# How nurses handle emergencies!!



## trauma1534 (Dec 8, 2006)

Hello everyone!  Just for the record, I am not trying to open a can of worms here to those of you who are cross trained as Medic/nurses.  And it is in no way ment to offend anyone!

I am just trying my best to figure out something.  I work with nurses everynight at the hospital.  They don't take emergency situations serious and imminent.  For example.  We had a 60ish yof patient one night, she was 9 hours or so post op on our unit.  I went in on my rounds doing vitals.  I found that her 02 sats were 68%.  At first, I thought it was a mechanicle error, but when I flipped on the bright lights, she was cyonotic around the lips.  Her lungs were wheezes noted in all 4 fields.  I imediatly raised the head of her bed.  Per protocol, I notified the RN.  She came in there, and guess what she did?  She places this hypoxic patient on 2 lpm 02 via NC.  No relief noted, as I didn't suspect there would be any relief.  I suggested to put her on 15, NRB.  She said no.  We were not in the field, this was a controled environment.  Anyway, she played around and played around, for about 30 min.  That patient coded, and I went into real EMS mode!  They thought I was crazy.  Hey... they weren't doing anything!  

It just amazes me as to how they go to school and it is suposidly so hard, and they (atleast the ones I work with) don't know what the heck they are doing.  For the record, we got her back and she went to STICU.


----------



## Ridryder911 (Dec 8, 2006)

First you must remember emergency and critical care are NOT taught in depth or even technically a part of the nursing curriculum. It is considered a speciality and to learn after you have chose to enter that department. The NLN RN board exam CANNOT have any cardiac or emergency test questions on it above CPR or first-aid level. 

Now, I really do understand your dilemma and full agreement with you, that it was a horrible reaction and poor care the nurse provided. Now, with that saying.. let's look at the other side... How diverse are you on colostomies, assessing newborns growth development, psychological development and classification of mental illness dependent on axis system? Again all of those are in standard nursing curriculum and then one still specializes to be proficient.  

Point being, EMT's are specialty trained (hopefully educated), and where a medic is able to control airway, etc.. They are not able to understand and function on most basic medical conditions. This is why physicians, nurses and most other allied health providers are confused on EMS personal role and ability to treat patients. Health care professionals are usually educated in general medicine then... pick a speciality and go in depth. Not in -depth and then general medicine. 

I use the analogy a Paramedic may be able to read a XII lead yet not be able to read a thermometer...totally opposite than most health professionals.

Again, I agree the nurse acted and performed poorly and this was NO excuse for her ignorance ! I would definitely consider writing an incident or variance report so this action would not re-occur. It appears that some of the staff is poorly trained, and not expected to handle emergencies. I would hope that this would raise awareness to change such immediately.

I wish I could say this is an isolated case, but this is not the case. I get onto nurses daily and probably most do not count me as part of the "sisterhood". At the same, I see EMT's all the time place foley catheter bags with urine in them on patients legs, abdomen, only to allow "old urine" with bacteria to run back into the bladder instead of "clamping" it off. This irritates me as well.. all poor care. 

This is why a full understanding of "medicine" is essential. Both for nurses whom are going to be exposed to emergency situations and EMT's on routine non-emergency medical care and procedures.

R/r 911


----------



## jeepmedic (Dec 9, 2006)

I am going to agree with Ridryder here somewhat. 

I think it is a mindset. I think that the best Nurses are former Paramedics, and Nurses think that the best Paramedics are Former Nurses.


----------



## Airwaygoddess (Dec 9, 2006)

The best of both worlds dont you think?


----------



## Airwaygoddess (Dec 9, 2006)

Ridryder911 said:


> First you must remember emergency and critical care are NOT taught in depth or even technically a part of the nursing curriculum. It is considered a speciality and to learn after you have chose to enter that department. The NLN RN board exam CANNOT have any cardiac or emergency test questions on it above CPR or first-aid level.
> 
> Now, I really do understand your dilemma and full agreement with you, that it was a horrible reaction and poor care the nurse provided. Now, with that saying.. let's look at the other side... How diverse are you on colostomies, assessing newborns growth development, psychological development and classification of mental illness dependent on axis system? Again all of those are in standard nursing curriculum and then one still specializes to be proficient.
> 
> ...


