tension between EMT and LTC nurses? - page 4

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   etmx5313
    I am an RN from a small town near Omaha NE, working in LTC and just want to say, that apparently our EMS in our town are among the few AWESOME EMT's. I have had ONLY one bad experience with one specific EMT arguing with me about whether someones hip was broken.......it was..........she argued......I am wondering why--I don't think that x-ray vision was on the list of class requirements but anyway....the EMT's are great in our town. Always friendly, they really are a fun bunch of guys----but they know their stuff. They know what they are doing, are courteous to the nurses and do their job. I'm sure they have been occasionally rude to some nurses--but I guarantee they deserved it. I know that personally there are nurses that call EMS, fill out the paperwork, then just hand it to them and walk away. How about giving report, a little history on the resident. I understand their frustration in certain situations. I actually go with them to the resident's room, giving history as I go, giving any other pertinent history that they should know--especially VRE, MRSA, etc. Some nurses leave that out. I certainly would want to know this info. and I assist them to get the patient transferred and out the door. Sheesh--isn't this our job? It's too bad that many people have had such bad experiences--mine had been great!
  2. by   etmx5313
    Im not sure in your facility, but in our LTC, there is no way we can send someone out without a MD order. We would have our butts in a sling if we did that!!!

    Quote from lgflamini
    Oops- i think I need to clarify my original question to mean

    if the scenario is one of where the pt is a clear case of end-of-life. Not dehydrated, or in need of ABTs. If the patient has signed a DNR, and made their wishes known to the family, can the family's wishes legally take precedence over the patient's in a clear case of end-of-life? With all the litigious family members out there, I'd be taking the safest route possible, too. If that means sending the pt out, and annoying EMTs and hospital nurses, so be it.

    Also, I can see where if the pt was having trouble and the Dr. wasn't available, why a NH nurse would choose to go ahead and send the pt out. I know you guys always call the ER and give them the low down on situations such as that, but us floor nurses don't receive that kind of info, so some of us might make assumptions as to why the pt was sent to the hospital. Thanks for shedding a little light on some of the reasons that we might not have thought about.
  3. by   etmx5313
    Oh, and also our EMT's are great about starting IV's when we can't get one in. We try our best but if they are an impossible stick, we call EMS and they get it 99% of the time. And they are PLEASANT about it!! I actually enjoy seeing them there :hatparty:

    Quote from lgflamini
    Oops- i think I need to clarify my original question to mean if the scenario is one of where the pt is a clear case of end-of-life. Not dehydrated, or in need of ABTs. If the patient has signed a DNR, and made their wishes known to the family, can the family's wishes legally take precedence over the patient's in a clear case of end-of-life? With all the litigious family members out there, I'd be taking the safest route possible, too. If that means sending the pt out, and annoying EMTs and hospital nurses, so be it.

    Also, I can see where if the pt was having trouble and the Dr. wasn't available, why a NH nurse would choose to go ahead and send the pt out. I know you guys always call the ER and give them the low down on situations such as that, but us floor nurses don't receive that kind of info, so some of us might make assumptions as to why the pt was sent to the hospital. Thanks for shedding a little light on some of the reasons that we might not have thought about.
  4. by   CCU NRS
    Quote from hogan4736
    Okay, you keep the pt at the nursing home, fight w/ the family, then said pt dies the next day and then on your days off 3 years from now, you can sit at a trial, be named as a defendant, and go through cross examination...

    DO NOT fight w/ families on this...It's their right, their business, not yours!
    Actually I did not suggest fighting but educating, subtle difference, you see if you are thorough and explain that the Pt wished to be let to expire in a setting that is for all intents and purposes their home and that you understand how difficult this is for a family member and you may even feel the same way were your (add relative association here)dying but that as someone of sound mind the Pt had made his/her wishes clear and wanted no intervention, also explaining all the while that you will gladly send thier loved one to the hospital if they insist but with a DNR in effect they will not perform any heroic measures there either, and if this family memebr is not a Power of Attorney or legal guardian then they do not have the power to revoke the DNR leagally. My point being that sometimes these family members are just greiving and they feel that if their loved is taken to a hospital there will be some intervention that will miraculously save their loved one when the fact of the matter is that no interventions will be performed because this is what DNR means.

    Now just in case there are doubts I am still expressing these thought regarding a DNR Pt that is in the last hours of life that can not be prolonged without, intubation, ventilation, BLS/ACLS and or other invasive measures that would go against a DNR, by all means if you have a Pt that is having acute Pnuemonia, or falls and breaks a hip I DO NOTexpect you to keep these Pts or withhold treatment, I am strictly speaking of DNR Pts that are dying and will die without interventions outlined in a DNR, Living Will or Advanced Directive.

