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Transfer of Care Concerns?

Discussion in 'BLS Discussion' started by FirstResponder, Feb 8, 2018.

  1. MSDeltaFlt

    MSDeltaFlt Forum Deputy Chief

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    OK, Tom, here's my thoughts from my point of view. Bare in mind I am not bashing you or anyone here, so bare with me as this can get a bit philosophical.

    What you say and people HEAR you say might not necessarily be the same thing. My partner and I can say the exact same thing with the exact same words, intonation, and syntax. And they will believe me before they will believe him because I look older, my hair gray (what little I have left), I'm bigger. I have a gut. And I have wrinkles on my face. Basically I talk with experience and authority. Because I'm old.

    Were the conversations not as effective as they could be? I used to think so when I first started.

    But after a few years I learned that most nursing home patients being sent to ER for evaluation are either stable or
    dead. Rarely are they dying. Dead is easy. Check rhythm/pulse. Check PMH, age, and prognosis. And either
    continue to work it or call it. The not dead or dying are also simple. Usually the result of an infection making their
    symptoms worse. Do they need a cardiac monitor or a regular bed? The dying definitely need more information.
    What happened? (keep it brief) Do they have a pulse? Are they breathing? Do they have a line? Do they need
    one? Are they a code? Are they a NO CODE? Do you have they paperwork? Even as a medic it's usually that
    simple for the most part.

    Did I have to pry information? When I first started before I learned to look at the big picture.

    Some of these nurses either don't know how give an EMT a bedside report or they don't have time or they don't
    care. And that depends on the nurse, on the day, and on the patient at that moment. Once you are able to see
    the big picture, odds are you won't need as much information from the nurses.

    Did I feel that my reports weren't taken seriously in ER? Yes, when I didn't realize what was really going on.

    Most of these nursing home patients we pick up we're picking up for the reason they were brought to the ER last
    month, and the month before that, and the month before that, and so on and so on. If you'll notice sometimes
    the nurses will look at the patient and might roll their eyes because they know who they are and why they're back.

    Now this is not every patient every day all the time. But "generally speaking" this "tends" to be the case. When you sharpen your skills: assessment, treatment, and verbal report, the ER will learn you and respect you. And when that happens this thread will become a distant memory.
     
  2. FirstResponder

    FirstResponder Forum Probie

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    Appreciate the response
     
  3. Akulahawk

    Akulahawk EMT-P/ED RN Community Leader

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    MSDeltaFlt pretty much hit the nail on the head with what goes on in the ED when you bring patient in from a SNF. I currently am an ED RN. I have seen (literally) the same patient multiple times for the same problem from the same SNF. When I get those, I really don't need a whole lot of information from EMS. I want to know why you were called out, what you found when you first saw the patient, and I want to know what you've done for the patient. Since I also know local protocol, if you tell me that you were following a particular protocol, that would be gravy. Most of what you need to tell me takes only about 60 seconds. Even if you have NO freaking clue about what's going wrong, a quick head-to-toe report takes less than 60 seconds. After that, I'm pretty much well into thinking about what I need to do for this patient and I'm already beginning my own assessment.

    But again, SNF patients that are sent to the ED are either going to be relatively stable or they're going to be basically dead, with very little in-between. As an EMS provider, what do I want to know? Simple: Code status - GIVE ME THE PAPERWORK!, how is this patient different today vs yesterday - what's the patient's normal mentation!, when did symptoms start? That's pretty much it. Oh, and GIVE ME THE PAPERWORK!!! As far as the paperwork goes, if all you have is an H&P and a current MAR, just copy it and give it to me. I can mine through the paperwork to get a good idea what's going on pretty quickly. That means in about 10 minutes, I'm going to be able to tell the ED what's going on and hit the highlights. Everything else is in the chart...

    Back when I first started, my reports weren't taken seriously because it was pretty clear that I was new. Over time, I sharpened my assessment skills, sharpened my reports, and eventually came to be known as someone to listen to because my reports were consistently accurate and provided the info needed to continue providing care while the ED team was working through their assessments. I also made sure that my verbal reports were less than 60 seconds long. Anything they need to know after that, well, I'm right there and they can ask me.