 BRAVO !!! well said!


----------



## Jon (Dec 14, 2006)

R/R 911 is 100% correct.

I've said this before when talking with nurses... they know so much, but I've had better training in the "oh sh-t" end of medicine. On the flipside - I stunk when it comes to the details of the disease processes of diabieates.

Oh... and the foley bag thing is something I notice, too... disgusting. We wonder why all the old folks have UTI and Bladder infections


----------



## Airwaygoddess (Dec 14, 2006)

There are good, the bad, and just plain ignorant with every job profession:wacko:


----------



## Stevo (Dec 15, 2006)

I can recall responding with the rig with only one other ems'er, to a multiple 10-50. the report added cpr in progress enroute 

a nurse that had witnessed the accident (T-bone) extricated the patient, started cpr, as well as informed a 19 yr old male bystander that _'it was his day to learn cpr'_

quite the little spitfire imho...

moral of the story?

the ABC's don't change from the first responder up to the dean of a medical school, they are a universal fundamental. 

Stereotyping any health care faction might be a tad of a stretch _vs._ holding the individual accountable here 

~S~


----------



## akflightmedic (Dec 16, 2006)

Stevo said:


> I can recall responding with the rig with only one other ems'er, to a multiple 10-50. the report added cpr in progress enroute
> 
> a nurse that had witnessed the accident (T-bone) extricated the patient, started cpr, as well as informed a 19 yr old male bystander that _'it was his day to learn cpr'_
> 
> ...



I understand where you were going and I don't knock anyone for trying, but an experienced EMS'er probably would never had started CPR to start with as we know the futility of working a trauma code.


----------



## trauma1534 (Dec 16, 2006)

I work with enough nurses to know that the majority of them are just not emergecy material.  They are rutine oriented providers.  They freeze in an emergency situation.  They are fine when they can get the doctor for orders, and the doctor can come down and do and assessment.  They do nuts when they don't have that crutch... they page the doc and he doesn't return it promptly and there is all hell breaking loose.  No, I'm not sterio typing, it's just a fact.  There are few nurses out there who CAN handle emergencies.  They want to through the "I'm an RN" at you, but they can't back it up.  Example.  I ran up an a wreck here in town.  It too was a t-bone.  I went over to it because it had just happened, if I had been looking in that direction, I would have seen it.  I walked up to the scene, and there was a nurse kneeling down beside the patient who was in the driver's seat unresponsive.  There was a man on the phone with 911.  I said I'm EMS, what do we have... to this nurse.  She said, I'm a nurse.  I was thinking to myself... ok... good for you... BUT WHAT DO WE HAVE.  She said... don't touch the patient untill EMS gets here.  I looked at her... I said... we need to take c-spine... she said... I'm an RN, and don't touch that patient.  I said... "WHAT I"M GONNA NEED YOU TO DO IS... EITHER TAKE C-SPINE so that I can assess the enjuries, or get out of my way.  She said... "You are not supposed to touch someone in an accident untill EMS gets here"  I finally just pushed right over her, and assumed c-spine.  I could here him gurgling.  I knew it wasn't anything much that I could do here, but I was there now, so I had to atleast assume c-spine.  The guy on the phone came back and started to tell me that 911 had advised him to firmly hold the head still to keep it in line and from moving.  Miss "Nursy" was pissed that I was right.  You know... we all need to work together.  Nurses need to learn thier place on a scene.  It pissed me off to a t.  I have not stopped at anymore wrecks for that reason.  I don't want to put myself in a spot that I have to play tug of war with someone who has no clue at a scene.  I just look at them now and keep riding.  Plus, it is a liability to stop.