    If education is beyond your scope or fails then if a family member insists yes you will havce to do as they wish, I just think when death is inevitable sometimes education may prevent needless transfer of Pts to facilities that will be able to nothing anyway!
  5. by   hogan4736
    Quote from CCU NRS
    Well I will jump in from a purely observational point of view.

    I never have worked LTC so I can't say how things go...

    'nuff said

    oh, and education is within all of our scopes
    and many times patients are admitted after hours, and an acute situation arises before the next BUSINESS day, and the waters are murky because no papers have been signed (they don't give me the key )

    and much of the wording within advanced directives themselves are ambiguous, and allow for much interpretation...

    a piece of advice CCU, I felt as you do before I went into LTC...I was the epitome of an ER nurse that hated LTCs and all of their "dumps"
    It's one big bowl of ambiguity dude...I don't care if a cousin in the room is demanding the patient go to the hospital...A seed of doubt planted by a distant relative now, can grow into a giant weed of litigation...(though handing the cousin the phone may be all the facilitation I need provide)



    sean
    Last edit by hogan4736 on Mar 22, '04
  6. by   hogan4736
    Quote from CCU NRS
    ...you see if you are thorough and explain that the Pt wished to be let to expire in a setting that is for all intents and purposes their home and that you understand how difficult this is for a family member and you may even feel the same way were your (add relative association here)dying but that as someone of sound mind the Pt had made his/her wishes clear and wanted no intervention, also explaining all the while that you will gladly send thier loved one to the hospital if they insist but with a DNR in effect they will not perform any heroic measures there either, and if this family memebr is not a Power of Attorney or legal guardian then they do not have the power to revoke the DNR leagally. My point being that sometimes these family members are just greiving and they feel that if their loved is taken to a hospital there will be some intervention that will miraculously save their loved one when the fact of the matter is that no interventions will be performed because this is what DNR means...

    oh, OKAY, why didn't I think of that??? :angryfire


    I tried that my first day as charge nurse in my LTC, let's just say the family didn't see eye to eye w/ your little speech...I learned my lesson quick

    As you said:"I never have worked LTC so I can't say how things go..."

    you're right, you haven't done it, and you really can't say how things go...it doesn't work that way...maybe someday in your Utopia, but for now...


    I do agree w/ you in principle, but it usually doesn't pan out that way

    And lest you think I don't fight for the patient who is a DNR, but I have found that the family will call 911 anyway if there is doubt in anyone's mind, so...

    Let's work on better wording and more specific dialogue within a DNR


    sean
    Last edit by hogan4736 on Mar 22, '04
  7. by   smk1
    Quote from lgflamini
    http://forums.studentdoctor.net/show...hreadid=109596

    Just thought I'd post a link to the thread so everybody else would know what the heck we were talking about.

    Again, I tend to agree with them- if your pt is SOA and desatting, and you call EMS because of that...put some darn O2 on them before the EMS gets there. I saw more of a "why aren't they USING their training?" as opposed to "They aren't trained." And I have worked in a bad nursing home (lasted a whole year there), and have seen some of the things they are talking about- consistently. I was treated like a trouble maker for sending someone out for a GI bleed, was yelled at by the doc after questioning his orders for Phenergan for coffee ground emesis (he didn't want to send this full code pt out), was looked at like I was a nut for calling the doc for a pt with a hemoglobin of 6, etc., etc. When I was agency, I worked in a few awesome nursing homes with much better ratios, and staff/administration that cared about the residents. But it's always the bad ones that are memorable, sadly. Heck, the scenarios I just mentioned took place over 8 years ago, and I remember them.

    I remember being a NH nurse, and letting off steam about things I saw there (at the bad NH). I guess I just feel that they're doing the same thing. I wonder if any of the good NH nurses would feel the same way about some of their co-workers who act like the nurses in the scenarios presented in the SDN thread. The thing is, in a hospital we have a code team to take over, and we assist- we don't wait for the EMS, we are the EMS. So naturally, their stories are going to be directed at NHs or HH in particular- that's who they deal with. If EMTs were as much of a presence in hospitals, they'd see some pretty screwed up things there at times, too. Not just from nurses, but from Docs as well.

    You don't expect the general population to know what to do in a medical emergency, but you do expect a nurse to know what to do. It's our responsibility to keep up on our skills- BLS, ACLS, practice codes, etc. Especially in NHs, where you are the nurse, RT, PT, OT, family member, advocate, and dietician all rolled into 1- for waaayyy too many patients, with way too much paperwork involved in everything you do.

