# EMS vs Nurses



## ParamedicLuvnNurse (Nov 21, 2011)

If you can't tell by the name already I'm a Paramedic loving Nurse. That's right, my husband is a Paramedic and I fully support him in his career and admire him for the work he does.  

I work in Long-term Care. It's not what I want, but it's where I am at until I finish up my degree and move forward to somewhere more desirable. 

I guess this thread is mainly to give all of you support and let you know that not all nurse's are trying to dump their resident's off on you for minor issues. My husband has been frustrated so many times for this very reason and all I can do is sympathize. 

I try my best to keep my residents in the building for the following reasons: 

#1 I hate the paperwork that comes with it, and there is a ton of it! 
#2 I can put ice on a bump or bruise and call X-ray out for an exam. I can utilize my knowledge, resources, nursing interventions and such. This makes me feel stronger and smarter, thus why I do it.   
#3 I'm all about keeping down cost towards Medicare and Medicaid!!

I have been given the cold shoulder so many times by EMS crews when they enter our facility to pick up a resident. When our MD's give us an order to send someone out even as minor and ridiculous as it sounds to us, we do it. Deviating from a MD's order (FYI, every resident that leaves a facility gets this order unless it's a dire emergency and we send out first, then contact MD) would cost us not only our jobs, but our licenses. Not seeing that a resident receives the treatment that is ordered is considered abuse and neglect, the same for you all I'm sure. Sending someone out with an obvious minor injury without consulting the MD will also have a nurse in trouble with the state. 

I personally appreciate you all because you ARE important to the nurse's that care and the one's who want to see healthcare make changes for the better. 

Smile when you see a nurse even if she doesn't smile back. It could mean the world to her/him that day because nursing is rough and you have to be tough as nails to survive it. We lose ourselves each day in protecting ourselves from other nurse's and keeping our jobs secure. Nursing is very ruthless and cut throat, so that is where the negative attitudes are coming from that you all see. I have spoken to my fellow nurse's about this and the attitudes have nothing to do with EMS crews, but they unfortunately take a beating from whatever the nurse is going through internally at that moment. For that, I am sorry for whoever has experienced such.  

It's definitely not roses. I think I am severely underpaid. Many days I wish there was something mindless I could do to earn a living like - basket weaving!


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## Handsome Robb (Nov 21, 2011)

I think a main thing that causes friction between nurses and paramedics beyond patient care is that many nurses look down at paramedics, somewhat to the view of "you couldn't hack it in nursing school so your a medic" type of thing. Yes our education is substandard with the select few medic programs going above and beyond, but when you look at it we have similar education when it comes to emergent problems. In fact the education of a paramedic may exceed that of a nurse in true emergent situations. 

I applaud you for your recognition of the problem and your efforts to be friendly towards EMS crews. The issue in my experience is nurses, either LPNs or RNs detachment when we are around. It always seems to be "The doctor ordered the transfer, get out of here with the patient" type of attitude in my experiences. I do agree that EMS crews need to be more friendly towards facility staff as well, it's a two-way street. 

I'll put a disclaimer on my post: I work 911 but there is no IFT company here, we do all IFTs, although the only thing that really gets transferred from hospital to hospital is traumas, all SNF calls come in as 911 calls.


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## RocketMedic (Nov 21, 2011)

Many times, we as EMS run into nurses who give incomplete, wrong, or downright negligent treatment and reports. I've watched an ER nurse transfer a CHFer out on 2l via NRB "because it's like a cannula if he's a mouthbreather". I've watched a nurse in the same facility (William Beaumont AMC) literally ignore a man in his late 80s having an MI and getting paler, and another one take nearly thirty minutes to even call for CPAP for a man who really, really needed it. I've seen nurses who literally don't know how to give D50 or Glucagon. 

I know there's great nurses, but you can see it from our side- we often make less than you, and we often see nurses at their worst...so you can see where we complain from.


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## RocketMedic (Nov 21, 2011)

NVRob said:


> I think a main thing that causes friction between nurses and paramedics beyond patient care is that many nurses look down at paramedics, somewhat to the view of "you couldn't hack it in nursing school so your a medic" type of thing. Yes our education is substandard with the select few medic programs going above and beyond, but when you look at it we have similar education when it comes to emergent problems. In fact the education of a paramedic may exceed that of a nurse in true emergent situations.
> 
> I applaud you for your recognition of the problem and your efforts to be friendly towards EMS crews. The issue in my experience is nurses, either LPNs or RNs detachment when we are around. It always seems to be "The doctor ordered the transfer, get out of here with the patient" type of attitude in my experiences. I do agree that EMS crews need to be more friendly towards facility staff as well, it's a two-way street.
> 
> I'll put a disclaimer on my post: I work 911 but there is no IFT company here, we do all IFTs, although the only thing that really gets transferred from hospital to hospital is traumas, all SNF calls come in as 911 calls.



This. So this. Way, way too many nurses look at us like quasi-skilled labor. It breeds hostility between us when one party thinks of us as too dumb to be in their shoes. To that, I say that EMS is probably more difficult in terms of true emergent situations.


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## Shishkabob (Nov 21, 2011)

This type of thing gets beat to death, so I'll say one thing:


My favorite nurse?  The nurse who is also a Paramedic.  I've yet to meet one that wasn't good at their job, whilest I've my fair share of nurses AND medics who are retarded beyond belief.


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## abckidsmom (Nov 21, 2011)

Linuss said:


> This type of thing gets beat to death, so I'll say one thing:
> 
> 
> My favorite nurse?  The nurse who is also a Paramedic.  I've yet to meet one that wasn't good at their job, whilest I've my fair share of nurses AND medics who are retarded beyond belief.



I agree.  Nurse/paramedics are a rare breed.


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## Handsome Robb (Nov 21, 2011)

Rocketmedic40 said:


> This. So this. Way, way too many nurses look at us like quasi-skilled labor. It breeds hostility between us when one party thinks of us as too dumb to be in their shoes. To that, I say that EMS is probably more difficult in terms of true emergent situations.



I'll play devil's advocate and say that long term care is more difficult than emergent care. We fix life threats and save lives occasionally however nurses deal with the trainwrecks we bring them from days, weeks or even months. I have a ton of respect for nurses but I don't take kindly to be disrespected by them or anyone else.

