tension between EMT and LTC nurses?

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BBFRN, BSN, PhD

3,779 Posts

Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

http://forums.studentdoctor.net/showthread.php?s=&threadid=109596

Just thought I'd post a link to the thread so everybody else would know what the heck we were talking about. :p

Again, I tend to agree with them- if your pt is SOA and desatting, and you call EMS because of that...put some darn O2 on them before the EMS gets there. I saw more of a "why aren't they USING their training?" as opposed to "They aren't trained." And I have worked in a bad nursing home (lasted a whole year there), and have seen some of the things they are talking about- consistently. I was treated like a trouble maker for sending someone out for a GI bleed, was yelled at by the doc after questioning his orders for Phenergan for coffee ground emesis (he didn't want to send this full code pt out), was looked at like I was a nut for calling the doc for a pt with a hemoglobin of 6, etc., etc. When I was agency, I worked in a few awesome nursing homes with much better ratios, and staff/administration that cared about the residents. But it's always the bad ones that are memorable, sadly. Heck, the scenarios I just mentioned took place over 8 years ago, and I remember them.

I remember being a NH nurse, and letting off steam about things I saw there (at the bad NH). I guess I just feel that they're doing the same thing. I wonder if any of the good NH nurses would feel the same way about some of their co-workers who act like the nurses in the scenarios presented in the SDN thread. The thing is, in a hospital we have a code team to take over, and we assist- we don't wait for the EMS, we are the EMS. So naturally, their stories are going to be directed at NHs or HH in particular- that's who they deal with. If EMTs were as much of a presence in hospitals, they'd see some pretty screwed up things there at times, too. Not just from nurses, but from Docs as well.

You don't expect the general population to know what to do in a medical emergency, but you do expect a nurse to know what to do. It's our responsibility to keep up on our skills- BLS, ACLS, practice codes, etc. Especially in NHs, where you are the nurse, RT, PT, OT, family member, advocate, and dietician all rolled into 1- for waaayyy too many patients, with way too much paperwork involved in everything you do.

I tip my hat to the good NH nurses out there (and there are a lot). I couldn't hang in that job and keep my stress level at anything less than extremely high. I don't know how they manage to do all they do on a long term basis. Thank God for them, because it really takes a special person to be able to handle that kind of work.

CoffeeRTC, BSN, RN

3,734 Posts

http://forums.studentdoctor.net/showthread.php?s=&threadid=109596

Just thought I'd post a link to the thread so everybody else would know what the heck we were talking about. :p

WOW! I just read thru that link. How offensive to nursing homes. Yes I am a LTC nurse, I wasn't the bottom of my class, nor the head and I do have common sense. I have seen many a bad situation in the nursing home and complain just like the EMS have, but never would I generalize like that. There are bad and good in every group. I do feel for the EMS when they come in it some of these bad homes. We have a few nurses where I work that I wouldn't let them take care of my fish :uhoh21: .

Although I haven't worked as an EMT I did get certified as one and have gone on a few runs with them. Yep... they put up the the same amt of bS that nurses do!

As far as the debate over sending DNRs to the hospital... as a nurse in LTC we are not the almighty gate keeper... if the resident needs attention and the doc/family/pt wants that done at the hospital...then so be it. Often times if it is something that we can do at the nursing home (Antibiotics, fluids) I suggest letting us treat at the home. But sometimes LTC facilities don't have the full range of services availble after hrs (XRAYs, labs, might be unable to start IVs or have nebulizer supplies ready) so I will send the resident to the hospital for an assessent or treatment....not a cure or heroic measure.

Well I will jump in from a purely observational point of view.

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.

Okay, you keep the pt at the nursing home, fight w/ the family, then said pt dies the next day and then on your days off 3 years from now, you can sit at a trial, be named as a defendant, and go through cross examination...

DO NOT fight w/ families on this...It's their right, their business, not yours!

BBFRN, BSN, PhD

3,779 Posts

Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

Could you be placed in a situation where you had to defend yourself in court, if the patient signed a DNR and was in sound mind when they did it? How does the wishes of the POA factor into this if the patient wanted a DNR, and the family doesn't? I've never had this happen to me- I was wondering if this happens to NH nurses. If this was a possible scenario, I'd probably send them out, too. Let the doctors handle something like that, and give all possible outcomes to the family to at least make sure they're educated on what decisions they want to make- even if they have to get admitted to the hospital to get it addressed.

CoffeeRTC, BSN, RN

3,734 Posts

Could you be placed in a situation where you had to defend yourself in court, if the patient signed a DNR and was in sound mind when they did it? How does the wishes of the POA factor into this if the patient wanted a DNR, and the family doesn't? I've never had this happen to me- I was wondering if this happens to NH nurses. If this was a possible scenario, I'd probably send them out, too. Let the doctors handle something like that, and give all possible outcomes to the family to at least make sure they're educated on what decisions they want to make- even if they have to get admitted to the hospital to get it addressed.

