Need For Definitive Care

[marineman]

I have no issue with the rendezvous thing. I do it all the time.

Its this...

It's very rare to package prior to calling for ALS however major multisystem trauma especially MVC's come to mind if there's not a wait on extrication my priority is getting the patient out of there and on their way to proper care. These patients require care above the scope of ALS and as some (questionable) studies show ALS for trauma patients may not do as much good as we all like to think. If I roll on scene and the FD has the patient ready to roll we roll and place the call enroute.

As for the ALS not catching you not sure what the problem with that is, take away the joking comment about the way I drive and it's nearly impossible to make up 10 minutes time on 2 vehicles running the same direction. On a 30 mile transport to catch me at the hospital door you would have to be going 20mph faster than me. To catch me half way to the hospital you would have to average 40mph faster than me. It's not probable for them to catch you unless you wait which is the reason why that's the only time I would wait.

I'm a medic student, believe me I get all amped up about ALS just as much as you but we all have to realize it's limitations and realize that expeditious transport will do the patient more good than waiting for a medic so he can start an IV that the hospital will replace.

 

[OzAmbo]

ah, im glad you qualified that marineman because at a glance your previous post about this smacked of arrogance

I'm settled now B)

 

[VentMedic]

The goal of ALS field treatment and the initial treatment of the ED are the same.

I'm a medic student, believe me I get all amped up about ALS just as much as you but we all have to realize it's limitations and realize that expeditious transport will do the patient more good than waiting for a medic so he can start an IV that the hospital will replace.

The hospital staff is not going the pull the Paramedic's IV out as you roll through the door and with good reason which I will answer below. But yes it will probably be changed in the ED or within 24 hours. That doesn't mean you use that as an excuse not to do one if warranted.

Originally Posted by RESQ_5_1
Not being a Paramedic, as well as having treated PE pts (it actually didn't end well even with ALS intercept), I would like to know what treatments a PAramedic can do for suspected PE. Or, is it just a matter of knowledge to be able to diagnose a PE.

People code due to hemodynamic instability. For any unknown, both the Paramedic's and the ED staff initial responsibilty will be to maintain hemodynamic stability until a definitive dx and/or treatment is started. That is done through fluids and pressors. You want to maintain an adequate BP MAP to supply O2 to the tissues. This is true for almost every scenario. Refer to the shock thread. PREVENT THE CODE FROM HAPPENING.

The BLS limitation is, without a cardiac monitor, the pulse you are feeling may only be the perfusing beats. The patient may have a HR of 240 but a palpable pulse of 80. Treat the hemodynamic instability: break the rhythm if possible and support BP through fluids and pressors. BLS does not have any of those capabilities.

Paramedic at scene of RESQ_5_1's scenario:

O2
History/meds
IV
12-lead EKG
- occasionally a PE will present with specific changes
- MI? initiate that protocol
Support the hemodynamics through fluids and pressors to maintain stability and prevent the code from happening.

The goal of any scenario is to maintain adequate oxygenation and hemodynamic stability by whatever means available. As well one should recognize the limitations for some situations and time such as trauma but the goals are the same. However, what can be started enroute will probably be benefiicial.


In the situation from the OP, whoever was closest, the Paramedics or the ED can initiate appropriate treatment to maintain hemodynamic stability for perfusion and oxygenation which is the goal for the patient regardless of who starts it.

 

[amberdt03]

Yes they can call 911, but it costs more. Nursing homes establish prices with transfer services for much less than a 911 transfer. So it is about the money not the patient or the law.

i heard that everytime a nursing home called 911, they get investigated by the state. not sure if its true or not, never really checked into. i once ran a call from a nursing home on a bp of 60/40. dispatch gave an eta of 30 min(we were the only als truck that night) and the nursing home said that it was ok even after dispatch suggested they called 911.

 

[rescuepoppy]

In regards to the original post this sounds like a good place to use a little common sense. Just consider the times, hospital is two minutes away ALS is an hour out, this patient is going in BLS. The hospital can start the definitive treatment. I am not going to risk standing in front of a judge explaining that I was afraid of looking stupid if I took in a patient without waiting for ALS to start their treatment. In my area if a BLS crew needs ALS assistance it is acceptable to start transport while rolling toward an intercept or if transport to the hospital is quicker to go ahead and transport there. The bottom line is what is the quickest and safest method to get the patient to a more advanced level of care.

