15 March 2010

Paramedic v. Nurse


**Newsflash** Hold all presses for news release, the Gate Keeper is an a$$ because he asks questions to a nurse. Well who woulda thunk. Let me fill you in on this one.

We’re called to a local managed care facility (nursing home) the other night for a patient experiencing some difficulty breathing. When we get there, as usual, there is no nurse with the patient who is in need of emergency treatment. Let me stop and spin tires here for a minute.

Would somebody please tell me why it is o.k. to call for an ambulance that is supposed to transport a patient who is supposedly sick enough to be outside the capabilities of the facility…and yet doesn’t have a nurse close by to manage said patient who is in such bad shape. Furthermore, why do the nurses not have proper training on the use of oxygen therapy and the delivery devices for said therapy? Really!?! Wouldn’t you think that we’d need to have that little baggie under the mask inflated just a little bit, and guess what my genius friends…five liters ain’t cutting it and two liters per minute with twenty feet of canula ain’t gonna do it either.

O.k., so I go to the patient’s room and sure enough she is having a rough time of it with her breathing. I ask a young lady who follows me into the room how long this has been going on.

“Oh I’m just an aide…I’ll go get the nurse.”, she says and scurries out of the room.

The patient is CA/Ox4 and also has some secondary issues with pain in her abdomen (RLQ) radiating down her right leg. For this she has had a morphine pump prescribed by her primary physician. I’m more concerned with the breathing since it is so labored with use of accessories. She is also pale and diaphoretic and which narrows my differential down even more.

Before long a nursely looking type appears in the room. I think I recognize this fella from the hospital, and if I’m not mistaking he also works in the CCU, so I breath a sigh of relief and start my interview with him. The patient was having such a hard go of it breathing, I didn’t want to stress her any more by getting her to talk.

I turned from the patient to ask the nurse, “When did all this start?”

“I’m not sure…I don’t work here all the time”, he answers not realizing he has just let me down already. Is this a standard response for any nurse who works in a nursing home that is taught in orientation or is there a special nursing class just for excuses and responses to EMS personnel?

It wouldn’t bother me so much if it was only every other time, but this is EVERY time I go to a nursing home to pick up a patient…any nursing home it seems.

Not thinking I continue on, “What kind of health history does she have?”

“That’s a good question”, is all I get.

Thinking that I may actually get somewhere with the next question, much to my chagrin I try again, “what types of medication is she taking”?

“That’s a good question too”, he responds

Really?!?! You mean to tell me that with two years training and many more years experience, the only thing that I have learned to do is ask good questions. What’s more amazing to me at this point is that this guy has just recently graduated from nursing school with the same two years of training, albeit in a different discipline. Of course you would think that a nurse would at least know the answers to some of these general assessment questions.

I’m just plain disgusted at this point and ask if we can get a chart or something or get someone who does know what’s going on with this patient.

Just then another nursely looking type walks in with some papers cradled in her arm. Maybe we’ll get somewhere with this one I hope deep from within my soul.

“Here’s her paperwork” she says while thrusting some papers in my direction.

“Whoa, just a minute…what exactly is going on here…how long has this been going on?” I ask.

“I’ve already gave the report to the ER and Dr. Hey’you wants her brought on over”.

“Well, that’s all fine and well, but I have to treat her between here and there…she’s not looking too good… I need to know exactly what’s going on”.

By this time I guess I had said some magic word that gave me security clearance to some personal medical history and events leading up to this point. She started in with her rendition of what was going on while I was in the process of hooking up the EKG, which showed an old infarct or even maybe an area of ischemia.

I’m going to stop here with the “case study” just because I want to preach a little bit about being a professional.

First of all, if a physician had came in my truck, dressed in the same uniform and asked the same questions, would it have made any difference what questions were asked. After all, are we not the eyes and ears of the physicians who have given us standing orders to act on their behalf?

I know there are nurses who don’t like us for one reason or another, and most don’t want to hear our reports at handover only because they are going to ask the same questions that we just did. Many more will certainly not want to hear about any pre-hospital treatment performed because that will just remind them that we do assessment based treatments rather than physician ordered treatments.

The reason that I’m so fired up over this is because this nurse happens to be friends with another friend of mine and called him to say that I just came across as a smarta__ and acted like an a___ole because of the questions I was asking.

