Critical Care Transports

[nremtp78]

With the recent distinction of Critical Care Paramedic, many services around my State (especially the rural and non-metro ones) have given thought to how they handle "critical care" transports.

Situation: Patient in rural hospital needs transported to urban hospital, but pt is sedated and intubated, has a chest tube in place, and is on a ventilator with PEEP of 15. Your state scope of practice says that Paramedics are only authorized to manage PEEP of 8 and they are not authorized to monitor placed chest tubes. The only helicopters in your area are out of service. How do you transport the patient to his destination?

Some places around here would take the patient with a paramedic attending, put a PEEP valve on their bag, and hope nothing goes wrong with the chest tube. Other places would just grab an RN who was willing to go and throw her in the back, regardless of whether or not she is familiar with the things in question. Our state does allow for an "RN Exception" to account for situations like this, but only certain RNs qualify. Quite a few legal issues at work here, but so far, I guess nobody has died (or at least no questions have been raised from their families).

I am just curious as to how this kind of thing happens in other areas and what your state/county/etc laws actually say on the matter.

[SilverCity4]

How do you transport the patient to his destination?


You don't, without trained personnel. It's not a very popular decision to make but the patient is better off in the rural hospital with a doctor and a couple of RNs rather than in a truck with undertrained medics (usually).

A RN riding along is a great idea, but if the RN hasn't been trained in the use of the equipment, what good are they? I'd think your butt would be hanging out just as far with the untrained RN as without.

Same thing with the chest tube or anything else that's out of your scope of practice.

I work for a flight service and we staff a MICU 12 hours a day. When the aircraft is out of service, the truck is up 24 hours a day. If both vehicles are out of service, then we've worked out a deal with Tulsa's EMS to provide a driver and a truck that picks up our crew for critical transports. The EMS service that serves the receiving hospital can probably pull a similiar arrangement with a mutual aid agreement.

[smurfe]

You should not take these transfers if you are not authorized to. Most people forget that in hospital to hospital transfers, it is the transfering hospitals responsability to ensure adequate patient care, the ambulance is technically for transportation. If you have that RN onboard, they are the ones ultimently responsible for that patient. If this is a common practive where you work, you should campaign to be trained in these issues and authorized by your state to carry out these procedures. When I was an equivelent to a Critical Care Paramedic in Illinois, we were trained in such procedures and various drugs outside our normal scope of practice. We were tested to assure compentancy and paperwork was filed with the state to be authorized to carry out these procedures. Work with your local hospital, EMS system and State department of EMS. You will be suprised what can be done and changed for you.

Smurfe:D

[RoryEl]

You should inform the transfering RN that this is outside your scope of practice. It's both of your *sses if the patient goes south, popps another pneumo, etc. and someone decides to look into what happened. The hospital dictates who is called for transfers, but the RN is responible for delegating care to you and should be aware of your qualification before transfering. Once care is transfered to you, your responsible for that patients care and that responsibility is relieved only opon your transfer to the receiving facility. If its outside your scope of practice, spell out the problem and maybe the PEEP can be decreased provided complinace isn't too high-doubtful at 15. If this can't be changed, then refuse to accept the patient to the nurse and tell them it would be an improper delegation. I'll be they will act quite different when they realize it's thier license on the line here too.

[Toering]

Interesting topic. If any one is stupid enough to take a pt. that has anything that he/she is not familiar with should not be a paramedic at all. Are you really doing the pt any good by not providing the care they need. Grab an RN and CYA (cover your *****)! Make sure you don't act tough and tell or act like you know what your doing when you really don't because in the long run you'll look like a fool.