ICU Medics? The Massachusetts Nursing Association Paramedic Position pg 1 of 2

[niko327]

Mentioned by a poster on the aeromedical thread.
More Interesting Reading.............................

The Latest Developments in the Massachusetts Nursing Environment

9.04.03

Mass BORN Joins MNA in Questioning Role of Paramedics in ICUs and ERs

As the hospital industry attempts to deal with a shortage of nurses who are willing to work at the hospital bedside in Massachusetts, the Massachusetts Nurses Association has been on the lookout for the implementation of management strategies that attempt to deal with the shortage by replacing or substituting registered nurses with lesser qualified, unlicensed personnel. Such practices have been utilized in previous shortages with disastrous results, and in a number of reports and studies, such practices are cited as a cause of the current shortage we now face.

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.

The advisory from the BORN provides important guidance to nurses and nurse administrators that prohibits any delegation of nursing duties or tasks that require the judgement and assessment of a registered nurse to paramedics in the hospital setting. In the ICU, it is clear from the BORN advisory that paramedics cannot function beyond the scope of a typical PCA or nurses' aide. In the emergency department, if a paramedic is to perform any duties beyond the PCA role, they can only do so under the direction and supervision of an MD. No nurse or nurse manager can delegate registered nursing duties of any kind to a paramedic without being in violation of the Board of Registration's nurse practice act.

The MNA sought the ruling by the BORN after it learned of a program being implemented at the MetroWest Medical Center, a hospital owned by for-profit Tenet Corporation in Natick, which called for the use of paramedics in the intensive care unit to perform a variety of functions that are the exclusive purview of the registered nurse. During the same time period, the MNA was alerted to a similar programs utilizing paramedics to assume nursing functions in emergency departments at Lawrence General Hospital. The MNA is also clarifying the use of paramedics in the emergency department at Merrimack Valley Hospital in Haverhill.

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[niko327]

At MetorWest Medical Center, management created and filled positions with the title, "ICU Paramedic." Under the supervision of the unit's nursing management, the position job description clearly states that the ICU paramedics contribute to the "assessment, planning, implementing and evaluation of patient care."

The ICU Paramedic job description includes a number of functions that the MNA believed clearly fall only to RNs to perform, including: auscultation of breath sounds, heart sounds, initiation of oxygen therapy, analysis of cardiac rhythms and monitoring patients with Swan Ganz catheter; chest tubes; or cardioversion and sunctioning of patients.

The letter to the MNA from the BORN's Nursing Practice Coordinator Gino Gisari, MSN, RN, stated that none of these activities comply with the Board's criteria for delegation. If a nurse were to follow the hospital's job description and delegate these tasks to one of the ICU paramedics, according to this ruling, he or she would be violating the Nurse Practice Act.

The MNA also asked for clarification as to the responsibility of nurse managers in allowing or sanctioning this level of delegation. The Board's response was again quite clear. The ruling states, "The regulations governing licensed nurses are the same regardless of job title or employment setting."

According to Dorothy McCabe, MNA Director of Nursing who initiated the discussion with the BORN on this issue, "There is no ambiguity here, this job description, as written, is in direct violation of the nurse practice act. Any nurse manager who participates in supervising paramedics in performing at this level, and any nurse who allows a paramedic to perform these tasks on their patients, is in direct opposition to and in conflict with the Board of Registration's position on delegation."

In another case, nurses at Merrimack Valley Hospital raised concerns to the MNA and with management when a paramedic assigned to the emergency department transported a patient to the ICU and proceeded to give a nurse orders for that patient. The nurse wisely refused to accept the orders from a paramedic and insisted that she would only take orders from a physician.

Based on the BORN letter to MNA and on subsequent conversations with offcials at the BORN, it is clear that the nurse acted accordingly. If and when a paramedic is working in an emergency room, they can only work under the supervision of the physician. If a paramedic works with a nurse, he or she can only function at the level of a PCA or traditional nurses aide.

At Lawrence General Hospital, the MNA local bargaining unit became involved in the issue when the husband of one of the nurses, himself an EMT, became alarmed upon bringing a patient into the hospital's emergency room only to be greeted by a paramedic who wanted to admit the patient. The EMT refused, stating that he would and could only turn his patient over to an RN. A nurse manager stepped in and allowed the paramedic to admit the patient. Again, this is in violation of the Nurse Practice Act and JCAHO standards, as it is only a nurse who can admit and take a history of a patient in a hospital setting.

