tension between EMT and LTC nurses?

TracyB,RN, RN · Mar 23, 2004

As a nurse, I will be donning my flame retardant suit, 1. . .2. . .3. . . NOW!!!!!!!!!!!!

I don't agree with the generalizations, but I think EVERYONE in healthcare is guilty of that.

I can understand why the EMS would be disgusted with some of the things they have seen. As I can understand why the nurses would feel offended at some of the rude treatment.

BUT . . . part of being an RN in LTC is to delegate appropriately. . .there is NEVER any reason that pertinent medical info shouldn't be given to the crews providing transport.

Maybe I have been spoiled by the respect that I have received from EMS crews, maybe it is b/c I act professionally & appropriately for the situation. Am I the perfect LTC nurse, NO WAY, but by admitting I don't know the answer for the situation, & giving the heads up to the crew I am turning my resident over to, I feel like I have earned & deserve the respect that I am given. In turn, I give the respect back.

Have I seen some nurses act, hmmm, how do I say this, completely STUPID, in some emergency situations, Hell yeah! Sometimes, you have to step in & take over, for the sake of the patient. That's probably part of the reason I could never leave work on time, when I worked LTC, I didn't just "endorse to the oncoming shift." I would stay & make the calls to doc when I picked up a condition change. I would stay with my patients, get to know the families, & develop a rapport with my Cna's, as they are my eyes & ears. It is usually the Cna reporting to me, so & so just isn't acting right. Sure, I missed ALOT of breaks to take 10 minutes & assess a patient, but hey, that's just me & alot of other LTC nurses, who really care about what they do & are just trying to make it better, even if only for one day.

It all boils down to one thing, healthcare in the USA is seriously lacking. . .short staffing, lack of training, etc, etc. I could go on for days. And don't even get me started on DNR vs. Do not treat. . . UUUUGGGHHHH!!!! I could just puke every time I hear someone say, "oh, she/he is "just a DNR."

I may be getting all Pollyanna, but I really like what I do as a nurse, I just HATE THE system.

CoffeeRTC, BSN, RN · Mar 23, 2004

I think my greatest tension between myself when practicing as a paramedic and the LTC nursing staff was that in 25 yrs of EMS I can count on one hand the number of times I have been met in the pt's room by the pt's nurse and given a decent report. The vast majority of the time I have been waved past the nurses station or had a room number shouted out me, only to find two, or even three elderly people with what I would diagnose as altered mental status. I always have to send my partner back out to the nurses station to find the nurse, then they send one down who gives the old song and dance about "this isn't my patient, I don't usually work on this floor, wing etc" "Why are you asking me all these questions?" You know stuff like, hx allergies, meds, baseline mental status. They never have the paperwork ready for you. The pt has been suffering with this condition for hours while they tried to contact the MD, but no one has had the foresight to copy his chart. Then they seal it in an envelope and tell you not to open it, only the Hospital can have that info. They entire time they're shooshing you out the door like a flock of recalcitrant chickens. And don't even start me on the times I've had to do simple things like suction a patient, or give a diabetic with a BS of 26 (which they hadn't caught) an amp of D50 while they stood around, clucked their tongues and tapped their shoes because " I was playing doctor"
It always seemed that instead being part of the continuum of care for this pt that me and my crew and even the pt were a major inconvenience for them. I've taken pt's out of LTC's in three states and it never varies.

Yep...I too have to agree. On the very rare occasion, the EMS beat me to the resident and start assessing (I'm probably coping the chart and filling in paper work for them) I feel soo bad and end up apologizing..like I said before My nurses know better than to wave the staff down the hall and say whatever... After all, I treat my residents like family and expect my nursing staff to do the same..Gramma deserves to get the best care and by giving report to the EMS we can ensure that the care will get provided. Maybe the one of the reasons nurses aren't being more supportive in the transport IS their lack of education and medical/ nursing skills.

Tracy B..you said it better than I could :)

smk1, LPN · Mar 24, 2004

just a thought, is it possible that the reason the nurse isn't there to greet ems a lot of the times is because there is only 1 nurse for the whole facility ( 50 or more residents) and sometimes there are more than 1 urgent situation happening, i am not saying they shouldn't delegate for aides to copy paper work etc... but i know that i worked in assisted living and more than once the lpn tried to get the office to get the copies done for ems and post an aid to greet the team but she was called away to assess a resident who was found on the floor or was in an altered condition, or shaking (diabetic) etc... Ideally someone should greet the emts at the door and have copies made an the nurse should be available for report, but sometimes when facilities only staff 1 nurse for 50 or more residents this may not be possible, i knopw that most of the nurses that i worked with were busy and caring providers but they can't be in 2 places at once, and if you have 1 emergent situation that is stable (no cpr etc.. ) and ems is already on their way, and another urgent situation crops up the nurse has to go deal with it....staffing levels really do come into play i think.

RNPATL, DNP, RN · Mar 24, 2004

smkoepke - I agree with you totally. Having been involved with nursing homes in my past career, I can tell you that the nurse is the lone ranger in these facilities. Many of these nurses spend most of their time giving medications and doing treatments as well as government regulated charting. Most often, when there is a crisis and 911 needs to be called, the nurse is prioitizing all the other work that he or she has to do. Now, I can agree that a decent report should be expected and should be given to EMS as well as emergecy care initiated prior to EMS arrival. But as far as paperwork is concerned .... I know there are many times when the nurse is doing her best to get all that needs to be done, done so the resident can be transported.

To often nurses in LTC are getting a bad rep because of all the challenges they face. I guess I would say, "walk a day in their shoes."

hogan4736, BSN, RN · Mar 24, 2004

I do walk in their shoes, and ALWAYS give a thorough report to the paramedic (we rarely use 911, instead we call an ambo company, unless, of course, a CVA is evolving right in front of us).