As for negligent care it happens prehospital, inhospital and in long term care homes. It shouldn't but it does happen. A coworker of mine ran on a "cardiac arrest CPR in progress" not too long ago. They show up to find an 88 yo female postictal enduring CPR. They were called to the same SNF 2 weeks later for a different patient, stopped to check on the 88 yo. She had circumferential bruising along with multiple broken ribs and was now bedridden due to her injuries sustained during the CPR that wasn't indicated....


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## JPINFV (Nov 21, 2011)

NVRob said:


> I think a main thing that causes friction between nurses and paramedics beyond patient care is that many nurses look down at paramedics, somewhat to the view of "you couldn't hack it in nursing school so your a medic" type of thing.



Meh, just remind those nurses that they're only nurses because they couldn't hack it in medical school.


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## Shishkabob (Nov 21, 2011)

JPINFV said:


> Meh, just remind those nurses that they're only nurses because they couldn't hack it in medical school.



My medical director is a Paramedic, RN and DO.  Worked as all 3 too, in that order.  Keeps up his certs and runs calls out in the field with crews consistently.  He has a habit of asking the Paramedic for 5 differentials during a call 


:unsure:


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## Handsome Robb (Nov 21, 2011)

Linuss said:


> My medical director is a Paramedic, RN and DO.  Worked as all 3 too, in that order.  Keeps up his certs and runs calls out in the field with crews consistently.  He has a habit of asking the Paramedic for 5 differentials during a call
> 
> 
> :unsure:



Now that's awesome. My friend's sister has been a CICU nurse for 6 years. She admits that when she rides with her brother she is completely lost on a scene. While we all practice medicine, we all practice very different forms of medicine. All that matters is that someone recognizes when they are out of their element.


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## STXmedic (Nov 21, 2011)

Linuss said:


> My medical director is a Paramedic, RN and DO.  Worked as all 3 too, in that order.  Keeps up his certs and runs calls out in the field with crews consistently.  He has a habit of asking the Paramedic for 5 differentials during a call
> 
> 
> :unsure:



Your medical director is awesome. I've met him a couple times; he always treats you with respect and without the superiority complex. Sat in on a sepsis speech from him a few months back that was awesome.


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## FourLoko (Nov 21, 2011)

Going to post then come back and read. 

I'd be happy if we actually had doctors asking for patients to be taken to the hospital. What usually happens is we come to pick up patients for dialysis who are routinely neglected by both nurse and respiratory therapist staff.

For example the patient we encountered with a BP of 190/100 when we show up. "Oh she got her meds" says the nurse. PT also in pain. Nurse proceeds to try and pump some new meds via Gtube. Doesn't work, Gtube is not working properly.

Should have been noted in the morning. Didn't take an RN or MD to realize the meds for BP and pain weren't being administered properly. We had to wait nearly 2 hours before we were finally able to get the paperwork to take this patient to the ER instead of dialysis.


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## DrParasite (Nov 21, 2011)

Rocketmedic40 said:


> Many times, we as EMS run into nurses who give incomplete, wrong, or downright negligent treatment and reports. I've watched an ER nurse transfer a CHFer out on 2l via NRB "because it's like a cannula if he's a mouthbreather". I've watched a nurse in the same facility (William Beaumont AMC) literally ignore a man in his late 80s having an MI and getting paler, and another one take nearly thirty minutes to even call for CPAP for a man who really, really needed it. I've seen nurses who literally don't know how to give D50 or Glucagon.


To be honest, that annoys me, because it is detrimental to the patient.  Or the cold and dead patient in the SNF who "was fine 10 minutes ago when I checked on them."  Yeah they ice up and have rigor start in that 10 minutes.

What annoys me to no end is when a facility calls 911, and then isn't ready for EMS when we arrive.   That means the chart isn't copied, no interventions have been done, the transfer form is all filled out or the nurse is no where to be found to give EMS a report of what is happening.  it takes between 4 and 11 minutes for EMS to arrive to a life threatening emergency (from the time the 911 call is made), and most of the time, EMS is going to be in and out in less than 30 minutes.  

If the nurse has the chart copied, the transfer sheet filled out, has done SOMETHING for the patient, and greets EMS at the patient's door with a report on the situation and what they have done and then steps back and lets EMS do their thing (but sticks around in case we have any questions), I am happy.  Even if they don't do the right thing, at least it gives me the information to do my job properly.

I understand that almost everything a SNF nurse does is at the doctor's order (running joke is a nurse can't fart unless a doctor says she can), and they get in trouble for deviating.  Personally, requesting an IFT truck from who knows where for a chest pain or seizure patient, and a 911 truck for a patient with a fever for 2 days annoys me, but I know often the doctor makes the call not the nurse.  

We all have our rules and our protocols, and sometimes they suck and handcuff you more than you want, but if you (the nurse) calls me, be ready for me so I can do my job.  don't hold me up because you haven't made the 911 emergency your priority, especially when you have given me a sick patient.


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## rmabrey (Nov 21, 2011)

Ive had my fair share of Nurses that look down on us and tell us we arent allowed to do things (look at the Pt's records, start Iv's, give meds).

Usually these are the same RN's that are Trying to bring a patient out of a seizure by running a VNS magnet over port access :rofl:, or wonder why a patient is unresponsive when they basically OD'd them.


But for the most part the nurses treat us with respect, and we do the same (even to the problem nurses, cause they will complain on us)


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## usalsfyre (Nov 21, 2011)

Beating up on LTC nurses is the national EMS pastime. Much of it stems from misunderstanding. Much of it also stems from the godawful care and excuses for said care that is all too common in these facilities (it's 2am, there's no way in hell you just got here, I saw you yesterday so you weren't on vacation and your one of two nurses in the facility tonight so it's probably your patient). 

That said....among the paramedics in here, who thinks they could handle a 50:1 ratio, while supervising the equivalent of multiple EMT-Bs and having to ring up med control (who's off duty) everytime something unforeseen happens? Because I couldn't, and that's commonly what RNs and LVNs in LTC are facing.


