Nursing Homes

[605medic]

Don't you just love running calls to nursing homes. I just had a call for cardiac arrest CPR in progress. Upon arrival nurse states pt is a full code and that the pt has been down no longer than 5 minutes. Get the line and airway established, first round of drugs. Pt is in PEA with a pacemaker at 65 bpm. Start to the hospital and my partner calls to notify them of the pt only to be told to stop because the pt has a DNR on file. Get to the hospital and then call the nursing home. The nurse looks back at the pt's chart and says oops it was right here on top I must have missed it!!! Very nice:wacko:

 

[bigbaldguy]

Sounds like she did an excellent job of making her problem your problem. You have admire skills like that. If she ever leaves the medical field she would no doubt do well in politics ^_^

 

[Smoke14]

Nursing homes get a bad rap from EMS people. Nursing home staff spend more time with the patients than they do with their own families. When something happens, they panic just like most people do when something bad happens with close family. Don't hold it against them because they become very attached to the patients.

When ever I go to a nursing home I just pluck the chart on the way past the nurses station and go through it on the way to the patients room.

 

[Journey]

The nurse looks back at the pt's chart and says oops it was right here on top I must have missed it!!! Very nice:wacko:

Stuff happens. We've had whole charts lost by ambulance crews on IFT when they sat it down to open the doors or to pick up something else especially when they have other things in their hands. Others have dropped the papers or the chart only to have everything fly across the parking lot and not recovered. Of course that means all of the patient's personal information is lost for public viewing some place.

There have also been crews who forgot to check for a foley catheter and rip it out in the move. The same for IVs, PICCs, pegs, NGTs, trach or stoma tubes, and wound vacs.

Mistakes and oversight can happen to anyone at anytime.

For any nursing home transfer there is a substantial amount of paperwork to be done other than just what you will be taking. The nurse may also be tryng to jostle med passes to 30 patients and 5 other transfers at the same time when an emergency does happen. ED RNs and EMS might criticize nurses who work at these facilities but I can almost guarantee not one of those ED RNs would want to trade places with them.

 

[usalsfyre]

While something like this is irritating as all get out, remember LTC patient ratios are commonly 40 or 50 to one.

 

[Veneficus]

So you practiced a code on a dead person.

In the spirit of medics everywhere, did you get the tube?

 

[605medic]

Yes the tube was good. At least they caught us before we did the needle decompression for the pneumothorax the pt had. That could have been a good learning experience. Too bad they told us to stop

 

[firetender]

So you practiced a code on a dead person.

In the spirit of medics everywhere, did you get the tube?

I'll put myself at risk here and go so far as to say that Vene pretty much nails it; a big part of the job involves getting as much practice as we can in any way (ethically) available to us.

That means working up individuals whom we're pretty sure don't have a chance. "You never know," is a strong part of the job as well, so this is not about lying to ourselves or anyone else. Building technical proficiency involves doing the work whenever you can. A "futile" attempt today could foster success tomorrow. That's just the territory.

More than one of us have found ourselves in the position of working someone up because inaction would likely devastate the family. The choices we make as to who and who not to work up are not found in cookbooks and are very human indeed!

At a certain point we are often faced with choosing to continue or stop what we're doing. Protected by "You never know!", really trying, in part to get more proficient, is NOT an evil thing.

 

[Veneficus]

Brave men and their proud simulators.

I know everyone likes to think that with advances in simulation technology, that practice on actual patients might somehow be unethical or immoral.

There will never be a substitute or equal to actual patient contact.

As firetender pointed out, sometimes that practice is justified by the term "heroic measures."

Most of the experts I look up to and I dare say myself are fairly good at predicting death. Not in terms of when it will happen, but the fact when it is inevitable. While there is always the occasional "miracle," the body can only take so much before the deal is done.

