Building Relationships for better patient care between LTC Nurses and EMTs

[downsouthlaff, LPN]

Hello again, been awhile since i posted here! I just wanted to take a minute to aplologize for past posts that may have offended Nurses, becuase of my hot headedness toward nursing. While working as a CNA I really gained a new prospective of how hard the Floor Nurses job is in a LTC Facility and how hard the CNAs job is too for that matter is in LTC Facility with the MANY problems and shortages that the LTC Industry faces. In my five months working as a CNA I realized that I just couldnt handle those unhumane LTC Resident to Caregiver ratios. I have developed a profound respect for all LTC LPNs and CNAs for being able to do those seemingly impossible routine tasks over and over day in day out and make it look so easy (I say LPNs because in my area only LPNs are floor Nurses, RNs are supervisors ONLY in LTC). Anyhow I also discovered that the Nursing field was not for me and enrolled in EMT training with private ambulance. And now love my job.

It just saddens me because i read alot of posts where long term care nurses and EMTs just cant seem to cooperate for continuty of care for the patient, and cant respect each others medical education. Because I worked in long term care I often have to settle my rowled up Paramedic or EMT partner when we arrive at an LTC Facilty when he is raising hell because all the paperwork wasnt completed on time, and I having worked in Long Term Care know that if one incident happens such as a fall or EMS call, or death, your scheduled routine is shot and it becomes a nightmare, almost worth bawing in tears over. I can understand how a Paramedic or EMT with no knowledge of Long Term Care mangement would get upset and misunderstand why things are not always on time. But last week our unit was dispatched to a proximal nursing home for emergency fall (pretty severe one too). We arrive and we have this LPN charge nurse with nothing but attitidude, beacause she was tied up with a family member raising cane, the CNA showed us wich room the patient was in, we begin assessing the patient and begin our treatment within our protocol and she barges in, and says "stop what you are doing now, you can not just come into the facility and begin care without informing me i could have you arrested, then she proceeds to say that I am a nurse, and you will follow my orders" I politely say mam I know your upset but we legally cannot stop emergency medical care once we begin it.

And as an EMT we cannot accept orders from a LTC Nurse. While my Paramedic partner is starting an a saline IV she then says that you cant do that, i do not want you to start an IV on this resident, i am giving an order an I will be contacting your supervisor if you fail to follow it. Im all for understanding an compasson but i could see that my partner was having trouble concentrating and she was basically to the point where she was obstructing emergency care, and it got so bad to where we were considering calling police for back up. But we just did our best halled her in and notified the ed we ere en route.

I think that its very neccessary for EMS and Nursing to act as professionals and get along. As an EMT i was instructed that EMS is higher emergency medical care when it comes to long term care. Wich means that when we get there the Nurses must cease care on our command, any rescuatative care they have began and turn over care to us. (and please dont get offended its not really our command its our Medical Directors). Accepting an order regarding emergency care from an RN, or LPN at the scene is highly agaist our protocol, the only way we could accept an order from a nurse is if the Nurse is a trauma certified RN, or of course an RN, EMT-P that is a feild supervisor other than that its a no no. And i havent been in EMS long enough to know but the seasoned veterans say often times there problems are with the Licensed Practical Nurses in long term care facilities. That the LPN doesnt understand (only some of them not all) that EMS has protocols for patient care that are different than the nursing protocols. Nurses are not superior to EMTs and Paramedics. Just like EMTs and Paramedics are not superior to Nurses. EMTs and Paramedics are prehospital emergency care experts. Our training is narrow and focused on Emergency Medicine. Nurses are condition managent and care planning exerts. So Nurses that think you have a higher education than an EMT or Pramedic you do have a higher university education, and a broader medical knowledge of all specialties of nursing, but that doesnt mean you know more than the EMT or Paramedic about pre-hospital emergency medicine, therefore it doesnt matter that you have more education, an Accountant has more education than a LPN too, but that doesnt mean that he can take over nursing care and supervise nurses, same thing with EMTs and Nurses.