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## JPINFV (Nov 21, 2011)

Linuss said:


> My medical director is a Paramedic, RN and DO.  Worked as all 3 too, in that order.  Keeps up his certs and runs calls out in the field with crews consistently.  He has a habit of asking the Paramedic for 5 differentials during a call
> 
> 
> :unsure:



I'd love to be a fly on the wall the next time a RN question's that paramedic's treatment decisions rudely. 

[youtube]LqeC3BPYTmE[/youtube]


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## Handsome Robb (Nov 22, 2011)

JPINFV said:


> I'd love to be a fly on the wall the next time a RN question's that paramedic's treatment decisions rudely.



"What do you think your a doctor or something!?"
"Actually, I am a doctor, and a RN, and a Paramedic..."
cue awkward silence...

Haha


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## JPINFV (Nov 22, 2011)

NVRob said:


> "What do you think your a doctor or something!?"
> "Actually, I am a doctor, and a RN, and a Paramedic..."
> cue awkward silence...
> 
> Haha



RN mad about the patient getting more than 3 doses of nitro: "...and where did you go to medical school?"

Paramedic in a deadpan voice: "Harvard."


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## Akulahawk (Nov 22, 2011)

Something that definitely chaps my hide about LTC nurses in general is that many times we'd get called out for something like "weakness and lethargy" or "failure to thrive" and when we get there, the patient is obviously in shock or is obviously having an MI or is obviously having CVA symptoms and 911 wasn't called because the vitals that were taken 2 hours ago were "stable."

While I definitely respect the fact that LTC nurses are very heavily burdened, my impression of many of them as being barely competent stems directly from the above experiences... and I've had more than enough similar experiences with different nurses at different LTC facilities to have come to that conclusion. 

Any "transfer" out to the ED, I'm going to discard the chief complaint given to dispatch and relayed on because inevitably it is going to be so wrong... I will listen to report (if I can find the patient's nurse) and probably discard most of it unless it actually makes sense based on what I find. 

I really don't mind if the nurse tells me that the doc ordered the transport for whatever reason or that the patient has been having whatever symptoms for however long and the ALOC is different from normal and tells me how so... 

Take two minutes out of your day to tell me what's going with the patient. Have the transfer paperwork ready, or at least a face sheet, copy of the MAR, and the patient's history along with a quick report as to why I'm taking the patient to the ED. And don't misrepresent the patient's status to me, especially if you tell me that the patient is fine, vitals are stable, and what I see is a patient who is circling the drain and clearly getting ready for celestial discharge... Yeah, I've had those patients more than once...


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## Handsome Robb (Nov 22, 2011)

JPINFV said:


> RN mad about the patient getting more than 3 doses of nitro: "...and where did you go to medical school?"
> 
> Paramedic in a deadpan voice: "Harvard."



Meh situational dependent, we aren't limited to 3 although at that point IV infusion would be better IMO but as long as their BP will handle it we can keep on giving it. Usually if we are far enough out to need more than 3 SL doses they will get NTG paste. It's better than 400 mcg slam then nada then 400 mcf slam then...you see what I'm gettin' at.


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## JPINFV (Nov 22, 2011)

NVRob said:


> Meh situational dependent, we aren't limited to 3 although at that point IV infusion would be better IMO but as long as their BP will handle it we can keep on giving it. Usually if we are far enough out to need more than 3 SL doses they will get NTG paste. It's better than 400 mcg slam then nada then 400 mcf slam then...you see what I'm gettin' at.




Ok, "Why isn't your patient on a backboard?"*

*Let me guess, you also have one of the fancy smancy selective spinal immobilization protocols?


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## Handsome Robb (Nov 22, 2011)

JPINFV said:


> *Let me guess, you also have one of the fancy smancy selective spinal immobilization protocols?



Maybe, maybe not.


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## ParamedicLuvnNurse (Nov 22, 2011)

After reading all of the posts I still can only sympathize with the rudeness, incompetency, and misunderstandings from nurses that you all have experienced. 

I was married to my husband Medic2409 before I became a nurse. I can say that he may have had a hand in molding who I was going to be and how I would respond to EMS crews from his experiences. 

I can say honestly that I always have copies of pertinent documents ready, a facesheet for the crew, ready to give report when crew arrives, and stay with the crew by my resident's side until they leave. 

I work nights with little resources with a 1:63 ratio. I could run a small village on my own if someone would let me. Really, it's all about prioritizing and you all know this. I agree that many nurse's do not have this skill. I agree that there are far too many nurse's out there that do not deserve to be. 

In the end, remember you have a little ol' nurse in DFW who is supporting you 100%.


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## Trashtruck (Nov 22, 2011)

DrParasite said:


> To be honest, that annoys me, because it is detrimental to the patient.  Or the cold and dead patient in the SNF who "was fine 10 minutes ago when I checked on them."  Yeah they ice up and have rigor start in that 10 minutes.
> 
> What annoys me to no end is when a facility calls 911, and then isn't ready for EMS when we arrive.   That means the chart isn't copied, no interventions have been done, the transfer form is all filled out or the nurse is no where to be found to give EMS a report of what is happening.  it takes between 4 and 11 minutes for EMS to arrive to a life threatening emergency (from the time the 911 call is made), and most of the time, EMS is going to be in and out in less than 30 minutes.
> 
> ...



What is a SNF? I know, bash me all you want...


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## abckidsmom (Nov 22, 2011)

Trashtruck said:


> What is a SNF? I know, bash me all you want...



Skilled nursing facility.  Nursing home.


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## JPINFV (Nov 22, 2011)

Trashtruck said:


> What is a SNF? I know, bash me all you want...




How about a mash?

[youtube]0thH3qnHTbI[/youtube]


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## Trashtruck (Nov 22, 2011)

abckidsmom said:


> Skilled nursing facility.  Nursing home.



Thank you. They're all lumped into one here...PMF. Private Medical Facility...form Dr's office to dialysis to nursing home.


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## medicsb (Nov 22, 2011)

Though I have had many of the same experiences as other medics and EMTs here, I partially blame EMS for the problem.

How many services go out and try and educate LTC/SNF/NH staff as to what is expected from them or how to handle the first 10 minutes of an apparent emergency?  I don't know of any education programs that are administered by medics or EMTs for LPNs, RNs, etc. that work at these types of facilities.  Seems like it would be worth our while for everyone, especially the patients.  

