Just another regular dialysis patient....so it was supposed to be.

[Aidey]

An RN is still legally a higher level of care than an EMT or Paramedic. They may not be able to give orders to the EMT or Paramedic, but they can refuse to turn over care, and continue to care for the pt within the scope of their own protocols and orders.

Telling someone to do something like checking a BP on both arms is part of a through medical assessment. Doing that is a lot different than saying "Give him 10mg of morphine".

I'm not sure about LVNs, but in the case of CNAs for sure, they are not considered medical practitioners, and a Paramedic is (but not an EMT), and thus they are a higher level of care.

 

[wyoskibum]

An RN is still legally a higher level of care than an EMT or Paramedic. They may not be able to give orders to the EMT or Paramedic, but they can refuse to turn over care, and continue to care for the pt within the scope of their own protocols and orders.

While I agree that a RN is a higher level of care, I don't think it applies in the field. Unless the RN in a Nurse Practitioner or is part of a Prehospital response with some sort of medical direction, they are not anything more than a good Samaritan. Outside of the clinical environments, they usually do not have any protocols or orders. RN's in the field cannot do anything more than assess the patient and provide first aid. Same goes for a Paramedic who happens upon a scene and not in their jurisdiction.

The Paramedic who has a duty to act and has online medical direction has more legal authoriti. ;-D

 

[Akulahawk]

An RN is still legally a higher level of care than an EMT or Paramedic. They may not be able to give orders to the EMT or Paramedic, but they can refuse to turn over care, and continue to care for the pt within the scope of their own protocols and orders.

Telling someone to do something like checking a BP on both arms is part of a through medical assessment. Doing that is a lot different than saying "Give him 10mg of morphine".

I'm not sure about LVNs, but in the case of CNAs for sure, they are not considered medical practitioners, and a Paramedic is (but not an EMT), and thus they are a higher level of care.

An RN might legally be a higher level of care, depending upon the scene. If the scene is treated as an interfacility transport, the RN is a higher level of care. If the scene becomes a prehospital scene, a Paramedic assumes command/control. Regardless, the EMT's in this case, could not do that. They should have remained under the direction of the RN.

The transition from interfacility transport to a prehospital call can be very sticky and have ramifications beyond that particular patient, if not done properly.

While I agree that a RN is a higher level of care, I don't think it applies in the field. Unless the RN in a Nurse Practitioner or is part of a Prehospital response with some sort of medical direction, they are not anything more than a good Samaritan. Outside of the clinical environments, they usually do not have any protocols or orders. RN's in the field cannot do anything more than assess the patient and provide first aid. Same goes for a Paramedic who happens upon a scene and not in their jurisdiction.

The Paramedic who has a duty to act and has online medical direction has more legal authoriti. ;-D

In any of the County EMS systems I've worked in, most RN's in the field are considered a lower level of care than a Paramedic... they're required to be BLS unless they're MICN's... and even then they may assist the Paramedic at most. This is in the prehospital setting. Where things get wierd is in medical facilities that call for a 911 ALS response. I've seen two different ways of handling these. One way is that an ALS crew can wait for 10 minutes... if the patient is not ready, the crew goes back in service and is available for other calls. The other way is that the scene becomes a prehospital one and the crew then reverts to their protocols and Physician/RN on scene protocol. Around here, I've rarely heard of problems with this as most of the time, the facilities call for IFT units instead of 911 units... they can go to entirely off-line medical direction... and they can wait for patients to be made ready for transport. They still can call for orders in the rare event that a patient's condition falls outside the existing protocols but still within a Paramedic's Scope of Practice.

 

[Aidey]

While I agree that a RN is a higher level of care, I don't think it applies in the field. Unless the RN in a Nurse Practitioner or is part of a Prehospital response with some sort of medical direction, they are not anything more than a good Samaritan. Outside of the clinical environments, they usually do not have any protocols or orders. RN's in the field cannot do anything more than assess the patient and provide first aid. Same goes for a Paramedic who happens upon a scene and not in their jurisdiction.

