EMS Revisited is an exclusive column that offers reprints of various columns and articles from our archives that are not currently available in electronic format. In the January 2003 issue of EMS Magazine (now EMS World Magazine) we began a year-long series on customer care in EMS. Here we will reprint the series in its entirety.
The night shift of Mercy 2 responds to Pine Valley Nursing Home for a respiratory patient. On their arrival, they wait impatiently for six minutes for someone to come unlock the door.
As the CNA leads them down a long hall, they ask, “What’s going on?” She shrugs and says she doesn’t know. On entering the patient’s room, they hear obvious gurgling rales. The patient is supine and in extreme respiratory distress.
“Where’s the nurse?” they ask, and the CNA points down the hall. The patient has no oxygen on, respirations are 34/min., her skin is cool, clammy and cyanotic, she has a rapid radial pulse, and pinkish-white foam is dribbling out of her mouth.
They sit the patient upright and put her on oxygen. Mary puts together intubation equipment while Todd starts an IV. The patient is nasally intubated and treated with Lasix and nitro per standing orders.
As they transfer the patient to the cot, the nurse arrives with the patient’s chart, which she has been photocopying. When asked about history and meds, the nurse starts scanning the chart, obviously not familiar with the patient. Mary says,“Whatever,” grabs the chart, and they leave. During transport, Mary contacts the receiving hospital, gets an order for morphine and notifies them of the need for a ventilator. The patient is transferred to the ED staff and later admitted to the ICU for exacerbation of CHF.
How do you think this call went? Does anyone feel good about it? Probably not, especially the patient. Lack of communication by both the nurse and the EMS crew contributed to the bad feelings that all parties experienced.
We may not realize that while we have protocols for patient treatment, so do nursing homes, and they can be very different. Money is a huge factor in the level of nursing home care, and staffing is commonly the minimum it can be to function. This is not necessarily right, but it’s true.
If the nurse has been pulled from another floor or even another facility, he/she can’t possibly be expected to know all the patients. Give them a break, not a scornful look. Also don’t forget that while we deal in emergencies, they deal in routine. When an emergency arises, they can’t be expected to function as well as we might.
Nurses spend a significant amount of their time preparing and giving medications. Compliance with dosages and times is closely tracked by nursing home administrations. This means they spend less time with patients than might be optimal. Is this good? No. Is it their fault? No. Try to be understanding.
Usually, when there is a change in patient status, the staff is told to contact the patient’s doctor to get orders. In some locations they cannot even give oxygen without an order. If it is late, the doctor may have been paged but not responded. The MD may choose to treat the patient and try to stabilize them. If that fails, they call 9-1-1.
Nursing facilities track how many patients go out via 9-1-1. There can be a lot of pressure on the staff to keep from using our services. A nurse who has a high number of patients going out via 9-1-1 may be flagged for increased scrutiny and unwanted meetings with a supervisor. This is not right, but it does happen.
Nursing homes often cut costs by reducing the number of RNs and replacing them with CNAs, or even “patient care technicians.” These people may only have rudimentary medical training and spend most of their time feeding, bathing and changing the patients. They probably have little understanding of the pathophysiology of fulminating pulmonary edema. It is not their fault if their training is insufficient.
In such a situation, I try to imagine I have received the patient alone in their home. If there is no one around to give you information, you deal with it and move on. Try to proceed with assessment and treatment based on what you see, and when the nurse returns from the copy machine, use the chart to supplement what you’ve already learned.