We don't often openly talk about it, but by far, we know when our "heroic measures" are just practice. In the absence of a DNR for any reason, it is that golden chance to practice rarely used skills on a real patient. Sometimes even the opportunity to make something up to see how it works. (or doesn't)

I am fairly confident in saying that such "practice" has gone on long before us and will likely go on long after us. So rather than get all bent out of shape about it, perhaps celebrate the opportunity to learn or perfect something today. After all, somebody died to give you that chance.

From the philosophical standpoint it is not really different from donating your body to a cadaver lab or for organ donation. It is all using what's left to try and help some other person.

Dr. Frankenstein would be so proud.

 

[46Young]

Don't you just love running calls to nursing homes. I just had a call for cardiac arrest CPR in progress. Upon arrival nurse states pt is a full code and that the pt has been down no longer than 5 minutes. Get the line and airway established, first round of drugs. Pt is in PEA with a pacemaker at 65 bpm. Start to the hospital and my partner calls to notify them of the pt only to be told to stop because the pt has a DNR on file. Get to the hospital and then call the nursing home. The nurse looks back at the pt's chart and says oops it was right here on top I must have missed it!!! Very nice:wacko:

That's nothing - on several occasions (yes, several), I've been called to the SNF arrest, and the staff reports that the pt was alive and talking to them ten minutes ago. The problem is, the pt was in rigor. A few times, I went to drop a tube, and I couldn't move the jaw. On another occasion, the whole body was stiff. I suppose the staff saying they were alive minutes earlier was an attempt to cover up the fact that they were neglecting the pt. It takes hours for rigor to develop, you know. As far as arrests, they can never seem to get it right. "BVM" through the NRB resevoir bag, BVM w/ 2lpm O2, proper BVM w/o compressions, proper BVM and compressions on the soft bed, or a CPR board under the pt and either bad airway management, no O2, or ineffective (or no) compressions. I've never seen it lined up properly. Forget about an AED; the pads cost around 55 bucks a pair, and the NH isn't into wasting them.

 

[46Young]

Nursing homes get a bad rap from EMS people. Nursing home staff spend more time with the patients than they do with their own families. When something happens, they panic just like most people do when something bad happens with close family. Don't hold it against them because they become very attached to the patients.

When ever I go to a nursing home I just pluck the chart on the way past the nurses station and go through it on the way to the patients room.

I don't know how it is out your way, but back in NY, it seems that the NH job scene attracts new immigrants, mainly from the islands or the Far East. We would go there all hours of the night. We routinely found pts soiled, worked arrests with food in the airway w/ an advisory for aspiration precautions bedside, stage IV decubitus (I guess they weren't following the guide to reposition the pt every couple of hours), CNA's curled up sleeping in their chair as pt's are calling for them, ringing the alarm, etc. NH's back in NY seem to attract the type of person who wants to work somewhere where they get a check, and don't need to do anything. I know this is a generalization, but in my experience, this has been true enough of the time to cause me to see it this way. We bring pts back and the staff groans and rolls their eyes. We try to teach the staff some basic medical knowledge, such as placing a diff breather fowlers for example, and they just aren't receptive. There have been NH nurses and CNA's who obviously care about their pt dearly and care about their job as well, but they were in the minority. It seems better here in VA, though.

 

[Veneficus]

It hs been my experience in every country I have ever seen nursing homes in, that most for whatever reason seem to be where the elderly go to die from neglect.

No longer functional to society they are simply moved out of sight and mind to die while spending as little on them as can be gotten away with.

The nicer ones I have seen come with a premium pricetag that is beyond the capability of all but the extremely wealthy.

Worse still, despite the efforts of some very capable and compassionate people, the cycle is so self perpetuating the providers are powerless to change it.

Old wisdom has always been that a quick death is mch better than a lingering one where a person suffers. Unfortunately the idea from the recent past that death was somehow an enemy to be vanquished has led to "advances" that can make sure the dying linger for decades.

One of my philosophical dilemas is where the line is drawn between returning people to health and not letting them die.

