Helpful Hints for SKILLED Nursing Facilities

[VentMedic]

I also learned that patients with tracheotomies don't breath out of their mouths or noses (though I did know that one already).

Broad generalized statement that is not always true. There are many different trachs now in the nursing homes especially if they are not on a ventilator that allow more "normal" functions to facilitate weaning. If you see a trach patient wearing a nasal cannula, it does not necessarily mean somebody doesn't know what they are doing.

However, it may not have been true for the situation you mentioned, but it is good to ask or know a little be more about recognizing different trachs, various speaking valves and prostetic airways. There are about 300 different airways out there. We try to give frequent inservices to the paramedics that service the area NHs but it always ends up being the paramedic who blew off the inservice that gets the call and mucks up the stoma.

If a trach patient accidentally decannulates, a BVM will still work when the stoma is sealed manually until recannulation unless it is a laryngectomy with a tie-off.

[akroeze]

Huh.

Well, how's this for education. In my third week of EMT school I learned that the oxygen flow rate for a nasal cannula is 2-6lpm.

I also learned that patients with tracheotomies don't breath out of their mouths or noses (though I did know that one already).

Remember. Basic EMT school.

So after I got my license and responded to a nursing home for a tracheotomy patient with difficulty breathing, I was somewhat concerned that he was turning gray and had a nasal cannula in his nostrils running at 8lpm, and none of the 3 degreed RNs in the room thought that this was a problem.

"Educated" indeed....

I once heard of an EMT who had an unbelievable 120hrs of schooling who stabbed them self with an epi-pen through their thumb. I've also heard of an Emergentologist doing it.

"Educated" indeed...

Aren't generalizations fun?

[AnthonyM83]

Well, how's this for education. In my third week of EMT school I learned that the oxygen flow rate for a nasal cannula is 2-6lpm.

I also learned that patients with tracheotomies don't breath out of their mouths or noses (though I did know that one already).

Remember. Basic EMT school.

So after I got my license and responded to a nursing home for a tracheotomy patient with difficulty breathing, I was somewhat concerned that he was turning gray and had a nasal cannula in his nostrils running at 8lpm, and none of the 3 degreed RNs in the room thought that this was a problem.

"Educated" indeed....

And again what I meant by that education versus training thread. I don't see training as a bad thing...training involves the mechanical stuff more, fluidity... As long as education to training ratio is maybe 80%-to-20% I don't know if it's that bad... Another way of looking at it is, I'd like a surgeon with a lot of education, but honestly I require that he's had a lot of 'training' as well...rote repetition of skills, muscle memory...it's not usually what you associate the word "education" with...

[wrenEMT]

First most of the calls I have been on lately have been for nurses calling me in for a patient that needs to have a "medical evaluation" at the ED. First of all they call it in as an emergent run, then when I get there and I ask what has been going on with this patient and they can't tell me the possible reason why the pt has had AMS for the last 9 hours. Because they started showing signs of AMS before breakfast and now it's 1830. Don't know if it's from the fact the pt "might have" dementia, alzhiemer's or the fact the patient has had 10 CVA's in the past 8 years (had that patient before). The only patient report you get is from the CNA or Care Partner, and the nurse is still sitting at the nurses station at the other end of the the ECF hallway.

Or I get the call from the ECF for an unknown illness and find the patient is knocking on death's door and get told that they have a DNR but want them transferred so the pt's roommate doesn't have to worry about them. Most of the nurses I have to deal with are decent but I wonder why they have me come in there just to get a patient out of their way, when it's their job to make them comfortable and treat them like they are at home in their facility. I realize it's difficult to do that when most of the times the facility doctor is out playing a round of golf and gets the call on his cell that patient X has severe pain from one of their multiple disorders and needs some pain management, but since the doc hasn't seen the patient for longer than 5 min while the patient was awake the doc sends them out to the ED.

I do have a really good friend that is an LPN at a ECF, oddly she lives right behind our station and married to a co-worker. I normally get a very good report from her but that is probably because me and some of the people I work with express our concerns with her and she realizes that sometimes the nurses suck and the orders they get are ridiculous. Although, she is also the one that laughs at the Doc because he walks into a patient room for 10 minutes without a BP cuff, stethoscope or any other instrument for vitals and writes down a perfect set of vitals and writes a report.

