EMS talking down to Nurse

JenTheSchoolRN, BSN, RN · Jan 30, 2018

School Nurse Vent!!!
So, I see my nurse assist per IEP diabetic three times a day, he sticks himself but I carb count for him and help him draw up the insulin, supervise and make sure hes rotating sites,ect. Today he came in very panicked. Stating he was in DKA.
Now this kid is happy go lucky and never has a complaint...ever. So immediately I am worried. He has Large ketones in his urine, Blood glucose 390 (he usually runs low,never seen him above 180) And generally knows whats going on with his own body, He's vomiting, kussmaul respirations, fruity breathe, weakness, blurred vision, sleepiness the whole nine yards.

So I call 911, the EMS team thought I was an idiot, the paramedic informed me "390 is not even that high" I replied that he is a type one with dx hypoglycemia issues per MD and even printed out his CBG record and MD note stating this. Still the whole time they rolled my eyes made a big production and were dragging there feet on taking him. At one point when I handed them his dx list they stated that this was probably a "panic attack" because of his mental health dx. None being anxiety mind you.
I finally tell them they need to go with him to the hospital now. With some shuffling they go on. My RN supervisor (I'm an LPN) Seems to think its because I'm young and stated the same thing happened to her....I was wondering if anyone else has had the same experience.

It just frustrates me that people with mental health dx are being overlooked when its a WAY bigger issu because "Its just part of it" Anyways...very upset about the whole thing and kind of still seeing red...

Update: He's being transported to the "big city" Diabetic Peds unit...it was DKA

I'm sorry this happened! All of those symptoms read red flag and DKA to me. I had a diabetic student present very similarly to my office a few years ago. Only reason I didn't call EMS was because I reached Mom immediately and she was

You did an awesome job here, so remember that.

ruby_jane, BSN, RN · Jan 30, 2018

Old Dude does this better than I do but you quite literally saved the kid today because of your assessment skills. So, YAY you.

And yes, this happens All. The. Time. EMS tried to decline transport of a parent with acute chest pain about four years ago (cardiac event but not MI).

EMS tells my female students All. The. Time. that it's anxiety. 18-yo student transported (grudgingly by them) in what turned out to be the early stages of sepsis and they leave here saying "calm down, you need to breathe more slowly."

But then there are the crews who do it right. It really doesn't seem to matter what kind of assessment I do or what kind of report I give. Seems to depend on who's in charge. In your experience it could be your age but that may not be true. You gritted your teeth and stood your ground and that's all good. Perhaps next time will go more smoothly.

Remember, it is only our job to advocate for the patient, not worry about what the ambulance guys think.

Hang in there, and again, good catch!!

Kaisu · Jan 30, 2018

As a former paramedic, I can tell you that the education level of EMTs even paramedics, is low. No pre-requisites to become an EMT and in most states, 120 hours to EMT-B level. There is a dichotomy between public service and healthcare. Public service includes the fire services who devote a lot of time to knowing how to rush into burning buildings and break down doors, as well as cut open cars. That is a different skill set and orientation to medical assessment.

Nevertheless, as over 80 percent of fire department responses are medical, many have devoted time to the two-semester coursework required to become a paramedic. Paramedic training is as rigorous as nursing, but is limited to recognizing and dealing with immediate life threats. There is no training, and I say training as opposed to education, to chronic conditions.

The nature of the work is that 9 out of 10 calls really do not need a 911 response and are the result of the health system medicalizing social problems. Often, EMTs trained to provide emergency, life saving care, become disillusioned with the true nature of the job. Those deeply interested in medicine will move on. Many, due to lack of motivation or aptitude, and often without financial incentives to expand their experience, feel"stuck" in pre-hospital care.

Bottom line is, many have no idea of what they don't know. They are stuck in protocol based "cook-book" medicine, yet putting in brutal hours of work for very little pay. That is not to say there are not intelligent, motivated and dedicated people in EMS. But often, nurses deal with anti-education individuals who devalue "book smarts" and totally underestimate the complexity of many of the issues they deal with.

EMTs see a very small slice of the healthcare continuum, yet often believe they have seen it all. In spite of this, blatant disrespect for other members of the health care team is inexcusable. I am sorry many nurses experience this. If you get it, take it where it's coming from. It's coming from a narrow minded, frustrated individual and is the mark of an underdeveloped mind.

Edit.. PS - the question to have asked that paramedic was "You've seen it much higher? In this patient? Really?

akulahawkRN, ADN, RN, EMT-P · Jan 30, 2018

While I'm not a school nurse (I'm an ED RN), I am also a Paramedic and have been for some time. I can see how this could very easily happen. What I suspect is that the Paramedic that you were working with has likely never seen a "good" case of what is nearly a textbook case of DKA. That Paramedic likely has seen a "relative" of DKA and that's Hyperglycemic Non-Ketotic Syndrome. With that, patients can easily have extremely high blood glucose levels and yet have no ketone production. In the ED, most of my DKA patients have blood sugar levels between about 350 and 700 or so, though I have seen a couple >1,000. The "textbook" case of DKA fits quite well with your description.

