Things LTC Nurses wish EMTs and Paramedics would understand.

[downsouthlaff]

The long lived what seems to be country wide rivalry between EMTs and Long Tern Care Nurses is an obvious one. Long into social media, you see EMT pages posting ridiculing memes about long term care facilities and the pooor nursing care provided. Visit and EMS forum, and you'll see threads doing the same.

As a former EMT, now LTC Nurse, I've come up with a list things that I do believe every LTC Nurse wished EMTs understood.

1. There's a big difference in quality of care when patient ratios are 2:1 rather than 1:40 plus. When an LTC Nurse doesn't know the answer to a question off the top of his/her head, doesn't know the events leading up to the emergency, I doesn't mean that they are lazy or incompetent, when you have 40 demanding residents, to give medications too, and loads of charting and other work to do, as a charge nurse, you will not know every detail about every resident every minute of the shift. Imagine getting to the hospital to give report on 1 patient and having 40 patients in the back of your ambulance.

2. We don't make the rules. Sometimes as EMTs you may think that just because a patient fell and has no S/S of head injury that the transport isn't necessary, but a doctors order is a doctors order. If a residents primary care physician orders an ER eval, then that's fina. There's nothing you can say that's gonna change the fact that my resident is going to the hospital. As a licensed nurse, I will not be standing in front of my state board at a hearing, having to explain why i refused to carry out a physicians order. I once told an EMT who was being difficult and causing a scene in the hallway, asking why we were sending a resident out for such a small not in his head, in such stormy conditions outside, " Because I'm not putting my license on the line by tellling Dr. Brown (not real name) that I am not sending his patient to the hospital, but you are more than welcome to do so,".

EMTs and Nurses play a very vital but very different part of healthcare today. And I do think that if we could be a little more understanding of each other's roles, responsibilities, obligations, and limitations, the ride for the resident from the LTC Facilty to the local ED may be a little less rocky.

[rallenwells, BSN, MSN, EMT-P, NP]

I am a Paramedic and an RN-BSN-CEN, working full time in a Level I Trauma Center EC as an RN and part time as a Paramedic on a Level I based ALS ambulance. On the ambulance we take all ALS calls, 911 calls and transports to and from LTC's. From my experience I can say, it is very frustrating to be called to a LTC for a patient that has fallen, is short of breath, cardiac arrest, AMS, etc. and face the following issues:

1. When you walk through the front door (which can take as much as ten minutes if it is late at night and the door is locked) and ask "where is the patient?" To which the response is "We don't know, we didn't call you, that must be another area." Once someone "points" we are directed to the area.

2. There is no nurse around when we arrive at the patient. Generally there is a tech, but their usual response to questions about the patient's welfare is "I don't know, you need to talk to the nurse." Then you must specifically ask, "where is the nurse?" To which you again receive the pointed finger."

3. Once the nurse arrives you ask her (if he problem is not obvious, i.e. cardiac arrest, shortness of breath) what the problem is and you listen to a list of issues, none of which are a reason to transport to the hospital. When you ask the nurse specifically, "why am I transporting this patient to the hospital today?" you get the (often) irritated and exasperated response, "because OUR doctor said to!" That is all well and good, but I still must have a specific chief complaint to chart and to give to the EC nurse and MD.

4. When you have a patient with dementia or Alzheimer's, altered mental status is not a chief complaint. Possible 60% of our transports from LTC's are for AMS on a patient with dementia or Alzheimer's. How does an altered patient have altered mental status?

5. We package the patient for transport, generally while the LTC staff watches without assisting in the lifting of the patient or the moving of any of the multiple pieces of furniture, etc in the room.

6. When asked, do you have any information on the patient to bring to the hospital, the staff member (nurse or tech) says either "what do you need" or "wait and I will get it." It's not that they didn't know we would need it when we were called.

7. The "information" is usually a photocopied sheet with the patients name, home address (from their old residence) and contact information of nearest relatives. Rarely (if ever) are we offered a specific document that states the pt. SS number, DOB, allergies, medications prescribed, medical conditions, phone number of attending physician, etc. If we are given one it is a copy of a fax of a copy of a fax that is barely legible.

