What's the deal with ER?

alabamaparamedic · Mar 20, 2011

Coming from an EMS perspective, sometimes we appear distracted, but that's usually because we're performing our own assessment, taking notes from what you're telling us, directing the actions of our junior partners, rearranging furniture in the room to fit the stretcher inside, and mentally forming a treatment plan. This I usually do within the first 5 min of patient contact, usually more quickly. I may appear distracted, but I'm usually paying better attention than I appear.

One way I make sure I have the correct information is to repeat the information back to the nurse and ask for clarification. It might seem that I'm just being dense, but I've corrected a lot of misunderstandings/transposed numbers that way :)

And I hope no one is offended when I recheck vitals...I'd be remiss if I didn't actually put my hands on a patient and perform my own assessment, although if the sending nurse has done a good job, it makes my job much easier!

As far as the ED goes...well, I can't explain that one, except from my personal experience. On occasion, I'll respond to a SNF for a call of "AMS". When asked exactly what is wrong, the nurse has told me "She's just asking differently". Despite my attempts at eliciting more specific info, I was told "It's hard to tell, she's just not herself". Keep in mind that I've never seen the patient a day in my life, and I have no idea as to what her baseline is. So, I transport the patient to the ER, present my findings, and when asked what the chief complaint, I reply "the nursing staff just said she was acting differently". The ED RN's roll their eyes at me, but there's nothing more I can say. So, the patient gets turfed back to the SNF after a series of generic tests, and the problem really doesn't get resolved like it should. Basically, it just really helps to articulate exactly what's wrong and how long it's been wrong for. I'm sure it can be hard to do if the change isn't something you can really put your finger on, but just be as specific as possible.

Also, something I really encourage the sending nurse to do is to call the ED yourself and give a quick verbal report to the ED RN. Y'all usually communicate with each other better than I do with the ED facility, simply because y'all speak a more common language (lab values, radiological tests, etc, that are a mystery to the average medic).

Nascar nurse, ASN, RN · Mar 20, 2011

What a nice response alabamaparamedic. No finger pointing, just an honest response as to how you see the situation and ways that ultimately help our residents.

JenniferSews · Mar 20, 2011

Coming from an EMS perspective, sometimes we appear distracted, but that's usually because we're performing our own assessment, taking notes from what you're telling us, directing the actions of our junior partners, rearranging furniture in the room to fit the stretcher inside, and mentally forming a treatment plan. This I usually do within the first 5 min of patient contact, usually more quickly. I may appear distracted, but I'm usually paying better attention than I appear.
One way I make sure I have the correct information is to repeat the information back to the nurse and ask for clarification. It might seem that I'm just being dense, but I've corrected a lot of misunderstandings/transposed numbers that way :)
And I hope no one is offended when I recheck vitals...I'd be remiss if I didn't actually put my hands on a patient and perform my own assessment, although if the sending nurse has done a good job, it makes my job much easier!
As far as the ED goes...well, I can't explain that one, except from my personal experience. On occasion, I'll respond to a SNF for a call of "AMS". When asked exactly what is wrong, the nurse has told me "She's just asking differently". Despite my attempts at eliciting more specific info, I was told "It's hard to tell, she's just not herself". Keep in mind that I've never seen the patient a day in my life, and I have no idea as to what her baseline is. So, I transport the patient to the ER, present my findings, and when asked what the chief complaint, I reply "the nursing staff just said she was acting differently". The ED RN's roll their eyes at me, but there's nothing more I can say. So, the patient gets turfed back to the SNF after a series of generic tests, and the problem really doesn't get resolved like it should. Basically, it just really helps to articulate exactly what's wrong and how long it's been wrong for. I'm sure it can be hard to do if the change isn't something you can really put your finger on, but just be as specific as possible.
Also, something I really encourage the sending nurse to do is to call the ED yourself and give a quick verbal report to the ED RN. Y'all usually communicate with each other better than I do with the ED facility, simply because y'all speak a more common language (lab values, radiological tests, etc, that are a mystery to the average medic).

