tension between EMT and LTC nurses? - page 11

i was reading some of the prehospital forum on a different medical board hoping to get some info and insight into their job because if there is a lag time between finishing my rn prereqs i have been... Read More

  1. by   Malt123
    Quote from Blackcat99
    I think it is OK for LTC to send DNR patients to the hospital. DNR means no invasive stuff like putting in a new trach. DNR means no CPR. DNR does not mean "no care".If a patient is having respiratory distress perhaps they can be helped with breathing treatments and breathing meds. Most LTC's I have worked at have no respiratory therapist on duty.So maybe the hospital can help in this kind of situation. And yes it is a family's right to send them to the hospital even if they are a DNR. LTC centers are usually much more short staffed than hospitals. Who wants their loved ones spending their last days on earth dying and being ignored in a nursing home?. Why not let them spend their last days on earth in a hospital(not ICU or CCU) where they will usually get more attention and better care?
    I beg your pardon. I hated sending my patients to the hospital from LTC because they often came back with decubes, confused, disoriented. it is very traumatic for them to be taken out of their environment, esoecially when they are ill to be around strangers who don't know all their littlquirks. DNR has nothing to do with putting in trachs, or giving ABT's. when a pt. is sent to the hospital for at least 3 days they then can get medicare which will cover IV ABt's and therapies. so unless they are on their death bed or have rquested not to be sent to the hospital, they go period.
  2. by   Antikigirl
    I just sent in a man who has been declining quickly from CHF over the past three months. He was unresponsive at lunch, even to mod/severe sternal rub and shouting at him in his ear. His heart was normal and strong at 82, resps at 18 with snoring, but just wouldn't respond! He has a DNR order and we know this mans heart is at the point that the heart just can't do this anymore (he has been sent in 3 times...good ol lasix time and time again and sent back...it isn't working folks!).

    I HAD to make the choice to send him in, even though I knew...oh goodie..more IV lasix, fluid restriction, and back home. He was very independant three months ago and still has the mindset to be independant, but each time he goes into the ED..he is weaker, and has less ablilities...but the same mind that says "I can do things on my own!" It is very sad...I know if he comes home he will be even more limited, more miserable, and less in spirit than the last time...breaks my heart!

    BUT I had to send him in...DNR's do not mean not to send someone to the ED if they have a pulse and breathing but are in trouble that you can't resolve! Unresponsiveness is a VERY valid reason to call 9-11 in, and you will get in serious trouble if you don't. Yes, sad choice, but the ONLY choice!

    I expressed this to the paramedics..and a small history of what has been going on. Since I knew most of them, and was able to communicate well...they knew that I was suggesting to really follow the DNR and not do anything invasive if not necessary for their protocols (our DNR's still have grey areas...so it was basically..okay guys, no grey..lets go cut and dry please if we can!)! They got it, and agreed with me..heck, they saw the look in my face like "I have to, it is whats right..but guys....oh man this really hurts!". Thank goodness I communicate, work and respect them so much...it helps a great deal!

    The patient all the sudden showed long runs of V-tach...okay. So off to the hospital code three. I know the paramedics will really honor the meaning of that POLST (our DNR orders), but the hospital...I have no idea! (along with the idea the last poster said about all the sudden they come back with tubes!!! It's like 'no invasive means' is missed! NO I am not blaming nurses..LOL! More like the old liablity and doc cycle.).

    I am hopeful if he does come back that the family and MD will FINALLY get him on hospice care like I suggested till I was almost red in the face three months ago! That way we can provide comfort care and stop this cycle of ED, home, ED, home!

    But I just thought it was very great to have such great teamwork with my local EMT's/paramedics...they listened because over the years I have shown them the utmost in respect...and it is paying off for my patients by providing excellent communication and respect between nurses and paramedics/EMT's

