tension between EMT and LTC nurses?

  1. 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.
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  2. 147 Comments

  3. by   pieWACKet
    I was a public health nurse for many years. The worst abuse I received was from an EMT. While many appreciated my thoroughness [ i gave FAR more info than was demanded and far more than they get from family members] this one is the EMT I will remember. I had had to call 911 because of a patient's devastating condition on an intitial home care visit, and the lack of safety evident in her community environment. She had to be rehospitalized. I always waited for EMT to arrive before leaving, and always gave thorough reason for the 911 call, and the symptoms meriting it, the meds I had found, the interns and residents and their beeper numbers, the attending of record, the history I knew, etc. This particular EMT was beyond rude...he was abusive. He said all home care nurses are stupid. He grabbed my paper work from my hand, and refused to release it to me causing me to delay for 40 minutes as he painstakingly copied it down. He said home care nurses are lazy. When I asked him why he would say such a thing, he said "because its the truth". His name badge was not displayed, so I asked for his name, fully intent on writing up a complaint. He refused to give it to me [This was in NYC where the whole thing is very complex, with multiple providers of EMT transport]. He would not give me the name of his company. His buddy refused also to give his name. Luckily, the truck and license plate were clearly evident when I exited the apartment. So his identity was able to be found.
    There is a fracture between EMT and Home care. I don't know why. I guess they expect we are "not able to handle our patients" and some perceive themselves the beleaguered hero forced to answer our distress call and do the work for which they are hired. You are absolutely right in your perception. I encountered this belittling more than once.
  4. by   MikeLPN
    Well, I've only had one "tense" epsiode. Resident was diagnosed with a UTI in AM. A new TMA called me down way late. He had crackles, mottling, an almost undiscernable BP way low, no intake, demented, SPO2 awful and DNR besides. The paramedics didn't want to take him even though the family wanted him to go. All I could do was repeat "The family wants him to go so he goes." I had explained the options and the poor girl just was so upset she couldn't make up her mind at 10 O'Clock at night so we decided to send him. The EMT went on about how it was a waste, etc and called his supervisor.

    I still wish we could have started our version of informal hospice instead of carting this poor guy around. It would have been so much better in retrospect.

    I feel that the EMT was right in a moral and economic sense but that his primary job was not to be so.
  5. by   Blackcat99
    When I have worked in LTC facilities I have met EMT's who seem angry because I haven't memorized every single fact and detail about my patient's physical condition prior to the emergency. I really wish I had the luxury of spending time reading and learning everything about my patient. However, in LTC most nurses are too busy running all day and night.
  6. by   plumrn
    I have never felt LTC nurses get the respect they deserve. NO ONE could have 80, (or some other awful amount of pts), to be responsible for, and take care of them like an Emergency Personnel would, on the ONE patient THEY, (usually 2 of them), are there to pick up. I've also heard the attitudes, and I never let the comments pass when I hear them at the hospital.
  7. by   Headhurt
    Maybe the EMTs are just hacked off because it is not a trauma case that most tend to thrive on. Either that, or they have some sort of inferiority complex that they are working through.

