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Prehospital Care

Mike MacKinnon mmackinnon at cox.net
Sun Apr 9 16:04:21 BST 2006


Dave, ill do my best to answer your questions.
 
But if working as an RN (specifically) why arent RNs taugh the art of airway
managment?
 
RNs are taught the full scope of airway management without the intubation
skill. I intubated in the ER in Canada as an RN. In the states, it's a
medicolegal liability. Why would you ever have a lower level of care perform
a high risk procedure when there is a physician right there? Secondly, it
would be a hugely expensive undertaking for the facility to train the RNs up
to the skill level where they could intubate safely as there are so many.
This is the main reasons hospitals cite as the reason they choose to train
RTs as backup intubators when the physicians are not avaliable, cost.
 
Medics get that type of experience of intubating upside down, in the dark
ect...this is valuable experience to cross over into the ED
 
We arent intubating people upside down in the ER. These people are intubated
in exactly the same position every time, in a well lit room with RTs RNs and
a physician at the head. I agree with you, as a medic and a flight RN I have
valuable experience with unusual intubation techniques , however, they are
only useful in that setting. I understand what your saying but it just
dosent translate to the ER.
 
Also, i feel that RNs dont work as well as medics under pressure to get
things done
 
Well now that depends on how you look at it. In the ER i have 5-6 patients
that i manage wholly by myself. Often under similar (but expanded) medic
protocols that allow me to get things done. When the crap hits the fan, it
isnt the Doc thats there, its the RN. I have been both places, and i totally
agree that most RNs couldnt manage a day in the field. However, i would
suggest the same of most medics within the hospital. Its easy to turn it
around and say this: " I see these medics come in on the fire service, 6 of
them for ONE patient? How easy must their job be now that they dump another
one off on the ER we cannot refuse and go back home to get in bed or finish
a movie?". ( or exchange that to 2 for one patient in a 3rd service, in
anycase, much less than 5:1 for nurses who have these patients either for
long periods of time or are turning over rooms constantly throughout the
shift without a chance to sleep or watch tv). I would suggest ER nurses are
certainly under pressure at 5:1 the rate of medics (i learned that the hard
way).
 
I am not trying to inflame you. I had the exact same belief structure as you
do now not that many years ago. Its a matter of seeing the otherside. I've
worked in the er with 3 vented ICU patients on 4-5 drips each with one on an
IABP (i was the only balloon trained RN in the ER), all by myself because
the ER was full and the hospital had no beds. It happens weekly. In order to
appreciate the differences between the professions you have to be there. 
 
I sometimes hear other RNs spout off about physicians wondering how it is
that they do all the work and the doc just sit there and writes the orders
yet makes 4-5 times more yearly? The answer in education, liability,
responsibility and experience. While these RNs may feel like they have
treated that MI patient a thousands times and could make the tx and dx
themselves, that is no substitute for the education that an ER physician
gets which allows them to pick out that lifesaving Dx which no RN would ever
come up with. I correct people quickly because I used to do the same thing
when i was a medic in regards to RNs (the ER/ICU ones anyway).
 
I have an immense respect for paramedicine. I still run paramedic classes do
refreshers and am about to recert here in the states. However, medics are
excellent at prehospital, RNs are excellent at hospital stuff. Sometimes a
transition goes well, but for the most part they are incompatiable. One is
not better than the other, just very different focus.
 
 
Mike M
 
-------Original Message-------
 
From: David Sullivan
Date: 04/09/06 04:46:27
To: Trauma &, Critical Care mailing list
Subject: RE: Prehospital Care
 
Mike,
 
  You must be joking? Why is there always a turf battle over who knows what,
and blah blah, blah...Why do RNs think that they are more effective
providers than medics? Sure, i agree that the training that a paramedic is
more narrow, but if working as an RN (specifically) why arent RNs taugh the
art of airway managment? I wrote a paper and that was one reason that medics
are used in the ED, b/c medics get that type of experience of intubating
upside down, in the dark ect...this is valuable experience to cross over
into the ED. Also, i feel that RNs dont work as well as medics under
pressure to get things done, a paramedic (as you well know) work with one
and rarely two other (hopefully similary) trained providers, RNs work on
teams ie trauma team, code team what have you....where they can be detailed
to one skill, IV, blood draw..ect...even though paramedics have a narrow
knowledge base, we treat a wide variety of medical emergencies. I am now
knocking on RNs, they do a
  tough job, and are well educated people, but this constant turf battle is
just crap, i accept that RNs are higher up on the medical "food chain" but I
also accept them as my peers, and i feel that, that respect is reciprocated
b/c of the pt care that I provide, pre-hospital. I did a paper on medics
working in the ED, and I surveyed local EDs to see what they thought, some
had medics and they were well used to provide care, b/c of standing orders
ect, traige ect....some hadnt thought of it, and seemed offened at the
thought
 
  dave sullivan BA NREMT-P
 
Mike MacKinnon <mmackinnon at cox.net> wrote:
  Steve
 
Get real.
 
I was a medic in Canada (P3) and a Nurse. Now an RN/Medic in the USA. I
never did anything as a medic near what I do as an RN, ever. Paramedic
education is highly specific to a very narrow scope of practice while RN
education (4 years science degree in Canada) is intentionally general
coverage of everything allowing the individual to specialize with a strong
science background. In the pre hospital setting I do much more than the
medics. Everything a medic can do is in the scope of practice of an RN while
the reverse is not true.
 
If there was a logical choice for a midrange person in hospital (when there
are no PAs or NPs available) it would clearly be an RN not a paramedic. RNs
would be used to the inner workings as well as the ER presentations,
treatments and knowledge base to make decisions.
 
A wise man once told my when I was an EMT (P1) planning to be a medic
shooting off my mouth how easy it looked "Son, you don't know what you don't
know.". Steve, your a paramedic looking in and making judgements without the
education or experience of a critical care RN.
 
Mike M
 
-------Original Message-------
 
From: Steve Urszenyi
Date: 04/08/06 22:57:02
To: 'Trauma &, Critical Care mailing list'
Subject: RE: Prehospital Care
 
Snippet from Andrew Bowman's post:
 
<< An added benefit would be the occasional procedure (ETT, central line,
etc) under the tutelage of an ED doc to give tips and tricks. >>
 
I few years back I was hired with about 3 or 4 other medics by a local
community hospital here in Toronto that wanted to create an ER Paramedic
position. The goal was to augment the physician staff with ALS paramedics to
assist in the Fast Track part of the ER. The very progressive-minded ER
director (an ER MD) envisioned us performing a pseudo Physician's Assistant
role. But guess what the biggest stumbling block was? The nurses' union.
They screamed blue murder that medics in the ER should not be able to do
anything above the skill set of the RNs. Never mind the fact that I do just
that every day out on the road where my skill set far exceeds anything they
are trained or permitted to perform. The program lasted around 8 months and
was then canceled. Oh well.
 
Steve Urszenyi
 
 
 
 
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