The Unwired Medic

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Texas ENA’s Unprofessional Attack on EMS


Texas ENA’s Unprofessional Attack on EMS

Author’s note: I generally avoid posting non-tech matters on my blog, but this unprofessional, unsubstantiated, fear-mongering attack of EMS in Texas has me boiling. I present to you something that doesn’t just affect Texas EMS, but EMS in the entirety of the United States of America. This has been fought in other states, and if it isn’t stopped now, will set a precedent and spill into many more states and regions. If you want to advance, you don’t do it by holding your siblings down in mediocrity and attacking their skills and intelligence. They seem to have taken a page out of the book, “How to Get Ahead in Life by Attacking Your Colleagues.” It is uncalled for. It has been professionally sanctioned by the San Antonio Chapter of and the Texas ENA, and they are imploring their members to spread this insult as if it were fact and we will bring the end of competent emergency care. I submit that they owe us a retraction and public, formal apology. My dog in the fight directly is that I have been a Texas Paramedic and if I want to return there in my future, my career options should not be limited by a board that played dirty politics from the word go with lies and mudslinging! My article also appears on Facebook (here) and I invite you to share it ad libitum. I would like to see the NAEMT take a professional position on this matter, and I would appreciate if you took time to contact the Texas NAEMT region board and state leadership, and the Texas EMA, decrying this deplorable behavior.

Warmest regards…


The Texas ENA is pushing to keep their thumb over EMS again and trying to keep EMS providers from crowding “their” domain. Consider asking your political representation to oppose the ENA efforts and to move to allow EMS to practice out of the preshospital-only areas. This push is to allow EMS to work to its full scope, under guidance of a physician, in ER and urgent care type sites, not ICU or other full admissions patient care environments.

I provide my counter-points to the letter at the end, factually debunking most of the ENA letter. Thanks for considering this and please SHARE!

The following is a letter sent to me by a Texas Paramedic:

The following is an email being sent to Texas ENA members in regards
to legislation being considered that would allow Texas EMT’s and
Paramedics to function within their scope in the hospital setting
under the direct supervision of the MD. HB 2020 and SB 1899 would
allow us to perform our clinical abilities in the emergency department
or urgent care setting with a physician in close proximity.
The stance of the Texas ENA essentially states that these procedures
are best performed by and RN and that we do not have the necessary
education or competency to perform these procedures within the hospital
setting despite performing them in the out of hospital setting.
Unfortunately we lack the legislative representation as EMS but if we
all call, write or visit ourstate representatives and senators we
might be able to fight back!
I have copied the email being circulated and you can read it in the
text below. The link is a link that will allow you to contact your
representatives both in the house and senate.
PLEASE SHARE THIS LINK TO ALL IN EMS; even if you do not practice in Texas!

Dear SAENA Member,

The Texas ENA Government Affairs Chair has asked that the following information be sent out to all of Texas ENA members:

House Bill 2020 and Senate Bill 1899 are currently under discussion and maybe moving for vote in the near future.

These bills would change the scope of the EMT-P and licensed paramedic to include the initiation of advanced life support measures such as; IVs, intubation, defibrillation / cardioversion and administration of medications under the supervision of a physician who is present in the same area or an area adjacent to the area. These actions would occur in an emergency or urgent care clinical setting, including a hospital emergency room or a freestanding emergency medical care facility.

The Texas ENA is opposed to the passing of these bills and requests members immediately contact their House and Senate representatives by calling, writing a letter or email, to express opposition to the bills. (To identify your representative, go to…/find-your-representative/ )

The Government Affairs Chair included a letter, written by a member, which identifies the issues related to these bills. Members may use the basic information in the document to compose their own letters to their legislator or to identify points to discuss when speaking to their representative.

I am writing today as a registered voter in opposition to HB2020 relating to the scope of duties of an emergency medical technician-paramedic and a licensed paramedic. This bill allows EMTs and EMT-Paramedics the authority to provide healthcare services including advanced life support in hospital emergency rooms and freestanding emergency medical care facilities under a physician delegation.

As an emergency nurse, I am concerned that this bill will potentially affect the safety and level of care provided to patients in the emergency department and encourage hospitals to utilized less qualified providers for staffing. Currently, EMT and paramedics are provided the authority to provide life saving measures in the pre-hospital environment until the patient can reach the emergency department which is a higher level of care. This role utilizes physician-developed protocols and direct communication with the hospital to direct care until the patient arrives at the emergency department. The focus of the training is on skills. The Texas Board of Nursing rules limits what tasks can be delegated to others. This restricts paramedics from administering medications and intravenous fluids in the hospital setting.

This differs significantly from the registered nurse role which is an autonomous provider who’s training includes independent decision-making in which the RN works collaboratively with the physician to ensure that adequate care is provided to the patient. There is extensive preparation in pathophysiology, pharmacology, skills, and critical thinking/clinical judgment. Current research shows a direct correlation between nursing care and positive patient outcomes. Most emergency departments require that emergency RNs are trained in advanced cardiac life support and trauma nursing care. There is a national certification body that also provides certification in emergency nursing. Furthermore, the Texas Board of Nursing rules does not allow nursing to carry out orders from an EMT or paramedic.

EMTs and EMT-Paramedics temporarily receiving direction for a physician could create a very unsafe situation during the most critical time in the patients hospital stay. Currently they receive directions (delegation) from a nurse so who do they listen to in this critical situation when the nurse needs help and the physician requests their assistance. Who is accountable when they accidentally misunderstand the delegation instructions.

I urge you to vote no on this bill for patient safety reason.’

Attached to this email is a copy of HB 2020 for you to review. In addition, at the end of the email are the names of the committees and links to the specific legislators now discussing these bills. You may contact these legislators even if they are not your district representatives.

I urge you to stand up and be heard! Contact your legislator NOW and tell them to vote NO on HB 2020 an SB 1899.

