Need nurse's advice for EMS policy development

[Aliakey]

Our ambulance service treats and transports quite a few patients who have dialysis cathers in place, grafts, PEG tubes, foleys, trachs, etc. Although our close-knit, current crew has a lot of experience in caring for the long distance transport of these patients (and are not hesitant to ask the patient's nurse for advice) we're expanding our service into another city, which will at least double the number of EMTs under our training. My opinion (shared by our current crew) is that we *need* to develop acceptable written training policies specifically for these patients now before hiring new crews. Our Field Training program is longer than most EMS services, but a good reference in the policies nips a lot of potential care problems in the bud. The last thing we want to do is harm our patient.

In the EMS education program, very little attention is given to these types of patients, as most EMTs move on to 9-1-1 services and require more focus on acute (emergency) conditions. Our service responds to mostly non-emergent, long distance facility transfers. Can anyone point a direction to reference sources (books, etc.) that we should use to develop these policies? We want to be sure that the policies are developed with sound "referenced" backing so they may be presented to our Medical Director for his approval.

I would also appreciate any concerns or thoughts to how things can be managed better between EMS and RNs with these patients. For example, I know accessing dialysis catheters by EMS is an absolutely last resort, and only to be considered in the patient is in extremely bad condition and is approved by a phone call to the receiving hospital's medical control. Sadly in the past, paramedics in this area were not made aware of the "last resort status" until bitter arguements ensued; not a good way to develop future policies.

Thanks in advanced for any help!

[Antikigirl, ASN, RN]

I will ask my hubby, he is a paramedic and they too do so many code one calls that he feels like a fancy taxi service!

I will ask him where to find their policy and procedure standards for these types of patients...

Are you with the state, or a privately owned company? (makes a difference).

For what I know of dialysis access..don't mess with it unless it is a very serious situation. One wrong move and it is surgery and replacement of another shunt, if you have a pt that already had a replacement...finding a new area for shunting...well...not good! So those things are best left alone! Remember also...no needle pokes (unless urgent) or BP on a shunted arm! Always opt for the unshunted arm..that is a good thing to go by :).

[Antikigirl, ASN, RN]

Okay talked to hubby...look for an RN that is willing to teach the care of these types of patients and have them do inservices. This is the best way to find out.

Also, there are many nursing books on these subjects, and lets see...I found that med surg books are the way to go on most tubes/wires... Someone may have a particular book that is their fav...I personally learned by asking during clinicals or...well I still ask! LOL!

You can also ask for the aid of your oncall MD's...maybe they would know someone that would be willing to do some inservices! Ours are excellent and funny and I have been to many of my hubby's inservices..they have tons (all CME too :) ). Heck, I know of a few LTC nurses that would be happy to do inservices...I am sure there are some in your area too :)...(heck, ya want to know about tubes...an LTC nurse lives and breaths by patients with them..LOL!).

As far as the RN and EMT thing...well, I have been there too several times being a ride along and most RN's thought I was an EMT. Not that I say it is the majority...but several didn't see any EMT or Paramedic more than just a taxi driver. Now I am a big PR rep for my hubby's company and through being cheerful and funny have breached many of those gaps wherever I go! Some nurses and doctors just need to change their perception of what an EMT/Parmedic is...and that is done through communication :). Trust me...after time it works...just get a few great RN's to encourage others to appreciate ya for what you do!

ALSO...having a few RN's do ride alongs helps!!! I did, and the communication between my facility and EMS is now strong and very very positive! Heck, now CNA's and RN's bend over backwards to make sure EMT/Paramedics get the info they so badly need for a safe transport! I mean...it is the patient that is at risk for a lack of communication..and well, that can be prevented :).

Good luck to you and hope this is helpful for you :).

[suzanne4, RN]

Dialysis catheters should be accessed only in a code situation, and for that reason only. Otherwise grave results could result, such as the medics not being aware of the 5000 units of heparin in each port and needing to withdraw that first, etc.

I have had doctors asking me to access them to get a blood culture from that port, and I will not do that. They are told that they need to wait for the dialysis nurse.

PEG tubes are normally clamped for transport. If the patient has a trach, you will need full suction capabilities as well as the training to replace it if it should come out, etc. Always have a back-up trach available during transport. Foley catheters just need the bag lower than the patient, so that urine doesn't back up in to the kidneys.

[Aliakey]

Thank you very much to both of you... hoping a few book recommendations pop into mind TriageRN_34.

Foleys: Now I do ask do, is it normal for a female patient with otherwise normal appearing urine (straw colored/ clear) and not dx with a hip fracture to complain of pain from the foley? We don't insert foleys here in the field, but when traveling a couple hundred miles and faced with that complaint, is there anything that should clue us in to the problem? Or is it normal discomfort? We hang the foley on the stretcher frame during transport so it is lower than the patient but able to drain into the bag, and the tubing is loose, not being pulled. I don't run into this compaint except maybe once a year, but I feel for the poor lady and would like to know if anything can be done to allevate the discomfort.

Dialysis catheters... the heparin bolus has been a big concern for us. With patients going sour (coding), after obtaining medical control authorization, we apply new gloves, disinfect the accessX2, draw off 10 cc to waste because of the heparin issue, and do use as sterile technique as much as possible. If we can't draw, we don't use that access. 60 gtts sets are used whenever possible/applicable to prevent fluid overload, and NS is the fluid of choice versus LR. Any additional thoughts or concerns? Is 10 cc enough to waste? I've had a variety of nurses, doctors, and others recommend anything from 5 cc to ???. Going off another EMS service's approved protocols, we do ten.

PEG tubes: Commonly, we run on patients with "pulled peg tubes" and sure enough, they're out. Normally, our transports to a rural hospital are not that long, but with longer transports (due to road ice and so on), is there anything besides maintaining cleanliness of the area (sterile dressings, etc.) that would benefit the patient?

I know I'll think of more... ;-)

Thanks again!

BTW TriageRN_34: Private service (no, not the scumbag ones, we honestly care about our patients and crews ;-) ) operating in Texas.

[suzanne4, RN]

10 ml is fine for the draw from the Dialysis catheter.

Sometimes with moving the patient, the balloon of the foley can be pulling at the urethra, you can have them just try to deflate the balloon and then refill the balloon.

It is not a good idea to pull the PEG, it just needs to be capped. Most now have a cover that comes right with it, depending on the brand. And if a foley catheter has been used, just use some type of hemostat, or larger to clamp. The issue that you have is depending on how old that the opening was made, if fairly recent and it remains out for a few hours, you have a good change of the patient needing to go to the OR or the GI lab to have it replaced. Not a good thing. If it comes out on transport, the medic can just stick a red catheter in, (Red Robinson) quite easy, and there is only one place for it to go.

[Aliakey]

Just to clarify... *we* try our best not to pull the PEGs out {grin}. The patient usually does it in the nursing facility and then we are called to transport the patient to the hospital. Sorry I didn't make that clear (I get longwinded and info tends gets lost or mis-typed, sorry). I do make sure that PEG tube is safely in place and well out of the way before the patient is ever moved, and this bit of education is also passed on to new crews. ;-)

Thanks for the Red Robinson tip... never thought of that. Sometimes we get called to a "freshly pulled PEG" and would like some way to prevent the access from closing for the patient's benefit. Thanks!

[suzanne4, RN]

Not sure who was doing the pulling....:) But the Red Robinson, or even a foley catheter, inserted quickly will prevent quite a bit of grief for all.

If you need any other little tricks, please let me know.