    I tip my hat to the good NH nurses out there (and there are a lot). I couldn't hang in that job and keep my stress level at anything less than extremely high. I don't know how they manage to do all they do on a long term basis. Thank God for them, because it really takes a special person to be able to handle that kind of work.
    thanks for providing the link i didn't know if that was ok or not... anyway i am not a nurse yet so i have no comment about whether the nurses in the ltc were performing the proper interventions etc.. i mainly was just a bit taken aback by the attitude that i saw in many of the posters and the fact that not many took up for nursing over there in that forum. lots of generalization over there but oh well.
  8. by   CCU NRS
    Quote from hogan4736
    oh, OKAY, why didn't I think of that??? :angryfire


    I tried that my first day as charge nurse in my LTC, let's just say the family didn't see eye to eye w/ your little speech...I learned my lesson quick

    As you said:"I never have worked LTC so I can't say how things go..."

    you're right, you haven't done it, and you really can't say how things go...it doesn't work that way...maybe someday in your Utopia, but for now...


    I do agree w/ you in principle, but it usually doesn't pan out that way

    And lest you think I don't fight for the patient who is a DNR, but I have found that the family will call 911 anyway if there is doubt in anyone's mind, so...

    Let's work on better wording and more specific dialogue within a DNR


    sean
    You seem awfully ticked about my simple suggestion for education, I never put down LTC care or nurses, I just think that most people when they understand a subject better will be more likely to accept things as they are, I explain many things to many people in my capacity as a CCU nurse and not the least of which is death and dying, I was not trying to offend you it just seemed that you were stating I said to argue with families when all I said was attempt to educate them. I do beleive that if DNR is explained properly and a person is not just hysterical with grief then it should be evident that transfering a dying Pt will not help in any manner. Maybe some people simply will not see the reasoning but I feel that most people of reasonable intelligence would.
  9. by   CCU NRS
    Quote from hogan4736
    'nuff said

    oh, and education is within all of our scopes
    and many times patients are admitted after hours, and an acute situation arises before the next BUSINESS day, and the waters are murky because no papers have been signed (they don't give me the key )

    and much of the wording within advanced directives themselves are ambiguous, and allow for much interpretation...

    a piece of advice CCU, I felt as you do before I went into LTC...I was the epitome of an ER nurse that hated LTCs and all of their "dumps"
    It's one big bowl of ambiguity dude...I don't care if a cousin in the room is demanding the patient go to the hospital...A seed of doubt planted by a distant relative now, can grow into a giant weed of litigation...(though handing the cousin the phone may be all the facilitation I need provide)



    sean
    Education is within all our scope but if one does not understand a subject thoroughly enough to attemtp to educate then it may be beyond one's particular scope.

    I am not saying you don't understand DNR or any subject, I don't even know you my statement was given in the spirit of what I have written above. Just because something is protected under one's scope of practice does not mean that every person is capable of performing this task and or including it in their "scope"

    Never did i state either that I hate LTC or imply LTC's dump Pts I simply stated that a DNR Pt experiencing Kussmaul resp with only hours to live should probably not be transfered and if DNR should definately not go to a CCU bed
  10. by   hogan4736
    CCU, in their (the families') defense, they have the family member dying...it's easy for us to think logically...that's all I'm saying...

    Like I said, I agree w/ you, it's just not usually how it goes down...One family member will want to be heroic, and others will follow...
  11. by   gingerzoe
    I was an EMT and a Paramedic at the same time I was an LPN. I went through EMT training after I was an LPN. They get extensive training on what to do in an emergency. THe extended care they know little about. When you are an EMT it is all about the adrenalin rush you get from knowing there was an accident/problem..Patients from nursing homes, let's face it are not real exciting. I enjoyed my four years as an emergency response person. I also have experience in working LTC, so I see two sides of the story. And, I did have an EMT yell at me after I called him about an elderly resident having a hard time breathing...He had a hx of copd and was on 2L of oxygen, the EMT told me to crank the oxygen up to 10L a minute... I said no I would not do that..then he basically told me I was a moron. I did get his name and wrote a complaint. His supervisor call our facility and told me to expect an apology. I never got one...so I guess the moral of the story is there are good ones and bad ones just like in every other profession.
  12. by   CoffeeRTC
    Did anyone check out that link that was posted. The one that got this whole discusion started? I think that was one of the most offensive things I have read reguarding any nurse. Like I said before... I've seen bad nurses everywhere, but to generalize like that........

    Someone mentioned education.... what about having the director of EMS services inservice the staff at the nursing homes on what they need for transporting or treating the residents.... I did this for our nurses and noticed that things went a little easier. Things you may want to include is what service to call, when to call, what info is need in verbal and written report to the EMT or paramedic (pt age, name, cheif complaint, list of current dx, meds, treatment, allergies, and a little psych/ social review) also calling the hospital with report and family notification.

    You know the old saying...get more bees with honey.... well it works. Most of our paramedics at the service we use will help us more than they should. (start IVs or get blood from some hard stick)
  13. by   BBFRN
    I didn't see anything worse on the thread than what we say about Drs, CNAs, administrators, or each other at times when we vent on this board. Maybe a couple of the LTC nurses on here could go over there and give them a bit of education?

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