Carol Twombly


San Antonio Chapter

Texas Emergency Nurses Association

Allow me to dissect their letter, its inaccuracies, outright lies, and unsubstantiated “fact” and offer counter-points:

Using less qualified providers…”

So we’re only less qualified when we pass through the magic portal that separates the ER from the parking lot? I don’t recall a statement in law showing Paramedics are less qualified providers. Desire to compare academic requirements? I do it later in this article. And before the “degree-based” requirement for nursing comes up, perhaps we can make sure to include all the presently certified/licensed nurses who maintain their certification/licenses despite being from diploma-based training programs. It was not very long ago that these were still commonplace and accepted, or has nursing forgotten the inconvenient. We in EMS are clearly moving toward a degree-based requirement as a field. In fact, in Texas, you must have an Associate’s Degree in EMS, or a Bachelor’s degree or higher (any field is allowed) to be a Licensed Paramedic.

a) Requirements for paramedic licensure.  (1) A currently certified paramedic may apply for a paramedic license if the candidate has at least one of the following degrees from an institution of post secondary education which has been accredited by an agency recognized by the U.S. Department of Education as an approved accrediting authority:    (A) an associate degree in emergency medical services (EMS);    (B) a baccalaureate degree; or    (C) a postgraduate degree. (link to Texas Administrative Code here)

So much for the degree argument.

Currently, EMT and paramedics are provided the authority to provide life saving measures in the pre-hospital environment until the patient can reach the emergency department which is a higher level of care.”

So, the issue actually is authority, not skill or qualification.


This differs significantly from the registered nurse role which is an autonomous provider who’s training includes independent decision-making in which the RN works collaboratively with the physician to ensure that adequate care is provided to the patient.”

RN’s are not autonomous providers. Ask an RN for an over-the-counter medication like Acetaminophen while you are a patient. A physician orders, and they execute, no different from Paramedics. You must be a licensed Nurse Practitioner, or more precisely, an Advanced Practice Registered Nurse (APRN) to work completely autonomously ( This also makes it sound as if we don’t work collaboratively with physicians, which although is only implied, it is strongly implied and not true.


“Furthermore, the Texas Board of Nursing rules does not allow nursing to carry out orders from an EMT or paramedic.”

This is completely irrelevant. Under what pretext would this statement be necessary unless nurses were acknowledging that Paramedics are higher levels of practitioners than they. No one has made such an assertion, and no one should. In Texas, a nurse and a Paramedic are neither higher than the other. No authority has been given to nurses to delegate to a Paramedic or EMT either. We are governed by different laws and boards. We take our patient care orders from physicians and other licensed independent providers, not RN’s.

EMTs and EMT-Paramedics temporarily receiving direction for a physician could create a very unsafe situation during the most critical time in the patients hospital stay.”

STOP! There isn’t a shred of evidence presented to support this egregious attack on our clinical competency, and it is nothing less than an attack. How do physicians and nurses interact with Respiratory Therapists, lab technicians, radiology technicians, PA’s, NP’s, RN’s, and LVN’s now? By virtue of this statement, there must be an extraordinary quantity of unsafe situations that already exist in the ER and in urgent care. One might wonder how a patient survives an encounter at the ER at all.

Are we truly supposed to believe adding another clinical professional into the equation will absolutely mean detriment to patient care? It could create a very unsafe situation… It’s absurd and inflammatory. It’s no better than saying, “The end of the world could occur at any moment,” and rather than support this statement with statistics and fact, we should resort to unqualified, unsubstantiated fear-mongering.

Here is the reality… Paramedics are trained extensively to work with physicians and nursing staff in the most critical and emergent situations, and after certification and licensure, we then do it nearly independently in austere and isolated environments, so should we be expected to crumble into babbling, incapable dolts the moment we are suddenly surrounded with an army of physicians, nurses, and other complementary healthcare providers? Hardly, and if anything, it will serve to bolster the patient care competency portfolio (fair note: I cannot substantiate my assertion here, but that isn’t stopping the ENA from urging their members to do that very same thing to us. The difference is I’m not suggesting a class of healthcare providers be prophesied as causing the downfall of emergency care by virtue of its delivery withing a walled building – read: ER or Urgent Care – instead of an uncontrolled physical and social environment – read: everything not an ER or Urgent Care – or a 100 square foot box on wheels).

And lest we forget, Paramedics undergo extensive clinical instruction and precepting in the Emergency Room under the supervision of, that’s correct, physicians and nurses, long before we are deemed competent and permitted to sit for our local and national certification boards. Nurses sign off on this competency! Again, the magic portal that separates the ER from the parking lot has astounding effects, and the best part is that the outcomes of the magic portal are selectively applicable when it suits the nursing lobby! The argument is contradicted within their own presentation against EMS. How can you decry our competence when you signed off on it?

Currently they receive directions (delegation) from a nurse so who do they listen to in this critical situation when the nurse needs help and the physician requests their assistance.

Fact: There exists no authority, whether self-derived from the Board of Nursing, or from any lawful EMS oversight committee or statute, to allow, or even imply a nurse is allowed to provide, direction or delegation to an EMT or Paramedic. If this relationship exists, it is that of a person who also happens to be a Paramedic working as an uncertified, unlicensed technician employee for a hospital, and it is because hospital policies, not law, have placed that person as an ER tech under the direct supervision of a nurse. They are absolutely NOT practicing under their license as a Paramedic… yet. Search job listings for ER Technicians in Texas and you will see that current or past certification and/or licensure is commonly highly recommended. It is not a position where a Paramedic is employed to use his license. Here are a couple major health providers in Texas to show examples from:

Who is accountable when they accidentally misunderstand the delegation instructions.

On its face, this seems like a valid argument, but like all the previous arguments I present from this letter sanctioned by the Texas ENA, it fails to recognize the reality of placing a licensed and/or certified provider in the job. When a certified or licensed Paramedic, employed under their own certification and/or licensure, makes a misunderstanding of delegated instructions in providing prehospital care, it is their own license that is on the line, not a nurse, and rarely a physician is held liable (disclaimer: I’m not an attorney, but a well-respected attorney and Paramedic in Texas has told me as much – I will endeavor to present more fact from case history if requested). It is no different than if a nurse “misunderstands the delegation instructions”. The nurse isn’t magically liable for any other provider’s license, but their own. Again, this statement serves to cloud the issue and incite fear of liability where it doesn’t exist. Logically, if you cannot substantiate your claim on fact, plea to the emotion of the bureaucracy and legislation and use fear-mongering to support your position.

There is extensive preparation in pathophysiology, pharmacology, skills, and critical thinking/clinical judgment.

