lazy nurse or maybe clueless

[under-dreaming]

No defibrillator and BVM, eh? Well... make the most with what you got and good luck. Stick around on this website though, there's a lot to be gained from this place.

[VentMedic]

tamaith,

I hate to say this but this happens like everyone else says more often than not. To take the advocate of nurses for a second, a single nurse can have as many as 15 patients or more. Im sure chbare can attest to this. A good RN yes will be able to rattle off everything under the sun about a patient. Some things may be left out due to various reasons. It happens we all have to deal with it. LVN's especially at NH typically don't dive into their patient's hx as much as they should. So it should not really be a shock to anyone that they didn't know the patient's hx upon your arrival.

As a EMT you are a health care professional. More so, its your job to find out all you can about a patient. Sometimes this means you have to play detective. Sometimes the answers concerning PHx are within the notes, medication lists, etc. Although going based on a med list can at times be misleading, it does kind of give you a clue as to what is going on with your patient(s). This is not really a new challenge, but an old one that you do everyday. If the syncope happened within a residency, and to add a degree of difficulty it was a 3rd party call. You would try to find out what meds your patient is currently taking, and if he is unresponsive you would try to piece what possible hx the patient has based on medications they are currently taking. Most people don't have a sheet just laying around in the open the tells their PHx. At a NH its really no different. Thats why patient assessment is important for every patient encounter you have.

Lastly, at every level of medicine there is ignorance due to lack of some type of education. There are really no exceptions to this. Thats why there is always room to learn, and to continue to learn. Where as some people do not take advantage of this, I encourage you to continue to learn all you can. Also encourage others to do the same. If a LVN doesn't know that atrial fibrillation is a cardiac condition, professionally educate them that this is cardiac. Maybe they knew it was cardiac but for whatever reason didn't feel it was pertinent even though it very well could have been. I don't know I wasn't there. But instead of being arrogant, we need to be professional, and help each other out. Just be tactful about it,and be ready to agree to disagree.

A good RN with 1 or 2 patients in the ICU will know everything about their patient.

The RN or LVN who has 20 - 40 patients to care for in one shift with 3 or 4 new patients per shift may not be able to memorize exactly everything in each patient's history. The LVN may know very well what A-Fib is and doesn't need an arrogant EMT-B trying to "educate" them about certain things that they themselves may not have a lot of education for. They have just enough time to get the necessary arrangements made, family notificed, paperwork for the ambulance and a brief report. Then it is back to the other 39 patients. Also what an EMT may believe to be a life threatening situation because it was mentioned in their text book in one sentence doesn't mean that is the condition causing the problem. Controlled A-Fib may not be an issue. Also, if a patient had a "hx" of it, that problem may have been resolved. Without a cardiac monitor you may not know what is the exact rhythm. In the meantime, while you are trying to show off what you learned in an EMT-B class, the patient is still not getting treated. The patient is going to a facility of higher care so that they can get the appropriate diagnostics and treatment. If the LVNs and RNs at the NHs could do or even had the time to do more diagnostics, they might be able to tell you what that patient's 12-lead EKG even showed. At a BLS level, it probably wouldn't make much difference. However, you still should be able to communicate with a ED when you have a drastic change in patient condition.

Since dialysis and NH calls are primarily medical, in a perfect world these transport trucks would have a Paramedic each truck who has a decent education in the many medical conditions of the elderly and chronically ill and not just first-aid training. Even many Paramedics are not adequately prepared for some illness and only know about the emergent. Thus, many things may be missed in an assessment. The LVN may have picked up these things but a Paramedic or EMT may not be aware of their importance. Example: "fever" in an elderly patient. Many EMT(P)s dismiss that as a bullshit call when it could turn life threatening very rapidly. The LVN, if he/she had time could probably educate the EMT(P) about a lot of things also if there was time. But, the EMT(P) would probably cop an attitude and be on one of these forums complaining that a "nurse" tried to tell them something about a "fever" or some BS "infection".

To the OP, continue to advance your education through college science and medicine courses such as A&P, Pathophysiology and Pharmacology.

