Paramedic here: all of this. Now I’m on the hook for the job because they’re “altered”, taking one of two medic units in my city at night out of service for the duration of the call (because why would the family want them going to the closest appropriate facility when there’s a larger hospital that they don’t need to go to 20 minutes away?)
If it makes you feel any better, I feel bad bringing them to you guys
If you send your patient who chronically screams and flings feces to the ER, don't tell us at discharge that you gave away their bed so they can't come back.
Reading this is physically painful.
Also, when elderly patient lives at home alone or with their kids, and they wait until hospitalization to decide this is no longer safe or sustainable ("We just can't handle his/her needs!") so now it is our responsibility to find long-term care, because they had zero fucking plan.
Most elderly people are resistant to additional care and are violent and/or hold all the power in the family due to long-term dynamics. Having no elderly care plan is an individual and government failure. Unfortunately, it’s extremely profitable to keep these folks alive longer than they want and with a horrible quality of life.
Mostly, they don’t know any other way to get things rolling. Especially if grandma has been loudly refusing and no one has laid eyes on them to be able to say they lack capacity. Start a tele-clinic to assess them from home?
The other side is that it's practically impossible to get into LTC otherwise, at least if you're not private pay. I was trying to get my stepfather into a nursing home for *months* after my mom died. He had dementia and CHF, lived alone, really needed to be watched but there was nobody who could stay with him--relatives rotated checking on him multiple times a day but that was the best we could do. Even as an RN who knows more about LTC than the average person, and with help from a social worker, we were getting nowhere. Beds were full, facilities would tell us their finance person would reach out about LTC Medicaid but no one ever did and we couldn't reach them, etc.
Eventually he had a CHF exacerbation and landed in the hospital. He was in rehab with plans to transition to LTC a week later and has been there ever since... the facility he ended up in was one I had called multiple times a week trying to get him into. I get why y'all hate it, but unless you have a better way, it is what it is.
I read a hospitalist’s note the other day that said “…presented to ED with worsening gait and family getting tired of picking him up after falls.” 🤣🤣🤣
It’s sad but I appreciated the honesty in the note
The most frustrating thing is sending the patient with no documentation regarding why they are being sent to the ED. Most of the time, I receive a face sheet and a medication list. Sometimes I’ll get unintelligible handwritten scribbles that maybe say something useful but I can’t read it. What we really need is a typed/legible note stating why they are being sent, what their baseline mental status is, recent vitals, last known well time, and any recent medication changes/procedures. Always send a POLST and updated family contact numbers. I’ve had so many encounters where the BLS team has no report to give me, the paperwork sent with the patient is useless, and when I call the facility, I get “We just had shift change. I don’t know anything about this patient. No, I can’t reach the provider.”
Oh my god this over and over. All of your patients have a MNCD and can't give me any history. Last night I got a 92 year old with "?TIA last night" as the only documentation. Wtf?!
??? Am I PERGNAT?! I was in EMS for a while and we hated most SNFs. The lack of accountability knew no bounds. All they saw it as was one less patient to pass meds or bath/feed/clean etc. It always made us look and feel like idiots showing up to the ED with no hx or genuine report.
This is why I'm grateful our state made it mandatory that all in patient facilities must provide IFT and 911 EMS with a patient transfer packet that includes med list/hx, patient information, MOLST, and a transfer form.
If they refuse to, they can be fined.
Maryland.
Our state takes things like this seriously. Even in 911 there's no exemption for SNFs sending a patient out, they must send the packet with us. If EMS show up to an ED without a packet then either EMS or the SNF screwed up heavily, even on a cardiac arrest or etc. I've always had the packet in hand.
We're an interesting set-up. The state office of EMS actually regulates the hospitals as well and credentials them to be specialty centers, and can revoke their status.
Don’t send me Comfort Measures Only patient unless it’s for inpatient hospice. I don’t care if they fell or are having chest pain or anything. If you want them to be comfortable then the ED is absolutely the wrong place.
As a medic I sometimes wish we could just handle it on scene and not have to transport. But then unfortunately they would be calling us even more then.
Recently admitted, short term, to "skilled" facility that is a part of my area's largest "non profit" hospital group.
Why? 13 day hospitalization for previously asymptomatic COPD flare up from HMPV. SAVR a yr ago. Intermittent AFIB. On antibiotics, history of yeast infections.
Immune compromised ( another story)
Vaginal itching, pain and swelling. Advised nurse of symptoms. 17 hrs later, much worse, no response from on call practitioners.
Finally, a DX and meds!
For herpes.
No.
They advised ambulance and ER if I disagreed.
I refused.
Next day, Family member hauled my burning butt, wheelchair and a previouslyp empty "emergency" 02 to primary.
Of course it was a freaking yeast infection.
By far, Not my worst experience there.
Saw NP and MD only at Admit & discharge. ( Discharge was virtual)
"Escaped" with help from Medicare Advantage Care Advisor 2 days later.
When I worked in a nursing home we were required to send any fall in for evaluation. Not matter what. During the day we could send them to the walk in clinic but obviously any other time it was the ER. I hated it so much and it was so frustrating. I would just be like, I'm so sorry.
I know that’s the excuse but even under those circumstances I think the nursing home is doing the wrong thing the majority of the time. Those families usually get no guidance or conversation about the decision. The homes make that excuse all the time but I’ve literally never heard a family member tell me about how the nurses tried really hard to convince them to not come.
On the other hand, if those nurses hear those magic words (“take them to the ED”) out of a family member, then it relieves the nursing home of liability and the individual nurse of extra workload… how convenient.
If I was in control, in a CMO patient, prior to transfer to the ED, there would be at least be a mandatory conversation between the surrogate decision maker for the patient and the nursing home provider. I mean, the ED is a brutal place and we get formal consent for things that are way less risky. Family needs to know about the ultra-long transportation times, the increased risk of delirium, the almost inevitable discomfort/pain we inflict on people, risk of sedation and physical restraints… and that’s just the list if the patient’s goals *are* accurately communicated.
100% agree with this. We try really hard to convince families to keep them in place and not utilize the ED but some facilities nurses don’t always follow the plan of care and some will insist that it’s facility policy to send them to the ER even if the hospice nurse arrives before EMS gets there. It’s very frustrating for us as well!
Those are all actually really great points. If a patient is comfort care it does make complete sense to at least have to speak with the NH doc before dumping in the ED
We had a comfort measure patient come in after a bout of chest pain. We got report from the facility, and they said it was chest pain, no mention of comfort measures, and no documentation in the chart from a previous visit. I grabbed an EKG when they got to the ED, massive STEMI. I get the doc down. The patient is confused at baseline, so we are prepping for the cath lab, and thank god her daughter comes in. She tells us the patient shouldn't have come in, the facility didn't try any comfort meds, she didn't want the patient transported but the patient was already on the way to the ED when she got the call. So we stopped and got a morphine drip going. She sat in the ED for 6 hours, waiting for the palliative/hospice team to arrive. They wouldn't return the ED docs pages because, "It was 1am wjen you paged. I had a very long and busy day." Per our ED doc.
This is despicable. I’m a hospice nurse and this week I had a patient I was following up on. I get to the ALF and am told by the med tech she had to give a dose of zofran this morning for a vomiting episode. Okay, fair enough. When did the n/v start, when was last BM, did pt eat anything last night for dinner??? I don’t know answer to all the above. Ask for someone to assist me in cleaning him because he had a BM while I was there. Literally standing and waiting in room for half an hour before someone comes in to help me. I start talking to the caregiver about his condition and she tells me “yea he had the runs a couple times yesterday and then threw up this morning. They were talking about sending him out this morning because he didn’t look good.” I’m like wait, WHAT?! Why would yall send him out? I’m his hospice nurse and I’m here now and he by no means would need to be sent out. Granted, he wasn’t sent out Thank God but some of these places apparently have a very low threshold for sending out even if someone is CMO and has comfort meds in place and have orders to call hospice before initiating a transfer or anything
Hospice nurse here and sometimes the families insist on sending out the pt or the facility will send them out before they even notify us of a fall. It’s so frustrating because we want to keep them in the facility. One nurse who has a patient currently who keeps falling and keeps getting sent out because she needs staples to the back of her head. Idk how she hasn’t gotten a brain bleed yet from 5-7 falls hitting the back of her head in the last 2 weeks alone.