Again, they imply that Paramedics haven’t this training, which we can document we have as part of the core curriculum of Paramedicine and in the NHTSA educational requirements. I don’t have anything on the national accreditation standards for Paramedic education as required by the NREMT, but I can’t see them negating the national educational model. Requirements from the federal government are the baseline and accreditation would only work its way up. To allay the fears that we are uneducated oafs given power tools and a license to kill, I provide a link below to the national education model standards for Paramedic training. You may find the 385 page outline on the curriculum stimulating, and that’s only the outline, not the multiple-volumes of anatomy, physiology, pathophysiology, pharmacology, life span development, terminology, differentiations from medical and trauma on each major body subsystem and age group, operations, incident response and coordination, documentation, and more, nor does it even touch the prerequisites of our allegedly subpar (per Texas ENA) education. All of that also doesn’t detract from the fact that although nurses are trained holistically and through a complete care cycle from admit to discharge, Paramedics are trained specifically for everything spanning from pre-admit through every conceivable emergency and critical care situation, and for inter-facility transport of the critically and chronically ill. We are emergency care specialists, not medical generalists.

Most emergency departments require that emergency RNs are trained in advanced cardiac life support and trauma nursing care.”

Again, anecdotal, and a broad overgeneralization, completely unsupported by facts and statistics. Texas isn’t most emergency departments. . This is a hospital matter and if it is driven by anything, I would suspect it is accreditation and reimbursement, and certainly not law. What Texas Department of State Health Services EMS (TX DSHS EMS) does regulate is trauma center level designation:$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=157&rl=125

In other words, this is smoke and mirrors and does not justify the Texas ENA position. ACLS and TNCC (continuing education certification courses for cardiac and trauma care) are not commonplace for typical nurses. ACLS is mandatory for Paramedics to maintain certification and licensure, and it is commonplace to see Paramedics teaching the courses, and we have a couple equivalent courses to TNCC specifically for EMS, or can even take TNCC for ourselves. So why bother bringing this up? To show that after you are licensed you need additional training so you can do what Paramedics had to do before they even left school? It isn’t helping your care, but when taken alone, it sure sounds like you are implying that your skillset exceeds ours.

There is a national certification body that also provides certification in emergency nursing.”

So what? We have a national certification board too. The difference is national certification in emergency nursing (a.k.a., CEN) isn’t required for state licensure, nor is it a regulatory requirement to work in an ER or hospital. In Texas, national certification IS required to obtain new or reciprocal certification and licensure as a Paramedic. The statement implies the untrue, that nursing is more qualified than EMS.

However honorable obtaining this prestigious certification, and it truly is, it is accreditation and reimbursement driven. Most states in the USA require national certification for Paramedics before being granted state or local certification and/or licensure to practice. Additionally, while emergency medicine is fully within our purview, the CEN (Certified Emergency Nursing – certification is not a core requisite of nursing. It is an adjunct certification to demonstrate competency in a specialty field which is not part of the primary nursing curriculum. Emergency medicine, pre-, peri-, and in-hospital, is at the very root of Paramedic education.

According the the BCEN (Board of Certification for Emergency Nurses), currently, more than 30,000 nurses hold the CEN certification. In my experience (anecdote), it is uncommon to encounter a CEN outside a large hospital system. I cannot recall encountering any in my 20 years in EMS that worked in rural hospitals. In fact, I have worked at a few rural places that call the local ambulance to the ER to run their codes (cardiac arrests) for them. You aren’t making a case that nurses are safer than Paramedics in an ER for patient care.

Furthermore, the Texas Board of Nursing rules does not allow nursing to carry out orders from an EMT or paramedic.

So what? The Texas Board of Nursing does not regulate emergency rooms or hospitals, nor does it write Texas law. The Texas Board of Nursing does not regulate EMS providers, either. We have already covered this ground. Under what circumstances would a Paramedic be giving orders? None. They aren’t independent healthcare practitioners. That’s the physician’s job. If a Paramedic were administratively higher than a nurse in an ER or Urgent Care, it would be a hospital decision, not a legislative one. Imagine that, a Charge Paramedic giving staffing orders to nurses. Of course, the Paramedic still could not dictate patient care or give orders. That has to be left to the physician/PA/APRN.

Now, I want to head off the next tired argument before it is presented. Nursing will sing to you of the requirements for continuing education to ensure clinical competency does not stagnate and the nursing practice is forever advanced, and the continuing education opportunities are impressive, to be sure. They are required to obtain a full 20 (twenty) CNE (Continuing Nurse Education) hours per two-year licensure cycle. Ten whole hours per year of class time dedicated to maintaining and expanding their knowledge base in nursing!

However, this pales in comparison to the 144 hours required by TX DSHS EMS for Paramedics (, every four-year certification/licensure cycle. Paramedics have the option of forgoing continuing education for renewal in lieu of sitting for a complete written licensure re-examination. To maintain national certification, the National Registry of EMT’s, our national certification board, requires 72 hours of continuing education every two-year cycle, which is nearly four times the continuing education requirement for nurses in Texas regardless if you look at annual, bi-annual, or four-year cycle. Of course, employers may always opt to require more education for their staff, Paramedic or nurse. As as comparison note, Texas physicians are required to obtain 48 continuing medical education hours per two-year cycle (

I am frankly appalled at the unprofessional, unwarranted, baseless attacks on EMS provided by the Texas ENA and the San Antonio chapter. I respectfully demand they retract their letter to their membership, require their membership that have submitted it to their legislative representation to issue a retraction letter and apology for unprofessional conduct, and issue a public, formal apology to all Texas EMS providers and especially Paramedics, both certified and licensed. Had an EMS organization the audacity to behave in the same manner, I have no doubt there would be attorneys representing nursing breathing down our necks asking this and perhaps more.

Nurses, we have decades working together symbiotically to support the patient care spectrum. We applaud your advancement professionally and encourage it. We have likewise opened our educational offerings to you in good faith, as you have to us. We are modeling your growing pains as a profession and we are walking in your footsteps, striving to implement national degree-based requirements and it will take time for us as it did for you, but this condescending air of superiority has got to stop. We are not your pawns. We are not inferior to you. We are not subordinant providers to you like CNA’s. We are no longer even technicians. We Paramedics are certified and licensed in our own right, just as you are. We are not subject to your boards, rules, and regulations. We are a profession unto our own. We have separate regulatory bodies, enforcement, and accountability. A good big sister helps her siblings grow, mature, and come into their own, leading them to betterment. She doesn’t beat them down every time they try to stand on their own or bully them into submission. Grow up.