Does anyone have a local education program for LPNs, CNAs, and RNs on this subject?


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## EMSrush (Nov 22, 2011)

Would I be going way off topic if I mentioned that an RN actually complained to my medical director because she felt that I checked a BGL unnecessarily? Funny, I thought a receiving RN would appreciate a thorough assessment and turnover report from me.

I was so shocked when I was called into the office, I didn't know whether to laugh or cry. 

*steps off soap box*


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## STXmedic (Nov 22, 2011)

medicsb said:


> Though I have had many of the same experiences as other medics and EMTs here, I partially blame EMS for the problem.
> 
> How many services go out and try and educate LTC/SNF/NH staff as to what is expected from them or how to handle the first 10 minutes of an apparent emergency?  I don't know of any education programs that are administered by medics or EMTs for LPNs, RNs, etc. that work at these types of facilities.  Seems like it would be worth our while for everyone, especially the patients.
> 
> Does anyone have a local education program for LPNs, CNAs, and RNs on this subject?



LOL! I think it's called nursing school...


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## BF2BC EMT (Nov 22, 2011)

medicsb said:


> Though I have had many of the same experiences as other medics and EMTs here, I partially blame EMS for the problem.
> 
> How many services go out and try and educate LTC/SNF/NH staff as to what is expected from them or how to handle the first 10 minutes of an apparent emergency?  I don't know of any education programs that are administered by medics or EMTs for LPNs, RNs, etc. that work at these types of facilities.  Seems like it would be worth our while for everyone, especially the patients.
> 
> Does anyone have a local education program for LPNs, CNAs, and RNs on this subject?



They would probably be met with hostility. I've never really had a problem with SNF's where I ran calls. Very wealthy area, the only time I had problems were on the borders of the county where the RN/LVN's first language wasn't english.

Also a lot of RN's disappear due to the fact they're the only supervisor on duty and their ratios are awfull, they have other things to tend to. Now that doesn't happen all the time. The only reason I bring that up is because we had a RN go ghost pro on us for a "BLS 911", come to find out a 2nd pt was tanking so we kept an EMT with the more stable pt and one next door to help the nurse. Luckily back up was 2 seconds away. We had to separate because CNA's at this facility weren't allowed to do CPR, even though they hold AHA cards.


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## PotatoMedic (Nov 22, 2011)

BF2BC EMT said:


> We had to separate because CNA's at this facility weren't allowed to do CPR, even though they hold AHA cards.


WTF?!  You have to be sh*tting me?!  Who's the idiot who came up with that rule?  Or I guess what I am asking is why?


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## VCEMT (Nov 22, 2011)

I've tried to make good relations with nurses, except ER nurses. The problem is the Filipino nurses that don't know a damn thing about the pt and try to pass blame on others. I hate ER nurses they think they are glamour models and in reality they are a bunch of bleach blonde burnt out old hags, that haven't even reached age 30. Another is the fact that Dr. Quack makes his decisions off of reports and phones or faxes orders in, instead of actually being present and assessing a pt.


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## JPINFV (Nov 22, 2011)

VCEMT said:


> Another is the fact that Dr. Quack makes his decisions off of reports and phones or faxes orders in, instead of actually being present and assessing a pt.



So, you never, ever call for online medical control? It's easier to say crap like this when you normally have no prior relationship with your patients and you only have to take care of one patient at a time. However, once you start having more than one patient (who you've seen and examined prior to today) and those patients are in multiple locations, including the patients who have an appointment to see you in your office, it all of a sudden becomes a whole hell of a lot harder to drop everything to rush to a nursing home because a patient needs a medication adjusted or suddenly developed a fever. Especially at 2 am (because physicians don't always have definite off times).


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## usalsfyre (Nov 22, 2011)

VCEMT said:


> I've tried to make good relations with nurses, except ER nurses. The problem is the Filipino nurses that don't know a damn thing about the pt and try to pass blame on others. I hate ER nurses they think they are glamour models and in reality they are a bunch of bleach blonde burnt out old hags, that haven't even reached age 30. Another is the fact that Dr. Quack makes his decisions off of reports and phones or faxes orders in, instead of actually being present and assessing a pt.



Word of advice, if everyone around you won't play nice...perhaps the problem isn't everyone around you...


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## medicsb (Nov 22, 2011)

PoeticInjustice said:


> LOL! I think it's called nursing school...



Where in the curriculum is patient hand-off to EMS covered?  How much does nursing school even cover the management of emergencies?  How much of that is even reinforced after training?  I'm really curious actually, because something tells that it isn't a whole lot.


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## JPINFV (Nov 22, 2011)

Wait, you mean to say that nurses who don't normally work or aren't specialized in emergency care are generally bad at providing emergnecy care? Next you're going to tell me that the sky is blue, water is wet, and EMS providers suck at chronic care.


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## BF2BC EMT (Nov 22, 2011)

JPINFV said:


> Wait, you mean to say that nurses who don't normally work or aren't specialized in emergency care are generally bad at providing emergnecy care? Next you're going to tell me that the sky is blue, water is wet, and EMS providers suck at chronic care.



And these same nurses who can't handle an emergent situation are allowed to enter a CRNA mill and run rooms unsupervised.


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## JPINFV (Nov 22, 2011)

BF2BC EMT said:


> And these same nurses who can't handle an emergent situation are allowed to enter a CRNA mill and run rooms unsupervised.



Somehow, I don't think the average SNF RN is going to have plans to become a CRNA.


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## Tigger (Nov 22, 2011)

VCEMT said:


> I've tried to make good relations with nurses, except ER nurses. The problem is the Filipino nurses that don't know a damn thing about the pt and try to pass blame on others. I hate ER nurses they think they are glamour models and in reality they are a bunch of bleach blonde burnt out old hags, that haven't even reached age 30. Another is the fact that Dr. Quack makes his decisions off of reports and phones or faxes orders in, instead of actually being present and assessing a pt.



So as long as the nurse is not Filipino everything's fine, right?

Sent from my out of area communications device.