I also send ALL H&Ps, MARs, TARs, Vital signs, face sheet, Advanced directive copies, then call a phone patch to the ED charge nurse.

Now, I am the house charge, and don't have a patient assignment (aside from IVs), so it's easy for me to do this...BUT, night shift is the ONLY time the house charge has a med cart, but rarely has any scheduled meds, so she has plenty of time...

sean

CoffeeRTC, BSN, RN · Mar 24, 2004

Happened to me a few weeks ago... I had a few bad situations all at once....First one a resident fell in bathroom (of course blood everywhere), looked like a hip fx and laceration on shoulder also c/o sob and chest pain....down the other hall at the same time 2nd resident with BS below 40 and unresponsive. Meanwhile my two favorite alz pts were at the doors trying to escape (2 of them at different doors). It was a mess, call bells ringing, door alarms ringing and it was the 11-7 shift with only me (RN) and 2 CNAs and 50 residents. (Mind you I'm 39 weeks pregnant and as big as the side of a house!) Needless to say 911 was called for both (full codes). I was unable to "meet" each crew and give them a full indepth history, but they got the rundown... (lucky I had my cell phone that night) paperwork was a little sloppy (ended up faxing it to the hosp). The EMTs and paramedics that responded that night were ANGELS (Probably worried I'd pop my baby out right there!)

Just a little look into what can happen in a LTC with "appropriate" staffing, when things go wrong.

leslie :-D · Mar 24, 2004

Happened to me a few weeks ago... I had a few bad situations all at once....First one a resident fell in bathroom (of course blood everywhere), looked like a hip fx and laceration on shoulder also c/o sob and chest pain....down the other hall at the same time 2nd resident with BS below 40 and unresponsive. Meanwhile my two favorite alz pts were at the doors trying to escape (2 of them at different doors). It was a mess, call bells ringing, door alarms ringing and it was the 11-7 shift with only me (RN) and 2 CNAs and 50 residents. (Mind you I'm 39 weeks pregnant and as big as the side of a house!) Needless to say 911 was called for both (full codes). I was unable to "meet" each crew and give them a full indepth history, but they got the rundown... (lucky I had my cell phone that night) paperwork was a little sloppy (ended up faxing it to the hosp). The EMTs and paramedics that responded that night were ANGELS (Probably worried I'd pop my baby out right there!)
Just a little look into what can happen in a LTC with "appropriate" staffing, when things go wrong.

sounds like it was a full moon that night.

hogan4736, BSN, RN · Mar 24, 2004

no doubt!

hang in there

jkaee · Mar 25, 2004

Just my 2 cents......

I am a LTC nurse, and a very good one! When the doctor and I decide that someone needs to be sent to the ER, I have obviously already completed a thourough assessment, I make 3 copies of info (one for EMS, one for ER and one for the floor in case of admission), the family has been notified, and I am waiting at the door for the ambulance crew. I bring them directly to the patient and give report to the EMS. I never allow a resident in crisis to be left alone, either the nurse on the floor or a CNA will be with them. I help transfer the resident to the stretcher and escort the crew back out of the building. I can completely understand why EMS gets annoyed and bad mouths LTC nurses, if they were treated the way they say they were. Granted, I have met my fair share of cocky, arrogant EMS, but I usually just ignore them. They aren't worth my time or energy.

The one thing I will say in defense to EMS is that on several occaisions, I was called up to assisted living to send someone out. On night shift, there is no nurse in AL, only a care aide. The aides don't call 911, or report to EMS (although they can, they don't feel comfortable doing it). So, if you ask me a question about the resident's history, and I don't know the answer, it's not because I'm stupid or lazy or undereducated. I just don't know them! I am in the same situation as you are.....I was called up to assess a person and decide if they needed treatment at the ER.

For the most part, the EMT's in my area are pleasant to work with, and we usually BS or joke around (not in front of the patient of course). But it drives me crazy because most EMT's, paramedics and even acute care nurses think we are less competent than they are. Maybe 20 or 30 years ago, you didn't really have to "do" or know anything to work in a nursing home. That certainly isn't the case now.

Just a word to clarify the whole DNR issue. If you read a living will, it states that the DNR/Living will is in effect only after a doctor has diagnosed them with a terminal or fatal condition. Anything else, and the DNR is not in effect. Most families I have dealt with have decided not to send their loved one to the hospital.....but I have also taken the time to explain to them what would be done for them at the hospital and what we can do for them here, and what the expected response from both treatment options would be. However, there is always going to be a family that wants dad/mom sent out, and do everything you can, vent them, pump them with drugs....only to have them die in a matter of days and weeks. As a matter of fact, this happened in my family not too long ago.......a family member was sent to the ICU, vented, given potent cardiac meds, ABT's, all with a DNR and Living will. The reason why is because when she was admitted to the hosp, it wasn't for a terminal/fatal illness......she went into multi system organ failure, was in a great amount of pain, and after a few weeks of this the doctor asked her if she was ready to let go. She nodded yes, all the nurses came in to kiss her goodbye, she was medicated and taken off the vent, and finally was able to die peacefully. So things are not always as cut and dry as they may seem. But I have never sent out a patient to the hospital just to die. The families in my facility are always educated on the dying process and allow their loved ones to die quietly in familiar surrondings.

Sorry for the long post! Just a lot to get out!

Jennifer

hogan4736, BSN, RN · Mar 25, 2004

jkaee,

well said...

you have set the bar higher...

good times!

nice work!

sean

minnib · Mar 25, 2004

I 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!

Agnus · Mar 25, 2004

LTC 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.