kind of a vent....Paramedics

[weirdRN, RN]

Okay, the other night I was working and one of the residents who is ambulatory by wheelchair went off on her own as is her habit. Apparently, she was trying to get into a locked nutrition room and cut or pinched her fingers badly enough that she bled a large puddle of blood in the hallway. So, when she was found a complete assessment was done. Cold compresses and pressure dressings were applied until she could be transported to the nearest ER for stitches. The ambulance company was called and transport arranged. When the crew to transport got there, the paramedic took the pressure dressing off!!!! right in front of me!!! and the woman's fingers commenced to bleeding again. The medic asked the EMT if she still had the (now contaminated) dressing or if she had trashed it. Of course she didn't trash it. The paramedic tried to stick the old dressing back on with no tape. He had the lady, who was confused, hold it on her fingers and she kept dropping it and kept bleeding. I went to get a new dressing but by that time, they had her on the stretcher and were leaving and the Medic said she would be fine with out it that she wasn't going to loose enough blood to hurt her!!!

I am a newly minted RN, and so do not fully understand all of the policies and procedures in my facility just yet. So, I talked it over with another RN. She said that when the transport comes, the resident becomes their patient and they can do what ever they want to them.

I told the secretary when I called the transport that the resident had a pressure dressing applied and that we already knew she would be haivng stitches. (steri strips were not an option) I understand about dropping the ball with regard to communication, but he didn't have to cause the woman so dad gum much pain when he ripped the tape off! He didn't need to do more than listen to me give report to him about what had occured.

So what is the role of the Paramedic? What is their scope of practice?

Any suggestions on what to do should this occur in the future?

[kat911]

Depends on the protocols the paramedic works under. Usually they have the option to check the wound or not. If the wound was pumping blood they may not look, other wounds they may look at how serious the wounds are for thier report to the ED. They do have to document an assessment and that includes circulation to injured body parts. Pulling tape off is an individual process, some do it better than others. You can always toalk to a supervisor, they always have one 24hrs a day.

[Altra, BSN, RN]

If I were transporting a pt., I'd want to see the wound for myself too. As was already mentioned in another post, "your" resident is "their" patient during transport, and IMO it would be careless, if not negligent, NOT to assess the wound.

Think about it if things were turned around ... when you come into work, you get report on your residents, but you also assess them yourself, correct?

[nursesarah]

when the paramedics picked up this patient and you gave them report, she became their patient. it is their job to check the wound and they would be negligent in not doing so. if i were in their position that is exactly what i would have done. the only reason you would need to report them is if you saw behavior that endangered the patient.

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

It depends on the protocol, but generally, wounds need to be assessed and documented on the run report. I am a paramedic (and nursing student) and I work for a private amulance company. We had a very similar incident several years ago: a nursing home resident accidently slammed her finger in a door and the wound was dressed upon the crew's arrival. The crew didn't assess it, and it turned out the patient had a near amputation! The doctor tore them a new one, and a memo was posted and distributed to all ambulance personnel reminding us to assess and document what we see.

[weirdRN, RN]

Well, I didn't say anything at all b/c I didn't know what was or was not OKAY the protocol... that kind of thing...

Thanks I will keep the comments in mind.

[Altra, BSN, RN]

He didn't need to do more than listen to me give report to him about what had occured.

You assess your patients, even though you get report on them, right? :stone That is the crux of the issue here, not a protocol.

[EricJRN, MSN, RN]

I think the title of your post didn't really convey what you were wanting it to convey. It really isn't a vent about paramedics, so much as a vent about a disagreement with one paramedic's management of one patient.

[weirdRN, RN]

You assess your patients, even though you get report on them, right? :stone That is the crux of the issue here, not a protocol.

:stone I am not really familiar with the role and scope of practice for a paramedic. Usually, the medics who have previously picked up patients for me have been load and go simple assessments that did not require a dressing to be removed. I have seen them do the same assesment that I do bedside.

So, can you imagine being unfamiliar with something and then feeling unsettled when it occurs. I didn't want to make a donkey's butt out of myself so I asked for input before I said anything to anyone. Geez, it's not like I started a screaming match or reported the individual for being less tender with the resident than I would have been.

My question was for informative purposes... I have the answer to one question. I will find the rest on my own.

[RNOTODAY, BSN, RN]

I think the title of your post didn't really convey what you were wanting it to convey. It really isn't a vent about paramedics, so much as a vent about a disagreement with one paramedic's management of one patient.

I think she did convey what she meant , actually....It sounds like she does not understand , once you call ems, you are "handing" the patient over, its their patient now, they dont just give a ride, they have their own scope of practice........

[LPN1974, LPN]

So, what exactly, did the medic accomplish by removing the pressure dressing?

Did he help the resident or did he create a bigger mess with more blood all over the place?

[vampiregirl, BSN, RN]

While I'm still a nursing student so I can't offer perspective from the nursing point of view, I can comment on WhimsieRN's experience from both the perspectives of an EMT and as a CNA in a LTC facility... First of all, yes, the EMS personnel are going to assess any patient they receive, as noted by above posters. Please don't take it at as a second guess or criticism of your assessment, basically it comes down to legal stuff/ documentation. It also allows the EMS personnel to observe any changes. In this case, the medic probably was assessing the wound as well as CMS to that extremity. If they were doing their job, they would also reassess in 5-10 min to see if there are any changes.

As far as protocols go, they vary from state to state and service to service. Also, you will find huge differences in the thought processes between nursing and EMS (at least that seems to be what I'm discovering as a nursing student). Just one example is O2 administration. Most of the time in a LTC setting, low flow O2 is applied to COPD patients. When EMS arrives, if the patient is having trouble breathing, most likely a non-rebreather will be applied per protocol. Another frustration that EMS has with LTC facilities is that they feel like they are just a "taxi service". Some times patients could be transported in a car... could be if they were not a patient in a facility. The patient needs to be seen in the ER and there often isn't another method of transportation aside from EMS. Or a doctor ordered a transfer to the hospital. Some EMS personnel don't (or won't) understand this. All they think is that they are missing a "real" call. Please don't think that this is all EMS personnel, just like nurses, there are EMS personnel who are great and those that aren't so great. I guess, WhimsieRN, my best suggestion to you would be develop a good rapport with the EMS crews you encounter. As you gain their trust and they gain yours, you may have the opportunity to ask them questions about their protocols. I thank you for asking the questions that you did, it shows that you are interested in understanding EMS. Ok, enough rambling from me, I hope this helps.