 

[medic417]

But a thought to ponder is would it be legal to downdrade the care from the higher level of a nursing home RN to a basic crew?

 

[Aidey]

I was just thinking about that myself medic417. It probably depends on the exact situation and what equipment the nursing home has vs the BLS ambulance.

 

[JPINFV]

Well, you're transfering care from a transpot incapable unit to a transfer capable unit. Also the greater good of the patient is being accomplished by a temporary downgrade in order to get the patient to an even higher level of care.

If this was an issue, then an RN shouldn't be downgrading a patient to a paramedic led CCT team.

 

[CAOX3]

But a thought to ponder is would it be legal to downdrade the care from the higher level of a nursing home RN to a basic crew?

Legal, It happens all the time. I would question isnt it also a downgrade from an RN to a paramedic.

Hospital transfer pts all the time they cant treat. They are downgrading care, our they not. This is a neccesary evil to get the pt to difinitive care.

 

[medic417]

Legal, It happens all the time. I would question isnt it also a downgrade from an RN to a paramedic.

Hospital transfer pts all the time they cant treat. They are downgrading care, our they not. This is a neccesary evil to get the pt to difinitive care.

The downgrade of care is still supposed to given to someone caple of providing X care. In this case BLS could not provide X care so they were to low a level. Other times patients are stable and only need transfer so Basics can do it.

As to Paramedic vs RN I'll leave that to another day.

Common sense says get patient to ER by BLS or 911. Neither applied common sense. But legally this is a case of darned if you do darned if don't.

 

[emtfarva]

SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.

 

[amberdt03]

The downgrade of care is still supposed to given to someone caple of providing X care.

have you ever actually talked to a nursing home nurse? i don't know how they are in your area but they ain't so great in dallas and surrounding areas. so i don't think that it would be a downgrade to a basic if the original care came from a nursing home nurse.

 

[amberdt03]

The hospital staff is not going the pull the Paramedic's IV out as you roll through the door and with good reason which I will answer below.

there is a hospital here in dallas that its their protocol to pull all out of hospital iv's. don't really know their reasoning for it but always get a kick when they can't start their own and have to use ours. (and by ours, i mean my medic partner)

 

[ffemt8978]

SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.

Since when did EMS become about "power"?

 

[VentMedic]

there is a hospital here in dallas that its their protocol to pull all out of hospital iv's. don't really know their reasoning for it but always get a kick when they can't start their own and have to use ours. (and by ours, i mean my medic partner)

This is not just one hospital but many across the country. This is nothing new. Have you not read anything about Medicare and acquired infections?

Considering the conditions that some EMT(P)s even brag about starting IVs under or how they don't have to follow all that cleaning stuff done in the EDs, would you trust EMS IVs for any great length of time?


emtfarva

SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic.

Wow, someone is on a power trip...

Ever count the things a nurse can do that EMT(P)s can't? You might find that to be a very long list.

If the nurses could leave their patients and go to the hospital with them, there might be a few less jobs for some EMT(P)s. Oh wait, RNs already do IFTs as part of their job on CCTs especially if the EMT(P)s aren't qualified to handle critical patients with a variety of drips that are not part of the Paramedic's scope. Some RNs and RRTs may also have to leave their hospital to accompany a patient that the Paramedics can not transfer by themselves. For whatever the Paramedic can't handle on these transports, the RN does.

The nurse in the SNF call EMT(P)s to do a job which they know they can not do nor can they leave to transport. It is your job and your specialty. If you want to seriously get into a power struggle with a nurse who just wants his/her patient provided with emergent care and transferred to a facility for a higher level of care, you will lose. As well, your company may lose that contract which may also put you looking for another job. Feel the power now?

 

[Sasha]

there is a hospital here in dallas that its their protocol to pull all out of hospital iv's. don't really know their reasoning for it but always get a kick when they can't start their own and have to use ours. (and by ours, i mean my medic partner)

Have you ever asked why?

