Being Questioned by Paramedics? Why?

BabyLady, BSN, RN · Jun 15, 2009

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!

A perfect example of a paramedic that has just enough knowledge to be dangerous.

I would have said ONCE that the physician is requesting transport.

When they started giving you the run-around, I would have said, "That is the decision of the physician...would you me to get the physician on the phone so you can explain why you are REFUSING transport?"

I have a feeling that their questions of nonsense will stop.

Morning-glory · Jun 16, 2009

I spent 6 hours one night trying to get a little old guy out to the hospital. I worked in a psych LTC. Little old guy had tried to take my head off with a wheel chair pedal. I got some help and gave him a shot of haldol. Then I went to call 911 to get him out to the hospital. By the time they got there, the guy was sleeping and wouldn't believe me. Called the on call doc, who wound up driving in a snow storm to come and tell them to go to the hospital. I had 2 paramedics, 3 cops and they were all standing around arguing the point. Finally the guy woke up and started to swing at them with his walker. We got him formed and he was in the hospital for 2 months for a "tune up". I was livid. Just get this guy out of here. I suppose it really was too much to ask. I wrote a report to everyone involved.

I had a paramedic lecture me about blood glucose levels when I was sending out a resident with CP and blood sugars in the basement. He was explaining the whole diabetes thing to me. "Hello?? That's why I'm sending him out". Now do you want to take him, or shall I call and get another ambulance here to take the patient so that we can chat about this? Twit.

Some are wonderful. I had a big guy throw a chair at me after trying to hit me in the face. I called 911 and the swat team was there before I got off the phone. No monkeying around there. I guess that after calling 911 and the operator trying to calm me down for 5 minutes before I could even explain who I was, helped.

Baloney Amputation, BSN, LPN, RN · Jun 16, 2009

I once had a LOL, A&Ox3, independent with everything, but she was rehabbing after an ortho surgery. She was going to be discharged the next day.

Anyway, she was declining since that morning. She was having issues with belly pain and vomiting but normal BMs. During 2nd shift (my shift), her cognitive status declined to where she was nowhere close to A&Ox3.

When I finally got everyone on board to send this patient to the hospital, the ******** paramedics were there loudly proclaiming, "I don't see anything wrong with her. I don't know why we're here." Um, a change in mental status is an emergency, right? She didn't APPEAR to be outwardly different than some of the other residents, if you didn't know this was an independent community ambulator who is normally A&Ox3, but they didn't want to hear that. She was at a nursing home, so this is normal to be confused!

Anyway, I heard she turned out being a proud owner of a small-bowel obstruction amongst other things.

maelstrom143 · Jun 16, 2009

It is terrible you had to deal with this issue. Paramedics may be knowledgeable, but their opinion does not supercede the physician's; if you received orders to send the patient to the ER then that is what must happen. It is not your job or the paramedics to second guess an order of that nature. To do so would make those responsible for delays legally liable should anything go wrong. Next time anyone gives you a hard time re: transporting a patient after getting doctor's orders, report them. Your main concern is your patient, not who is inconvenienced by having to transport them.

ToxicShock · Jun 16, 2009

I've read a lot of experiences like these with paramedics. Do they think they're better than nurses just because they deal with emergencies "more"? Sounds pretty arrogant to me.

NurseKitten, MSN, RN · Jun 16, 2009

Hmmmm...where to begin, where to begin??

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.
First of all, your widened pulse pressure speaks to possible hypovolemia, and a "wet" cough doesn't mean he doesn't have relative hypovolemia. It's the condition of the pump (heart), the diameter of the pipes (vasculature) and what is in the pipes for the pump to push around (circulating blood volume). The DBP of 44 tells me his systemic vascular resistance was for nothing, and the majority of SVR is found in the arterioles, so right there, it makes me question the diameter of the pipes, at least on the side of the circulation that should have some "tone" to it. What could cause relaxation of the pipes? Lots of things. Blood pressure medication, sepsis, you name it.
RR of 42 means he's working awfully hard to keep that sat of 97, and if his sat's 97, that only means that 97% of his RBC's are saturated...and his sat will read 97% whether that's a hgb of 15.0, or 4.2. Don't know what his labs are, but if he's struggling that hard for his air, and sounding "wet", my guess is there's a borderline pulmonary edema component in there. Struggling that hard "pulls" fluid across the alveolar membrane, and even though you didn't hear anything (yet!), it doesn't mean it wasn't setting up. And fatigue is a prime culprit in respiratory failure.
The pulse being 105...well, tachycardia is any elderly's enemy. Was he tachycardia because of fever, hypoxia, fear, sepsis...any way you add it up, it equals increase oxygen demand on the heart, leading to the increased respiratory rate, requiring active work of breathing, leading to increased oxygen demand on the heart, etc etc etc...it's a vicious cycle.
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.
I just gave you your physiology argument above as to why they were full of it. I wasn't there, so I can't tell you anything for sure, but from what you describe, you were not wrong to send him.
You are never wrong to listen to your gut and advocate on behalf of your patients.
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!