    (not to mention we are in the middle of a huge ice storm...our poor EMS is going nuts today and folks are doing doubles with no breaks!!!! OUCH! So them listenening to me on top of a crazy day for them...awesome!!!!!).
    Last edit by Antikigirl on Jan 16, '05
  3. by   nyccemt-p
    OK, first off we do not thrive on trauma calls, nor do we have an inferiority complex. We are plain tired of ariving at LTC facilities and having the nurses not provide ANY information on the patient, if they even bother to come down to the room themselves versus sending a CNA. When you call for an emergency ambulance, you should have ready, or someone other than yourself in the process of copying the patients MAR, recent H&P, and labs. Half the time we get to the facility and we are handed a slip of paper with insurance info, basic demographics, recieving facility name, and maybe a code status. Don't tell me that they just need transport and you already sent the info to the hospital via fax. Also, don't seal the envelope that you give to me with the info and tell me I can't read it, I'll just open it in front of you. Also (I know I ranting but sorry) someone gaining 20# over the past week, with NO acute SOB is NOT an emergency, don't call 911, either increase their diuretic, or call a commercial agency for a non emergency transport.
  4. by   nyccemt-p
    Quote from Agnus
    FYI the hiarcheal order is RN then Paramedic then EMT.

    What The EMT and Para do not comprehend is the complexity and range of nursing.

    LTC is a very different focus than emergency or even acute care.

    Emergency care is based on algarythms. EMTs and paras memorize these because basically they do not deviate from them.

    Acute nurse (even much more than emergency nurses) use critical thinking more and use them when applying algarythms. The nurses education is more extensive and complete than the para.

    The para has ONE very narrow focus in thier entire education, emergency care.

    Your education is much broader and more involved.

    In emergencies they are the expert.

    However. to dis a LTC nurse because her emergency skills are not up to par of some one who works only in emergency is like diss'ing an obstetrition because he cannot do heart surgery.

    Thier ignorance stems from the fact that they do not know what they do not know. They are contstantly required to act in emergency conditions and have had to memorize protochols so that they are automatic without thinking. and working in emergency give these folks a false sense of being some kind of superior care giver because "they save lives".
    All they really do is keep a situation as controlled as possible UNTIL the real care and life saving can take place.

    Often they are adrenaline junkies, with a hero complex. Sorry, but I have had the misfortune of sitting in a firehouse listening to these self proclaimed heros tell the same story over and over such as about how they put in an IV on the fly (an event that took place over 2 years privious) To them that is a major big deal, worth repeating to every one who had an ear.

    They do a lot of talking and patting self on back.

    So how can they possible respect someone who has the job of a mere mortal and does not deal with life and death emergency every day.

    I think much of the critcism about transporting DRNs etc it the funding. Unless they do certain procedures during trasport they do not receive funding for that run.

    We have mostly volunteer emergency response here. However, there are several medical transport companines that are not emergency but do provide medical transport for patients. maybe this is who we should be calling. However they are not available on a moment's notice.
    Excuse me, no the hiarchy order is NOT RN, Paramedic, EMT. Once you call me to the scene, the hiarchy is patient, on-line med control, Paramedic, EMT, and LTC nurses on the bottom. We do NOT provide temporizing care, Paramedics provide definative care. When you forget to round on your diabetic patient and find them unresponsive, we are the ones who wake them up. We are the safety net for our contries health care system. As far as bragging, it's called having pride in our work. I can't tell you the last time I heard a bunch of LTC nurses sitting around talking about the big enema they gave just the other day. Finally for the funding issue, guess what, we are suffering from the same lack of reimbursement that you are. Most basic EMT's earn less by working on the ambulance than by reciting the phrase "would you like fries with that?". But they do it anyway, they have pride in what they do. Also remember as you stated, you have mostly volunteer responses. What other health care profession is there where people have a full time job, families, and still find the time to go to school for EMS and volunteer to take calls.
    Last edit by nyccemt-p on Mar 14, '05
  5. by   Biffs25
    Quote from psychomachia
    Agnus expounds: FYI the hiarcheal order is RN then Paramedic then EMT.

    Me: And FYI "hiarcheal" is usually written as hierarchical. Also, there are some who would argue the order should be MD--->God--->Midlevel practitioners (PA/NP/CRNA)--->RN---->LPN---->CNA.

    There are also other branches from above God where you have Firefighters and everyone else below them. Another branch starts above God where you have Police Officers and, of course, everyone else below them (the Police and Firefighter brances are often in mortal combat for the elusive taxpayer dollar and have to align their forces in conjunction with political candidates who, of course, are above God but under the Devil.