----------



## TheDoll (Dec 16, 2006)

akflightmedic said:


> I understand where you were going and I don't knock anyone for trying, but an experienced EMS'er probably would never had started CPR to start with as we know the futility of working a trauma code.



i have been reading this thread with interest, and learning quite a bit. however, i was wondering if you could please further explain this statement. i'm still really new to ems (i just finished my emt-b class), and this seems to go against almost everything that i just learned--at least without having more details of the scene. i'm sure there is a good explanation that i don't know bc of my lack of experience.


----------



## akflightmedic (Dec 16, 2006)

Sure I will tell you why.

First, the survivl rate for a traumatic arrest is less than 1 percent. I do not want to misquote but it is something like .001 percent or .01 percent. Ridryder will validate that later.

As a flilght medic, we do not respond to nor do we transport traumatic arrests unless they happen to code after we have picked them up.

As as street medic, if I rolled up on a scene where there was more than 1 patient and one of the victims was in arrest, he does not get my attention...he gets a sheet.

That is proper triage and utilization of resources.

When someone goes into traumatic arrest, unless they are on the doorstep of a Level 1 facility, they are out of luck..it just wont happen.

Traumatic arrests need surgical interventions, so you can do all the CPR you want but that is not correcting the problem that caused the arrest in the first place. 

As you gain more experience in this field and attend more classes all of this will become painfully obvious. We can not save them all, nor should we try.

If you noticed how CPR classes have changed over the years, we have finally come to the point where we are being selective about who should and shouldn't recieve all out measures and we are encouraging active family involvent in regards to termination of efforts. For the past 6-7 years I have worked under systems where we have the option of calling medical codes in the field and trauma codes we do not work at all unless they happen to code after our arrival, then at that time we evaluate transport time versus doing a few rounds of drugs and corrective measures before calling it where it is.


----------



## Ridryder911 (Dec 16, 2006)

Ditto.. traumatic arrests are dead.. period. No resuscitation measures are even attempted. Medical arrests are dependent upon the situation but most are called if they are in aystole, or have not responded to the second set of ACLS medications. 

R/r 911


----------



## Stevo (Dec 16, 2006)

akflightmedic's right Doll, but i posted it as an example of a health care provider that was not intimidated by the scene. other than working a trauma code, she had all the right moves

and speaking of right moves, maybe if everything didn't change in the ER's trauma room they'd have it all down a tad better in the field

~S~


----------



## prizonmedik (Dec 16, 2006)

"Point being, EMT's are specialty trained (hopefully educated), and where a medic is able to control airway, etc.. They are not able to understand and function on most basic medical conditions."



If I weren't afraid I'd get grounded again I respond to this, but uh, I'll just say you never cease to amaze me.


----------



## Para-Devil (Dec 16, 2006)

*Yes!!*

Well Said ridryder!!


----------



## trauma1534 (Dec 16, 2006)

prizonmedik said:


> "Point being, EMT's are specialty trained (hopefully educated), and where a medic is able to control airway, etc.. They are not able to understand and function on most basic medical conditions."
> 
> 
> 
> If I weren't afraid I'd get grounded again I respond to this, but uh, I'll just say you never cease to amaze me.



Come on... please do respond!  You can find a nice way to put things and not get grounded!  HA!.... wait a min... I forgot who I was talking about!  LOL  Still... respond.. I'm curious!!!


----------



## Jon (Dec 18, 2006)

prizonmedik said:


> "Point being, EMT's are specialty trained (hopefully educated), and where a medic is able to control airway, etc.. They are not able to understand and function on most basic medical conditions."
> 
> 
> 
> If I weren't afraid I'd get grounded again I respond to this, but uh, I'll just say you never cease to amaze me.


I think what is trying to be said is that medics don't have the same base knowledge of disease proscesses that RN's do... we know that 12, or 50 are BAD numbers on the glucometer, and 100 is a GOOD number... but we don't really know WHY 200 or 250 can be a BAD number... I mean, the patient seems fine and has no complaints, right?


----------



## EMT007 (Dec 19, 2006)

> Ditto.. traumatic arrests are dead.. period. No resuscitation measures are even attempted.