The Paramedic who has a duty to act and has online medical direction has more legal authoriti. ;-D

In this situation the pt WAS in the clinical environment though, which is why I made the point I did. This is not some guy with chest pain in Starbucks and an RN happens to be there on a coffee run. Dialysis nurses have standing orders and follow protocols just like we do. In this situation, or in the case of a RN at a SNF/Rehab facility they may be able to do more to treat and stabilize the pt than you can.

 

[wyoskibum]

In this situation the pt WAS in the clinical environment though, which is why I made the point I did. This is not some guy with chest pain in Starbucks and an RN happens to be there on a coffee run. Dialysis nurses have standing orders and follow protocols just like we do. In this situation, or in the case of a RN at a SNF/Rehab facility they may be able to do more to treat and stabilize the pt than you can.

Sorry, my mistake. You are correct. This thread has been going on so long, I forgot what the original details were! ;-D

 

[Akulahawk]

In this situation the pt WAS in the clinical environment though, which is why I made the point I did. This is not some guy with chest pain in Starbucks and an RN happens to be there on a coffee run. Dialysis nurses have standing orders and follow protocols just like we do. In this situation, or in the case of a RN at a SNF/Rehab facility they may be able to do more to treat and stabilize the pt than you can.

Yep. Dialysis RN's typically have, on hand, the orders and equipment to render actual care at a higher level than EMT-B personnel. Even as an ALS call, I'd be inclined to treat this patient as an interfacility transport that is emergent than a regular scene call.

I've been in SNF/Rehab facilities where the RN's orders were more restrictive than the prehospital EMT-B's. No IV's unless specifically ordered, no Advanced Airways, (actually, they'd need orders to put in an airway adjunct) No ACLS... Just basic CPR, whatever orders are in the patient's chart, and O2... max @ 3 LPM. Yes, I said 3 LPM by Nasal Cannula... for patients who are acutely SOB.

 

[medic_texas]

Am I the only one really confused?

Nope

It's one story, and another story, then the other story but this time the other basic is a medic who works as a basic who tells paramedics working as such that they know what's best for the patient and off they went.

I think that clears it up.

 

[medic_texas]

Did the patient ever consent to being treated/transported? He "feels fine", why would he want to go to the hospital? ..Other than 2 rookie-asses jumping around like a couple of monkeys :censored::censored::censored::censored:ing a football.

 

[VentMedic]

the RN's orders were more restrictive than the prehospital EMT-B's.[/b] No IV's unless specifically ordered, no Advanced Airways, (actually, they'd need orders to put in an airway adjunct) No ACLS... Just basic CPR, whatever orders are in the patient's chart, and O2... max @ 3 LPM. Yes, I said 3 LPM by Nasal Cannula... for patients who are acutely SOB.

Can an EMT-B administer Nitro (any form except drip), pain meds, inhalers, lasix, or BP meds?

Many of the SNF patients have PRN meds with parameters and may already have been given before EMS or a transport ambulance is called. Yes, these can still considered emergent.

Orders for an EMT-B are usually very generic and may do little harm if initiated. For a more definitive care, RNs will have PRN or standing orders specific to each patient. Also, RNs have many drugs at their access and may call a physician, not because they don't know nothing, but because each patient presents with different disease processes and a plan of care for definitive treatment can be initiated before the patient arrives at the hospital. That physician will then call the ED him/herself with more information and orders until he/she can assume care. Of course the ED physician can also do what he/she feels necessary.

This is not about who can do more or what, but rather what is best for the patient. If a definitive plan of care can be initiated by the RN at the SNF, who care if he/she calls the physician. This is for the good of the paitent. It is much better than an EMT-B just scooping the patient and running with only O2 real fast to the ED because "their medical directors says they can do that without calling".

Also, the reason a physician is called when a nurse initiates O2 or an airway adjunct is because the status of that patient has changed. That is a big deal and further assessment may need to be done to determine the level of care. Why does the person need a nasal trumpet when they were up playing cards just a couple hours prior? What changed to cause a patient to require O2?