    Branches usually do not intersect as you have suggested. This may occur on a forum, such as this, when the debate over who should work in an ER (paramedic vs RN) and who should be the supervisor of the other's actions, but these are only "pseudo-branches" as they are often just the cogitations of "internet experts" who like to tell stories about their first hand experiences in dealing with the other brances. Thus, the RN vs paramedic battle is usually fought in the small minds of those who often have never worked both jobs, yet think they know all about the other because they spent a few hours in a firehouse or an ER.

    Your command of grammar and spelling is a challenge and I had difficulty trying to grasp your somewhat rambling ruminations.

    As an RN I'm not impressed with your hypothetical argument of emergency care being "one narrow focus," since emergency medical conditions can be very broad based. Perhaps what you meant was the focus of the paramedics training is on the initial identification of life-threatening conditions and their treatment with stabilization until delivery to an Emergency Dept. You can argue that "definitive" care starts in the hospital, but if all you get are dead bodies...well...might as well call yourself the morgue.

    As a paramedic, I'm very impressed with how poorly you make your argument which rings of jealousy from not being able to ride around in the big red trucks with the lights and sirens on. Listen, if you want I'll help you get your paramedic certificate and then you too can join us at the firehouse for a little BS session as we kick back in the La-Z-Boy recliners and eat ice cream...but don't think for a second you get to hold the remote control...
    All I have to say is AMEN.


    oh and, if you're in my firehouse, it's my remote control!! hahaha
  6. by   nyccemt-p
    Quote from psychomachia
    Agnus expounds: FYI the hiarcheal order is RN then Paramedic then EMT.

    Me: And FYI "hiarcheal" is usually written as hierarchical. Also, there are some who would argue the order should be MD--->God--->Midlevel practitioners (PA/NP/CRNA)--->RN---->LPN---->CNA.

    There are also other branches from above God where you have Firefighters and everyone else below them. Another branch starts above God where you have Police Officers and, of course, everyone else below them (the Police and Firefighter brances are often in mortal combat for the elusive taxpayer dollar and have to align their forces in conjunction with political candidates who, of course, are above God but under the Devil.

    Branches usually do not intersect as you have suggested. This may occur on a forum, such as this, when the debate over who should work in an ER (paramedic vs RN) and who should be the supervisor of the other's actions, but these are only "pseudo-branches" as they are often just the cogitations of "internet experts" who like to tell stories about their first hand experiences in dealing with the other brances. Thus, the RN vs paramedic battle is usually fought in the small minds of those who often have never worked both jobs, yet think they know all about the other because they spent a few hours in a firehouse or an ER.

    Your command of grammar and spelling is a challenge and I had difficulty trying to grasp your somewhat rambling ruminations.

    As an RN I'm not impressed with your hypothetical argument of emergency care being "one narrow focus," since emergency medical conditions can be very broad based. Perhaps what you meant was the focus of the paramedics training is on the initial identification of life-threatening conditions and their treatment with stabilization until delivery to an Emergency Dept. You can argue that "definitive" care starts in the hospital, but if all you get are dead bodies...well...might as well call yourself the morgue.