Contact the Texas ENA here:

Link to Texas ENA contact information provided by the National ENA

ENA, Texas State Council

ENA, Texas State Council









Contact the San Antonio Chapter of the Texas ENA here:

And the author of the insult letter here:

Carol Twombly, RN at

Carol Twombly, President of San Antonio Chapter of the Texas ENA at or (210) 260-3699

Carol Twombly, President of San Antonio Chapter of the Texas ENA












Contact the NAEMT leadership here and ask them to address this professional misconduct head-on:

Conrad T. “Chuck” Kearns

Dennis Rowe

Terry L. David
Director, Region IV

Troy Tuke
Director, Region IV

Matt Zavadsky
At-Large Director


Ben Chlapek
At-Large Director

National Association of Emergency Medical Technicians
PO Box 1400
Clinton, MS 39060-1400

Physical Address:
132-A East Northside Dr.
Clinton, MS  39056

Phone: 601-924-7744
Toll Free:
Fax: 601-924-7325


I encourage you to read this article from “A Day In The Life Of An Ambulance Driver” for his considerations of this deplorable attack on EMS, and he is offering a template letter for EMS and anyone else to base their own letter to your Texas Legislators.

I invite you to use this preformatted letter as a starting point for your own letter to the Texas Legislature. Please remember to keep your own responses professional, without stooping to unsubstantiated data, opinion, and lies, unlike our colleagues at the Texas ENA.  You may wish to open the PDF and then copy the text into your text editing program (Word, Google Docs, etc.).  Thank you for your support in this matter!

Texas Legislature Preformat Letter for HB2020 – PDF


  1. This is why Paramedics need to start to actually form our public voice! It’s time for the NAEMT to actually do what we pay them to be there for!

  2. You covered all the arguments completely. Out continued training and skills verification by a physician ensure that we maintain our knowledge base and skills to the top level. I instruct in ACLS, PALS, BLS and ITLS in addition to holding provider in these areas. I have also taught ATLS for physicians even though we are not allowed to take the course for certification, but we can audit the class for hours. Here in KY I have worked in the ER at rural hospitals and it was a smooth union between all parties working there. We triaged, treated, gave medications and charted the patient from time they entered and they were released. As was mentioned above, most Docs would allowed us to run codes due to the fact that we handles more of them on a regular bases. Sorry for any misspelled words, it is late and I am sleepy.

  3. As a paramedic and an RN, I see this with a different perspective. In the 1990’s they were using paramedics as ED tech’s in AZ. I was one at that time. My scope of practice in the ED was up to the hospital medical director. This has since been changed to the Az. Paramedic scope of practice. The reason for this was not due to the infringement of the ED by medics. But by the bean counters realizing that they can hire multiple ED techs to one RN. So there were multiple hospitals that would have one RN overseeing 2-4 ED techs.(medics).
    This on the surface may not appear to be a bad thing. There are some things that typically require an RN. That does not mean a paramedic can not be trained in performing.
    I see a lot of the content in this note as posturing by the RN. Instead of insulting paramedics they should offer alternate ideas. As in one ED tech per RN staffing limitations and require documented instructions for those medications and procedures that typically are in the RNs scope of practice.

    • Good points, D. This nursing group has chosen to make this attack not on merits, but to invoke fears that (even if they were valid in the past) have largely been addressed since the 2009 curriculum revisions for Paramedic, and dare I say the 1999 revisions also make leaps forward in our knowledge and skill base. What you mention here would again put Paramedics in a subordinate role in the ED, not a peer role. This legislation to allow Paramedics to operate to the full scope of their license represents nursing’s failure to fill an identified gap in patient care and staffing and now the knee-jerk reaction reduced to insults that the ENA is sanctioning. Rather than bring solutions, they are trying to stomp back those with initiative and training to fulfill the role. (Well if we can’t have it all, you certainly won’t get any.) They could have had us as their techs, or with us working under them like LVN/LPN’s work under an RN’s supervision. I’ve worked in ER’s many times in recent decades. Nothing that I have seen happens there below the physician level that is outside a Paramedic’s training and scope, including drugs and drips, ventilator management, testing, suturing, or otherwise. Now if the patient were to be admitted, that’s another story and I agree we are not adequately trained for that. Thank you for contributing to this discussion!

  4. as far as paramedics doing what nurses do,nursing school was put into place to help stop on the job training for nurses which is what there doing putting paramedics in the nursing field i am a paramedic and have been since 1979, i got my bsn a few years ago, nurses and paramedics training is diffrent for a reason prehosiptal care and inhospital care are very diffrent.we as paramedics were trained in prehospital care, we start ivs and intubate patientsbut do not know how or when to remove these safe after the patient has undergone the care needed days or weeks later sure we can take those thing out but timming is the key knowing what to look for or when they dont need them anymore, so prehospital care and long term care needs diffrent types of trained people to do those things, paramedics are not nurses and nurses are not doctorsgood luck keeping the overlapping skills separate

    • Holy cow, for crying out loud, grammar, spelling and punctuation are your friend! That was one of the most painful things to try to read I’ve seen in a long time. If you want to be regarded as a professional, for Pete’s sake try to communicate like one!

    • Your argument here is invalid. Nurses don’t know when to dc IV’s or extirpate either. That, is up to the Doctor. Your statement is no better than the Texas ENA’s diatribe of bias against Paramedics.

    • Actually Terry here in Texas we are a delegation state meaning if our Medical Director approves it Paramedics and EMTs can do it. I can start an IV in the field and if I deem necessary remove it. I have also worked as an ED tech and guess what I was able to remove start and remove IVs if the doctor asked me to.

  5. As a volunteer fire and rescue member all I can see is a lot more people suffering in the field for lack of emergency care

  6. As both an RN & a Paramedic I see both sides of this issue. I agree that Paramedics have superior pre-hospital knowledge vs an RN. And Paramedics can run circles around most RN’s (and mds) during a code, but what they lack is knowledge about long-term care of the patient and their families. Nurses are scared that hospital administration will see the cost savings of hiring a “tech” at 1/3 the salary of an RN and RN’s will be pushed out of the ED. I’m not sure there is an easy answer to this dilemma. As an ENA member I will be voicing my concern but not be degrading my fellow Paramedics.

    • The funny thing is that the legislative bills won’t allow Paramedics into practice in admissions units. The ER and Urgent Cares are outpatient, acute care. No one, including the legislature’s bills sponsors is advocating for putting Paramedics onto nursing floors or in long-term patient care. A. Dean, I appreciate the professional response from you and your points about how you feel EMS would impact nurses in acute care. Would you consider adding a note when you voice your concern expressing disapproval of the ENA’s sanction of the attack on EMS? We would appreciate member support? Thank you for contributing to the discussion!

