Mid-sized ER Madness; Thoughts?

I know, I know, I spend way too much time ranting about work in the emergency department.  But after some recent shifts, my box of rants is full once more.  And what I want to point out is the enormous struggle of the mid-sized emergency departments in America today.

I know this is a problem; I work in them, and I know and talk with people who work in them.  It’s getting harder all the time.  So what is that ‘mid-sized’ ED?  For purposes of my discussion, I’d say (depending on coverage) somewhere from 16,000 to 40,000 visits per year.  Now that’s not scientific, that’s just for the sake of discussion, and based on personal experience.

I’d love to hear commentary from readers, because I’m trying to figure it all out.  But let me start with a story.  When I was fresh out of residency, I worked at dear old Oconee Memorial Hospital in Seneca, SC.  Our volume as I recall was around 23-25K per year.  We had pretty good coverage at first, with three 12 hour physician shifts a day.  Patients were sick but we moved them through.  And when I worked nights, I remember that it wasn’t unusual for me to lie down about 3 am and sleep till 7 am.

Fast forward.  Even at my current job where I see 19K per year, there’s barely a night when patients don’t come in all night long.  So is volume spread out more?  Maybe.  Are patients sicker?  Possibly.  I think some of this may be that patients have no primary care, and so they don’t even have an option to ‘wait till morning.’  In addition, a large number of patient (in all ED’s) are jobless.  So in their defense, 3 am is as good as 3 pm when you don’t have to go to a job in the morning.  (I’m not disparaging; but I do think this is true.  Think about your teenagers who sit up all night in the summer if they don’t have jobs!)

I also wonder if our patients are sicker.  I mean, medicine is pretty amazing nowadays, and people who would certainly have died when I was in medical school now repeatedly survive significant heart failure, MI, stroke, pulmonary embolism, respiratory failure, various infections and all sorts of problems.  And when they do, they have to come back to the ED frequently.

For those with docs in the community, I’m sure the offices are crazy busy all the time. Even those docs have patients they just can’t squeeze into appointments. They use the ED.  And maybe, just maybe, our patients are much more ‘medicalized’ than before.  So much of what the emergency departments see is really psycho-social.  Anxiety, depression, suicidality, substance abuse.  The numbers of these conditions seem to be exploding, and they can seldom afford primary care, much less mental health care.  The all-night ED is the place they go.

And there is a subset of patients who use the emergency department for entertainment or convenience; rides, snacks, a way to avoid arrest.  ‘Officer, I…have…chest pain!’  These also take time and space.

So what happens is all of this descends on departments with limited resources and staff.  And all day, and all night, one physician or two, maybe a PA or NP, struggle to sift through five or six chest pains alongside two stroke alerts, a suicidal overdose, two septic senior citizens, a dialysis patient who missed two appointments and has a potassium of 10 and a femur fracture.  Add to that the family of five with head colds.   Sure, this is what we do.  We are emergency physicians and nurses and mid-levels.  But into this mix, in the mid-sized department, recall that there is:  no cardiologist, no neurologist, no psychiatrist or counselor, sometimes no available ICU beds, possibly no pediatrician and definitely no dialysis in the hospital.

The day is spent sorting, stabilizing, making phone calls, transferring and waiting for ambulance or helicopter to become available.  All the while?  Sifting through very cumbersome and inefficient computer documentation systems designed for billing not flow.  And being scrutinized for through-put, time stamps, protocols, national standards, Medicare rules, re-admissions and all that mess.

I really don’t want to sound like a complainer. What I’m concerned about is 1) the safety of the patients and 2) the physical and emotional health of the caregivers.  At the end of the day, we’re all exhausted.  And so much is going on that we can barely find the obvious stuff, much less the subtle things that can also kill.

It sometimes seems as if departments are intentionally understaffed to save money.  I understand that it’s expensive to have doctors, nurses, etc.  But administrators get mad at folks ‘standing around,’ without realizing that in the chaos and suffering of the ED, sometimes it’s really important to ‘stand around.’  To breathe, to think, to rest, to gather oneself, to look up a condition or problem, to debrief.  To eat.  To pee.

I think that the world of medicine has decended on the emergency department.  I know that we handle it valiently.  But I don’t think it’s safe; and it’s nowhere as unsafe as in the relatively under-staffed and under-equipped mid-sized community hospitals of the world.

I’m proud of what we do.  But some days, most days, I wonder how we do it.

Any thoughts?

Edwin

Watch for signs of depression in your teen.

This is my latest column in the SC Baptist Courier.  Teens are wonderful!  But that transition from childhood to adulthood can be so hard on them.  Please remember that they can be afflicted by depression, and watch yours carefully. And their friends!  Text follows link.