Oh yeah, it's happened to me, in an outpatient dialysis unit, and I had to stomp my feet and threaten to call their Captain. I didn't have NEAR the knowledge and tools I have now to know exactly what was going on at a physiologic level, but I learned quick that if they crumped on me, it was going to be ME trying to explain on the witness stand why I didn't stand my ground.

My advice would be to go to your DON or administrator and ask for some guidance. It would help if you knew the outcome of this patient (e.g. if you were RIGHT to send him) and see if he/she feels it would help to escalate your concerns to a higher level, e.g. EMS supervisor or equivalent.

Do not...DO NOT....go out and make a complaint on your own. Yes, yes...it sounds like they were royal a$$e$, but being a young nurse, you may not have a good feel for all the politics and alliances that are interagency-dependent. A complaint of that magnitude needs to come from management, and if your management is worth their paycheck, they will back you on this one.

Regardless, it sounds like you stood your ground and did good. :)

casi, ASN, RN · Jun 16, 2009

You may want to call a transport company next time. I am a EMT-B/CNA/Nursing Student, and I occasionally pick up shifts for a local ambulance transport company. We pretty much specialize in transporting LTC to hospitals/doctors appts/other places. The 911 guys are more of a call in an emergency situation, and they get a little huffy about doing anything that lacks getting to intubate someone (sorry 911 guys, but you know you do it for the adrenaline, not the transports, at least all the 911 guys I know). Anyway maybe that will eliminate some of your future problems.

This guy was definately not BLS transport material. Even though he was keeping his sats up okay respirations of 42 are not stable. What happens when this guy doesn't have the energy to keep up the respirations of 42? Chances are if his resp. drop his sats would drastically drop, because he's breathing at 42 for a reason. I don't know about you, but I wouldn't want that happening in the back of BLS transport. I'd want the adrenaline junkie who knows how to intubate.

jayde_RN · Jun 17, 2009

I am happy that others agree with me on this. But it sucks that this has happened to others. Everyone involved in healthcare should be working together to help patients, but I guess that would be a perfect world.

But just to update, I haven't found out exactly what happened to him, but I know that he is still not back at the rehab. And today one nurse pointed that out and told me I did good. It feels so good to now that a new nurse can still trust her gut!

maelstrom143 · Jun 17, 2009

I am glad you did what was best for the patient, as evidenced by the fact that he is still in the hospital. I hope he will be ok. Keep trusting your gut and good luck!

BTW, hope whoever that person was that argued with you was written up. :twocents:

CoffeeRTC, BSN, RN · Jun 18, 2009

I refuse to get involved in the us vs EMS debate. We both haave equally important jobs. Some of us get cranky at times (most of them work 24hr shifts) and that shouldn't be an excuse.

I do my part, I assess the pts, rely on my nursing experience and assessment, call the doc for orders. When they or the family order transport...they get it.

EMS comes...they get a good verbal report from me even if they don't want it, they get paper copies of the chart, meds, CPR stuff, etc. (I even give them a second copy for their charting etc). I call the hospital to give report.

If I get any complaints or attitude I will repeat the above assessment and remind them that "Im just the nurse" and the doc ordered the transport.

Rarely an issue of late. In years past...I've dealt with my share...you better believe that my DON is made aware.

GeauxNursing · Jun 18, 2009

Honestly you should contact the supervisor of that transport company. Oh nevermind, if it was 911...

We deal with transport companies at the dialysis clinic. Sometimes it seems that even just bringing our patients to us is a hassle to them. Picking them up on time? Not usually. Poor lady lying in the chair sometimes over an hour after getting off the machine, just waiting for her ride to come. It's sad.

But not all companies are crappy. I've met some really caring, genuine young men and women that love their job. These are the ones that volunteer with the fire dept and are going back to school for nursing or paramedic.

I've made my share of complaining to our social worker about various companies. Consistent horrible service gets you booted! There are plenty of transport companies out there. Our patients don't deserve to be treated like they aren't important.

coffee4metech · Jun 18, 2009

How could someone argue with you when a patients life is at risk , that seems like a ego trip to me and only makes the EMS look stupid.