tension between EMT and LTC nurses? - page 6
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
Mar 25, '04I just have to say Pittsburgh, PA must have the nicest, most professional EMT,PARA around! Everyone of them I have come in contact with have been respectful and professional even if I am sure deep down they felt our clients from the MH/MR facility I worked at did not need to go! So Kudos to our EMS in Pittsburgh!
Mar 25, '04LTC is so very different than any place else. I feel for those nurses. Most other nurses have no clue the often redicilous legal restrictions on LTC nurses. The paper work along is greater than any other setting. Few nurses in other settings are responsible for 30 -50 patients by them selves.
EMTs too have restrictions and have to meet (sometimes silly) requirements with a run in order to get reimbersement. So they may do an unnessary FBS or give oxygen when the patient could have done without it inorder to get reimbursed for the trip.
Families are funny too. Education may or may not be the answer when they are being lead by fear and emoation.
Here is an example. We did a terminal vent wean. The MD promised to keep the pt comfortable until they died off the vent.
The patient did not suddenly stop living when taken offf the vent. The family (a la hollywood TV education) thought they would suddenly be dead the minute he was off the vent.
They kept asking how much sooner, they clearly wanted it to be over. I gave several doses of ms previously ordered and geve them as requested by family. Then in the middle of all of this they suddenly became concerned that I might adict or KILL this person with the ms. Even though it was clearly understood he would die this day, without the ms. They had planned and accepted this and requested the terminal wean and DNR status.
I have seen this same type of thing over and over. Hospice patient. We explain that it does more harm than good to force feed once a pt has started to decline food and water. They know he is dying. But now he is declining food and they want him to eat or he will die. Yet they earlier with the patient had said that there would be no force feeding or pushing food on the patient if he did not want it.
There is no logic in emoation. And people do change thier minds.
DNR does not mean do not treat. All it means is no CPR. As long as they are still alive you have an obligation to treat unless there is specific instructions to the contrary.Last edit by Agnus on Mar 25, '04
Mar 27, '04This really hit home. I've been an advanced EMT for many years and am graduating the ADN program this spring. It seems like there is a feeding chain that occurs in health care. I've seen ICS dis on med-surg nurses, RNs on LPNs, LPNs on CNAs, Paramedics on Adv EMTs and Adv EMTs on basics. It also seems that the one's that are the meanest are also the most incompetent or lazy. I hope a way of making a difference is being involved in both the EMS and nursing fields. But to change it I think it's important to be a part of both worlds. That way you can serve as a type of "interpreter" because even though we're all in health care, there are completely different perspectives and understanding is the only way to personalize the positions and not rely on outdate or just plain arrogant misconceptions. As an EMS instructor, I also address this subject in the basic, advanced and refresher courses that I teach.
Mar 27, '04Reading all yours posts have been very interesting for me. I worked in an acute care situation in a progressive hospital. If you needed quick care, you could always call the emergency room and just bring them down.
During my schooling and experience in the hospital I heard over and over again that only the nursing failures ended up in LTC. I dedieded I would never ever work in a LTC.
Then I moved, the only jobs open where - you quessed it LTC. So, I began my career as a LTC nurse. Quickly I found out to my surprise that the pt load was bigger than I could have ever imagined. I had 52 residents to care for. I had two aides, one who's priority was to paint her nails, and the other who was weak and sickly, should have been admitted herself.
I have met many competent nurses in LTC. But as in any place, the person who you are relieving sets the pace for the next few hours. Eventually our facility changed the way they did business and started a rehab unit. I am working there right now.
One thing that took me by surprize is the total lack of equipment. Is it possible to find a stethascope-one that has ear pieces? NO. We are progessive enough to have an emergency kit of med, but it is kept locked on the other side of the facility. In an emergency we have to run, beg for a key and sign countless forms before we are "allowed" to get IM Lasix or such. The defibulator is on the other side of the facility as well. Countless times we've asked for supplies and equipment to be kept on our unit. So far they installed a room to supply us with nasal cannula's and O2 tanks.
It's a start.
Working in a rehab unit in a LTC, I can't plug a meter into the wall and start O2, I can't do hardly anything. No equipment, no supplies, no nothing. Sometimes I feel my only recourse is to stick a straw into their nose and breath. just kidding.
So, I work nights. We are considered the dumbest of the dumb. A night LPN. Most of the nurse's I follow are on top of things with their pts. However, you get to know which ones are not. Many trips to the hospital could be circumvented with good assessment and early treatment. However, that doesn't always happen. Most of the people I need to send in, I discover during the first 30 mins to an hour of being on the floor. I can't help it, and many times I feel embaressed for the facility, sending someone in who should never have been allowed to get into this condition.
