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?

0 members like this

▶ Reply to This

Replies to This Discussion

Permalink Reply by Ben Waller on August 6, 2008 at 10:06pm

Here's the bottom line on interfacility transports...it's spelled E-M-T-A-L-A.
That's the federal law that among other things makes the patient the transferring phyician and hospital responsible for the patient until care is transferred to the recieving hospital and physician. The standard is that the patient is supposed to get the same level of care during interfacility transfers as they do in intrafacility transfers.

How many times have we seen the hospital send a RN, a tech or orderly, and a respiratory therapist just to take the patient upstairs to the ICU via an elevator...but the same hospital thinks nothing of sending an even sicker, more critical patient an hour or two away in an ambulance with a single paramedic or even EMT-B in the back? EMTALA sez that's a big no-no. Common sense does, too.

In most states, the RN is a higher level of certification/licensure than paramedic, and it's definately a higher level than EMT-B. More importantly, if the patient has recieved RSI, is on a specialty ventilator, is recieving drugs the EMS system doesn't carry, or has other specialty equipment like an isolette, then the hospital is obligated to send people that are trained and certified to use those specialty drugs/equipment with the patient. The EMS crew is still responsible for operating the vehicle and any onboard systems including their heart monitor, oxygen system, suction, electrical power, etc.

The answer is teamwork and training.

Unfortunately, there are hospitals out there who have patients they can't handle, and they just want to make it someone else's problem...quickly. When they send a patient out without staff qualified to care for the patient's needs - all of his/her needs - then they're not getting rid of the responsibility or legal liability. They just got the EMS system to share in any liability that pops up and created more defendants for the civil case.

If you transport high-risk OBs, critical neonates/preemies, or ventilator patients, you should be taking hospital personnel with you unless you run a well-equipped CCEMT-P unit. If the hospital personnel aren't comfy with this, the answer is some joint training on the types of critical care patients that are your joint problem...prior to the next interfacility transport. We pound training here in the Nation all the time...how about we extend that training to people from outside our agency that we're inevitably going to work with sooner or later?

▶ Reply

Permalink Reply by Jim on September 5, 2008 at 8:40pm

When we were a county service we were bls w/IV and mast cert intermediates. We took nurses on any als transfer and never had a problem. Since the hospital took the service over we are running paramedics and full mod I's and the nurses only ride if we need the extra hands. As far as liability goes the medical director for the abulance service and the hospitals medical director, if they are not the same person just need to come up with memorandum of understanding that covers the nurses on the transfer. The biggest liabilty comes from having a non-ambulance personnel riding in the back should there be a crash.

▶ Reply

Permalink Reply by Jay Nicholson on September 5, 2008 at 11:14pm

Way back when, as an EMT-B we were not allowed to transport pts. with any meds on board. This included asprin. So if a pt was to be moved between facilities, a Critical Care Nurse came along. That was the law and protocal here. Your state and county may be different. They were in charge during the transport, but if another emergency call came in, we were in charge. The logic was who do you want in charge. The EMT trained in emergency care, or the phyciatrist MD.

▶ Reply

Permalink Reply by Mike Schlags (Captain Busy) Retd on September 5, 2008 at 11:15pm

this is not the type of post that I enjoy reading... I started in 1973, if you are called oldman, then what about me? yikes!!!

▶ Reply

Permalink Reply by Mike Schlags (Captain Busy) Retd on September 5, 2008 at 11:38pm

Having worked as a certified mobile intensive paramedic in the early 70's, when the EMS experience was just starting, I continued my certification until the mid-80's when I moved over to the world of hazmat. I had a fairly myopic opinion of what a nurse could do. At that time, I would have easily sided with one of the comments on this blog that nurses are like a fish out of water when it comes to handling an EMS situation. This is far from accurate.

And how do I know? Well... I helped my wife go through the RN program at the local community college and when she left the program, she went right to the emergency room where she certified in ACLS, PALS, TNCC, Triage 1st and AHLS. I know what she had to memorize, perform and act upon, all the time comparing it to my experiences as a paramedic, certifying in Los Angeles County when the TV show EMERGENCY! was a hit.

So when you are speaking about a nurse that is outside of his or her environment, you have to be specific about what kind of nurse you are talking about. Comparing a nurse who works in ICU, CCU or the Emergency Room to a nurse in a doctors office is apples and oranges. And if you are considering looking at the top of the emergency medicine food chain, then anyone who works as a flight nurse should be considered the very best. Only these nurses with a minimum of 5-7 years critical care experience can even apply to get on the medivac helicopters. These specially trained RN's are allowed to do RSI for example when dealing with severe head injuries or other situations that dictate knocking out the persons respiratory drive. Paramedics are not allowed to do things like central lines, cardiac pacing, RSI to mention a few. Typically, it's nurses who train paramedics anyway. There is no situation where a paramedic has more education or capability than a certified registered nurse working under a doctors orders.

Regardless of the discipline that the nurse specialized in, compared to any EMT, EMT-B, Paramedic or in some cases even doctors, no one can touch the assessment skills that nurses are taught now. Nursing programs require rotation through all of the departments so even new grads have a fairly competent background when it comes time for patient care and assessment. Rules, regulations and a physicians orders dictate what a nurse can or cannot do. To not follow these orders could mean the nurse losing his or her license. These nurses won't have a clue about extrication or some of the equipment that we use but when working together as a team, you can easily couple your expertise with the nurse riding on your bus to ensure a successful outcome for your patient(s).

Finally, nurses on ambulances in my county is common place because all patients transported by one of the medivac helicopters require the flight nurses to stay with the patient until they turn over the patient to an equal or higher source of care. A nurse cannot hand over a patient that they have cared for to a paramedic.

▶ Reply

Permalink Reply by Phil Ferris on September 6, 2008 at 4:01am

Michael you have made very valid points. My health care career started in an advanced first aid course in 1977. Since then I have continued my education through EMT and Paramedic to Registered Nurse. I have worked in some aspect of critical care nursing for 23 years both in the intensive care unit and in the emergency department and I still maintain my Paramedic certification. What a nurse or paramedic can or cannot do in the back of an ambulance may be dictated by that particular state’s nurse practice act and/or EMS legislation. For example, in Pennsylvania when I am working as a Paramedic I can only administer medications and treatments that are on the states approved EMS list. Just because I have experience with cardizem, I cannot administer that drug when working as a Paramedic. Vice-Versa just because I intubate patients in the field, the hospital says no I can’t do it when I’m working as the nurse. So there are a lot of different factors to think about. The important thing to remember is the well being of the patient. In many cases a paramedic and a nurse can make a great team on inter-facility transfers.

Now responding to emergency incidents can be a little sticker in my opinion. I think the nurse must have some kind of critical care training with ACLS, PALS, etc along with EMT style training to learn the skills needed for extrication, scene safety, emergency vehicle operation, etc.

That is how I see it folks.