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## Tigger (Nov 22, 2011)

medicsb said:


> Though I have had many of the same experiences as other medics and EMTs here, I partially blame EMS for the problem.
> 
> How many services go out and try and educate LTC/SNF/NH staff as to what is expected from them or how to handle the first 10 minutes of an apparent emergency?  I don't know of any education programs that are administered by medics or EMTs for LPNs, RNs, etc. that work at these types of facilities.  Seems like it would be worth our while for everyone, especially the patients.
> 
> Does anyone have a local education program for LPNs, CNAs, and RNs on this subject?



My service does provide this service to our contracted facilities. Not everyone takes us up on this offer though.


Sent from my out of area communications device.


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## mycrofft (Nov 23, 2011)

*Are we telling the emperor his clothes are absent today?*

Many EMT's come on as cowboys, many nurses come off as being nursing supremacists, the majority are just busy doing their job and you never remember them.
Nursing as a culture tends to be very interested in finding fault and avoiding blame, sort of a circular firing squad deal.
EMT's doing IFT are often disillusioned or bored.
THis makes for a bad interface.

Don't get me into the cross-cultural nursing subject.  Many excellent nurses there, but the issues of language barriers and the difference in cultural expectations regarding gender, nursing autonomy and medical excellence...just don't.:wacko:


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## systemet (Nov 23, 2011)

usalsfyre said:


> Beating up on LTC nurses is the national EMS pastime. Much of it stems from misunderstanding. Much of it also stems from the godawful care and excuses for said care that is all too common in these facilities (it's 2am, there's no way in hell you just got here, I saw you yesterday so you weren't on vacation and your one of two nurses in the facility tonight so it's probably your patient).



I agree completely.

It's ok for them to not know every patient's complicated history inside or out.  And it's ok for them to be stressed about emergency care, and relieved when we come.  No problem.  I recognise it's sometimes difficult to appreciate the severity of the patient's condition when you lack acute care experience.

But then you have these situations where the patient has a perfect set of vital signs five minutes ago, the nurse is saying "he was complaining of feeling a little short of breath", and the patient is pre-code, completely septic and ARDS looking, or they're about to get intubated without sedation, or they're profoundly hypoxic / hypotensive.  Or maybe even rigored.  But the documentation and report don't reflect the change in the situation.  I recognise that situations change, I do, and I've been caught out when I arrive at the hospital to find somethings changed, but when this happens a lot, it makes me a little skeptical.

Not being an ER / ICU is fine.  Not accurately representing the patient's conditon, not so much.



> That said....among the paramedics in here, who thinks they could handle a 50:1 ratio, while supervising the equivalent of multiple EMT-Bs and having to ring up med control (who's off duty) everytime something unforeseen happens? Because I couldn't, and that's commonly what RNs and LVNs in LTC are facing.



Amen.  I couldn't either.  And if I wanted to learn, I think I'd go to nursing school.  I wouldn't want to switch roles.


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## Shishkabob (Nov 23, 2011)

ParamedicLuvnNurse said:


> In the end, remember you have a little ol' nurse in DFW who is supporting you 100%.



Which part?


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## Farmer2DO (Nov 24, 2011)

I guess what irritates me the most is when other providers (nurse, mid-level, physician, RT, take your pick) feel that they know more than me about my scope of practice, my training and education, and what I should be doing.  Every field has their stellar providers, their miserable people, and their incompetent window lickers.  Nursing and EMS are no different.  

One of the hospitals I am currently working out of has several RN/paramedics in the ED, and a group of EM physicians that are very EMS knowledgable.  For those, I'm pretty lucky to be working there.  A large group of midlevels, esp the NPs, however, are CLUELESS about what a paramedic knows or can do, even at the most basic level.  The don't understand at all the tiers of BLS, ALS and critical care for interfacility transfer, and quite a few have no desire to learn.  This is the attitude the bugs the crap out of me.  Every provider has their strong and weak points, and their areas of knowledge where they excel.  Telling me how to do my job (and being wildly wrong) while refusing to have a conversation where I try to politely educate you about what I do means that I have minimal, if any, respect for you.

I think one of the reasons that nurses get blasted by EMS so often is that we simply interface with them more than any other medical provider.


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## Pneumothorax (Nov 24, 2011)

NVRob said:


> While we all practice medicine, we all practice very different forms of medicine



Not many people realize this!

Being an EMT in the field, and ER tech in the hospital & working in the capacity as an RN (still in school:/)  I see both sides of the coin & it really disgusts me to see how RNs treat EMS as I've experienced it first hand. I never want to be like that and hope I won't be. Some days I wish I had my RN license so I could say --- hay! Get off your high horse, I'm just as smart as you are so stop talking to me like I'm an idiot and grow up! 

Oh, & ppl who are nurses aren't the ones who couldn't hack it thru med school whoever said it. Maybe they didn't want to be a doc!


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## ParamedicLuvnNurse (Nov 24, 2011)

linuss said:


> which part?



sw ftw


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## Bullets (Nov 25, 2011)

My issue is perceived lack of care. The METHODIST HOME SNF in my area is great, hand you complete copies of records when you walk in, nurse supervisor gives a detailed report, and the PCAs assist us in anything we need. They are a fantastic group.

But the other SNF in my town gets the attitude. Calls 911 for unresponsive/CPR we arrive to find pt sleeping, or ice cold and livid, but was normal "10 minutes ago, or complaining of chest pain for 3-4 hrs and when nurses do this at 2am, believe they are getting an attitude


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## Veneficus (Nov 25, 2011)

I couldn't help but notice a lot of complaints here about not getting a printed history or a concise report.

I must ask the people complaining:

Do you not perform your own history and physical absent the bias of another provider?

Do you have trouble correlating your findings?


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## usalsfyre (Nov 25, 2011)

Veneficus said:


> I couldn't help but notice a lot of complaints here about not getting a printed history or a concise report.
> 
> I must ask the people complaining:
> 
> ...


Every patient gets a physical exam and history by me, however, around 75% of the patients I'm dealing with are too demented/intubated to give a good history. Which again, is not a huge problem...until I don't have anything other than a transfer report. At that point it gets a little tough to explain to the ED staff why I have nothing other than physical exam findings on this patient (and that includes the junior and senior who flipped out the other day because I wasn't fast enough with the paperwork apparently).