DNR

Do

Not

Rescesitate

Living Wills ( a little more specific on what the pt wants)

Sometimes our LTC residents have both but not always... most have a CPR consent or DNR order in their chart (If not they are a full code)

We all read and know that a DNR doesn't mean do not treat. For example... Say a person has dementia and other medical dx gets a bad UTI or Pneumonia... a few days of IV antibiotics would help and get this person some relief. Lets say the LTC facility isn't able to get an IV in, or doesn't have the drugs or their pharmacy won't be able to get the meds for a day or they don't have an XRAY service who will come out and do a chest on Sat eve. I will send that resident out to the hospital for treatment...Of course I will send all the paper work including living will and code status with them and make sure everyone knows. This is one senario where it is total appropriate to send a DNR to the hospital for treatment.

How many of us nurses say "I want to be DNR" don't even think about doing CPR on me! Some of us even have the paper work.... soooo does that mean if we get into an accident or maybe need to go to the hospital for treatment of an infection or something we shouldn't get treatment???? No.

We all have our opinion about what may be best for our pts, but who are we to say... ultimatly it is the pt and family who are legaly able to make thier own decisions.

Sorry for any typos!

Nurse2B73

53 Posts

Specializes in Med Assistant, EMT and CNA.

Hello everyone,

I am Shonda and I was interested what everyone was talking about here so I started reading. I am sort of shocked that EMTs were doing this.

I was an EMT for 8 years and I had friends who were nurses. I have not ever had that kind of encounter but I must say if you got the company name and the unit number for that vehicle make sure you call them and let them know. He could be disciplined big time or even fired. Companies do not tolerate behavior like that. I am taking a CNA course now and the EMTs that show up where we are seem to be ok. If any EMTs were to make in kind of those comments I would let them have it. For the time I have been an EMT I would have never ever created those thought and they should not either.

I am so sorry that you had to go through that with those idiots. There are some EMTs out there that think they are Gods gift to green earth and they know everything. The training is only 4 months and we learned very basic stuff live give O2, splint, CPR, reports, Glucose, tractions, fractures, some anatomy and explanation of different illness. But when it come to it we basically transport people from place to place. The have to become a paramedic if they want to be more than that. The things they train are things any civilian can do.

Well take care and I hope that you get the right person and he gets a good discipline action from the company.

God Bless

BBFRN, BSN, PhD

3,779 Posts

Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
DNR

Do

Not

Rescesitate

Living Wills ( a little more specific on what the pt wants)

Sometimes our LTC residents have both but not always... most have a CPR consent or DNR order in their chart (If not they are a full code)

We all read and know that a DNR doesn't mean do not treat. For example... Say a person has dementia and other medical dx gets a bad UTI or Pneumonia... a few days of IV antibiotics would help and get this person some relief. Lets say the LTC facility isn't able to get an IV in, or doesn't have the drugs or their pharmacy won't be able to get the meds for a day or they don't have an XRAY service who will come out and do a chest on Sat eve. I will send that resident out to the hospital for treatment...Of course I will send all the paper work including living will and code status with them and make sure everyone knows. This is one senario where it is total appropriate to send a DNR to the hospital for treatment.

How many of us nurses say "I want to be DNR" don't even think about doing CPR on me! Some of us even have the paper work.... soooo does that mean if we get into an accident or maybe need to go to the hospital for treatment of an infection or something we shouldn't get treatment???? No.

We all have our opinion about what may be best for our pts, but who are we to say... ultimatly it is the pt and family who are legaly able to make thier own decisions.

Sorry for any typos!

Oops- i think I need to clarify my original question to mean if the scenario is one of where the pt is a clear case of end-of-life. Not dehydrated, or in need of ABTs. If the patient has signed a DNR, and made their wishes known to the family, can the family's wishes legally take precedence over the patient's in a clear case of end-of-life? With all the litigious family members out there, I'd be taking the safest route possible, too. If that means sending the pt out, and annoying EMTs and hospital nurses, so be it.

Also, I can see where if the pt was having trouble and the Dr. wasn't available, why a NH nurse would choose to go ahead and send the pt out. I know you guys always call the ER and give them the low down on situations such as that, but us floor nurses don't receive that kind of info, so some of us might make assumptions as to why the pt was sent to the hospital. Thanks for shedding a little light on some of the reasons that we might not have thought about.

etmx5313

24 Posts

I am an RN from a small town near Omaha NE, working in LTC and just want to say, that apparently our EMS in our town are among the few AWESOME EMT's. I have had ONLY one bad experience with one specific EMT arguing with me about whether someones hip was broken.......it was..........she argued......I am wondering why--I don't think that x-ray vision was on the list of class requirements but anyway....the EMT's are great in our town. Always friendly, they really are a fun bunch of guys----but they know their stuff. They know what they are doing, are courteous to the nurses and do their job. I'm sure they have been occasionally rude to some nurses--but I guarantee they deserved it. I know that personally there are nurses that call EMS, fill out the paperwork, then just hand it to them and walk away. How about giving report, a little history on the resident. I understand their frustration in certain situations. I actually go with them to the resident's room, giving history as I go, giving any other pertinent history that they should know--especially VRE, MRSA, etc. Some nurses leave that out. I certainly would want to know this info. and I assist them to get the patient transferred and out the door. Sheesh--isn't this our job? It's too bad that many people have had such bad experiences--mine had been great!

etmx5313

24 Posts

Im not sure in your facility, but in our LTC, there is no way we can send someone out without a MD order. We would have our butts in a sling if we did that!!!

