The Nether Zone

On TV, the paramedics are met at the ambulance bay by at least two doctors who ride the rails as the medic gives the story. The patient is moved over to the hospital bed where a team of ED staffers are ready to go to town in a seamless continuum of care.

Sometimes this mirrors real life. Except for the two doctors running alongside the stretcher.

Too often, however, I find there is a significant interruption in the care continuum. There is a nether zone where the patient who has been getting fully attended care is no longer being seamlessly cared for.

While some of this is hospital dependent, I don’t believe any hospital is immune to it.

Here are some examples.

The triage line: While you wait to be triaged, the patient’s breathing treatment runs out, their pain medicine starts to wear off, they are due for their next nitro, or perhaps they start seizing. Unless you bring your gear into the hospital, there is a gap in care.

The hallway: Your patient is left in the hallway or placed in a room, and they throw up or they need to be suctioned. If you are in a room, at least you can use the in-room suction. If you are in the hallway, and can’t shout for someone to bring you an emesis basin, you need to think fast and grab a towel or something else to try to contain the splatter, and hold them on their side to protect their airway.

The code room: The staff is there, but monitors need to be switched, tubes reconfirmed. The dopamine gets shut off and not restarted. The pacer is disconnected. The doctor is still trying to figure out what is going on. The patient maybe has gone back into arrest. An IV line is pulled out by overanxious ED staffers. No one is doing CPR or maybe the ED staffer doing it has not had the latest ACLS push hard, fast and deep lecture.

Many people believe that once you enter the hospital doors, you are no longer in charge of your patient. The problem with that thinking is who is in charge of the patient? They are in the nether zone where they may be under the care of the hospital, but have not yet been placed in the care of a medical professional with the available equipment to properly treat them.

We don’t turn off the 02 when we enter the hospital’s doors. We don’t shut off our running IV lines. We don’t turn off our heart monitor. We don’t stop doing CPR as we roll down the hallway. I argue that we should continue to care for the patient, including bringing our equipment into the ED until the ED is ready to assume complete control and care for the patient.

If we are in the triage line and our patient with CHF needs their next SL NTG, we should give it to them. If their pain scale rises back up because the fentanyl is wearing off, we should redose them (I usually redose in the ED parking lot to avoid this). If they start seizing again, we should be ready to hit them with our Versed. If our patient is post cardiac arrest, we should keep them on our monitors, and our drips running until we are sure that the receiving MD is fully aware of the care we are providing and is ready to assume seamless care. If we are doing CPR, we should insist that proper CPR and rhythm checks and defibrillations are done until we are satisfied proper transition has occurred. If it is time for the next epi, we should give it until the ED is in position to have their drug cart open and drug in hand be able to give it. We are responsible for our patient’s care and for an orderly transition to the hospital’s care. If we do not feel the transition offered is acceptable, we need to advocate for our patient. If we think our patient is too unstable to be left alone in a back hallway we need to make that clear. If a nurse is too busy to take our report, and we feel the report needs to be given, then we have to either find a doctor to give the report to or insist to the nurse that the report be given. Our patients rely on us to do the right thing by them.

Back when we first started using CPAP, I had a situation at the hospital where a nurse told me to take the patient off CPAP because her ED required an order for it to be given and she did not want to lose her license but having the patient on it without the order. I refused to discontinue the CPAP and refuse to let her discontinue it until a physician came into the room and issued the order to continue it.

And then there is the questions of what do you do when you are standing in line with your patient and there is a BLS crew in line with their patient, and their patient is having a severe asthma attack? Using every accessory muscle, diaphoretic, frightened, with declining SATs and no audible air movement. Do you run out to your ambulance and come back in with your equipment and intercept with them right there in the triage line? I will leave that discussion for another day. (But if I had to answer, I would say, you need to bring that patient to the attention of the triage nurse and be fairly insistent).

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