Long Term Care and dealing with EMS with an attitude

[sandyth]

I work in a LTC facility& had a pt with chest pain (crushing); Hx: A-fib, CHF, and multiple other heart problems; also 2 weeks post op Left hip fx. Pt wont ambulate blah blah...Anyway I call the MD after the Nitro doesnt relieve chest pain and he said to send her to ER for evaL AND TX. oKAY the EMS get there and say she is asymptomatic and medicare woulnt pay for transport (the EMS) had just been woke up)and proceeded to try and talk this woman into NOT going. I pressed the issue and finally they transported. Most of the EMS people are nice when they have to come but has anyone had this kind of problem with the EMS before?

[aimeee, BSN, RN]

I do remember a team with an attitude one night when I sent a lady with terminal lung cancer out who was very dyspneic and whose sats kept dropping below 88%. She may have been terminal, but she was a full code so what choice was there?

Just as in any profession, there are great EMT's and then there are some stinkers! I've had to send residents to the hospital for eval at times and felt really stupid for doing it, but you have no choice when you call the physician to report a change (thinking you will get orders for monitoring vitals and a UA and maybe a CBC) and the Dr. (who doesn't know the patient from Adam) orders them sent to the ER because its the best way to cover his behind.

I've also had to call the EMT's to start IV's for me at times. They were usually very gracious, and some actually gave me pointers. They do dozens of starts each day, whereas in LTC we might go for months without doing one.

[flameangel]

Medics are not permitted to refuse to transport anyone in our area - but I'm sure grateful when they talk the "I have a splinter in my finger, I need a ride to the hospital" and the "I hurt my leg three weeks ago but it needs an ambulance at 3:00 am Monday morning" patients into an AMA. I think our EMS system suffers a lot of this type of abuse. Actually refusing a transport, however, is an unheard of concept here.

[pappyRN]

Good Morning,

I am so glad to see this subject. I believe that in my area it is a HUGE problem regarding the actual meaning of DNR.

DNR is NOT synonymous with DNT-Do Not Treat! My Mom was having an MI and the nurse told the EMT when she called 911 that Mom was a DNR. So, what did they do? They came at their own pace. They entered the LTC as if they were on a Sunday walk, they kept repeating to us that she was a DNR so there would be "no lights and sirens, bells and whistles." At the time we were so upset it didn't even dawn on us that it basically meant they were giving her a ride and nothing more. They started an IV and gave her O2 per NC @ 2L/min.

NO NITROGLYCERIN tabs were given at all. I followed the ambulance which took it's time at 40 mph on an interstate. The paramedic/EMT in the back with her was the CAPTAIN of the paramedics/EMT for the fire district where the LTC was located. I certainly hadn't expected HIM to misinterp[ret the spirit of the intent of DNR!

They arrived at the hospital and the doctor asked WHY was she brought there if she was a DNR. She said she wanted to be treated. But..they admitted her to a regular, non monitored floor on a Medical division. again, "because your Mom is a DNR we are NOT going to put her in telemetry bed.

At around 5AM the next morning when enzymes were being drawn(I guess I should be grateful they were even ordered) I got a frantic call from the floor nurse that Mom was being transferred to the ICU because her enzymes were very elevated and that indicated a possible MI-no shit, sherlock! I got to thinking about all the events of that less than 24 hr period.

I went to the Clinical Coordinator's offices for ICU and ER-same person- and asked her to explain to me how being a DNR meant that you were NOT to be treated. She arrived at a common conclusion -it didn't!

I proceeded to explain how this started at the level of the LTC calling EMT and then EMT assuming this means to barely treat, then we get to the ER where NO one made any big effort to get to the bottom of this. I explained the admit to a medical and not telemetry floor and then the frantic call. Why the rush now because they had done EVERYTHING humanly possible to get OUT of treating her. She had to admit that they were wrong. A lot of good that did for my Mom. She ended up staying for 3 weeks in the ICU having 3 cardiac caths, 4 stents and 3 balloons!

The head nurse/clinical coord. asked me if I would mind mtg with the director of Critical care services. I figured sure, why not? We three spoke at length and we came to the conclusion that there is just a HUGE discrepancy about the real interpretation of DNR-in fact, "interpretation" is what clouds the issue.

DNR- means Do Not Resuscitate. It doesn't mean if the pt c/o crushing chest pain ignore her because if she codes she just wants to die. Do Not Resuscitate implies that the pt is DEAD when that decision comes into play. IF she coded with the EMS, ER or ICU staff they had a legal obligation to do everything they were able to in an attempt to save her according to the clin.coord. and the med. dir. They said it was unethical NOT to treat her because they had everything right there at their fingertips.

This still doesn't explain the lack of any type of intervention in trying to fend off the MI Mom was having. I do not work any more due to disability and worked in NICU. I know there is an IV med that can be given in the case of impending MIs because it was given to me when I had to go to the ER for chest pain.

They blew any chance for Mom to receive that drug and possibly not have to have the stents and balloons. She may still have needed some but the area of infarction might have been prevented or reduced.

Why are the elderly considered useless and not important to save. Mom is now 85 years old but she has decided that she still wants to be resuscitated now as a full code. She had changed to full code while in the hospital. With all the problems we have had at her LTC, I doubt whether it would be successful anyway. I am trying to discourage her from going through something that could be futile and very painful in the end for her.

