I'll have to disagree with their statement that "use of any level of EMT as a principal crew member significantly reduces the level of care". It may be my gut reaction whenever I hear a nurse say they think they can be a paramedic just because they completed nursing school and have a wider scope of practice, but I think it's important to have an experienced street provider on the bird. While interfacility transports make up the majority of helicopter transports, scene runs to the prehospital arena are a significant part of the job, and whoever is on the helicopter should be trained in providing care under these sometimes austere conditions. (Something more extensive than reading the chapter on EMS in Tintinalli or doing a couple of ride-alongs) Ideally this would be an experienced paramedic who has gone to nursing school or medical school or completed a CCEMTP program, rounding out their field accumen with more advanced medical knowledge.

The assumption that the nurse can be trained in prehospital skills but the paramedic cannot extend their knowledge of physiology and how to work the fancy little transport gizmos is asinine. This kind of condescension to the EMT by hospital-based providers is getting old.

Maybe I'm just sick of nurses obtaining their RN degree and sitting for the paramedic exam because they feel they've earned it. As a physician, I don't expect that I can sit for the nurse's exam. I'm not trained or precepted in that role, nor are nurses routinely extensively precepted in the prehospital environment. The RN is not ready to do critical care right out of nursing school, nor is the paramedic fresh out of medic school. If you have to do additional training and gain additional experience to get to this level of care, I see no reason why RN should be a requirement and EMT-P can't.


'zilla

 

[southerndoc]

Well said Doczilla. Nurses should be required to go through paramedic training in order to sit for a paramedic exam. Many states have eliminated this and now require formal training to become a paramedic.

Paramedics do serve a role, and I think even in dual nurse flight configurations, at least one nurse should be a trained paramedic. If all flights were interfacility, then you could possibly do a nurse-RT, nurse-nurse (with airway training), or similar combination. However, the majority of flight programs have on-scene flights comprising a significant percentage of their total flights. Many programs complete more scene flights than interfacility transfers. In those cases, a nurse-paramedic team is definitely the way to go.

 

[pushinepi2]

I'll have to disagree with their statement that "use of any level of EMT as a principal crew member significantly reduces the level of care". It may be my gut reaction whenever I hear a nurse say they think they can be a paramedic just because they completed nursing school and have a wider scope of practice, but I think it's important to have an experienced street provider on the bird. While interfacility transports make up the majority of helicopter transports, scene runs to the prehospital arena are a significant part of the job, and whoever is on the helicopter should be trained in providing care under these sometimes austere conditions. (Something more extensive than reading the chapter on EMS in Tintinalli or doing a couple of ride-alongs) Ideally this would be an experienced paramedic who has gone to nursing school or medical school or completed a CCEMTP program, rounding out their field accumen with more advanced medical knowledge.

The assumption that the nurse can be trained in prehospital skills but the paramedic cannot extend their knowledge of physiology and how to work the fancy little transport gizmos is asinine. This kind of condescension to the EMT by hospital-based providers is getting old.

Maybe I'm just sick of nurses obtaining their RN degree and sitting for the paramedic exam because they feel they've earned it. As a physician, I don't expect that I can sit for the nurse's exam. I'm not trained or precepted in that role, nor are nurses routinely extensively precepted in the prehospital environment. The RN is not ready to do critical care right out of nursing school, nor is the paramedic fresh out of medic school. If you have to do additional training and gain additional experience to get to this level of care, I see no reason why RN should be a requirement and EMT-P can't.

'zilla

Wow! At the risk of sounding like the previous poster, "well said!" There is a 'smatter' of research on things like scene time / outcome with regard to staffing. It will be difficult to come to a clear consensus on ideal staffing because different locales place different demands on regional EMS response. An excellent critical care nurse has a well-carved out niche within air medical and critical care transport. Often, the transport of critically ill/injured patients requires chest tube maintenance, infusion administration, and the use of medications that don't fall within the purview of a medic. Conversely, it is ridiculous to assume that just because this same RN passes the EMT-P test that they are somehow competent to perform paramedic interventions.

In some of the successful flight programs that I've seen or rode along with, it seems that the nurse-paramedic team has several virtues. That composition takes advantage of the paramedic's abilities while expanding the pre-hospital scope of practice. Often times, nurses are required or encouraged to complete the paramedic exam due to legal issues with nurses 'practicing' outside of the hospital. With programs that respond to a fair amount of 'scene calls,' the critical care orientation often involes skills labs, survival skills, and advanced airway seminars. The oritentation addresses 'Zilla's concern about so-called patch medics not being field tested.

Further clouding the issue are courses like CCEMT-P. Though this aim of this course is to familiarize medics/RRTs/RNs with the critical care environment, it does not guarantee any basic level of competency. I took this course back in 2000 and I would routinely ask for a veteran ER or CCRN when charged with a difficult interfacility transfer. It takes time to become comfortable with such patients and courses like CCEMT-P are simply steps in the right direction. Many paramedics, unfortunately, are only concered with getting the patient to the hospital ALIVE. Ventilator dependent patients, for example, require painstaking attention to detail along with specialized equipment.