    Don't worry...EMT's are equally rude to their patients. I was in an accident, my face badly burned, blind as a bat. I was in extreme agony, and when I asked for something to put on my face, I got yelled at by the EMT for being impatient. Well, EXCUSE ME BUTTHOLE, BUT IT IS NOT YOUR FACE THAT FEELS LIKE SOMEONE THREW ACID ON!!!
  8. by   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, 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.
  9. by   RubyRN,CHPN
    Quote from pieWACKet
    I was a public health nurse for many years. The worst abuse I received was from an EMT. While many appreciated my thoroughness [ i gave FAR more info than was demanded and far more than they get from family members] this one is the EMT I will remember. I had had to call 911 because of a patient's devastating condition on an intitial home care visit, and the lack of safety evident in her community environment. She had to be rehospitalized. I always waited for EMT to arrive before leaving, and always gave thorough reason for the 911 call, and the symptoms meriting it, the meds I had found, the interns and residents and their beeper numbers, the attending of record, the history I knew, etc. This particular EMT was beyond rude...he was abusive. He said all home care nurses are stupid. He grabbed my paper work from my hand, and refused to release it to me causing me to delay for 40 minutes as he painstakingly copied it down. He said home care nurses are lazy. When I asked him why he would say such a thing, he said "because its the truth". His name badge was not displayed, so I asked for his name, fully intent on writing up a complaint. He refused to give it to me [This was in NYC where the whole thing is very complex, with multiple providers of EMT transport]. He would not give me the name of his company. His buddy refused also to give his name. Luckily, the truck and license plate were clearly evident when I exited the apartment. So his identity was able to be found.
    There is a fracture between EMT and Home care. I don't know why. I guess they expect we are "not able to handle our patients" and some perceive themselves the beleaguered hero forced to answer our distress call and do the work for which they are hired. You are absolutely right in your perception. I encountered this belittling more than once.
    Thanks for sharing yours story---I do home health and hospice and in the past 7 years of working in a rural area (where there are very few "paid" EMS staff-most of them volunteer) I have witnessed the attitude you describe above many times. Many of the volunteer EMT's who respond to calls are surprised that my scope of practice involves more than emptying bed pans. Seems I've seen the role of the "belaguered hero" more than once in my line of work; don't think for a minute if there is family present in a home they aren't quick to pick up on this mistreatment and attitude especially if you have formed a trusting rapport with them. I will say that one municipality I work in has paramedics who respect the role of the home health nurse, my physical assessment skills, my IV skills when they cannot locate access. Ihave even had one Captain call my supervisor when I had to perform CPR during a visit (the gentleman coded as I walked in the front door) and commend me on my excellent use of CPR during an emergency. It's important we (nurses & EMS staff) recognize we are all vital componants in the care of our communities. It's unfortunate that experienced, licensed professionals have to endure the type of abuse our reader board members have endured.
  10. by   RubyRN,CHPN
    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, 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.
    I can thoroughly understand where your are coming . When I'm in the home and I run into this situation. When I call 911 and request transport to the hospital, I explain to the EMS that "pt is going to the hospital to recieve the appropriate level of care including a medical assessment. Living wills often require MD (1-2) to certify pt condition is life limiting. Our state has a POLST form (Physician orders for life sustaining treatment) which specifically directs EMS how and what care can be provided during transport, home and hospital setting as it pertains to treatment and comfort. If the examining MD at the hospital wants to initiate a discussion with the pt/family at the hospital regarding end of life care and/or include hospice as an option if appropriate, this would be an appropriate setting in this instance.
  11. by   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?
  12. by   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.
    Last edit by Agnus on Mar 20, '04
  13. by   CCU NRS
    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 may have given the wrong impression, I do believe that an elderly Pt with say pnuemonia that is acute should come to the hospital to recieve care even if they have a DNR in place, however I was talking about people that are basically already having kussmol(sp) type resp. and are only likely to live a few more hours, sent to hopsital and then even to CCU where they will pass without intervention.

    Hypothetically: A person could be in a hospital from a nursing home D/T exacerbation COPD, they could have a DNR in place. They could be on a med/surg floor and be recieving resp tx's etc. and could even be slated for D/C back to Nsrg Home that day.
    The Doc could order ABG prior to D/C, a resp therapist could be drawing said ABG and Pt just go unresponsive and resp therapist call a code, the code team could arrive and start ACLS, then the Pts own Doc could arrive and ask what is going on and why Pt is being coded and inform of DNR status. At this point the code must continue. The Pt's nurse for some reason may have missed that the Pt was DNR and resp. Therapist had no knowledge and a Pt could end up on a ventilator and full life support and in CCU for several weeks until they die without ever regaining consciousness.

    Beleive me IT could happen!!!
  14. by   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...

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