I think we all need to realize that we have different gripes and complaints but it all comes down to making sure the patient is taken care of. There are good and bad ECF's everywhere, there are good and bad EMT's ie the EMT with the iPod stuck in his ears. There are also places where there are bad docs (Ohhh my not a bad doctor!!!!) but it's true there are some people meant for the jobs we work in, and there are some that get into it for the money, not any EMT I know of, but the nurses and docs sometimes do it for the money, and those are the ones that don't give 2 schits about patient care let alone care if patients have been treated with any type of dignity or respect. Ok I'm done..

[VentMedic]

And again what I meant by that education versus training thread. I don't see training as a bad thing...training involves the mechanical stuff more, fluidity... As long as education to training ratio is maybe 80%-to-20% I don't know if it's that bad... Another way of looking at it is, I'd like a surgeon with a lot of education, but honestly I require that he's had a lot of 'training' as well...rote repetition of skills, muscle memory...it's not usually what you associate the word "education" with...

But the education stuff will give you enough clues about the patient's disease process to know what I meant by broad generalization. No one expects a Paramedic to know all the devices out there, but there are some basic clues to tell how much patency there is by understanding more about anatomy and disease processes. The reason we have ongoing inservices is to provide education to go with some of the mechanical generalizations made in EMT and Paramedic school which sometimes are less than adequate in a technologically changing medical world. Without a solid foundation, it is more difficult to build on.

Ever see the results when someone yanked and twisted on a Montgomery Tube because was they thought it was a regular trach tube? It ain't pretty. Education is needed for understanding when to yank, when not to, why and the alternatives. The education will compliment your assessment to determine which way the patency of the airway flows.

http://www.bosmed.com/trachbronch/safettube.html

Now as far as NHs, between the government cuts and a few greedy NH owners, there is little left in the budget for training or education. And, just like all of the threads here from EMTs who hate doing the NH trucks, nursing has a stigma for some jobs also. Even if they love geriatric medicine, the right RNs will burn out soon in the wrong facilities. Their replacements aren't always the best suited for that job and should be working in facility where there is more supervision of their education and training. The same can be said for some EMTs and Paramedics. The skills paramedics do now might not be in such controversy such as intubation. EMTs and Paramedics get into it because "they can" with little or no requirements and little class time. Sort of an"instant career" as it is advertised by some PDQ Marts.

[Dustdevil]

So after I got my license and responded to a nursing home for a tracheotomy patient with difficulty breathing, I was somewhat concerned that he was turning gray and had a nasal cannula in his nostrils running at 8lpm, and none of the 3 degreed RNs in the room thought that this was a problem.

"Educated" indeed....

Kat clearly said that the RNs education was more relevant in that setting. The RNs you are referring to clearly recognised that this patient had deteriorated outside of their "setting," and were appropriately sending her to a facility where the patient could receive relevant care. I don't see a problem with that.

I do, however, see a problem with you cherry-picking individual things that they did or did not know and using them as logical fallacies to discredit their education. That's about as relevant as them criticising you for not knowing anything about diverticulitis. So... you're a pro at operating a flowmeter. Very impressive. I bet you couldn't carry on a five minute discussion about the patient's disease process, which the nurses could.

It amazes me that you still spout this sort of silly nonsense here, day in and day out, when you are obviously smarter than to believe half the BS you post.

[Scaramedic]

Thank you Ventmedic, that sight was really informative. I had always wondered why they place uncuffed trachs, now I know why. Not only that I now know they are called Moore tubes. I gotta to thinking reading this thread that I never have had a patient pull a cuffed tube, only the uncuffed types. Good post, it shows we are never to old to learn something new. This old dog just learned a new trick.

Maybe we should have weekly learning posts from specialties outside EMS. We have Doczilla, ER Doc, Ventmedic, and a bunch of RN's. It would be nice to learn something new every week. That is of course if y'all have the time and patients to put up with us.