What should I have done?

[kstockdaleRN]

Okay, here's the scenario: I had a 39 year old patient with viral cardiomyopathy, new onset CHF, EF of 10% on telemetry floor. He was on dobutamine at 4mcg/kg/min. Fairly stable, but as you know, EF of 10% is pretty touchy. He was already not perfusing to extremities as well, and his creatinine had gone up over the last 24 hrs. Tolerating the drip okay, and adequate urine output. VS stable. Few crackles in the bases, but nothing new or worse. I was to transfer him to a larger university hospital for, hopefully, a transplant. Our hospital is 800 bed and does everything but heart transplants. It was a fairly urgent situation, and the transfer was arranged quickly. This would involve about a 4 hour ambulance ride. I called report to the receiving RN and notified her when EMS showed up as to what time to expect the patient. The problem was - I felt that the EMS guys who picked him up were borderline incompetent. I explained the dobutamine gtt - 1000mcg per ml concentration, dose was 4 mcg, patients weight, etc. - drip rate was 21 ml per hour. They acted totally baffled. They didn't even bring plum pump tubing with them. (they were informed of the drip and cardiac monitoring before coming to get the patient) They were asking me things like "what do I need to watch for with this stuff?" etc. I realize that their training is more ACLS/emergent type protocols - but I really didn't feel comfortable entrusting my patient to these guys. However, I spent the time patiently explaining etc. I called the receiving hospital several hours later to make sure he was stable and okay. I gave EMS our number to call if they had questions. Has anyone had any experience with this? Is it even an option to refuse to hand off care to someone like this? Just wondering, and questioning myself.

[zacarias, ASN, RN]

Usually RN's ride with a pt also if they're on a gtt like that cuz too many things can go wrong. Yes EMTs/medics are trained for emergencies but a cardiac nurse is almost a necessity with drips. This guy could easily become unstable on the way, especially if it was a four hour trip!

[CathMarkRN]

Under NJ law all critical care patients must go with at least one licensed RN. Where I worked all had an extensive backgrounds. What state did this occur? If you felt the care would be inadequate maybe you should of referred the issue to a supervisor etc...

[steelydanfan]

I'm pretty amazed that this patient was on a telemetry floor to begin with. An EF of 10% is not touchy, its critical. Especially in a 38 year old.

I come from a rural background, so maybe I don't realize what happens in big cities.

I would not have let this patient leave with the personnel that you described. You realized that they were not capable of handling this situation, and in an emergency, could not have intervened appropriately.

No amount of inservice would suffice.

If anything had happened to this patient enroute, you would have been deemed liable(?)

I know the patient needed to leave for better care, but a patient who does'nt arrive can't get care at all.

CA

[rnbedone]

In our hospital an Rn that is acls certified must ride with the pt to the hospital unless the ambo has an acls certified nurse on. You have to remember to do what a prudent nurse would do.That is if you feel that they are incompetent or lack the knowledge to take care of the pt, then you should have gone or called you supervisor on the subject at hand. You are responsible if you hand over the pt. knowing that they are unable to take care of them. One word comes to mind lawsuit.