    As a paramedic, I'm very impressed with how poorly you make your argument which rings of jealousy from not being able to ride around in the big red trucks with the lights and sirens on. Listen, if you want I'll help you get your paramedic certificate and then you too can join us at the firehouse for a little BS session as we kick back in the La-Z-Boy recliners and eat ice cream...but don't think for a second you get to hold the remote control...
    WELL PUT!
  7. by   nyccemt-p
    Quote from flowerchild
    I can honestly say that in my years of nursing, NO ONE has treated me with less respect than the EMT's. In HHC, LTC, and in my current clinic environment! Nor in my personal experience, as 2 EMT's came to my home in answer to my EMS call d/t my husband having an MI, asked me what kind of nurse I was, rolled their eyes and proceded to do everything in thier power to disprove my diagnosis. I was right, thier ineptness and grandious attitude was the number one contributing factor to my husband losing 30% of his heart muscle d/t lack of treatment. Problem was, they followed him into the ER and did the care at the ER too! It took me SIX HOURS before someone finally believed me and started his treatment.
    I have more stories too, like the HHC COPD patient gone bad, I called, got the attidtude, as usual, they took him only on my insistance, patient died within 24 hours.
    Or how bout the kid in my clinic with a BS of 17, they stuck thier head in the door, from 5 feet away, took one look at the kid, and said, you have it under control, he is fine, and WALKED out on me!!! Mind you, I'm in a clinic all alone. No back up, no emergency equipment or medication. EMS is my ONLY backup.
    I reported those cases to the head of the dept. They were reprimanded. After my hubby, an entire cardiac program was revised for EMS. I am currently on a first name basis with the dirctor of our large county EMS program, I am continually asking him to help improve the knowledge of EMT's about Nurses and our function. Over the years since I started this fight, in 1995, things have gotten better, but it is a continious fight for respect.
    And, yes I agree, the classes that the EMT's took, both prereq and req's are not on the level of the nurses. The nursing requirements are much stricter and of higher levels. PERIOD.
    I can only sumise that saving lives and picking up people off the pavement, skews the EMT's perception as to who they are.
    OK, EMT's flame me at will but what i have said is the truth of the matter.
    The bottom line...there are good nurses and paramedics, and there are bad nurses and paramedics. You have good days and bad days, we have good days and bad days. We must ALL remember what comes first, and that's the patient. It's not about "my stethescope is bigger than yours". Look at it this way, would you nurses treat a MD the same as you treat your EMS crews. EMS, would you treat the LTC nurses the same as you would the ER RN's or your medical director?
  8. by   Antikigirl
    Quote from nyccemt-p
    Excuse me, no the hiarchy order is NOT RN, Paramedic, EMT. Once you call me to the scene, the hiarchy is patient, on-line med control, Paramedic, EMT, and LTC nurses on the bottom.
    When a paramedic is on scene, I AM STILL IN CHARGE till I TRANSFER CARE (either by report or saying so) care over to the paramedic! NOW, seeing as I am married to a paramedic and one of the most paramedic friendly nurse I know...I rarely have probelm with it at all (some fire paras yes...but mine have larger chips than usual...LOL, even my hubby complains about certain ones, but alas..they get the same respect from me as anyone else..which is high..they just don't return the favor..that is obvious, I am the devil as far as they are concerned..LOL!)!

    But I see it this way...(and yes I work LTC!), I called paramedics for their equipment and knowledge/experience in these situations to assist the patient...so I depend on their expertice in order to help my patient, but their expertice doesn't outweigh my responsiblity or ability to help as well (because I am the highest ranked in MY protocols/procedures unless an MD is present...kinda a clash there in disaplines between the EMS and RN...hey, I didn't write the stuff..just have to go by it..LOL!).

    I don't butt in unless I am asked because I feel that I may delay treatment, but I am sure as heck there, and luckily more trained than most in prehosp and emergency care! We are a team, I respect my team, I work with my team, no fussing over who has a license vs certification, or even who has more education/experience...there is no time for that...just 'okay you are an EMT or EMT-P...okay lets do this crazy thing ...

    I trust my team, and that includes paramedics...and of all of my team members..a paramedic has never let me or a patient down (which I can not say of other nurses or Doctors for that matter!).

    NOW, as far as your protocols...who do you report to when you must transfer care??? "A nurse or Doctor or equivalent",(which I still don't understand what the equivalent is...but it is in our protocols so...eh). So tends to reason that nurses are indeed NOT at the bottom of chain of command in emergency scenes...but somewhere in the grey on the side..and believe me, I seem to be placed there a lot despite my very obvious respect and known ability to assist as needed (why the heck do you think a nurse would take ACLS and CME in pre hosp emergencies when you work LTC...because I work with paramedics and depend on them...feel it only just to be able to help if needed..that means...got to know something of what they do!).

    When care is transfered...you bet...that chain of command as you say, but any good paramedic knows that listening to a nurse is a pretty good thing to do as long as it doesn't hinder care. Nurses will have info to help you to understand pre existing conditions, recent probelms, and most if not all the questions you ask a patient (but we know the facts, and most often those facts are not remembered at the time by the patient). And with all the new ACLS and new protocol guidelines now..having to think of more 'underlying causations' and what not...I was shocked...I was in ACLS class saying ...shoot, then they have to be nurses too...geesh give them a heck of a lot more money folks..that is tough!

