Reprinted with permission from The Unwired Medic

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…

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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!

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

URGENT TEXAS PARAMEDICS!!!!!!

The following is an email being sent to Texas ENA members in regards to legislation being considered that would allow Texas EMT’s andParamedics 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 our state 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!

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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 http://www.house.state.tx.us/memb…/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
President
San Antonio Chapter
Texas Emergency Nurses Association

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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.

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“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.

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“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 (https://www.bon.texas.gov/laws_and_rules_nursing_practice_act_current.asp). 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.

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“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

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“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?

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“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:

   •   http://jobs.texashealth.org/job/Bedford-TECHN-HYPERBARIC-I-PRN-Job-TX-76021/253475700/

   •   http://jobs.texashealth.org/job/Bedford-Monitor-Tech-%287a-7p%29-Central-Monitoring-Dept-Job-TX-76021/262911100/

   •   Go To Baylor’s Career website and search for “Paramedic”. The only jobs that appear are “ER Technician”, not Paramedic: http://www.baylorhealth.com/Careers/Pages/Default.aspx

   •   Methodist Health Systems, where I had my own son delivered via emergent C-Section and in the NICU, has nothing with EMT or Paramedic as a requirement or even desirable: https://www.healthcaresource.com/methodisthealth/index.cfm?fuseaction=search.categoryList&template=dsp_job_categories.cfm

   •   Houston: EMT preferred: https://www.healthcaresource.com/methodisthealth/index.cfm?fuseaction=search.categoryList&template=dsp_job_categories.cfm

   •   Austin: EMT required, not Paramedic: https://hca.taleo.net/careersection/0hca/jobdetail.ftl?job=1761798&src=JB-11444

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“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.

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“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.

http://www.ems.gov/pdf/811077e.pdf

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“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: http://texreg.sos.state.tx.us/public/readtac$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.

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“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 – http://www.bcencertifications.org/Home.aspx) 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.

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“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.

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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 (http://www.dshs.state.tx.us/emstraumasystems/scehours.shtm), 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 (http://www.tmb.state.tx.us/page/resources-cme-for-md-dos).

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.

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Contact the Texas ENA here:
http://www.txena.org/contact-tena/
Link to Texas ENA contact information provided by the National ENA

ENA, Texas State Council

Contact the San Antonio Chapter of the Texas ENA here:
http://www.sanantonioena.org/

And the author of the insult letter here:
Carol Twombly, RN at cltwombly@aol.com

"Chris Matthews has been in EMS for over 16 years, advancing through all levels of certification from First Responder through Paramedic and EMS Educator. He teaches all levels of EMS from First Responder through Paramedic, and many CE and card class programs, such as ACLS, PALS, EPC, PHTLS, AMLS, ITLS, and CPR/First Aid. Chris is also a successful grant writer. Seen as sort of a "Tech Geek", he has been dabbling with various mobile technologies for many years, such as using PDA's (like Palm and Windows Mobile devices), smartphones, laptops, Tablet PC's, and such, and many of his colleagues and coworkers ask questions about how they can get their devices to do some of the things he uses them for. Chris wants to share that knowledge with others in EMS and public safety so they can learn to maximize the use of their expensive smart phones and mobile devices."

About the Author: Christopher Matthews is a Nationally Registered Paramedic and is a licensed Paramedic in Nevada. He also holds several Microsoft and CompTIA IT certifications. EMS has been a part of him for 20 years. He also authors the public safety tech blog, The Unwired Medic in his "spare" time. His hobbies include recreational shooting, tinkering with technology, and hiking with his wife and two kids.