If you work in commercial EMS, you are also likely to do what we call transfers. These are non-emergency calls where you take a patient to a destination that is not the emergency department. This can be a trip to dialysis, from a hospital or nursing home to a home or from a home to a direct admit at a hospital or a trip to a doctor’s office. If the patient is going to a doctor’s office or to a hospital for a procedure that doesn’t take too long, you often wait with the patient and then return them to where they started. These trips are called wait and returns. Dispatch tries to give them to the basic ambulance crews in order to leave the paramedic ambulances available to take 911 calls, but on days when the paramedic rooster is full, medics can be asked to help out with the transfer load.
In the age of COVID, there are now COVID transfers. I have been involved in a few of them. Back shortly after the epidemic began in the spring the state started opening skilled nursing facilities (SNFs) solely for recovering COVID patients. Several times I have transferred a patient from Hartford to a SNF over a hour’s drive away. I drive while my BLS partner sits in the back with the coughing COVID patients, unless of course the patient needs ALS monitoring, in which case I am in the back. This happened once. You can’t maintain six feet of distance from a patient in the back of an ambulance. You just gown up, turn on the exhaust vents and hope for the best. Our PPE (personal protective equipment) are not self-contained biohazard suits, and even though the patient is wearing a surgical mask, they often have dementia or sometimes a simple unwillingness to keep their mask on properly, and even if they do have their mask on, COVID can still get around it. The crew member is basically trapped in a COVID soup for the length of the trip. Sixty minutes is too long.
I don’t think the system has had time to properly process what a COVID transfer means. This one didn’t happen to me, but I have heard of it happening to two other crews. In the hospital patients are often kept on COVID wards where each room is biocontained. That means, the medical staff dons PPE in a foyer, enters the room, treats the patient and then doffs their PPE in the foyer before returning to the hallway and medical worker’s stations. You can’t wear PPE in the hallway. Now enter the EMS crew. EMS dons their PPE in the foyer, enters the room, puts the patient on their stretcher, and then exits. They are asked to remove their PPE. No. But you can’t be in the hallway with PPE on. Well, how the hell do you get the patient down to the ambulance? You can’t wear PPE in the hallway. You will contaminate the rest of the building. Do you have a chute we can put the patient in that will automatically deliver the patient into the back of our ambulance? Because otherwise we need to walk through the hallways to get back to the ED and our ambulance. Put a clean sheet on the patient. And what about us? You can’t wear PPE in the hallway of this ward. We are not taking our PPE off. See you later. (I heard that a compromise was later reached on one floor where EMS doffs the PPE they wore in the room, then immediately puts on a new set of PPE and are permitted to leave enter the hallway with the patient who is covered in a clean sheet, except of course for their face covered with a surgical mask.)
In the meantime in the ER, EMS crews donned in full PPE with their COVID patients, wait in the same triage line snaking out the door as do crews with only surgical masks on with COVID negative (based on screening questions), and once assigned a space, the PPE covered EMS crews and their patients maneuver their stretchers down ED hallways with regular overflow patients sitting in chairs or lying on beds. This is opposed to the early days of the epidemic where all possible COVID patients entered the ED through a separate decontamination room.
Then there are the COVID wait and returns—calls in which you can be with the same patient for several hours. I did one of these recently. The patient needed to go to the hospital for a procedure. Taking a patient to a hospital for a procedure can involve many stops as you are directed from one floor to the next. No, this is the wrong floor, you need to be in radiology, that’s down a floor, take a left when you get off the elevator, go down a hallway, turn right, go through the double door, and then it’s your next left. Those types of directions are common.
So imagine this. An ambulance crew fully gowned in decontamination gear with a coughing COVID positive patient on oxygen on their stretcher wandering the halls of a hospital. I wish I had a camera to record the terror on people’s faces. We went to admissions where we had been told they would send someone down with a bed to take our patient, instead we were sent to another floor. After several stops we finally ended up where we were supposed to be, which was a hospital office waiting room. I waited with the patient in the hallway, while my partner checked the patient in. Recognizing that the COVID patient was a potential hazard to the others in the hallway as well as the waiting room per their policy, we were escorted into a small room off the waiting room. The appointment was not for another hour and a half so they wished us to wait there until with the patient until they were ready. This is another common issue with wait and returns. The nursing homes often schedule the pickups early compensating for the times the ambulance is late due to 911 call volumes, so we often end up arriving at the destination only to find we are an hour or two hours earl for their true appointment. Our dispatchers don’t like us to wait more than twenty minutes. Often we can unload the patient onto a hospital bed to wait for their appointment and send another crew to pick them up when ready, but the hospitals and the doctor’s offices can’t always accommodate this. They try to keep us there by saying they are almost ready and it shouldn’t be long, but the time keeps ticking away and we are stuck there. On this call, the staff came back moments later and said not only did they not have a bed we could move the patient too, but they asked us to close the door to the room where we had the patient as keeping it open was in violation of their policy. The room was not a patient room, but a closet sized consult room with barely enough room to fit the stretcher. I told them if I closed the door if would be hazardous for my partner and I. We discussed it and I asked them to call a member of their safety team. The team member who was very pleasant explained the reasons the door had to be kept shut. I understand those, I said, but do you believe it is safe for my partner and me to be in this confined space with this patient for an hour? What about the ambulance? the safety person said. Aren’t you confined there? Well, we have exhaust vents and we are usually not in with the patient for an hour. Point taken. They moved us to another room which was larger. By this time we were close to running out of oxygen, and then the room that they had moved us to, the staff who normally used the room were uncomfortable with us being in there with a COVID patient, so we were moved again to the hallway (waiting a further solution) where we stood and watched other visitors scurry past us. In the end the hospital cancelled the procedure and we returned the patient to his facility with instructions to reschedule and to have the nursing facility send someone with the patient next time who could wait with him in whatever space they would try to figure out that they could safely border a COVID patient while waiting for his procedure.
When we returned to the SNF where our journey began, the guard at the door took all our temperatures per the facility policy before allowing us entry. Fortunately none of us had fevers so we were allowed to go down a hallway, up an elevator, down two more hallways and through a set of double doors where we at last came to the patient's hallway, found his room, and returned the patient to his bed.
How likely were we to get COVID from this patient? Well, I was just vaccinated, but only with the first shot and my partner had already been out for a few weeks with COVID pneumonia several months back, but they say it is possible to be reinfected. We kept our PPE on the full time. (I doffed mine each time I drove, and then had to put on a new set to reengage the patient). I was glad the hospital safety officer was understanding and recognized the danger to us and responded to it. No way was I going to close that door. Scene safety at all times.
I am glad Connecticut has recognized EMS as a priority 1A group at risk for COVID exposure.
COVID has been hard on everyone, and people are doing their best, adapting to the challenges.
