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...

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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 can not 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.

Pain management

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 circumstances 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 Powerpoint 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.

In today's world we are connected, whether we like it or not. Technology plays an increasing role in what information we receive and what information we distribute.

In 2006 I attended a conference where a speaker declared technology is going to shape our destiny. He continued...

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In today's world we are connected, whether we like it or not. Technology plays an increasing role in what information we receive and what information we distribute.

In 2006 I attended a conference where a speaker declared technology is going to shape our destiny. He continued by telling a story of his then 16-year-old son who was up in his room doing homework. As his dad poked his head in the door he was amazed how "connected" his son was. With ear buds in his ears for his iPod, his computer on in front of him, cell phone on his right and text book across his lap, he was doing his homework.

"How might you be doing homework?" asked his father.

"It's easy dad," came the reply. "Jeremy posted the answers to the first question on his Facebook page. Amanda and John are texting me the solutions to the problems I missed because of practice. Wait - Justin tweeted me to check out a website for the rest of the information."

In amazement, his dad turned and left the room. This same speaker made a striking revelation I still vividly remember: "People born into the world today will have access to more information in 12 hours than their grandparents had in a lifetime."

Think about it, my grandparents came to Canada from Europe as Ukrainian immigrants. They came with a steamer trunk of possessions on a ship that took weeks to get to Canada. When they arrived they then took the train west. Arriving at some distant point, family met them with a horse and buggy to ride to the farm some hours away. Likely telephones were scarce and communication via mail took weeks.

Today, from our BlackBerry we can read today's paper on the morning commute to work. We can text a colleague at a meeting or get instant messages on the latest sports scores. We watch video of the war halfway around the world in real time. Streaming video of anything else is at our fingertips. Today we are connected. Tomorrow, who knows?

A quick visit to YouTube with the search "ambulance crash," "paramedic" or just about anything else will yield countless videos of humour or embarrassment. We take note of the ambulance collision and quietly mutter, "Thank goodness it didn't happen to me."

The downside of social media

With bystanders with cell phone cameras or paramedics with access to personal cell phones during shifts, things are shared for the good or bad. Take for instance the cell phone pictures taken by a colleague while at work of a fellow crew member sleeping in an easy chair while at work. Innocent in thought, posted on their Facebook page, these images are shared with hundreds of friends or millions of viewers and are a total embarrassment for your agency.

Take for instance cell phone pictures taken in an emergency room of a nurse celebrating her birthday - a couple of colleagues together, smiling. The pictures get posted on Facebook but in the background the patient board can be clearly seen of who in the emergency room is having what done. Social networking can be a curse and media nightmare for your public affairs department.

While on some downtime at a standby or staging for police, a paramedic texts a friend to say what they are doing. Maybe the friend texts back: "Sounds pretty boring." The reply is: "Sure is...the boss makes us do this s**t all the time."

Now friend X updates his Facebook page to tell his friends what's happening and the paramedic's comments might end up on that page too. Sounds like a pretty disgruntled employee who lacks a lot of professionalism and doesn't give a care what they might say or do.

What about another employee who shares highlights of a recent ambulance call?

Names and location are omitted but it's a humorous example of what might be called "stupid people calls."

What if the information gets shared beyond the two people? What if that work e-mail now goes outside the work environment into the world of public? What if someone takes offence to the comment and posts to their Facebook page. It is so easy for what seems like a random funny to be moving the cyberspace world in places you never thought of!

If you don't want to be tomorrow's front page, then don't say anything. If you don't want to be sitting in the boss' office reading your comments, don't type them. It's one thing to say something. It's another to print it for the world to see.

Does your organization have a social media policy? What prevents an employee from taking pictures at a motor vehicle collision and sharing them on their Facebook page? In Saskatchewan, the Health Information Protection Act (HIPPA) protects the client's personal health information. In essence, HIPPA ensures that your private and personal medical information is not just shared with anyone but only those who have a need to know.

Drafting a social media policy could protect your agency

So what might a social media policy look like for an organization? If we develop one, how do we enforce or control the activity?

First, there needs to be some education on professionalism for the employee. Professionalism is a tall ladder to climb as paramedics everywhere seek to be recognized amongst other colleagues or professions. As a young profession, EMS continues to evolve and, not without some bumps in the road, elevate itself to a professional stature.

Just in the way Twitter and other social networking sites can spread the news, so too can you quickly find a policy tool to draft a social media policy. The policy below is taken from Policy Tool – Policy for the Masses. Visit socialmedia.policytool.net to see a sample. (For space in this article, the sample policy has been edited.)

My Ambulance Company

Social Media Policy

This policy governs the publication of and commentary on social media by employees of My Ambulance Company Ltd. and its related companies ("My Ambulance Company").

For the purposes of this policy, social media means any facility for online publication and commentary, including without limitation blogs, wikis, social networking sites such as Facebook, LinkedIn, Twitter, Flickr and YouTube. This policy is in addition to and complements any existing or future policies regarding the use of technology, computers, e-mail and the Internet.

