911 call to nursing home at 3AM

[VentMedic]

I agree, you can't blame the nursing home staff for following protocols, but you can and should blame them for incompetence.

An EMT-B with 110 hours of training is going to judge licensed healthcare professionals, including doctors, about their competence? How about the administrators or the attorneys? How much education did that 110 hours provide for the legal contracts made between Federal, State and private insurances as well as those between the ambulance and 911 services? Few are even aware such agreements exist or believe they are the first to notice "routine" calls for things they may not know the reason to because they don't qualify as an "emergency". Yet, they may be the only option available. Some insurances won't pay unless it is this criteria. Some won't pay for that. Unless you are well versed in all the legalities and have read all the P&Ps for the nursing homes as well as the contracts made between your service and the LTC facilties, you may be just talking BS and showinng your own ignorance.

My remarks are not necessarily directed at HERBIE1.

Edited April 14, 2009 by VentMedic

[EMS49393]

I won't lie here, I stopped at the post about "starting a line enroute" to the ER post. It was enough for me.

1. Assess the patient, completely. If the only reason I am called is to transport really is for forgotten labs and I find nothing acutely wrong with the patient, I will handle it from there. Until then, I owe the patient an assessment, because, as we all know, we always get a COMPLETE report from the sending facility.

2. Should I see no acute reason this patient needs to be taken from their nice warm bed, put into an ambulance, dragged to the ER, probed and proded by more people, enduring a return trip, and most likely, arriving back to the nursing home after breakfast, I will handle a few different ways. First I would ask to see the order from the physician stating to send the patient out for a non-emergent procedure. If that isn't there, it will make things a lot easier if I have to go all the way to the end of my decision tree. If it is there, then it's ordered, and I will comply with the order, no matter how pointless and unethical I feel it is. He may know something the nurses are keeping from me. If said patient is their own person legally, and is able to make decisions, I will explain this whole deal out to them and let them decide if they want all of the above done to them. If they have a legal power of attorney because they are no longer competent, I will wake that person up to explain the situation and ask them what they would like done. I'm sure they'll be thrilled that I woke them up because XYZ facility "forgot" to collect their loved-ones routine labs today. If none of those apply, I'll call the receiving ER and talk to the doc. I'm so fortunate to have a great rapport with most of the doc's here. I'm more than sure they will tell me the facility will wait for the morning to torment the patient. After that, our doc will handle it, believe me, they will handle it, both with the facility and the sending physician.

3. DOCUMENT!

It is unethical to move a patient from a long term or rehab facility in the middle of their night's sleep because you forgot a doctors order that day. Ambulance rides are very hard on most of these patients. Transfer from bed to gurney is often very hard on these patients. If it's not warranted, it shouldn't be done.

This doesn't really have much to do with the original post, but since someone brought up a completely unnecessary IV, I just had to jump up on my soapbox.

It gets right up in my arse how people want to start IV's on every damn patient, often without even assessing them. If I pull Gramma Moses out of a nursing home for a complaint of a fever, she is 900 years old, has one good vein (maybe), and is hemodynamically stable or compensating well enough for transport, I will usually forgo the IV. The bigger picture tells me this patients more than likely getting a septic work-up. We're talking two sets of blood cultures, CBC, CMP, and anything else that may interest the duty doc. I'm leaving the nurses that one vein. If I don't need an IV for fluids, medications, or potential of them, I'm not starting one. I have fought this protocol here, and won. It's not necessary, and often, it takes away the only port in the storm left. Antibiotics are time sensitive, and need to be administered as quickly as possible upon diagnosis. Prolonging that treatment to establish a PICC or central line is irresponsible on the part of the paramedic.

DISCLAIMER: Please note I used the word "facility" instead of nursing home. Long term sub-acute hospitals, rehab hospitals, psychiatric hospitals, etc., do their fair share of transferring patients for no real reason. Besides, my new years resolution was to stop picking on nursing homes and fire departments.

[brentoli]

OK folks, this was not a bash the nursing home thread.

No one has really talked about how they would handle the situation. Aside from making mention about the vengeance you would get on the nursing home.... How are you going to treat this patient assuming all of the details I gave are correct?

Vent, some of the ways you have indirectly quoted me, lead me to believe you have taken offense to me posting this, is that the case?

[VentMedic]

OK folks, this was not a bash the nursing home thread.

No one has really talked about how they would handle the situation. Aside from making mention about the vengeance you would get on the nursing home.... How are you going to treat this patient assuming all of the details I gave are correct?

Vent, some of the ways you have indirectly quoted me, lead me to believe you have taken offense to me posting this, is that the case?

You set if up for a bash and thrash of nursing homes, nurses and old people.

This isn't really a senario, just throwing the topic out for debate. This was relayed to me by a friend of mine who works in a large ER.

A 911 ambulance is called to a nursing home, at 3am for a transport. On arrival they are presented with a paitent who was just woken up for an ambulance ride, because day shift forgot to get his labs, and the doc is making rounds in the morning. The RN in charge made the decision to send him to the ER for lab work. No other complaints. Nothing else wrong. Routine old person labs.

