With Emergency Departments becoming increasingly crowded and extended EMS wall time becoming more common, I raise the question should EMS ever bring their equipment into the hospital to treat their patient while waiting for bed assignment and transfer of care? I am not talking about continuing treatments such as oxygen or a medication drip started in the ambulance. I am talking about new treatments you would start in the ambulance if your transport was continuing for another 20 minutes. Patient suddenly feel nauseous? Give them some Zofran. Ten minutes since the last aliquot of fentanyl, give them another 50 mcgs. Patient starts seizing again, give them some Versed. But if you are in the triage line instead of in your ambulance, can you do this (inside a hospital) without creating a major incident?
I confess to, on several occasions, remedicating a patient with fentanyl while in the triage line. I happened to have my controlled substances kit on me and I always keep a spare syringe, needle and alcohol wipe in my pocket, so it wasn’t too hard to do. I did it quietly. The patient appreciated it.
Once I had a patient start seizing and I told the triage nurse (who was slow to respond to the incident) I was going to give the patient some of my Versed unless the triage nurse immediately sent us to a room with a medical alert. I even had my kit out, but she said I couldn’t administer the drug because I didn’t have an ambu-bag. I said I was going to do it anyway as the patient was shaking so hard I thought he would come off the stretcher. I assumed somewhere in the ED there was an ambu-bag if needed to breathe for the person should the drug temporarily knock out their respiratory drive. She got us a room quick, but I still think I should have just hit the patient there with the Versed. The sooner you stop a seizure, the easier it is to stop. Someone goes into cardiac arrest in the triage line, I am going to start doing compressions. No hesitation. Isn’t giving Versed for a violent generalized seizure similar?
In the ambulance, we have access to all our gear. Not so against the hospital wall. I recently had a patient who I sedated for violent agitation. The patient was alert and oriented on scene, but in severe drug withdrawal. I initially just BLSed the call, as he was a difficult patient, crying and scratching himself and moaning. A few minutes out from the hospital, he started banging his head against the cabinets, so unable to stop him from banging his head or kicking me, I gave him 5 mg of Versed IM. He was calmer, but still talking to me when we came through the ED doors. I had to leave his side to go give a report to the nurse. When I came back five minutes later he was snoring on the stretcher with declining SATS. I had an oxygen tank on the stretcher, but no oxygen supplies. No suction if he started vomiting.
In an ideal world, you radio the hospital ahead of time, and then you come through the doors and go directly to a room where a nurse is waiting for a bedside report, and a doctor is there too (if the patient meets a certain acuity). That rarely happens anymore, except with the most critical patients.
I know ED nurses work hard and are short-staffed. I just don’t like being in a position where I have to leave my patient’s side for prolonged periods to give a report to someone who is not laying their eyes on my patient and I don’t like not having access to my gear if my patient’s condition evolves before I have properly turned over care with a face-to-face bedside report..
Time of turnover is much different in real life than what is likely reflected in a patient’s chart. You back into the ambulance bay at 12:00. You go through the ambulance doors at 12:02. You get registered at 12:10. You give a report to a nurse at 12:20. You put a patient in a bed in the hallway at 12:30. The patient is not getting EMS level or ED level care in that half hour in between.
As an EMS Coordinator, I get sometimes complaints from the ED staff about EMS leaving patients in conditions far worse than they described in their radio patch or report to the nurse. I have the EMS run form to read and I have the ED chart to read. They describe two different patients. If I wasn’t still working on the road, I might side with the ED more than with EMS, but as an EMS worker, I bring that experience. Sometimes the patient’s condition changes in the five, ten, fifteen, twenty or more minutes between ambulance arrival and ED assessment.
Fortunately I work in a smaller hospital, where while very busy, the EMS waits are not nearly as long as at larger area hospitals. I also work in a state which typically doesn’t have the excessively prolonged EMS wall times that other states I hear about do. But you never know what the future holds. I don’t like the way it is trending. ED staffing is stressed both from facility cost-cutting and staff burnout. I’ve been holding up the wall lately more than in the past.
I wonder what the triage nurse will say if next time along with my patient, I bring in my over the shoulder medical pack with drug, IV and oxygen supplies along with my portable suction and a spare oxygen tank.
I sit on our regional medical advisory committee. I am going to formally ask this question at our next meeting. It should be an interesting discussion.
Update: Initial discussion was indeed very interesting. While we are going to chesk with other states to see if they have written protocols for these situations, there was a pretty unanimous view that EMS should do what they feel is best for the patients. If that means medicating someone having a seizure while in the hospital prior to transfer of care, then so be it.