tension between EMT and LTC nurses?

hogan4736, BSN, RN · Mar 22, 2004

...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...

oh, OKAY, why didn't I think of that??? :angryfire

I tried that my first day as charge nurse in my LTC, let's just say the family didn't see eye to eye w/ your little speech...I learned my lesson quick

As you said:"I never have worked LTC so I can't say how things go..."

you're right, you haven't done it, and you really can't say how things go...it doesn't work that way...maybe someday in your Utopia, but for now...

I do agree w/ you in principle, but it usually doesn't pan out that way :)

And lest you think I don't fight for the patient who is a DNR, but I have found that the family will call 911 anyway if there is doubt in anyone's mind, so...

Let's work on better wording and more specific dialogue within a DNR

sean

smk1, LPN · Mar 22, 2004

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.
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.

thanks for providing the link i didn't know if that was ok or not... anyway i am not a nurse yet so i have no comment about whether the nurses in the ltc were performing the proper interventions etc.. i mainly was just a bit taken aback by the attitude that i saw in many of the posters and the fact that not many took up for nursing over there in that forum. lots of generalization over there but oh well.

CCU NRS · Mar 22, 2004

oh, OKAY, why didn't I think of that??? :angryfire
I tried that my first day as charge nurse in my LTC, let's just say the family didn't see eye to eye w/ your little speech...I learned my lesson quick
As you said:"I never have worked LTC so I can't say how things go..."
you're right, you haven't done it, and you really can't say how things go...it doesn't work that way...maybe someday in your Utopia, but for now...
I do agree w/ you in principle, but it usually doesn't pan out that way :)
And lest you think I don't fight for the patient who is a DNR, but I have found that the family will call 911 anyway if there is doubt in anyone's mind, so...
Let's work on better wording and more specific dialogue within a DNR
sean

You seem awfully ticked about my simple suggestion for education, I never put down LTC care or nurses, I just think that most people when they understand a subject better will be more likely to accept things as they are, I explain many things to many people in my capacity as a CCU nurse and not the least of which is death and dying, I was not trying to offend you it just seemed that you were stating I said to argue with families when all I said was attempt to educate them. I do beleive that if DNR is explained properly and a person is not just hysterical with grief then it should be evident that transfering a dying Pt will not help in any manner. Maybe some people simply will not see the reasoning but I feel that most people of reasonable intelligence would.

CCU NRS · Mar 22, 2004

'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 )
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

Education is within all our scope but if one does not understand a subject thoroughly enough to attemtp to educate then it may be beyond one's particular scope.

I am not saying you don't understand DNR or any subject, I don't even know you my statement was given in the spirit of what I have written above. Just because something is protected under one's scope of practice does not mean that every person is capable of performing this task and or including it in their "scope"

Never did i state either that I hate LTC or imply LTC's dump Pts I simply stated that a DNR Pt experiencing Kussmaul resp with only hours to live should probably not be transfered and if DNR should definately not go to a CCU bed

hogan4736, BSN, RN · Mar 22, 2004

CCU, in their (the families') defense, they have the family member dying...it's easy for us to think logically...that's all I'm saying...

Like I said, I agree w/ you, it's just not usually how it goes down...One family member will want to be heroic, and others will follow...

gingerzoe · Mar 22, 2004

I was an EMT and a Paramedic at the same time I was an LPN. I went through EMT training after I was an LPN. They get extensive training on what to do in an emergency. THe extended care they know little about. When you are an EMT it is all about the adrenalin rush you get from knowing there was an accident/problem..Patients from nursing homes, let's face it are not real exciting. I enjoyed my four years as an emergency response person. I also have experience in working LTC, so I see two sides of the story. And, I did have an EMT yell at me after I called him about an elderly resident having a hard time breathing...He had a hx of copd and was on 2L of oxygen, the EMT told me to crank the oxygen up to 10L a minute... I said no I would not do that..then he basically told me I was a moron. I did get his name and wrote a complaint. His supervisor call our facility and told me to expect an apology. I never got one...so I guess the moral of the story is there are good ones and bad ones just like in every other profession.

CoffeeRTC, BSN, RN · Mar 23, 2004

Did anyone check out that link that was posted. The one that got this whole discusion started? I think that was one of the most offensive things I have read reguarding any nurse. Like I said before... I've seen bad nurses everywhere, but to generalize like that........