    BUT lord in heaven I know those 'nurses' or even caregivers or 'docs' that try to run the scene or even try to barge in and start being Mr. or Mrs. big shot (and not reserved totally for emergencies..happens all the time). Seen it SO much on ride alongs and on scene. That is why I made sure the paramedics and fire know me, and I wait at a safe distance for any assistance as needed by their que... Makes me feel like an idiot sometimes...just standing there...but it is best and my feelings do not ever outweigh my patients health. So I stand their and wait for assistance PRN (although okay, most times I have their equipment out of the bag just as they call for it to hand to someone so they don't have to walk around furnature to get it..LOL...they all the sudden call for it and boom...there it is that very second and me with a big grin.."hey, I know your bags!").

    We must work as a team...none of this "I am better than you" crud that only hinders care and created hard feelings! That patient doesn't care who you are, just as long as you can help...and that is the focus the patient!

    But may nurses also remember, once transfer of care is given the EMT/EMT-P are held very responsible just like us for anything they do...so don't start getting in there and doing things without their consent! Seen some nurses do this, and oh boy does the stuff hit the fan...delay care...and just not cool at all...

    Oh, and I find saying "I don't know" to make me feel horrible when paramedics ask me a question...I like to say "it is unclear in the chart"...that helps when you don' t have the info, like MOST LTC's...and doesn't make you feel like you are seen as a goonball..LOL! Just a little hint I picked up...