    I'm also going to echo something from earlier in this thread: every EMS provider you run into will have different levels of knowledge. In my case, I'm the guy that's trained in sports med. I "see" MOI very differently than most. I've taken both PHTLS and ITLS. I've taken ACLS and PALS (and stayed up to date) for the past 18 years. I've taken traditional Paramedic and RN programs. I've done NIHSS. I've had many years of experience doing patient care in the field. I've had a few years of experience doing patient care in the ED. The report you'll get from me is going to be quite different from the guy that's fresh out of EMT school or medic school. I have little experience working with ICU patients, and that shows... I just do my best to care for those really sick patients until I can get them to the people that specialize in providing care for them. Just know that you need to keep doing your best, keep learning how to better assess patients, and how to give good, thorough and concise reports and you'll do just fine.

    Just don't stop learning. There's always something more to learn!
     
    MSDeltaFlt likes this.
  4. MSDeltaFlt

    MSDeltaFlt Forum Deputy Chief

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    Amen, Akulahawk. Brevity is key.
     
  5. FirstResponder

    FirstResponder Forum Probie

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    no argument there!
     
  6. CityEMT212

    CityEMT212 Forum Crew Member Premium Member

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    I always felt respected by receiving department care members, and dialogue was two way. Although I personally haven't encountered any negative interactions or frustrations I'm aware it is possible for that to occur. Once I renew my card and go back on a bus, I'll look forward to getting back into the EMS world, and working my best with others. Should I encounter any issues or frustrations, I'm sure I'll return to your post...
     
    FirstResponder likes this.
  7. ZombieEMT

    ZombieEMT Chief Medical Zombie Premium Member

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    I have had a recent experience working for an SNF. I honestly can say it opened up my eyes to a lot of issues and complaints I have had as an EMT. I fee that it has given me a better understanding of the changing climate and made me a better provider.

    The constraints of SNF are far beyond what I imagined. Some facilities provide very minimal autonomy for nurse and they practically need orders to wipe a butt. The staffing ratios are at times rediculous. Company policies can be crazy and make no sense. I witnessed nurses having stbding orders for narcotic pain medication but not oxygen. SNF nurses are so limited its unbelievable.

    With that being said, I do expect certain things as an EMT.

    1. I expect that the primary nurse is present and can provide me with the same level of report they provide to the ED, including as much relevant as they know.

    2. I expect honesty. If you messed up or missed something, dont lie. If you did no vitals, tell me.

    3. I expect the same level of respect you would like to receive.

    4. I expect that you know basics on the payient you are primarily responsible for. What is their baseline? Why are they there? History of present illness. I DO NOT expect a nurse with 30 patients to know complete histories amd medications off the top of her head. I know some do.

    Many times I have to pry information and that is my responsibility. Many times we are just the transportation to the hospital and nothing more. Thats all they see us as many times. I accept that.
     
    FirstResponder likes this.
  8. Peak

    Peak ED/Prehospital Registered Nurse

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    The ED gets little to no report on those patients. I've called nursing homes to figure out why a patient was on antibiotics, and their primary nurse didn't even realize that the patient was being treated for an infections.
     
    FirstResponder likes this.
  9. ZombieEMT

    ZombieEMT Chief Medical Zombie Premium Member

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    I don't doubt that. However, I have been to several SNF that have to be prompted to provider the ambulance with report and respond, "Well I gave the charge nurse/doctor report." That is because some SNF staff find the ambulance as just a taxi ride and not healthcare provider.

    Also, please don't take the last part in any wrong way. I am a big supporter of the fact that one of the most important (if not the most) things that we do for our patients is to transport them.
     
    FirstResponder likes this.
  10. chriscemt

    chriscemt Forum Crew Member

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    That can be a weird way to avoid the topic entirely. Countless times I've been told that only to find that no report was provided.
     
    Kevinf and FirstResponder like this.
  11. FirstResponder

    FirstResponder Forum Probie

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    These are important conversations to have. I'm happy we're still having them! That was the goal...
     

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