Holding Patients, Watching the Portents

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I recently worked an evening shift in the emergency department, the day before New Year’s Eve. Patients arrived in waves, by car and by ambulance. They seemed to check into the triage area every few minutes. When I left at midnight there were 23 patients awaiting admission in the ER; waiting for four, six, 12 or more hours; some for a full day. Simultaneously there were about 20 waiting to be seen in a waiting room bursting at the seems, not only with illness and injury but with frustration.

That’s 23 out of about 26 beds tied up (depending on how you count them). A few more were available but without sufficient nurses to staff them.

I pointed this out in an online forum used by emergency medicine colleagues around the country. They began to send me their own numbers.

“61 holds in a 46 bed ED.”

“34 holds in a 21 bed department.”

“26 in a 19 bed ER.”

“9 holds in an 18 bed Critical Access Hospital, and we can’t transfer anyone because nobody will accept transfers.”

“50 in a 35.”

Overwhelmed. More patients than rooms, more patients than stretchers, more patients than staff. Almost universally.

Another sent me a list of all of the ‘left without being seen’ patients. About 35 on the board at once. These folks checked into triage but left because waits were too long.

Some of those who leave without seeing a physician are actually very ill. They feel too badly to wait. This is well known.

I worked in another site a few days later. Sick, sick people with no way to admit them or transfer from a small, rural hospital. The ER was an island of mercy in a dark sea of mountains where the ill were stranded.

Many of those we see across the country appear to be sicker than ever. Heart disease, stroke, sepsis, the list is long. Maybe we’re doing a better job with the sick, with helping the frail, aged to hang on longer. Or people just aren’t as well as before in general. Or something else. I don’t know. But the needs they bring to us are enormous. And I feel for them.

I’m old enough to remember (I love saying that) when hospitals weren’t crushed. When patients had more access. When they were adequately staffed most of the time and when admissions went to a room outside of the emergency department in a timely manner. A room where they could rest (as much as one can in a hospital) and receive more dedicated nursing and physician care.

In those days admission didn’t mean lying in the hall by a cold ambulance door. It didn’t mean listening to the screams of those in pain, or with mental illness, all night long. It didn’t mean being moved from place to place to make room for the next chest pain, gunshot wound, overdose or car crash victim; the next wheezing, coughing patient with respiratory illness.

I’m old enough to remember slow shifts when staff had time to think, time to stock, study, counsel one another. All of that is in the rear-view mirror. A speck on the receding horizon.

Right now, in hospitals across the land, there is a state of daily and nightly disaster.

Admissions stay in the ER. Transfers mostly stay in the ER; because every other hospital faces the same thing. Heart attacks, strokes, sick children, OB, trauma, these fortunate (well, you know what I mean) patients can sometimes be transferred or admitted if needed. The rest not so much.

When, in the midst of the maelstrom, we contact an on-call administrator, they have no answer. And I understand why. I suspect they are as frustrated as those at the bedside. There is nobody to call in to help. And so there are no beds to open. Staffing shortages existed before the pandemic. They are far worses now as health care ironically hemorrhages workers.

Disaster plans, designed in better times, practiced occasionally, printed, stored in those ancient three ring binders and on hard-drives, are theoretical constructs with no relevance anymore.

When we call EMS services, because we found a bed somewhere and can transfer our patient, the ambulances are out of town on another call; or their crews, too, are short handed. Imagine that? A job paid far less than it should, involving blistering Summer weather and frigid Winter weather, threats of violence, danger of accident scenes and enormous, meticulous oversight. Why aren’t there more people doing it? Weird.

It seems as if I’m beaten the same tired drum. Or dead horse. Whatever metaphor you like. But I consider myself a kind of ‘town crier,’ reminding everyone that things remain far, far from normal.

As I write this, in our hilltop home in South Carolina, on January 12, 2023, the sky outside is dark with heavy clouds. Thunder is ringing around us as rain starts to fall. Lightning flashes across the sky. An odd thing, those Winter thunderstorms. They make me worry about Winter tornadoes. They seem portentous.

That’s what I’m saying. Our situation is portentous. It won’t just resolve. And it isn’t about COVID or influenza, it isn’t about RSV or addiction or mental illness. It sure isn’t about left or right politics, vaccines or disinformation. It may be a little of all of that. But it’s more. I can’t put my finger on it because it’s simultaneously too large and too obscure. A forest making the trees obscure.

How many times in history of humans ignored the warning signs? How many times have we in the prosperous West simply crossed our fingers, pursued the money and danced the night away, only to awaken to disaster? How many wars that could have been averted? How many economic nightmares that could have been forseen? How many healthcare disasters, from infectious pandemic to the ravages of obesity; from addiction to exploding mental illness?

These overwhelmed nurses and physicians, clerks, medics and techs in these struggling hospitals, all of these holdouts, these fortresses against death, are screaming warnings. Crying out, if only by quitting because they can’t bear it any more. They tell us that things are bad and getting worse.

Stay healthy, make good choices, get in shape and look after those you love.

The storm has passed here tonight.

More storms will follow, real and metaphorical.

Edwin