 

[Journey]

it seems that the NH job scene attracts new immigrants, mainly from the islands or the Far East.

Laziness is not always restricted just to the immigrants. Americans are considered to be the laziest and fattest group by many of the other countries. Even the American made cars are deemed to be inferior due to the work ethic of Americans.

worked arrests with food in the airway w/ an advisory for aspiration precautions bedside, stage IV decubitus (I guess they weren't following the guide to reposition the pt every couple of hours), CNA's curled up sleeping in their chair as pt's are calling for them, ringing the alarm, etc. NH's back in NY seem to attract the type of person who wants to work somewhere where they get a check, and don't need to do anything.

Aspiration precautions do not mean the patient can not eat. It may just mean certain precautions are to be followed and the patient may sitll aspirate with the best of care. It is also frustrating when EMS doesn't recognize the aspiration, fails to clear the airway and assumes it is CHF which will get CPAP to assist the food to get further into the lower airways. As far as the stage 4 decubitus, the patient may have come from home or the hospital with it and the NH is attempting to heal it. These patients will also have a precaution of not sitting in a high fowlers position which some might take very literally even with respiratory problems.

You will have people who want to do very little for a check and EMS is probably no different. We hear grumbling quite often from EMTs and Paramedics who are called to do a transport between facilities even if it is a CCT with a very critical patient and an RN who will do most of the patient management. I can't imagine what the nurses at the LTC centers must hear from them.

I'm not sticking up for every nursing home but if you want to compare horror stories, the staff in hospitals and nursing homes could fill a few books about EMS muck ups also.

 

[46Young]

Laziness is not always restricted just to the immigrants. Americans are considered to be the laziest and fattest group by many of the other countries. Even the American made cars are deemed to be inferior due to the work ethic of Americans.
True, but in my experience, the overwhelming majority of NH employees, from CNA to LPN to RN, were from the islands or the Far East. The CNA position has a low barrier of entry, so it's an easy job to get as soon as you get here. CNA's are paid low to begin with, and NH's pay as little as possible. This fosters apathy in the work environment, /COLOR]


Aspiration precautions do not mean the patient can not eat. It may just mean certain precautions are to be followed and the patient may sitll aspirate with the best of care. It is also frustrating when EMS doesn't recognize the aspiration, fails to clear the airway and assumes it is CHF which will get CPAP to assist the food to get further into the lower airways. As far as the stage 4 decubitus, the patient may have come from home or the hospital with it and the NH is attempting to heal it. These patients will also have a precaution of not sitting in a high fowlers position which some might take very literally even with respiratory problems.
If the pt has aspiration precautions, then why am I finding solid food auch as green beans and meat in the airway, and why are they laying nearly supine, with the food tray still in front of them? We learned in EMT school to place someone fowler's if they're not breathing well. I'm sure they learn the same thing in CNA school. Common sense things like that seem to be in short supply in NH's. And, I know the pt with decubitus isn't being turned often enough because their diaper is loaded, and coming out the sides, implying that they haven't been changed for many hours. How much feces and urine are you producing on a NH diet, when you're bed confined and on tube feeding?

You will have people who want to do very little for a check and EMS is probably no different. We hear grumbling quite often from EMTs and Paramedics who are called to do a transport between facilities even if it is a CCT with a very critical patient and an RN who will do most of the patient management. I can't imagine what the nurses at the LTC centers must hear from them.
These EMT's and medics don't belong on the job any more than the slacker NH employees. You're being paid to do a job that you voluntarily applied for. Continue to do your job, but in the meantime make moves to change your employer, or change your career altogether.

I'm not sticking up for every nursing home but if you want to compare horror stories, the staff in hospitals and nursing homes could fill a few books about EMS muck ups also.

Low barriers to entry will do that to a profession. If it takes little to nothing to get the job, in this case EMS, the employee may not value their paid position and skell out/complain constantly.

