Being Questioned by Paramedics? Why?

[jayde_RN]

So the other night I was at work. The power went out earlier that day so we were running off of a half way working generator. Well I go to change my elderly pt's tube feed and noticed he was breathing pretty fast and retracting. Took some vitals BP 114/44, R 42 and labored, pulse 105, and O2sat 97%. He had a wet sounding cough but clear lung sounds. And overall, he just did not look right, he had a look of distress or "oh God" on his face, lol. When I asked him how he was feeling, he looked at me and continued breathing, usually he would respond without hesitation. So of course I call the on call and tell her my assesment, she immediately said send to ER for resp distress.

So when the paramedics get there, they take vitals and assess, and look at me like I am stupid and say "his Sat is 98%.". So basically for ten minutes I get to just about argue them down as to why they should take him. They also sounded irritated that he was a full code. There arguements were 1) his vitals were good and lung sounds clear and 2) he has dementia, so how is he supposed to respond to you (***? HELLO! DEMENTIA DOES NOT EQUAL NOT ALERT!). They even asked me to call and ask the Dr's opinion. (HELLO! I CANT CALL YOU WITHOUT CALLING THE DR FIRST!) I had to tell them that I have seen a pt in resp ditress sat-ing great at 99%, and de-sat to 0% within seconds and code right before my eyes, and I did not want to wait and see if it happened with him. The Dr and I wanted him in the ER, at least they can do more than basic CPR (which is all i can do in my ltc facility). So they reluctantly took him.

Has anyone had this happen to them? Why? A nurse cannot diagnose just as a paramedic can't, and neither one of us has MD behind our name! Do you think they didn't want to take him bc he was elderly in a nursing home? I mean, they really burned my butt with this!

[southernbeegirl, BSN, RN]

working in LTC i've seen it all. from EMS guys who think we are all stupid to nurses who think the EMS is nothing but a transport meat wagon.

i used to work in this horrible place. we werent allowed to make copies from the chart to send with the patient because copies cost too much. everything had to be hand written. they treated the EMS guys like they were nothing but a taxi. the DON overheard me giving them report one day and chewed me out because their job was only to "take the patient where we say take them". and they wonder why that place is on the government's watch list now.

at my current job i have tried to teach the nurses i manage to give the paramedics and the ER both a very good report of what is going on with the patient and why. honestly, it's took quite some time to earn the respect of the EMS guys and the hospitals because many do actually think nursing home nurses are stupid. i'm proud that they take us seriously when we call for them now. i always meet them before they enter the room with a good report and paperwork. when i copy the chart for the hospital, i make a copy of the facesheet, medlist and advance directives for the EMS too so that they dont have to try and get the info at the hospital. while they are loading the patient, i call report to the hospital and then i tell them who i spoke with so they have a contact person when they get there. when i call dispatch for a transfer, i ALWAYS tell them if i need emergent transfer or nonemergent transfer. that way they dont waste the time of the paramedics when i just need a BLS truck if my patient is stable. sure, they are transporting for me, but while that patient is in their ambulance, they are responsible for anything that happens to them.

i've only called their supervisor once to report a paramedic and that was because she was HORRIBLE in the way she acted.

i've found that if i respect them, know what i'm talking about concerning my patient and treat them as part of my team, they respect us.

it's not easy sometimes with some of their attitudes, lol. but i think about it like this...

i WANT my police officers and paramedics to think they are God because they could be out there to save my life one day.

so for the most part...i ignore their cockiness.

[Medic09, BSN, RN, EMT-P]

Southernbee, what a shame that I have to commend you on your professional approach to this whole issue. As a medic and a nurse, I appreciate that you understand the roles and responsibilities and the need for good continuity of care FOR THE PATIENT'S SAKE. This is how it should be; not an exception.

I've had LTCs hand over a patient to me (as a ground medic) with the chart in a sealed envelope. "You don't need to see that stuff." No, m'am! This is my patient for the next 30 minutes. I want a good report and a good chart, including EKG, films, and all studies. You can bet I may have to continue Tx in the back of my bus on the way to the hospital.

To be fair, I'll point out that there is some history to this on both sides of the cart. SOME transport-only services are places that EMTs and paramedics (you do know that a paramedic is technically an EMT, called EMT-P?) end up when they can't get a 'better' job. Most of us are trauma junkies with a bit of a hero complex and want to be responding to car wrecks and cardiacs. So, in some cases, the quality of staff and care on transport services leaves something to be desired. What's more, the work tends to be pretty monotonous; not inspiring great diligence. Sound familiar? Sure it does; because it is also true about SOME LTCs, eh? The monotony in LTC leaves many nurses numbed after a long enough while. And some nurses end up there because they didn't make it in the acute care environment. Is it any wonder that LTC nurses expect little of the transport crews; and the medics responding to an LTC expect little of the nurses and staff? (I myself once responded 911 to a rural LTC to find the patient being bagged against her will while spontaneously breathing well enough to mouth at me from under the mask 'help me'. )

In many cases, we can discern who's who. When I show up on my flight crew for an interfacility transport, the hospital staff expect a certain level of skill and competence. OTOH, we have a ground transport company in our area that I wouldn't trust to transport my cat if I had another choice. That's why when we have to transfer someone to the next big city for specialty care, we call the flight crews. Because we know we don't have a highly-skilled ground-based Critical Care Transport company in the area. In some big cities, BTW, the flight crews do ground transport, as well. When I lived out east, Boston MedFlight (an outstanding group) operated two heavy duty ICU-equipped ambulances for short hauls or when the weather grounded the aircraft.

BTW, some of you may find it worth knowing on the side that the BCCTPC has instituted a board certification for Critical Care Transport Paramedic. It is similar to the board certification for Flight Paramedic (FP-C). Although paper certs don't guarantee anything, the medics will have to be pretty sharp to pass this exam. FP-C is almost identical to the CFRN exam. Expect the board certified CCP-C to have a good knowledge base about ICU, at the least. The Board's website is http://bcctpc.org/ .

[southernbeegirl, BSN, RN]

thanks, medic.

i feel like we SHOULD act as a team from the bed, to the transport, to the hospital. the patients deserve that.

i also got tired of hearing "that was the best report i ever got from a nursing home" type stuff. EVERY report should be that good.

i think we are lucky in my town. we have a great group of EMT's from the transport trucks to the ACLS trucks. we use a certain company for each. we have one guy basically assigned to our facility to do our MD appts and couldnt ask for a better guy. he stays with the patients, ALWAYS gives us report of what the doc said and even takes people thru McDonalds if they are hungry and he has time.

i had a lady crash on me a few weeks ago. she aspirated. sats in the 50s and she was a full code. i was suctioning the heck out of her and trying to get her sats up when the paramedics came bounding thru the door. instead of pushing me out of the way, they jumped in to help me, asking what was going on,etc and i was finally able to turn her over to them to intubate. i bagged while they started lines,etc. and guess what? she made it!

besides...the uniform is SEXY!

[tencat]

Wow, you must have the same ambulance service we have in our town....I argued with EMS once about sending a patient with altered mental status who had no caregiver in the home, who was having apnea as well. Turns out he'd had an overdose on morphine......but EMS just wanted to walk away and not take the patient to the ER. They could have given him narcan at the scene, but no one figured (myself included) that this was what had happened due to the fact the patient was a liver patient and had symptoms that were in line with encephalopathy. He got his narcan in the ER and woke right up :)

[paratroopa]

There is a reason they are referred to as "paraGODS"