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## NomadicMedic (Nov 25, 2011)

+1. A 911 call to a SNF is what it is. And if I don't get any paperwork, oh well. However, when I was doing IFT, I wanted a full packet and I'd wait until I got one.


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## RocketMedic (Nov 25, 2011)

Money matters too. Many SNFs and such dont fund adequately, or the staff doesnt keep up or care. When I see a patient with an houes or days old diaper or who is suffering due to neligence, and the nurses are the ones responsible, that breeds resentment and dislike.


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## Veneficus (Nov 25, 2011)

usalsfyre said:


> Every patient gets a physical exam and history by me, however, around 75% of the patients I'm dealing with are too demented/intubated to give a good history. Which again, is not a huge problem...until I don't have anything other than a transfer report. At that point it gets a little tough to explain to the ED staff why I have nothing other than physical exam findings on this patient (and that includes the junior and senior who flipped out the other day because I wasn't fast enough with the paperwork apparently).



Why would the ED get upset all you had was a physical exam?

If you brought in an unconscious patient found in the street, you would only have a physical exam. 

Is there really a difference between an unreliable history and no history on any patient  population?

Sounds to me like the ED was just pissed they had to actually do some work.


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## Farmer2DO (Nov 25, 2011)

Veneficus said:


> Is there really a difference between an unreliable history and no history on any patient population?



Yes, I think there is.

These patients are coming from a facility with medically trained staff.  Some nurse, somewhere, called a doctor to get permission to send the patient out.  These are licensed providers who are being paid, often quite well, to provide care to people who can't do it themselves.  

I'm OK with overworked staff doing the best they can.  I'm OK with staff that is in over their heads, clinically and knowledge wise.  I'm NOT OK with staff that doesn't do a decent baseline assessment, doesn't have paperwork with AT LEAST demographics, history, meds and allergies, and isn't willing to give a report of what they've found and why they've called.  Not only is it common courtesy to pass along all of this information in an organized manner from one provider to another, it's accepted as good baseline medical care, and important to the patient's well being and ability to get good care where they go.

I haven't even touched on the attitude of not regarding me as a professional, or looking at me as an ambulance driver, or something they just peeled off the bottom of their shoe because I'm not a nurse.


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## JPINFV (Nov 25, 2011)

Veneficus said:


> I couldn't help but notice a lot of complaints here about not getting a printed history or a concise report.
> 
> I must ask the people complaining:
> 
> ...



How often are SNF patients normal at baseline and competent historians both in terms of HPI and past medical history?


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## JPINFV (Nov 25, 2011)

Veneficus said:


> If you brought in an unconscious patient found in the street, you would only have a physical exam.
> 
> Is there really a difference between an unreliable history and no history on any patient  population?



Having no history because no competent historian is available is unfortunate, but unavoidable. 

Having no history when a competent historian is available is poor patient care from at least one, if not both, sides of the equation.


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## Veneficus (Nov 25, 2011)

JPINFV said:


> How often are SNF patients normal at baseline and competent historians both in terms of HPI and past medical history?



Does it matter?


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## JPINFV (Nov 25, 2011)

Veneficus said:


> Does it matter?



If your patient has a level of consciousness less than A/Ox4, then yes, knowing that the patient has dementia or Alzheimers, or any sort of other non-acute disease processes that changes the patient's neurological status is rather important. 

If the patient is status post CVA with persistent deficits, that becomes important to know both the fact the patient has a CVA and what the deficits are.

Edit: Alternatively, do we treat every patient as having no history, thus rerouting and upgrading for clinical signs that in reality have no acute significance?


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## Veneficus (Nov 25, 2011)

JPINFV said:


> If your patient has a level of consciousness less than A/Ox4, then yes, knowing that the patient has dementia or Alzheimers, or any sort of other non-acute disease processes that changes the patient's neurological status is rather important.
> 
> If the patient is status post CVA with persistent deficits, that becomes important to know both the fact the patient has a CVA and what the deficits are.



Will it change the workup any in the ED?

How about for EMS?

Are people with prior deficits not checked for new onset pathology?

The point I am trying to make is that this nursing home thing has been going on for at least decades, and rather than complain an moan about it, simply take steps to move on.

We can argue the importance of it forever, but in terms of the acute event, whatever it was called in as, a full assessment will have to be done again. 

Exams are repeated by each provider for a purpose.

Do you always trust the report or exam of another provider, particularly one of lesser training or one you have never met?


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## Akulahawk (Nov 25, 2011)

Veneficus said:


> I couldn't help but notice a lot of complaints here about not getting a printed history or a concise report.
> 
> I must ask the people complaining:
> 
> ...


When my patient from a SNF actually _can_ tell me their HPI and their PMHx, I obtain their version of it. When they can't, I can't. I have to go by what I see and what's in the transfer packet, if there is one. Also, since the patient is coming from another medical facility, the ED expects that there will be some kind of packet showing the patient's known medical history, what meds the patient is currently on, and so on... Do you think you could remember all 15 meds you're on when you think Eisenhower is President?


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## JPINFV (Nov 25, 2011)

The question isn't if a physical exam is repeated, but how the results of the physical exam are interpreted. While it may not change the ED workup, it could easily change the patient's course in EMS through, as mentioned, transport code, the decision to request paramedics from an EMT crew, or the decision to reroute to the nearest or to a specialty hospital instead of transporting the patient to his home facility.


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## Veneficus (Nov 25, 2011)

Akulahawk said:


> the ED expects that there will be some kind of packet showing the patient's known medical history, what meds the patient is currently on, and so on... Do you think you could remember all 15 meds you're on when you think Eisenhower is President?



Then the ED may have to request it themselves and hospital administration can take up the issue about the facility in question rather than field providers. 

They should be well aware of the state of SNF care.

It is not the responsibility of the EMS provider, and certainly not that person's fault when it isn't obtained or sent by the facility.

Individuals are expected to give the best care they can under any given circumstance. One of those circumstances is the lack or ineffectiveness of a history or report.

Do you really think when some MD or DO nursing home jockey gets a call at 2 am from a nurse his response isn't send them to the ED 99% of the time no matter what the nurse says?

Do you think they don't punt patients who they view as potentially breaking their routine?