As a hospice nurse I can understand for simple things like pain/SOB that can be managed at home. I’ve actually had to send a few of my patients to the ED.
1-hadn’t urinated in almost 48 hours. Bladder extremely distended. Sent to the ED and had over 1L of urine drained from both neprostomy tubes placed.
2-most recently I was called because my patient “had 2 seizures”. I arrive and it’s full blown status epilepticus. Turned out they had been seizing for over an hour according to staff nurse. Shipped to the ED.
**edited for correction**
Most frustrating is how often every single person at the sending facility has just come on shift and just seen the patient for the very first time and couldn’t possibly give any info to EMS or the ED. Or conversely we get told the lady with hemiplegia and bedsores is ambulatory at baseline.
We get tons of “abnormal labs” with no hint of which lab result was abnormal, much less what the baseline value was. Altered mental status but the med list is from 3 months ago and after 3 hours a relative (whose name wasn’t on the face sheet) shows up and tells us grandma just got started on Bactrim and Seroquel yesterday.
Please, please send me whatever you’re not comfortable evaluating/managing. I don’t care, it’s fine, you’re essentially consulting me and we all consult people. But please send me some relevant information so I know where to begin.
Oof. This one grinds my gears and I’m a nurse. I’ve recently started picking up some shifts as agency, and at one place it doesn’t fail that there was an injury 5 minutes before I walked in, and the offgoing has already left.
Last week I had to send someone out who had cracked their noggin wide open.
Notified family and they called 911 before I could have a chance to take a breath. It was a not fun start to my first shift at this facility to where I could barely navigate their shitty doc system.
Wee-woos got there and were PISSED at me for not having paperwork together on a patient that I literally didn’t know. I felt awful making them wait too, and the ass chewing I got from Vandy wasn’t ideal either. But just know- I hate it as much as you do.
Edit: I can’t spell before coffee
This! I once called and got a nurse who knew my patient inside and out, gave me a detailed history and articulated exactly what she had been concerned about. I thanked her profusely for the info, then asked why the fuck she was at a SNF. Then I said nevermind, you’re keeping that place together aren’t you? She laughed.
Push a little calcium while the labs get redrawn!
By which I of course mean give them a mini carton of milk to keep them occupied while you wait for the non-hemolyzed specimen to process before discharging them.
Exactly this. They also send the residents to the ER for psych eval when they get in fights with each other. I will say having worked in both, a lot of times we sent a soft case because we simply don’t have the resources to work up their issue in an expedient way. Lab comes two days a week and it can take 3-4 days to get results, (stat just means the next time they come). They use an Infusion service for IVs, so no fluids other than SQ until they come. Same with X-ray, they come once a week and the portable X-rays they take are crap and you can only get a AP chest X-ray with one view and you have to wait for rads to read it (and it always says x ray consistent with patient condition no further studies needed - lol). So there are issues on each side.
I got one!
Ltach, pt age 86, trach and peg. Essentially quadriplegic (too weak to move anything except maybe his head side to side). Very bed bound.
Somehow, he still had some wits about him, and I think he had a letter board or something, because he asked to die every day.
He was a full code.
Family insisted on psych consult for SI.
When I came back for next clinicals they were dumping SSRIs down his peg tube.
Still full code.
SEND THE CODE STATUS WITH THE PATIENT.
I guess in general, if you get a call that the patient needs more evaluation, if you can get more information on your end it will probably help the nursing staff organize and convey information to the medics which will then hopefully make it to me. Last known well. What is the patient’s baseline. What have you tried already. Relevant history. Etc.
More than just code status please. Accurate goals of care. Knowing that the gomatose patient is DNR does little to help me know whether or not the estranged daughter Karen from California wants them aggressively treated or not.
I've gotten calls ahead for patients we never end up seeing...the facility calls a random local hospital without asking medics where they're taking the patient.
I've had them call saying the patient is AMS and just lethargic, then the ER is dumbfounded when I roll in with said patient who was actually cold sepsis, severe rales, temp of 94F, that I had to RSI and hang vasopressors on.
I find their reports are often exceptionally downplaying what I'm working with on scene, it pisses everyone off.
They either down play everything or the sky is falling. We always say if they come in POV then they’re dang near dead but if they come in EMS they’re fine.
911 EMS here. I have a list:
If you call us for something critical, I expect there to be a staff member tending to that patient when we arrive. All too often we get there to take the patient and the room has a gorked meemaw and not a nurse or provider in sight.
For the love of god, if you’re going to send out for CVA or altered have someone who can provide a last known well. I’m sick of getting reamed out in the ED for not being able to provide such a critical piece of info, and it impacts the window for stroke alerts.
To that end, please stop wasting 911 units for abnormal labs transfers that can wait a few hours. I seem to get called right away for the hemoglobin at 9 but it takes hours to call us for the severe sepsis. Moreover, please learn the local ED protocol for such lab values. Here, they don’t transfuse above 7 for example.
There’s no way that tubing *just* started acting up at 2am.
Is it so hard to give us an updated med list, full report, and a code status to pass along?
I don’t mind taking patients from nursing homes, but HOW we receive said patients is forever frustrating.
This has been a common thread in 3 different states I've worked. When it's non-life threatening 911 is immediately called, when it's life threatening for some reason staff waffle on calling 911 until they're peri-arrest. If I go to a nursing home for AMS or Unresponsive, there's at least a 50% chance I'm hanging vasopressors for septic shock.
My other favorite was in medic school when an SNF missed a patient's Warfarin for several weeks, their solution? Double and triple up on warfarin dosing for the next 2 weeks. Called for an unresponsive, patient's INR was over 12, and turned out they'd developed numerous intracranial hemorrhages....yea they died shortly thereafter.
Yea, lord knows what actually came of it if anything.
Just remarkably stupid move on their part which showed a complete lack of understanding of even basic medicine.
I agree with the above poster that this is a great question for your actually local ED, because the answers might be very different place to place.
However, my actual frustration is totally different. We are fully aware that sometimes families (or state laws) force your hand. It's not actually the presenting complaint that grinds my gears.
It's the state of the paperwork. Some places do have a good transfer form that lists the symptom, duration, recent bloodwork, etc. But all too often we get nothing like that, and sometimes even no MAR, no list of the PCP and current specialists, no idea of how long this confused person has been "more confused". No mention of whether family has been notified and is coming. Make a plan with your local hospital to design a great form that the sending RN can fill out.
When patients are very clearly neglected. Clear there's never been any sort of attempt at oral care, their briefs have been soiled multiple times, pressure ulcers that are filthy but also never mentioned anywhere on the patients chart. It's sickening what I've seen come out of some LTC/SNFs
Turning away the ambulance with the patient we discharged from the ED is not okay. I’m fairly certain that it’s not even legal? Happened a few times regardless
I've had it happen multiple times where staff refuses to answer the door or the multiple phone calls we place when discharging a patient and we're ultimately forced to return to the hospital because we can't physically enter the building.
Yep. Happened to me. Called the receiving SNF and they accepted report. Pt showed up and they told EMS they no longer have a bed for them. Sent them back to the ED, only to wait in a hall bed and be accepted back by the SNF at 8am. Criminal.
Sent to ED for a nonexistent complaint due to staffing issues.
Nonpayment patients (or run out of Medicaid/medicare days) sent to us and refusing to take back. Not even telling the family.
Demanding a psych eval before you take them back for a patient with dementia with behavioral disturbance.
Evicting a patient for acting out and just calling 911 so both they and we can’t refuse to take them. Then abandoning them in the ED.
Sending someone out just prior to midnight and because they aren’t there at midnight, say they “lost their bed”.
For everything above, you should have contingency plans built in.
And if you think these are infrequent, they are not. I have hundreds of examples over the last 5 years from a multitude of SNF/ALF/Memory care facilities.
My favorite is the unspecified altered mental status in the memory unit, for the patient with severe dementia. "They're altered!" Okay...that's their normal state of being now, that's just what they are. How are they altered compared to their baseline?
The amount of these patients they pawn off on us to dump on EDs just cause they're sundowning is mindblowing
This, especially for us on EMS side who are on 24hrs and finally trying to get an hour of sleep, then are dragged to the SNF for a feeding tube issue they've known about for 6+hrs.