The federal government's EMTALA mandate provides docs and prehospital providers with some rudimentary guidelines. Part of the Emergency Treatment and Active Labor act mandates that "appropriately trained personnel" accompany complicated patients. It is ultimately up to the transferring physician to decide the best means of conveyance. For post-arrest pediatric patients, it may be wise to send a children's critical care team. For the post-MI patient requiring transport to definitve care, the local ALS service may suffice. Again, we're brought back to an understanding of local resources. The nearest helicoper may not have the most ideal crew configuration, but it may represent the fastest and highest level of care locally available. Minimum standards for CCT teams are not practical simply because paramedic level care cannot be ensured in all of this nation's fifty states.

That said, the conclusions of the ASTNA paper are no surprise. It is politically and economically wise to adopt a position statement that supports the very existence of your profession. Ironically, the paper states that a majority of patients cited in their paper suffered "traumatic" and "medical-cardiac" conditions. These patients, according to the ASTNA research, may require "lifesaving" interventions while en route to the receiving facility. Perhaps paramedics would be well served to conduct a study comparing intubation success rates between seasoned pre-hospital ALS proviers and "specially trained nurses." I'm sure the NFPA (national flight paramedics association" has something to say about that!

 

[niko327]

I'll have to disagree with their statement that "use of any level of EMT as a principal crew member significantly reduces the level of care". It may be my gut reaction whenever I hear a nurse say they think they can be a paramedic just because they completed nursing school and have a wider scope of practice, but I think it's important to have an experienced street provider on the bird. While interfacility transports make up the majority of helicopter transports, scene runs to the prehospital arena are a significant part of the job, and whoever is on the helicopter should be trained in providing care under these sometimes austere conditions. (Something more extensive than reading the chapter on EMS in Tintinalli or doing a couple of ride-alongs) Ideally this would be an experienced paramedic who has gone to nursing school or medical school or completed a CCEMTP program, rounding out their field accumen with more advanced medical knowledge.

The assumption that the nurse can be trained in prehospital skills but the paramedic cannot extend their knowledge of physiology and how to work the fancy little transport gizmos is asinine. This kind of condescension to the EMT by hospital-based providers is getting old.

Maybe I'm just sick of nurses obtaining their RN degree and sitting for the paramedic exam because they feel they've earned it. As a physician, I don't expect that I can sit for the nurse's exam. I'm not trained or precepted in that role, nor are nurses routinely extensively precepted in the prehospital environment. The RN is not ready to do critical care right out of nursing school, nor is the paramedic fresh out of medic school. If you have to do additional training and gain additional experience to get to this level of care, I see no reason why RN should be a requirement and EMT-P can't.


'zilla

Agree with Doczilla
The reason for the condescension IMO is that the nursing lobby is very powerful and very old. Nursing can bully its way into virtually any arena it sees fit. Nurse anesthetist, Independent Nurse Practitioner, Flight Nurse/EMS are 3 examples. All you really need is for a Board of Nursing to say that a particular field is open to nursing professionals, and PRESTO! No need to respect any other governing professional body when you can draft your own professional guidelines and say your practice is really an advanced form of nursing. I give the nursing lobby alot of credit, their example needs to be emulated by EMS if it expects to gain any real political clout.

 

[deleted6669]

yeah, all those MD/medic teams need to be replaced by rn/rn......NOT
my personal favorite combo is 1 emt-p/rt(dual cert) and 1 md

 

[bell412]

Show me bad outcomes with RN/RN teams? I was an Army trained medic. Then became a trained EMT-P. Finally a flight nurse. Scene call is a scene call. Doesn't matter what badge you have on.

 

[canjosh]

A scene call is a scene call, and an inter-facility transfer is a transfer...the badge (training/backgroud) does matter! When you respond to a scene, you're seeing the pt in the first minutes after an event. No radiological studies have been done, no lab work, no ddx formed by a physician. You're escalating care on nearly every scene response, whereas a transfer is hopefully a maintenance/small escalation of care. In my experience on a peds/neonate critical care team (RN/RT/EMTP), none of the nurses I worked with would be comfortable without the above mentioned information that would be provided by the transferring facility. I'm not saying that nurses can't learn to function successfully in the 'field'. But to say that nurses can expand their knowledge to include prehospital care, but medics can't do the reverse is absolute horse dookie. (sp?) Another example of the nursing profession being self-inflating at the cost of the perceived value of other healthcare professionals. I'm married to a nurse--no problems with nurses in particular--I just have a problem with the pattern of constant condescesion (by the Nursing profession/lobby) towards ANYBODY that doesn't have RN after their name (EMS, RT, x-ray, etc.). Rant complete...I feel better.

 

[bell412]

The air medical industry was introduced in the US after the Vietnam war. I believe St. Anthony of Denver had the first rotor program. Nurses not paramedics were staffed on the helicopters. The reason nurses took this role is because the air ambulance was and still is hospital based. Paramedics have never traditionally been employees of hospital systems. Nurses always have been employees of hospitals. Thats how they became involved in prehospital. I'm not saying that its right or wrong. Its just how it is. RN's have been successful in the industry no question. People can say they have no buisness doing prehospital but they are wrong. If people were not getting quality care then RN's quite simply would not be providing prehospital care. Again show me that RN/RN teams have poor outcomes.