Up until recently, this wasn't the case in Los Angeles County. Unless there was decapitation, incineration, evisceration of heart/lungs/brain, mortis, lividity, etc, they got worked up. Recently (past year or so) a provision was added to allow ALS to pronounce death in the field for traumatic arrests only if there is no organized EKG activity (narrow supraventricular complex)


----------



## Ridryder911 (Dec 19, 2006)

This is why Emergency Physicians in LA have been outraged in EMS protocols. One physician has even spoke at numerous conventions and medical seminars, declaring ...."EMS is nothing more than a hearse with lights on it!".. The point being if the patient has no chance of survivability, the patient should be able to be declared dead on the scene. Period. There is nothing more in resuscitative measures a ER is going to perform or do that the field ALS/EMS has not already performed. So why transport and increase financial burden, decrease available beds ? 

Hopefully, we will be seeing more and more declarations in the field. This will be either by no resuscitative efforts being started or field termination. 

R/r 911


----------



## Summit (Dec 19, 2006)

Pls correct me if I am wrong but in my readings I remember seeing something that said field arrest due to blunt trauma has the <1% number but arrest due to penetrating trauma had much higher save rates.


----------



## jeepmedic (Dec 19, 2006)

Ridryder911 said:


> This is why Emergency Physicians in LA have been outraged in EMS protocols. One physician has even spoke at numerous conventions and medical seminars, declaring ...."EMS is nothing more than a hearse with lights on it!".. The point being if the patient has no chance of survivability, the patient should be able to be declared dead on the scene. Period. There is nothing more in resuscitative measures a ER is going to perform or do that the field ALS/EMS has not already performed. So why transport and increase financial burden, decrease available beds ?
> 
> Hopefully, we will be seeing more and more declarations in the field. This will be either by no resuscitative efforts being started or field termination.
> 
> R/r 911



But the Emergency Physicians are the ones making the protocals. We write what we think should be done and they approve or disapprove them. So if they do not want us to try to save there life then rewrite the protocals.


----------



## Ridryder911 (Dec 19, 2006)

They are.. look at the new recommendations from ECC and ACS on cardiac and trauma resuscitation. Local politics apparently is preventing some advances. 

Summit, you are right blunt has a higher morbidity.. but even with that saying penetrating ballistics of vital organs still have a high morbidity. The problem being is the usual "tumbling" of the projectile missile is likely to strike multiple areas. It is very rare to have a "clean" through and through.. albeit, it can happen. I would have to evaluate the location and case.. but chances are I still would declare traumatic arrest DRT (dead right there).

R/r 911


----------



## Summit (Dec 20, 2006)

Ridryder911 said:


> Summit, you are right blunt has a higher morbidity.. but even with that saying penetrating ballistics of vital organs still have a high morbidity. The problem being is the usual "tumbling" of the projectile missile is likely to strike multiple areas. It is very rare to have a "clean" through and through.. albeit, it can happen. I would have to evaluate the location and case.. but chances are I still would declare traumatic arrest DRT (dead right there).
> 
> R/r 911



I am familiar with wound profiles for various rounds at various ranges (I am a weapons enthusiast).

But I could have sworn that field arrests of penetrating trauma had much much higher save rates than from blunt trauma.

http://www.caep.ca/page.asp?id=BC71D7E2C2DF4126AFB049B34EC57144
indicates resuscitative thoracotomy penetrating trauma arrests prior to arrival in the ED have a 35% save rate (2 studies are quoted, also argues for no rescusitative thoracotomy on blunt arrests) although presumably they coded while enroute, not PTA EMS.

http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-146
reported the opposite in regard to resuscitative thoracotomy finding a study with 0% discharge survival for penetrating arrests.

ok i only felt like opening 2 google hits since i've opened 2 beers


----------



## TheDoll (Dec 21, 2006)

i thank you all so much for being patient with my question as well as taking the time to post your explanations. every time i think i know the answer to something i find i have a million questions to follow it up! anyways, you are all so kind not to make me feel like a nimrod! you know, i wish i could just buy a bottle of about 10 years of experience, but i have to put my time in just like everyone else! 
again, thanks!