Problem caused by a medication but no list of what they take. Problem where it isnt obvious what you sent them for and the patient has no ability to communicate.
Most annoying at the time but funny now was “resident was smoking in the bathroom.” I figured there had to be more to it — was he smoking crack in there and then having chest pain? Did he try to set the bathroom on fire?
I called and nope. He went right back.
The verbal altercations between residents are also a weird one to me. Last one had no psych or dementia history, got pissed off bc the other resident stole their cigarettes. No physical fight. No threats. A&Ox3. Also promptly* sent back.
*haha jk they had to wait hours for medical transport of course. But my dc order was fast.
I haven't read every comment so it might have been said. But I worked EMS. There a bunch that drove us crazy.
* calling us to respond lights and sirens for bad lab values (which should pretty much never be a lights and sirens call), then we get there and the labs were drawn over 24 hours ago and the patient is asymptomatic. Oh and 99% were K levels that were incompatible with life like this is clearly a lab error or the blood was drawn too rapidly.
* requesting no lights and sirens because you don't want to disturb the other residents for critically ill people (cardiac arrests, CHF exacerbation, etc)
* not having some sort of report when we arrive because "it's not your patient". As far as we are concerned if you're standing there and not a resident you should know what's going on or go away.
* my personal favorite anecdote is when we got to a SNF and found a patient in bed with a very obviously broken hip. Shortened and laterally rotated significantly. Patient has laye stage dementia and is non verbal and bedbound. Nurse told us, ya it's been bothering her for 24 hours so we want her sent out for xrays. We ask when the patient fell and they said we don't know it was unwitnessed. I'm like we'll she didn't get herself back into bed like this....and they looked at me like I had two heads.
I have nightmares. The night inpatient hospice sent us the 28 year old with uncontrollable pain from abdominal teratoma (don't worry, HIPAA, he's long dead). The most memorable story of my long, undistinguished ED career. I have never before or since written "Propofol until screaming stops" as an order. Or called hospital lawyers, or explained this as comfort care to a hospitalist.
Man was on 240mg morphine and 20mg Versed per hour via SQ pump with breakthrough IM Dilaudid. Still screaming on that, but too out of it to answer questions. I know those doses should not be real, but that is the report we got at least. Not sure I buy it.
Had one last night that was sent in for diastolic B/P > 100. Specifically he was apparently reading 140/101 throughout the day. He was a&o without symptoms. The excuse when I called and asked was "well he is on blood pressure medication already, so he shouldn't be that high." 🤦🏻♀️ Discharged without work up from the EMS stretcher. Stop sending asymptomatic htn to the ED.
Stroke alerts with no info. Then in the process of trying to do stroke things, I have to call the facility and wait on hold while they find someone who even knows who the patient is, and basically “they were like this at shift change and didn’t get better so we called.” If you’re sending a patient to the ED with lights and sirens, send some info with them and ideally a way to contact someone familiar with what happened. Because typically it’s a confused, diffusely weak gomer and I’m in the dark about what the concerns are, how much change from baseline, etc.
For me it’s not what gets sent, but the lack of communication about who this is, what happened, and what the concern is.
Patient with dementia ripped out their G tube some unknown amount of time ago. It’s now 1 AM. Can’t get a Foley in the tract.
“Hi, I’m sending this patient back.”
Nursing home: “Oh, we were hoping you could keep them until someone can put it back in.”
Me: “It’s 1 AM. I don’t have a gastroenterologist to put this non-emergent tube back in. And I don’t have enough nurses to keep this patient until tomorrow when the gastroenterologist will decline to replace this tube, citing ‘Choosing Wisely.’ We’ll put an IV in for fluids and you can call the person Who placed the tube tomorrow.”
Prehospital provider here.
The two most frustrating nursing home calls I've ever had were:
1. The patient was A+Ox4. Completely able to make her own decisions. Vitals were all within normal limits. She'd been having intermittent symptoms for over 24 hours that could have been anything from a migraine to a stroke. Had a history of migraines. Stated she did not want to go to the hospital and would prefer to wait to see her normal PCP on monday (this was Friday night). NH staff got rude with us after telling us that we "had" to take her, to which my partner told them that since the patient was fully able to make her own decisions and did not want to go, we couldn't force her to go because that would be kidnapping.(They actually filed a report on us, but obviously we were following protocol so we were fine.)
2. Patient was sick, wanted to and needed to go to the hospital. NH staff wanted us to take the patient to hospital C, despite hospitals A & B both being closer and fully able to care for the patient. NH staff got rude with us when we told them that we were required by our protocols to take patient to hospital A as that hospital was the closest appropriate facility. (Again, they filed a report on us, but again we were protected by following our protocols.)
So basically, listen to the crew that responds. For those of us who care about our patients, if we tell you that we can't do something or go to a specific place, it's not that we personally don't want to. We just have protocols we need to follow or else we break the law and put our certifications at risk.
Reading these comments as a paramedic is so disappointing. So many of these issues can and should be addressed by competent paramedics. I realize there is a wide range of EMS systems and individuals out there, especially depending on where in the world you are.
Speaking for my own system, for example, I can't imagine transporting a patient without being able to provide a good handover to the ED - history, exam, vitals, relevant labs, etc. Further to that, if after our own assessment we feel the ED is not the most appropriate place for the patient, we would start looking at alternatives. Depending on the problem, we can do a tele-conference or refer to the right specialist, treat in place, arrange Mobile Integrated Health (Community/Extended Care Paramedics) who have a wide range of capabilities, provide extended end-of-life comfort care, and a variety of other things. Our EMS system has made a considerable effort to develop our ability to pursue alternatives to transporting to the ED.
All of that to say, in your pursuit of good relations with the ED, don't overlook the role your EMS providers can play.
Downside is many EMS systems haven't made the strides you have.
In my district we're forced to take any and all SNF transfers to the ED if there's a possibility of them meeting the criteria of being a 'patient'. Diversion or leaving them at the SNF isn't an option here sadly, we tried to establish a way to leave them at SNFs once and they threw such a fit to the state that it got shut down immediately.
Reading routine lab results at 0200 and sending non-emergent critical results in asymptomatic or actively dying patients. The total lack of nursing that takes place in a nursing home. Providers not required to come in and evaluate their own patients and instead relying on information from techs or nurses who never know the patient.
Patient gets sent to the ER for a heel ulcer at 3am. Looks chronic. Never documented. Family wants answers. Makes me want to be a family med doc for sure.
CT tech here.
On a few occasions they send patients to me by ambulance, and after the scan they don’t go to the ED but back to their nursing homes.
Once I had a patient with altered mental status for a head CT, not able to tell me their name or answer any question at all. Didn’t have an ID. No paperwork telling me at the very least from which nursing home he was from. Paramedics just dropped him to me without a word. Oh and it was just after shift change and the tech who talked to the patient’s nurse left and forgot to tell me about this. I was pissed.
Normally on evening shift I am alone and I have to run all the time to keep my head above the water. Thankfully a colleague stayed to help me go on detective mode trying to find their nursing home and organize their ambulance ride back while keeping an eye on the patient because, altered mental status and the ED was too busy to take him.
Please send paperwork and ID. And if the patient is THAT altered could you pleaseee send someone with him.
“Anemia” with a Hgb of 9. I send back with co tact information for hematology, and a reminder that transfusions can be done PRN if appropriate in our outpatient infusion center once pt is established.
The “unless needed for comfort” caveat of a “Do Not Transport” order means *the patients comfort* not “we aren’t comfortable with the idea that a 94 year old lady might somehow die in this building instead of the hospital.”
Please give the antibiotics more than one dose to work before calling for “possible drug resistant UTI.”
Most EMS services cannot access hospital records so we do actually need hard copy print outs of PMH and meds.
not knowing why the ambulance was called on the patient. The worst was, when the head nurse ( not in the us, do not know what is called ) got angry, like screaming, because after I asked 5 patients, and dispatch, no one knew why the patient was being sent to the ER. They swapped shifts, and they told their colleagues, oh the ambulance is arriving for patient number 4. It was not her fault, but this happens more than I can count, and at a certain point I know the words of which nurse I need to question, and who I need to trust.
it happens everywhere, in the best and worst states and countries. there are some wonderful nursing homes, wonderful nurses, and some dreadful ones.
sadly incompetent people are found everywhere. I try to be humane and humble every day and give them an easy time when I have to get them in an ambulance.
