By: Darrell Bardua
As EMS Off-load delays in the emergency department continue to plague systems across North America and beyond, are we prepared to meet the demands of our patients in this setting?
Most paramedics are clinically prepared to manage patients in the hallways of emergency departments. However, there are more than just clinical implications. A new set of skills is often required to get through these extended delays in the transfer of care. Many of these skills involve common sense and using the “soft skills” that all good paramedics possess. Unfortunately, we need more than good communication skills, such as knowing how to interact with the diverse community of patients we face each day. We also need specific skills we do not focus on during our education and training. There are also system issues that can be barriers to being effective in this setting.
Urinals and bedpans
Sure there are urinals and bedpans in the ambulance, but many of us pride ourselves for not having to use them very often.
There isn’t very much room in the back of an ambulance for number one and even less for number two.
Trips to an actual washroom in the ED are a treat in comparison. However, those patients who cannot ambulate find themselves using urinals and bedpans in some very odd spots while still on ambulance stretchers. The other day I watched a crew escort a patient on the stretcher into a custodian supply closet for some privacy to use the urinal. Last week a crew used one of the family rooms, which is private but not well ventilated. I know paramedics can struggle with these situations.
But this is not the experience we had hoped to provide patients with.
Extended psychiatric care
In some cases, paramedic crews are asked to remain with certain psychiatric cases that cannot be safely transitioned to the ED waiting room. Many of these folks were difficult to convince to come to the ED and now the skills to keep them there are often exhausted. Most EDs only have so many spots to utilize for the uncooperative patient. When there is a delay in the transfer of care that means there are no rooms in the inn.
Recently I watched a paramedic work the “stick around and get seen” routine with a manic patient for a solid two hours. I wandered by to lend some support between tasks and by the end of the experience we were restraining the patient and administering Lorazepam and Haloperidol.
The frustration in the paramedic’s voice was unmistakable as he explained the situation to the emergency physician who came down to lend a hand. It was an unusual tone for someone I interact with on a regular basis. As he left the ED an hour or so later, I sincerely wished for him some simple experiences on his remaining runs for the night. You cannot always reset your patience after it has been tapped into for an extended period.
Palliative care and monitoring
A paramedic shared with me the story of bringing an elderly patient into the ED for failure to thrive. There were conflicts between the family members on scene regarding the resuscitation status. The crew left for the ED as they were not concerned the patient would require any aggressive interventions based on their current assessment. Four hours later in the hallway the patient deteriorated and the do not resuscitate (DNR) discussion needed to be clarified in a busy ED hallway.
The discussion moved out to the ambulance bay, which is of course a lovely setting for such a dialogue. A comfort care DNR decision was arrived at and the patient later died prior to placement in the ED. It wasn’t the perfect situation but a reality of a busy ED with patients of higher acuity needing the space.
Managing pain is an issue many paramedics are seeking consultation on as they wait for extended periods with limited options to manage some types of pain.
Very few EMS services have the same access to medications that an ED has, so it is not uncommon for a crew to request the ED staff become involved and make available further treatment while still under the care of paramedics.
This presents all sorts of circum- stances that vary widely from one service to another. I have heard tales where the paramedics’ Online Medical Control will not support them once inside the hospital and the ED will not write orders until a formal transfer of care had taken place. Can you say “limbo?”
This should not be a true story—but it is. Some medications are outside the scope of the attending paramedic staff so it is not reasonable to offer this option if ED staff are not assigned to the patient yet.
Some settings are more patient-focused and better options have been found for this type of EMS hallway medicine to work.
I am familiar with some ED staff who are more than happy to write an order for a medication not typically carried by the paramedics, but is the right drug for the current situation, and the crew manages their care in the interim.
These are simply a few things paramedics are faced with during delays in the ED. Patients need to eat, make phone calls, and our stretchers are not designed for prolonged periods so moving them often and into different beds is necessary.
Portable oxygen supplies, unique ways to hang fluids from areas with no IV poles, 12-leads in closets, finding a place for the family to sit (never mind a spot for you— after all steel toe boots are great for a day on your feet in the ED)—these are all realities when there is a delay. Some situations have no simple answer.
Hang in there
EMS Hallway Medicine needs to be included in the next new classroom Power- point lesson.
I highly recommend reviewing cases that go poorly in rounds so we all can learn from your experiences; invite some of the ED administration to listen in. Hang in there gang. I realize these are some of the longer shifts at work.
Don’t forget—it is still important work and when done well it is appreciated by patients, families and your colleagues.
Let us pray that the delay in transfer of care in EDs is a problem that can be resolved before we see a chapter in textbooks on EMS Hallway Medicine.
About the Author
Darrell Bardua has been involved with EMS for 20 years with experience in both rural and urban EMS settings. After many years as a front line Operations Supervisor with EHS in the Halifax Regional Municipality he has returned to his clinical roots and is presently working as an Emergency Department based Paramedic with Capital District Health Authority in Dartmouth, Nova Scotia. Darrell is also involved with the developing NS College of Paramedics and is a member of the faculty at the Maritime School of Paramedicine. In addition, Darrell acts as a
co-section editor for the Evidence Based Proto- col Project coordinated through the Division of EMS at Dalhousie University and is an advocate for increasing the body of research in EMS