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?

[Jen2]

Whimsie, i can understand all of your frustrations and questions. I have seen all sides of this. I am talking from the point of view as an ER nurse. You have to realize that everyone is important with their own scope of practice and their are good and bad everyones out there.

When an LTC facility calls me to give me report on a patient that they are sending. I write it down and ask any pertininet questions that I need to know. This IS VERY IMPORTANT to answer your above question. I need to know what room I need to put the patient in and what I need to have ready at bedside when the patient gets to me. The ED is never empty and I may need to save the suture room. I could not put that patient in a gyne room. I base all of this info on the report I recieve from the nurse at the LTC facility.

As far as EMS assessing the patient. I need that too. It sometimes may take EMS an hour or more to get the patient to the ED. When the patient arrives to me, I have the appropriate room ready (on a good day, otherwise the patient goes in the hallway). I need to hear EMS report on the patient to see if the assessment has changed since I recieved it from the sending facility. These two reports allows me to use my judgement on how soon I need to get this patient to see a physician. It happens more often than not that the reports are totally different. I then need to do my own assessment and see for myself.

You sound as if you are a great nurse and very concerned about your patients. Trying to understand others focus will make you much better and I commend you for asking. That is what this board is for. It helps us understand each other. The focus of nursing and EMS is different depending on where you work. I have called report to the floor for a patient that I had to give Atropine to earlier because their heart rate was 30 and the nurse on the other end asked me when their last BM was. I thought to myself, who cares the patients heart rate was 30 I had no time for questions like that. It's all a learning process.

I think it is great that you want to get a better understanding of EMS. I love the EMS guys and gals in my area. You eventually develope a repor and know who you can and cannot trust. I have one paramedic that will bring chest pains off the truck without O2 because he does not feel like bringing in the tank. I learned that after I got to know all the EMS crews that he's the same one that the rest of them never want to ride with. Try volunteering with your local EMS. Thats what I did when I first started working in the ED. It really helped me understand and gave me a ton of respect for what EMS does. They are a great group of people and believe me they do it because they love it not for the paycheck.

[weirdRN, RN]

God Bless you Jen2! Thanks for the encouragement!

[Altra, BSN, RN]

Let's put aside the different titles for a minute, and just think about yourself as a generic medical professional: would you take responsibility for a patient without assessing them yourself? I think not.

As an ER nurse, when I get report from an LTC on a patient who's coming to the ER, the info that is most helpful from the LTC nurse is background on the pt. & recent labs & tests. I expect, and get, a full report on the patient's current condition, head to toe, from the medics who have transported when they arrive.

[RoxanRN]

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.

No, we are not allowed to practice willy-nilly. We have to practice within the scope of practice set by our state Board of EMS (varies state to state) and service Medical Director (we practice under his license). If an RN wishes to be in charge of an EMS scene, they need to become pre-hospital certified (PHRN - some state recognize this, some don't) or become an EMT-P.

This is a link to the final draft of the National Scope of Practice. This is intended to help make EMS for standardized across the country. As it stands right now, each state is responsible for their own Scopes of Practice. http://www.ksbems.org/Scope%20of%20Practice%202.pdf. Here is a link to the statues which regulates authorized activites for EMICTs for KS http://www.ksbems.org/stats2003.htm#65-6119.

[RoxanRN]

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

Call the EMS service you are interested in riding with. Don't limit yourself to one type of service. Transfer services (sometimes called 3rd services) typically do transports of generally stable patients who need an ambulance to go to the dialysis or be transferred to another facility (LTC or teriary care center, etc.)). They may also get some 911 overflow calls as well (depends on the area). Primary 911 services are the ones who will (most likely) see the other stuff - MVCs, shootings, stabbings, AMIs, strokes in progress, stubbed toes and abdominal pain x4 months. :icon_roll Ask to talk to the Training Officer or Operations Manager. They will get you directed from there.

Good luck and I hope you have fun!!

[CA_Nurse]

You are correct to assume that the care of the patient is turned over to the paramedic once they are on scene. It is advisable, however, to include in your nursing notes something like "Care released to (name) at (time)." In this way you can protect yourself and the facility from any liability.