Edit: Sorry for the small font; I messed up

 

[looker]

It hs been my experience in every country I have ever seen nursing homes in, that most for whatever reason seem to be where the elderly go to die from neglect.

No longer functional to society they are simply moved out of sight and mind to die while spending as little on them as can be gotten away with.

The nicer ones I have seen come with a premium pricetag that is beyond the capability of all but the extremely wealthy.

Worse still, despite the efforts of some very capable and compassionate people, the cycle is so self perpetuating the providers are powerless to change it.

Old wisdom has always been that a quick death is mch better than a lingering one where a person suffers. Unfortunately the idea from the recent past that death was somehow an enemy to be vanquished has led to "advances" that can make sure the dying linger for decades.

One of my philosophical dilemas is where the line is drawn between returning people to health and not letting them die.

If you're sick and/or old and do not have much money where else would you go? Unless you have kids and they are willing/able to let you live with them and can take care of you the only place you can be at old age is nursing home. It's unfortunately the fact of being old/poor.

 

[Veneficus]

If you're sick and/or old and do not have much money where else would you go? Unless you have kids and they are willing/able to let you live with them and can take care of you the only place you can be at old age is nursing home. It's unfortunately the fact of being old/poor.

Without a doubt. Still not a pleasant thought.

 

[emt seeking first job]

Without a doubt. Still not a pleasant thought.

At forty four, a bit flabby with a belly, its my motivation to excercize more.

 

[emt seeking first job]

Low barriers to entry will do that to a profession. If it takes little to nothing to get the job, in this case EMS, the employee may not value their paid position and skell out/complain constantly.

You may have noticed this from being in NYC before, a lot of skells have cover jobs, for a minimal paycheck and benefits, and they conduct some other activity from that "base" of operations.

Like a CNA or EMT job is a "front" for something else.

And of course, even higher level professions.

I remember in midtown, in plain view, a UPS Driver would take football bets as he made his rounds. NYPD beat cops would place bets with him.

Not to threadjack, but of gambling was legalized and regulated......

 

[Phlipper]

That's nothing - on several occasions (yes, several), I've been called to the SNF arrest, and the staff reports that the pt was alive and talking to them ten minutes ago. The problem is, the pt was in rigor. A few times, I went to drop a tube, and I couldn't move the jaw. On another occasion, the whole body was stiff. I suppose the staff saying they were alive minutes earlier was an attempt to cover up the fact that they were neglecting the pt. It takes hours for rigor to develop, you know. As far as arrests, they can never seem to get it right. "BVM" through the NRB resevoir bag, BVM w/ 2lpm O2, proper BVM w/o compressions, proper BVM and compressions on the soft bed, or a CPR board under the pt and either bad airway management, no O2, or ineffective (or no) compressions. I've never seen it lined up properly. Forget about an AED; the pads cost around 55 bucks a pair, and the NH isn't into wasting them.

That's been my experience in the short time I've been doing this job, as well. We never know what we're liable to see going into one of the many LTC facilities in our district. By and large, the LPNs and CNAs appear to be the bottom of the barrel around here. I'm sure there are excellent facilities, but we don't have them in VA. I could go on and on with amazingly stupid LTC Nurse stories, but there's no point.

My wife and I have a deal that if either of us get to the point we're heading for a nursing home, the healthy spouse is to start slapping on Duragesic patches till the sick one stops wiggling.

Oddly enough, the other night I woke up with her peeling a few Fentenyl patches off and sticking them on me in the middle of the night. I asked her "WTF?" and she said "Just practicing." and put them away. Kinda made me nervous since then. I don't sleep much.

 

[HeadNurseRN]

Nursing homes get a bad rap from EMS people. Nursing home staff spend more time with the patients than they do with their own families. When something happens, they panic just like most people do when something bad happens with close family. Don't hold it against them because they become very attached to the patients.

When ever I go to a nursing home I just pluck the chart on the way past the nurses station and go through it on the way to the patients room.

I totally agree, it's more easy to work with nurses then make them the bad guys.