I would suggest that you find a way to contact the EMS coordinator with the EMS agency or the hospital EMS liaison nurse about that particular paramedic and let them know what you saw. Do not put in your own subjective info, just what the Paramedic stated to you as to what he/she thought the problem was and go from there. You're not trying to beat up the Paramedic, you're trying to get the Paramedic educated about something and could very well end up with that Paramedic becoming extremely knowledgeable in dealing with patients that are in DKA, regardless of "where" the patient presents or how many other "issues" the patient also has.

nmr79 · Jan 30, 2018

Way to stick to your guns! I'm sorry you dealt with that, but I'm sure that kid and his family are glad you were persistent!

SchoolNurseTXstyle · Jan 30, 2018

I have had EMS tell me I really need to get a parent to provide an Inhaler for school. "Really, never thought of that!!! Only been calling this parent ever day for 5 months to try to get one. But thanks for your input!!!"

OldDude · Jan 30, 2018

...EMTs see a very small slice of the healthcare continuum, yet often believe they have seen it all. In spite of this, blatant disrespect for other members of the health care team is inexcusable. I am sorry many nurses experience this. If you get it, take it where it's coming from...

...I would suggest that you find a way to contact the EMS coordinator with the EMS agency or the hospital EMS liaison nurse about that particular paramedic and let them know what you saw. Do not put in your own subjective info, just what the Paramedic stated to you as to what he/she thought the problem was and go from there. You're not trying to beat up the Paramedic, you're trying to get the Paramedic educated about something and could very well end up with that Paramedic becoming extremely knowledgeable in dealing with patients that are in DKA, regardless of "where" the patient presents or how many other "issues" the patient also has.

These two posts really nailed the perpetuation of the "problem." EMS just gets the middle of the event and seldom sees the entire incident from start to finish so it's difficult for them to "grow." It would be good if each transport could be followed up with the ultimate diagnosis, prognosis, and outcome.

WineRN · Jan 30, 2018

As a former paramedic, I can tell you that the education level of EMTs even paramedics, is low. No pre-requisites to become an EMT and in most states, 120 hours to EMT-B level. There is a dichotomy between public service and healthcare. Public service includes the fire services who devote a lot of time to knowing how to rush into burning buildings and break down doors, as well as cut open cars. That is a different skill set and orientation to medical assessment.
Nevertheless, as over 80 percent of fire department responses are medical, many have devoted time to the two-semester coursework required to become a paramedic. Paramedic training is as rigorous as nursing, but is limited to recognizing and dealing with immediate life threats. There is no training, and I say training as opposed to education, to chronic conditions.
The nature of the work is that 9 out of 10 calls really do not need a 911 response and are the result of the health system medicalizing social problems. Often, EMTs trained to provide emergency, life saving care, become disillusioned with the true nature of the job. Those deeply interested in medicine will move on. Many, due to lack of motivation or aptitude, and often without financial incentives to expand their experience, feel"stuck" in pre-hospital care.
Bottom line is, many have no idea of what they don't know. They are stuck in protocol based "cook-book" medicine, yet putting in brutal hours of work for very little pay. That is not to say there are not intelligent, motivated and dedicated people in EMS. But often, nurses deal with anti-education individuals who devalue "book smarts" and totally underestimate the complexity of many of the issues they deal with.
EMTs see a very small slice of the healthcare continuum, yet often believe they have seen it all. In spite of this, blatant disrespect for other members of the health care team is inexcusable. I am sorry many nurses experience this. If you get it, take it where it's coming from. It's coming from a narrow minded, frustrated individual and is the mark of an underdeveloped mind.
Edit.. PS - the question to have asked that paramedic was "You've seen it much higher? In this patient? Really?

Thank you for sharing your experience. I actually work close with our local fire/ems, so there are times when I know the people walking up to my building. And sometimes they STILL give me a hard time. And I do get that they are "stuck in protocol based "cook-book" medicine" (love the phrase), but sometimes I just want to yell at them to YOU KNOW YOU CAN TRUST ME. I promise I never call 911 for fun.

peacockblue · Jan 30, 2018

You advocated for your patient. That is what you are there to do. I recently sent out a post op ACL repair who had a clot in her leg and was on lovenox. She had chest pain so I sent her out to r/o a PE. Yeah, it was anxiety. Yeah, she was fine. Yeah, I would send her again. We have limited (no) diagnostic ability so we need to do what is bes t for our patient. Fortunately, our local EMS is the best. Always great with both the stidents and myself.

heynurse1996 · Jan 30, 2018

Yes! Just had dad call me and felt a lot better about the whole thing...it is tricky ground being a new nurse (and LPN at that) very often people devalue your assessment/ assume you know nothing.

heynurse1996 · Jan 30, 2018

Right? Part of me wanted to tell them I defiantly do not get a kick out of calling EMS and scaring my poor students/admin to death