This is just a few of the issues I've encountered time and again going to LTC's. I understand you carry a large case load. As a result of being a practicing RN and Paramedic I can appreciate having to juggle multiple tasks and patients. When EMS is called to a nursing home, as a general rule all we know is "person fell... possible cardiac arrest... shortness of breath, etc." We have no other information to go on.

From the emergency provider perspective the entire patient treatment experience would be handled much better if:

1. The nurse or an escort meets us at the door upon arrival to direct us personally to the patient.

2. The nurse or care provider is at bedside and available to give direction and answer questions about the patients conditions, past and present.

3. Nursing home staff is available to assist with packaging the patient. Many LTC's have very small patients rooms that are full of furniture and pt. belongings. This includes a bag for belongings a patient "must" bring with them.

4. A prepared document package for EMS that lists all contact information, including pt. personal information, prescribed medication list, pt. medical history including allergies and a signed copy of any Advanced Directive.

I understand we are all part of the long term care chain of continuum for our elderly and disabled. The concept "seek first to understand, then to be understood" is a very real concept in this case. We only ask that the LTC provider understand that EMS has no idea what is going on when we arrive. After wandering through a maze of hallways and wheelchairs we finally arrive at an unattended pt. We need information. It is incumbent upon the LTC provider to give us a clear, concise and competent report and documentation of the patient's status and CC for us to provide competent care to the patient.

The issue at hand is communication. The EMS provider needs to understand that the LTC provider is often overworked and "crazy" busy their entire shift. The LTC provider needs to understand EMS has no idea what is going on with the patient without a report and we have to provide a report to the EC nurse when we bring the patient into the hospital.

[knurse10]

A lot of demented patients who come from LTC with "altered mental status" end up having sepsis or pneumonia.... It is a valid reason to call for help.

[lindseylpn]

In my first week of working as a nurse I experienced my first death of a patient and had my first encounter with EMS. Shortly after shift change a CNA discovered a resident had passed, the patient had terminal cancer but, was a full code. The other nurse on the unit (an RN) and I started CPR and EMS was called. When EMS arrived they refused to transport the patient to the ER. The patient had been a frequent flyer to the ER, refused most treatments, wouldn't sign any advance directives and was terminal. The Dr was called by the EMT from the nurses station while we were still working with the patient, he brought the phone to the RN and the Dr gave an order over the phone for the RN to pronounce death. Policy was that an RN could pronounce death on a DNR but, a full code was to be transported to the hospital for a Dr to pronounce. The EMT ended up getting fired and the Dr supposedly got in trouble as well. This was like day 3 of working in LTC.

That was definitely the oddest encounter I've had with EMS. Some EMTs where known to be rude but, not all or even most that came to my LTC. One thing I did notice though was that most just didn't seem to understand how many patients we actually had or that we were very limited in what we could do, especially at night. With 25-55 patients to care for, several that may be very ill and one that isn't looking so good, that patient is going to the ER. I got asked several times by EMS "You can't treat this here?!" No, sorry I can't diagnose why this patient is running a 104 fever, having trouble breathing and walking or prescribe IV antibiotics etc. I can treat the symptoms but, the patient still needs a Dr. I've always heard, "When in doubt, send them out."

As far as being ready and waiting for EMS with the patient and all paperwork ready as mentioned by a poster above, we wish it could be that way too but, unfortunately it won't always happen like that. At my facility unless the patient was receiving CPR or in active distress we had so much to do before EMS arrived. We had to fill out about a half inch stack of paper which I liked to do at beside if possible, we had to call the patients Dr or the Dr on call and their next of kin, the ER to give report and we then had to go to the copy room and make copies of several items out of the chart, we were supposed to have all this completed when EMS arrived. They usually arrived when I was in the copy room. Luckily the copy room was next to the main entrance so, we'd hear them coming in. And of course this would always be the time another patient or three would fall or something else would happen. Sometimes another nurse would come over and help with the patient or the paperwork, we'd half ass fill it out in a hurry or we'd fax some of it over after EMS left and then later be reprimanded for it. Some Drs had orders too like, "Never send Dr. Paranoids patients to the ER without his consent, don't call the on call Dr. ever for his patients." or "Only send Dr. LostPrivileges patients to So and So Hospital (out of county)." That was a fun one, I once had a patient with a mental status change, severe pain under her leg cast, swelling and a high fever. The Dr only wants his patients to go to a hospital out of the county. I spent way more time than necessary trying to get this poor lady to the ER. In county EMS say they won't take her out of county, the other county's EMS says they won't come down to pick her up and the ER Dr at the in county hospital says he doesn't want to see any of Dr. LostPrivileges patients, ugh. She finally ended up getting treatment after the Drs hashed it out.