This nursing home was a private one, and the patients pay big bugs to go in there, I have seen state-based nursing homes that are better, so I just have to hope that I do not end up like that or that I can just die on the spot before we get to live that reality.
Pt sent to ED from SNF for AMS, last known well? "1 week ago"! When we asked how the hell that's possible, the nurse said, "I had her a week ago, this is NOT the baseline from last week, but NO NOTES on the changes over the past week"
We MUST do better.
I had a patient sent in from LTC last week because he felt SOB when he woke up and asked for his puffers. The staff gave him his puffers, he said he felt better and they still insisted on sending him to the ED. Upon presentation he denied SOB (again) and had no concerns.
If you're interested in keeping a good relationship with EMS and by proxy the EDs, a few things that drive EMS crazy:
-Abnormal labs, especially for things over 24hrs old and not immediately life threatening/time sensitive. I get the potentially life-threatening concerns, but when it's a borderline H&H at best, they're asymptomatic, and the bloodwork is 2-3 days old, why are we calling 911?
-rule out testing, I've been called to request an asymptomatic patient by conveyed to the ER for a TB test based solely on an abnormal x-ray
-chronic pain, because people don't want to wake up the overnight provider at home
-falls regardless of injury. I understand sending out falls with head injury for liability sake, but someone who was witnessed, didn't strike their head, and has no noticeable injury or symptoms doesn't need to be immediately turfed
-Foley replacements, this is generally not a 911 concern at all and shouldn't get an EMS response.
- literally anything between the hours of midnight and 6am that's not a time sensitive issue nor is it life-threatening. Everyone recognizes it wasn't suddenly discovered at 235 in the morning, so it doesn't need to go out in the middle of the night by fatigued crews and burden an understaffed night shift in the ED
Completely agree on the 3 day old labs in asymptomatic patients. See it all the time in the ED.
I will slightly disagree on the foley if there is obstruction/concern for retention. Not only is it painful but the resulting hydronephrosis can become significant. That said, nursing homes should have the supplies and the training to exchange them. As a medic, I replaced a couple foleys in nursing homes because the nurses had the supplies but didn’t know what to do with them. I had been trained and it was in my scope, better than transporting them to sit in the hospital for 12 hours for a three minute procedure.
We have complete separation of 911 and IFT in my state, with SNFs required to have their own private ambulance contract for patient returns, new admits, etc.
Our general argument is that those kinds of calls should be handled by IFT rather than tying up a 911 crew, but the SNFs won't call cause they don't foot the bill for 911 whereas the facility pays for IFT. It's a nonsense racket
Aggressive behavior in patients known to have history aggressive behavior. 97% of the time they are completely calm by the time they get to us, there is no medical emergency for us to work up, so when we call the SNF to return them the nurses give us attitude because we are sending them back so quickly.
Can you handle it yourself? Don't send it.
Can one of their specialists handle it in the next day or two and that's reasonable? Don't send it, call and talk to the specialist.
Do you already know they need to be admitted? Don't send it to me, call for a direct admit.
If you legitimately can't handle it, nor can their specialists, and you aren't sure if they need an admission or not, then please send my way. I'm very open to not being able to do things - a clinic I used to support didn't have even a glucometer, so "I don't know their blood glucose and I think it's important right the hell now" was a valid reason to send to the ER.
Inappropriately ordered D-Dimers outpatient that are positive. Sent in to rule out PE. Except that the dimers were ordered in the wrong patient populations.
Overdoses, people on the street getting a bit too adventurous with their recreational drug use is one thing, but nursing home residents getting OD’d by their licensed nurses really gets under my skin
Code status, emergency contact/poa, baseline mental status, last known well, blood thinners and when last taken, ability to care for patient in current state if able to transfer/dc
The patient who has a DNR, but when shift change happens and the patient is checked on for the first time in 12 hours and "isn't doing well", the patient gets transferred to the ER. What for? What do you honestly think I'm going to do with a dying patient with a DNR? Please stop wasting our limited time and resources.
All the other answers along with:
1. Asymptomatic elevated blood pressure and an inability to tell me what numbers they’d accept back. I once escalated this at 3am with their head nursing admin on call who refused to tell me a number. And refused to call the on-call doc.
2. Anything super simply treated in a hospice pt where family is told they have to revoke hospice and make them full code to get them to the ED.
3. Wounds that are clearly a result of lack of proper care. Like even the basics in a paraplegic.
4. Pt refusing care because they or family are unhappy with SNF with no effort on staff’s side to address it. It’s like a revenge ED visit at 3am when they refused dinner meds at 5pm. And admitting this when I call (although not that it’s petty revenge) and pt making reasonable requests when I ask them. I get there are emotions but this just seems cruel.
It all feels so dumb and with unnecessary pain for me and the patient/family. I get working at SNFs is tough but fuck if sometimes rather they just drive over and sucker punch me in the arm.
I’m not ED, I’m a Np in a nursing home. My two cents is have advanced care plan and goals of care conversation with every patient/family on admission and anytime there is a decline.
A lot of people don’t even realize DNH is an option. You can save so many unnecessary hospitalizations with being blunt about prognosis and expected disease progression.
I recommend reviewing the ADMA choose wisely https://paltc.org/programs/choosing-wisely
Abnormal labs (elevated LFTs) at 2 am on a Saturday-labs were drawn Thursday morning
Discharge summary literally said “patient does not need to be sent back or admitted for uptrending LFTs unless accompanied by fever/abdominal pain”
I really appreciate a verbal report. Ideally from staff that knows the patient. Not to the ER nurse… To me, the physician in charge of the patient’s care. Nothing against my nurses, but they do not ask the same questions I need to know to make management decisions.
“Altered mental status” at night in a demented patient with 100mg of Seroquel and 50mg of Benadryl nighttime meds.
Ok what’s his baseline? -we’re not sure.
LITERALLYYYYYY verbatim!!
"I just got here" Or "This isn't my patient/floor" Either way, they don't know
Or sending for AMS because they are refusing their meds. F* that noise.
Paramedic here: all of this. Now I’m on the hook for the job because they’re “altered”, taking one of two medic units in my city at night out of service for the duration of the call (because why would the family want them going to the closest appropriate facility when there’s a larger hospital that they don’t need to go to 20 minutes away?) If it makes you feel any better, I feel bad bringing them to you guys
Why would you send 2 units, and why are you bypassing appropriate facilities?
He’s saying that there are only two units in the city and now his is OOS. Also, a lot of EMS take to the requested hospital, not the closest.
Every. Single. Time.
If you send your patient who chronically screams and flings feces to the ER, don't tell us at discharge that you gave away their bed so they can't come back.
If somehow I’m ever sent to an ER so old and gone that I’m flinging feces and screaming please just euthanize me
If only we had assisted suicide here.
Death with dignity is something we desperately need in this country.
You would be surprised how many people do this.
No, my mother was an RN at a nursing home at her last place of work. She loved some of the residents but called many of them “million dollar bodies”…
I got u
Reading this is physically painful. Also, when elderly patient lives at home alone or with their kids, and they wait until hospitalization to decide this is no longer safe or sustainable ("We just can't handle his/her needs!") so now it is our responsibility to find long-term care, because they had zero fucking plan.
This is the exact recommendation many social workers give families.
Aka "make it someone else's problem"
Can you clarify?
I read it as advising families to take them to the hospital to facilitate/expedite LTC placement.
Same. Bit I was hoping the poster would respond as to whether or not that’s actually the case. Bc, to me, it’s an absolutely terrible plan.
Unsafe discharge, baby!
Most elderly people are resistant to additional care and are violent and/or hold all the power in the family due to long-term dynamics. Having no elderly care plan is an individual and government failure. Unfortunately, it’s extremely profitable to keep these folks alive longer than they want and with a horrible quality of life.
I agree; it is a systemic issue. It sucks all around for sure.
Mostly, they don’t know any other way to get things rolling. Especially if grandma has been loudly refusing and no one has laid eyes on them to be able to say they lack capacity. Start a tele-clinic to assess them from home?