This I understand to some extent. But when I'm tried to explain 3-4 times and the next set of EMS come in and ask what the situation is, the EMS in the room still don't seem to know but they still want to give report to the oncoming EMS. It's frustrating and teaches the nurses not to bother talking. We all get being frustrated by those transfers where the nurse doesn't really know the answers. But those transfers are rare in my facility and if a nurse does that twice with no outcome then the supervisor assesses before they are sent out.

On the other hand of course I expect you to do your own assessment. When another nurse comes to me with a question the first thing I do is assess the patient myself. I will give my vitals if I think someone wants them, but I expect you will be hooking up for your own set. I'm happy to wait until you are ready to listen but when you leave and not a single person has ever asked why we called 911 I wonder how that patient is ever going to get the care they need. Wouldn't knowing if they have a history of CHF and an EF of 15% be useful info when they are in respiratory distress?

As for calling report, I've tried it. I got a "why are you interrupting me with this nonsense, we are the ER and we will decide what is wrong" response and I never tried calling report again. You get tired of the "you aren't a real nurse" attitude. Although all of these issues are with ONE hospital now that I think about it. Maybe I should attempt it with the next transfer to somewhere else.

I guess I'm just a little frustrated today with people assuming we are too dumb to make good clinical judgements and use basic assessment skills. The leaving the O2 off thing was just beyond all!

alabamaparamedic · Mar 20, 2011

I can see where you would be frustrated...all I can do is offer my perspective.

As far as the "sets of EMS"...generally, there should only be two people, and those are the people transporting the patient. The person you need to give report to is the person who's going to be riding in the back with the patient, usually a paramedic but sometimes an EMT, depending on the city or the individual contract with your SNF.

If there are more than one "set of EMS" there, then that's unusual. If you called 911, you might wind up with a fire response as well as EMS. The fire engines will often have paramedics or EMTs on board, and since they usually have more convenient station locations, they can usually arrive before the transport service.

If I see an immediate life threat, I'm going to treat that ASAP, and I might only be listening to the nurse's report with half an ear at that time. Unfortunately, people in general weren't made to multitask...so if my ambulance partner (driver) is asking the sending nurse questions...and I'm focused on treating the patient, I might not hear the questions/answers, and I might ask again. Usually my partner is very good at filling me in (but bless her heart), she isn't a medic, and is still learning how to interpret information. So, I ask again. I've seen a few nurses become frustrated, and I can empathize. I'd just rather be sure I get the correct information than my partner's interpretation of it. I try to keep that from happening, by having my partner perform the initial assessment while I obtain report, but until I can figure out how to clone myself, that isn't always feasible :)

I don't know what EMS is like in your city; just giving a few explanations from my experience as to why you're getting that sort of treatment when you try to give report.

Other options...it might not hurt to learn a little bit about EMS in your city. Always helpful to find out if your SNF contracts for emergency/non-emergency calls, who they contract with, if an EMT or a paramedic is going to be coming out, if fire responds for 911 calls, etc. A wee bit of research might make your contacts with EMS go more smoothly. At least, if you know that, say...if you call 911, the city transports and the fire department shows up (multiple first responders tends to create a chaotic scene), but if you call the transport service via private line, only two well qualified people show up (much more controlled), then you can at least be more informed when you call for an ambulance.

In summary, the key is to find out who is actually transporting the patient and give the bulk of your report to them. If you really don't have faith in that particular medic's ability to remember what you said and correctly report it to the ED, write it down and include it in the transfer packet. I may forget the occasional detail, but I never forget to give the ED their paperwork! :)

Hope my midnight half asleep ramblings helped. Ultimately, we all just want the patient to get better :)

JenniferSews · Mar 20, 2011

Thanks for your advice paramedicalabama. When it is a true life or death emergency I couldn't care less whether I am completely ignored. It's those emergent but non life threatening calls that become an inpatient stay that bug me, especially when they come back with inpatient notes that don't reflect the reality of the patient. And sometimes my hands are tied. If a patients medical POA insists they be sent out despite the DNR and obvious end of life stage, I have to transport. It's not that I'm too stupid to realize what is happening.