I haven't worked in LTC for a long time and hopefully things are different or better in another facility. Less hoops to jump thru when trying to send a patient out, etc. I work in a group home now and I can say that as long as I've worked here (11 years) I don't think I've ever encountered a rude EMT, paramedic, dispatcher, ER nurse when giving report or cop. If I have it didn't make an impression. Everyone has been super nice and totally understand that I'm the only one here and can't really do much in an emergency. Idk if it's because, it's a different town/county or because, I'm in a different field.

[lindseylpn]

I am a Paramedic and an RN-BSN-CEN, working full time in a Level I Trauma Center EC as an RN and part time as a Paramedic on a Level I based ALS ambulance. On the ambulance we take all ALS calls, 911 calls and transports to and from LTC's. From my experience I can say, it is very frustrating to be called to a LTC for a patient that has fallen, is short of breath, cardiac arrest, AMS, etc. and face the following issues:

1. When you walk through the front door (which can take as much as ten minutes if it is late at night and the door is locked) and ask "where is the patient?" To which the response is "We don't know, we didn't call you, that must be another area." Once someone "points" we are directed to the area.

2. There is no nurse around when we arrive at the patient. Generally there is a tech, but their usual response to questions about the patient's welfare is "I don't know, you need to talk to the nurse." Then you must specifically ask, "where is the nurse?" To which you again receive the pointed finger."

3. Once the nurse arrives you ask her (if he problem is not obvious, i.e. cardiac arrest, shortness of breath) what the problem is and you listen to a list of issues, none of which are a reason to transport to the hospital. When you ask the nurse specifically, "why am I transporting this patient to the hospital today?" you get the (often) irritated and exasperated response, "because OUR doctor said to!" That is all well and good, but I still must have a specific chief complaint to chart and to give to the EC nurse and MD.

4. When you have a patient with dementia or Alzheimer's, altered mental status is not a chief complaint. Possible 60% of our transports from LTC's are for AMS on a patient with dementia or Alzheimer's. How does an altered patient have altered mental status?

5. We package the patient for transport, generally while the LTC staff watches without assisting in the lifting of the patient or the moving of any of the multiple pieces of furniture, etc in the room.

6. When asked, do you have any information on the patient to bring to the hospital, the staff member (nurse or tech) says either "what do you need" or "wait and I will get it." It's not that they didn't know we would need it when we were called.

7. The "information" is usually a photocopied sheet with the patients name, home address (from their old residence) and contact information of nearest relatives. Rarely (if ever) are we offered a specific document that states the pt. SS number, DOB, allergies, medications prescribed, medical conditions, phone number of attending physician, etc. If we are given one it is a copy of a fax of a copy of a fax that is barely legible.

This is just a few of the issues I've encountered time and again going to LTC's. I understand you carry a large case load. As a result of being a practicing RN and Paramedic I can appreciate having to juggle multiple tasks and patients. When EMS is called to a nursing home, as a general rule all we know is "person fell... possible cardiac arrest... shortness of breath, etc." We have no other information to go on.

From the emergency provider perspective the entire patient treatment experience would be handled much better if:

1. The nurse or an escort meets us at the door upon arrival to direct us personally to the patient.

2. The nurse or care provider is at bedside and available to give direction and answer questions about the patients conditions, past and present.

3. Nursing home staff is available to assist with packaging the patient. Many LTC's have very small patients rooms that are full of furniture and pt. belongings. This includes a bag for belongings a patient "must" bring with them.