God Bless Nurses and CNAs for all they do. That is truley a very very very tough job, very stressful. I have the utmost respect for Nurses and there education. As an EMT I listen when a Nurse gives report an I say yes mam/yes sir. I also like it when i see a new young nurse say yes sir to a 30 plus year paramedic, it just shows respect. As Nurses and EMTs we are colleagues, and should treat each other as such. We should treat our medical knowledge as not equal, not one side higher than the other, but seperate. Seperate entities of the broad medical field. And let nurses handle nursing and let EMTs handle pre hospital emergency care. And when it comes to DNR, I assure you a good EMT are Paramedic will no what there doing because in school we spend a great deal of chapters dealing with DNR ethics and protocols. And I can tell you now, EMS does not like or endorse DNR, wich meanse there not taking anybodies word for it, if you dont have the signed original and place it in the EMTs hand there is NONE!! The residents family can be threatining on every legal threat they can find, and the nurse can talk till she turns blue in the face if we dont have the original there getting full rescusitative care. So for one second think that DNR means slower arrival time or anything of the sort, until we get there and receive the DNR order its a full care case!! HAPPY HOLIDAYS EVERYONE!!

[TheCommuter, BSN, RN]

I have written about the invisible rift between EMS and LTC nurses in the past.

In a nutshell, rude healthcare workers of all types need to shove their differences aside, drop the funky attitudes, act with some professionalism, and start placing the patient at the top of the hierarchy. Without the patients, there would be no reason for LTC or EMS, period.

[jadelpn, LPN, EMT-B]

As both an LPN and an EMT, it has not a THING to do with "medical knowledge" and everything to so with following protocol and being professional. The nurse needs to be 100% certain that the LTC patient does NOT have a "do not hospitalize" order, needs to make an informed decision prior to calling rescue. It is then the EMT's protocol to then obtain consent. And YES, the EMT's were incorrect in starting care without obtaining consent. If while the EMT's are enroute, the patient or the health care decision maker chooses to not have the patient transported, then YES, the EMT's were in the wrong to start treatment without obtaining such consent to treat. And YES, you can legally stop treatment once you begin it if you did not obtain consent to treat, (much like a patient can in fact stop your treatment at any time), and to touch a patient without consent is battery. And arrested is a bit harsh, however, at that point I would have whipped out the "refusal of treatment" form and had the nurse sign it. There's lots of reasoning behind refusal's to treat, and perhaps the family in this case said "nooooo I want to bring Mama to the other hospital" or some other dynamics that as EMT's we so don't need to get into. Always Always obtain consent.

Paramedics have a scope, but not without medical direction on some of the more grey areas--and a prudent paramedic would call for some. They are not doctors. So unless an MD would say "start this patient on fluids until reaching the ED" if there was a question on the patient's wishes, I certainly would not do a thing without medical direction and not until----yep, you guessed it--obtaining consent.

The NURSE needs to start a code on a patient who is not a DNR, and continue until rescue arrives. The EMT's need to see the DNR order prior to not continuing the code. If the patient is a full code, teamwork is essential and in a perfect world, the EMT's and nursing staff working in cooperation with each other. If the patient is a DNR, (or MD makes the person a DNR mid code) then all code efforts stop. It is the doctor that makes these decisions, not the nurse nor the EMT's. The nurses do NOT have to "cease on an EMT's command" if the patient is a full code. Because the EMT's at that point have not even obtained consent. I am not sure where all this misinformation is coming from.

Everyone has paperwork, including the EMT's. So perhaps both can be done at the same time. If the paperwork is ready, then we still have the EMT's paperwork to review and sign as well. So to get "riled up" about it is just poor professionalism. And reflects poorly on the EMT who is getting "riled up". Yes, we all have busy days but when one is at work, and paperwork is a part of the job, welp, what is it that one is being kept from? The uber cool accident on the highway???? Excuse the obvious sarcasm, but honestly, why the rush, rush getting all hot under the collar? Does one have something else they need to be doing? Meanwhile, EMT's are on this call, however, I now have 40 of my 80 resident's who have ambulance syndrome and are all having chest pain. I am the only nurse here. Let me stop and be sure you have your paperwork, but cut some slack to the nurse trying to do it all, meanwhile, the family is fighting about should we/should we not have Mom go the the General or Mercy ER????? (or the infamous "what are we paying these people for, can't Mama just stay HERE?????) Dynamics. We all got em.