For the EMS portion I will look into it and ask my local EMS friends how we can do better. As for the docs, I'm still at a loss. It's frustrating to not be taken seriously and have patients and families thinking we missed something so simple as turning on their oxygen.

Bill E. Rubin · Mar 20, 2011

The extent to which some physicians disrespect nurses can be an eye-opener at times. Combine this with the fact that many MD's may be spinelessly covering their own butts against litigation by blaming the nurses.

I was once sitting in rounds when an pt (not mine) who was about to be discharged came into the room, all agitated. It seems that a clinician was in his room showing him the results of some imaging study and explaining them to him while a visitor was in his room who happened to be a coworker of the pt's. The clinician was female, and the pt identified her as "a nurse or doctor."

The attending MD left the room to talk to the pt and returned telling the team that "some nurse" had done the aforementioned act and that the coworker in question blabbed the information at his place of employment and that it had ramifications for the pt's job.

While it is possible that it could have been a nurse, it is highly unlikely given the act (what nurse would do such a thing unless asked to by.a pt??) And more likely to be either a member of the medical team or a consult (I.e. An MD of some kind). He said he was going to file an incident report.

While an incident report is warranted in this case, his dismissing the culprit as "some nurse" rather than "a clinician" just made my blood boil.

ObtundedRN, BSN, RN · Mar 20, 2011

This I understand to some extent. But when I'm tried to explain 3-4 times and the next set of EMS come in and ask what the situation is, the EMS in the room still don't seem to know but they still want to give report to the oncoming EMS. It's frustrating and teaches the nurses not to bother talking. We all get being frustrated by those transfers where the nurse doesn't really know the answers. But those transfers are rare in my facility and if a nurse does that twice with no outcome then the supervisor assesses before they are sent out.

Perhaps the first set of EMS is your first responders. In my area, where I used to work EMS, the first responders are either paid city fire fighters or volunteer fire fighters. They have to be an EMT as well, but they never do transport. So their medical experience is usually very limited to either showing up, maybe getting a set of vitals, and then helping the EMS crew load the patient, or in a emergent case, helping with the same stuff plus maybe riding to the hospital in case the crew needs a driver or extra hand in the back. An EMT that works EMS transport will usually have a better idea of what you are telling them. An EMT that works on an ALS truck with a paramedic will usually have an even better idea of what is going on when you give report. I'm not trying to bad talk first responder EMTs but it really does come down to their experience with actual patient transport and care.

CapeCodMermaid, RN · Mar 20, 2011

We have the same problem here. After carefully assessing the resident, writing out a detailed 3 page referral, calling the ED and speaking to the person in charge, we STILL get comments back from the hospital that they had no clue why we sent the patient. I had one doctor write "The nursing home sent the patient with 4 different lists of medications. Only the most observant person would have seen they were different" DUH....there were 4 pages of medications because the resident took that many different pills. I was standing next to the nurse when she called to tell them why we sent the resident to the hospital and read the 3 page referral which was extremely well detailed. I made the medical director go to the hospital and speak to the chief of medicine. His answer "The new psychiatrist in the ED is crazy'.

We have guys who drive the ambulance that think they know more than anyone and come in with a swagger. Aren't we all supposed to be on the same side here?

As far as saying the resident isn't acting quite right.....my old medical director had students coming into the facility with him. I heard him say on more than one occasion "If one of these nurses tells you the resident just isn't acting right or they know there is something wrong but they can't put their finger on it, LISTEN to them."

I've also had ER nurses call and threaten the staff saying they were going to call the state. We sent a woman to the hospital with a fractured hip...pathological fracture. The ER nurse called and told the charge nurse that we must have lied...she said we either hit the woman or dropped her. I called her back and asked her to clarify what she had said. She said we must have dropped her or hit her because little old ladies don't just break bones. I told her to look around the ER until she saw Dr X the orthopedic surgeon. Then I told her to put down the phone and ask Dr X about pathological fractures in 98 year old women with significant osteoporosis. She finally came back to the phone and said the doctor told her there is such a thing...OMG! I told her never to threaten any of the nurses again. I had already started the report to the DPH.