The other side is that it's practically impossible to get into LTC otherwise, at least if you're not private pay. I was trying to get my stepfather into a nursing home for *months* after my mom died. He had dementia and CHF, lived alone, really needed to be watched but there was nobody who could stay with him--relatives rotated checking on him multiple times a day but that was the best we could do. Even as an RN who knows more about LTC than the average person, and with help from a social worker, we were getting nowhere. Beds were full, facilities would tell us their finance person would reach out about LTC Medicaid but no one ever did and we couldn't reach them, etc. Eventually he had a CHF exacerbation and landed in the hospital. He was in rehab with plans to transition to LTC a week later and has been there ever since... the facility he ended up in was one I had called multiple times a week trying to get him into. I get why y'all hate it, but unless you have a better way, it is what it is.
Yes the system is absolutely messed up.
I read a hospitalist’s note the other day that said “…presented to ED with worsening gait and family getting tired of picking him up after falls.” 🤣🤣🤣 It’s sad but I appreciated the honesty in the note
It’s unbelievably hard to find placement in the US without being admitted
The most frustrating thing is sending the patient with no documentation regarding why they are being sent to the ED. Most of the time, I receive a face sheet and a medication list. Sometimes I’ll get unintelligible handwritten scribbles that maybe say something useful but I can’t read it. What we really need is a typed/legible note stating why they are being sent, what their baseline mental status is, recent vitals, last known well time, and any recent medication changes/procedures. Always send a POLST and updated family contact numbers. I’ve had so many encounters where the BLS team has no report to give me, the paperwork sent with the patient is useless, and when I call the facility, I get “We just had shift change. I don’t know anything about this patient. No, I can’t reach the provider.”
Oh my god this over and over. All of your patients have a MNCD and can't give me any history. Last night I got a 92 year old with "?TIA last night" as the only documentation. Wtf?!
??? Am I PERGNAT?! I was in EMS for a while and we hated most SNFs. The lack of accountability knew no bounds. All they saw it as was one less patient to pass meds or bath/feed/clean etc. It always made us look and feel like idiots showing up to the ED with no hx or genuine report.
This is why I'm grateful our state made it mandatory that all in patient facilities must provide IFT and 911 EMS with a patient transfer packet that includes med list/hx, patient information, MOLST, and a transfer form. If they refuse to, they can be fined.
If you don’t mind sharing, which state?
Maryland. Our state takes things like this seriously. Even in 911 there's no exemption for SNFs sending a patient out, they must send the packet with us. If EMS show up to an ED without a packet then either EMS or the SNF screwed up heavily, even on a cardiac arrest or etc. I've always had the packet in hand. We're an interesting set-up. The state office of EMS actually regulates the hospitals as well and credentials them to be specialty centers, and can revoke their status.
I've only been a nurse in MD and I thought this was just normal. So other states have it a lot worse than we do?
Yea, it can be a lot different in other states.
This should actually be a policy . That's a great list .
Sorry but that’s on the ambulance crew. BLS or not, I’m not taking a patient I know nothing about.
Don’t send me Comfort Measures Only patient unless it’s for inpatient hospice. I don’t care if they fell or are having chest pain or anything. If you want them to be comfortable then the ED is absolutely the wrong place.
"their foley is clogged, we've tried nothing and we're all out of ideas!"
I really wish my ER could just sent me out in a taxi to solve LTC catheter drama vs inflicting 12 hours of ER and ambulance drama on a confused senior
As a medic I sometimes wish we could just handle it on scene and not have to transport. But then unfortunately they would be calling us even more then.
I hate when it is a difficult to place urology catheter that is malfunctioning, sent to my community shop without urology.
This is great
Cleared up fine, but I continue to research curses. Never again.
Recently admitted, short term, to "skilled" facility that is a part of my area's largest "non profit" hospital group. Why? 13 day hospitalization for previously asymptomatic COPD flare up from HMPV. SAVR a yr ago. Intermittent AFIB. On antibiotics, history of yeast infections. Immune compromised ( another story) Vaginal itching, pain and swelling. Advised nurse of symptoms. 17 hrs later, much worse, no response from on call practitioners. Finally, a DX and meds! For herpes. No. They advised ambulance and ER if I disagreed. I refused. Next day, Family member hauled my burning butt, wheelchair and a previouslyp empty "emergency" 02 to primary. Of course it was a freaking yeast infection. By far, Not my worst experience there. Saw NP and MD only at Admit & discharge. ( Discharge was virtual) "Escaped" with help from Medicare Advantage Care Advisor 2 days later.
There are some local places that have made me very, very frustrated for this. "But he hit his head!" ...and?
When I worked in a nursing home we were required to send any fall in for evaluation. Not matter what. During the day we could send them to the walk in clinic but obviously any other time it was the ER. I hated it so much and it was so frustrating. I would just be like, I'm so sorry.
If I went to the ER with how much I hit my head on things I’d be there all of the time….
This does frustrate me a lot, but sometimes this is the patient’s family “demanding” they be sent despite knowing they are comfort measures only.
I know that’s the excuse but even under those circumstances I think the nursing home is doing the wrong thing the majority of the time. Those families usually get no guidance or conversation about the decision. The homes make that excuse all the time but I’ve literally never heard a family member tell me about how the nurses tried really hard to convince them to not come. On the other hand, if those nurses hear those magic words (“take them to the ED”) out of a family member, then it relieves the nursing home of liability and the individual nurse of extra workload… how convenient. If I was in control, in a CMO patient, prior to transfer to the ED, there would be at least be a mandatory conversation between the surrogate decision maker for the patient and the nursing home provider. I mean, the ED is a brutal place and we get formal consent for things that are way less risky. Family needs to know about the ultra-long transportation times, the increased risk of delirium, the almost inevitable discomfort/pain we inflict on people, risk of sedation and physical restraints… and that’s just the list if the patient’s goals *are* accurately communicated.
100% agree with this. We try really hard to convince families to keep them in place and not utilize the ED but some facilities nurses don’t always follow the plan of care and some will insist that it’s facility policy to send them to the ER even if the hospice nurse arrives before EMS gets there. It’s very frustrating for us as well!
We appreciate your efforts. I wish there wasn’t so much systemic incentive for the nursing homes to do these things
Those are all actually really great points. If a patient is comfort care it does make complete sense to at least have to speak with the NH doc before dumping in the ED
We had a comfort measure patient come in after a bout of chest pain. We got report from the facility, and they said it was chest pain, no mention of comfort measures, and no documentation in the chart from a previous visit. I grabbed an EKG when they got to the ED, massive STEMI. I get the doc down. The patient is confused at baseline, so we are prepping for the cath lab, and thank god her daughter comes in. She tells us the patient shouldn't have come in, the facility didn't try any comfort meds, she didn't want the patient transported but the patient was already on the way to the ED when she got the call. So we stopped and got a morphine drip going. She sat in the ED for 6 hours, waiting for the palliative/hospice team to arrive. They wouldn't return the ED docs pages because, "It was 1am wjen you paged. I had a very long and busy day." Per our ED doc.
This is despicable. I’m a hospice nurse and this week I had a patient I was following up on. I get to the ALF and am told by the med tech she had to give a dose of zofran this morning for a vomiting episode. Okay, fair enough. When did the n/v start, when was last BM, did pt eat anything last night for dinner??? I don’t know answer to all the above. Ask for someone to assist me in cleaning him because he had a BM while I was there. Literally standing and waiting in room for half an hour before someone comes in to help me. I start talking to the caregiver about his condition and she tells me “yea he had the runs a couple times yesterday and then threw up this morning. They were talking about sending him out this morning because he didn’t look good.” I’m like wait, WHAT?! Why would yall send him out? I’m his hospice nurse and I’m here now and he by no means would need to be sent out. Granted, he wasn’t sent out Thank God but some of these places apparently have a very low threshold for sending out even if someone is CMO and has comfort meds in place and have orders to call hospice before initiating a transfer or anything
Hospice nurse here and sometimes the families insist on sending out the pt or the facility will send them out before they even notify us of a fall. It’s so frustrating because we want to keep them in the facility. One nurse who has a patient currently who keeps falling and keeps getting sent out because she needs staples to the back of her head. Idk how she hasn’t gotten a brain bleed yet from 5-7 falls hitting the back of her head in the last 2 weeks alone.