"We became alarmed to see a pattern of behavior that signaled to us that the hospital industry was once again responding to a shortage of nurses by seeking to implement strategies that called for the replacement or substitution of RNs by lesser qualified, cheaper substitutes—in this case, paramedics," said Karen Higgins, RN, president of MNA. "We have been down this road before, during the 80s and throughout the 1990s and it was disastrous for both nurses and for patients. In fact, these policies are what created the current shortage. We have nothing against EMTs and paramedics. They serve a valuable role in providing pre-hospital care. But they are not and cannot function as a registered nurse."

The MNA's position is supported by a number of studies, including two recent studies published in the New England Journal of Medicine and the Journal of American Medical Association, which both found that when there is a skill mix with fewer RNs, the quality and safety of care is negatively impacted.

"The bottom line is, if you want to provide safe, quality patient care, there is no substitute for a registered nurse," Higgins said. "Our hats are off to the Board of Registration in Nursing for reinforcing that concept. Now it is up to every nurse and nurse manager to stand up for quality patient care and to not allow misguided administrators to attempt to destroy nursing practice by handing our practice over to lesser qualified personnel."

A copy of the MNA publication "Accepting, Reflecting and Delegating a Work Assignment: A Guide fro Nurses," can be obtained by calling the department of nursing at 781.821.4625. A free 1.2 contact-hour program can be scheduled at your facility by contacting Dorothy McCabe at 781.830.5714 or via e-mail at [email protected].

I like the fact that you can get CME credit for the above, outstanding!
I've got my own opinions about this, what do all of you guys think?????

 

[tkim]

Haha, now that's funny.

I worked at Metrowest as a paramedic when they implemented that plan. The ICU nurses loved the extra help, the MNA lodged complaints.

Ah well, moot point for that hospital since our unit was dismantled in 2003 ...

 

[bell412]

I can certainly see paramedics functioning in the ER without a problem. In fact they would be an incredible asset to the ED. The ICU might be a tough one.

 

[canjosh]

I find it darn near hilarious that the nursing profession insists upon viewing us medics as 'lesser qualified personnel'. When will they learn?!

 

[niko327]

I can certainly see paramedics functioning in the ER without a problem. In fact they would be an incredible asset to the ED. The ICU might be a tough one.

What the heck prepared you so well to do ICU care in nursing school???? I mean really, please tell me! Hell, I'll go out on a limb and offer the following; flame me if you want to: I'd rather take a medic fresh out of medic school and put him in the ICU than a nurse fresh out of nursing school. Nursing theory goes right out the window when your patient has got one foot in the grave and the other on a banana peel. The thing that makes nurses better qualified to be in the ICU is simply the opportunity to work in this setting, with time comes training and experience. Training and experience that is just as accessible by medics as it is to nurses. Nursing does not have the monopoly on intelligence, intellectual curiosity and the ability to assimilate knowledge and experience into useable skills. Period.

I find it darn near hilarious that the nursing profession insists upon viewing us medics as 'lesser qualified personnel'. When will they learn?!

Fact is there's alot of overlap between what medics can do and what nursing can do. I don't think we're lesser qualified as medics or superiorly qualified for that matter. Our training is simply different. Comparing the two professions in terms of who is "better" really isn't possible. The fact of the matter is that nursing has been around much longer than EMS, with that comes greater public recognition, better representation and a stronger lobby. I really believe that all of the opportunities for advancement seen in the nursing profession are as a result of the aformentioned recognition, representation and lobbying power. I believe that bell412 is correct. Nurses are moving into advanced and varied roles and doing well in them, their continued existence in these roles is evidence to support this. But the fact of the matter is this, just because there are many advancement opportunities out there for nurses does not mean that nurses are the only ones capable of doing well in them. I can easily see advancement programs out there designed specifically for paramedics to step into roles much like the CRNA or the NP. In fact the PA role was originally designed to take seasoned military paramedics and turn them into a competent healthcare providers. There is already some talk out there about advancing the role of paramedics. I hope this happens as I believe that our background as medics is a great base to build upon, I'd love to see EMS come into it's own as a recognized and respected profession. I'll spare you the crappola about celebrating our differences and diversity with the nurses, what we really need to do is to take a page out of their book and learn to advance, promote and protect our profession like they have. When this happens I think we'll see alot less inflammatory nonsense from organizations like the Massachusetts Nursing Association.

