tension between EMT and LTC nurses?

RubyRN,CHPN · Mar 20, 2004

Well I will jump in from a purely observational point of view.
I never have worked LTC so I can't say how things go, I did do my laddertrack course with several Paramedics however,(the program required either LPN or paramedic)and like Mike mentioned I did have occasion to hear them complain about LTC sending DNRs to the hospital, to which I have to agree to some extent. The problem with sending a DNR Pt to the hospital for care is we can not do anything invasive or take heroic measures either (BLS/ACLS)so the reason they became DNR is so that when they begin to go nothing will be done and if they live in LTC this would like dying at home for them. I understand the problem with families interefering and saying they need to go to the hospital but the second problem is once they get to the hospital an eager resident or ER doc will talk to this greiving family member and explain that we can not do anything as long as the Pt remains DNR and 9 out of 10 time the DNR will be revoked and then a Pt that wanted to be DNR and die peacefully will be fully coded and put on a vent and suffer a long agonizing death. So I am not sure if more education would help at the LTC to explain to families that your loved one wished to be DNR and is now dying and this is like being able to die at home and is what they wanted etc. or if they should let the Pt be sent to a hospital.
The problem EMT services have with transporting DNR Pts is that it makes them feel useless because they know they are dying and are not allowed to do anything, however the autonomy they enjoy as paramedics is sometime too much and they may perform some things that maybe they should not.
It is a difficult situation for all involved, I also dislike recieving a DNR Pt from LTC especially to CCU just to appease a family, we can do nothing, they take a CCU bed which should never have been given to them and they will die and they will not be at home or what they considered home the LTC, many times it is the family that are not ready for the Pt to go and these things are all done for greiving family members when the Pt had made their wishes and their mind up about the entire situation I also feel that many times this situation is brought on by the families because of guilt that they did not visit more or do enough for their loved one prior to them reaching this condition.

I can thoroughly understand where your are coming . When I'm in the home and I run into this situation. When I call 911 and request transport to the hospital, I explain to the EMS that "pt is going to the hospital to recieve the appropriate level of care including a medical assessment. Living wills often require MD (1-2) to certify pt condition is life limiting. Our state has a POLST form (Physician orders for life sustaining treatment) which specifically directs EMS how and what care can be provided during transport, home and hospital setting as it pertains to treatment and comfort. If the examining MD at the hospital wants to initiate a discussion with the pt/family at the hospital regarding end of life care and/or include hospice as an option if appropriate, this would be an appropriate setting in this instance.

Blackcat99 · Mar 20, 2004

I think it is OK for LTC to send DNR patients to the hospital. DNR means no invasive stuff like putting in a new trach. DNR means no CPR. DNR does not mean "no care".If a patient is having respiratory distress perhaps they can be helped with breathing treatments and breathing meds. Most LTC's I have worked at have no respiratory therapist on duty.So maybe the hospital can help in this kind of situation. And yes it is a family's right to send them to the hospital even if they are a DNR. LTC centers are usually much more short staffed than hospitals. Who wants their loved ones spending their last days on earth dying and being ignored in a nursing home?. Why not let them spend their last days on earth in a hospital(not ICU or CCU) where they will usually get more attention and better care?

Agnus · Mar 20, 2004

FYI the hiarcheal order is RN then Paramedic then EMT.

What The EMT and Para do not comprehend is the complexity and range of nursing.

LTC is a very different focus than emergency or even acute care.

Emergency care is based on algarythms. EMTs and paras memorize these because basically they do not deviate from them.

Acute nurse (even much more than emergency nurses) use critical thinking more and use them when applying algarythms. The nurses education is more extensive and complete than the para.

The para has ONE very narrow focus in thier entire education, emergency care.

Your education is much broader and more involved.

In emergencies they are the expert.

However. to dis a LTC nurse because her emergency skills are not up to par of some one who works only in emergency is like diss'ing an obstetrition because he cannot do heart surgery.

Thier ignorance stems from the fact that they do not know what they do not know. They are contstantly required to act in emergency conditions and have had to memorize protochols so that they are automatic without thinking. and working in emergency give these folks a false sense of being some kind of superior care giver because "they save lives".

All they really do is keep a situation as controlled as possible UNTIL the real care and life saving can take place.

Often they are adrenaline junkies, with a hero complex. Sorry, but I have had the misfortune of sitting in a firehouse listening to these self proclaimed heros tell the same story over and over such as about how they put in an IV on the fly (an event that took place over 2 years privious) To them that is a major big deal, worth repeating to every one who had an ear.

They do a lot of talking and patting self on back.

So how can they possible respect someone who has the job of a mere mortal and does not deal with life and death emergency every day.

I think much of the critcism about transporting DRNs etc it the funding. Unless they do certain procedures during trasport they do not receive funding for that run.

We have mostly volunteer emergency response here. However, there are several medical transport companines that are not emergency but do provide medical transport for patients. maybe this is who we should be calling. However they are not available on a moment's notice.