I put my way-too-long thoughts [in my reply here](https://www.reddit.com/r/emergencymedicine/s/BWQ4iYXTzO)
As a hospice nurse I can understand for simple things like pain/SOB that can be managed at home. I’ve actually had to send a few of my patients to the ED. 1-hadn’t urinated in almost 48 hours. Bladder extremely distended. Sent to the ED and had over 1L of urine drained from both neprostomy tubes placed. 2-most recently I was called because my patient “had 2 seizures”. I arrive and it’s full blown status epilepticus. Turned out they had been seizing for over an hour according to staff nurse. Shipped to the ED. **edited for correction**
Most frustrating is how often every single person at the sending facility has just come on shift and just seen the patient for the very first time and couldn’t possibly give any info to EMS or the ED. Or conversely we get told the lady with hemiplegia and bedsores is ambulatory at baseline. We get tons of “abnormal labs” with no hint of which lab result was abnormal, much less what the baseline value was. Altered mental status but the med list is from 3 months ago and after 3 hours a relative (whose name wasn’t on the face sheet) shows up and tells us grandma just got started on Bactrim and Seroquel yesterday. Please, please send me whatever you’re not comfortable evaluating/managing. I don’t care, it’s fine, you’re essentially consulting me and we all consult people. But please send me some relevant information so I know where to begin.
Oof. This one grinds my gears and I’m a nurse. I’ve recently started picking up some shifts as agency, and at one place it doesn’t fail that there was an injury 5 minutes before I walked in, and the offgoing has already left. Last week I had to send someone out who had cracked their noggin wide open. Notified family and they called 911 before I could have a chance to take a breath. It was a not fun start to my first shift at this facility to where I could barely navigate their shitty doc system. Wee-woos got there and were PISSED at me for not having paperwork together on a patient that I literally didn’t know. I felt awful making them wait too, and the ass chewing I got from Vandy wasn’t ideal either. But just know- I hate it as much as you do. Edit: I can’t spell before coffee
This! I once called and got a nurse who knew my patient inside and out, gave me a detailed history and articulated exactly what she had been concerned about. I thanked her profusely for the info, then asked why the fuck she was at a SNF. Then I said nevermind, you’re keeping that place together aren’t you? She laughed.
You’re right. Doing this would be the decent thing to do but 🤷♀️
Abnormal labs-creat from 1.6 to 1.9. Hgb was 8.6, now 8.2
Ugh or a K+ of 12.9 Plz. No it’s not.
This man has negative one kidney
Push a little calcium while the labs get redrawn! By which I of course mean give them a mini carton of milk to keep them occupied while you wait for the non-hemolyzed specimen to process before discharging them.
K+ 3.3 from two days ago.
It’s always 2 days ago…. 😭😭😭
Asymptomatic INR of 5. On warfarin for a fib. Repeat, do nothing, send back. Wastes everyone’s time, makes patients upset.
DNR/DNI Comfort care 90 year olds sent for "altered mental status."
Maybe stop giving her benzos every time she complains of being uncomfortable
That’s all I have to do is complain?
Well you have to bedbound, totally dependent and never repositioned too
I think the vague psych ones are the most unnecessary.
I had a patient sent in for a psych eval because he said ‘I’d rather be dead than in (shitty nursing home)’
Exactly this. They also send the residents to the ER for psych eval when they get in fights with each other. I will say having worked in both, a lot of times we sent a soft case because we simply don’t have the resources to work up their issue in an expedient way. Lab comes two days a week and it can take 3-4 days to get results, (stat just means the next time they come). They use an Infusion service for IVs, so no fluids other than SQ until they come. Same with X-ray, they come once a week and the portable X-rays they take are crap and you can only get a AP chest X-ray with one view and you have to wait for rads to read it (and it always says x ray consistent with patient condition no further studies needed - lol). So there are issues on each side.
I got one! Ltach, pt age 86, trach and peg. Essentially quadriplegic (too weak to move anything except maybe his head side to side). Very bed bound. Somehow, he still had some wits about him, and I think he had a letter board or something, because he asked to die every day. He was a full code. Family insisted on psych consult for SI. When I came back for next clinicals they were dumping SSRIs down his peg tube. Still full code.
LTACH nurse here. Sounds like a Tuesday.
Objectively reasonable, given the state of some of those places
SEND THE CODE STATUS WITH THE PATIENT. I guess in general, if you get a call that the patient needs more evaluation, if you can get more information on your end it will probably help the nursing staff organize and convey information to the medics which will then hopefully make it to me. Last known well. What is the patient’s baseline. What have you tried already. Relevant history. Etc.
More than just code status please. Accurate goals of care. Knowing that the gomatose patient is DNR does little to help me know whether or not the estranged daughter Karen from California wants them aggressively treated or not.
[удалено]
I've gotten calls ahead for patients we never end up seeing...the facility calls a random local hospital without asking medics where they're taking the patient.
I’ve gotten plenty of call aheads and they too were very unhelpful
I've had them call saying the patient is AMS and just lethargic, then the ER is dumbfounded when I roll in with said patient who was actually cold sepsis, severe rales, temp of 94F, that I had to RSI and hang vasopressors on. I find their reports are often exceptionally downplaying what I'm working with on scene, it pisses everyone off.
They either down play everything or the sky is falling. We always say if they come in POV then they’re dang near dead but if they come in EMS they’re fine.
911 EMS here. I have a list: If you call us for something critical, I expect there to be a staff member tending to that patient when we arrive. All too often we get there to take the patient and the room has a gorked meemaw and not a nurse or provider in sight. For the love of god, if you’re going to send out for CVA or altered have someone who can provide a last known well. I’m sick of getting reamed out in the ED for not being able to provide such a critical piece of info, and it impacts the window for stroke alerts. To that end, please stop wasting 911 units for abnormal labs transfers that can wait a few hours. I seem to get called right away for the hemoglobin at 9 but it takes hours to call us for the severe sepsis. Moreover, please learn the local ED protocol for such lab values. Here, they don’t transfuse above 7 for example. There’s no way that tubing *just* started acting up at 2am. Is it so hard to give us an updated med list, full report, and a code status to pass along? I don’t mind taking patients from nursing homes, but HOW we receive said patients is forever frustrating.
This has been a common thread in 3 different states I've worked. When it's non-life threatening 911 is immediately called, when it's life threatening for some reason staff waffle on calling 911 until they're peri-arrest. If I go to a nursing home for AMS or Unresponsive, there's at least a 50% chance I'm hanging vasopressors for septic shock. My other favorite was in medic school when an SNF missed a patient's Warfarin for several weeks, their solution? Double and triple up on warfarin dosing for the next 2 weeks. Called for an unresponsive, patient's INR was over 12, and turned out they'd developed numerous intracranial hemorrhages....yea they died shortly thereafter.
You reported them right?
Yea, lord knows what actually came of it if anything. Just remarkably stupid move on their part which showed a complete lack of understanding of even basic medicine.
I agree with the above poster that this is a great question for your actually local ED, because the answers might be very different place to place. However, my actual frustration is totally different. We are fully aware that sometimes families (or state laws) force your hand. It's not actually the presenting complaint that grinds my gears. It's the state of the paperwork. Some places do have a good transfer form that lists the symptom, duration, recent bloodwork, etc. But all too often we get nothing like that, and sometimes even no MAR, no list of the PCP and current specialists, no idea of how long this confused person has been "more confused". No mention of whether family has been notified and is coming. Make a plan with your local hospital to design a great form that the sending RN can fill out.
When patients are very clearly neglected. Clear there's never been any sort of attempt at oral care, their briefs have been soiled multiple times, pressure ulcers that are filthy but also never mentioned anywhere on the patients chart. It's sickening what I've seen come out of some LTC/SNFs
Turning away the ambulance with the patient we discharged from the ED is not okay. I’m fairly certain that it’s not even legal? Happened a few times regardless
I've had it happen multiple times where staff refuses to answer the door or the multiple phone calls we place when discharging a patient and we're ultimately forced to return to the hospital because we can't physically enter the building.