    • The bill proposed specifically mentioned that Medics would only be performing these skills in an ER, or stand alone Urgent Care clinic. They have taken in to account the differences between emergency, and long term care, and stated in the bill that Medics would not be used in the Med/Surg or ICU setting.

  7. “Less qualified providers”
    How are nurses providers in any sense of the word?

  8. Why would they hire a paramedic at 1/3 the salary. Lol doubtful, as much as you want to believe that, sorry buddy but we will make the same as the ED nurse getting the boot. They would have too, since now they would have providers in the ED who are use to working by them selfs, not relying on doctors orders.

    Oh and by the way, protocols are just that. As a paramedic you can deviate from protocols. In many systems you don’t even have to call the doc. Just saying .

    • Christian — you best check yourself.

      Texas Emergency Healthcare Act: Sec. 773.007. SUPERVISION OF EMERGENCY PREHOSPITAL CARE. (a) The provision of advanced life support must be under medical supervision and a licensed physician’s control.

      A paramedic who doesn’t follow his protocols and standing delegation orders is acting as an independent practitioner. If you ever get sued or investigated by DSHS, you will have no defense for your actions if you deviate from protocols.

      Stating that paramedics can practice paramedicine however they want is not the way to win an argument about limiting a paramedic’s ability to work in an ER.

    • You’re quite daft if you think they’d hire medics, to work in the ED, at the same rate, as the nurses get. They’ll easily pay less than what an RN gets, but more than a medic makes, on the truck.

      This same thing happened, in 2000, at one of our local ER’s. Our initial rate was $15/hr. Not near what a new RN made, but that hospital wasn’t known for paying the most, when one was fresh out of school. However, they had medics beating down the door. 13 years later, when I quit (I was only PRN), I was making $20.23. Unfortunately, the hospital was taken over by corporate, and within two years, all the medics, save one, were gone, and he’s delegated to “tech” status.

      Re, your comment about deviating from protocols. No, you can’t. Operating outside your protocols is practicing medicine without a license. Good luck finding am attorney to defend that, when you get sued.

    • In FL EMTs and Paramedics have been able to work as ER techs for as long as I can remember. It’s true, they only make about 1/3 to 1/2 of what RNs do. It starts at $10/hr here, and I don’t live in a small town or rural area. I actually live in an area with a high cost of living, definitely higher than Texas. So don’t expect to be making the same when this passes.

  9. I think ED, ICU and “trauma” nurses should do mandatory ride alongs (especially in high volume areas) to see what we do on the box. Where I worked (Portsmouth, VA), the medical director at Portsmouth Naval Hospital assigned new doctors shifts on medic units to train them in the fine art of pre-hospital care. At that time, Portsmouth had the highest murder rate in the state. They were amazed at what we could do (especially in a code)! Most asked why we didn’t have to call for orders.

    I also taught ACLS, PALS & PHTLS attaining IP in all usually the first time in class. It was the doctors and nurses that had the most difficulty, especially in the practical areas. (not bashing…fact)

    The ENA is trying to protect jobs, plain and simple. I also think there is some envy due to the fact that most nurses can’t push drugs without orders during a code, intubate or defibrillate/pace. I am also going to stand with you in this matter! Even though I’m in Virginia, I’m sure this spector will rear it’s ugly head!

    Robert Wilson, NREMT-P

    • Just clarifying, we don’t push meds during a code of our own volition. We do them under a physician’s orders. We would be prescribing if we did it without physician authorization. Nurses can also operate under protocols as we Paramedics do. Again, this just shows that we are not a subordinate provider, but lateral. Thank you for your comments!

  10. Is it legal for one nurse to give another nurse an order?

    • Nurses don’t issue orders, period. Neither do paramedics. Both providers operate under delegated authority from a doctor. The doctor issues orders, and nurses and paramedics are given the skills and knowledge to carry them out.

    • We give nursing orders not medical orders.

  11. Thank you! It’s about time the animosity between nursing and EMS is addressed. I believe that the root of the problem lies in lack of education and awareness of what our knowledge base and capabilities are, which you did a phenomenal job of explaining! I am fortunate in that the majority of the nursing staff in our ERs respect us and treat us as equals, so it was extremely disappointing to read such a condescending letter that hopefully represents only small, close minded group. What I find is that I experience more of the condescending attitude from urgent care, clinic and nursing home nurses (and docs)…until they frantically need us to intubate a child or run a code…and magically we’re not uneducated dimwits anymore.

  12. I personally believe that there is a real line.. The ER is hospital and we are pre-hospital.

    I see in Chicago the use of Techs, replacing RNs. There needs to be a workable model for techs and a statutory change. Modeling a “tech” training program?

    Why are EMT’S and Paramedics in the Emergency Room? Cost… Nothing more then that.. We are cheaper..

  13. All I see are jealous people trying to bully themselves into more power.
    I am only a wife, mother & grandmother. Who also was a Navy Hospital Corpsman. It wasn’t ment for me to be nurse but I have enough common sence & knowledge. EMT’s & Paramedics today have a whole lot more required training that should make them qualified to do just about everything a nurse can do. It seems to me that whom ever is instigating this has something personal against EMT’s & Paramedics. If I was ridding in the back of an ambulance & I feel confidant that the EMT or Paraamedic is knowledgable to take care of me. Why not in an ER or Trauma Dept. in a hospital. My common since tells me that someone has a vendeta against the EMT’s & Paramedics. Someone just doesn’t want to recognize them as just as qualified as RN’s.
    Someone better take notice of this or they are going to do more harm than good. EMT’s & Paramedics have come a long way since the beginning. It would a terrible shame to spoil something that has been proven over & over again to help. It would be ashame to not put their training to further use so doctors can handle the most important cases.
    I’ll be praying that the Texas legislatures open their eyes & do wahts good for their state & not the self centered individuals.

  14. Let me preface this by saying I’ve been a paramedic for 23 years and a ER/Trauma Nurse for 10 years at one of the busiest Level 1 Trauma Centers in America. So I think understand both sides of this issue.

    Let’s start with education. I’m sorry EMS folks, but nursing education and clinical requirements outweigh EMS requirements hands down, and that’s ok. As a medic we are trained to care for patients in a very short time frame, nurses are trained for a continuation of care that lasts from hours to weeks to months. So as a nurse we have a deeper understanding of the pathophysiology of diseases. Nurses also have a more robust A&P background. That is not a slight against paramedics, but a recognition that paramedics have a different scope of practice.