But, I do agree that DNR doesn't mean do not treat. I also agree that there are very few reasons an end stage terminal person should be transported. Given proper meds and equipment, we can handle most things we encounter. My facility is very specific about the fiancial aspect of using emergency services. One reason, if this person we send is not admited to a unit, we foot the bill. Not a happy thing.
Not having the oppertunity to come in contact with an emt in a setting where we can sit down and talk about what they encounter, I have learned much. When deemed necessary to send a person to ER, We first get a doctors orders, an OK from the Pt and or contact person. We then call the ambulance company and relay the situation and things important for the EMT's to know, we then all the ER and repeat this again. Then we begin the process of paperwork, while admisintering drugs which we just ran two blocks to get. I always thought we covered all our bases.
When the EMT's come, I always give an overview. But, I never have given them a list of meds (good idea). I figured the report we gave their dispatch was given to the EMT's. The ride to the hospital is less then 3 minutes. I personally check to the room to move furniture so EMT's can get in and out. By the time EMT's get here, I have done everything the doctor has ordered and everything I can think of.
Maybe instead of being angry, if you met a nurse who you think is imcompetent, give her a little (freindly) advise. Most nurse's I work with are willing to change to met your needs, if only we knew what it is you expect. So from now on I will also included a med and diagnosis list for the EMT.
Mar 27, '04The above is an excellent post. Having been in health care for many years, I agree about the feeding chain. Many times, the people who are doing the "dising" are the people that have limited self-esteem and limited confidence in their own ability. Talking nasty about another co-worker is a way that these individuals validate their own existence in their respective profession.
We have all witnessed the nurse that comes to work and nothing the previous shift did was right or good enough. The same is true of EMS personnel and I would imagine the same is true amoung physicians. For me, having been a nurse and having the skills and confidence to know what I can and can not do, I generally ignor these poor, pathetic people and recognize that their opinion is really worthless in the bigger picture. Your post drove the point home.
Apr 5, '04Hello,
I know I'm new to the forum, and I'm digging up an older post, but I really felt as if I had to comment on this one.
I currently work as an EMT for a private ambulance company. We do BLS, ALS, Critical Care Unit work, along with having quite a few other services. It's an honor to work in a field with you professionals, and I hope that you value us as much as we value you.
I think its critical to understand that EMS professionals have their place in Emergency Medicine, just like you do. Sure I only took a shorter class, but what I learned was very focused. It's not our job to diagnose complex illnesses, we're there to provide pre-hospital emergency care to those who need our assistance. Just like my knowledge of physiology is limited, I'd like to place you at an accident scene and see what you do. I have very specific treatments that will be given for specific problems, and sometimes I'll even think outside the box.
I can't tell you how much as an EMT we rely on qualified nurses and doctors, but sometimes our treatments will differ. To the person why said not to give a COPD patient in respiratory distress oxygen, I'll like to see that get by my Quality Improvement (QI) board. In EMS I'd apply high-flow oxygen via non-rebreather. Unless our transport is a couple of hours, it is protocol, and part of the National Registry of EMTs standards. But there are a million of these situations. Working in the pre-hospital setting, we only get to see patients for a very short period, and our goal is to stabilize and treat serious life-threatening wounds.
Lastly, I know my colleagues and I see nurses as part of a larger medical team. My partners and I have always treated you with respect, knowing that your day most likely has been as hectic as ours. Understand that the thrill of the lights and sirens is not why we do this job. It doesn't rationalize the low pay and long hours. We do this because we truly care, and hope that our treatment, whether it be complex, or a simple reassuring smile, is able to comfort and help the person.
When it comes down it it, we're here for many of the same reasons you are
Apr 5, '04I guess I will have to get on my soapbox for a just a few minutes, I have been a critical care paramedic for 16 years, I have always treated my patients with dignity and care and have treated them like family. I have always treated with respect any nurse I came into contact with and believe me I have seen some make mistakes but no one is perfect. I am now a RN in the Operating Room, but I have also worked ER and ICU. So please don't judge all EMS personel on the mistakes of a few. You never know when you may need a medic to save your life.
Apr 5, '04Two points-
You're right ...DNR does NOT mean do not treat and the family has the right to send even a DNR or Palliative Care or anyone they want from an LTC.
