Nursing Homes..........

i've allready decided when i'm too old to care for myself, i want my kids to let me die at home. please, please don't put me in a nursing home!

 

Are you sure they ever learned their "training?"

Seriously. I think a lot of nurses that work in nursing homes weren't in the top of their class.

Yes, yes, I realize that many nurses in nursing homes are really good nurses (I know a few), but the majority that I've met have been subpar to say the least.

 

Long term health care requires a special type of person that can do it and do it for only a few bucks. Most facilities that I know only require one RN on staff at a time and sometimes at night that RN only has to be reachable by pager. So, most of the staff is CNA's and supervisor LPN's.

With that being said, I dreaded going to nursing homes when I had transfer patients. Though some of the assisted living/nursing homes were actually really good there were some that made me want to run away.

 

It was the kind of code you hope your medical director never hears about. Vomit everywhere, no airway to be had for love or money, a half-dozen 18 gauge holes in the patient's arm, and a nursing-home staff that "just" found her like that. I was part of a 2-paramedic crew, we had an FD crew for assistance, and none of that training and resources was achieving anything but making a mess.

Ten minutes into this farce a nurse runs into the room, waving a piece of paper. "She's got a DNR!" he exclaimed. "Do you have to continue?"

We just stopped in mid-flail, stood up, and packed up. Medicine marches on.


In all fairness to nurses in nursing homes; they are given a Herculean task, given little help, and are not permitted to do even the simplest task without a doctor's order. The newest EMT-B has more leeway in patient treatment than they do!

 

ARGH. Things like that piss me off. Not because you have to stop treatment but it is because they probably wanted to limit suffering and should have died peacefully without EMS being needed for interventions. If I was the family I'd be upset.

 

How about this one:

"I just got here and she was breathing funny. I didn't want to do anything until you got here. I think she might need some oxygen or something."

The patient had agonal breathing and subsequently coded.

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They said she had a DNR, but could never produce it. If you don't physically see a DNR you are supposed to resuscitate from a legal standpoint. What do you do if you have a 90 year old female and noone can produce a DNR, although they claim she has one?

 

HIPPA...Repeat pt's from NH's need exceptions to this rule for every transport.

(Just some gripes about HIPPA)
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I had pt's we took every shift for years from NH's I knew their medicaid, medicare, SS#'s, Mx, Dx, Tx, by heart. We still had to have them sign papers for Hippa.

We had call bunuses for having our paperwork in order we would lose it if the pt was to sick to sign the HIPPA-our signature wasn't good enough with a remark that pt was unable to sign...we were diagnosing!!!

Any other Insurance, HIPPA, or rediculous paperwork situations.

 

I am allergic to Nursing Homes

 

My most frequent NH line: Which patient are you taking out. Usually followed by can you take the patient from our floor first she annoyes us.

Also: "The patient is all ready in their room." You arrive and either they have all their bags, are all dressed up, and ready to take their medicaid cab, or they are lying on the floor in their own feces with the nurses/cna's unaware.

 

Infinium...just hit the "quote" button. It will make your posts much more clear.

 

This one is not the fault of the nursing home staff:

We have a assisted living/skilled care facility in our town. We are a volunteer ambulance and are emergency tx only - not a taxi service/wheel chair van, etc. The NH calls the professional service in the next town over for non-emergency txs. If they are too busy/understaffed, they call our dispatch and make the call sound like an emergency to pass it to us. When we arrive with lights and sirens, the NH staff is confused because we weren't even who they called.

Then of course we have the opposite situation: pt is circling the drain and the staff calls for a non-emergency transport not realizing that they should have dialed 911.

 

Thanx

 

Here's one of my worse ones working private...

BLS scheduled call for a direct admit for a pt. who hasn't been eating for 3 days for a possible G-tube insertion. We get there and start with paperwork while the staff says to wait until they finish changing his clothes, because they just tried to feed him and they got food all over. After 5 mins we go in there, and see that the pt. has nice clean clothes but is unresponsive to pain and with major turgor. I don't remember his vitals, but he had a hx. of respiratory distress and was breathing at the time. We bring him down to the rig because we wanted to get away from the staff asap and to call medical control to get out of there. Now here's a case of medical control gone wrong...

We give him O2, take a glucose level, etc. and call medical control, and say that we are 4 minutes away from a hospital, and that our private ALS is 10-15 minutes away. Do they want us to go to the hospital, wait for our ALS, or call for a city ALS? They say for us to stay put and wait for our als. Meanwhile my partner and I are hoping that he doesn't go into respiratory arrest while we are waiting. Finally our ALS comes, and they can't even get an iv in because he's so dehydrated. While they are sticking him, he starts to come to and tries to pull the monitor tags off, but soon later he becomes unresponsive to pain again. By the time we get to the hospital he's A and O x1.

I have more...for another day I guess.

 

How about this:

Nursing home calls for pt. w/ SOB & <SaO2. On arrival, they state "She's a full code and her sats are in the 70's". PMH: CHF, COPD, MI, CAD, Pneumonia, UTI Exam: < LOC, RR - 50, HR - 130 SR, BP 80/40, SaO2 68%, Temp 37.1, lungs full w/ scattered wheezes, HT inaudible. O2 by NRB increased sats to 75%. In truck, pt. given versed 5mg, anectine 50mg followed by tube placement and norcuron 5mg followed by infusion. Albuterol was given by inline neb. Lasix 60mg IV was also given after BP increased, as was 4mg MS. Vitals at arrival to ER were RR - controlled, HR ~110 SR, BP 120/60 SaO2 91%. LOC remained decreased and LS remained rel. unchanged except for abation of wheezing. With a busy ER awaiting our arrival, pt was transferred to an awaiting full team. Several minutes later, a visibly unhappy nurse informed us that in fact the pt. was a DNR, and produced a copy from the hospital chart. Pt was admitted to ICU where she died a few days later. Upon calling the nursing home to inquire, the response was "Oh yes, here it is. Did I tell you it was a full code? Sorry." Click.
I think that nurse should have gotten the bill.