4. A prepared document package for EMS that lists all contact information, including pt. personal information, prescribed medication list, pt. medical history including allergies and a signed copy of any Advanced Directive.

I understand we are all part of the long term care chain of continuum for our elderly and disabled. The concept "seek first to understand, then to be understood" is a very real concept in this case. We only ask that the LTC provider understand that EMS has no idea what is going on when we arrive. After wandering through a maze of hallways and wheelchairs we finally arrive at an unattended pt. We need information. It is incumbent upon the LTC provider to give us a clear, concise and competent report and documentation of the patient's status and CC for us to provide competent care to the patient.

The issue at hand is communication. The EMS provider needs to understand that the LTC provider is often overworked and "crazy" busy their entire shift. The LTC provider needs to understand EMS has no idea what is going on with the patient without a report and we have to provide a report to the EC nurse when we bring the patient into the hospital.

An altered mental status on a patient that already has an "altered mental status" could be lots of things, increased agitation, lethargy, they stopped talking or are talking more. Anything that's different from their norm. I've had a patient for 11 years that is profoundly developmentaly disabled and non verbal. If I were to say to you in report that she's not been rolling her eyes , flexing her neck, grunting or blowing air for a few days that might not mean anything to you but, it means a lot to me. It means something is wrong with her. The last time she had a mental status change, she was having an adverse reaction to a med, coded twice and spent weeks in the ICU.

[CoffeeRTC, BSN, RN]

While I never practiced as an EMT, I had taken the classes, did the ride alongs and got certified. I see EMS point of view. I've also been the only nurse on duty taking care of 50 residents with needs.

When your local EMS has the same type of issue with the local LTC, has your director ever voiced their concerns with the administration of that facility? I strongly urge you to have a meeting or at least a call with the DON. Some nurses are just clueless on the life of an EMT or Paramedic. It doesn't need to be an us verse them. We have a great relationship with our local service (including the 911 services).

Nurses....if you see EMS treating your nurses like crap...get to the bottom of it. Call them out. yeah, some folks just have a bad day.

If we call EMS, we work as a team. CNAs know to get the room ready (clear out all the WC, chairs, bedside tables etc) and to get the resident ready (clean gown and brief) if we have more than one nurse on...we take turns getting the papers ready and taking care of the resident. Have someone greet the medics when they come in. yeah...all of this is thrown to the side in a true 911 emergency code.

We just recently had a 911 code. CPR was started, defib uses EMS arrived on the scene and took over. While I wasn't around for this one, in the past, after it was done..we would reach out to the EMS team and ask for feed back. Sometimes it isn't nice to hear the negative critic, but it is good to learn from these situations.

[downsouthlaff, LPN]

Your generalization about LTC Nurses and broad lack of respect is unfair based on a few bad examples ! That's like me saying that I lack respect for all EMTs and paramedics simply because there's usually 2 providers to one patient and they'll never understand bigger patient loads ? What kind of sense would that make ! Have you ever considered working as an LTC Nurse with 40 demanding patients, working every minute of 8 hours without a break and then some? Yes when, the game changes when it's one provide to. 40 patients ! I love to see you and a lot of paramedics like yourself work just one shift in LTC. Bet your tone and perspective change real quick !

[downsouthlaff, LPN]

I am a Paramedic and an RN-BSN-CEN, working full time in a Level I Trauma Center EC as an RN and part time as a Paramedic on a Level I based ALS ambulance. On the ambulance we take all ALS calls, 911 calls and transports to and from LTC's. From my experience I can say, it is very frustrating to be called to a LTC for a patient that has fallen, is short of breath, cardiac arrest, AMS, etc. and face the following issues:

1. When you walk through the front door (which can take as much as ten minutes if it is late at night and the door is locked) and ask "where is the patient?" To which the response is "We don't know, we didn't call you, that must be another area." Once someone "points" we are directed to the area.

2. There is no nurse around when we arrive at the patient. Generally there is a tech, but their usual response to questions about the patient's welfare is "I don't know, you need to talk to the nurse." Then you must specifically ask, "where is the nurse?" To which you again receive the pointed finger."