Do said providers regularly provide the patient Dx or do you think it comes from the hospital that constantly performs the tests when these patients are sent there or the specialist for various forms of care?


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## abckidsmom (Nov 25, 2011)

Akulahawk said:


> When my patient from a SNF actually _can_ tell me their HPI and their PMHx, I obtain their version of it. When they can't, I can't. I have to go by what I see and what's in the transfer packet, if there is one. Also, since the patient is coming from another medical facility, the ED expects that there will be some kind of packet showing the patient's known medical history, what meds the patient is currently on, and so on... Do you think you could remember all 15 meds you're on when you think Eisenhower is President?



I feel really sorry for medics who take it personally and think that the satisfaction of the ED staff is in any way relevant to the medic's competence.  (Not you personally, just in general.)

You do the best you can, get the best history you can, and any deficiencies after that fall on the SNF staff, right?  So, it doesn't actually matter what the ED staff expect except that there is a standard.  If the standard isn't met, then the ED staff can place the blame where-ever it lies.

Now, I will say that SNF charts for the most part have the info you're looking for somewhere in there, and it's up to you to tease it out.  For whatever reason, the MAR is where the best PMH is found at our favorite SNF, and it rarely matches the PMH on the transfer sheet.  Oh well.

ED nurses are not the enemy, but it's also not our job to make them happy, the same as it's not their job to judge our competence.


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## Veneficus (Nov 25, 2011)

abckidsmom said:


> I feel really sorry for medics who take it personally and think that the satisfaction of the ED staff is in any way relevant to the medic's competence.  (Not you personally, just in general.)
> 
> You do the best you can, get the best history you can, and any deficiencies after that fall on the SNF staff, right?  So, it doesn't actually matter what the ED staff expect except that there is a standard.  If the standard isn't met, then the ED staff can place the blame where-ever it lies.
> 
> ...



exactly

well said


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## Farmer2DO (Nov 25, 2011)

abckidsmom said:


> ED nurses are not the enemy, but it's also not our job to make them happy, the same as it's not their job to judge our competence.





You hit the nail on the head.


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## BF2BC EMT (Nov 27, 2011)

Veneficus said:


> Then the ED may have to request it themselves and hospital administration can take up the issue about the facility in question rather than field providers.
> 
> They should be well aware of the state of SNF care.
> 
> ...



99% of the time? That is very exaggerated, as most pts can be handled appropriately within the SNF. I also read earlier where you said its the hospitals job to get pt paperwork sorted. You would get an absolute tounge slashing from the ER team for bringing a no transfer order pt into the ER without atleast a med list, while they wait for it to be faxed over. 

Now nurses do need to get called on their unethical doings. Avoiding crews, lying about pt status(calling bls for an als pt so they don't reach a certain number of als calls), empty threats about calling your sup. because you won't transfer bls and at the same time calling the sketchy ambulance company that will transport. Bully tatics and throwing your weight around leaves an overflow of animosity. Another reason private companies shouldn't be allowed to hold contracts with SNF's as money is always more important than the employee


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## systemet (Nov 27, 2011)

Personally, I'm not too interested by the nursing staff's assessment.  It would be nice to have reliable elements of the history, like "When did this problem start?".  If the answer is, "I saw this guy 5 hours ok, and he was ok then", then we can work from there.

There's a certain level of competence you expect from a medical facility.  If they're calling EMS because the patient needs transport, and potentially a higher level of care than they can provide, then I can accept that the medical treatment provided might not be optimal.  If the staff don't see acutely sick people on a regular basis, I can understand how they might not be clued in.  But it seems like it would take very little effort to:

* Photocopy the patient's meds / hx sheet / DNR / Personal Directive.
* Not deliberately falsify vital signs.
* Not lie about the patient's condition.

I don't think that's coming in with a "para-god" attitude.  I understand the point that Vene is trying to make.  But it is nice to know the patient's baseline neuro status, have some idea about stroke history, a rough guess as to whether renal function has been a problem before today, hx of anaphylaxis, and code status.  Admittedly the answers to these questions are usually (i) 14, (ii) yes, (iii) it's borderline, (iv) they have 8 meds listed as "allergic", but most of them were put on the list due to hypersensitivities or misunderstanding of the normal side effects, e.g. morphine makes me nauseous and (v) despite the presence of multiple life-limiting pathologies and a poor baseline QOL, the family has inexplicably requested a full code on this 90 year old.


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## Veneficus (Nov 27, 2011)

BF2BC EMT said:


> 99% of the time? That is very exaggerated, as most pts can be handled appropriately within the SNF.


_
Do you really think when some MD or DO nursing home jockey *gets a call at 2 am from a nurse* his response isn't send them to the ED 99% of the time no matter what the nurse says?_

I stand by my statement. 

Most nursing home docs I know just do it for extra cash. It is not their primary job, and just like many EMS medical directors, want to put as little effort into it as possible. I also know they do not visit the facility everyday.

I also think it is a responsible choice.

If somebody calls about a SNF patient in the middle of the night, the only responsible things to do is drive out there and evaluate the patient or send them for evaluation. There may be some treatment ordered in the meanewhile.

Given the level of neglect in any SNF I ever saw, in 7 states and 4 countries, no way in hell would I accept a nursing assessment over the phone, order treatment over the phone, and consider the matter taken care of.

There are simply too many variables. 



BF2BC EMT said:


> I also read earlier where you said its the hospitals job to get pt paperwork sorted. You would get an absolute tounge slashing from the ER team for bringing a no transfer order pt into the ER without atleast a med list, while they wait for it to be faxed over.



That is location specific, and I will draw upon my ED experience in a 94k+ patient yearly census ER.

If the patient doesn't need a relatively simple procedure like replace a peg tube, drain a cyst, etc. the goal becomes rule out acute pathology and admit to the proper service.

Usually the diagnostics for a new onset acute event began before anyone even looked at the nursing home packet. (around 2 hours) that is quite enough time to have the secretary call for a chart. 

If you are lucky, you don't have to sift through 200 pages of mismatched papers trying to figure out what the most current pathologies and treatments are.

A patient with previous neuro deficits is not immune from having new onset CVAs, infarcts, sepsis, etc etc. 