 

Wholly Healthy: Watch for signs of depression in your teen

It’s August, and that means that school is starting. Middle school and high school, in particular, are times of significant emotional challenges. Not only are students adapting to physical changes and emotional growth and maturity, the fact is that depression is a big problem for young people. In 2012, according to government statistics

http://www.childstats.gov/americaschildren/health4.asp, 11% of kids between ages of 12 and 17 had at least one major depressive episode. These episodes increase their risk of suicide and drug abuse.
All parents know that raising adolescents is a challenge. The complexities of adolescent culture are compounded by their even more complex brain chemistry. In the end it can be very difficult to sort through which behavioral changes are normal and which are pathologic and dangerous.
Because of this, it’s very important to educate yourself, and talk to your kids. And talk. And talk. If you think you’re being intrusive or invasive, that’s not necessarily bad. (In general, they want your attention more than they admit.) Young people will frequently say ‘everything is fine,’ when everything is far from fine and they are feeling sadness and despair.
It’s important to spend a lot of time with the kids. And while you do, to watch for signs of depression, like withdrawal from friends and family, loss of enjoyment of normal activities, expressions of guilt or worthlessness and increasing emotional outbursts. Be attentive to increased physical complaints such as fatigue and loss of appetite. This list just scratches the surface, so I’ve attached a link with more details. http://www.mayoclinic.org/diseases-conditions/teen-depression/symptoms-causes/dxc-20164556
Furthermore, as you talk to your kids, don’t be afraid (or ashamed) to snoop. Know what they’re doing, where they are going and who their friends are. Ask who they are texting, what they’re reading, and what they’re thinking about. And don’t accept ‘oh, nothing’ as an answer. They are always thinking about something.
And since most of them seem permanently attached to a telephone, snoop there as well. There are ways to track their phones and to follow the websites they visit and the texts they send and receive. And you can simply tell them that you want access to their passwords. Odds are you’re paying for the thing anyway. This isn’t to be mean, but to be diligent. The texts and searches on their phones can be clues to their emotional struggles and also to dangers or cries for help.
Remember that even kids with loving, attentive families can spiral into dangerous depression. Don’t forget that Christians have brains and depression is a real disease of the brain, not a moral or spiritual failure. So never be afraid to discuss it with the kids, admit that it’s real and seek counseling and medication as indicated.
Your efforts might just be life-saving.

You’re not alone; especially in a stadium full of people like you.

Not Alonehttp://www.greenvilleonline.com/story/opinion/contributors/2016/04/24/ed-leap-reminder-youre-not-alone/83295392/

When I was a resident in training, I spent a day working as a physician at the Indianapolis 500 race, with my lovely bride accompanying me. It was an impressive spectacle. In fact, at least then, it was the largest single day sporting event in the world, with some 300,000 attendees. (And coming around again next month by the way!)
Although I admit to never attending a NASCAR race, I’m sure it’s a similar feeling. The press of humanity, the sound of engines, the smell of gasoline, the rivers of soft-drinks and beer. The inappropriate clothing…but I digress. The whole thing was simultaneously exhilarating and overwhelming.
I sometimes reflect on the enormity of that place. And then I think, oddly enough, about loneliness and isolation, as if in stark contrast to the race. One of the worst things in the world is isolation, actual or perceived. Many people suffer enormously because they feel utterly alone in life. And worse, they feel alone in times of trial.
I wonder what would happen to the hearts and minds of those people if we had special days when everyone with similar problems could meet in a vast stadium for a day. If, from every small neighborhood and farm community, every big city, every subdivision, people could come together with others who shared their trials. Can you imagine? In order to help envision it, I’ve done a little research.
According to the CDC, about 3.5% of American adults suffer from Major Depression. Since we have about 314 million persons in the US, that comes to almost 11 million adults. (I’m not even counting children and adolescents afflicted with the same). If the Indianapolis Motor Speedway holds 250,000 persons (50,000 more in the infield), it would take 43 stadiums to get all of those folks into stadiums to come together.
How about that endless specter, cancer? The National Cancer Institute of NIH reports that in 2014 there were 14.5 million people living beyond their cancer diagnosis. They also report that it is estimated that in the US there will be some 1,685,000 new cases in 2016. That would require 138 stadiums the size of Michigan Stadium in Ann Arbor to get the survivors together; many of whom still suffer anxiety and side effects of their treatments.
The Partnership for Drug Free Kids website says that there are, in America today, 22 million individuals addicted to drugs or alcohol. Since Clemson’s Death Valley only holds some 81,500 Tigers and other species, it would take a lot of similarly sized facilities to manage all of those with addiction issues. In fact, it would take 269 such stadiums, to be precise.
Sadly, about 800,000 persons are widowed each year in the United States, of which 700,000 are women, the remainder men. (From the website widowshope.org. ) While it would take fewer stadiums, it would still require the equivalent of eight versions of LSU’s Tiger Stadium.
In 2012, 1.25 million American adults and children had type 1, insulin dependent, diabetes. This from the American Diabetes Association, who should know such things after all. Getting them together for some low-carb food and fun would require 13 stadiums the size of Wembley in London. (For all of those fans of the ‘other’ football…)
It sounds like I’m trying to bring everyone down. But I’m not. My point is exactly the opposite. For all of the loneliness that all of these people may feel, the larger reality is that they are part of much larger groups. It’s all too easy, alone in the hospital, the doctor’s office, the same chair at home, the same lonely church pew, to feel completely alone.
This is, of course, the reason for support groups. It is also point of friendship, love and outreach. While we may not share all the same afflictions as others, we can certainly be with them, listen to them, comfort them in their trials. And to the extent that we have the same problems, we can be even greater reassurance. This is why we were instructed by St. Paul to ‘rejoice with those who rejoice, and weep with those who weep.’
We mean something entirely different when we quip, ‘misery loves company.’ But the truth is that it does. It craves company. Those in pain and loss, those struggling or afraid, need to know they aren’t alone.
And it needn’t take a trip to the Indy 500 to make that a reality.