 

[southerndoc]

The air medical industry was introduced in the US after the Vietnam war. I believe St. Anthony of Denver had the first rotor program. Nurses not paramedics were staffed on the helicopters. The reason nurses took this role is because the air ambulance was and still is hospital based. Paramedics have never traditionally been employees of hospital systems. Nurses always have been employees of hospitals. Thats how they became involved in prehospital. I'm not saying that its right or wrong. Its just how it is. RN's have been successful in the industry no question. People can say they have no buisness doing prehospital but they are wrong. If people were not getting quality care then RN's quite simply would not be providing prehospital care. Again show me that RN/RN teams have poor outcomes.

It is important to note that RN/RN teams usually have at least one provider certified at the EMT level.

 

[a_ditchdoc]

The air medical industry was introduced in the US after the Vietnam war. I believe St. Anthony of Denver had the first rotor program. Nurses not paramedics were staffed on the helicopters. The reason nurses took this role is because the air ambulance was and still is hospital based. Paramedics have never traditionally been employees of hospital systems. Nurses always have been employees of hospitals. Thats how they became involved in prehospital. I'm not saying that its right or wrong. Its just how it is. RN's have been successful in the industry no question. People can say they have no buisness doing prehospital but they are wrong. If people were not getting quality care then RN's quite simply would not be providing prehospital care. Again show me that RN/RN teams have poor outcomes.

Likewise, the air medical concept came from vietnam with military medics on the choppers. And, what you fail to take into account is that the paramedic curriculum had not been fully developed by then, it was still in it's infancy. I would not say that RN/RN teams have poor outcomes. Likewise, I do not think you can show me that paramedic teams have poor outcomes. People seem to either directly, or indirectly, insinuate that Paramedics cannot become competent in more advanced procedures while Nurses can. Using the same logic I could say that nurses, who historically do not do advanced airway procedures, could not learn to do them as proficiently as paramedics. This is not the case. I know that each profession has it's own loyalty, and it's own desire to further advance the profession. But to do it by belittling people in other professions is arrogant as well as shameful. The nursing lobby seems to try to place a stranglehold on every other profession. Soon I can see the nursing profession trying to bring the "Emergency room to the patient" and trying to staff ambulances.

While people in the nursing profession are quick to point out the scope of practice of paramedics as a reasoning for excluding them from air transport, their scope of practice is quickly expanding and in my home state the guidelines have recently been broadened. The medical director of each service is allowed to dictate the skills available to medics as well as determine what environment he can work in (ie emergency rooms, clinics, etc).

I am not sure where the future of air transport is going, but I would prefer to see the skills from both medics and nurses utilized on aeromedical transports. The training is very different and both have unique skills in some areas that are stronger than the other. Perhaps if people can diminish their arrogant attitudes when working with the "other" professionals, we can see them as assets instead of competition.

 

[bell412]

Why do you think RN's cannot learn advanced airway concepts? Is there some secret paramedics learn in school that is any different from teaching RN's when there hired onto flight programs? The way you become proficient doing advanced airway is by doing it. Once the Paramedic or RN has done it many times I sure the outcome would be the same. I think RN/medic teams are great. I sure they have same patient outcomes. It really comes down to a turf battle once again. Nurses have traditionally have been the providers on air ambulances and there not going to give up jobs. I was a flight nurse for 8 years on a RN/RN team. The nurses on the team were excellant in prehospital management. Yes all of us were RN/EMT-P certified and yes many sat the exam for EMT-P and thats all. I know that makes the EMS community angry but i say to them go get your RN. Its not that difficult.

 

[southerndoc]

Why do you think RN's cannot learn advanced airway concepts? Is there some secret paramedics learn in school that is any different from teaching RN's when there hired onto flight programs? The way you become proficient doing advanced airway is by doing it. Once the Paramedic or RN has done it many times I sure the outcome would be the same. I think RN/medic teams are great. I sure they have same patient outcomes. It really comes down to a turf battle once again. Nurses have traditionally have been the providers on air ambulances and there not going to give up jobs. I was a flight nurse for 8 years on a RN/RN team. The nurses on the team were excellant in prehospital management. Yes all of us were RN/EMT-P certified and yes many sat the exam for EMT-P and thats all. I know that makes the EMS community angry but i say to them go get your RN. Its not that difficult.

People seem to either directly, or indirectly, insinuate that Paramedics cannot become competent in more advanced procedures while Nurses can. Using the same logic I could say that nurses, who historically do not do advanced airway procedures, could not learn to do them as proficiently as paramedics. This is not the case.

bell412, a_ditchdoc did not say that RN's could not learn advanced airway concepts.

With regards to paramedics getting their RN's, many paramedics are in fact doing this through self-study programs. The state where I am from allows a paramedic-to-RN bridge program that is easy (and fast) to awarding an RN associates degree.

Many states no longer allow RN's to simply sit for a paramedic exam without some sort of training.

 

[bell412]

Sorry ditch doc I should have read your post closely. I think thats great there are bridge programs for paramedics to get there RN. On the same note there should be bridge programs for RN's to get their EMT-P. Because the best care providers on air ambulances is attendents with both credentials.

 

[niko327]

Paramedics have never traditionally been employees of hospital systems.

I can think of one example right off the top of my head. NY Hospital has had an ambulance service since the late 1800s, originally staffed by a physician and ambulance driver assistant. They eventually became staffed with paramedics and emts since the inception of those programs in the late 60's and early 70s. Several other hospitals followed suit. Hospital based EMS services were the very first providers of prehospital care in the City of New York, before NYC EMS and before the FDNY took over. I can't speak for all the other places in the country, but hospital based EMS is quite prevalent in the City of NY which is no small system.