    Nursing practice also involves taking care of multiple patients at a time all the time. We can’t call for an MCI when 10 patients arrive at the same time, that’s just a typical Monday morning. Again not a slight against EMS, it’s just EMS is trained to primarily take care of 1 patient at a time, which is how it should be in the prehospital world.

    I am a strong advocate for paramedics that want to leave to prehospital world and become nurses in the ER, because I believe we make awesome ER Nurses, but I do not believe a paramedic should work in an ER and functioning for all intents as a nurse, there is a knowledge and experience gap.

    Scott S., BSN, LP, RN

    • Thank you for contributing with your position. In this context, we aren’t discussing legislation to allow Paramedics to function past the acute care level, like would be necessary for admissions to a nursing unit for prolonged care. I agree we in Paramedicine aren’t educated to provide that. We are talking about outpatient acute care, and that is something Paramedics are perfectly capable of handling. Honestly, I don’t even care if I have to report to a Registered Nurse, as my ego doesn’t stand in the way of me providing the best patient care possible, but this legislative matter is about allowing a Paramedic to practice with their full scope in an ER or Urgent Care. How the Texas ENA has chosen to confront their concerns directly to the legislature is deplorable. I appreciate your comments.

    • I respectfully disagree. One of our local ED’s hired medics, to be full-functioning members of the direct care team (FT, PT and PRN), back in 2000. While the vast majority of the “nurse stuff” was learned via OJT, we soon acclimated ourselves. While this hospital isn’t a Level 1, we still easily handled being assigned multiple rooms/patients. Additionally, we had no issues taking care of the same patient, throughout the entire 12 hour shift, if need be. Granted, some medics eventually washed out, but that also happens on the truck, as it does with some nurses in the ED.

      One of the positive side effects of working in the ED, was that it made me a much better medic. Some examples: I learned to appreciate what happens to the patient, after we leave the ED. I also probably started 4:1 more EJ’s in the ED (and also up in Med Surg, during nights), as I did, on the truck. I learned so much more about lab values and how treatment directly affected their outcome. I also learned how to anticipate what those labs potentially might be, based on a particular (EMS) patient’s condition.

      My point is, it given the chance, many paramedics can, and DO, turn into excellent in-house care providers.

    • I’m sorry Scott but your comparison of dealing with 10 patients is baseless. In a level 1 center you are always staffed with more that just 2 people, like most ambulances are. If you were staffed with just 2 people and had 10 patients, you would be calling an MCI. Likewise, if an ambulance was staffed with 10 to 20 personnel and had 10 patients, then the need to call a MCI would be mute, wouldn’t it?

  15. i have read the post and some comments, although I understand the RNs point, this is turf war and a butt hurt issue. Fact is, medics are here to stay. Think of us more as the trifecta of the extension of the MD. (PA,NP,medics) we don’t want your RN jobs, we want to assist you and our patients. We are another resource to lean on. Don’t fight us, accept us. It works well in many other states, nursing and paramedics, but it started just like this. It will be okay. You should be excited for some relief in your work load. It isn’t easy to accept the changes, but the sooner Texas does the better the care will be for the population.

  16. A small chime in… we are no longer the technicians that memorize a flow chart and cookbook our way through every patient encounter… we have grown in knowledge and responsibility to even be considered physician extenders. We practice under protocols that a physician has blessed and has confidence that we have the education and skills to not only read and follow the protocols.. but to apply our knowledge and dicision making ability to distinguish when why and how! We ARE NOT subordinate in any way… in many ways we are equal and many we are superior! I also am an ACLS, BCLS, ITLS instructor and provider. To add also Critical care, AMLS provider. Our skill set is put to the test each and every time we arrive on a scene until we turn over to a hospital. To demean us will only push us to become better, stronger and smarter. We are now going INTO PATIENT’S HOMES… providing physician level care… social service care… emotional and even psychiatric care.. with physician blessing (of course) because we have deemed ourselves not only beneficial to the patient and physician… but as a relief to nursing as we help alleviate some of the strain in the emergency departments. I agree that our base education is far more than we receive credit for! I am not voicing to bash nurses… we are ALL necessary cogs in a patient’s wellness and recovery… but if we have something to offer such as practical independence and clinical decision making… working side by side with nurses means a potentially better outcome for the lives that we serve! THAT IS ALL… Please fellow brothers and sisters in EMS.. don’t succumb to the obviously unaware! We know our value and worth! Stand up and be true and know that we are not what we were! We are who WE ARE! Much love from Ft. Worth, Texas!

  17. I applaud your willingness to stand up for your profession. The EMS community has for so long simply cowed down when confronted in legislative battles or were too apethetic and exhausted from their 3 jobs to fight.

    Your rebuttals are correct in every point and the CE issue is a sticking point for me since my current state requires NO CE for RNs. But I digress.

    It is my hope that when Texas moves ahead, other states will follow. It’s what we know will happen. The world will not stop spinning and the tides will not roll back. And … When it happens; in Texas or Oregon or Midsissippi or New Jersey, every other state will do it too. And that is the fear that drives the ANA, State Boards and all specialty practice

    The Nursing profession has made itself indispensable in all facets of health care. “No one but an RN” has the almighty training etc to do . This is the root cause of the supposed nursing shortage. It drives “everything” in healthcare. But any attempt, by anyone, to do anything to fix it is “attacking ” the nursing profession.
    I will conclude by addressing some of your other posters many of whom have identified themselves as “seeing both sides” while being a member of both professions. Please remember that THIS is the reason YOU went back to school- because NO ONE (RN/MD etc) valued you where you were. YOU QUIT- to do something else; now as others point out the hypocracy you are “seeing both sides”. Why didn’t you see this side before?
    Respectfully; John.

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  19. All I can say is wow, are you guys serious? I’ve been a paramedic for so long that I can recall running prehospital calls for dinosaur bites, Lol. In addition to my extensive prehospital experience, I have applied my skills and training in a level 1 trauma center under the direct orders of an E.R physician to include chest tube insertion, arterial line establishment, providing total care to traumatized pts while my Trauma Nurse was recording all events for me and we never had any problems. I truly believe that it’s about being competent and when one have these competencies most nurses or physicians have no issues and view the paramedic as a force multiplier. Personally I have no issues with RN’s, my wife have been a nurse for over 20 years. Sounds like some folks fear for their jobs simply because as a paramedic we don’t have to wait for a physicians orders to initiate ALS care or administer medications. Paramedics are deemed essential in these settings when the nurse cannot establish a difficult I.V, a pt requires sutures and I could go on and on. Simply stated paramedics and Emt’s at all levels are under appreciated and underpaid until the feces hit the fan and then we become important. Yes lots of us uneducated prehospital personnel make a difference on a positive note in the streets as well the E.R. I’ve intubated numerous pts that the resident physician couldn’t and the E.R nurse would never be considered to attempt such a procedure. We compliment one another and have different roles that should be about nothing other than quality pt care not sensitivities. Let’s all focus on our individual skills and that alone should keep us busy enough.

