I am writing in response to a letter of response written by Renata Graef, RN, MSN,1 focusing on the article “Recruitment and Retention Benefits of EMT-Paramedic Utilization During ED Nursing Shortages.”2 While I am in agreement with some of the author's points of rebuttal, I am concerned with Ms. Graef's blanket statement that “Paramedics view their jobs in the emergency department as temporary and are not motivated to do their best.”1 I am concerned that Ms. Graef's views unfairly portray EMT-paramedics as lazy and not suitable for employment. Quite candidly, the use of EMT-paramedics within the hospital setting can be a vital asset to the provision of safe, effective patient care. Having been licensed as a registered nurse since 2000 and certified as an EMT-paramedic since 1995, I would like to lend my professional and academic background to highlight some of the positive and productive contributions that EMT-paramedics, especially those dually employed as firefighters, can have on patient care outcomes within the hospital setting. This author challenges readers to objectively evaluate and consider the valuable role of the EMT-Paramedic within the ED setting.
Having successfully managed a dual career as a firefighter/paramedic and a registered nurse for 9 years, I am confident that all patients that I have cared for, both prior to hospital treatment and in the inpatient setting, have received the highest caliber of care afforded within the scope of my practice. At no time was it compromised due to my professional diversity but instead was elevated as a result of the many diverse experiences that have shaped my practice in both settings. Although the institution where I presently work does not employ EMT-paramedics within the emergency department setting, I have personally worked as a nurse in an institution that does. I have also worked in the capacity of an EMT-paramedic in an emergency department. The institution at which I currently work utilizes what is known as a personal care assistant (PCA), a position that is synonymous with the patient care technician (PCT) referenced in Ms. Graef's article and discussed by Mr. Cormier in 2007.3 Qualifications to become a PCA include enrollment in a nursing program, among other personal attributes and skills sets. Certification as an EMT is not a requirement for employment. Having worked in 2 kinds of hospital systems, 1 that employs EMTs and 1 that employs nursing students and/or lay persons as PCTs, I can confidently say that both qualifications have their merits. However, this letter will primarily focus on the contributions that EMT-paramedics can have on patient care outcomes and on nursing staff within the ED setting.
I disagree with Ms. Graef's assertion that it is wasteful to have 3 levels of health care professionals. Emergency departments today are overcrowded and often overwhelmed with an increasingly acute patient population. While having 3 levels of care has the potential to be confusing, it also has the potential to augment patient safety as well as to maximize staff efficiency, thereby increasing the nurse-to-patient care ratio. There is potential for confusion with 3 levels of care, primarily because 2 of the 3 levels (the PCT role and the EMT-paramedic) can have overlapping responsibilities. However, the confusion can be eliminated by having clearly delineated responsibilities and roles for each position. Furthermore, it is incumbent upon the registered nurse, who is the highest member of the health care team, to familiarize himself or herself with the job descriptions, academic backgrounds, and scope of each member of the team so that he or she can appropriately delegate tasks.
One of the most fundamental facets of the nursing profession is the ability to be a part of a multidisciplinary team where all members of the team are valued for their contribution. It is imperative that each member of the team be familiar with the scope of practice of other team members so that the team as a whole can maximize its potential and consequently optimize patient care outcomes. The EMT-paramedic is a valuable asset to the health care team due to their scientific background as well as their clinical skills and personal attributes. In general, as a result of the dynamic field environment in which they work, the EMT-paramedic is noted for the following character attributes that include but are not limited to the following qualities: adaptability, ingenuity, quick response time, flexibility, excellent communication, rapid assessment skills, and the ability to think critically. Unlike the hospital setting, the environment in which the EMT-paramedic works is not a controlled environment but frequently can be characterized as intense and chaotic. The EMT-paramedic typically is the first person on scene after some of the most horrific accidents and is charged with caring not only for multiple patients at once but must do so in the presence of family, friends, and bystanders, many of whom are frantic, anxious, and even irrational. Consequently, the EMT-paramedic must make both clinical and logistical assessments simultaneously in order to best execute whatever interventions he or she deems necessary under the circumstances. There is no coincidence that many of these same qualities are common to ED nurses, as well. Paramedicine, despite the medical model approach toward patient care, is similar to nursing in that it utilizes a systematic approach to patient care. The EMT-paramedic, like the nurse, must begin by assessing the patient using the principals of anatomy, physiology, and biology to collect subjective and objective data. The paramedic then uses this data to formulate a tentative diagnosis. Interventions are then selected by the paramedic in conjunction with the patient that best achieve the best outcome based on the data collected in the assessment phase. The paramedic then continues to monitor the patient, continually reassessing the patient, making adjustments based on his or her evaluation. This systematic approach can be applied to patients in both the pre-hospital and inpatient setting.
