SNFs dumping patients...

[john_boston]

Jesus, VentMedic, chill out!

It's clear this is a really important matter to you and you aren't interested in having a discussion about the very real problem of SNFs dumping patients to EMS, then to the ED. If you've never had this experience, or don't routinely have this experience, I wish I had your job.

And for what it's worth, condescension doesn't win an argument. I'm currently finishing medic school, returning to complete a biology degree next fall, then sitting for the MCAT. In my free time, I obsessively read biology, biochemistry, and pathology books and have for years.

...so yeah, I guess I'm just a total moron Ricky Rescue who likes lights, sirens, and batman belts full of EMS accessories, not a young person with ambition who is disappointed to discover that the old adage about carnivores seeing how meat is made applies without modification to the corporate health care industry in the US.

[john_boston]

And would somebody please please please point out where exactly I stated that I thought "all nursing home calls are BS" or that "nursing home patients don't deserve our care and compassion".

I think you'll realize I never said it, in fact I said the opposite.

[VentMedic]

Not trying to win any arguments, just trying to point out where a little more medical education might be needed since you are the one who said you didn't know anything about lab values.

Did you read any of my posts particularly the part where those "awful corporate people" lose money if the the bed is not occupied but are obligated to hold it? You would also have read about how many LTC patients we do get in our ED in just one shift.

Patients in long term care are very fragile, get sick and sometimes it is hard to know just how sick they are. Even ER docs and RNs that complain at first may end up eating their words later when the lab results are done.

What's with the name calling? Nobody called or suggested you to be a total moron? Get your skin thicker and do some more studying.

[john_boston]

If you know nothing about lab values or if the patient has altered mental status, how are you the one to determine it is BS?

The SNF did not call us for altered mental status based on a lab result, it called because a nurse noticed a patient's disorientation and did not know the patient's PMH included dementia(!).

This is the same facility that called us for "altered mental status" at 4pm and we arrived to find a 70something y/o f pt. hx of TIA/CVA, nonverbal/aphasic, pale, RN reported "She's been having trouble moving her left arm and left leg." Me: "Oh? When did you notice that?" Her: "Since maybe...oh...9 this morning?" Verdict: R MCA CVA.

Also, did you know that many facilities may be obligated to hold a bed for 7 days for a patient AND NOT get paid during that time. It is not always in their best interest to ship patients out unless it is necessary AND ordered by the physician.

Right. It's too bad that in none of the cases I wrote my original post to vent about did an MD or DO order the pt. to be seen at the ED.

Please stop assuming the particulars.

[VentMedic]

The SNF did not call us for altered mental status based on a lab result, it called because a nurse noticed a patient's disorientation and did not know the patient's PMH included dementia(!).

Right. It's too bad that in none of the cases I wrote my original post to vent about did an MD or DO order the pt. to be seen at the ED.

Please stop assuming the particulars.

Pts with dementia can ALSO have a change from their baseline mental status.

Nurses are required to contact the physician for ALL transfers be it routine or 911. Hopefully if it is a really acute incident they activate 911 first. But, of course, that will vary from facility to facility depending on what agreement they have with your agency and the physicians.

You might also consider the number of times you ARE NOT called because the RN called the doctor and after a call to the family, the code status was changed to comfort care. Or, they may have been able to treat something at the SNF/NH/SA. Considering the number of patients in LTC facilities, you should be thankful that they do have certain protocols they must follow. These patients are not healthy and they have multiple symptoms that are routines treated without transfer. You only see those that they are not sure about or they (RN & MD) are just playing it safe.

[AMESEMT]

Easy there vent and John.

Vent- You have valid arguments that patients from a nursing facility have the potential to be very sick patients and that we need to be alert for such things and that we might not know everything about the patient. Not all nursing facilities are quality or have quality and educated RN's staffing. You pointed out it is the RN that calls the doctor about potential problems, thus they are the first line where a mistake, possible laziness, or a true emergency is seen. Keep in mind that john is just venting, probably about those few nurses or facilities, that do call 911 for a patient who does not have a complaint, or even the nurse who has supposedly taken care of the patient or quite some time but does not know a single thing about them and what is going on.

John- I understand where you are coming from. I did my ride time in a large city where I saw both the good nurses and facilities and some of the worst the city had to offer. One call we got called to an unconscious. We get there and fire is waiting in the hall by the room we were told to go to. They told us there was not anyone in the room. So we look for a staff member and did not find one for about 1 minute. Finally, a staff member tells us (a CNA or RN) tells us that it is the next room down. This is after fire had been standing there for 3-4 minutes and them trying to find out where the patient is. We tried getting info from the RN and she did not know a single thing about what was going on, what happened, hx, meds., nothing about this patient who she had been taking care of for awhile. So we scooped and left, grabbing paperwork as we were wheeling the pt. out. With regards to what vent is saying, there are health care providers who are undereducated and do treat these patients like there is nothing wrong with them, despite some subtle signs there is the potential for the patient to become very sick. And there are EMT's, paramedics, other EMS workers who are undereducated with regards to the geriatric population and those important lab values for them. I saw you said you don't have the qualifications to interpret lab values, at least you recognize that and can possibly correct that or at least get a pocket guide with normal values (the paramedic pocket guide has them in there).