Edited August 30, 2009 by VentMedic

[wrmedic82]

<!--quoteo(post=222455:date=Aug 29 2009, 01:06 PM:name=wrmedic82)--><div class='quotetop'>QUOTE (wrmedic82 @ Aug 29 2009, 01:06 PM) <a href="index.php?act=findpost&pid=222455"><{POST_SNAPBACK}></a></div><div class='quotemain'><!--quotec-->tamaith,

I hate to say this but this happens like everyone else says more often than not. To take the advocate of nurses for a second, a single nurse can have as many as 15 patients or more. Im sure chbare can attest to this. A good RN yes will be able to rattle off everything under the sun about a patient. Some things may be left out due to various reasons. It happens we all have to deal with it. LVN's especially at NH typically don't dive into their patient's hx as much as they should. So it should not really be a shock to anyone that they didn't know the patient's hx upon your arrival.

As a EMT you are a health care professional. More so, its your job to find out all you can about a patient. Sometimes this means you have to play detective. Sometimes the answers concerning PHx are within the notes, medication lists, etc. Although going based on a med list can at times be misleading, it does kind of give you a clue as to what is going on with your patient(s). This is not really a new challenge, but an old one that you do everyday. If the syncope happened within a residency, and to add a degree of difficulty it was a 3rd party call. You would try to find out what meds your patient is currently taking, and if he is unresponsive you would try to piece what possible hx the patient has based on medications they are currently taking. Most people don't have a sheet just laying around in the open the tells their PHx. At a NH its really no different. Thats why patient assessment is important for every patient encounter you have.

Lastly, at every level of medicine there is ignorance due to lack of some type of education. There are really no exceptions to this. Thats why there is always room to learn, and to continue to learn. Where as some people do not take advantage of this, I encourage you to continue to learn all you can. Also encourage others to do the same. If a LVN doesn't know that atrial fibrillation is a cardiac condition, professionally educate them that this is cardiac. Maybe they knew it was cardiac but for whatever reason didn't feel it was pertinent even though it very well could have been. I don't know I wasn't there. But instead of being arrogant, we need to be professional, and help each other out. Just be tactful about it,and be ready to agree to disagree.<!--QuoteEnd--></div><!--QuoteEEnd-->

A good RN with 1 or 2 patients in the ICU will know everything about their patient.

The RN or LVN who has 20 - 40 patients to care for in one shift with 3 or 4 new patients per shift may not be able to memorize exactly everything in each patient's history. The LVN may know very well what A-Fib is and doesn't need an arrogant EMT-B trying to "educate" them about certain things that they themselves may not have a lot of education for. They have just enough time to get the necessary arrangements made, family notificed, paperwork for the ambulance and a brief report. Then it is back to the other 39 patients. Also what an EMT may believe to be a life threatening situation because it was mentioned in their text book in one sentence doesn't mean that is the condition causing the problem. Controlled A-Fib may not be an issue. Also, if a patient had a "hx" of it, that problem may have been resolved. Without a cardiac monitor you may not know what is the exact rhythm. In the meantime, while you are trying to show off what you learned in an EMT-B class, the patient is still not getting treated. The patient is going to a facility of higher care so that they can get the appropriate diagnostics and treatment. If the LVNs and RNs at the NHs could do or even had the time to do more diagnostics, they might be able to tell you what that patient's 12-lead EKG even showed. At a BLS level, it probably wouldn't make much difference. However, you still should be able to communicate with a ED when you have a drastic change in patient condition.

Since dialysis and NH calls are primarily medical, in a perfect world these transport trucks would have a Paramedic each truck who has a decent education in the many medical conditions of the elderly and chronically ill and not just first-aid training. Even many Paramedics are not adequately prepared for some illness and only know about the emergent. Thus, many things may be missed in an assessment. The LVN may have picked up these things but a Paramedic or EMT may not be aware of their importance. Example: "fever" in an elderly patient. Many EMT(P)s dismiss that as a bullshit call when it could turn life threatening very rapidly. The LVN, if he/she had time could probably educate the EMT(P) about a lot of things also if there was time. But, the EMT(P) would probably cop an attitude and be on one of these forums complaining that a "nurse" tried to tell them something about a "fever" or some BS "infection".

To the OP, continue to advance your education through college science and medicine courses such as A&P, Pathophysiology and Pharmacology.

Easy there vent. and your very right about a fib. as I was stating to the OP that it is possible. I know there are many reasons that cause a change in mental status. And yes most EMT-B's are clueless about the pathophys of a fib. But thats kinda getting off the path I was going with this. And I will say that anyone coming to reproach anyone with arrogance is not well accepted by anyone. If an opportunity presents itself to offer insight, experience or education I feel people should take advantage of these opportunities. Its not about one being smarter than the other. And well all cant "get it all". Im not advocating just thrust your nuts in a nurses face to show them how big they are. Like the old proverb says as iron sharpens iron we should sharpen not just ourselves, but others when appropriate.