3. Once the nurse arrives you ask her (if he problem is not obvious, i.e. cardiac arrest, shortness of breath) what the problem is and you listen to a list of issues, none of which are a reason to transport to the hospital. When you ask the nurse specifically, "why am I transporting this patient to the hospital today?" you get the (often) irritated and exasperated response, "because OUR doctor said to!" That is all well and good, but I still must have a specific chief complaint to chart and to give to the EC nurse and MD.

4. When you have a patient with dementia or Alzheimer's, altered mental status is not a chief complaint. Possible 60% of our transports from LTC's are for AMS on a patient with dementia or Alzheimer's. How does an altered patient have altered mental status?

5. We package the patient for transport, generally while the LTC staff watches without assisting in the lifting of the patient or the moving of any of the multiple pieces of furniture, etc in the room.

6. When asked, do you have any information on the patient to bring to the hospital, the staff member (nurse or tech) says either "what do you need" or "wait and I will get it." It's not that they didn't know we would need it when we were called.

7. The "information" is usually a photocopied sheet with the patients name, home address (from their old residence) and contact information of nearest relatives. Rarely (if ever) are we offered a specific document that states the pt. SS number, DOB, allergies, medications prescribed, medical conditions, phone number of attending physician, etc. If we are given one it is a copy of a fax of a copy of a fax that is barely legible.

This is just a few of the issues I've encountered time and again going to LTC's. I understand you carry a large case load. As a result of being a practicing RN and Paramedic I can appreciate having to juggle multiple tasks and patients. When EMS is called to a nursing home, as a general rule all we know is "person fell... possible cardiac arrest... shortness of breath, etc." We have no other information to go on.

From the emergency provider perspective the entire patient treatment experience would be handled much better if:

1. The nurse or an escort meets us at the door upon arrival to direct us personally to the patient.

2. The nurse or care provider is at bedside and available to give direction and answer questions about the patients conditions, past and present.

3. Nursing home staff is available to assist with packaging the patient. Many LTC's have very small patients rooms that are full of furniture and pt. belongings. This includes a bag for belongings a patient "must" bring with them.

4. A prepared document package for EMS that lists all contact information, including pt. personal information, prescribed medication list, pt. medical history including allergies and a signed copy of any Advanced Directive.

I understand we are all part of the long term care chain of continuum for our elderly and disabled. The concept "seek first to understand, then to be understood" is a very real concept in this case. We only ask that the LTC provider understand that EMS has no idea what is going on when we arrive. After wandering through a maze of hallways and wheelchairs we finally arrive at an unattended pt. We need information. It is incumbent upon the LTC provider to give us a clear, concise and competent report and documentation of the patient's status and CC for us to provide competent care to the patient.

The issue at hand is communication. The EMS provider needs to understand that the LTC provider is often overworked and "crazy" busy their entire shift. The LTC provider needs to understand EMS has no idea what is going on with the patient without a report and we have to provide a report to the EC nurse when we bring the patient into the hospital.

Sorry dude but no an LTC Nurse can not be at the bedside of a resident patiently waiting for you to arrive. We don't have 30 minutes to wait for you when we are already staying sometimes hours over Pitt shift completing work. We have strict windows with med passes, labs and physician orders to take care of and 35 other patients, other patients and families summoning our assist elsewhere. As a former EMT who was educated on emergency protocol, when did they start teaching in EMS training that when EMTs walk into a call everything will be nice and organized ! Is it like that for regular calls ? I think not.

[CrazyGoonRN]

I agree 100% with everything you said. I was a LTC LPN for 3 years and I had many frustraing encounters with EMT's. My supervisor would get mad and tell them to just "load and go" because that is their job. I am now a critical care RN and I have no more than 1-3 patients at a time and it is very different. I am treated with much more respect by the EMT's and paramedics than I was as a LTC LPN. There is absolutly no reason that I should have been treated so poorly by them when I worked in LTC. IN LTC nurses rarely ever know the entire medical history of their patients because it is not practical when you have 30-40 during one shift. I remember running non stop for 12-16 hours when in LTC and never getting a break. I sure didn't have time to look up medical history on any of my patients.