What's in her chart at the present?

" Full Code: PT/Family requests Lights and sirens, Bells and whistles.".

There is a climate of taking DNR to one's own interpretation but this very simply means- Do Not R E S U S C I T A T E!!!

Do you resuscitate someone while they are still living? The only occasion left is when they cease living. I just fail to see what is so difficult about it.

Don't try to read anymore into it. It's not there.

This ER/ICU med. director and the RN Clinical coord. are the ones who provide the hospital inservices for Paramedics/EMT/10 Fire Districts. The hospital we use is the only trauma center even remotely close to where we reside. The other hospitals that had a trauma certification ER dropped it because of money.

I can not imagine how many poor souls lose their lives from just this one misinterpretation. I believe the number is apt to be higher than one is comfortable with. If this situation doesn't get straightened out, it could be me that they fail to treat because they weren't given the accurate and only explanation there is for what DNR really means.

If you are sick and needing to go to the hospital but because your chart says you are a DNR, does that just mean "tough bologna, you can't get treated for this, even though it COULD kill you. We aren't even going to try to prevent that type of circumstance because first we aren't going to arrive until we feel like getting there, next we are just going to mosey on in at the pace we feel like using, then we are just going to wheel you out to the ambulance stopping to say hello to nurses we know as your stretcher passes through their divisions. After we get you in the ambulance we are now going to put an O2 cannula in your nostrils and then we are going to put an IV in although we don't even have ANY plan to use it and then...we take our time and cruise on down the highway at a speed reserved for Sunday drivers. Oh, look. There is your daughter behind us. She is having difficulty driving so slowly on an interstate with no traffic. OK. Here we are at the hospital. We'll put you in triage but not tell the nurse the daughter is also here as the daughter overhears the nurse saying what in the hell-why are they farming these people out to us for? Whaaaatttt???She's a DNR? What is SHE doing here? This is a 'dump' if I've ever seen one!"

At this point, I introduce myself as the daughter of the 'dump'and ask her to put a lid on emphasizing her code status and that it is NONE of her business if my Mom along with her doctor choose to seek treatment at the hospital especially since she is still very much ALIVE. As it was, the idiot nurse at the LTC left her symptomatic for almost EIGHT HOURS all the time telling Mom it was her stomach so she pumped her full of Maalox and again, NO NITROGLYCERIN! (She had been complaining since 5am and it was 1:130PM when my sister and I arrived at the NH. The nurse had called my sister twice to tell her she was c/o of a tummy ache. I took that second call so to me she told me Mom was c/o epigastric pain. I asked her if she had ever heard of the abnormal presentation of cardiac symptoms in women. Sorry to digress...

Back to the hospital. The doctor moves like he needs an enema, the ER is almost empty. If I had counted how many times and how many people couldn't refrain from drilling the initials DNR into Mom's head...

Mom asked me what was the big deal with them and why were they getting so flustered. So, I explained it was because of her DNR status and asked her if she understood. She said she did and that was still her wishes UNLESS they found something that could be fixed. Her answer was "then what the hell am I doing here if they aren't going to do anything?" I already told you the rest of the story. She ended up where she belonged in the first place by the next morning.

Isn't there a way to make the meaning of DNR clear? I know there is a middle ground for DNR which back in the Dark Ages of nursing some almost 30 years ago we used to refer to as a" Slow Code" or "Walk Backwards Code". It just meant to take your time because the poor pt was in miserable shape and would find rest through death. Fortunately, although I had heard about the occurrences of this type of code, I never experienced having to participate in one, Thank God!

There just HAS to be some universal way to interpret DNR. It's just wrong to let a person die due to a common misconception about a phrase. Hope this all made sense. I have been up all night due to pain and the resultant insomnia. Thanks for reading my reply.

Warm personal regards,

PappyRN

[bluesky, BSN, RN]

1st I've been doing EMS myself for years (8 as an EMT, 2 as a paramedic) and I have NEVER witnessed such travesties commited by myself or anyone else for that matter. They should be criminally prosecuted for attemting to coerce a pt if they engage in trying to convince a pt not to go to ER. They should know that as medical professionals with higher level of training, they shouldn't argue with you.

I do suggest a little reflection on your part concerning response times, however. Believe it or not, response times are often poor not because EMS has some magical a priori knowledge of who your patient is (DNR or not, etc)and they chose to slack off. Often, the unit is wrapping up another call or even at a location far from the incident when it gets dispatched.

PappyRN- are you referring to TPA for the drug? It is very possible that the ER was participating in the C-port study or that your mother wasn't eligible for TPA. They had to wait for her cardiac enzyme results (and coags if TPA was being considered) from the lab before any major interventions anyway (unless she was severely decompensating of course)- unless she had major EKG changes. They should have given her nitro basically upon arrival, however- did they? Angio is a first line intervention just like TPA- not a last resort. It is true that controversy exists about angio in women but still it's not as if she was being underserved by getting angio. Did you confront the ER staff with your reservations and get an acceptable explanation?

[ktwlpn, LPN]

This thread is proving the point that we all need to leave our personal prejudices AT THE DOOR....