I am a professional. I am a patient advocate. It is my job and responsibility to assess the mental acuity, history and needs of the patient and then render the treatments necessary to preserve life and/or the quality of life until care is turned over to a higher trained individual, or in most cases someone in their charge, such as a nurse.

It does not matter to me who the patient is, where they come from and it certainly doesn’t matter what their social standing is. I refuse to accept the mentality that just because a person is in an environment such as a nursing home, that they have given up all rights to make decisions for themselves if they are able.

I can not tell you the number of times I’ve heard a nurse tell a patient “you have to go, the doctor said to send you over” all the while the patient is protesting going anywhere. If the patient can tell me who they are, where they are, how they are and why I’m standing there…they’re in control of their destiny, period. Now I feel the need to clarify something here. I know that sometimes a patient will not want to go for fear that they might inconvenience someone, but if their condition warrants a visit to the ER, it is still my job to advocate for the patient and I’ll do everything in my power to encourage them to seek treatment. But it stops there. I don’t and will not participate in the coercion of a patient to do something they do not want to do.

For the ones who cannot speak and think for themselves, I wish I had the power to say (after a thorough assessment) “No there’s no need to for them to go to an emergency room” just because they bumped into a door. I would love to protect those that don’t need or understand what’s going on from the battery of test and the isolation of the ER.

My tongue will bare the scars from the teeth that kept me
from saying the things I want to say, but my conscious will be clear because I gave every patient the best even when others around wouldn’t.


**Just to note. This same nurse does in fact also work in the CCU. This is the same CCU where the students from ALS cources go to do their clinical rotations for their respective program training. Supposedly they have a lot to teach up there, but I’m sure this one doesn’t understand what his true responsibility is to the medical profession.

35 comments:

  1. Every EMS provider out there is familiar with this story. Most have experienced it personally. There are two things at work here.

    First:

    channeling "Cool Hand Luke"

    Folks, what we have here is a failure to communicate!

    The nurse has already contacted the doctor and the ER. She or he has orders to do what has been done. The main issue here is that they are used to working with aids, CNAs, and other unlicensed assistants.

    A nurse in this situation is never asked detailed medical history questions so they tend to think of everyone else other than nurses and docs as at the same level. A wrong assumption, sure. We have to treat the patient and manage them on the way to the hospital.

    Solution: Be patient (hard, I know). This nurse is likely overseeing care of 10-20-30 patients and they all need attention, too. (also see part two)

    Second:

    remember to "walk a mile in the other's shoes"

    Nurses and paramedics (and EMTs, too) do not understand how the two professions are different in their focus and training.

    If you're reading this, you know what the EMS providers are trained to do. We are trained to assess and treat immediate life threats. We don't have time to contact the physician directly in emergency situations so we operate off of protocols and our own initiative.

    Nurses have a different focus on patient care. They are trained to deal with caring for the patient in terms of days, weeks, months, even a lifetime of health care.

    Why does this cause a problem? Most nurses don't receive much emergency care training beyond CPR. Everything else is focused on carrying out direct physician orders and if there is ever a question about an order, there is usually time to ask a question of the on call physician.

    (I know that this doesn't apply to ICU, Flight Nurses, and other critical care trained nurses)

    Once you understand this, you begin to see why nurses are so obsessed with giving too much oxygen to COPD'ers and things like that.

    EMS providers don't worry about giving high flow oxygen to any patient because in the standard transport times we see, we will never cause the hypoxic drive to kick in and reduce respiratory rate.

    The short version of this comment could be summed up in Rodney King's famous statement "Can't we all just get along?"

    I hope so!

    ReplyDelete
  2. Jamie, you are correct on much of what you posted. As an ER nurse and ex-paramedic, I have seen this scenario too often to remember. I too have found it hard to "bite me tongue" even after the patient reaches the ER and I call for more information.

    Paramedics (by and large) are focused on the here and now and have very little desire to know about the long term issues with a patient. And rightfully so in almost every case. Nurses, on the other hand, don't gain much experience in dealing with emergent or even urgent problems (unless they work critical care areas). I liken it to responding to a code (fill in the blank here with neuro/blue/99/etc.) on a floor in the hospital. If you stop and just watch what id going on, many times you'll see numerous nursing personnel who look strangely like bystanders when you respond to a call in the field. They have the "stare of life" in their eyes. That all consuming paralysis of action overtakes them nd they just stand there.
    Now, put a paramedic on the same hospital floor and ask them to care for even 5 patients in the context of nursing and they too would be lost. That's not to say they are not competent in their skills. They are not trained/educated for that role. But, let a code happen and they'll be all over it. And well they should!