CCU NRS · Mar 20, 2004

I think it is OK for LTC to send DNR patients to the hospital. DNR means no invasive stuff like putting in a new trach. DNR means no CPR. DNR does not mean "no care".If a patient is having respiratory distress perhaps they can be helped with breathing treatments and breathing meds. Most LTC's I have worked at have no respiratory therapist on duty.So maybe the hospital can help in this kind of situation. And yes it is a family's right to send them to the hospital even if they are a DNR. LTC centers are usually much more short staffed than hospitals. Who wants their loved ones spending their last days on earth dying and being ignored in a nursing home?. Why not let them spend their last days on earth in a hospital(not ICU or CCU) where they will usually get more attention and better care?

I may have given the wrong impression, I do believe that an elderly Pt with say pnuemonia that is acute should come to the hospital to recieve care even if they have a DNR in place, however I was talking about people that are basically already having kussmol(sp) type resp. and are only likely to live a few more hours, sent to hopsital and then even to CCU where they will pass without intervention.

Hypothetically: A person could be in a hospital from a nursing home D/T exacerbation COPD, they could have a DNR in place. They could be on a med/surg floor and be recieving resp tx's etc. and could even be slated for D/C back to Nsrg Home that day.

The Doc could order ABG prior to D/C, a resp therapist could be drawing said ABG and Pt just go unresponsive and resp therapist call a code, the code team could arrive and start ACLS, then the Pts own Doc could arrive and ask what is going on and why Pt is being coded and inform of DNR status. At this point the code must continue. The Pt's nurse for some reason may have missed that the Pt was DNR and resp. Therapist had no knowledge and a Pt could end up on a ventilator and full life support and in CCU for several weeks until they die without ever regaining consciousness.

Beleive me IT could happen!!!

psychomachia · Mar 20, 2004

Agnus expounds: FYI the hiarcheal order is RN then Paramedic then EMT.

Me: And FYI "hiarcheal" is usually written as hierarchical. Also, there are some who would argue the order should be MD--->God--->Midlevel practitioners (PA/NP/CRNA)--->RN---->LPN---->CNA.

There are also other branches from above God where you have Firefighters and everyone else below them. Another branch starts above God where you have Police Officers and, of course, everyone else below them (the Police and Firefighter brances are often in mortal combat for the elusive taxpayer dollar and have to align their forces in conjunction with political candidates who, of course, are above God but under the Devil.

Branches usually do not intersect as you have suggested. This may occur on a forum, such as this, when the debate over who should work in an ER (paramedic vs RN) and who should be the supervisor of the other's actions, but these are only "pseudo-branches" as they are often just the cogitations of "internet experts" who like to tell stories about their first hand experiences in dealing with the other brances. Thus, the RN vs paramedic battle is usually fought in the small minds of those who often have never worked both jobs, yet think they know all about the other because they spent a few hours in a firehouse or an ER.

Your command of grammar and spelling is a challenge and I had difficulty trying to grasp your somewhat rambling ruminations.

As an RN I'm not impressed with your hypothetical argument of emergency care being "one narrow focus," since emergency medical conditions can be very broad based. Perhaps what you meant was the focus of the paramedics training is on the initial identification of life-threatening conditions and their treatment with stabilization until delivery to an Emergency Dept. You can argue that "definitive" care starts in the hospital, but if all you get are dead bodies...well...might as well call yourself the morgue.

As a paramedic, I'm very impressed with how poorly you make your argument which rings of jealousy from not being able to ride around in the big red trucks with the lights and sirens on. Listen, if you want I'll help you get your paramedic certificate and then you too can join us at the firehouse for a little BS session as we kick back in the La-Z-Boy recliners and eat ice cream...but don't think for a second you get to hold the remote control...

Hellllllo Nurse, BSN, RN · Mar 20, 2004

Agnus expounds: FYI the hiarcheal order is RN then Paramedic then EMT.
Me: And FYI "hiarcheal" is usually written as hierarchical. Also, there are some who would argue the order should be MD--->God--->Midlevel practitioners (PA/NP/CRNA)--->RN---->LPN---->CNA.
There are also other branches from above God where you have Firefighters and everyone else below them. Another branch starts above God where you have Police Officers and, of course, everyone else below them (the Police and Firefighter brances are often in mortal combat for the elusive taxpayer dollar and have to align their forces in conjunction with political candidates who, of course, are above God but under the Devil.
Branches usually do not intersect as you have suggested. This may occur on a forum, such as this, when the debate over who should work in an ER (paramedic vs RN) and who should be the supervisor of the other's actions, but these are only "pseudo-branches" as they are often just the cogitations of "internet experts" who like to tell stories about their first hand experiences in dealing with the other brances. Thus, the RN vs paramedic battle is usually fought in the small minds of those who often have never worked both jobs, yet think they know all about the other because they spent a few hours in a firehouse or an ER.
Your command of grammar and spelling is a challenge and I had difficulty trying to grasp your somewhat rambling ruminations.
As an RN I'm not impressed with your hypothetical argument of emergency care being "one narrow focus," since emergency medical conditions can be very broad based. Perhaps what you meant was the focus of the paramedics training is on the initial identification of life-threatening conditions and their treatment with stabilization until delivery to an Emergency Dept. You can argue that "definitive" care starts in the hospital, but if all you get are dead bodies...well...might as well call yourself the morgue.
As a paramedic, I'm very impressed with how poorly you make your argument which rings of jealousy from not being able to ride around in the big red trucks with the lights and sirens on. Listen, if you want I'll help you get your paramedic certificate and then you too can join us at the firehouse for a little BS session as we kick back in the La-Z-Boy recliners and eat ice cream...but don't think for a second you get to hold the remote control...