My Ambulance Company employees are free to publish or comment via social media in accordance with this policy. My Ambulance Company employees are subject to this policy to the extent they identify themselves as a My Ambulance Company employee (other than as an incidental mention of place of employment in a personal blog on topics unrelated to My Ambulance Company).

Before engaging in work related social media, employees must obtain the permission of the Big Bad Boss.

Notwithstanding the previous section, this policy applies to all uses of social media, including personal, by My Ambulance Company employees who are Managers and Supervisors, as their position with My Ambulance Company would be well known within the community.

Publication and commentary on social media carries similar obligations to any other kind of publication or commentary.

All uses of social media must follow the same ethical standards that My

Ambulance Company employees must otherwise follow.

Setting up social media

Social media identities, login IDs and user names may not use My Ambulance Company's name without prior approval from the Evil IT Person.

Don't tell secrets

It's perfectly acceptable to talk about your work and have a dialog with the community, but it's not okay to publish confidential information. Confidential information includes things such as unpublished details about our software, details of current projects, future product ship dates, financial information, research and trade secrets. We must respect the wishes of our corporate customers regarding the confidentiality of current projects. We must also be mindful of the competitiveness of our industry.

Protect your own privacy

Privacy settings on social media platforms should be set to allow anyone to see profile information similar to what would be on the My Ambulance Company website. Other privacy settings that might allow others to post information or see information that is personal should be set to limit access. Be mindful of posting information that you would not want the public to see.

Respect copyright laws

It is critical that you show proper respect for the laws governing copyright and fair use or fair dealing of copyrighted material owned by others, including My Ambulance Company's own copyrights and brands. You should never quote more than short excerpts of someone else's work, and always attribute such work to the original author/source. It is good general practice to link to others' work rather than reproduce it.

Respect your audience, My Ambulance Company and your coworkers

The public in general, and My Ambulance Company's employees and customers, reflect a diverse set of customs, values and points of view. Don't say anything contradictory or in conflict with the My Ambulance Company website. Don't be afraid to be yourself, but do so respectfully. This includes not only the obvious (no ethnic slurs, offensive comments, defamatory comments, personal insults, obscenity, etc.) but also proper consideration of privacy and of topics that may be considered objectionable or inflammatory, such as politics and religion. Use your best judgment and be sure to make it clear that the views and opinions expressed are yours alone and do not represent the official views of My Ambulance Company.

Think about consequences

For example, consider what might happen if a My Ambulance Company employee is in a meeting with a customer or prospect, and someone on the customer's side pulls out a print-out of your blog and says "This person at My Ambulance Company says that product sucks."

Saying "Product X needs to have an easier learning curve for the first-time user" is fine; saying "Product X sucks" is risky, unsubtle and amateurish. Once again, it's all about judgment: Using your blog to trash or embarrass My Ambulance Company, our customers or your co-workers is dangerous and ill-advised.

Disclaimers

Many social media users include a prominent disclaimer saying who they work for, but that they're not speaking officially. This is good practice and is encouraged, but don't count on it to avoid trouble - it may not have much legal effect.

Wherever practical, you must use a disclaimer saying that while you work for My Ambulance Company, anything you publish is your personal opinion, and not necessarily the opinions of My Ambulance Company.

The Director of Public Affairs can provide you with applicable disclaimer language and assist with determining where and how to use that. This is but one abbreviated example of a policy an organization might choose to engage in. It doesn't need to be complex but use of company proprietary and confidential information outside of the corporate environment is likely grounds for dismissal.

Trust is both ways, but trust is also earned not given freely.

As employees have access to work computer terminals, wireless Internet, BlackBerry and other hands free devices, the world is literally at their fingertips. How we manage the world and encourage communication is the challenge.

What's your current position?

I am the senior director of the Sunnybrook-Osler Centre for Prehospital Care (SOCPC). Our organization operates the base hospital for a large region in south-central Ontario, as well as the province's Emergency Medical Assistance Team (EMAT)...

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What's your current position?

I am the senior director of the Sunnybrook-Osler Centre for Prehospital Care (SOCPC). Our organization operates the base hospital for a large region in south-central Ontario, as well as the province's Emergency Medical Assistance Team (EMAT). This is a multidisciplinary field hospital staffed with over 130 professionals, capable of deploying anywhere in the province within 24 hours from notification.

When did your first job commence as an EMS professional?

I hit the streets as a paramedic in May 1982 after graduating from the Ambulance and Emergency Care program at Centennial College. I had a number of places where I could have started my career, but the chance to work in Toronto was something I could not turn down. I was impressed with the innovation and dedication I saw from the leadership at Metro Ambulance. To some degree I was hedging a bet that if advanced paramedicine ever came to Ontario, Toronto would certainly have a program.

Why did you decide to pursue a career in EMS?