 

[MacGyver]

This thread is SOOOO typical of midlevels and their constant hypocrisy


MDs: NPs arent qualified to do X
NPs: Yes we are, we demand you give us that scope

NPs: RNs arent qualified to do X
RNs: Yes we are, we demand you give us that scope

RNs: CNAs arent qualified to do X
CNAs: Yes we are, we demand you give us that scope

MDs: PAs arent qualified to do X
PAs: Yes we are, we demand that scope

PAs: Paramedics arent qualified to do X
Paramedics: Yes we are, and we will add it to our scope



I'm so sick of this never ending circle of bull****. Everybody thinks they can upgrade their scope to the next level, but when lower tier people claim the SAME THING about them, they fight to the death against it.

 

[spo0kman]

This thread is SOOOO typical of midlevels and their constant hypocrisy

I stopped reading here.. you dingus.. way to elevate yourself among all of us "lesser people". Get over yourself.

As for the original post, the old saying goes "nurses go to school for 4 years only to get detailed instructions as to what to do, medics go to school for 1 year and can think on their own"

 

[QuikClot]

I don't take the "patient care" angle presented by the OP's source very seriously (which is why I'm not offended by the implication that I'm not competent to suction a pt. or listen to their breath sounds.) These are people trying to protect their hours, their wages and their jobs. Of course they're going to say it's about safety. But it is turf, plain and simple. So you can replace half your $60 an hour ICU nurses with $20 an hour medics. Of course that's scary if you're a nurse. Hate to see working people at each others' throats, but in this case, I think it's inevitable.

These issues will not arise when medics, who have similiar scope and responsibilities (to be generous to the average RN) win similiar compensation. And we'll do it the way they did it; get organized, get unionized, educate the public and demand a fair deal from employers.

 

[viostorm]

I stopped reading here.. you dingus.. way to elevate yourself among all of us "lesser people". Get over yourself.

As for the original post, the old saying goes "nurses go to school for 4 years only to get detailed instructions as to what to do, medics go to school for 1 year and can think on their own"

Ha ... spoOkman

You are so typical a subset paramedics we don't need in our profession ... they think they know everything ... instead of realizing in fact they haven't even scratched the surface of medicine. If you truly realized how little you know about taking care of patients your attitude would be much different

Lets talk about the facts:

1) you aren't qualified to work in an ICU
2) you aren't qualified to work in a hospital setting beyond pushing patients to x-ray
3) Most research shows you aren't qualified to perform ALS

Such a joke you think ICU nurses don't think.

Thanks for making the profession shine spookman. Thanks.

-Vio, CCEMT-P

 

[MacGyver]

Lets just cut thru the bull**** right here

Fact #1: Turf wars happen because of MONEY, not because people get no access to healthcare.

Fact #2: 99% of turf wars are started by groups who are NOT doctors trying to encroach on doctors turf

 

[viostorm]

MacGyver ... you are right, we debate the midlevel thing all the time and it really just needs to stop, although your post comes off a bit strong and perhaps you could have posted it without the inflammatory language.

I think you have made one error in your assessment of paramedicine.

Paramedics are NOT practitioners ... they are technicians. And hence not mid-level practitioners like NP/PA. My understanding is RN/BSN's are not considered practitioners either.

Medics have an algorithm to follow and must do so or else risk practicing medicine without a license. Nurses have direct physician orders to follow.

I think it is best to consider paramedics/EMTs as not practitioners ... "encroaching on physicians", but rather health care providers with a distinct role as evolving experts at prehospital medicine.

Doctors can't function without nurses, nurses can't function without doctors, EMS can't function without paramedics.

I think it is best if everyone just does the job they chose to do, and if they want to do something different then get trained to do it.

 

[logos]

Sounds like a turf war to me.

Nursing = 2 years Associates
Paramedic = 2 years Associates

Similar educations and scope of practice.

Therefore, I think a fair arguement can be made that

Nurse ~= Paramedic

Not the same, but close enough I could envision some overlap.