The decision to transfer is patient to a hospital is a big deal and does require a physician's approval for many situations unless it is a true emergency. Yes, sepsis can be an emergency especially in a frail patient.

 

[Aidey]

Yep. Dialysis RN's typically have, on hand, the orders and equipment to render actual care at a higher level than EMT-B personnel. Even as an ALS call, I'd be inclined to treat this patient as an interfacility transport that is emergent than a regular scene call.

I've been in SNF/Rehab facilities where the RN's orders were more restrictive than the prehospital EMT-B's. No IV's unless specifically ordered, no Advanced Airways, (actually, they'd need orders to put in an airway adjunct) No ACLS... Just basic CPR, whatever orders are in the patient's chart, and O2... max @ 3 LPM. Yes, I said 3 LPM by Nasal Cannula... for patients who are acutely SOB.

Just FYI I used to work in a Dialysis clinic. On the flip side of the SNF issue, I was at a facility the other day that had standing orders for the RN to administer several painkillers, and she could get verbal orders for Morphine. It is facility dependent, which is why it is important to know the capabilities of the facilities you go to. And rather than challenging the RN or whomever, ask what they can and can't do, rather than assuming you can do more than they can. (That is a general statement, not directed at you AKulahawk)

 

[medic_texas]

This again eh..

As a nurse working in the hospital (ER and SICU) we have protocols and standing orders that we do not have to have a "doctor tell us what to do". Many of the protocols in the ER are similar to my EMS protocols and others are more invasive than my paramedic protocols on the street. The standing orders are more patient specific and in this situation, is probably what the nurse was initiating.

Until that patient is on your cot and you have consent to treat and transport, keep your mouth shut and let people do their job.

 

[KillTank]

On the scene I will only follow a medic or a doctor. In the hospital I will follow a RN or Doctor. I checked my protocall today and it states that In pre hospital care only a Doctor or Medic can control the scene and Only a EMT, Doctor, or Paramedic may give care. The way I look at it... A RN or LVN have a emergency room at there disposal. In the field they don't and are not trained in pre hospital care. The patient was In a clinic the RN is in charge until the Paramedic has begun care on the patient.

 

[Hal9000]

Learn

Learn from mistakes. Understand your failures. Correct them. When life knocks you down, dust yourself off, start over, and eliminate the next challenge. Learn to keep your balance.

The odds are that this will be one of the things where you look back and say, "Man, what an a:censored::censored::censored::censored::censored::censored: I was. Hope I never seem like that to anyone again."

Learn. Learn from these things. Don't be too cowardly to accept them. Admitting flaws that the public has seen is hard; it's easier to wall them off. The pain is worth it. You'll be a better person all around for it. You will gain perspective. You will eliminate the old self and rebuild someone more dignified. Realize that being calm is a virtue in this field.

I know this is true. I've been a foolish idiot more times than I can count, but I do count those times, and I count them often. The best way I can teach people is with the examples of my own failures. IF you can do this, you will have the ability to progress. I have found that my biggest failures have had a silver lining: the worse the fall, it seems the bigger my recovery stride has been, taking me to new, undiscovered levels. Each of these has made me more valuable to true professionals and has earned me more respect.

You have that same chance.

 

[medic_texas]

So when the nurse takes a phone order from a doctor and tries to initiate the order while you run in and save the day, are you following the doctor or are you stepping out of your boundaries?

Apparently, the OP was to take this patient back home or wherever, they were never called there; it was a scheduled transfer.

Obviously, if there was a need for EMS they would have called EMS; not the basics who showed up. If I'm in the clinical setting and I'm a little uneasy about the basics showing up, I can refuse to have them transport the patient and call for another unit. A nurse's license will outweigh a basics certification any day. If two jackasses come to transport a patient and make the patient even more anxious, I can ask them to leave. The patient is still in the care of the LICENSED healthcare provider and does not have to release care of the patient. Who are you going to take the patient to anyways; another nurse?

Luckily for me, I don't work in a dialysis center or the clinical setting.