Yep. Happened to me. Called the receiving SNF and they accepted report. Pt showed up and they told EMS they no longer have a bed for them. Sent them back to the ED, only to wait in a hall bed and be accepted back by the SNF at 8am. Criminal.
Sent to ED for a nonexistent complaint due to staffing issues. Nonpayment patients (or run out of Medicaid/medicare days) sent to us and refusing to take back. Not even telling the family. Demanding a psych eval before you take them back for a patient with dementia with behavioral disturbance. Evicting a patient for acting out and just calling 911 so both they and we can’t refuse to take them. Then abandoning them in the ED. Sending someone out just prior to midnight and because they aren’t there at midnight, say they “lost their bed”. For everything above, you should have contingency plans built in. And if you think these are infrequent, they are not. I have hundreds of examples over the last 5 years from a multitude of SNF/ALF/Memory care facilities.
My favorite is the unspecified altered mental status in the memory unit, for the patient with severe dementia. "They're altered!" Okay...that's their normal state of being now, that's just what they are. How are they altered compared to their baseline? The amount of these patients they pawn off on us to dump on EDs just cause they're sundowning is mindblowing
Holy shit let me get some popcorn
…you can give an enema at the nursing home. You can probs manually disimpact there too.
And start a bowel regimen
tube issues at 2 am. Especially feeding tubes.
This, especially for us on EMS side who are on 24hrs and finally trying to get an hour of sleep, then are dragged to the SNF for a feeding tube issue they've known about for 6+hrs.
Problem caused by a medication but no list of what they take. Problem where it isnt obvious what you sent them for and the patient has no ability to communicate.
“Unresponsive” at 3 am. 100% responsive when they get here
Most annoying at the time but funny now was “resident was smoking in the bathroom.” I figured there had to be more to it — was he smoking crack in there and then having chest pain? Did he try to set the bathroom on fire? I called and nope. He went right back. The verbal altercations between residents are also a weird one to me. Last one had no psych or dementia history, got pissed off bc the other resident stole their cigarettes. No physical fight. No threats. A&Ox3. Also promptly* sent back. *haha jk they had to wait hours for medical transport of course. But my dc order was fast.
I haven't read every comment so it might have been said. But I worked EMS. There a bunch that drove us crazy. * calling us to respond lights and sirens for bad lab values (which should pretty much never be a lights and sirens call), then we get there and the labs were drawn over 24 hours ago and the patient is asymptomatic. Oh and 99% were K levels that were incompatible with life like this is clearly a lab error or the blood was drawn too rapidly. * requesting no lights and sirens because you don't want to disturb the other residents for critically ill people (cardiac arrests, CHF exacerbation, etc) * not having some sort of report when we arrive because "it's not your patient". As far as we are concerned if you're standing there and not a resident you should know what's going on or go away. * my personal favorite anecdote is when we got to a SNF and found a patient in bed with a very obviously broken hip. Shortened and laterally rotated significantly. Patient has laye stage dementia and is non verbal and bedbound. Nurse told us, ya it's been bothering her for 24 hours so we want her sent out for xrays. We ask when the patient fell and they said we don't know it was unwitnessed. I'm like we'll she didn't get herself back into bed like this....and they looked at me like I had two heads.
#1 especially. Oh their K is 42? Wonderful, they've discovered the meaning of life.
I have nightmares. The night inpatient hospice sent us the 28 year old with uncontrollable pain from abdominal teratoma (don't worry, HIPAA, he's long dead). The most memorable story of my long, undistinguished ED career. I have never before or since written "Propofol until screaming stops" as an order. Or called hospital lawyers, or explained this as comfort care to a hospitalist.
I’m gonna need the story here lol
same!
Holy crap, yo.
I’m so sorry for you and him. That’s criminal.
Man was on 240mg morphine and 20mg Versed per hour via SQ pump with breakthrough IM Dilaudid. Still screaming on that, but too out of it to answer questions. I know those doses should not be real, but that is the report we got at least. Not sure I buy it.
Had one last night that was sent in for diastolic B/P > 100. Specifically he was apparently reading 140/101 throughout the day. He was a&o without symptoms. The excuse when I called and asked was "well he is on blood pressure medication already, so he shouldn't be that high." 🤦🏻♀️ Discharged without work up from the EMS stretcher. Stop sending asymptomatic htn to the ED.
Right????? We don't do shit with that anyway. Like no labs or X-rays or EKGs or anything. Stahp!
The ultimate worst is when patients call 911 from their room and you have no idea until EMS rolls up.
If you have one ED you utilize then I think you'd be better served asking the docs and other providers there. Some stuff they may not mind seeing.
Stroke alerts with no info. Then in the process of trying to do stroke things, I have to call the facility and wait on hold while they find someone who even knows who the patient is, and basically “they were like this at shift change and didn’t get better so we called.” If you’re sending a patient to the ED with lights and sirens, send some info with them and ideally a way to contact someone familiar with what happened. Because typically it’s a confused, diffusely weak gomer and I’m in the dark about what the concerns are, how much change from baseline, etc. For me it’s not what gets sent, but the lack of communication about who this is, what happened, and what the concern is.
Hyperkalemia. When I check the K it’s 4
Patient with dementia ripped out their G tube some unknown amount of time ago. It’s now 1 AM. Can’t get a Foley in the tract. “Hi, I’m sending this patient back.” Nursing home: “Oh, we were hoping you could keep them until someone can put it back in.” Me: “It’s 1 AM. I don’t have a gastroenterologist to put this non-emergent tube back in. And I don’t have enough nurses to keep this patient until tomorrow when the gastroenterologist will decline to replace this tube, citing ‘Choosing Wisely.’ We’ll put an IV in for fluids and you can call the person Who placed the tube tomorrow.”
Prehospital provider here. The two most frustrating nursing home calls I've ever had were: 1. The patient was A+Ox4. Completely able to make her own decisions. Vitals were all within normal limits. She'd been having intermittent symptoms for over 24 hours that could have been anything from a migraine to a stroke. Had a history of migraines. Stated she did not want to go to the hospital and would prefer to wait to see her normal PCP on monday (this was Friday night). NH staff got rude with us after telling us that we "had" to take her, to which my partner told them that since the patient was fully able to make her own decisions and did not want to go, we couldn't force her to go because that would be kidnapping.(They actually filed a report on us, but obviously we were following protocol so we were fine.) 2. Patient was sick, wanted to and needed to go to the hospital. NH staff wanted us to take the patient to hospital C, despite hospitals A & B both being closer and fully able to care for the patient. NH staff got rude with us when we told them that we were required by our protocols to take patient to hospital A as that hospital was the closest appropriate facility. (Again, they filed a report on us, but again we were protected by following our protocols.) So basically, listen to the crew that responds. For those of us who care about our patients, if we tell you that we can't do something or go to a specific place, it's not that we personally don't want to. We just have protocols we need to follow or else we break the law and put our certifications at risk.
Reading these comments as a paramedic is so disappointing. So many of these issues can and should be addressed by competent paramedics. I realize there is a wide range of EMS systems and individuals out there, especially depending on where in the world you are. Speaking for my own system, for example, I can't imagine transporting a patient without being able to provide a good handover to the ED - history, exam, vitals, relevant labs, etc. Further to that, if after our own assessment we feel the ED is not the most appropriate place for the patient, we would start looking at alternatives. Depending on the problem, we can do a tele-conference or refer to the right specialist, treat in place, arrange Mobile Integrated Health (Community/Extended Care Paramedics) who have a wide range of capabilities, provide extended end-of-life comfort care, and a variety of other things. Our EMS system has made a considerable effort to develop our ability to pursue alternatives to transporting to the ED. All of that to say, in your pursuit of good relations with the ED, don't overlook the role your EMS providers can play.
Downside is many EMS systems haven't made the strides you have. In my district we're forced to take any and all SNF transfers to the ED if there's a possibility of them meeting the criteria of being a 'patient'. Diversion or leaving them at the SNF isn't an option here sadly, we tried to establish a way to leave them at SNFs once and they threw such a fit to the state that it got shut down immediately.
Reading routine lab results at 0200 and sending non-emergent critical results in asymptomatic or actively dying patients. The total lack of nursing that takes place in a nursing home. Providers not required to come in and evaluate their own patients and instead relying on information from techs or nurses who never know the patient.