    My concern with non critical care nurses is their lack of focus in missing a decline in the status of a patient *before* it becomes an emergency. This can be tricky, I know. But good assessment skills and a high index of suspicion goes a long way. It still behooves the nurse in a LTC facility to kow their patient's history......even when calling the physician on call. Ya' gotta know he's going to ask questions. :)

    On sending patients out who do not necessarily *need* to go to the ER, I can agree. Unfortunately, many times you're dealing with patients who don't understand the potential problem at hand, or who have a diminished capacity to make appropriate decisions. On the side of the paramedic, would that *every* paramedic were a patinet advocate. But alas, many times these calls are seen as "lizard runs" and aren't given the same caring attitude a a true 911 call. And I have known many a medic in my day to try and keep from transporting a patient.....at almost any cost. True, this is not the norm, but it does happen. This, coupled with nursing's (in general) lack of critical care skills, and toss in a little bit of "the physician doesn't want to be bothered with the problem or take the risk of being sued for negligence" and you get the transportted patient who doesn't need to go to the ER. ER's are chock full of people who don't *need* to be there. They have no where else TO go. Sure, they might be able to see their PMD within the next 2 weeks, or they might be on death's doorstep by then. (Alcoa presents) You make the call. But be warned, if you're wrong you run the risk of losing your ability to practice your livelihood. See my point? The system is flawed, not the people within the system. And again, many systems don't allow for the medic to make a "no transport" decision until after contacing medical command.

    Here's an idea....why don't you as the paramedic make a suggestion to your admin to set up some educational opportunities for the nursing homes in your area? You could go teach them a few things about what should/could/might need to happen when effecting a transfer via 911. Sure, you won't change the world. But even if you change one or two of them, maybe the seeds will be planted? Just a thought. I've made that offer where I work and have even done it personally on my off time recently. Time will tell if it happens, but at least I'm trying.

    ReplyDelete
  3. I agree with everything you've said here, and I too run into the same problems every shift that I work. I'm also about to graduate with my degree in nursing this semester, and so I do know what they teach to nursing students. As for the start of your post, referring to the airway management, the answer is No. No they do not teach much about proper airway management or oxygen therapy. Its sad really, and its one of the bigest concerns of mine throughout my nursing education. Seeing as how I started in EMS, I am very concerned with airway care. So when they breeze over it in nursing classes, almost as an after thought, it makes me cringe. I suppose they expect respiratory techs to come in and save the day (which they're a joke as well). I've done my best to educate my classmates about EMS and the problems we face with patients and nurses in various settings. Hopefully my efforts haven't been a waste of time.

    ReplyDelete
  4. This is a comment from said nurse at nursing home from above story. There are of course two sides to every story. This transport occurred right at shift change and as the arriving nurse one wan thrust into the situation not know anything about the patient. However, I can remember from the situation looking at the patient and seeing she was not in any life threatening distress. In fact her oxygen saturation was holding steady in the low 90's on 2L nasal cannula with however much tubing. Seeing as how this patient was a chronic COPD patient and said nurse is familiar with intensive care medicine and ACLS there, there was no need to palce patient x on a non-rebreather if for no other reason than to keep her from a hypercapnic coma. Oh, wait I forgot, sometimes you EMS people love the excitement and drool at the opportunitiy to intubate or code people, but I've seen it happen enough where its just not that exciting anymore. As far as her EKG changes the EMT was referring to, anyone could see from the simple strip running across the screen that it was an old ischemic event and there was no need to follow a cardiac workup. Oh wait, I guess I knew that because I see a lot of old cardiac event on ECG and I'm pretty familiar with what they look like. Furthermore, said EMT mentioned that he could make patient x feel better because he could give her solu-medrol on the back of the truck. This patient had already been given Decadron earlier in the day and I made the EMT aware of the doseage, but I did not know the exact time. However, it did not matter the half-life of decadron is well over 8 hours and the peak effect is sustained for quite awhile. Since decadron is not on the back of an ambulance, there is no way said EMT could have known this. Finally, I did take offense to the fact that said EMT stated that it was going to be a minute before they began transport because there were some things he needed to do on the back of the truck. Another example of an EMT trying to diagnose and treat instead of delivering a stable patient to the hospital for evaluation. I did follow up with the patient later in the night, and she was admitted to a med-surg floor. Being friends with the admitting doctor, I found out that there was no criteria for a telemetry or CCU admission. This is the same conclusion that I had already came to upon assessing the patient before EMS arrived. A simple case of pneumonia causing a mild COPD exacerbation. The patient was admitted for IV antibiotic therapy plain and simple. The nurse had already determined this far before the EMT arrived and decided to make the situation far more complicated than it needed to be for his own personal ego and self gratification. Remember everyone this was not a 911 or emergency call; it was just a simple transport to a doctor for evaluation. It just so happened that this patient's doctor's office was closed and she had to go tot he carillion doctor at the ER.