[cosgrojo]

Easy there vent. and your very right about a fib. as I was stating to the OP that it is possible. I know there are many reasons that cause a change in mental status. And yes most EMT-B's are clueless about the pathophys of a fib. But thats kinda getting off the path I was going with this. And I will say that anyone coming to reproach anyone with arrogance is not well accepted by anyone. If an opportunity presents itself to offer insight, experience or education I feel people should take advantage of these opportunities. Its not about one being smarter than the other. And well all cant "get it all". Im not advocating just thrust your nuts in a nurses face to show them how big they are. Like the old proverb says as iron sharpens iron we should sharpen not just ourselves, but others when appropriate.

While your ideas about sharpening each others education is commendable (and something I happen to agree with in theory), I think Vent is debating the appropriateness of doing so in an evaluation setting. When the consequences of delaying transport and definitive care are unknown. Also EMT-B's and P's alike are notoriously ill-equipped with the social skills needed to properly engage in said educational debates. Not to mention that no one likes having some one else walk into their sand-box and tell them how to patrol it. It would be nice if we all could "just get along" and respect each other enough to have these knowledge gaining conversations... but it is not feasible under most situations. If you happen to be one of the few that has the skill set to provide good patient care, and hold impromptu con-ed classes while getting report... then by all means... But don't assume that others have the same ability.

[VentMedic]

That is my point.

When I am on a Specialty team or IFT CCT or Flight, I will often pick up from a hospital that has very little specialty knowledge or resources to stabilize a neonate or serious trauma patient adequately. If asked directly "what could we have done differently", we may give a good brief reply or if it is something very simple like a little "tip" to secure or setup something appropriately we will make a brief "causal" comment. But, we will leave an information package full of instructions and tips to move the process along quicker when it comes to paperworks, labs and packaging. We will also leave the number and business card of our education department who arranges education classes even if it is just NRP, STABLE (including the cardiac module, TNCC and PALS for the employees. Some classes we may also extend to them free of charge. As well, our physicians are also available to the hospital's doctor while we are enroute to the facility. For the most part, the staff is just relieved we are there and will step back to allow us to work and move the patient quickly which for some neonatal transports that could mean 2 - 3 hours of stabilizing before we move.

In other words, we are cautious not to offend especially if we know what resources they have and don't have. We also know that a thorough basic foundation may need to be developed before we just rattle off a bunch of treatment theories which could be mistaken for arrogance rather the assistance. Thus, we put the patient first and only educate if time allows or it is appropriate while on scene. We are not there to purposely find fault with that facility and its staff. If it was gross negligence (assumed or blatant), it will be brought out during the patient review and dealt with at a higher level.

Florida has also been revising its statutes to where the rec'g facility determines the level of care need to move the patient safely and under whose medical director or what is required of the medical director and team. Thus, neonates, pedi and cardiac patients with VADs/IABPs with serious drips will not be tossed on just any BLS or even ALS truck to run real fast between facilities. Sometimes I believe this concept should be adopted by facilities that receive SNF patients so that the patient can get the appropriate care regardless of age and the nursing home stigma. It is often the EMS companies and the city/county that determine how the SNF/NH calls for transport and it is not always with appropriate patient care in mind. BLS trucks are not always the way to go but unfortunately due to contract situations, risk of penalties and cost containment, the patient care part is often missed.

The RNs/LVNs know they do not have the resources available and know the many things that EMTs don't know that can go very wrong with an elderly or compromised patient. They may not have an exact diagnosis for you since they do not have the necessary diagnostics but know the patient just well enough to know they need a higher level of care. They also know they are taking a risk by sending the patient too late or even too early as the RN/LVN will be severely scrutinized by their management. If they dare to call 911 for what may be an emergency, they are scrutinized more so than you will ever know. The crap will run downhill to them as the SNF/NH takes a penalty from Medicare or whatever insurance and the county if the RN/LVN made a transport decision based on patient care appropriateness or erring on the side of caution but didn't have a crystal ball to see the acutal diagnosis. It just comes with the license and chosen place of employment which is why there is a turnover at these facilities. Having the physican make the determination for transport helps but the physician can also snap back when questioned by management why the patient was transported and say the nurse did not tell him/her "something" even if they did. Some EMT(P)s would run and cry if they had to go through the almost daily drillings those who work in SNF/nursing homes go through to answer for their actions. Most nurses that work in these facilities are darned if they do and darned if they don't.

Edited September 1, 2009 by VentMedic