 

[southerndoc]

I can think of one example right off the top of my head. NY Hospital has had an ambulance service since the late 1800s, originally staffed by a physician and ambulance driver assistant. They eventually became staffed with paramedics and emts since the inception of those programs in the late 60's and early 70s. Several other hospitals followed suit. Hospital based EMS services were the very first providers of prehospital care in the City of New York, before NYC EMS and before the FDNY took over. I can't speak for all the other places in the country, but hospital based EMS is quite prevalent in the City of NY which is no small system.

Only hospital-based systems can provide ALS in New Jersey.

I think the majority of EMS is provided by fire-based systems now.

 

[FoughtFyr]

O.K., to really understand his argument, you need to take a step back and look at the larger picture. Let's step into the way back machine for a moment.

Medicine is a very old art / science, developed over time with some ideas that were well founded (germ theory, etc.) and others that weren't (bleeding, humours etc.). Over time three distinct categories of health care providers emerged...

The Practitioner - A physician, (or now PAs or Nurse Pracs) who is charged with diagnosis of disease and the planning of therapeutic regimens.

The Therapist - A professional who is given control, and some measure of autonomy, over a specific part of a course of treatment for an ailment that was diagnosed by the practitioner. The best example of this is a physical therapist, who treats an injury as diagnosed by a physician within the limitations set forth by the same. The PT can act with their own methodology administering specific courses of treatment "their way" but their actions are grossly observed by and limited by the practitioner.

The Technician - An individual charged with providing a specific course of treatment within strict guidelines for procedural issues. There is no true autonomy; the therapy is to be performed exactly as ordered. There may be pre-existing protocols to define the actions, but on the whole there is no exercise of professional judgment. The best example here is a lab tech, who will perform a CBC as ordered by a physician, the same way, every time.

Notice I left out nurses. That was intentional. Historically, as medicine developed, many tasks, best suited to technicians or therapists, were created or defined. As the processes of education and the defining of new categories of professionals are very slow, nurses stepped in to fill many of these voids. The role of the nurse expanded to fill many positions in medicine. Return to the case in point of physical therapy. Almost all bachelors degreed nurses had course work on active and passive ranges of motion. Many learned about strengthening and stretching. At one point, post surgical rehab was initially performed by nurses. Now as the methods have become more specialized, and in-patient stays have shortened, Physical Therapists run these programs.

The original mandate of nursing was supportive care for patients. The theories of practice by Orem, Nightingale and others aptly demonstrate this. The idea was (and still is) that a nurse is present to enable and assist patients with their own care as ordered by a practitioner (as defined above). Note Orem's self-care deficit theory, a guiding principle of nursing education,

"Self-care deficit theory teaches that people benefit from nursing because they have health-related limitations in providing self-care. Limitations may result from illness, injury, or from the effects of medical tests or treatments. Two variables affect these deficits: self care agency (ability) and therapeutic self-care demands (the measures of care required to meet existing requisites). Self-care deficit results when self-care agency is not adequate to meet the known self-care demand."​

from: http://dana.ucc.nau.edu/~jmg8/central_concepts_of_the_theory.htm

Nowhere in the self care deficit theory is the nurse enabled to diagnose a medical condition or direct the treatment of one.

Politically, as all of this was happening, the nurses organized and protected specific skills under Nursing Practice Acts (laws passed by states to define what a nurse is and what they can do). These Acts were passed to hold up the core sets of skills that defined nursing. The nurses "protected" these skills from being passed to other professions/vocations. Rightfully so.

Around this same time, the idea of nursing diagnosis was started. For those of you on this forum with only an EMS background, a nursing diagnosis addresses some deficit in a patient’s ability to function, either physically, intellectually or socially. This is not a medical diagnosis (AMI, CVA etc.) but generally takes the form of altered ability to communicate, or inability to [insert task necessary to self care here]. The named diagnosis is usually followed by a statement "related to" where the actual medical or physical pathophysiology is denoted followed by the phrase "as evidenced by" where the observations leading to the nursing diagnosis is listed. So a complete nursing diagnosis may read,

"Altered ability to communicate related to post-CVA aphasia as evidenced by patient's willingness to write statements but apparent lack of ability to produce more than guttural tones when attempting to speak" - (My sincere apologies to any nursing instructors in the forum, it has been a while since I have written one of these).

The idea of a nursing diagnosis was to allow the nurse to focus on assisting the patient to realize and adapt to the limitations their conditions may place on them. It is left to medical science to heal the body, nursing concentrates on adapting the patient. Obviously this is a long term focus.

So what about the ED (and flight)? Well there in lies the rub. Nurses were and are vital parts of the medical treatment team. But they are trained very differently than EMTs. An argument could be made that given a little extra training in broader based medicine, a paramedic MAY be better suited to an ED practice than a nurse, BUT THAT IS NOT THE CASE NOW!

It is true enough that a newly graduated nurse is not likely to be ACLS, PALS or BTLS certified. It is also true that a newly graduated nurse is unlikely to perform well in an ED without additional training. It is certain that without training in scene safety, extrication, fire, HAZ-MAT etc., a nurse (new or not) is likely to endanger their own life as well as that of their patient if placed in the pre-hospital environment.