Typical arrogance. I respect EMS. I think their jobs are tough, interesting, and require a great deal of knowledge and skill, as does mine.

I wish that some rude and arrogant EMS whom I've had the misfortune to come in contact with would reciprocate this repect.

I find that female EMS are a lot nicer to deal with.

yankees32 · Mar 20, 2004

I live in a rural community that runs an active EMS crew. We have 4 full-time EMT's and numerous volunteers who work various hours. I've been an EMT for quite some time and cannot ever remember there being tension between our staff and the LTC community. We take every call the same, whether it's a LTC transfer, a cardiac emergency, or a trauma call, it's all run the same. We have a short transfer time to our closest hospital, so an entire background on the person's medical history would probably take longer than the transport itself. We get what we can get when we can get it and we go from there. Whether that is a verbal report or a copy of their chart, we just take it and go so we can work out the details later. I'm sure bigger cities don't work the same as we do. We aren't so busy as to look down on LTC transfers, and it doesn't matter whether there is a DNR or not. So please don't lump us EMT's all in the same group. There are some pretty cocky medics out there who work in the busier areas and see LTC as an inconvenience to them, but we take all calls seriously and never criticize or condemn anyone for calling 911. That's what we are there for, and that's what we do (especially those of us who volunteer). This just gives another side to the argument of whether or not tension exists, and it may just depend where you are and how busy your EMS service is.

Marie_LPN, RN, LPN, RN · Mar 20, 2004

The LTC that i do PRN shifts at doesn't seem to have this problem. Six of the nurses met their husbands there. The husbands were the EMTs that picked up residents lol.

Blackcat99 · Mar 21, 2004

:chuckle Wow! That's nice to hear that some nurses and EMT's got married!

Thanks CCU NRS for clarifying your position in regards to DNR.Yes, what is the sense of sending them to the hospital if they are going to die in a few hours?. You are so right about the importance of everyone being aware of the DNR status of a patient. I have heard of "horror stories" where patients have ended up on ventilators.

flashpoint · Mar 21, 2004

As a paramedic, I expect certain things when I walk into an LTC to tranport a patient. If it is an emergent transport, at the very least, I expect to be told why I am transporting the patient...I want to know if they fell or are having chest pain or whatever. I expect a NURSE to be there to give me at least a little report...not a CNA, not the family member, not the patient's roommate, but NURSE...I don't always get that. I would also like a copy of the resident's med list and face sheet and something with their primary diagnosis...it really helps me out while we are transporting. It only takes a few minutes to make the copies and it doesn't take a nurse to make them. Yes, you are going to feel my frustration, if I don't have at least minimal information on the patient. I know we treat patients without a bit of information about them all the time, but when our patients come from a health care facility, I expect a little more and your residents deserve more than the patients we pick up from the streets. I also expect someone to be near the facility doors when the ambulance arrives. Someone needs to direct us to the resident's room...again, it doesn't have to be a nurse, but I shouldn't have to get my cell phone out and call the LTC while I stand in their lobby in order to get a staff member to direct me. If I have to do that, you will probably feel my frustration.

For a scheduled transport, I expect the resident and their paperwork to be ready when I arrive. If the ambulance service knows about the transport 24 hours in advance, the LTC knows about it 24 hours in advance...don't waste my time by having the resident in the middle of a shower or by not having their paperwork ready.

Also, don't assume that because we're volunteers that we don't know what we are doing...we don't need to be told that we can only turn the O2 up to 6 by cannula or that we need to check for peripheral pulses after moving a hip patient...we are professionals, just like you. We'll treat you with the same respect that you treat us.

BBFRN, BSN, PhD · Mar 21, 2004

I saw the thread the OP is talking about on SDN, and I didn't feel the EMS posters were being disrespectful. They had some legitimate complaints, actually. I think I would feel the same way if I were them. (Don't flame me, please).:chair:

Blackcat99 · Mar 21, 2004

:chuckle Hey lgflamini

We see you hiding under that chair you coward lol. Don't you know that's the fun part (being flamed) after you give your opinion?