The hospitals I do clinicals with and deliver to on rides pulls EMS lines if it's non-emergent, (ie the line is not needed to stabilize, even then they pull it as soon as they establish their own.) Why do they do this? Because the field is very dirty, you start IVs in people's houses or trucks, we clean our own ambulances and people get lazy and don't clean it properly. They don't know if you've changed your gloves, done it with out gloves, used an alcohol prep, etc. EMS lines are dirty lines. People get infections from them, and sepsis has a disturbingly high mortality rate.

SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.

Way to perpetuate an "Us Vs. Them" mentality, yet again. Nurses are far more educated than EMTs and Medics. I'd love to hear how you taking control of a code with a nurse on board works out. Saying nursing home nurses aren't trained for emergencies is BS. If things go south, I'd rather have a nurse than an EMT any day.

 

[ffemt8978]

The hospital I worked at pulled ALL field IV's within 24 hours of them being established for the simple reason of reducing infection. Generally the ER would establish a new IV and pull the field one just before admitting the patient and transferring them to the floor. If the patient was going to be a treat and street, they didn't pull the line until the patient was discharged.

 

[Aidey]

SNF nsg staff are not trained for emergencies. They can't run a code. When transporting a Pt with a nurse aboard, I as a basic has more power than the nurse if the Pt was to crash. That also inculdes medics. I the Pt crashes the nurse has to leave care to the medic. ussally the nurse is there because the Pt has something running a medic can't take. So to answer your question, no, basics have more power than the nurse at the SNF. If someone or the EMS crew onscene feels that this is an emergency, then an EMS provider takes charge, unless Fire or Pd have control of the scene.

I wouldn't bet on that 100%. My aunt was a nurse for years, and when she retired from the ICU she worked at a nursing home for several years as a transition into retirement. Even after being out of the ICU for a few years I bet she still knew how to run a code.

As for RN vs MICP during a code, it would totally depend on the MICP and the RN. Some RNs could run a code with one hand tied behind their backs, others wouldn't know epi from Excedrin. Same with some medics.

There is also a difference between a MICPs scope and their standing orders. We have to use RNs occasionally where I work for IFTs when the patient has something that is within the MICP scope, but not within my agencies standing orders, such as a nitro drip.

 

[VentMedic]

. Saying nursing home nurses aren't trained for emergencies is BS. If things go south, I'd rather have a nurse than an EMT any day.

Taking care of a patient in an emergency may actually be easier than caring for 25 patients at one time so that they don't have an emergency.

Nurses DO know their limitations and will allow someone better suited to handle what they can't. Some in EMS have yet to learn the limitations of their own education/training or believe a 110 hour couse is all there is to medicine. There are also those that don't know what they can do or should do. I believe the scene illustrated in the OP demonstrates this.

 

[emtfarva]

Nurse's can't ETT a Pt. I didn't mean to sound like I was on a power trip. The ICU nurses that you are all talking about have this in their standing orders. A nurse has to have orders to increase O2 on a Pt. I have standing orders to increase O2 if clinically indicated. A nurse can not run ACLS protocols. Basically, A nurse can only run HCP CPR, if they don't have standing orders for it. Also I haven't seen a SNF that has ACLS drugs. Yes nurses have a hell a lot more training than I do, but the nurses that work in SNF deal with more long term issues. They care for daily needs not emergent needs. That is why Pts are sent to the hosp. They have no way to manage emergent situations. They do not have RTT on staff (unless they are a rehab hosp). I have been to SNF where nurses don't even take VS on emergent Pts. They also tend to use nurse's on a stick. Not one call for hypotension or HTN that I have been on has a B/P done manually. Something that comes to my mind is cases that I would transport Pts from a L&D to a higher level care L&D. The nurse would come with us so the Pt could cont. on LR, and also to monitor the fetus. If the Pt crashed we would be responsible for Pt care. The nurse would also be there if the Pt decide to deliver her child. Maybe the word power was wrong but I think we would provide a higher level of care than a nursing home nurse. We can also transport a Pt to a higher level of care. There is a debate about this same situation in an area near me. A private company, per their company policy can not transport a priority 2 or above Pt, they have to wait for Fire. It doesn't matter if it is AMS or cardiac arrest. This in my opinion is very wrong. Per statewide treatment protocols, Bls providers should transport ASAP with or without Als. They go against the states treatment protocols. I am sorry if I offended anybody with my little power trip. I, again, didn't mean it as some of you presumed I meant it.B)