# UNC-CH PAs-former 18Ds



## Devildoc (Mar 9, 2017)

Nice article.  Every now and then the light blue place down the street gets something right.  Some of y'all may know some of these fellas.

Bronze Stars, White Coat — News Room - UNC Health Care


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## TLDR20 (Mar 9, 2017)

My good buddy Nick is a former SARC/SOIDC and is in the program currently...


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## Devildoc (Mar 9, 2017)

It's a great program.  I tried talking the Duke PA program into something similar (since Duke's was the first program and founded on Navy IDCs), but they don't have any interest.


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## TLDR20 (Mar 9, 2017)

UNC does still require a bachelors degree and a bunch of pre-reqs. That is one thing most 18Ds don't know or think about. They think, "I'm basically a PA now" when in reality no they fucking aren't...


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## Devildoc (Mar 9, 2017)

TLDR20 said:


> UNC does still require a bachelors degree and a bunch of pre-reqs. That is one thing most 18Ds don't know or think about. They think, "I'm basically a PA now" when in reality no they fucking aren't...



I think all PA programs require a bachelors degree now.  Not to be overlooked, all advanced practice nursing degrees are transitioning to Doctor of Nursing Practice (a pile of bullshit), which you well know.

A friend of mine, a former 18D-turned-RN with whom I worked at Carolina Air Care at Chapel Hill, is now a CRNA.  He thought his time as a 18D and flight nurse would allow him to crush the program.  I think he was humbled.  Advanced practice may share some similarities and cross over, but different game with different rules.


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## Grunt (Mar 9, 2017)

TLDR20 said:


> They think, "I'm basically a PA now" when in reality no they fucking aren't...



There are posers in every aspect of life....


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## TLDR20 (Mar 9, 2017)

Devildoc said:


> I think all PA programs require a bachelors degree now.  Not to be overlooked, all advanced practice nursing degrees are transitioning to Doctor of Nursing Practice (a pile of bullshit), which you well know.
> 
> A friend of mine, a former 18D-turned-RN with whom I worked at Carolina Air Care at Chapel Hill, is now a CRNA.  He thought his time as a 18D and flight nurse would allow him to crush the program.  I think he was humbled.  Advanced practice may share some similarities and cross over, but different game with different rules.



I do think my time as an 18D would help me with hands on skills in cRNA school. Having taught intubations is def a plus. However there is a lot more that goes into being a CRNA than IV starts and intubations...


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## Red Flag 1 (Mar 9, 2017)

.


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## Devildoc (Mar 9, 2017)

Red Flag 1 said:


> Anyone sitting at the head of the OR table is expected to be THE expert in airway management. Airway management is a learned skill but is such a small part of the picture. Today the provider at the head of the OR table needs to be, in essence, the Internal Med provider in the room. The depth of knowledge for the CRNAs is considerable, and not everyone can make the cut. The other part of Anesthesia is conduction and block Anesthesia. Not all the CRNA programs were teaching that skill, some of the CRNAs were trained and some were not. In many cases the line between CRNA and MDA was in regional Anesthesia.
> 
> Traditionally, Nurses and techs are expected to defer a lot of decision to the MD's . Teaching ACLS in the early days, I saw the understanding in the non-MD students. They had the answers, but they would hesitate at the "Mega Code" station to make the calls required of them to pass the course. It took some time to coach the non-MD's to cross the line and make the proper call. Advanced practice Nurses have to have the ability to cross the line and make the traditional MD calls.



I cannot speak to CRNA practice since I know very little about it.  It's why I went into nursing but frankly I cannot stand the OR and I really only wanted to do it for the money.  That would be a problem.  God saw fit for me to do other things.  But with oral intubations, nasal intubations, a retrograde intubation and a handful of surgical airways, I was pretty good at airways.  It is the "skill" bedrock of pre-hospital/out-of-hospital providers, civilian and military.

As for ACLS, I think one reason paramedics excel is because like physicians we are required to think independently and autonomously, make the decision without relying on another to "make the call" (or less nicely, "write the order").  I agree that nurses in general stink at ACLS for that very reason, but once they move on to advanced practice and the paradigm changes, it becomes much easier.


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## TLDR20 (Mar 9, 2017)

Having just done some ACLs with new grad nurses I can agree that the oomph just isn't there. They are hesitant to do anything without a doctor/NP babysitting..