Oops- i think I need to clarify my original question to mean

if the scenario is one of where the pt is a clear case of end-of-life. Not dehydrated, or in need of ABTs. If the patient has signed a DNR, and made their wishes known to the family, can the family's wishes legally take precedence over the patient's in a clear case of end-of-life? With all the litigious family members out there, I'd be taking the safest route possible, too. If that means sending the pt out, and annoying EMTs and hospital nurses, so be it.

Also, I can see where if the pt was having trouble and the Dr. wasn't available, why a NH nurse would choose to go ahead and send the pt out. I know you guys always call the ER and give them the low down on situations such as that, but us floor nurses don't receive that kind of info, so some of us might make assumptions as to why the pt was sent to the hospital. Thanks for shedding a little light on some of the reasons that we might not have thought about.

etmx5313

24 Posts

Oh, and also our EMT's are great about starting IV's when we can't get one in. We try our best but if they are an impossible stick, we call EMS and they get it 99% of the time. And they are PLEASANT about it!! I actually enjoy seeing them there

Oops- i think I need to clarify my original question to mean if the scenario is one of where the pt is a clear case of end-of-life. Not dehydrated, or in need of ABTs. If the patient has signed a DNR, and made their wishes known to the family, can the family's wishes legally take precedence over the patient's in a clear case of end-of-life? With all the litigious family members out there, I'd be taking the safest route possible, too. If that means sending the pt out, and annoying EMTs and hospital nurses, so be it.

Also, I can see where if the pt was having trouble and the Dr. wasn't available, why a NH nurse would choose to go ahead and send the pt out. I know you guys always call the ER and give them the low down on situations such as that, but us floor nurses don't receive that kind of info, so some of us might make assumptions as to why the pt was sent to the hospital. Thanks for shedding a little light on some of the reasons that we might not have thought about.

CCU NRS

1,245 Posts

Okay, you keep the pt at the nursing home, fight w/ the family, then said pt dies the next day and then on your days off 3 years from now, you can sit at a trial, be named as a defendant, and go through cross examination...

DO NOT fight w/ families on this...It's their right, their business, not yours!

Actually I did not suggest fighting but educating, subtle difference, you see if you are thorough and explain that the Pt wished to be let to expire in a setting that is for all intents and purposes their home and that you understand how difficult this is for a family member and you may even feel the same way were your (add relative association here)dying but that as someone of sound mind the Pt had made his/her wishes clear and wanted no intervention, also explaining all the while that you will gladly send thier loved one to the hospital if they insist but with a DNR in effect they will not perform any heroic measures there either, and if this family memebr is not a Power of Attorney or legal guardian then they do not have the power to revoke the DNR leagally. My point being that sometimes these family members are just greiving and they feel that if their loved is taken to a hospital there will be some intervention that will miraculously save their loved one when the fact of the matter is that no interventions will be performed because this is what DNR means.

Now just in case there are doubts I am still expressing these thought regarding a DNR Pt that is in the last hours of life that can not be prolonged without, intubation, ventilation, BLS/ACLS and or other invasive measures that would go against a DNR, by all means if you have a Pt that is having acute Pnuemonia, or falls and breaks a hip I DO NOTexpect you to keep these Pts or withhold treatment, I am strictly speaking of DNR Pts that are dying and will die without interventions outlined in a DNR, Living Will or Advanced Directive.

If education is beyond your scope or fails then if a family member insists yes you will havce to do as they wish, I just think when death is inevitable sometimes education may prevent needless transfer of Pts to facilities that will be able to nothing anyway!

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...

'nuff said

oh, and education is within all of our scopes

and many times patients are admitted after hours, and an acute situation arises before the next BUSINESS day, and the waters are murky because no papers have been signed (they don't give me the key :p )

and much of the wording within advanced directives themselves are ambiguous, and allow for much interpretation...

a piece of advice CCU, I felt as you do before I went into LTC...I was the epitome of an ER nurse that hated LTCs and all of their "dumps"

It's one big bowl of ambiguity dude...I don't care if a cousin in the room is demanding the patient go to the hospital...A seed of doubt planted by a distant relative now, can grow into a giant weed of litigation...(though handing the cousin the phone may be all the facilitation I need provide) :rotfl:

sean

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