    ReplyDelete
  5. Jerry...what more can I say than "Thank You"? Because of your response I have a greater respect for you as a medical professional and a person.

    While my recounting of the incident was more out of frustration, you helped me to re-center and focus on the true purpose for my blogging and the whole EMS 2.0 movement. I know this recounting may have seemed confrontational and surely it was one sided and biased, but the true spirit was captured with your response; to have a conversation.

    I am not a nurse, I may not even make a good one. Most certainly I make no claims at being the perfect pre-hospital care proviver, but that is the reason I have made a commitment to life long learning.

    From here we move forward with a clearer understanding, however skewed by perception it may be, of how each other operates and what our primary focus is. But one thing is has been shown and that is the fact that the patient was in the forefront of interest...even though caught in the middle.

    ReplyDelete
  6. All the "he said," "he said" aside it is nice to see two professionals come together and discuss this, even if it is a time delay discussion.
    However...
    I do have to take issue with the "it was shift change" excuse and the assumption we're all glory hounds drooling at the chance to intubate. Or that having 10-20-30 patients is a reason to not have a chart ready, especially if it's a scheduled transfer. 911 ring I;ll give a 3 minute grace time. If I risk my ass lights and sirens for Erma's diarrhea I expect papers.
    I have had bad experiences with patients like the one described that started as a simple "She has a UTI" that evolves into the CPR run, then noting that the same person has initialed her medications everyday for the last 3 months.

    There are good apples and bad apples on both sides of the cot here, I see that, but the "EMT's" need to remember nurses aren't good with sudden patient changes and "nurses" need to remember they called us so we ask the questions, just like I'm going to get grilled when your nurse friends find out I'm taking up an ER bed with a chronic COPD patient who could wait to be seen.

    The system is broken and we all have to suffer from the buck passing the MDs are doing over our heads. I want Erma with the dislodged catheter out of my rig as fast as you want her off your ward, believe me, I get it, but don't cross you arms (I'm referring to most of my recent encounters, no longer the example listed above) and just tell me to transport and the chart will get sent over later.

    We all need to get along and I'm glad to see this story has a civil and agreeable ending. we need to respect each other because nursing and EMS are doing all the heavy lifting in health care right now and a united front could lift us all up.

    Strong work gents,
    HM

    ReplyDelete
  7. Nice words Ronnie and Happy Medic. I'm sure you were following your protocols, all be it some of which I do not completely agree with, protocols are protocols.

    I will be the very first to say that I am not a great nursing home nurse sometimes, and the care that those patients get before me and after me is very frustrating because I try to aplly CCU nursing where I care for two patients at a time to sixty patients at a time in the nursing home. It is very frustrating because you do not know very much about some of the patients only working a shift every couple of weeks there. In the CCU we only have to deal with EMS after we have stablized the patient.

    Some nurses are very skilled and adapted to noticing sudden patient changes and treating them accordingly. In fact it is best to head theses sudden changes off before they occur in critical care nursing. All of us are ACLS certified and we run our own codes without input from a physician a lot of times. In fact a lot of times all we need a physician for is to come say " time of death."

    Anyway, there are no hard feelings on my part and the patient recovered and is back at the nursing home. I think that is the most important fact to everyone here. I agree with Ronnie's attitude that we all have to make a life long commitment to learning every day if we want to excell in our professions and produce the best patient outcomes.