Sometimes it is easy to forget that education is not there so much to teach us how to do something, but to give us the intelligence and background to figure it our for ourselves.

 

[deleted6669]

Sounds like a turf war to me.

Nursing = 2 years Associates
Paramedic = 2 years Associates

Similar educations and scope of practice.

Therefore, I think a fair arguement can be made that

Nurse ~= Paramedic

Not the same, but close enough I could envision some overlap.

Sometimes it is easy to forget that education is not there so much to teach us how to do something, but to give us the intelligence and background to figure it our for ourselves.

agree-
also:
bs/ba in anything + 1 yr training = bsn.......that means there is 3 yrs of fluff in a typical bsn program.....if you can teach someone with a history degree to be a nurse in 1 yr what does that say about folks who take 4 yrs to learn the same thing and get the same degree.....

and relevant to the original discussion...my local hospital, a level 1 trauma ctr, uses medics in the er to supplement rn's with the same scope of practice with 1 exception in favor of the medics...if there is an in house code and no md available the medic runs the code.....makes sense, it is what we are trained to do after all.....here is the job posting:
Department: Emergency
Job Category: Allied Health
Posted: 01/23/2006
Job ID: IRC14544 CH
Job Status: FULLTIME
Description
The ED paramedic is responsible for his/her own actions, working under the license of the physician, within the appropriate scope of practice. performs tasks requested by the physician, including data collection, assessment and re-assessment of the patient's condition and initiation of emergency stabilization and procedures.
Qualifications
Requires agency or state sponsored skills competency verification every 2 years to meet Oregon state requirements. Current Oregon EMT-P certification. Current ACLS certification. Minimum of two years pre-hospital or related experience. PALS/PEPP certification. Prefer prior ED experience, PHTLS/BTLS certification. Strong verbal and written communication skills. Ability to prioritize.
Schedule and Salary Range
12 hour shift; .9 FTE; Salary Range: $19.30-26.21/hour.

 

[spo0kman]

Ha ... spoOkman

You are so typical a subset paramedics we don't need in our profession ... they think they know everything ... instead of realizing in fact they haven't even scratched the surface of medicine. If you truly realized how little you know about taking care of patients your attitude would be much different

So because I call him out for being an arrogant ass and trying to make himself into a better human than us "midlevels" you can jump to the conclusion that I am similar to other paramedics you may have met who feel they know everything?

Lets talk about the facts:

1) you aren't qualified to work in an ICU

I never said I was, and that statement has nothing to do with my post. It actually appears, however, that you are stating this to once again attempt to elevate yourself above others.

2) you aren't qualified to work in a hospital setting beyond pushing patients to x-ray

Before I answer this statement, I would like to know what your prehosptial experience is, where you worked at, what your run volume was, and what your patient acuity was as a general norm.

3) Most research shows you aren't qualified to perform ALS

Most research wasn't conducted upon me personally, but thanks for the over generalization anyhow.

Such a joke you think ICU nurses don't think.

Such a joke the fact that you can't see the quotation marks and smily face, hence implying this thing called a "sarcastic joke"

Thanks for making the profession shine spookman. Thanks.

-Vio, CCEMT-P

So quick to jump down someones throat. I do make my profession shine, every day I work. Go ahead and continue posts with this flavor of attitude, trivializing the prehospital setting. You may go ahead and assume that you know the me, or the paramedics that work at our department. The fact of the matter is, you don't. You can pretend that medicine in hospital is so much different than that outside the hospital, and that we as paramedics are nothing more than ambulance drivers and cot pushers. I won't defend this. The level of ignorance you show proves to me that no matter what I say it won't change your mind.

Thank you for making my day

 

[RNtoFNP]

I'd rather take a medic fresh out of medic school and put him in the ICU than a nurse fresh out of nursing school. Nursing theory goes right out the window when your patient has got one foot in the grave and the other on a banana peel. The thing that makes nurses better qualified to be in the ICU is simply the opportunity to work in this setting, with time comes training and experience. Training and experience that is just as accessible by medics as it is to nurses.

I agree a lot with Niko. As a graduate of a one yr accelerated BSN program, I can tell you that I knew close to nil when I graduated. It all comes with experience and good preceptors. You learn something from all the ancillary staff and specialty nurse/PA/RTs around you, and you use that info to build your base of knowledge. With the same environment, paramedics can probably learn the same way. I'm pretty new to nursing myself, and Im still learning everyday, be it with assessment or interventions.