I am with spenac on this one. There are facilities out there where they call EMS for something the RN or staff can do in house. As a student, I can see the potential for students to be influenced to think a certain way about nursing home runs. I always kept an open mind about what I see, hear, experience with the facility and staff. I treat the patient on what I get from them and what is going on with them. A compromise between facilities and EMS needs to be established, as well as more education on lab values (maybe during a GEMS course). Hopefully someday this could be established.

[sjslennon]

May I offer a different perspective?

Let me say up front, "BS dumping" does occur. And we all need a safe happy place to blow of steam.

On the other hand, EMTs and paramedics often do not have the knowledge to diagnose a pt with BS. But some do, and get no feedback that they were wrong, so they assume their diagnosis was right. I saw a pt last month for "headache, resolved." The pt was triaged to fast track and waited almost 2 hours to be seen. I read the run sheet before seeing the pt (yes, we DO read them) - it started by saying the pt's doctor ordered a CT head for headaches that morning, and in the afternoon the doc called to tell the pt the CT was abnormal and to call 911. It went on for several lines about the pt having no pain, carrying own suitcase, headache resolved with Tylenol, etc. The phrase "in no distress" was written 4 times, including once in all caps and the height of three lines.

Tylenol may resolve the pain of head bleeds in some cases, but doesn't fix the bleed in any case.

I took it up with the crew the next time I saw them, and the cocky kids saw nothing wrong with how they managed the pt. No stroke sxs, so how were they to know? My point exactly - if you don't know, don't assume you know.

My advice (for what it is worth) is to make a habit of following up on your patients. Find out who in the EDs is open to talking to you guys so you can find out if your pre-hospital hunches are correct. You'll learn from this - if you remain open to learning - and will have sharper judgment. You can also identify trends of BS dumping, substantiated by ED records, making any formal complaint you bring more likely to be taken seriously.

[JPINFV]

On the other hand, EMTs and paramedics often do not have the knowledge to diagnose a pt with BS. But some do, and get no feedback that they were wrong, so they assume their diagnosis was right. I saw a pt last month for "headache, resolved." The pt was triaged to fast track and waited almost 2 hours to be seen. I read the run sheet before seeing the pt (yes, we DO read them) - it started by saying the pt's doctor ordered a CT head for headaches that morning, and in the afternoon the doc called to tell the pt the CT was abnormal and to call 911. It went on for several lines about the pt having no pain, carrying own suitcase, headache resolved with Tylenol, etc. The phrase "in no distress" was written 4 times, including once in all caps and the height of three lines.

Grr at the basic who wrote that report. If you need to document that you have a LOL in NAD, then document that you have a LOL in NAD. What you don't do is vent on the run sheet.

[VentMedic]

So we look for a staff member and did not find one for about 1 minute. Finally, a staff member tells us (a CNA or RN) tells us that it is the next room down. This is after fire had been standing there for 3-4 minutes and them trying to find out where the patient is. We tried getting info from the RN and she did not know a single thing about what was going on, what happened, hx, meds., nothing about this patient who she had been taking care of for awhile.

How many EMTs and Paramedics are also able to memorize all the details of 30 - 50 patients and their meds? They give you misinformation and you'll go off on him/her for that. That nurse will hand out over 400 meds in her shift. He/She is responsible for every patient on his/her watch. It would really be nice if the RN could just sit at the bedside of a patient like the EMTs do but it is not possible. The minute you turn your back something is happening with another patient. Or, if they take too long a patient suffers the consequences of not getting their meds on time. As I said before, you don't know how many paitents you haven't been called far. But, they did call you for assistance with JUST THAT ONE PATIENT. Try to take care of that ONE patient without showing your very superior attitude and taking your frustration out on everyone you meet including the patient. Some EMTS need to sit at any hospital or NH nursing station and listen to their own co-workers. Not all are glowing representatives of the

EMS profession either and that is with JUST ONE PATIENT.

Get your RN license and work in a LTC facility for awhile if you can do better. I've been there, done that and it ain't as easy as it seems. No sleep or TV time at all.

My comments are not nessarily directed at AMESEMT. It is meant for those who bring a pt to the ED from a NH and don't bother doing their own vitals or assessment but fill the ED staff's ears full of "what lousy care" at the NH.

[AMESEMT]

Vent- I understand the RN's there have many patients with lots of information about each patient and cannot memorize it all. But when the RN calls 911 for someone unconscious and cannot supply information about when they noticed this, the last time they saw them conscious, a blood sugar since they are diabetic. Most other LTC facilities I have gone to will meet you at the door and give you their paperwork and show you to where the patient is, and give you some information (as much as they know), and any treatments they have done prior to EMS arrival. For me, I always take my own vitals and assessment and form my own opinion. I realize what the RN's have to go through at LTC facilities. But when you call 911 and don't meet the crew at the door or have someone meet them at the door, don't have any paperwork to at least see what the meds., allergies, etc. are, and tell them they have no idea what is going on, that causes me to form a negative opinion on that person and their care. Don't get me wrong, there are bad apples in every profession and each profession will bad mouth another. Most of the time it is because the other party does not know the other sides story. I am sure you have had a bad day and something sets you off and you need to vent your frustration, even with the knowledge of what the other side goes through. I am sure when you where an RN at a LTC facility you complained about the EMS crews sometimes. Am I right? One bad apple can ruin it for all, and we need to keep in mind that the one bad apple is not representative of all in that career.