The patient is likely going to get a CT head, certainly new heme and urine labs, an EKG, and whatever diagnostic seems to be indicated regardless of what is on the chart except a DNR.

I think many of the problems are simply from the system. Having agency nurses who change every few shifts.

Too high of nurse to patient ratios. 

Too many ancillary tech staff and not enough nurses. 

Way too much paperwork for the nurses which is required for billing but keeps them away from the bedside where they belong and do the most good.

I have had my fair share of run ins with SNF staff. I understand what level of quality is expected. But I have been around EMS for a considerably longer time, and I can say they are not without sin either. More than a few crews I know never make any effort to engage the nursing staff. Worse they are minimum ability/interest providers who probably contribute to nurses not even knowing what EMS expects of them.

As for the BLS/ALS thing. It may be a bit shocking, but when a RN from an SNF calls a private transport dispatcher who advises that a BLS squad is available in 10 minutes and an ALS in 40, the patient may warrent being transported by BLS rather than waiting. (especially when private companies have a habbit of exaggerating response times) 

I also can't blame nursing (and I waste no opportunity to) for not knowing what different level EMS providers can do and can't. With 3 levels, treatments that vary with each agency, the personality types and level of competency variations in EMS, on any given day who can say what type of EMS service is needed in any given location on any given day?


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## BF2BC EMT (Nov 27, 2011)

Veneficus said:


> _
> Do you really think when some MD or DO nursing home jockey *gets a call at 2 am from a nurse* his response isn't send them to the ED 99% of the time no matter what the nurse says?_
> 
> I stand by my statement.
> ...



I generally agree with the above, the only thing that's sends me up the wall is avoiding crews all together when gran goes down sick. Around here fire does 911 along with a private BLS company, the RN/SNF know exactly who to call and take advantage of that. We also don't have 40 min response times for 911 so I've never seen a situation like that, but a BLS first response in a situation like that is the only responsible thing to do.


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## Veneficus (Nov 27, 2011)

BF2BC EMT said:


> We also don't have 40 min response times for 911 so I've never seen a situation like that, but a BLS first response in a situation like that is the only responsible thing to do.



It is not just about response times. 

Many SNFs contract with private EMS in order to avoid calling 911.
(for a host of reasons, not least of which is when a municiple 911 agency bills the facility that called)

So it can happen in any urban environment.


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## jjesusfreak01 (Nov 27, 2011)

Veneficus said:


> It is not just about response times.
> 
> Many SNFs contract with private EMS in order to avoid calling 911.
> (for a host of reasons, not least of which is when a municiple 911 agency bills the facility that called)
> ...



IFT companies don't charge as much for the transport, especially for a BLS truck, even at 2am.


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## Bullets (Nov 28, 2011)

I just want a face sheet with demos, history, meds, and allergies...


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## johnrsemt (Nov 28, 2011)

When I worked IFT we had many of the same problems;   and the SNF (ECF etc) had many of the same problems.

  I worked with quite a few of the ECF's to help alleviate the problems between them and transport companies and crews (my company and others).  
  When I was on night shift and was posted in area's I would go to the ECF's:  and talk to the staff; introduce myself and my partner and let them know what was needed paperwork wise for transporting patients:   Demographic's, doc's orders med sheets etc.   (Surprising how many of the nurses don't realize that we need the paperwork for the transport:  alot of them were told to fax it to the ED only).     THe other thing that I did; was go through the charts (with permission from nurses); and copy the demo sheets for each patient:    5 or so per chart.  and then left them in the charts.  That way it saved them a little bit of work on transfers; either to doctor appt or ED.

   It wasn't much savings for them, and not much work for us;   but it helped the staff and gave them a better attitude about the EMS.   and it is a good PR thing to do for your company.


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## usalsfyre (Nov 28, 2011)

If the OP is still out there...please dear lord send the whole MAR, not the version with the administration times cut off.


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## Akulahawk (Nov 28, 2011)

usalsfyre said:


> If the OP is still out there...please dear lord send the whole MAR, not the version with the administration times cut off.


I second this... wherever possible, send a copy of the whole MAR because the ED will want to know what has been given and when. Med choices they make could very well depend upon this and the wrong med choice could be fatal...

That being said, I've rarely had the sending facility send the whole MAR along. It's always been just the list of meds, with no differentiation between PRN and scheduled meds.


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## mycrofft (Nov 28, 2011)

*They don't want to send out their med errors and omissions.*

I used to ALWAYS send a copy of the MAR. Let the chips fall, the pt is the one who counts.

-_-


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## usalsfyre (Nov 28, 2011)

mycrofft said:


> I used to ALWAYS send a copy of the MAR. Let the chips fall, the pt is the one who counts.
> 
> -_-



I'm gonna take a stab and say your MARs weren't signed for the week on Monday though .


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## JPINFV (Nov 28, 2011)

usalsfyre said:


> I'm gonna take a stab and say your MARs weren't signed for the week on Monday though .


...or the MARs weren't accompanied by the required TPS report face sheet.


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## usalsfyre (Nov 28, 2011)

JPINFV said:


> ...or the MARs weren't accompanied by the required TPS report face sheet.



If you could just go ahead and do that it would be grreeaattt. And I'll male sure you get a copy of that memo, mm'kay?


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## Missedcue (Nov 29, 2011)

DrParasite said:


> To be honest, that annoys me, because it is detrimental to the patient.  Or the cold and dead patient in the SNF who "was fine 10 minutes ago when I checked on them."  Yeah they ice up and have rigor start in that 10 minutes.
> 
> What annoys me to no end is when a facility calls 911, and then isn't ready for EMS when we arrive.   That means the chart isn't copied, no interventions have been done, the transfer form is all filled out or the nurse is no where to be found to give EMS a report of what is happening.  it takes between 4 and 11 minutes for EMS to arrive to a life threatening emergency (from the time the 911 call is made), and most of the time, EMS is going to be in and out in less than 30 minutes.
> 
> ...



This is so true... I should have put this in the pet peeve thread because it happens so often. However, when I do get that RN who does exactly what I expect of them and has their act together I am always quick to comment on how grateful I am for their good work. (This also goes to firefighters who bother to ask for a med list then actually write it so I can read it.)


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