Waiting and Miserable in the ER

When we go to an airport, we can get a sense of how things are going by reading the screens that display arrivals and departures. When the screen says “delayed” or “canceled,” we know it’s going to be a long day; and that maybe our trip won’t happen at all.

Something similar is happening in emergency departments across the land. It’s right there on the glowing electronic tracking boards. Those boards list patients by identifier, room number, complaint and disposition; that is, “what’s happening next.” They will variously say “treatment in progress,” or “ready for discharge.” Frequently these days it says “holding for admission” or “transfer.” And that’s where it gets interesting. Because the “time in department” column often says 8 hours, 12 hours, 2 days, 5 days or more. A look at a theoretical board might reveal just a few reasons why those numbers keep rising.

The 55-year-old woman was resuscitated after her cardiac arrest. She has been on the ventilator for 24 hours because there are no intensive care beds in a three hour radius of the hospital.

Down the hall, but sadly not too far away, a 12-year-old boy paces in his room, his suicidal thoughts racing. He has been in the emergency department for 90 hours. There are no pediatric psychiatric beds in the state. And since he is on Medicaid, another state isn’t an option.

There is also 72-year-old man with diabetes and a complicated skin infection. He is developing sepsis (a widespread, life-threatening infection). He was accepted at larger hospital with more resources. He had a bed at first, but no ambulance was available to take him and the weather was too bad for a helicopter, so he lost his place in line.

Almost as sick is a 19-year-old woman with a heart valve infection due to IV drug abuse. She is in withdrawal and has spiking fevers. She needn’t be transferred. But the house is full and she will continue to lie in the emergency department.

As if it weren’t complicated enough there is also an 89-year-old woman with dementia and frequent falls. She lives alone. Admission to the hospital requires a ‘medical diagnosis’ which she lacks. Admission to rehab or nursing home requires admission to hospital.

People sometimes leave emergency rooms and die at home. We used to say, “well if they were that sick, they wouldn’t leave!” But research shows that those who are very sick and frustrated leave waiting rooms (where we increasingly treat our patients) and leave treatment rooms because they’re just miserable. They go home and sometimes die, in part, from waiting.

This is a nationwide struggle. An ED with 20 beds might well have 12 or 15 patients waiting to be admitted or transferred. That harsh numerical reality doesn’t stop ambulances from arriving, or the sick or dying from walking through the door.

But why are all of the ED beds full? In part because the hospitals are full on the inpatient side. It’s a shortage of nursing staff to care for patients. It’s a shortage of physicians in many areas. People are living longer with more complex illnesses and are frequently hospitalized. Insufficient access to primary care is also a factor, as chronic illnesses just aren’t managed.

Mental illness, inadequately funded and treated, fills our departments with the suicidal and psychotic. Hospitals continue to struggle with increased volumes of patients suffering from overdose and other consequences of addiction to opioids and methamphetamine. And as rates of violence increase across the land, every facility finds its resources stretched further.

Many areas also suffer from hospital closures due to the fact that lower populations of relatively poor citizens aren’t considered “profitable” enough to maintain a community presence. Rural areas often lose all of their OB care. Those people have to go to other hospitals, further from home and already full.

The tracking board is an emblem of the progressive, accelerating collapse of American healthcare. Our emergency departments and our hospitals in general are creaking under the strain of a system that has never kept up with the needs of the populace, was always on the razor’s edge of disaster and which was nearly decimated under the pandemic. Indeed, many of our current problems such as mental illness and addiction seem to have been clearly worsened by the pandemic, as its wave of devastation continues to destroy.

Only the dedication of staff really kept the system functioning. But staff have retired or quit. And staff have died. For those professionals who remain, the crushing weight of our own inadequacy to the task lies heavy on our shoulders.

I don’t know why we aren’t discussing this nationally. I do know that the boards are full of patients. And Americans are suffering and dying, daily, for lack of care. And that it could get much, much worse before it gets better.