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## Devildoc (Mar 9, 2017)

TLDR20 said:


> Having just done some ACLs with new grad nurses I can agree that the oomph just isn't there. They are hesitant to do anything without a doctor/NP babysitting..



I was not a 18D, SARC, or of the high-speed variety.  But even so, military medicine (and paramedicine) pushes decision making down; there just isn't a physician at the platoon level.  I think nursing school shows the contrast; I think your first nursing job (as a former 18D) _really_ shows the contrast, the critical thinking, and speed at which you make decisions.  In any of the merit badge courses--ACLS, PALS, TNCC, PHTLS, even TCCC--you see new nurses, new grad nurses, get wrapped around the axle while you already thinking about third- and fourth-order effects and decisions.


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## policemedic (Mar 9, 2017)

TLDR20 said:


> Having just done some ACLs with new grad nurses I can agree that the oomph just isn't there. They are hesitant to do anything without a doctor/NP babysitting..



Typically, that's not the case with ED or critical care nurses. They will make decisions.  The other nursing specialties, not so much. That's not a dig on the profession of nursing, it's just an observation of job roles i.e. ED vs med-surg. 

Generally what I've seen is that clinical decision making is a learned, practiced skill.  Those who have the opportunity to do it get better at it and become more willing to do it (and to own their decisions).


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## policemedic (Mar 9, 2017)

Devildoc said:


> I was not a 18D, SARC, or of the high-speed variety.  But even so, military medicine (and paramedicine) pushes decision making down; there just isn't a physician at the platoon level.  I think nursing school shows the contrast; I think your first nursing job (as a former 18D) _really_ shows the contrast, the critical thinking, and speed at which you make decisions.  In any of the merit badge courses--ACLS, PALS, TNCC, PHTLS, even TCCC--you see new nurses, new grad nurses, get wrapped around the axle while you already thinking about third- and fourth-order effects and decisions.



It's a shame those courses have been dumbed down. The ACLS EP course is better because it delves into problem solving more than basic ACLS (@Muppet has taught it so he can speak to it more than I can).  I have to recert ACLS next week and I'm dreading the stupid.


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## TLDR20 (Mar 9, 2017)

policemedic said:


> Typically, that's not the case with ED or critical care nurses. They will make decisions.  The other nursing specialties, not so much. That's not a dig on the profession of nursing, it's just an observation of job roles i.e. ED vs med-surg.
> 
> Generally what I've seen is that clinical decision making is a learned, practiced skill.  Those who have the opportunity to do it get better at it and become more willing to do it (and to own their decisions).



Yeah. Like I said these were new grad nurses for the most part, many in the ICU's but new grads still.


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## policemedic (Mar 9, 2017)

TLDR20 said:


> Yeah. Like I said these were new grad nurses for the most part, many in the ICU's but new grads still.



How do you feel about newly minted RNs working in critical care? Your background makes you the exception, of course, because you've already developed the ability to think critically and multi-task.


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## TLDR20 (Mar 9, 2017)

policemedic said:


> How do you feel about newly minted RNs working in critical care? Your background makes you the exception, of course, because you've already developed the ability to think critically and multi-task.



It really depends on the individual. 90% aren't cut out for it initially, but either get with it or do something else. The other 10% just have it. Most of that 10% did something else before nursing.


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## Muppet (Mar 10, 2017)

I have been teaching ACLS / EP for years now. Both nurses and paramedics. Hell, I have even recert'd MD's. You would be surprised how MD's are in regard to ACLS. They can cut your chest apart but when you ask the dose of 1,10,000 Epi or make push does Epi, they shit the bed but in reality, they have the guides to look at when working a code in the SICU of something.

ACLS, frankly, all of the canned courses are just that, canned and that is why student that have taken it more than twice, say fuck it, same info, lets get it over with. I attempt to make it more colorful for nurse and medic students. For example. I will take 2 medics to start the code, drop in front of the family (family being the nurses, pick 3 or 4 of them and make them yell and cry). Then I will add 2 more medics and 2 medics acting as fire dept. They will work the code, low light maybe, all of the crying and yelling to simulate family freaking. Make them work the code with NO MD over site. See, for those that don't know what paramedics do in codes, we do the first 45 mins. working in the home, get code back and start ROSC care or pronounce pt. I have had, myself, 7 codes since this year started, not counting OD's.