    • Just to clarify, neither nurses nor Paramedics are able to begin advanced life support interventions (IV, defib, medications, etc.) without implicit physician orders. Standing protocols are implicit physician orders and both Paramedics and nurses can work under them. To do otherwise would be to exceed our scopes of practice. Only mid-level practitioners and physicians have that latitude. Thank you for your comments.

    • I like the way you phrased us as a “force multiplier.” I think that’s a perfect description for what this bill wants to do.

  20. I encourage you to read this article from “A Day In The Life Of An Ambulance Driver” for his considerations of this deplorable attack on EMS, and he is offering a template letter for EMS and anyone else to base their own letter to your Texas Legislators.

  21. For all the folks that refer to prehospital care providers as ambulance drivers your views will certainly change when yourself or a loved one have an emergency situation. I look forward to the day when we are appreciated as well compensated for the work that we do in the uncontrolled setting versus the safe haven of the E.R and all its amenities. As well maybe we will have some type of representation in the future and leave all the politics out. Just another ambulance driver.

  22. I look forward to seeing how this plays out in Texas. I believe a paramedic can bring valuable skills and knowledge to the ED when allowed to work at a full scope of practice level. Having worked as a flight paramedic in several states including Texas and having a partner who is a nurse I believe the two professions can create a great team with complimentary skills. I understand the nurses who post on here in support of the ENA view are just protecting their jobs. I am not surprised the ENA or the ANA will do whatever necessary to protect nursing jobs even at the expense of other healthcare professions. If/when legislation like this happens the flood gates will open in other states. A precedent will have been set. The ENA/ANA fear this.

  23. I consider this all irrelevant. Several times in my career, when a sick patient comes into the Resuscitation room, it’s taken the skills of Doctors, Nurses and the Paramedics (who kindly stuck around help) to perform the skill of life-saving. We’re All unique professions, we all work under our own competence and direction, but we must all WORK TOGETHER and not against each other for benefit of the patient.

  24. As both an ER RN, and Flight RN/EMT I can see sides on both sides of this debate. However as a Texas ENA member I must say this was not an appropriate approach to this proposed legislation and was demeaning to all pre-hospital providers. This debate, on both sides, shows a mutual misunderstanding of the requirements and roles of ER nurses and paramedics. Neither the nursing profession nor the paramedic profession fully understand the other and therefore animosity abounds. As I am near completion of my advanced degree for APRN I can say this is the same battle that has existed for 20+ years between the Medical boards and the nursing boards that is hindering nurse practitioners from practicing to the full capacity of their training and preciously between MDs and DOs. Until egos are set aside by all (yes that includes the all mighty RNs and the ParaGod medics!) this issue will continue to divide us all. I personally believe we should support each other not hinder anyone’s career ladder.
    Perhaps the solution is to develop a certification for ER paramedic – Similar to the CEN, which is an advanced certification that designates clinical proficiency and does not equat to the NREMT that was previously compared to it (the nursing comparison to the NREMT exam would the NCLEX that is a nation board certifying exam that we take in order to obtain or RN). There are currently paramedic certifications similarly the CEN (or CFRN or CCRN and many others) such as the FP-C or CCTP but they are currently all focused on critical care in the pre-hospital and transport environment…why not develope such a competensy exam for ED medic? Just a thought.

    • What a fantastic suggestion. I will submit this to a group of Paramedics that are working together to push degree-based Paramedic programs and to develop plans for advanced training and certification after Paramedic school. Thank you for your comments!

  25. I thought these facts (gathered today, April 27th, 2015 as part of an ongoing national study of paramedic vs nursing education) would be helpful: 1. Of the 29 paired paramedic/registered nursing programs at Texas community colleges, colleges granted emergency medical education more college credits than nursing education more than 80% of the time. 2. Texas community college paramedic programs are granted an average of 5 more credit hours for emergency medical education than nursing program receive for nursing education. -Scot Phelps, Professor of Ambulance Science at the Emergency Management Academy.

    • “In fact, in Texas, you must have an Associate’s Degree in EMS, or a Bachelor’s degree or higher (any field is allowed) to be a Licensed Paramedic.”

      A license that in no way required to find employment as a paramedic and does not grant any additional privileges. House Bill 2020 also specifically states that it covers both certified paramedics and licensed paramedics.

      Directly from the Texas DSHS website: “EMS degree programs are available, though many courses are offered through technical programs and others are approved through programs outside college settings.”

      “So much for the degree argument.”


      I don’t agree with the Texas ENA’s position or appreciate the tone of their letter, but why do you feel the need to misrepresent the level of education required to work as a paramedic?

    • It’s hardly a misrepresentation, sir, and the facts concerning becoming a licensed Paramedic in Texas are not in dispute. It is clearly posted on the DSHS website. I didn’t say certified Paramedics had to have a degree or couldn’t find work, but there are also diploma nurses still licensed in Texas. It isn’t a misrepresentation. You are reading into something that isn’t there. Thank you for your comments.

  26. Here is a copy of the letter i sent to the Texas Emergency Nurse Association regarding their little faux pas:

    RE: San Antonio Chapter Letter Concerning Texas HB 2020 and SB 1989

    I am a retired Paramedic and EMS Instructor/Coordinator in Michigan. I recently became aware of the above-named chapter’s letter regarding the mentioned proposed legislation, which would expand the use of EMTs and Paramedics in the hospital setting, allowing them to utilize their full scope of practice under the Law.

    Frankly, I was appalled by this letter. It is full of gross distortions and outright lies. I can only hope that the author has no real knowledge of EMS Education of Scope of Practice, and that ignorance gave them the freedom to ignore reality and spout such nonsense.

    You should know that this is gaining attention across the nation, and is casting the ENA in a very bad light. I have been in the business since 1970. I had thought we had resolved the whole issue with nurses – mainly, that we were after their jobs. That has never been the case. We just want to be able to do OUR jobs, which in turn compliments yours. I believe that is what the whole concept of “Allied Health Professionals” is about.

