I can not tell you how many times I have seen a patient in respiratory distress at an SNF on a nasal cannula on 2 to 6 LPM. I have seen it at other types of facilities too. I often write the name on the nametag of the nurse who made this mistake in the run report so it can be investigated later. I hate to bad mouth SNF's since I have seen some good ones with very competent and caring staff, but I think some of them should be shut down this second.
(Poorly) Skilled Nursing Facilities
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ERDoc
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Don't forget that those nurses have to operate within their protocols, just like you do. Many don't have protocols that involve anything more than a nasal cannula. The blame goes to the doc that writes the protocols, not the nurses.
PS-I cannot believe I just stuck up for nursing homes but I have seen some crap sent to the ER by the MD/DO/PA.
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It's not that you're necessarily sticking up for nursing homes, you're providing more insight as to where the problem of protocols lie. It's the Doc's fault or the Doc's glory as they're the ones that write the medical protocols. I've seen patients that were "all the way up" to 2 LPM and still doing very poorly, as we all have... unfortunately, sometimes their protocols really are that poor to where the SOB patient gets at most 2 LPM and if still SOB, gets sent to the ED for further eval, almost no matter what the complaint is. That's what those nurses are stuck with and without an order to implement medical care (including meds), they can't do much without running risk of "practicing medicine." Sometimes they get a really good Doc that writes good, well-thought out protocols... so when they call for EMS, you're going to get a truly sick patient.
We EMS folks are just as stuck and it's just that our protocols are usually more extensive and more aggressive than what's typically found at a nursing home for emergent care. If we dare to exceed those protocols, we run the same risk.
I agree that they may be following protocol, but I think they may fail to assess how severe the situation is and communicate that to the facility's doctor when they call them about transferring the patient to the hospital. I've also seen this mistake made in facilities that have a respiratory therapist in house 24/7. I think it's often not directly the nurses fault, but I think this mistake occurs with such frequency that it warrants discussion.
Also I do think there are some very stuck-up EMS providers, but also some of the most caring and friendly people I've ever met.
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Sometimes they are able to do exactly that and the facility's doctor may not put much stock in anything told to him or her by the nurses and therefore may not actually appreciate the severity of the problem. If the nurses don't somehow properly assess the situation and the doctor doesn't trust the nurses and can't appreciate the severity of the problem (whatever it may be), then that's a double whammy to the not good side.
Had a ECF get new Pulse Ox units; the readouts were reversed; so they were freaking out the 1st shift with them (no training on them, no break in period where they could check patient with the old units) 1st floor got them 2 days later 2nd floor got them). Pt's with O2 sats in the 60's and HR at 94. Or worse O2 sat in the 130's. They called us to ship out 22 patients to the ED across the street, (entire floor). We got there, started checking patients using our units on one hand theirs on the other. We SHOWED them what was going on and they still insisted on shipping them (due to call to the doc with orders and paperwork done). Fastest turnaround time at the ED ever (1st patient took about 5 minutes, after that it was less than 1 minute each. after the 5th patient the ED doc came back with us and evaluated them at the ECF.
We cancelled the other 3 trucks and my partner and I took the 5 patients, finished the paperwork for the round trips (10 PCR's) in less than an hour too
We cancelled the other 3 trucks and my partner and I took the 5 patients, finished the paperwork for the round trips (10 PCR's) in less than an hour too
ERDoc
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Was contacting the receiving ER or medical control an option? Sometimes the stupid just hurts too much.
there the policy is You Call, We haul. We can't tell them no; and what do you do when they tell you to take them to the hospital. If I called dispatch (I called our supervisor, he was down the hall with our patient) we would have been told to transport them: If we told ECF nurse no, they would have called someone else. Company actually got paid for every transport, both ways.
Yeah, 22 round trip transports, 44 transports at a couple hundred bucks a piece, 22 ER evaluations at a couple hundred bucks a piece. Probably all medicaid and medicare, and people wonder why our healthcare system is so broken, and our taxes so high. Your med control doc couldn't call the ER doc, straighten it out without treating and transporting 22 people for no reason?
It was only 7 round trips (there were 22 patients on the floor we only took 7): before one of the ED docs came back with us to clear them at the ECF, we requested them to call the ECF after the 1st one, they were slow responding. ECF floor nurse called and complained about us refusing to take the rest even after the doctor cleared them at the ECF and she (the ED Doc) and I showed them what the problem was.
ED only charged the 1st 2. We would roll in with them after that and roll right back out.
Was it perfect? no; If I had gotten permission from someone not to do what we did, and stopped transporting them; they would have called another service who would have been stuck with the same problem and either transported all of them or ended up doing the same thing. (Indy at the time had 9 IFT services, so it was hard to try and stop abuse from ECF's because they would just call someone else.
ED only charged the 1st 2. We would roll in with them after that and roll right back out.
Was it perfect? no; If I had gotten permission from someone not to do what we did, and stopped transporting them; they would have called another service who would have been stuck with the same problem and either transported all of them or ended up doing the same thing. (Indy at the time had 9 IFT services, so it was hard to try and stop abuse from ECF's because they would just call someone else.
Underoath87
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I've seen patients on a NRB at 2-4 LPM who either just coded or were completely cyanotic. I guess their orders specify the oxygen flow setting, but not the delivery device (which is terrifyingly stupid).