The problem is in the focus of practice. No nurses are trained to diagnose. Granted, many years in the ED will give a competent provider of any description a fair idea of common diagnoses. But it returns to original training. Paramedics or EMTs DO diagnose in the field. Semantic games are often played (field impression, symptomatic treatment, etc.) but the facts boil down to this, the EMT is unique among technicians because they decide the diagnosis they are treating. They will perform the treatment by standing orders detailing exact procedures (as other technicians) but what they treat is up to their professional judgment.

This is the limitation to the much heralded "higher education" of a BSN. The courses taken are based in nursing theory, with nursing implications. Hence the age old EMS argument about oxygen in the COPD patient. By a nurse's pathophysiology text and coursework, high flow O2 is withheld from the COPD patient. In the long term this is true and correct. Since the nurse does not have to decide if the patient has COPD (the diagnosis is provided by the medical practitioner), a course can be run in this manner. It is not how an EMT can or should act. The immediacy of the situation and the short term outlook combine for a totally different, but equally correct view point. Nurses (with the exception of NPs) do not perform medical diagnoses, period. Within set boundaries, EMTs do.

So what is the solution? I don't know. But name calling isn't it. Nurses and EMTs need to realize the inherent differences between the professions. There is some overlap, and there are definitely differing view points. Personally I would like to see a program similar to the training given to a BSN become the standard for paramedics. I would like to see EMT practice acts, and professional licensure. In the mean time the standards are what they are. Nurses and 'medics are different. They are trained differently, approach patients differently and have different guidelines for their "practices". Accept that, work within it and treat the patient.

As for flight, there is certainly nothing intrinsic to the nursing training that prepares them exceptionally well for flight work either. In fact, on the average flight shift, a nurse will only use a small percentage of his/her training. As described above, most of that training is based in a theory that does not lend itself well to flight. I know that almost no flight programs allow newly graduated nurses to fly, but isn't that an argument against flight nursing? Shouldn't the base training of a professional prepare them to do the job? How do you qualify their experience level? How do we know that the nurse has achieved enough experience to begin to diagnose patients accurately?

Now the paramedic will use a large portion of their training on the average flight shift. The problem is they will likely get in over their head. There are far more possible diagnoses encountered in helicopter transport medicine than a paramedic has the skills to treat. However, in the basic and emergent care of the patient, the paramedic is far more superiorly armed than the nurse. Leading resuscitation efforts is part and parcel of a paramedic's practice. Not participating in efforts, but leading them and making the needed clinical decisions and diagnoses surrounding them.

So in my mind, a mixed paramedic/RN or an MD/RN crew is the best configuration. The need to have an individual who is directly trained and experienced (outside of the specific orientation / training given when starting a flight job) to resuscitate patients is key to the needs of the patient in helicopter transport medicine.

Just my $0.02 (actual cash value $0.005).

- H

 

[bell412]

If everything you say is true then why are nurses performing so well in prehospital care?

 

[Jambi]

...why are nurses performing so well in prehospital care?

To what standard is, "performing so well," measured against?

The fact remains that a new paramedic is/will be more proficient in the pre-hospital setting that a new nurse. Without experience and additional training a nurse will never be on par with a paramedic when it comes to the pre-hospital setting.

Education for EMTs (all levels) is specialized and focused on the pre-hospital setting. Nursing education is generalized. Find me a nurse that learns and is proficient in spinal immobilization, KED, traction splints, ACLS and resuscitation protocols, BTLS, PHTLS, PALS, or EMS minded medical and trauma assessments.

As stated above, the education and focus for each profession is different and a transition from one environment to another (field<->clinical) requires additional training in order for an individual to function safely.

 

[FoughtFyr]

If everything you say is true then why are nurses performing so well in prehospital care?

They are? Where is the evidence? And, where is what I said inaccurate? Were you not trained in nursing diagnoses? Was your training not guided by nursing theory? Please tell me you found a nursing school that didn't require you to write nursing diagnoses and nursing care plans ad nauseum... and how many of those plans had any bearing on emergency medicine (prehospital or in the ED)?

I do not doubt the ability of any reasonably intelligent individual to "pick-up" things they are not trained in through some experience. But that doesn't change the nature of your initial training, nor does it re-align its focus or expand the scope of your practice. Are you (as a nurse) allowed to, outside of the flight crew, diagnose any medical condition? How many codes had you run (as the team leader) prior to working on the helicopter? What medical treatment decisions, in terms of specific pharmacotherapy or invasive procedures, had you ever ordered prior to joining the flight team? Now ask the same questions of a paramedic...

- H

 

[bell412]

Show me statisical evidence that flight nurses have poor outcomes. If they do you should call your local congressman today.

 

[FoughtFyr]

Show me statisical evidence that flight nurses have poor outcomes. If they do you should call your local congressman today.

Spurrious argument. Show me where in their training that they can do the job. (BTW - my argument was not for medic/medic crews. There are aspects of patient management such as IV pumps, toco monitors, etc., that are nursing. My argument is for an RN/medic or RN/MD crew.) Your argument is similar to the 15 year old who steals a car and doesn't crash it. He then says to his mom - "see, I can drive safely". The question is not if current flight nurses can do the job, it is a question of a systems problem that might lead to patient safety issues at a future date. Practices are not nursing merely because nurses say they are.