Once overhead:
Nursing home nurses were either the bottom of their class (too dumb to get a job elsewhere), or the top of their class (absolutely not one iota of common sense).

 

I worked with a volunteer ambulance with a similar situation... except we have multiple, multiple NH and they are all as bad. We as the volly service are the official 911 ALS providers for the town. If the patient needs non-emergent transport, the NH are supposed to call a commerical BLS transport service.

However, the NH are all staffed by "attendants," CNA's and LPN's that do not know an emergency if it hit them in the face.

One example:

Patient is a 67 yo female that normally had pretty good mentation. Initially the NH staff calls the commercial service for a non-emergent BLS transport. However, when the commercial bus gets there, they dial 911 quickly. Upon our arrival, pt presents left-sided facial droop, drooling, blown pupil, mental state almost non-existant. Classic s/s of CVA. So we ask the staff how long she has been like this. They said the last time anyone had seen her was sometime yesterday. Once the patient had missed 3 meals, the smart NH staff decided someone should check on her. It was finally determined that the incompetant staff had let the patient stroke out for 32 hours... Talk about excellent care there....

At the same NH, they decide to call 911 for a routine transfer of a patient for non-emergent evaluation of obstruction/constipation... Taking out the only ALS ambulance covering the town... However they know we can not refuse... Are there any jurisdictions where 911 ambulances can refuse non-emergent transports from NH, and instead refer them to a commercial service?

 

It is stated in my will. If my children put me in the nursing home, they get nothing. THe estate gets donated to my squad

 

So, there I was, a tired paramedic with an hour left in my shift when I get paged to my favorite nursing home for an 'unknown, unconscious' patient.

For once, we were actually met by a "nurse" at the door who started describing why we were there. It seems this 80-ish woman is normally perfectly functional with no cognitive deficits at all. She was pushing another resident down the hall in a wheelchair while munching happilly away on a PB&J sandwich.

Apparently, mid-munch, she stops pushing the wheelchair, looks anxious, puts her hands around her throat in the universal sign for choking (not that I've ever seen it before but still). The nurse tells me she watched this for awhile before the patient 'turned blue' and then fell to the floor, hitting her head, and then had a seizure.

The nurse then picks up the patient, puts her back in her bed and calls her private doctor. Brilliant doc then tells the nurse to call the local ED; the one with no in-house coverage (this was back in the late 80s). The nurse at the ED chats with the nice nurse from the NH and, eventually, they decide it might be a good idea to call EMS.

Seemingly months later, we arrive. Needless to say, my patient has coded. We start CPR and I get my first look in her oropharynx...full of PB&J! What a suprise.

The nurse continues to tell me something (I quit listening) as I started digging my way through the PB&J with forceps, flicking as much of it as I could onto the nurse's leg (not that I have passive-aggressive issues or anything). As soon as I get a tube in and a little epi, our asystolic patient gets a rhythm and pulse back.

Ah, the memories of nursing homes. Certainly that's one thing I won't miss from my EMS days.

Take care,
Jeff

 

The worst nurse I ever met was not in a nursing home - she was a school nurse! I have great respect for nurses and I think they are often treated pretty shabbily by the other healthcare professions, but this lady was dangerous.

I was a high school senior and new EMT. It was 1986 and I will let you imagine what my hairstyle and clothes looked like. But I digress....I was in the nurses office with some bad menstrual cramps (i.e. - didn't want to be in history class) and in came this freshman girl.

"I swallowed a whole bottle of Tylenol this morning." she says to the nurse who just about falls off her chair. She leaves the girl just standing there and starts freaking out looking through her policy manuals. The girl is scared to death and the nurse is running around and looking like SHE is going to pass out. I tell the nurse I am an EMT and she needs to call an ambulance and the girls parents. She starts screaming that this is none of my business and that she needs to find the correct policy to follow. She kept yelling 'I'm in charge here!'. Anyone who repeatedly yells this phrase should be removed from the scene immediately but that was not an option here.

She finally calls the principal who tells her to call an ambulance. In the meantime I sit the girl down, take her vitals, and get her history and talk with her. The nurse really got pissed when the cop and EMTs who arrived on scene ignored her and addressed me to get the pt info. The nurse starts sccreaming at the ambulance crew that they should have waited outside until the next class period so that no students would be in the hallway. The whole time she is still trying to look up the 'right policy'. After everyone leaves she tells the principal I was interfering with her pt care. They both try to lecture me on the importance of patient confidentiality and then got mad when I wouldn't tell them what the girl told me.

Thank God this girl was not a critical patient! I can't even imagine the result with this idiot nurse 'taking charge'.

Despite some of our bad experiences.....

Give thanks to all the great nurses out there!!!!

I bet some of them have some pretty scary EMT stories to tell





I know I do.

 

Jeff, we must be living parallel lives, take the above story, substitute Nurse for CNA and PB&J for egg noodles. I'm sure epi is the main ingredient used in making plant food.