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Ambulances and RN's
We are a volunteer BLS service in a small rural town. Our town has a 12 bed Critical Access Hospital that can do basic stabilization only. Generally speaking a patient is going to be transferred if they present to ER with anything more than a minor problem. There have been occasions that the patient required medication (or might require medication) during transit, and on those occasions the hospital has sent an RN with us. Lately we have had an RN on the box with us fairly often. None of the RN's have any kind of EMS license (i.e. they are not EMT's nor Paramedics)
Is this a common practice? Are there any problems we should be aware of by allowing this? Are there any problems the RN's should be aware of?
Is this a common practice? Are there any problems we should be aware of by allowing this? Are there any problems the RN's should be aware of?
Replies to This Discussion
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Permalink Reply by Medicine Man on
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Well, yeah first of all, I dont know how they do things there, but here an RN without an EMT-P certification is pretty much useless in the back of an ambulance. They could monitor medication drips and follow any written orders given prior to hospital transfer. However they cannot operate under prehospital protocols, intubate, give med's out of the drug bag, etc. They could call for orders with the hospital, however in the arena of prehospital the paramedic would be the person performing the skill, giving the med, etc. Now if the RN is a paramedic also then that kinda changes things and they become the man/woman running the show. Best advice I can offer is check with your Medical director and your local protocol. Most RN's around here are reserved for MICU's and air transport. I am curious to know if you guys are running BLS then what medications are the RN's giving. Sounds as if they are just kinda CYA, which is not going to help if the pt.starts circling the drain. As for the RN's being aware, they should be made aware that you guys are BLS only and should not be transfering critical care pt's with a non medic nurse.
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Permalink Reply by chele on
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There doesn't seem to be anything in our protocol to cover this situation exactly. Seems we are so often put into unusual predicaments due to our remote location. We have to transport critical patients because sometimes there is no other way to do it. We use air transport as often as we can, but they can't always get here due to weather. It's usually very windy here, so a helicopter can't land. If they send a fixed wing then we have to transport 30 mins. to the nearest air strip.
It used to be that an RN went with us only during the transports to Wichita (3 hours away) to monitor IV meds, or the Doc would send a specific drug with the RN with instructions regarding admnistering it. Now the RN's have a little box of "goodies" they keep ready so they can go with us. I'm concerned there may be no written orders regarding those drugs.
My concern for the RN's is that because they are not EMS they are not exactly covered by our insurance. They are on the clock at the hospital, but will that stand up in court if something happens and we are sued since they may not be actually within the scope of their license?
I know nothing about any of this, I'm just an EMT, but I sure don't want to put any of us in jeopardy.
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Permalink Reply by Lawrence W on
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Medicine Man has your best advice: Check local protocol and your Medical Director.
In my area, a BLS unit will occasionally transport a nurse, but only to meet with the ALS equipped unit that will be performing the Critical Care transport. There is a distinct separation between hospital and pre-hospital care. A nurse is not permitted to transport a patient between facilities without being accompanied by an EMT-I or EMT-P.
Does the nurse bring along ALS equipment (heart monitor, IV equipment, IV fluid, Medications, ET kit, etc.)? Do they bring along standing orders from the facility sending or receiving the patient for their use? This situation draws many questions, and if you are concerned (as you have stated), please contact the appropriate driving policy makers to decide what is best for your patient, your volunteer company and you.
Thanks,
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Permalink Reply by Joe Stoltz on
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My thinking is that this is an interfacility transfer, not a prehospital situation. In the case of interfacility transfer, the sending facility doctor has taken responsibility for the care of the patient; made an assessment of the patient's condition; developed a treatment regimen; and instructed the RN as to this regimen. The Dr. would authorize the RN to administer specific drugs during the transport if specific conditions develop. Otherwise it would be just monitor the IV and drug administration until the receiving hospital is reached.
The RN is operating under the sending doctor's orders; the ambulance is providing the transport vehicle. I would think a paramedic could (and in many places, does) provide this treatment supervision if an RN is unavailable.
It sounds like the doctor has authorized the RNs to carry specific "goodies" to deal with certain situations. If it's anything like New York State, you can rest assured that nothing has happened without a) written orders from the doctor, and b) thorough, documented training and certification of the RN in the ability to carry out these specific orders.
As to the insurance coverage on the RN, I think the sending doctor's license is the umbrella for malpractice. For personal injury due to an accident your department's insurance would probably cover it. Good questions to ask your medical director or the chief of the hospital.
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Trust me, I plan on taking this to the EMS Director in hopes that it will be taken to Medical control. As far as I know there are no protocols to cover this situation. I've not been trained in any.
