kind of a vent....Paramedics

[weirdRN]

Okay, the other night I was working and one of the residents who is ambulatory by wheelchair went off on her own as is her habit. Apparently, she was trying to get into a locked nutrition room and cut or pinched her fingers badly enough that she bled a large puddle of blood in the hallway. So, when she was found a complete assessment was done. Cold compresses and pressure dressings were applied until she could be transported to the nearest ER for stitches. The ambulance company was called and transport arranged. When the crew to transport got there, the paramedic took the pressure dressing off!!!! right in front of me!!! and the woman's fingers commenced to bleeding again. The medic asked the EMT if she still had the (now contaminated) dressing or if she had trashed it. Of course she didn't trash it. The paramedic tried to stick the old dressing back on with no tape. He had the lady, who was confused, hold it on her fingers and she kept dropping it and kept bleeding. I went to get a new dressing but by that time, they had her on the stretcher and were leaving and the Medic said she would be fine with out it that she wasn't going to loose enough blood to hurt her!!!

I am a newly minted RN, and so do not fully understand all of the policies and procedures in my facility just yet. So, I talked it over with another RN. She said that when the transport comes, the resident becomes their patient and they can do what ever they want to them.

I told the secretary when I called the transport that the resident had a pressure dressing applied and that we already knew she would be haivng stitches. (steri strips were not an option) I understand about dropping the ball with regard to communication, but he didn't have to cause the woman so dad gum much pain when he ripped the tape off! He didn't need to do more than listen to me give report to him about what had occured.

So what is the role of the Paramedic? What is their scope of practice?

Any suggestions on what to do should this occur in the future?

[flashpoint]

If someone is going to get into the back of my truck, once ABCs are intact, they are going to get a head to toe assessment...that means I am listening to their lungs, palpating their abdomen, checking their pupil, and taking off any dressings. I need to ensure that the injury is what is reported...I once got called to a house for a patient with "severe bleeding" after she put her hand through a window...when we took the dressing off, she had nothing more than a scratch...personally, I wouldn't have even put a bandaid on. We've also been called to "small lacerations" that were really complete amputations. We have an obligation to assess the wound (or whatever else we are being called to a scene for)...once the patient gets to the ER the dressings are going to come off too.

[smk1, LPN]

Is it possible that there was some confusion about "medical transports" coming and "paramedics". I know that I have been guilty of blanketly calling all medical transport EMS in the past. Not because I meant any disrespect, but I just kind of thought of it as the "calvalry arriving" lol.

[burn out]

I wonder if the dressing would have been removed if a physician had told the paramedic the patient was actively bleeding and leave the dressing on? When I went to school we were told that the care of the patient was the responsibility of the person with the highest title...would that not be the RN and if she said to leave the dressing on (having already been assessed (sp) by a licensed medical person that to do otherwise put the patient at risk and what did the paramedic do differently anyway?

Yesterday I had a patient with a bleed from a central line..she had a pressure dressing and a sand bag on her neck..there was no way in h--- I was going to remove that dressing and dislodge the clot until I had the surgeon there to take over. I based that decision on the assessment of another RN.

[weirdRN, RN]

The people we call for transporting patients to the ED are a commercial ambulance/medical transport company, staffed by EMTs and Paramedics. They are great people. I trust their competency, because I have known and observed them in other situations. We use them instead of the local EMS so that we are not a drain on local community resources. So the EMS guys aren't complaining about missing a "real" call.

However, in this instance, this resident had already lost a significant amount of blood, and b/c she was on coumadin, it wasn't going to just stop. We didn't have any vit K in stock and if we had had any and given it to her we did not have the resources to monitor her clot times. The pressure dressing was intended to stop the profuse bleeding until they could get her to the ED and a DR could determine what needed to be done beyond the pressure dressing and the stitches.

I am still looking at scope of practice. I am learning more about required documentation and what the role of the paramedic is. I want to be better informed so that I am not upset when something like this occurs in the future. I want to be clear so that I can adequately advocate for my resident/patient rather than having to stand by and just let stuff happen.

I wasn't angry. I was uncertain of what my response should be other than just to turn and walk away. I was anxious b/c I felt that I had somehow failed in my role as advocate.

[BBFRN, BSN, PhD]

If someone is going to get into the back of my truck, once ABCs are intact, they are going to get a head to toe assessment...that means I am listening to their lungs, palpating their abdomen, checking their pupil, and taking off any dressings. I need to ensure that the injury is what is reported...I once got called to a house for a patient with "severe bleeding" after she put her hand through a window...when we took the dressing off, she had nothing more than a scratch...personally, I wouldn't have even put a bandaid on. We've also been called to "small lacerations" that were really complete amputations. We have an obligation to assess the wound (or whatever else we are being called to a scene for)...once the patient gets to the ER the dressings are going to come off too.

I agree. Having worked in the ED, I would rather have had report from an EMT that had actually looked at the wound. It would be important to know if it was an arterial bleed, would Hand need to be consulted, etc. (Where I worked, Hand was consulted for muscle or nerve involvement, etc.) Having an EMT there who actually visualized the wound when you're triaging the pt would make a difference.

I say the EMT was doing his job, and the drsg removal for a visual was part of it.

[RoxanRN]

I wonder if the dressing would have been removed if a physician had told the paramedic the patient was actively bleeding and leave the dressing on?

