I worked a lot the last two weeks. Things aren’t improving. I tried transfering some sick patients yesterday, from a smaller hospital to large facilities with more beds and more specialty resources. Pretty much every hospital in our region was on ‘closure’ or ‘diversion,’ which meant that EMS was being told to try to find other places and that the hospitals weren’t accepting transfers.

Patient volumes are high. EMS stretchers line up in front of our desks like small, tragic train cars from some war-zone. On them, old men and women slump in exhaution or cry from broken bones. On others, young addicts struggle against restraints because of their methamphatamine use, or scream because Narcan robbed them of their high; saving their lives causes instant and miserable withdrawal. They park as we try to find rooms in which to put them when all the rooms are full. Treatment in the the hallway, or in the waiting room, is routine. Nurses, short-staffed as always, try their best to keep up with orders from physicians and balance that against very simple needs of patients, like food, clean gowns or trips to the bathroom. Bedpans in the hallway are, obviously, less than optimal.

Patient acuity, that is the level of illness and injury, is almost unmanageable. Critically ill patients are a daily reality. I’m intubating (putting artificial airways in the trachea) more than I have in a while. I’m placing more central lines (large IVs in the neck, chest or groin), managing more complicated illnesses for longer than ever as they sit in the ER awaiting another place where they can get the care they need…in an actual hospital bed and with specialists.

Why is it? Even I don’t know all of the answers. Lack of nursing staff. Lack of foresight in building hospitals in the face of aging populations. Retiring physicians. Lack of primary care. The fact that about half of all American healthcare happens in the ER. This was suggested in research from 20017.

https://journals.sagepub.com/doi/abs/10.1177/0020731417734498?journalCode=joha

It has probably eclipsed 50% now, as the emergency department is the ‘go to’ for everything from trauma to life crises.

Other things are happening too. As I’ve said before, our population is living longer with more complex problems. That’s a good thing. But we aren’t prepared for it; we are victims of our own success.

Worse, we’re living longer but probably worse. Lack of fitness, lack of healthy diets, obesity, all of these take a toll and create complicated patients who live from injury to illness and illness to injury, from one hospitalization to another. The trajectories of their lives are not about time with family or enriching experiences. They are defined by heart attacks and strokes, by CT scans and echocardiograms, cardiac catheterizations and hip replacements, rehab stays, returns to home and then another event that returns them to the hospital. Their charts read like medical textbooks; the strange, detailed chapters of scientific novels that move from introduction to bitter closure and denoument, a fading away in a nursing home.

So many of them are simply lonely and alone. A hospital stay, a urinary tract infection, this is perhaps a highlight. Lights and clean linens, the attention and touch of caring people

Still another population is addicted. I realized recently that people aren’t asking me for pain pills as often. Because they’re just buying heroin and fentanyl, or buying pills on the street. They fill our ERs with visits for overdose, then for infected injection sites that lead to endocarditis (heart valve infections). They are septic (with widespread systemic infections), but have terrible veins from endlessly shooting up. They lose limbs, they die. Until then, they are brought by family members ‘because she needs help,’ and some go to rehab but most circle back to the drugs.

Marijuana is no innocent player here. It makes our patients anxious and paranoid, and in some cases creates psychosis, tipping them even into full-blown schizophrenia. And it is so often used in addition to other drugs. Never mind the vomiting, the loud, aching vomiting and abdominal pain that comes with chronic use. But which they refuse to believe is the problem. As one patient told me, angrily, ‘I’ve been smoking since I was nine years old. It’s not the problem!’

Mental illness fills our rooms as we ‘medically clear patients’ by doing physical exams and lab tests at the request of psychiatric hospitals, whose beds are also full. The fortunate few with some insurance (even Medicaid) will go the same day; others after days or weeks in ER beds. Until then they wander the department to the bathroom or nurse’s station, living in paper gowns, eating out of safe styrofoam, not even using potentially dangerous plastic implements if they’re suicidal, deprived of their phones. Broken ghosts, haunting the hallways, frequently diagnosed and medicated but almost never ‘cured’ as if to even suggest it were heresy; to mental health workers and to the patients.

In all too many places, violence plagues the ER. Shooting or stabbing victims dropped off in the ambulance bay as a car screeches away from the scene. I recall one stabbed in the heart and brought in a pickup truck. Drug crime, gang crime, personal intimate violence, all of it lands in the already full ER, blood pooling on the floor as physicians, nurses, medics techs and others step through it and over it and try to staunch the flow so that it remains inside the body of the dying. These events stop everything, all hands on deck, and in the midst of life-saving efforts, the psychotic psych patient still screams and the infant with fever still cries and the senior with dementia still climbs out of bed and falls onto the floor, another CT scan then needed to make sure their brains aren’t injured from the tumble. The heart attack isn’t diagnosed as fast as it could be. Meds aren’t given, admissions don’t happen.

And the ambulances and walk-in traffic proceeds as always.

Every day, everywhere in the emergency rooms of America (and I assume, much of the developed world), this is the picture. We’re doing our best. But our best isn’t very good these days.

We thought we had won the war when COVID receded. Turns out, we only won a battle. The war continues and we are losing. We can build beautiful new hospitals and pavillions and our billboards can offer lower wait times and smiling faces. But we’re just sinking and patients, the reasons we do what we do, are suffering, waiting, hoping and all too often just dying.

Why, I ask you, isn’t this on the news every….single…day?

Send a few migrants to Martha’s Vineyard and it’s the news cycle from right and left for weeks.

Watch healthcare collapse and there’s a collective averting of the eyes.

I don’t get it. I’m proud to try my best. But I just don’t get it.

Edwin

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