Let's face it, we still have a long way to go before we are respected as nurses.

GM2RN · Mar 20, 2011

Coming from an EMS perspective, sometimes we appear distracted, but that's usually because we're performing our own assessment, taking notes from what you're telling us, directing the actions of our junior partners, rearranging furniture in the room to fit the stretcher inside, and mentally forming a treatment plan. This I usually do within the first 5 min of patient contact, usually more quickly. I may appear distracted, but I'm usually paying better attention than I appear.
One way I make sure I have the correct information is to repeat the information back to the nurse and ask for clarification. It might seem that I'm just being dense, but I've corrected a lot of misunderstandings/transposed numbers that way :)
And I hope no one is offended when I recheck vitals...I'd be remiss if I didn't actually put my hands on a patient and perform my own assessment, although if the sending nurse has done a good job, it makes my job much easier!
As far as the ED goes...well, I can't explain that one, except from my personal experience. On occasion, I'll respond to a SNF for a call of "AMS". When asked exactly what is wrong, the nurse has told me "She's just asking differently". Despite my attempts at eliciting more specific info, I was told "It's hard to tell, she's just not herself". Keep in mind that I've never seen the patient a day in my life, and I have no idea as to what her baseline is. So, I transport the patient to the ER, present my findings, and when asked what the chief complaint, I reply "the nursing staff just said she was acting differently". The ED RN's roll their eyes at me, but there's nothing more I can say. So, the patient gets turfed back to the SNF after a series of generic tests, and the problem really doesn't get resolved like it should. Basically, it just really helps to articulate exactly what's wrong and how long it's been wrong for. I'm sure it can be hard to do if the change isn't something you can really put your finger on, but just be as specific as possible.
Also, something I really encourage the sending nurse to do is to call the ED yourself and give a quick verbal report to the ED RN. Y'all usually communicate with each other better than I do with the ED facility, simply because y'all speak a more common language (lab values, radiological tests, etc, that are a mystery to the average medic).

As an ED nurse, I'd say that this post is spot on. You truly wouldn't believe how many patients we get with such vague complaints that we really have little to no idea what we should be looking for in trying to diagnose and treat these patients. We also get complaints reported by EMS (as told to them by the sending nurse) that are completely different than what patients sometimes report, for those who are oriented enough to tell us.

I have to absolutely agree with calling the ED to give a report yourself. It's much more helpful to get a first hand account of the complaint. Plus, it gives us the opportunity to ask questions when something is unclear.

MelissaLPN, ASN, LPN, RN · Mar 20, 2011

I work in both a SNF and an ER and I have seen first hand that the problem is everyone thinks they are right. For example I heard a MD in the ER tell a family member that a SNF gives trazadone to "incapacitate" the pt due to low staffing ratios. I was appalled. So then the family will probably go to their respective SNF and demand she stop receiving it. Meanwhile, mama will be up all night, asleep all day and the worst part is, mama probably took trazadone prior to admission to a SNF like most medicated elderly, or elderly in general.

To be fair on the ER/EMT's behalf, I have heard some pretty bad reports in my time. I try to share my assessment and VS obtained with emt, mostly they ignore me. Oh well. But I have taken report from nurses who do not even remember who their residents are. Let alone any type of assessment.

Its due to a lack of respect. I am not really sure how to fix that other than continue giving detailed reports, document information give to EMT and keep doing a good job.

debRN0417 · Mar 20, 2011

I don't have a problem with the ER nurses (used to be one), I have a problem with the doctors telling family members stuff that they have no valid evidence for. Then this causes the family to get all over the LTC that "the doctor said you all just about killed him" and crazy stuff like that. I have investigated WAAAAAYYY too many complaints that were the result of the physician, (not only just ER physicians- which don't get me wrong I have a great respect for physicians) telling something totally absurd to the family which was unsubstantiated, but caused a great deal problems.