How would you handle that call when you arrived on scene?

By not other complaints, was the patient tracking his/her own lab levels? While some patients may feel ill when their labs are out of whack, those with chronic illnesses may not immediately notice a difference. Some may have a K+ of 8 or higher and not notice a thing until the heart notices it.

I would take the patient to the hospital for the labs. Their next dose of meds may be dependent on those results. Interrupting the cycle or having/creating a toxic level may not be in the best interest of the patient. There may be a bigger picture here that you are not seeing. Unfortunately, illnesses don't function 9-5 so sometimes a 0300 call is necessary. The RN has to explain his/her actions as every transport from a facility requires documentation that must be signed by the physicians and the adminstrators. They are working on a budget and must answer to the payors and accrediting agencies. Again if you feel it is fraud or abuse, document and write a report to the appropriate authorities. Don't just turf it to the ED nurse to do your work.

Just because someone isn't coding or bleeding doesn't mean their continued care is not important. Maintaining fragile patients for the long term is a delicate balance. Yes, what a shame sometimes things get over looked but healthcare providers are human. If EMS was absolutely perfect, let them throw stones. But we know that not to be true for some ambulance services and providers. Again, if you understand everything about healthcare and all the business aspects at several levels, excellent. You should then know how to make a point through the proper channels.

When EMS providers put M.D. behind their name they can then over rule the other M.D. issuing the orders. If you want to converse with the physician, great. Just remember there will be those taking notes for the next contract negotiations if your area has competitive services.

[brentoli]

Ok I set this up for failure.

Even though I have never taken out any thing on a staff member or patient at any time of day or night for any complaint and always treat them the way I wanted my father treated while he was in LTC. This call had nothing to do with me. The way it was presented to me I thought it would be an interesting topic to discuss. Many vaild points have been made, even though I don't agree with their presentation. And yes I do take offense to the way I was referred to. I don't believe the tone implied by the wording was appropriate.

Edited April 14, 2009 by brentoli

[TDP]

This isn't really a senario, just throwing the topic out for debate. This was relayed to me by a friend of mine who works in a large ER.

A 911 ambulance is called to a nursing home, at 3am for a transport. On arrival they are presented with a paitent who was just woken up for an ambulance ride, because day shift forgot to get his labs, and the doc is making rounds in the morning. The RN in charge made the decision to send him to the ER for lab work. No other complaints. Nothing else wrong. Routine old person labs.

How would you handle that call when you arrived on scene?

The bread and butter of emergency medicine,as once stated is geriatric patients........so get use to it bub.

[Katiebug]

I have seen very competent RNs at nursing homes and I have seen some that are completely brain dead. We all have our nursing home stories. By the same token, we all have our stories about the EMT that was a complete moron too. At times, most of us have felt like that moron.

To answer the OP's question, it's pretty cut and dry. Do the transport. If there is an ethical question about it being abuse of the system, discuss it with your medical director the next day.

As the medic, it is not your place to go stepping on toes without first going through the chain of command.

If you can't get any satisfaction from those in charge, and you feel you must get on a soapbox and make a crusade of it, then so be it. Just be prepared for the backlash. Make sure it's worth it to you.

In the meantime, be nice, be professional, represent your company positively and do the transport you were dispatched to.

[brentoli]

The bread and butter of emergency medicine,as once stated is geriatric patients........so get use to it bub.

Your opinion is worthless.

Heh. =)

[EMTBUNGO]

In this situation, if the paitent is mentally capable, can they refuse transport after explaining to them they are being woken up for bloodwork?

If its a paitent who can't refuse treatment due to mental capacity, would it be appropriate to contact MedControl?

Yes they can still refuse treatment after that is explained to them. It's not up the the nurse, it's up to him, hes still an adult. And if he cant refuse treatment becasue of mental status, i was taught to transport then contact med control en route, but that is still depending on protocol.

Edited April 15, 2009 by EMTBUNGO

[VentMedic]

Yes they can still refuse treatment after that is explained to them. It's not up the the nurse, it's up to him, hes still an adult. And if he cant refuse treatment becasue of mental status, i was taught to transport then contact med control en route, but that is still depending on protocol.

Whose responsibility is it to "get the patient to refuse"? Who should explain why going to the hospital is important...or not?

EMT(P)s who just crawled out of bed and have a bad attitude due to it being 0300 and they already had made up their mind it was a BS call before entering the facility?

The RN (and doctor) who may have known the patient for several months or even years?

What influence will the EMT(P)s attitude have on the decision if the patient senses they are a "bother" to the ambulance crew? The patient may even feel they have no choice but to say no if they feel they are a bother just by the actions of the EMT(P)s. Of course, if the patient doesn't refuse, the trip to the ED can be very unpleasant for a frightened elderly person with two pissed off EMT(P)s in the ambulance talking crap about the nursing home, nurses and the doctor all the way to the hospital. Or, the patient gets stone cold silence and treated as an object and not a patient. Many of us have seen examples of that come into an ED whether it is from a nursing home or any call that the EMT(P)s feel is not worthy of their service.

Edited April 15, 2009 by VentMedic