It would depend on who the physician is. We (EMS) are not obligated to follow medical orders issued from any physician other than our company's medical director (off-line direction) and the physician whom we contact at the receiving facility (on-line direction). The only physician license we actually work under is that of the company's medical director. We can actually tell any other physician to leave (but we rarely do). However, if they start giving orders contrary to our protocols/standing orders, they are then obligated to either take total responsibility of the patient's care (becoming direct medical control) and RIDE with us to the hospital IN the ambulance or back off and let us work under our protocols.

When I went to school we were told that the care of the patient was the responsibility of the person with the highest title...would that not be the RN and if she said to leave the dressing on (having already been assessed (sp) by a licensed medical person that to do otherwise put the patient at risk and what did the paramedic do differently anyway?

Please don't start waving around 'licensed medical person.' We are licensed medical personnel. And actually, RN is not the highest title in the EMS world. It's paramedic (with few exceptions). This is our world. Please don't confuse a paramedic with a glorified orderly. We are not. We are an extenstion of the physician under whom we work. While our training and education are similar to that of nursing, it is also very different. The way of thinking is different. The way we approach a situation is different. The toys we have to play with are different.

I'm not intending to start or get into a pissing match about who's daddy is bigger. We each have our place in patient care. The quicker everyone realizes that, the better the patient will be.

*** steps off soapbox ***

Roxan EMT-P, RN, CCRN

[weirdRN, RN]

Does it matter that the RNs called report to the ED as if it were an inhouse transfer? Complete vital signs, meds, recent labs, recent dx's, estimated blood loss, size, location and shape of laceration, how it was supected that the resident incurred the laceration? Does any of that matter? If it doesn't then why are we (the LTC Facility) doing it?

[BBFRN, BSN, PhD]

The transporting EMT is responsible for the pt during pick-up, transport, and hand-off. The receiving triage nurse is still going to want/need report from the EMT in most cases. You are not giving report to triage (at least that's been my experience)- you are giving report to someone back in the ER who will be receiving the pt after they are triaged. It is appropriate for you and the EMT to give report, as you might not be giving report to the same person, and there *might* have been changes that have occurred during the transport.

They're just doing their job- it's not about you. And I have received pt's with lacs, etc. as described earlier by one of the EMTs- reported off by the NH nurse incorrectly. It does happen more frequently than you would think. It's just a different kind of expertise, that's all.

[RunnerRN, BSN, RN]

I wonder if the dressing would have been removed if a physician had told the paramedic the patient was actively bleeding and leave the dressing on? When I went to school we were told that the care of the patient was the responsibility of the person with the highest title...would that not be the RN and if she said to leave the dressing on (having already been assessed (sp) by a licensed medical person that to do otherwise put the patient at risk and what did the paramedic do differently anyway?.

As an ER nurse, one of the more frustrating things is receiving a pt (from anywhere) and not getting the full story from EMS. When a pt is transferred from LTC to the ER, the care is also transferred to EMS, then to ER personnel. If I don't get the full story from the paramedic (i.e. "We removed the pressure dressing once en route, and the wound immediately began to bleed again.") then I often have no way of getting the full story. Yes, I can sometimes call the LTC facility, but usually we are much too busy to do that. It makes no difference if the OP called the receiving ED to give report; the EMS crew has no way to know that, and this is still their patient. As was posted before - no one here would chart an assessment on a wound they hadn't really assessed.

As for the above quote - I'm guessing you haven't had much interaction with EMS crews. Generally, as soon as report is given, that is their patient. And even if the RN (or an MD) had said "the wound is bleeding because the pt is on Coumadin, leave the dressing on" I'd bet 99 times out of 100 the paramedic would simply wait until he/she made it to the ambulance, pull the dressing, and assess the wound. And those are the paramedics I would want to care for me or my family members.

[burn out]

Oh please Roxann I never intended a pissing matche but you started it. In my post I never intended to imply that a Paramedic was a glorified orderly, My intentions were to communicate that the RN was the licensed medical person that originally looked at the wound and took proper care by applying the pressure dressing and to remove it put the patient at risk. If one EMT had done it and told the other why would that be ok but not if a RN did the same thing? I realize you get called to scenes where a lay people call a laceration an amputation but we are talking one medical person to another here..don't treat nurses as glorified orderlies either.

So let me get the second part straight...EMT and paramedics do not have to answer to anyone and are free to perform and practice as they see fit? Could you please send me the the name of your states practice act for your profession because I have a hard time buying that one. Let's see doctors aren't god Paramedics are.

[RoxanRN]

I am still looking at scope of practice. I am learning more about required documentation and what the role of the paramedic is. I want to be better informed so that I am not upset when something like this occurs in the future. I want to be clear so that I can adequately advocate for my resident/patient rather than having to stand by and just let stuff happen.

Might I suggest you do a ride-a-long or two with the local EMS folks. This will give you a better idea of what we do than just reading it - the 'book vs reality' thing.

[weirdRN, RN]

Might I suggest you do a ride-a-long or two with the local EMS folks. This will give you a better idea of what we do than just reading it - the 'book vs reality' thing.

That is an idea. I have considered that but, I am not certain how I should go about asking/ setting that up.

Knowledge is Power. People who know things are empowered. People who do not know things are powerless.