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Reporting From the Healthcare Disaster

— A few observations from a run of ER shifts

MedpageToday
A photo of a motion blurred nurse pushing a patient on a stretcher in a busy hospital hallway

I worked a lot the last 2 weeks. Things aren't improving. I tried transferring 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 emergency medical services (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 exhaustion or cry from broken bones. On others, young addicts struggle against restraints because of their methamphetamine 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 hallway or the waiting room is routine. Nurses, short-staffed as always, try their best to keep up with orders from physicians and balance that against the 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 is almost unmanageable. Critically ill patients are a daily reality. I'm intubating more than I have in a while. I'm placing more central lines and managing more complicated illnesses for longer than ever as patients 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 such a disaster? Even I don't know all the answers. Lack of nursing staff. Lack of foresight to build more 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 . It has probably eclipsed 50% by 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 denouement, as they fade 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.

What else is happening? Another population is addicted. I realized recently that people aren't asking me for pain pills as often. Because many are 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. 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" -- but oftentimes, they aren't ready for help. Some go to rehab but often circle back to the drugs. None of them set out to become addicted. They hate the life in which they're trapped but drugs bring them back to the hospital again and again.

Marijuana is often no innocent player here. It makes our patients anxious and paranoid, and in some cases creates psychosis. 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 9 years old. It's not the problem!"

In other patients, 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, deprived of their phones, eating out of safe Styrofoam, not even using potentially dangerous plastic implements if they're suicidal. Broken ghosts, haunting the hallways, frequently diagnosed and medicated but almost never "cured."

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 -- it's all hands on deck. But in the midst of life-saving efforts, the 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 the severe COVID numbers declined. Turns out, we only won a battle. The war continues and we are losing. We can build beautiful new hospitals and pavilions and our billboards can offer lower wait times and smiling faces. But we're just sinking, and patients, the reason 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?

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 Leap, MD, is an emergency physician who blogs at , and is the author of and . You can read more of his writing on his Substack column, , where originally appeared.