There is a huge level of difference in protocol. The best thing that can be done is to be familiar with what that is, and follow it accordingly.

[downsouthlaff, LPN]

You see Jade LPN, this is the kind of atttitude that might cause friction between EMT and LTC LPN, maybe you have training in EMS as a Paramedic im not sure but if you dont then theres goes Nurses again thinking they know EMS protocols when in fact unless less you have training in the EMS field i dont see how that could be possible!! And actually when the very same nurse called our company gave us report on the condition and patient thats consent the Nurse should have already contacted the healthcare power of attorney wich in this case there wasnt any, and this resident was not a DNR, and yes the RN Supervisor and 2 other Nurses were running the code while this charge nurse was tending to a family member, And actually we as EMTs and Paramedics can call the code when the ER doctor tells us to, and take over once EMS gets to an LTC faciilty higher Medical Emergency Care has arrived and medical care has to be turned over to EMS! And actually a paramedic in my state does not need a physicians order to start an IV, just as an EMT does not need a physicians order to administer oxygen therapy via NRB 10lpm or Nasal Cannula 6lpm this is standing orders that we follow, we have to contact the Medical Director to administer IV medications (paramedic) and to administer neb treatments, nitroglycerin and other medications (EMT). And maybe you miss understood or I didnt explain my self clearly, we didnt just begin treatment with no consent at all, there was an Weeknend RN, and i guess what was two treatment nurses, who didnt seem to object to us begining care, the Charge LPN was mad because she didnt get to give us her oral report on the patient/resident im guessing!

[downsouthlaff, LPN]

Jadelpn sorry for not cathing your first sentence there saying you are an LPN and an EMT, you also have to remeber that every EMS agency has different protocol, yes we all are Nationally Registred, but when it comes to state licensure and certification its all different just like the boards of nursing for each state. When a nurse calls the ER doctor, and the doctor gives an order for the patient to be transfered by ambulance to the hospital, the Nurse cant just in spite decide that they dont need to go anymore! Unless the Docotor changes his mind! Maybe im wrong but from my understanding a nursing home resident who does not have a DNR form, or anybody making healthcare decisions for them, they are regular citizens who have all of there rights rite and should be treated the same as someone calling the ambualnce from there house right? Correct me if im wrong i mean i am still a fairly new EMT but maybe im thinking to much from all those resident srights pounded into my head from CNA.

[jadelpn, LPN, EMT-B]

My only point is at ANY point in time the resident/patient and/or the POA if patient unable to make decsions can stop treatment at any time, doctor's order or not. Patients have the right to refuse. Yes, the nurse could be considered in the wrong, as BEFORE she calls any rescue, she needs to be sure that there's a plan that has been covered, ie: DNR/Full code, if patient has a not to treat--something of that nature. And no, a doctor's order or not, EMT's to cover themselves HAVE to obtain consent. If I call rescue from my living room, they package me up and are ready to go, and I say "I changed my mind" vs. EMT's starting treatment without first obtaining the verbal consent that they are to administer treatment. I understand different protocol, however, I would not touch a patient without consent. Which sounds to me like what happend in this instance. That is correct, you do need to have a DNR in HAND before efforts cease, however, a nurse calling EMS to report condition is far different than consent. I have been an EMT for 28 years, and a nurse for 10, and I am well aware of protocol, keeping in mind differences, however, to CYA one needs to hear it, to see it before they do it. LTC residents is a difficult dynamic, however, communicate, be professional, and know exactly what kind of care this patient wants AND CONSENTS TO-- before one starts a wide open bag of fluid through the 18 gauge.