Question: I am asked to transport a patient to the cath lab. The new onset unstable angina patient (who is bradicardic with a lowest rate of 38 and multiple unifocal pvcs) and is only CP free because of the nitro during patch put on by the ER doctor.

Does leaving the patch on constitute me giving a medication that is out of my skill set? Since she/he is bradicardic (but has a good pressure) do I have to remove it? Do I have the ability/obligation to remove a treatment started by the attending ER physician? Escort required? Other suggestions?

 Excellent question! In terms of the patient stability and the role of including a possible medical escort, this is a real issue that you must communicate with the sending physician. You should explain your concerns regarding the patient condition; explain the limits of your scope of practice and your ability to intervene if the patient were to deteriorate.

Ultimately, the sending physician is responsible for the welfare of the patient on transport and the role of appropriate medical escorts. However, when situations have arisen in the past, crucial conversations as to the various escorts that may be available to assist you (RT, RN, MD, Ornge) have led to enhanced patient safety on transport. Your supervisor and or the Base Hospital Physician may also be a useful resource if you are confronted with a transport where you feel the patient may benefit from an enhanced scope of practice. The Base Hospital will stand behind you in addressing safety concerns you may have when asked to transfer an unstable patient you feel requires additional medical escorts.

To answer your specific questions, no, transporting a patient with a NTG patch does not constitute you administering a medication that is out of your skill set. In your example, this medication was prescribed by the sending physician and they are the most responsible for the welfare of this patient and the safe administration of this medication.

You do not have to remove the NTG patch because the patient's vital signs fall out of the parameters whereby you are authorized to administer NTG spray. The attending physicians are not required to follow the same indications and contraindications however are responsible for the safety of their patient. Voicing your concerns and explaining the limits of your scope of practice is an essential communication that should take place and a medical escort may be indicated.

You are not obligated and nor should you discontinue a medication that has been ordered for a patient by an attending physician. Again, if you are concerned about the appropriateness of that medication, you should highlight your concerns in a non-confrontational manner in the interest of patient safety.

Miscellaneous,Policy/Procedures

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