I'm starting an NP program now, and it will be interesting to see how I compare with my minimal nursing experience to those students with 10+ yrs of experience. Will the education make us all "equally competent" NPs, or will years of nursing experience really make a significant difference.

 

[zenman]

I agree a lot with Niko. As a graduate of a one yr accelerated BSN program, I can tell you that I knew close to nil when I graduated. It all comes with experience and good preceptors. You learn something from all the ancillary staff and specialty nurse/PA/RTs around you, and you use that info to build your base of knowledge. With the same environment, paramedics can probably learn the same way. I'm pretty new to nursing myself, and Im still learning everyday, be it with assessment or interventions.

I'm starting an NP program now, and it will be interesting to see how I compare with my minimal nursing experience to those students with 10+ yrs of experience. Will the education make us all "equally competent" NPs, or will years of nursing experience really make a significant difference.

I really don't think paramedics should be in ICU. Think about what paramedics were created for. The ER and maybe ICU for training then you need to be out in the field.

RN to FNP, every little bit of experience will help. I've got 32 years of experience behind me and I'm in NP school. I've got experience I wouldn't trade, including EMS, ARMY corpsman, Helicopter Flight Nurse, ED, ICU...and on and on.

 

[RNtoFNP]

I really don't think paramedics should be in ICU. Think about what paramedics were created for. The ER and maybe ICU for training then you need to be out in the field.

RN to FNP, every little bit of experience will help. I've got 32 years of experience behind me and I'm in NP school. I've got experience I wouldn't trade, including EMS, ARMY corpsman, Helicopter Flight Nurse, ED, ICU...and on and on.

I'm not saying that experience won't help. Of course, experience makes a big difference. But think about it this way, try to compare the training of paramedics to nurses. Thinking about it myself, you cant really, since the nursing programs can range from dismal to terrific. Like I mentioned before, with my schooling, I could have easily been shaped into a school nurse, ER nurse, or even ICU nurse. What makes me competent in each of these areas? Training. I get trained to think and learn school nursing, and thats what I'll do. Train me and give me the tools to increase my knowledge in ICU, and I'll be an ICU nurse.

I think it can work the same way with paramedics. (Not 100% sure though, because I've never fully researched a paramedic course curriculum.) Give a paramedic a good preceptor, the right environment (i.e. inpatient), and they'll grow into that role. Half of medical education, anyways, is what you teach yourself and learn on your own. Did we learn EKGs in nursing school? Sure, how to differentiate SR from asystole. (I'm kidding you realize.) How did I learn to really read EKGs? Taught myself, and still learning.

Paramedics can be given the same tools to critical think and respond to different scenarios. Originally they're trained to work in the field, but if we add to their education the inpatient component, then I think they can take that on.

Zenman, in your opinion, what would the difference be between a student nurse who has not yet started clinical rotations, and a student medic who hasn't either done any rotations yet? I think they may be equals, all ready to be molded into whatever we make them.

But then, just too confuse myself, why not just train them to become an RN in the first place...? Overlapping roles...

Just my thoughts.

 

[fuegorama]

The scope thing is always an interesting topic.

Anybody notice that the real sticky thing about the letter is the idea that a nurse cannot delegate to a paramedic without violating the nurse practice act. My answer then is don't.

At least in EDs, why is a nurse delegating to a medic anyway?

I have a close perspective on this as the first paramedic to work in an ED in a certain little place in the South. I had worked in the ED as a tech through EMT school the fire academy and then my medic program. The department could not keep their nursing shifts filled.

I was young (over 12 years ago) and stupid enough to suggest to the physician group that they sell the role of a medic in the dept. They did it and left me and my partner to write a job description. The first draft had us as hospital employees answering to nurse admin. The nurses batted that idea down like a fly. I thought the idea was dead until an attending involved in EMS described what eventually became our model. He was our medical control on the street. Our license depended on staying in his graces. We now answered to him and the colleagues in his group. We took a full patient load and performed exactly like nurses including pharm. (in retrospect not the safest move) Our paycheck came from the hospital. Of course the finance folks loved us since we cost a minimum $8/hr less than the RNs. The docs and the smart RNs dug us because we had the absolute worst shift (3p-3a +call). The rest of nursing hated our guts. It was an incredibly stressful, nasty 2 years.