[flashpoint]

We need to know what the wound looked like when we picked the patient up so it can be comapred to what it looks like when we get to the ED. There would be a huge amount of liability if the patient had pulses, ROM or whatever in the nursing home and then didn't have it when they got to the ED and no one noticed the change because no one assessed the patient properly.

I wouldn't give a med based on someone else's assessment...I'm not going to transport a patient without assessing him either.

[Antikigirl, ASN, RN]

One, I think it is important to distinquish between using the words EMT and Paramedic. EMT is Emergency Medical Technition...it is the general title, and used for certain levels of education. Typically when one says EMT that means a basic, where as paramedic is the top! They are all EMT's by levels...but I feel when you use EMT for a paramedic interchangably...well, that is like calling a CNA, LPN, RN, NP 'just nurses'.

When called on scene a EMT or Paramedic must assess the patient just like we do! That includes seeing and documenting and treating the main complain (as well as any others). I would most certainly have taken the dressing off to assess the main complaint so that I may communicate to other disiplines (IE the ER MD or RN) what is going on. That one is an easy answer~!

The using the same dressing...I may have grabbed a gauze and used it instead of using the same...but remember...this patient will more than likely get the wound cleaned and abx tx in hospital! Also, that dressing will be removed AGAIN by the ER! So leaving it off actually to stop from it being removed/applied/removed was a good choice! Control bleeding is A#1 at this point...and that can be done in the ambulance with a chux or 4x4 with direct pressure and save from applying another dressing!

Also please remember, this was certainly NOT a sterile dressing when you applied it unless you went through the whole sterile glove and sterile technique in a controlled sterile environment...it is called a 'clean' dressing dependant...and that is what Paramedics do as well.

YES, when you report to the Paramedic you are handing care to them! In my state, the moment you called you have given them the patient as soon as they arrive. They are held to a very stern set of protocols and rules as we are as RN's...and are medics in every sence of the word! They also have more CME requirements than we do!!! They are trained for these types of situations...and believe me, no one knows geris like the Paramedics...LOL, that is their general population no matter where you go!

Also remember...HIPAA means nothing when giving report to a Paramedic...they are part of the healthcare team and are just like giving report to another nurse or doc! Paramedics also have a really great opportunity while in the ambulance to focus directly one on one that isn't done in hospital or even facilities! They can get so much more info and do so much direct focused care that it makes me very envious! Appreciate that :)...and 9/10 they find something else going on we may have missed...another big bonus!

Also, know the differences between fire Paramedic, and your Paramedic companys. Fire paramedics are awesome and do the acute stabilization and assessment of the patient right away since (well around here anyway..LOL!) they are the first one scene. The Ambulance Companies Paramedics are typically the ones continuing this (and doing their own assessments and treatments) on the way to the hospital. Know who you are reporting off too so you don't have to repeat yourself over and over again. I give a quick report to the fire including all the stuff they need to record (like meds/Hx and so on), and a little more detail PRN to the one doing the tx in transport!

Sorry this is long...but I work PR with a local ambulance co and teach nurses about what Paramedics do and what they need! Any other specific questions...feel free to ask me :). Like my hubby (paramedic) says...'we may get paid the same as a taxi driver...LOL, but we certainly aren't!!!!!".

[RoxanRN]

Very well said!!

[traumaRUs, MSN, APRN]

Whimsie - first of all thanks for asking questions. Your concerns are very valid. I do agree that as an RN would assess the wound, so should the EMT's. I would not re-use a dressing, but would nonetheless assess the wound myself.

In IL - I am a licensed pre-hospital RN and my scope of practice is in keeping with that practice act.

This is a good thread - let's keep it on target. THanks everyone for your input.

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

WhimsieRn:I would like to thank you for not addressing us as "Ambulance Drivers" as most nurses do. That made my day! By your title of this post, it sounds as if you are bashing Paramedics as a whole. As the feedback comes in, I hope you now realize we don't just "load and go." It is unfortunate that some nurses are ignorant of our duties. My ten years of being a Paramedic has been a valuable asset in nursing school, and I'm not so sure I could have made it without it. I commend you for wanting to learn more about EMS, and as suggested earlier in this post, please do some ride-alongs with the fire dept AND private ambulance company.

[chadash]

Not a nurse, but, I think I would have held a pressure dressing in place (no ouchy tape) or have put it in place with something that could be easily removed by the EMT.

I would sort of assume they would want to look.