    Thanks for the rhetoric,
    Jerry

    ReplyDelete
  8. This comment is for "Anonymous". Just to provide you with some education that you are clearly lacking. There is no such thing as a "Respiratory Tech" There is a Registered Respiratory Therapist and a Certified Therapist. A Respiratory Therapist has as much education and training as a nurse or paramedic just in a different discipline. There has been so many bad patient outcomes based on nursing staff that knew absolutely nothing about O2 modalities, ventilators, or Bipaps. I would not expect a nurse to know everything about these therapies, but at least know enough to not harm the patient. But again this is two different disciplines focusing on two different things. I know this is completely off topic, but I found your comment about "Resp Techs being a joke" as being very offensive. Maybe things are different at your facility, but here we are the first line of defense in a critical patient situation.

    ReplyDelete
  9. Hey, Im a first time poster but just had to respond to the story about the R.T. going to the nursing home. Now I am a R.N.in the ER, and have worked in the CVSICU. In the CVSICU I completely managed the vent from right after the pt had open heart surgery to weaning the pt, to extubating the pt my self. I did all ABG's and adjusted vent accordingly. I did all vent/trach care including all types of suctioning
    In the ER by the time the R.T. gets there the pt is tubed and on vent. They check the set-up and move on. the nurse is able to do the rest. Now i not only do that as a R.N. but also adjust all the vasoactive drugs after studying the pt swan line, and a-line readings. I draw all blood work, do ekgs when needed, and manage when x-rays and other studies can be done.
    so you see the job of a nurse encompases not only job of the R.T and lab, but every thing that is done to the pt. If anything goes wrong with the pt the nurses ass is the one on the line.
    Im sorry to go off, but it upsets me when people talk down on the R.N. Talking about they make to much money, well the way i see it the nurse should get their pay, R.T. pay, and labs pay, but no where im at i get paid the same as the R.T. who only sometimes gives a few breathing treatments. I kknow the role of the R.T. varies greatly from place to place, but so does the nurse.
    Working in the ER I work with lab,R.T., and paramedics all the time, and I am greatful for there help. The nurse just cann't focus on one area of the pt, but most be aware of everything and ready to fix many pt conditions. So the next time you get upset about a nurse forgetting something remember they probably have alot on there plate not just the one thing you can focus all your time on

    ReplyDelete
  10. Uh a respiratory therapist has nowhere near the training or education as a Paramedic or RN. Hate to break it to you. Your "discipline" (breathing txs, cpap, bipap, ventilatory support, ABGs, etc) are all things that every paramedic and nurse are already trained in and is only one part of their tool kit whereas a resp "therapist" has one thing that they do. I AM a certified resp therapist, went to paramedic school, then did the bridge to RN. I've done all three in my 20+ years and to even suggest that a resp therapist has anywhere close to the knowledge or expertise as a paramedic or RN is absolutely laughable. A brand new, straight out of school Paramedic already surpasses a resp therapist because unlike an RT, they can intubate and provide all of the tx you just mentioned without any orders. CPAP, BiPap, and ventilators are all standard pieces of equipment on any ambulance. Pull your head out and get down off your high horse. An RT is a tool for the Doc or RN to use, that's all. Much like taking your car to get the oil changed. Yes, most people can do it themselves, but time management is key in an acute setting such as an ER and frankly, drawing ABGs, PEEP settings, and breathing txs are all things you could teach any 18 year old out of high school to do. Get over yourself.

    ReplyDelete
  11. Wow, so many comments, so little time. I agree that there is a great divide (at times) between medics and nurses. Not sure exactly why that is, but it is. Just last weekend, I was transferring a patient from the ER to another hospital for more definitive care and the medic asked if the patient needed the IV fluid that was hanging at TKO. I replied that he did need it due to dehydration. I later found out that the medic, once in the back of the bus, disconnected the IV and threw the fluids away so that he could be in front and have the basic in the back with the patient. Things like that don't really make me want to give him a hug the next time I see him.

    However, that being said, each medic and each nurse should be judged on their personal behaviors and abilities (or lack thereof) instead of being lumped together with others just because we share the same title. Just like any other type of -ism (like racism, sexism, etc) it just creates/perpetuates a bad situation.

    Thanks for reading. GagaRN

    ReplyDelete
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