When I took patients to the ICU, the charge nurse, the nurse taking the patient, and any other RN hanging around would go over our charting literally line by line looking for errors. Every dose of anything we pushed was checked so many freaking times it seemed like we were doing RSI on everybody. There was this crazy vibe of zero-tolerance for mistakes.
I placed an IO in a child that died, and it went to MM on nursing request on the chance I did anything that harmed the pt.

We ate alone, didn't pee, and never turned down a request for staying over or coming in early. We also studied in empty rooms or in the bay whenever we could. We, in fact were slightly out of depth on pharm. Ironically this situation was made more dangerous b/c we couldn't ask a nurse for any advice. If we had made a drug error that would have been fine.

After about 10 months nursing got in a big bunch over us and called the state board who sent an investigator. This sweet little lady in squeaky shoes follwed me for a whole 12 hours. What a great time!
Midway through the night we went to eat together. She bought me dinner in the cafeteria and we talked about nursing and EMS. She told me how nurses not only in other departments but also in other hospitals had griped about our role. she then told me we were independent b/c of how we were set up and she liked our role. Yippee.

It was great to see faces the next day. The department was sure we would be gone.
If ya can't beat 'em...join 'em. One year later I did the Regent's thing and got my AD RN. The hospital initially refused to hire me as a nurse. They finally came around after my doc once again went to bat and I was employed in the same s hitty shift as before. I moved 6 mos later.

I have pretty big hang-ups w/medics acting independently in ICUs. As basic EMT-ps we are not trained for that scene. I think some of the crit. medic programs have a pretty great start. If the unit clinical time is there then it could probably work. What must be done to be successful however, is to end-run nursing and keep independent licensure. The nurse practice acts are fluid documents that can morph to encompass or restrict anything that can effect the nursing power house. Their scope creep is incredible, but don't even try to tread there.

If you didn't guess, that experience from over a decade ago has had a pretty big effect on me. I was very young and maybe a little tender, but my tolerance for nursing will always be low.
Thanks for being my therapists. Where do I pay?

 

[deleted6669]

I agree that a new grad medic would need additional training to work in the icu. so would a new grad rn.
I think a good medic right out of school could functiuon in the same capacity as an er nurse with minimal additional training. see my note above about the emt-p position in a local trauma ctr near me.

 

[zenman]

To answer some of the comments above I'll just use myself as an example. I challenged the California State Nursing Boards after medic training and passed. Remember, the State Boards and now NCLEX just means that you have passed a minimal safety level. So now I'm working as an RN in a level 1 trauma center in Jackson, MS having never spent a day in nursing school. Very quickly, I'm 3-11 charge nurse and then in a year Nurse Manager. I was reading and studying on my own all the time. Then I got my BSN through Regents, then a traditional masters and now working on FNP. I continue to learning what I didn't know the day before. There is also a difference between education and training. Those liberal arts courses actually mean more than many think. So, basically as a medic I was "trained" to do a job, and as a nurse "educated." I do wonder why anyone who wants to be a paramedic would be interested in an inpatient setting...it's just too safe inside

 

[fuegorama]

I do wonder why anyone who wants to be a paramedic would be interested in an inpatient setting...it's just too safe inside

A:$$$$$$
I made $8.50 with a BA and an EMT-P ticket running systems status (18 hrs in a truck on corners). $12.50 in an ED. With a partner/future spouse that chose a house over a ring, those 4 bucks made a huge diff.

The unforseen positive of that decision was exposure to medicine. If I hadn't been in the hospital, I would hopefully be a captain in the dept. Instead I am 380 days from being a physician.

I gotta keep telling myself it was the right move.

 

[zenman]

A:$$$$$$

I gotta keep telling myself it was the right move.

Did you forget about the FD pension...you screwed up bad, LOL!

 

[igcgnerd]

I dont think its fair to compare nurses and paramedics. As a current EMT and medic in training, I can say that they are both autonomous professional and both bring alot to the table. Paramedics are useful in the ER since they have a very large scope of practice. I think the nursing scope and the paramedic scope compliment each other. In stead of fighting for patients and procedures, share them.