- H

 

[Jambi]

Show me statisical evidence that flight nurses have poor outcomes. If they do you should call your local congressman today.

That's not the point. The point is, is that there is no "baseline" with which we can compare outcomes. Any statement made attesting to the great performance by nurses in the pre-hospital setting in purely anecdotal.

 

[bell412]

So I arrived on scene with the helicopter and find an unconscious patient from an mva with a GCS less than 8 and posturing. Primary and secondary assessments done. Airway, c-spine, 2 large bore IV's and back boarded. See I would diagnosis this as a closed head injury with multiple trauma. Oops I'm a nurse can't do that I don't diagnose. So you better contact you senator. See I'm actually practicing outside my scope of practice. But if I can relate it somehow to Orem’s theory.

 

[Jambi]

So I arrived on scene with the helicopter and find an unconscious patient from an mva with a GCS less than 8 and posturing. Primary and secondary assessments done. Airway, c-spine, 2 large bore IV's and back boarded. See I would diagnosis this as a closed head injury with multiple trauma. Oops I'm a nurse can't do that I don't diagnose. So you better contact you senator. See I'm actually practicing outside my scope of practice. But if I can relate it somehow to Orem’s theory.

Do you actually read the posts? If you had then you would have noticed that I referrenced nursing education. Show me a nurse that learns that in nursing school.

 

[bell412]

that right jambi their are NO medic/medic configured air medical teams other than Maryland’s police helicopter.

 

[bell412]

your right we never learned prehospital in nursing school. But for some strange reason we have been doing prehospital since the 1960's and we will continue forever and ever.

 

[FoughtFyr]

So I arrived on scene with the helicopter and find an unconscious patient from an mva with a GCS less than 8 and posturing. Primary and secondary assessments done. Airway, c-spine, 2 large bore IV's and back boarded. See I would diagnosis this as a closed head injury with multiple trauma. Oops I'm a nurse can't do that I don't diagnose. So you better contact you senator. See I'm actually practicing outside my scope of practice. But if I can relate it somehow to Orem’s theory.

#1. Wow, closed head injury. Good for you. Now which class was that in nursing school that taught you to intubate that patient? How about that primary and secondary trauma survey - where was that in your cirriculum? Even the c-collar wasn't really covered was it? Hmm, what if the diagnosis wasn't so straight forward. Maybe throw in pinpoint pupils, pre-existing known brain tumor, known cardiac problems or drug use. What then? And before you answer, think about where that answer comes from, nursing school, your experience or the training you recieved after joining the flight team? I'll bet the honest answer is the latter two!

#2. If you honestly believe that you "diagnosed" the patient, as opposed to acting on standard orders from your medical director, then you are guilty of practicing medicine without a license. I wouldn't call my Senator, but calling the DA in your area would not be beyond the pale. See, this is where the problem lay. An EMT is made acutely aware of their role and the legalities surrounding it. You weren't. Thanks for again proving my point!

#3. I just love how you talk around any question directly asked of you and instead throw down a "heroic" story of your helicopter exploits. Big deal! I have done flight as a medic and an MD. Flight nurses don't impress me much. They are just members of the team like everybody else. Now back to the point, you have yet to cite an error in any of my posts. You have failed to address the questions asked in any way other than to thump your chest and brag about your vast experience. ***SNIFF, SNIFF, I smell a troll - us "woctors" have good noses for that***

#4. Where was it you learned to secure your scene again? Who was it that managed the patient's care during the extrication? How is it that you kept yourself safe on the scene? I don't know of any nursing school that teaches scene safety or extrication. Where is this magical place you went to school?

- H

 

[FoughtFyr]

your right we never learned prehospital in nursing school. But for some strange reason we have been doing prehospital since the 1960's and we will continue forever and ever.

To quote my original post...

"Notice I left out nurses. That was intentional. Historically, as medicine developed, many tasks, best suited to technicians or therapists, were created or defined. As the processes of education and the defining of new categories of professionals are very slow, nurses stepped in to fill many of these voids. The role of the nurse expanded to fill many positions in medicine. Return to the case in point of physical therapy. Almost all bachelors degreed nurses had course work on active and passive ranges of motion. Many learned about strengthening and stretching. At one point, post surgical rehab was initially performed by nurses. Now as the methods have become more specialized, and in-patient stays have shortened, Physical Therapists run these programs."​

Yeah, don't hold on to the forever and ever thing. Nurses used to ride ambulances. No so much anymore. Just like PT, nursing will, slowly, bit by bit, hand EMS over to EMS providers. Why? Because on the whole we took nursing's cue. There are EMS practice acts in almost every state. More and more they are being employed to show nursing the door in EMS. Thanks for showing us the way!

- H

 

[bell412]

Easy FoughtFyr you’re the one who’s throwing stones. I'm just replying to your condensation. Sorry if I didn’t give you more details of my little scenario. By the way that was my diagnoses. Sorry pal.

 

[Jambi]

that right jambi their are NO medic/medic configured air medical teams other than Maryland’s police helicopter.

Los Angeles County Sheriff's Department also staffs medic/medic.

 

[bell412]

Looks like you got your study Jambi!!

 

[bell412]

Foughtfyr, I didn't learn a thing about prehospital in nursing school. Just bed making. Are you happy now.