I really HAVE to disagree though about it being better for the patient to die at the hospital because of better staffing. We are constantly short staffed where I work, but the CNA's really care about their patients. I had many families tell me they would rather have their family member die with people who had taken care of them and cared about them rather than going to a hospital to die with strangers
Apr 5, '04You say that you have never worked in LTC so therefore you don't know what it is like. DNR means Do Not Rescitate not Do Not Treat. Just because someone does not want heroic measures to save their life does not mean that they don't have any rights as a patient. I have had alert and oriented patients that are DNR's that choose to go to the hospital and would be shocked to hear that a nurse such as yourself does not want to care for a DNR patient because you "can do nothing". Maybe before you start running your mouth about LTC nurses you should work a day in a long term facility to see what it is like to care for 40 residents the majority of whom are dying plus their families then maybe you would change your point of view:angryfireQuote from CCU NRSWell I will jump in from a purely observational point of view.
I never have worked LTC so I can't say how things go, I did do my laddertrack course with several Paramedics however,(the program required either LPN or paramedic)and like Mike mentioned I did have occasion to hear them complain about LTC sending DNRs to the hospital, to which I have to agree to some extent. The problem with sending a DNR Pt to the hospital for care is we can not do anything invasive or take heroic measures either (BLS/ACLS)so the reason they became DNR is so that when they begin to go nothing will be done and if they live in LTC this would like dying at home for them. I understand the problem with families interefering and saying they need to go to the hospital but the second problem is once they get to the hospital an eager resident or ER doc will talk to this greiving family member and explain that we can not do anything as long as the Pt remains DNR and 9 out of 10 time the DNR will be revoked and then a Pt that wanted to be DNR and die peacefully will be fully coded and put on a vent and suffer a long agonizing death. So I am not sure if more education would help at the LTC to explain to families that your loved one wished to be DNR and is now dying and this is like being able to die at home and is what they wanted etc. or if they should let the Pt be sent to a hospital.
The problem EMT services have with transporting DNR Pts is that it makes them feel useless because they know they are dying and are not allowed to do anything, however the autonomy they enjoy as paramedics is sometime too much and they may perform some things that maybe they should not.
It is a difficult situation for all involved, I also dislike recieving a DNR Pt from LTC especially to CCU just to appease a family, we can do nothing, they take a CCU bed which should never have been given to them and they will die and they will not be at home or what they considered home the LTC, many times it is the family that are not ready for the Pt to go and these things are all done for greiving family members when the Pt had made their wishes and their mind up about the entire situation I also feel that many times this situation is brought on by the families because of guilt that they did not visit more or do enough for their loved one prior to them reaching this condition.
Apr 5, '04The common thread I see here is that we are basing opinions of all LTC and EMS providers on the one individual who treated us like crap. As a pre-hospital provider of over 25 years who is now beginning a nursing career I've seen both sides. There are lazy nurses and lazy paramedics who don't deserve to practice, period. I love it when an on-scene professional can give me a quick, concise low-down on what's going on with the patient and why I am there. I hate it when I've been called to a nursing home patient who is in obvious CHF and circling the drain and I'm told the patient has been getting worse over several hours. Some times this is due to poor practice by nurses and sometimes it is due to management that won't hire enough nurses to see that such a patient gets re-assessed in a timely manner. Know the facts before you judge. As for EMTs or Paramedics who are uncivil to other professionals, I hope their employers dismiss them immediately. If they think their only job is to be a hero, they're in the wrong profession. There's a lot of lip service paid to the priority of patient care in EMS. Sometimes care is wrapping a patient in a sheet before placing him on the stretcher because he was left alone and his neuro deficits have caused him to defecate and urinate all over himself. Not heroic, but necessary to get him the care he needs. As for DNRs, in NY state the only thing I can't do in the ambulance is work a cardiac arrest in the presence of a valid DNR. Up to that time IVs, meds, ECGs and even ET tubes are fair game. It's a team effort, folks, let's try to treat is as one.
Apr 6, '04I have worked LTC for many years, and only occasionally have the EMT's been rude. One reason we may send a DNR to the hospital is that if they are having a seizure, our facility license doesn't allow us to give IV/IM meds to stop the seizures. And though they are DNR, I feel it is unreasonable for them to have to die by seizing to death for hours. The hospitals can often give meds we legally can't, thereby allowing them a more comfortable death.
I have seen nurses who are inexperienced get frightened by the decline of a patient, and they are unsure of what to do, and rather than call in a supervisor or ask for help, they ship the patient out.
An elderly patient with a raging UTI can go absolutely nuts....totally out of control from it, and we can't give IM haldol to settle them down (again, a matter of facility licensing rules) so we have to send them to ER for a dose of IM haldol so we can get their UTI meds down them and pull their minds back to normal. We also can't restrain them to force meds like a hospital can. I think alot of EMT's don't realize our facility rules are different than the hospitals.
Usually when EMT's seem annoyed, I'll tell them why I'm sending them out for care rather than giving it myself....."This pt. needs an IM of Haldol and we can't give it here, so you'll probably be returning him before long...." and I shrug and they seem to be cool.