Similar to the nursing profession, EMT-paramedics are licensed professionals and as such are held accountable to state and regional licensing officials. The EMT-paramedic like the nurse must remain active within their profession as mandated by individual state agencies as evidenced by the completion of biannual continuing education and re-certification training. Ironically, though the nurse is considered to be a “higher” level of licensure than the EMT-paramedic, nurses in Massachusetts are only mandated to complete 15 hours of continuing education biannually. The EMT-paramedic is held to a much more rigorous standard, mandated to complete 25 hours of continuing education. They also must complete an additional 48 hours of educational and didactic instruction, the content of which is determined by the Office of Emergency Services.
Clinically speaking, EMT-paramedics possess a very specific skill set that is both unique and mutually exclusive to the profession. For example, a paramedic can intubate, defibrillate, and medicate a patient within defined protocols based on a standing physician's order. Essentially, the EMT-paramedic can determine and administer treatment modalities independently. Because of this, the EMT-paramedic must employ astute critical thinking skills and impeccable assessment skills for this system to be successful. The registered nurse cannot intubate and cannot perform defibrillation and/or medicate a patient without a direct doctor's order. Clearly, the EMT-paramedic can be of great assistance to the nurse caring for a critically injured or ill patient.
Another potential benefit of the EMT-paramedic is that he or she can reduce the workload of the nurse by being able to transport critically ill patients to an intensive care unit or other inpatient setting without the nurse needing to travel with the patient. Again, this can occur because the paramedic like the nurse has a defined educational body of knowledge on which to base his or her clinical decision making skills. Furthermore, the paramedic can operate complex medical machinery, interpret ECGs, establish intravenous, and monitor the patient's vital signs all of which are needed to safely
EMT-paramedics should be used in addition to PCTs to carry out the “lower level skills” as outlined by Mr. Cormier, but not if there is a task that takes priority and requires the EMT-paramedic level. Confusion that may arise is most likely a result of poor delegation and mismanagement of staff resources. Perhaps one of the largest barriers to the successful use of EMT-paramedics within the ED setting is a general knowledge deficit among nursing staff regarding the role of the EMT-paramedic within the hospital setting that has resulted in an underutilization of paramedics. Furthermore, nursing staff often have difficulty effectively delegating tasks as a direct result of a lack of knowledge about the academic preparation and skill sets specific to the EMT-paramedic.
In summary, it is the responsibility of the nursing profession to employ nursing students as PCTs, as it affords students many educational opportunities within the clinical setting. Students are able to watch the nursing process being practiced in a real-life setting and are able to transition their academic knowledge into clinical practice. However, in many hospitals, the role of the PCA is limited to task-oriented things such as assisting with ADLs, stocking supplies, and taking vital signs. The EMT-paramedic, unlike the nursing student, is a licensed professional who can be a valuable asset to the team of health care providers in the ED setting. The role of the PCA and the role of the EMT-paramedic have many overlapping responsibilities yet also very unique distinctions that render them both valuable positions.
Whether you are a registered nurse, an EMT-paramedic, a PCT, or another health care worker, we all practice as members of a team regardless of our titles or certifications. Registered nurses are a valuable asset to the health care team and to patient care. However, we must not discount the value of other health care professionals based on their employment status as part time, full time, or per diem. Instead, we must embrace the attributes of every member of the health care team and strive to maximize the team contribution to patient care by remaining objective and positive.
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