----------



## Summit (Dec 22, 2006)

Doll, you asked a valid question with a good attitude. 

When someone finds out how to sell bottles of 10 years of experience, they are gonna be rich... rich I tell you!


----------



## Nycxice13 (Dec 22, 2006)

What exactly do they expect us to do? If the patient is gone, no one can bring them back, period. Would they rather us not even try? Not exist? What?

To say we are driving hearses with lights on is ridiculous, Im sure there are a GREAT number of patients that have survived due to our efforts.

Just because you are a doctor, doesn't mean you know all or have great common sense.


----------



## Ridryder911 (Dec 22, 2006)

What they expect us to do is get involved in protocol development and demand to use new standards. Yes, do nothing (when it is appropriate). Traumatic deaths (especially crushing) * do not live...Period*

Cardiac arrests in aystole do not respond after the second level or round medications ... * period*. Therefore, protocols should be changed to new studies and research that has demonstrated such for the past 15 years and several thousands of patients. 

To bring a patient in and then immediately cease the code, only causes false hopes in families, increase costs and actually should be considered unethical since we actually know it will be futile. 

Medics should be active in their protocol development and be encouraging the medical director(s) or committees to change. This data and standards is not new, and should be changed as soon as possible and monitored. 

R/r 911


----------



## Stevo (Dec 22, 2006)

and do you know of any ems orginization that has, or is willing , to champion these grass root causes *Ryder*?

~S~


----------



## Fedmedic (Dec 22, 2006)

That's pretty much how we handled it at my last agency. Traumatic arrest would automatically get bilateral decompression, secure the airway, two rounds of drugs, if no success, we confirmed DRT. 

Medical arrest, if asystole-two rounds of drugs, if no change-confirm DRT. 
Basically we didn't even load CPR's in the ambulance. We worked it until either they were dead and left them on the scene or we had a pulse. Not in protocol that way, just rule of thumb. We would call in to the medical control and tell them what we had done and that we had d/c'd efforts and they were cool with it.


----------



## Ridryder911 (Dec 22, 2006)

Stevo said:


> and do you know of any ems orginization that has, or is willing , to champion these grass root causes *Ryder*?
> 
> ~S~





Sure American Heart Association has published several articles including discussion of not starting resuscitation in the Healthcare Providers  BLS book and ACLS as well. National trauma courses such as PHTLS, ITLS and ATLS  both endorse and teach the likelihood of traumatic arrest (crushing) of being terminal or fatal. 

Other organizations such as American College of Surgeons (ACS), Emergency Nursing Association (ENA), all have published standards and guidelines as well. 

Again, this is really old standards that have been around greater than 10 yrs. 

One of the services I worked for performed field termination even in the late 80's.

R/r 911


----------



## Stevo (Dec 23, 2006)

imho, it would be a big step for the powers that be to hand us the holy water, but i would welcome it.

~S~


----------



## jeepmedic (Dec 24, 2006)

Now for the answer "How nurses handle emergencies?" 


They Call 911 to get a Paramedic.


----------



## medic03 (Jan 1, 2007)

akflightmedic wrote: ....As a flilght medic, we do not respond to nor do we transport traumatic arrests unless they happen to code after we have picked them up......

Yep, it amazes me every time we are about to land at the LZ or a few min out and they say, " Tell the medic that we are doing CPR...." and I get on the radio and tell them to go by ground.  Only if I fly someone off the beach will I pick up an arrest due to there being no streets that lead to a hospital. From some points where we cover you need a ferry to get you back to the main land or marine PD will take you by boat.


----------



## firecoins (Jan 30, 2007)

in 1996 when I was 18 and in the middle EMT class I came upon a bad head on collision.  I "worked" the car accident telling adults 2x my age what to do including an RN.  RN didn't seem to really know what to do in an emergency but she obviously knew more about general medicine. She just did what I told her to do.  

The medics who I worked with told me a story of an RN who did CPR on a patient who conscious.


----------