    Funny story on top of a very long post..LOL! My hubby, a Doc and I were chit chatting at a function and we were jokind about how we always sign check or other things outside of work with our rank initials....and my hubby pipped up "hey...I have more..EMT-P...does that mean I win???". It was funny as heck! Then the doc pipped up "no, it just means you need more letters to remember just like your protocols....how fun for you..." LOL!!!!!
    Last edit by Antikigirl on Mar 14, '05
  9. by   ERNurse678
    Quote from nyccemt-p
    The bottom line...there are good nurses and paramedics, and there are bad nurses and paramedics. You have good days and bad days, we have good days and bad days. We must ALL remember what comes first, and that's the patient. It's not about "my stethescope is bigger than yours". Look at it this way, would you nurses treat a MD the same as you treat your EMS crews. EMS, would you treat the LTC nurses the same as you would the ER RN's or your medical director?
    Very well said. I have dealt with both both RN's and Paramedics that I would not want taking care of me or my family and I have dealt with RN's and Paramedics that I would trust with my life in their hands. We need to all learn to work together and stop talking about whose job is harder. We all have a hard job and I give EMS a lot of respect, because I don't think I could do their job. And because I respect EMS, they respect me when they bring me patients in the ER. None of us are superior to one another. We all have a different job. So, EMS does a wonderful job. Keep up the good work.
  10. by   Nurse Hatchett
    I think this will be a war that will never end, just as LPN/RN, ASN/BSN, etc. There are good nurses and good paramedics. I myself haven't had many problems from EMT's, but I have all my paperwork copied, know a (somewhat, if from another hall) hx of pt. move dressers. w/c etc. out of way and help with transfer. Most of the time I get a thank you and I'm treated with respect. Of course you have your jerks out there too. One night my house supervisor was told that sending this man out was a waste of taxpayer's money, with his wife and him present. On the other hand, while performing a code, I had a fellow nurse tell the paramedic, she knew what he was doing because she had seen it on ER. I about flipped. My respons was we aren't all that stupid. No wonder they think we're retarted when someone makes such a stupid comment. Another thing to consider is, if we call an on call Dr. the majority of the time that is their all time fix, send to ER. You literally have to fight tooth and nail to have something simple treated at facility. There are many times I have sent someone to ER that I didn't feel they needed to go, but family or MD ordered. I usually just apologize to paramedics and explain the situation. I almost always have the understanding and sometimes sympathy. If I have one come in all cocky, usually by the time they have left, their attitude has changed, as I have all my info ready, follow to res room and assist as needed. They are trained for emergency situations way more than I am, I tell them to let me know how I can best assist them without getting in their way. If I was dealing with something going on the floor, I am more trained and expect them to stay out of my way!!!!! There are idiots all over in every profession, unfortunately, and we just have to deal with them in the most professional way we can. Sorry for the rant and any typo's I was on a roll for a minute
    One more point, If I feel I need to send a res out and the paramedics want to tx me like sh**, then that's ok too. I'm doing what I think is best for my res. They also have a lot more equipment then I do in LTC and can get results back a lot sooner.
  11. by   paraloco
    Quote from SMK1
    i was reading some of the prehospital forum on a different medical board hoping to get some info and insight into their job because if there is a lag time between finishing my rn prereqs i have been thinking i might enroll in the emt-b program, to get a heads up on a few skills. Anyway i was really disappointed to see the disrespectful posts regarding nurses and in particular LTC nurses. I have considered the source of course (because the board is a part of SDN), but i still was surprised at the overwhelming belief that nurses are not as well educated as paramedics or even emts. (among the ems providers this seemed to be the consensus at least) At my school the RN program not only has more gen ed requirements and (higher levels at that) but more science such as chemistry and microbiology and nutrition., so i don't quite understand where this idea of nurses knowing less is coming from. I guess i am just disappointed to see other non-doctor medical personnel downing nursing. I think that everyone has a vital role and don't see why the bashing is necessary.
    I have respect for LTC nurses, I have an idea what their jobs are like. Most encounters (few now) are pleasant, LTC nurses are people too. The problem I had when I frequented LTC facilities was not with the rudeness or politeness of the staff. The problem was that we would recieve a call as shortness of breath, but find that the patient was cold, with dependent lividity. *****!! That was a frequent scenario. Or get called to a code, and find them doing compressions on a soft bed, with a simple face mask not attached to ANY O2 source (as if that would have made a difference) and NO ventilations. Or (not the LTC facility's fault, but still annoying), getting the call for abdominal pain from a private EMS, to arrive and find that its really a g-tube replacement transfer. They would rather tie up a 911 med unit than let one of their competitors get a foot in the door at 'their' facility, cuz who knows how much candy, doughnuts, pens, coffee cups, (and yes, 'love') they hadda spread around to get the facility's business. Don't get me started on private EMS. Once again, LTC nurses are people, worthy of respect.
  12. by   sandyth
    THERE IS A GENERAL CONSENSUS BETWEEN LTC NURSES AND EMTS. I WORK LTC PRN AND SOME OF THE EMTS ARE TOTAL A*****, BUT SOME ARE GREAT . THERE IS ONE IN PARTICULAR THAT COMES IN AND TRIES TO TALK MY ELDERLY PTS INTO REFUSING TO GO TO THE ED. WE HAVE CLASHED SEVERAL TIMES. MY MAIN NURSING IS IN THE ICU , SO I FEEL AS EDUCATED IF NOT MORE SO THAN HE.
    Quote from SMK1
    i was reading some of the prehospital forum on a different medical board hoping to get some info and insight into their job because if there is a lag time between finishing my rn prereqs i have been thinking i might enroll in the emt-b program, to get a heads up on a few skills. Anyway i was really disappointed to see the disrespectful posts regarding nurses and in particular LTC nurses. I have considered the source of course (because the board is a part of SDN), but i still was surprised at the overwhelming belief that nurses are not as well educated as paramedics or even emts. (among the ems providers this seemed to be the consensus at least) At my school the RN program not only has more gen ed requirements and (higher levels at that) but more science such as chemistry and microbiology and nutrition., so i don't quite understand where this idea of nurses knowing less is coming from. I guess i am just disappointed to see other non-doctor medical personnel downing nursing. I think that everyone has a vital role and don't see why the bashing is necessary.
  13. by   betweenprofessions
    One of the biggest issues that I've seen in my 10 years as a paramedic is a lake of respect that sometimes, but not always, occurs between the LTC nurse and the paramedic.

    I realize, as my mother has been a LTC nurse for many, many years that nursing facilities are not emergency rooms, and many times you all are limited with supplies and equipment to treat a patient in a medical emergency. And any paramedic that is disrespectful to you because you perhaps don't have the patient on high-flow 02 (only have NC's or SFM's in the facility)then that person is just plain ignorant of your capabilities. It does not mean that you are incompetent.

    On the other side of the coin, I do not like to be treated like I am a glorified taxi service, or an "ambulance driver" either.

    When we ask for allergies, medications, etc...we aren't trying to be a nuisance, or arrogant. We need to know these things, as we have licenses to protect just as you do. We have assessments to perform and document as well. If a patient is in ventricular tachycardia, and we need to administer lidocaine-the fact that the patient is allergic to novocaine is very pertinent information.

    But those are my 2 cents worth, and I'm sure that most of you already know these things.

    Let us have peace among us.

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