Yes, during transports from the local hospital to the receiving hospital there are generally written orders regarding the drugs.
ALS is not an option UNLESS the plane/helicopter can land. EMT-I in Kansas is nothing at all like National Registry EMT-I, I know because I am one - we are not licensed to administer nor monitor meds except the EMT-B ones.
What I should have made more clear is that the RN's have started running with us on our emergency calls. The other day one went with us to an MVA. I'm not exactly sure how that came to be, and intend to find out. All I know is she showed up at the barn and loaded into the ambulance with us. I have nothing against the RN's and in fact, the one that went with us the other day is excellent at running with us. I am afraid it leads the RN's to working outside the parameters of their license. I'm concerned it puts ME at risk as the highest EMS license on scene; i.e. is she working under my license while she is working outside the parameters of her license? If she has drugs with her, what does she intend to do with them, as there is no written order I know, and since she can not diagnose she can not administer drugs and if she can not administer drugs why is she even there? It's a big (potentially) ugly circle, and my gut says it needs to stop before we get hung.
I will be asking our Director about all this. I need to know if this is a standard practice for other departments. I need to know the legalities of allowing this. I need to know the tough questions to ask. This is CYA at it's finest about to go into action.
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Permalink Reply by anne potter on
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When a hospital transport a pt Most of them send a nurse... EMT's can't transport with IV fluids.. Atleast in NY.. The nurse transports and gives meds in the rig...They bring their equipment from the hospital.. Insurance does cover this....I once got in trouble for transporting a pt from a medical hospital with a IV because I was playing nurse at the time, we had no emt.. So I sortof went as both and thank god did not get into much trouble...Sometimes they transport with anitbiotics running ... that is a med and the emt is not able to manage that... The paramedic also cannot transport with this... That is why they send nurse.... Some states are different I am sure of that. Check and see what your state says about these situations before you reply to something you really don't know.... I know in Ny upper this is standard for this to happen .. In another state I have no ideaL
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Your right Joe in upper NY it is standard call for the hospital to send a nurse ,the hospital is responsible for that pt.. Some unstable pt's need different drugs than what a paramedic can give..So with a written order from md's.. The Rn can give.. I know EMT's can not transport with a active Iv ,saline lock yes ,but not a IV.. Alot of the services up here don't have alot of als,so they send a nurse for even a Iv's running... The Rn is still running under the hospital insurance as far as care of the pt.... Alot of hospital send lpns also as the nurse....
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Here in the Finger Lakes region of NYS a EMT-B can transport a patient with an IV in an MCI situation, but ONLY with a saline lock; the IV must be discontinued.
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Permalink Reply by Niki Hoffman on
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I can tell you from personal experience in both the hospital arena and the EMS arena that it can get alittle sketchy at times with an RN in the back of your bus that has no EMS experience. Altough the RNs that are sent should be more than capable to monitor the pts that are being sent... it isn't always the case, it may be the only nurse that could be "missed" from the floor. Putting a RN in the back of a bus with no previous experience is like asking a fish to breath out of water. We all know that anything can and probably will happen during a transport and when that happens often the RN is truly out of their element. Being one of only 2 or 3 RNs with EMS background working in a very small rural critical access center , I often would volunteer to be the RN to go on transports and was also one to be called in on days off to accompany a pt on gtts to a larger hospital. My best advice is to be completly aware of what is going with you and be upfront with your RN... let them know what you expect from them and where they can help in the event of an emergency. The pt is still technically theirs (as far as I know with Cobra laws) but they are out of their element and the will rely on you. After reading the rest of the posts.. it sounds like this is pretty common place at least in NY. And agree with Joe and Anne in their comments and statements. Good Luck.
This is info based soley on my personal experience.
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Permalink Reply by Oldman on
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This s a very common practice, especially in rural areas. The nurse is there strictly for advanced proceedures which might be needed during the transfer. Don't sell all nurses short. Many of them specialize in Critical Care and are very good at what they do. They are covered under the Chief of Staff of the hospital, and have physicians orders for their care.
A good basic EMT will use these transports as a learning tool. Pick their brains about everything from signs and symptoms, to any advanced procedures which they might might be preforming. The added benefit of these types of transports is you will get to know each other better. The more you work with a particular nurse the more comfortable you each will get. This comes in handy later as you progress in your career, they will trust your skills and knowledge more.
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If the nurse goes with pt then IV still can run??????? ...
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I have done alot of transports to upper ny hospitals where I have had the MD,REsp therapist,and a nurse with just about enough room for me..... I think at this point yea I am there for the ride..... They always treat me with respect I do the vitals and fill my PCR sheet out....
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