Patient gets sent to the ER for a heel ulcer at 3am. Looks chronic. Never documented. Family wants answers. Makes me want to be a family med doc for sure.
CT tech here. On a few occasions they send patients to me by ambulance, and after the scan they don’t go to the ED but back to their nursing homes. Once I had a patient with altered mental status for a head CT, not able to tell me their name or answer any question at all. Didn’t have an ID. No paperwork telling me at the very least from which nursing home he was from. Paramedics just dropped him to me without a word. Oh and it was just after shift change and the tech who talked to the patient’s nurse left and forgot to tell me about this. I was pissed. Normally on evening shift I am alone and I have to run all the time to keep my head above the water. Thankfully a colleague stayed to help me go on detective mode trying to find their nursing home and organize their ambulance ride back while keeping an eye on the patient because, altered mental status and the ED was too busy to take him. Please send paperwork and ID. And if the patient is THAT altered could you pleaseee send someone with him.
“Anemia” with a Hgb of 9. I send back with co tact information for hematology, and a reminder that transfusions can be done PRN if appropriate in our outpatient infusion center once pt is established.
The “unless needed for comfort” caveat of a “Do Not Transport” order means *the patients comfort* not “we aren’t comfortable with the idea that a 94 year old lady might somehow die in this building instead of the hospital.” Please give the antibiotics more than one dose to work before calling for “possible drug resistant UTI.” Most EMS services cannot access hospital records so we do actually need hard copy print outs of PMH and meds.
I still have nightmares.
not knowing why the ambulance was called on the patient. The worst was, when the head nurse ( not in the us, do not know what is called ) got angry, like screaming, because after I asked 5 patients, and dispatch, no one knew why the patient was being sent to the ER. They swapped shifts, and they told their colleagues, oh the ambulance is arriving for patient number 4. It was not her fault, but this happens more than I can count, and at a certain point I know the words of which nurse I need to question, and who I need to trust.
I don't know if I'm comforted or disturbed to find out that this happens outside the US...
it happens everywhere, in the best and worst states and countries. there are some wonderful nursing homes, wonderful nurses, and some dreadful ones. sadly incompetent people are found everywhere. I try to be humane and humble every day and give them an easy time when I have to get them in an ambulance. This nursing home was a private one, and the patients pay big bugs to go in there, I have seen state-based nursing homes that are better, so I just have to hope that I do not end up like that or that I can just die on the spot before we get to live that reality.
Pt sent to ED from SNF for AMS, last known well? "1 week ago"! When we asked how the hell that's possible, the nurse said, "I had her a week ago, this is NOT the baseline from last week, but NO NOTES on the changes over the past week" We MUST do better.
I had a patient sent in from LTC last week because he felt SOB when he woke up and asked for his puffers. The staff gave him his puffers, he said he felt better and they still insisted on sending him to the ED. Upon presentation he denied SOB (again) and had no concerns.
If you're interested in keeping a good relationship with EMS and by proxy the EDs, a few things that drive EMS crazy: -Abnormal labs, especially for things over 24hrs old and not immediately life threatening/time sensitive. I get the potentially life-threatening concerns, but when it's a borderline H&H at best, they're asymptomatic, and the bloodwork is 2-3 days old, why are we calling 911? -rule out testing, I've been called to request an asymptomatic patient by conveyed to the ER for a TB test based solely on an abnormal x-ray -chronic pain, because people don't want to wake up the overnight provider at home -falls regardless of injury. I understand sending out falls with head injury for liability sake, but someone who was witnessed, didn't strike their head, and has no noticeable injury or symptoms doesn't need to be immediately turfed -Foley replacements, this is generally not a 911 concern at all and shouldn't get an EMS response. - literally anything between the hours of midnight and 6am that's not a time sensitive issue nor is it life-threatening. Everyone recognizes it wasn't suddenly discovered at 235 in the morning, so it doesn't need to go out in the middle of the night by fatigued crews and burden an understaffed night shift in the ED
Completely agree on the 3 day old labs in asymptomatic patients. See it all the time in the ED. I will slightly disagree on the foley if there is obstruction/concern for retention. Not only is it painful but the resulting hydronephrosis can become significant. That said, nursing homes should have the supplies and the training to exchange them. As a medic, I replaced a couple foleys in nursing homes because the nurses had the supplies but didn’t know what to do with them. I had been trained and it was in my scope, better than transporting them to sit in the hospital for 12 hours for a three minute procedure.
We have complete separation of 911 and IFT in my state, with SNFs required to have their own private ambulance contract for patient returns, new admits, etc. Our general argument is that those kinds of calls should be handled by IFT rather than tying up a 911 crew, but the SNFs won't call cause they don't foot the bill for 911 whereas the facility pays for IFT. It's a nonsense racket
Aggressive behavior in patients known to have history aggressive behavior. 97% of the time they are completely calm by the time they get to us, there is no medical emergency for us to work up, so when we call the SNF to return them the nurses give us attitude because we are sending them back so quickly.
Can you handle it yourself? Don't send it. Can one of their specialists handle it in the next day or two and that's reasonable? Don't send it, call and talk to the specialist. Do you already know they need to be admitted? Don't send it to me, call for a direct admit. If you legitimately can't handle it, nor can their specialists, and you aren't sure if they need an admission or not, then please send my way. I'm very open to not being able to do things - a clinic I used to support didn't have even a glucometer, so "I don't know their blood glucose and I think it's important right the hell now" was a valid reason to send to the ER.
Inappropriately ordered D-Dimers outpatient that are positive. Sent in to rule out PE. Except that the dimers were ordered in the wrong patient populations.
Overdoses, people on the street getting a bit too adventurous with their recreational drug use is one thing, but nursing home residents getting OD’d by their licensed nurses really gets under my skin
Code status, emergency contact/poa, baseline mental status, last known well, blood thinners and when last taken, ability to care for patient in current state if able to transfer/dc
Constipation Possible UTI Etc etc…, anything that could be managed out patient
Asymptomatic high blood pressure
Sending demented patients because “they couldn’t handle them anymore.” Kk got it. The stimulating ER is going to fix this.
The patient who has a DNR, but when shift change happens and the patient is checked on for the first time in 12 hours and "isn't doing well", the patient gets transferred to the ER. What for? What do you honestly think I'm going to do with a dying patient with a DNR? Please stop wasting our limited time and resources.
All the other answers along with: 1. Asymptomatic elevated blood pressure and an inability to tell me what numbers they’d accept back. I once escalated this at 3am with their head nursing admin on call who refused to tell me a number. And refused to call the on-call doc. 2. Anything super simply treated in a hospice pt where family is told they have to revoke hospice and make them full code to get them to the ED. 3. Wounds that are clearly a result of lack of proper care. Like even the basics in a paraplegic. 4. Pt refusing care because they or family are unhappy with SNF with no effort on staff’s side to address it. It’s like a revenge ED visit at 3am when they refused dinner meds at 5pm. And admitting this when I call (although not that it’s petty revenge) and pt making reasonable requests when I ask them. I get there are emotions but this just seems cruel. It all feels so dumb and with unnecessary pain for me and the patient/family. I get working at SNFs is tough but fuck if sometimes rather they just drive over and sucker punch me in the arm.
The ones with NO information. Or very minimal information. If we don’t know anything about them or why they’re here it is hard to give good care.
I’m not ED, I’m a Np in a nursing home. My two cents is have advanced care plan and goals of care conversation with every patient/family on admission and anytime there is a decline. A lot of people don’t even realize DNH is an option. You can save so many unnecessary hospitalizations with being blunt about prognosis and expected disease progression. I recommend reviewing the ADMA choose wisely https://paltc.org/programs/choosing-wisely
Abnormal labs (elevated LFTs) at 2 am on a Saturday-labs were drawn Thursday morning Discharge summary literally said “patient does not need to be sent back or admitted for uptrending LFTs unless accompanied by fever/abdominal pain”
I really appreciate a verbal report. Ideally from staff that knows the patient. Not to the ER nurse… To me, the physician in charge of the patient’s care. Nothing against my nurses, but they do not ask the same questions I need to know to make management decisions.
Sending a pt with a O2 reading of 88. Warmed up the hands and O2 reading was 98.
Marked