 

[FoughtFyr]

Foughtfyr, I didn't learn a thing about prehospital in nursing school. Just bed making. Are you happy now.

Well, I wouldn't state it so glibbly. (But the fact that the NLN does require a practical exam on bedmaking at all accreditated programs is too funny! ). I realize how in depth your nursing training was. What I don't see and what you have yet to answer is how that makes you "better" at pre-hospital medicine (specifically flight because the ambulance battle has already passed) than an EMT-P?

- H

 

[bell412]

did i say i was better?

 

[FoughtFyr]

that right jambi their are NO medic/medic configured air medical teams other than Maryland’s police helicopter.

Don't forget the U.S. Armed Forces including the Coast Guard. They are the original aeromedical teams and paramedics were created right alongside the medevac flight. Why? It was felt nurses couldn't function without direct and present physician oversight in such less than austere conditions.

And, if nurses are the pinnacle of prehospital medicine, why aren't the Air Force parajumpers trained as RNs instead of EMT-Ps? And why is the FBI's HRT team composed of EMT-Ps with not an RN in sight?

- H

 

[bell412]

FoughtFyr, you don't know what your talking about.

 

[FoughtFyr]

FoughtFyr, you don't know what your talking about.

Yeah, I know, but prove it. Where am I wrong?

- H

 

[FoughtFyr]

did i say i was better?

Well...

If everything you say is true then why are nurses performing so well in prehospital care?

O.k., not exactly saying you are better, but coming close. Face facts, your RN is not why you are competant to do flight. But don't worry, just keep flinging out one line responses to complete posts and the challenges they pose to your dogmatic thinking. That will change everyone's mind!

- H

 

[southerndoc]

Spurrious argument. Show me where in their training that they can do the job. (BTW - my argument was not for medic/medic crews. There are aspects of patient management such as IV pumps, toco monitors, etc., that are nursing. My argument is for an RN/medic or RN/MD crew.) Your argument is similar to the 15 year old who steals a car and doesn't crash it. He then says to his mom - "see, I can drive safely". The question is not if current flight nurses can do the job, it is a question of a systems problem that might lead to patient safety issues at a future date. Practices are not nursing merely because nurses say they are.

- H

The real question at hand is not if RN or medic is the best flight member, but whether air ambulances make a difference at all. I think this has not been supported by evidence. The air ambulance industry has an incredibly high crash rate.

 

[FoughtFyr]

The real question at hand is not if RN or medic is the best flight member, but whether air ambulances make a difference at all. I think this has not been supported by evidence. The air ambulance industry has an incredibly high crash rate.

There is some literature but on balance I think you are right. Two papers for aeromedical transport are here:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10589149&query_hl=2

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10724739&query_hl=2

One that suggests there might be some utility, but concludes further research is needed to identify populations who benefit is here:
http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=9420109&query_hl=2

This one dealing with pediatric patients found that there was a benefit for patients who truly required, but also found that 85% of calls in their study did not require the resources of the aeromedical team:
http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=8863261&query_hl=2

And lastly, here is an intersting paper that examined the effects of discontinuing a hospital based aeromedical program. The findings? No significant increase in transport times or patient mortality from trauma. See:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=11901324&query_hl=2

- H

 

[bell412]

FoughtFyr, Coast Guard and the military paramedic services are for search and rescue. Far cry from civilian EMS. Our competence can only come from the licensure we practice under. We are successful in prehospital because we are RN's plain and simple.

http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=11805762&query_hl=22

Here you go. See no difference. RN/RN, RN/Medic. I never said the RN is better at prehospital management. The only thing I'm saying is we have a role in pre-hospital and are experts and are not going away ever.

 

[bell412]

Over 150 hospital based rotor services in this country. More being added not declining. It’s easy to write a biased study.

 

[southerndoc]

Over 150 hospital based rotor services in this country. More being added not declining. It’s easy to write a biased study.

More are being added not because they are saving lives, but because many vendors are expanding because of increased payments by insurance companies. Over the last few years, there has been an explosion of private aeromedical services and relatively few increases in the number of birds provided by county agencies, not-for-profit hospitals, etc.

Studies may suggest that aeromedical services save lives, but one must question the number of lives lost due to aeromedical crashes. There were 18 people in 2004 who died in an air ambulance (rotor wing) crash. There have already been 4 who have died this year.

One must question if the number of true lives saved is greater than the number of lives lost each year from crashes. By true lives saved, I do not mean a patient was airlifted and lived. I'm talking would this patient have died if transported by ground EMS.

 

[canjosh]

We are successful in prehospital because we are RN's plain and simple.