    I believe that you as an organization should issue a retraction immediately, as well as an apology to the EMS Community. We are all professionals here. We all want a common goal – optimal patient outcomes. We each have our own unique educational background and scopes of practice to achieve this goal. Insulting comrades-in-arms is not only demeaning to all, but shows incredible lack of professionalism on your part. It’s ironic, isn’t it; especially under these circumstances, when the San Antonio ENA chapter is questioning the professionalism of another discipline?

    As I understand the proposed legislation, the changes in scope of practice for EMS personnel inside the hospital environment will in reality enhance Nurses’ ability to perform their duties.We all know how overworked you guys can be, and sympathize totally! This proposed change will actually cut nurses some slack. Again, there is no competition between the two professions – in many ways, it’s apples and oranges. God knows, there’s enough action in the ER to keep everybody busy; there is plenty of pie to go around! So I think this one needs some rethinking on ENA’s part.Of course, I’ve only been working in both the hospital and pre-hospital environment since 1970, including going to LPN School along the way; so I am of course basing my opinions on my own observations and experiences, and those of my colleagues – both EMS personnel and nurses. – but even anecdotal evidence has validity.

    To close this out – this could be a real Win-Win for both professions. I urge you to act together with your EMS comrades to bring it to a successful fruition and resolution. Again, the main name of the game is “what will be best for the patients?” This is best achieved by mutual support and respect between all allied health care professionals. Teamwork, you know…..

    Thank you for your time and consideration, and allowing me to express my opinions on this issue.

    Matthew Donnell
    EMT-P (retired)

    I hope that this meets with everyone’s approval. (If not – well, too bad, so sad….) We all need to witness for EMS on this one!

  27. My background- EMT-B in PA for 10 years before starting EM residency, been an ER doc in Texas for the past 6 years (counting residency). Nothing I say represents my employers, blah, blah, blah.

    I agree with the outrage here towards the Texas ENA on this issue and I find it incredible ironic. Essentially they are arguing that they don’t want someone with less training taking over their job. While this does not apply to those medics with a bachelor’s degree, it would be an argument for those with a diploma or associates since there is a difference in number of years of training. It’s not a good argument but it’s an argument. What the breakdown of Texas medics with those specific diplomas or degrees are- I have no idea. When I left PA for residency there was a movement toward’s an associate’s degree for medics, not sure what the status of that is now.

    My point is this- how blind must the ENA be to say that medics shouldn’t be doing these jobs when NPs are fighting to expand their practice scope and practice independent of physicians? Then they get upset when physicians come out against it. The irony is so thick here you could cut it with a Sawzall. NPs are saying that they are just as qualified to act independently as physicians are yet they have a small FRACTION of the training.

    Now before anyone goes off on me being an elitist doctor- I work with plenty of great NPs (and PAs, nurses, medics, etc.) and they do great work. The best ones know what they know, know what they don’t know, and know when to ask for help- as goes for ALL healthcare workers, no matter your job, position, or title. That being said- there is a standard for completely independent practice and that should still remain at the level of a physician. The times that NPs get into trouble are when they don’t recognize the limits of their training and experience but try to go at it alone anyways. There is a reason why the path to being a doctor is 4 years of college, 4 years of medical school, and 3 (or more) years of supervised practice in residency/fellowship. That’s 10 years- NPs are looking to do it in as little as 6 (4 college, 2 NP) with many fewer clinical hours and with much less ability to make their own decisions when they do their clinical hours.

    How dare the ENA come out against this bill. They can dish it out but they can’t take it. I see why they are worried and scared. With all the freestanding EDs that are popping up like whack-a-moles in Texas, they should be concerned about their jobs if medics are allowed to function at essentially the level of an ED nurse. Texas medics have a point- they are allowed to do a lot in the field so this is a logical extension of those skills into the ED. Shame on the ENA for having the gall to limit someone else’s scope of practice and job opportunities and then whine when they can’t expand their practice scope against physician opposition (although in some states they are winning or already have won). They should have thought twice before going after the EMS community like this.

    • Thank you for your support. I think my position that a good sibling lifts the others and not beating up on them when they try to make something more of themselves is appropriate. We work together seamlessly all over the country in prehospital, interfacility, and acute care, so why should the magic ER door change that? Let us work under our own certification and licensure regardless. It is apparent by the support given to this effort that a substantial number of healthcare providers agree, and even nurses are standing up for us against their own organization. I believe the ENA and its chapter should advocate for their members, but this wasn’t the right way. Thanks for commenting!

  28. As a TX and NC, Paramedic as well as an RN, I find Twombly’s assertions troubling. This reminds me of the old rivalry at work. I work in a Level 1 trauma center ER as an RN. I would look forward to seeing Paramedics utilized in the hospital setting. Frankly, we can use all the help we can get. I applaud TX for forward thinking and hope the rest of the country opens up for discussion. Kudo’s

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  30. I wanted you to know that another bill is coming up in the Texas House. This one would add EMS to the tuition waivers law that LEO’s and Firefighters already enjoy. Consider lending your support!

  31. Will this bill also allow ER RN’s to fill Paramedic jobs in the field? That seems like a great idea, equally trained .. Equal jobs!

  32. Both bills were signed into law as of June. Remember that ER nurses have jobs because there are paramedics who provide them with a census of patients. we should work together as a team and not as a competition.

  33. This is a true story and due to HIPAA I will eliminate identifiers.

    I was and currently work as a paramedic but also moonlighted as a tech in a free standing ER. in south Texas ( 1 yr ago). A patient became apneic due to his medical condition. The RNs prepared meds and equipment while I was bagging the patient. The physician came in attempted a failed intubation. As it happens to the best she intubated the stomach and had bile return. instead of acting as a professional she was grossed out and walk out the room leaving the staff to fend for ourselves.

    The 2 RNs working that night with me, were not trained in endotracheal intubation but I was. knowing that I, even though I wasn’t allowed by regulations do so in that environment, I could not see another human die as a result of it. The staff and I agreed that I would perform the procedure. The outcome was great for the patient and the staff collectively felt great.

    The doctor was relieved of her duties and later terminated that same night.

    So what happened afterwards? Patient lived, Nurses and I continued to work as a team but with more mutual respect.

    The facility as a result to avoid any liability, avoided any official or unofficial praise or comments in the case. Not even a good job or a thanks for covering our butts.

    So the moral of this and other cases alike is that both levels of professionals can coexist with mutual respect without one or the other being delegated or in charge of the other, case in point just ask the hundreds of flight Nurses and Medics who work hand in hand everyday.

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