 

[KillTank]

So when the nurse takes a phone order from a doctor and tries to initiate the order while you run in and save the day, are you following the doctor or are you stepping out of your boundaries?

Apparently, the OP was to take this patient back home or wherever, they were never called there; it was a scheduled transfer.

Obviously, if there was a need for EMS they would have called EMS; not the basics who showed up. If I'm in the clinical setting and I'm a little uneasy about the basics showing up, I can refuse to have them transport the patient and call for another unit. A nurse's license will outweigh a basics certification any day. If two jackasses come to transport a patient and make the patient even more anxious, I can ask them to leave. The patient is still in the care of the LICENSED healthcare provider and does not have to release care of the patient. Who are you going to take the patient to anyways; another nurse?

Luckily for me, I don't work in a dialysis center or the clinical setting.

Good point. When I was working transport we would contact FMS if we felt the patient was not stable unless we had a medic with us.

 

[Flight-LP]

On the scene I will only follow a medic or a doctor. In the hospital I will follow a RN or Doctor. I checked my protocall today and it states that In pre hospital care only a Doctor or Medic can control the scene and Only a EMT, Doctor, or Paramedic may give care. The way I look at it... A RN or LVN have a emergency room at there disposal. In the field they don't and are not trained in pre hospital care. The patient was In a clinic the RN is in charge until the Paramedic has begun care on the patient.

Flight nurses???????

 

[daedalus]

I can't imagine what some nurses think of us when we come into a clinic or something acting like this.

 

[Akulahawk]

Flight nurses???????

Flight Nurses would fall under a different policy than MD/RN at scene. They fall under a "Medical Scene Authority" policy. Usually this refers to ground providers who may be of different license levels, training, or even different agencies. Here's where things get interesting. If a helicopter is dispatched, I have the authority as a Paramedic to cancel their response right up to the point where they make patient contact.

Transfer of care from a ground to a flight unit is also covered under a transfer of care policy. Normally, in my County, if my patient is unstable (and I'm a non-transport Paramedic), I can not turn patient care over to any other Paramedic. I go to the ER with the patient. I can transfer care to a Flight Paramedic for the purpose of air transport. That means I can also transfer care to a Flight Nurse for the purpose of air transport.

The point is, Flight Nurses and Physicians are the only providers that can take over command of my scene and care of my patient. Normally though, the Flight RN's aren't called out to the scene unless they're needed and I intend to transfer the patient to them anyway.

Sacramento's Medical Scene Authority Policy is copied, in part, and highlighted by me:

Authority for patient health care management in a non-disaster medical emergency shall be vested in that licensed or certified health care professional, which may include a EMT-P, or other prehospital emergency personnel at the scene of the emergency, who is most medically qualified specific to the provision of rendering emergency medical care.

Flight nurses are considered "other prehospital emergency personnel" as are EMTs, in the event that only EMTs are on scene.

 

[Flight-LP]

Thank you for the insightful info, but I was directing this towards another individual who has potentially been misinformed or is misperceiving his protocols.

Yes, they are a different animal all together.

 

[KillTank]

Thank you for the insightful info, but I was directing this towards another individual who has potentially been misinformed or is misperceiving his protocols.

Yes, they are a different animal all together.

What does a Flight Nurse have to do with working on the scene at a residence vs a hospital or clinic? I never stated I wouldn't let a Flight Nurse touch my patient. I do not walk into a clinic thinking I'm going to run the show. The nurse knows more about the patient than I do and I rather the nurse assist me. But on the scene of a MVA or a Medical call outside of a hospital or clinic a RN, LVN, or CNA will not be allowed to assist according to my local protocols. In fact if a Doctor or another EMS official arrives on scene MY local protocol states I must check for credentials before allowing to take command or assist. A flight Nurse is considered a EMS official and does not take control of the scene, only the patient It will be transporting after the on scene Paramedic or Doctor has handed over care.

I am not trying to walk over anyones profession or state who is better. Depending on what training you have depends what role you can take in certain situations. Its only common sense.