Someone mentioned education.... what about having the director of EMS services inservice the staff at the nursing homes on what they need for transporting or treating the residents.... I did this for our nurses and noticed that things went a little easier. Things you may want to include is what service to call, when to call, what info is need in verbal and written report to the EMT or paramedic (pt age, name, cheif complaint, list of current dx, meds, treatment, allergies, and a little psych/ social review) also calling the hospital with report and family notification.

You know the old saying...get more bees with honey.... well it works. Most of our paramedics at the service we use will help us more than they should. (start IVs or get blood from some hard stick)

BBFRN, BSN, PhD · Mar 23, 2004

I didn't see anything worse on the thread than what we say about Drs, CNAs, administrators, or each other at times when we vent on this board. Maybe a couple of the LTC nurses on here could go over there and give them a bit of education?

Tutti · Mar 23, 2004

Many of the nurses at an assisted living facility I used to work at have had bad reports about the EMT's when they arrive. Sometimes the nurses don't know the meds these Pts. take because they self admimister. It's their home. So when the nurse responds to an emergency in someone's apartment, she responds as if she is finding someone in their own home.

On a personal note, when I was called to my 7yr old's school because she was dizzy and falling down and was unsafe to put her on the bus, I came to find her verbally unreponsive, sitting on the floor, falling over every which way, couldn't hold her head up, abnormal movements. Very scary. When the EMT's arrived (15 min. later), as soon as they heard my baby had a mental illness, they said, oh, well that's a behavioral thing, there's nothing we can do about that. Excuse, me, someone with a mental illness can't be sick, or as in her case toxic from her medication, which I informed them she had an increase of dose and had not eaten in 2 days. I could not drive her safely in her condition. At least the ambulance gave us a ride home, so I could observe her while I decided what I wanted to do. What a nightmare!

flashpoint · Mar 23, 2004

EMS is not all about the adrenaline rush...yes, we get plenty of the, but an experinced EMT learns to keep the rush in check. Most of my expereinces at LTCs are pretty positive. It does make me angry when we show up and the nurses or CNAs start telling us how to do our jobs, though. The LTC nurse called US because the resident was in a situation that she or the facility was unable to handle appropriately. Don't tell us not to put oxygen on the patient or how to start an IV or ask us to wait while you put the resident's dentures in or finish shaving them, etc. If you called 911, it is an EMERGENCY...treat it like one...be there to give the crew report and assist the crew as needed...the LTC is a health care facility...we should expect more (and actually get more) than when we go to a private home...give us a med list, give us a report of WHY we are transporting this resident, but don't tell us how to do our jobs and don't panic when we give O2 to a COPD patient...we ARE trained professionals, just like YOU are.

Medic946RN · Mar 23, 2004

I think my greatest tension between myself when practicing as a paramedic and the LTC nursing staff was that in 25 yrs of EMS I can count on one hand the number of times I have been met in the pt's room by the pt's nurse and given a decent report. The vast majority of the time I have been waved past the nurses station or had a room number shouted out me, only to find two, or even three elderly people with what I would diagnose as altered mental status. I always have to send my partner back out to the nurses station to find the nurse, then they send one down who gives the old song and dance about "this isn't my patient, I don't usually work on this floor, wing etc" "Why are you asking me all these questions?" You know stuff like, hx allergies, meds, baseline mental status. They never have the paperwork ready for you. The pt has been suffering with this condition for hours while they tried to contact the MD, but no one has had the foresight to copy his chart. Then they seal it in an envelope and tell you not to open it, only the Hospital can have that info. They entire time they're shooshing you out the door like a flock of recalcitrant chickens. And don't even start me on the times I've had to do simple things like suction a patient, or give a diabetic with a BS of 26 (which they hadn't caught) an amp of D50 while they stood around, clucked their tongues and tapped their shoes because " I was playing doctor"

It always seemed that instead being part of the continuum of care for this pt that me and my crew and even the pt were a major inconvenience for them. I've taken pt's out of LTC's in three states and it never varies.

flashpoint · Mar 23, 2004

Medic946RN...you said it better than I ever could...