We are expected to know every code drug, dose, every code protocol, we have no guides. Then, know AND understand the reason for ROSC care, which is actually where paramedics come into play because frankly, codes are BLS, CPR and shock. I have had myself in 2 years, 5 codes, walk out of the hospital, neuro. intact.

So, with that said, these students work the code to show the nurses the difference we go through, the thought process, the operations on how to work in an "austere environment" because anything NOT in hospital is not controlled. I don't have the docs, 10 nurses to help. Then operations on how to get pt. down 4 flight walk up apartment building while still ventilating, checking pules and ECG every flight of stairs, making sure CPR device is working correctly, checking tube placement. As a senior medic, I am responsible for all of this and called on the carpet for good or bad during QA.

Then, I have the nurses attempt a code, using the class MD (our medical director) act as the doc on call and they are permitted to use guides. Having the doc give orders, preform tasks to standards. They understand now, what we as medics go through, and the medics understand the difference between in and out of hospital codes. More importantly, nurses not familiar with paramedics get an understanding of how we do things and when we show up at the E.D. and the line looks ugly with the tape job or there is vomit on the pt.'s chest, they get that things are not pretty in a home.

I have seen in recent years, a disconnect with younger students, that believe that ACLS is actually helpful but in reality, nothing, including cardiac meds have been proven to work, ever. It is shocking and fucking awesome CPR. When I get the attaboy for a code well done, I pass the info back to the medical director that says, my team worked it. They broke sweat and bad knees doing the job. They carried the 350 pound pt. down 3 flight walk up's, sweating for that cat to walk out of the ICU neuro. intact. I just happened to be crew chief.

M.


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## Devildoc (Mar 10, 2017)

TLDR20 said:


> It really depends on the individual. 90% aren't cut out for it initially, but either get with it or do something else. The other 10% just have it. Most of that 10% did something else before nursing.



My first job out of nursing school was in a surgery-trauma ICU; I floated to Neurosurg ICU and the burn center.  My nurse manager offered me a job before I started my last year of nursing school; she was a corpsman in the Navy Reserve because she was a Canadian citizen and could not get a commission bec of her citizenship and wanted to do something for her new country. 

I echo @TLDR20, 90% can't hack it until they get some experience.  Of my 8 new-grad cohort, two of us stayed; 5 left to go to med-surg for experience.  That said, those first couple months was like drinking from a fire hose.  ED statistics for new-grad nurses are similar, but most of a new grad's success comes from how the orientation is set-up.  In the ED we had a 6-month orientation for new-grads, and for the most part they were fairly successful.  The problem in the ED was ICU RN transfers; most just couldn't handle the ADD environment.


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## Devildoc (Mar 10, 2017)

policemedic said:


> It's a shame those courses have been dumbed down. The ACLS EP course is better because it delves into problem solving more than basic ACLS (@Muppet has taught it so he can speak to it more than I can).  I have to recert ACLS next week and I'm dreading the stupid.



Yes. Very much a shame.  My first ACLS class, circa 1991, was with incoming house staff at UNC-Chapel Hill.  Maybe 75 in the class.  They started off with the whole "look left, look right, one of you will fail."  In fact, I think they took pride that over 50% failed ACLS.  Now, that was one end of the spectrum, and now the pendulum is on the other side and everything has been dumbed down.


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## Muppet (Mar 10, 2017)

Devildoc said:


> Yes. Very much a shame.  My first ACLS class, circa 1991, was with incoming house staff at UNC-Chapel Hill.  Maybe 75 in the class.  They started off with the whole "look left, look right, one of you will fail."  In fact, I think they took pride that over 50% failed ACLS.  Now, that was one end of the spectrum, and now the pendulum is on the other side and everything has been dumbed down.



I can remember taking my first ACLS in the mid 90's. I remember people so nervous, they were vomiting. We were told we all would fail. A quarter of them did fail. Now, there is "re-education", none fail, unless you are a total fucking retard. Even then, you are offered a chance to re-test.

M.


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## Gunz (Mar 11, 2017)

I think you are all amazing people. A few years ago I took the first part of an EMT-B course at a local college and was astounded by the amount of information one has to absorb even at that very rudimentary level. It gave me an even greater appreciation for folks in medical fields than I'd had before. And medics and corpsmen were sacred to me then.


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## Muppet (Mar 11, 2017)

Thanks brother.

M.


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