I was first turned onto the idea by the television show, Emergency. Yes, I admit it. I started to explore the profession more directly when I visited a local ambulance station a few years after a bus-train collision that occurred near my home over a level crossing. I recall driving past the accident with my family watching some of the frantic rescue efforts. I was hooked.

Who was the biggest inspiration to you when you were first starting in EMS?

There were many, however one does stand out. Paramedic Don Reid was my first partner on my first day. He is a dedicated and patient-centred paramedic who really loves the job. This was evident to me on my first day and again some nine years later when I became an Advanced Care Paramedic (ACP). Don was my first preceptor! He gave me what I feel is the best advice I could have ever received - every patient is sick until proven otherwise.

Please provide a brief description of your career.

I worked as a paramedic with Toronto EMS for the first 18 years of my career, and the last eight as an ACP. During the time that the program was expanding in both the city and the province. I left TEMS in 2000 for a position at the Sunnybrook Base Hospital where I continue to work today (now known as SOCPC). I have been fortunate to have experienced a number of roles there including managing the ACP program, clinical coordinator, senior manager and now as the senior director responsible for the organization. The base hospital structure has changed significantly over the past five years, resulting in seven large regional programs (reduced from 21). I had the honour of serving as the chair of the province's base hospital group during the transition process. As I noted earlier, SOCPC was selected to operate Ontario's EMAT team in 2009.

I decided to enter the politics of EMS when I became president of the Toronto Paramedic Association in 1995. I served during a time when the paramedic program was undergoing significant change, and my position afforded me the opportunity to represent interests of the profession in the city's council chambers. In 1999 I was elected president of the Ontario Paramedic Association where I served until the fall of 2006. During my tenure I was proud to lead Ontario's paramedics through a controversial debate concerning the potential creation of a regulatory college for our profession. After years of discussion, stakeholder involvement, town hall meetings across the province and political lobbying, I was pleased to see our Minister of Health ask for a review of the regulatory process for paramedics to consider if the creation of a college is in the best interest of our patients and profession. The evaluation process is underway, and we hope to hear the results soon.

I firmly believe the most important role for any paramedic is to share your experience and knowledge through education. I have enjoyed being a preceptor, education lead, and part-time faculty member at community college paramedic programs.

What is your most memorable situation while on the job?

While the outcome was unfortunate for the patients and family, during my preceptorship as an ACP, I attended a double drowning involving two infants. My newly developed skills were put to the test as we (yup, Don Reid was the lead medic on this call!) attempted to resuscitate the infants. I mark this call as the moment when my confidence began to grow. Since the case received widespread media attention, the importance of an ACP program to a community was really crystallized in my mind.

I have to mention one other situation that provides me with a positive memory. Following a successful resuscitation, I visited the patient and his family some days later in the hospital. While I was fortunate to have had a number of similar opportunities, this was the first for my partner, who was early into his career as an intermediate level paramedic. Following our visit we headed back to our medic unit. I noticed that my partner was quite emotional. He said: "That is why we do this." He was right.

What's the biggest challenge facing EMS today?

We remain a young profession, but I am amazed at how quickly we have developed. Our true identity remains our greatest challenge. We need to continue to discuss where we want to fit. In other words, are we health care or public safety? Each has advantages, however the fact that EMS tends to shift between both worlds makes it difficult for us to find a home. Despite this we have moved forward in a very positive sense without really resolving the question. This leads me to believe that we are, in fact, the hybrid between the two. If true, it is exciting that we are carving out our unique place.

If you could change one thing in EMS, what would it be?

Despite some substantial progress, paramedics remain generally disconnected from research. Sure, there have been some incredible success stories. Nova Scotia has emerged as a leader, and we now have a number of paramedics who have published as principle investigators. However, the importance of demonstrating that paramedics can successfully participate in clinical trials cannot be understated.  Academic leaders, policy makers and the public expect health-care professionals to continuously look to how we can better serve - and save - our patients.

What's your favourite tool/technology available to EMS professionals and why?

I look forward to the continued integration of data collection tools and biometric devices. Paramedics of the (near) future will be able to work with fewer devices, while collecting real-time data that provides the kind of comprehensive information necessary to make even more sophisticated clinical decisions.

What does the future of EMS look like?

Paramedicine was once defined by a skill set. The tools of the trade were, in many ways, the headline while the professionals using them were just part of the story. This is changing. Paramedics are emerging as true clinicians. This is providing us with new opportunities to help our communities in terms of community medicine projects, destination bypass decisions, and the management of complex illnesses. If we continue on this trajectory, our future is bright.

Paramedics see a lot of strange things in their work. What's the funniest thing you've witnessed in EMS?

There are a number of "40 station alumni" who are wondering what the answer to this question will be! Let me just say that the best thing that can happen to a paramedic is a great partner who can keep things light, and in perspective. I've been blessed with some great ones.

What do you do when you're not working?

I enjoy spending time with my wife, Grace and son, Jonathan. I play some golf (or some unreasonable facsimile), and dabble in amateur astronomy.