In my view, this statement serves as an excellent descriptor of the attitude of the nursing profession towards other direct caregivers. I'm probably not the only frustrated medic around who has felt this attitude from nurses. It's the ole', I can do this BECAUSE I'M A NURSE. YOU CAN'T do X,Y, and Z because YOU'RE JUST A PARAMEDIC. This is a dangerous attitude. Take this example: I worked for a couple of years in the PICU at a well-known pediatric tertiary center. A paramedic on the unit was suspended for 5 shifts (no pay) for bagging an intubated 'critical' patient (aren't nearly all PICU patients critical?!). The RT, RN, and PICU fellow were at the bedside during the child's decompensation. The RT was unsuccessful in maintaining the kid's sats, and needed to set up nitric oxide. The RN (remember in a PICU) was not confident in her ability to bag the pt so the paramedic took over for the RT. The nurse manager happened to walk by the room during the event and saw the medic bagging, and she proceeded to 'put him in his place' by suspending him. Nothing detrimental happened to the pt as a result of the medic's actions. He was simply suspended because of the attitude of nursing that paramedics are inferior and subordinate care providers on the food chain. Unfortunately, the nursing profession feels that us medics are nothing without them, and that without the delegation of nursing care to us we might as well be doorstops. Look, to get to my point...you might be successful in the prehospital setting, but it is NOT just because you are a nurse. If you take that attitude everywhere, you'll never recognize when you're in over your head. Or, do you believe that you will never be in over your head--because you have a license which has a 'nationally supported minimum standard'?


*Sorry for the poorly organized, scatter-brained, ADD-inspired post! I hope it makes some sense...*

 

[bell412]

SouthernDoc your concern is a real problem. Maybe we should start a new thread on this topic. How about posting the same one you posted on this thread.

Canjosh that really is to bad that happened to your co-worker. That nurse manager is retarted. I really feel the paramedic should be utilized more in the hospital setting. Heck I think the paramedic should be utilized as the RN fuctions in the ER!!

 

[FoughtFyr]

FoughtFyr, Coast Guard and the military paramedic services are for search and rescue. Far cry from civilian EMS.

First of all, while the Coast Guard is definitely search and rescue, the remaining military services employ flight primarily to evacuate wounded from the battlefield to the hospital. Same as civilians. And between wars, they are used to support civilian EMS under the MAST program (see: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=10782602&query_hl=14 for an example. Note the two medic aircrews.).

Our competence can only come from the licensure we practice under. We are successful in prehospital because we are RN's plain and simple.

Actually competence has NOTHING do to with licensure. A trauma surgeon from England is certainly competent to perform surgery in the United States, but he/she may not be licensed to do so. Similarly, while I hold an EMT-P license in the State of Illinois, my success in the trauma bay probably has more to do with the training I had later in life. I agree that the RN provides you with an adequate background to be trained to do flight work. But without that extra training you would not be competent to do so at all. Are you suggesting that a newly graduated nurse could function on a flight team with no additional training, merely as a consequence of his/her license?

And again, the question is not if nursing has "stepped up" to fill a role adequately. The question is, do they (nurses) still represent the best option to fill that role in terms of efficacy and cost? I would argue no.

Here you go. See no difference. RN/RN, RN/Medic. I never said the RN is better at prehospital management. The only thing I'm saying is we have a role in pre-hospital and are experts and are not going away ever.

Wow, I just love it when someone else proves my point for me. As you said "see no difference". So, the medical director of XYZ aeromedical service has to staff his helicopter. He/she can do so with either:

a. An RN who will require training in a variety of procedures, including but not limited to intubation, surgical crics, central lines, chest tubes, and scene safety as well as requiring re-training to the medical model of assessment and diagnosis​

or

b. A paramedic who will require training in more mundane "maintenance" type things like IV pumps or catheters.​

Additionally, since at most institutions the department of nursing has mandated that a nurse can only be supervised by a nurse, using the nurses to staff the crew requires a nursing administration to be in place. So, in short, the paramedic can be sent to the CCEMT-P course, costs less to hire, requires no additional administration costs, and their training will focus on "non-crisis" areas as they are already trained in the emergent procedures. Hiring the nurse will require designing a course (there are no national standard courses for flight nursing), retraining the individual in an entirely different approach to the patient, and the fact that most of the new skills are for crisis management might be a cause for concern. Additionally, an entire "chain of command" must be built for nursing administration. Given, as you say, "there is no difference" and the data out of Maryland that a medic/medic flight crew has decent outcomes (see: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=10724739&query_hl=10 and http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=15715519&query_hl=8), the better question is why have flight nurses at all?

- H

 

[FoughtFyr]

I really feel the paramedic should be utilized more in the hospital setting. Heck I think the paramedic should be utilized as the RN fuctions in the ER!!

Well, "Woctor" Foughtfyr and "Murse" Bell412 finally agree on something!

The problem is that nurse practice acts in most states prohibit this. From: http://home.earthlink.net/~douglaspage/id77.html

"According to ANA’s 1992 Position Statement, "Other regulatory entities have been pressured to lower agency staffing standards, for instance by allowing emergency medical technicians to function in the emergency room without registered nurse supervision or by substituting unlicensed personnel for licensed nurses. These unlicensed persons have not completed nursing education programs, or met other licensing requirements. In many instances, substitution of unlicensed personnel for licensed nurses clearly violates state nurse practice acts. At the very least, it is not in the interest of the health, safety, and welfare of the public".​

and from: http://www.massnurses.org/News/2003/09/emt.htm

"Last month, the Massachusetts Nurses Association sought and obtained a written opinion from the Massachusetts Board of Registration in Nursing regarding just such dangerous and misguided policies being implemented by the three Massachusetts hospitals that call for expanding the use of paramedics inside of hospitals to substitute for nurses in both intensive care units and emergency rooms."​

It has been a violitile issue, but the gist is without significant changes in the law (practically impossible given the power of the nursing lobby) it won't happen.

- H