“You never want a serious crisis to go to waste. And what I mean by that it’s an opportunity to do things you think you could not do before.” – Rahm Emmanuel

The first steps towards a province-wide virtual Emergency Department

Three weeks ago, I was on my last of a string of four out of seven days on call in a rural northern BC emergency department. Three hours into my shift, I received word from a remote worksite that someone was seriously unwell and on their way to my hospital. We had a name, a personal health number, and an hour to prepare – no further information could be gathered from our health authority or clinic electronic medical records.

Like other departments around the province, our patient volume in April 2020 has been significantly lower than the historical average. This meant in this instance my nursing colleagues and I had time to “pre-brief” – run through different scenarios we might face with this patient given our limited information and preemptively address any identified issues.

After my team and I were confident we were adequately prepared for whatever was coming in, I stole away to the physician’s lounge – a small area just down the hall from the department. In the past I would use these precious moments to review my ACLS, ATLS and other algorithms for the hundredth time. This time however, I had another option to help me prepare to care for a potentially critically ill patient.

I rolled the department iPad into the lounge and accessed the new ROSe service through Zoom (note, there is now an app available). Within a minute, I was connected to Dr. Omar Ahmad, an intensive care and specialist emergency physician, and their first words were “How can I help?”

Within a minute, I was connected to an intensive care physician, and their first words were “How can I help?”

It didn’t matter that the only things I knew about this patient were their name, PHN, and the fact that they were sick enough to be heading to my resuscitation bay. It did not matter that I had not yet formulated a specific clinical question for them. It did not matter that I had not even had the chance to lay eyes on the patient yet. All that mattered is that I had an ill patient coming my way. Though my team and I had some preliminary plans and actions in mind for when they hit the door, as a relatively new in practice physician, I needed someone more experienced to run these plans by before I led the team to face this challenge.

After about ten minutes of bouncing ideas back and forth, confirming and refining my thought processes and cognitive preparation with the intensivist, I walked back over to the department with renewed confidence. A few moments later our patient arrived, and my team and I got to work. Once we had monitors on, an IV line secured, and I obtained a better history, physical exam, rapid point of care ultrasound scan and ECG, I beamed in the intensivist in again. This time, they could see the patient with us and appreciate how this clinical scenario was playing out in real-time.

Luckily, our patient was stable and we had time to get some lab work and other ancillary information to guide our care. My distant consultant not only provided advice but crucially also gave me the confidence and latitude necessary to interpret and implement that guidance – supporting me in my role as the most responsible physician in this case. Within ninety minutes, we had further stabilized and dispositioned this patient. After a short Patient Transfer Network call, he was on his way to our referral centre for further management within four hours of arriving at our emergency department. What was the most anxiety-provoking presentation of the prior few days became one of the smoothest cases I have ever managed.

What was the most anxiety-provoking presentation of the prior few days became one of the smoothest cases I have ever managed.

This kind of real-time virtual support has been brewing and intermittently in existence over the last two years. However, the development and implementation of these projects have been hampered by various factors that I cannot begin to delineate here. But over the last two months, the public health crisis we have all been facing has provided the perfect impetus and opportunity to accelerate access to these supports.

Even three months ago I did not have the option of bringing in an ICU physician to assist with my (in this case, non-COVID) patients care. The threat of COVID made it possible for this support to be fast tracked into existence and be there right when I needed it this past month.

In addition to the ROSe line, rural physicians also now have access to the RUDi line – an experienced rural or specialty-trained emergency physician colleague to run less critically ill cases by. They are analogous to the senior colleague hanging out in the lounge during your shift, or in the workstation next to you. They are available for you to run a clinical conundrum by, but they are also able and willing to see the patient with you at the bedside and provide an opinion on and further refine your diagnosis and plan for them. For example, in the last few weeks I have used the RUDi line to help me evaluate a potentially dangerous rash in an infant, to confirm my decision making on how to manage a patient with both cardiac and psychiatric complaints, and to double check my physical exam findings on a Bell’s Palsy vs stroke presentation, only to name a few instances.

These services, along with the Rural Dermatology line and other resources in development, have the potential to enhance and extend the already broad skill set of physicians providing coverage emergency department coverage and primary care around the province. I believe this will improve not only patient care, but also the experience of care for both patients and physicians, and potentially lead to improved clinical outcomes for some presentations.

The physicians and nurses on call, awoken in the middle of the night to attend to patients in remote locations are no longer truly on their own. They are today part of a province-wide virtual emergency department, with colleagues available to help at the drop of a hat. What would have taken likely many more months, potentially years, to realize has become available and established in a matter of weeks. Despite the anxiety in the air, there has never been a better time to provide rural emergency medical care.

The physicians and nurses on call, awoken in the middle of the night to attend to patients in remote locations are no longer truly on their own.

Of course, like anything moving at high speed, and in this case pivoting at the same time to tackle a pandemic, there is the potential to stumble along the way. Communication lines, consultation and transport patterns between sites are well established by decades of practice and relationships. The introduction of these new virtual services could potentially create unnecessary confusion and duplication of work and expertise in some cases at best and generate conflict between sites and services at worst. Documentation for both clinical and medicolegal purposes also needs to be seamless and presents a challenge when dealing with physicians and patients scattered across health authority lines. Some may question the necessity and appropriateness of these services in larger rural departments that have more ready access to resources and consultants than others. In my opinion, these challenges, legitimate as they are, only present opportunities to further refine and develop this concept of a province-wide virtual emergency department to the benefit of patients and clinicians.

As I mentioned in my last blog post, COVID has rapidly changed the way medicine is practiced and we as a province and profession have risen to meet the challenge. Though we are still working through it, this crisis has already generated an incredible benefit in the form of these real-time virtual supports that I sincerely hope persist and grow long after the crisis of SARS-CoV-2 has passed.

Did you know about or have the opportunity to use these services yet? If you’ve used them already, what was your experience like? If you haven’t, is there a specific reason? How do you see the concept of a province-wide virtual emergency department growing and changing in the near and far future? Do you see any challenges or negative aspects with this emerging model of care – the “virtual emergency department”? What further opportunities to enhance clinician and patient experience might present themselves as this technology becomes established?

Disclaimer: The views and opinions expressed in this blog post are those of the authors and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.