My choices as a doctor in the emergency room are up or out. Up, for the very sick. I stabilize things that are broken, infected or infarcted, until those patients can be whisked upstairs for their definitive surgeries or stents in the hospital. Out, for everyone else. I stitch up the simple cuts, reassure those with benign viruses, prescribe Tylenol and send home.
Up or out is what the E.R. was designed for. Up or out is what it’s good at. Emergency rooms are meant to have open capacity in case of a major emergency, be it a train crash, a natural disaster or a school shooting, and we are constantly clearing any beds we can in pursuit of this goal.
The problem is, traffic through the emergency room has been growing at twice the rate projected by United States population growth and has been for almost 20 straight years, despite the passage of the Affordable Care Act, and through both economic booms and recessions. Americans visit the E.R. more than 140 million times a year — 43 visits for every 100 Americans — which is more than they visit every other type of doctor’s office in the hospital combined.
The demand is such that new E.R.s are already too small by the time they are built. Emergency rooms respond like overbooked restaurants during a chaotic dinner rush, with doctors pressed to turn stretchers the way waiters hurriedly turn tables. The frantic pace leaves little time for deliberating over the diagnosis or for counseling patients. Up, out.
Private exams on stretchers in hallways, patients languishing without attention for hours, nurses stretched to the breaking point; all of it has become business as usual. I think about this on nights like tonight, when I start my shift inheriting 16 patients in the waiting room. I think about what I will learn that these people need, and about what I will fail to provide.
Work starts simply enough. Twenty-two-year-old was drunk and drove into a tree, now has a sore elbow. The X-rays are normal and he is sober enough to walk: discharge home with girlfriend. Woman with a migraine holding a towel over her eyes and a crumpled blue emesis bag in her right hand, for when she vomits. I start the standard “migraine cocktail” of IV drugs and turn off the lights in her room. I will wait until she feels better, then discharge her, too.
More. A woman six weeks pregnant with cramps and vaginal bleeding; I check whether her miscarriage is inevitable. A drug overdose, likely a suicide attempt; I clear for psychiatric care. Homeless man with foot pain, back pain and a cough, but here mostly because it’s too cold outside. I hand him a sandwich.
Then an ambulance crew rolls a gaunt man with one leg toward me on a stretcher. The paramedics hand over a thick packet of paperwork from his nursing home and walk away. I read the label: Jean-Luc. Age: 38.
Jean-Luc doesn’t have a typical amputation stump. His left hip is also missing. According to his file, 10 months ago an aggressive strain of bacteria attacked his thigh and quickly began to liquefy his flesh. Antibiotics would not work fast enough; the only way to stop the bacteria’s spread was to cut out the infected parts.
The paperwork tells me nothing about who Jean-Luc was 10 months ago. All I know is that those few hours of surgery rendered him dependent on nurses for most things he used to do himself.
I leaf through Jean-Luc’s packet and find a scribbled nursing note. Someone was concerned that his urine looked different the past few days, and this morning he spiked a fever. Did he have a urinary tract infection? Jean-Luc’s belly is tender over his bladder, and his urine looks cloudy and smells pungent. I send some samples to the lab.
You get little hints about the quality of nursing homes from the patients they send us. If a patient’s hair is combed and his clothes are neatly pressed, the nursing home is probably decently staffed. Most impressive is healthy skin. The skin of a bed-bound patient is paper thin; keeping it intact, like the unbroken film on a French pudding, requires a herculean effort.
Jean-Luc’s skin had not been so fortunate. He had a bed sore; it was less than an inch wide, but I could probe an instrument through it to the bone. Once such holes form, doctors don’t really know how to coax the skin to heal itself. Creams, high levels of oxygen, even maggots — nothing works reliably. This is going to be a problem, I think to myself.
Forty minutes later, the lab results come back positive for a urinary tract infection. I start Jean-Luc on antibiotics. The E.R.’s role is considered completed at this point. Up, not out. The waiting room is busy; I should admit Jean-Luc to the hospital for IV antibiotics and free up his stretcher.
I look over from my desk. Jean-Luc is polite and not a complainer, but I can tell he is depressed. A month ago the nursing home put a catheter through his penis and into his bladder, presumably because emptying a bag is easier to schedule into a shift than running over every time he rings a call bell asking for help, and safer than letting him sit in his own urine, which would further break down his skin.
But for bacteria, that plastic tube is a boulevard into the body. He would be better protected by a condom catheter, which catches urine the way a condom catches semen. I start to mull this over when a nurse calls me: “Gina, Bed 5 is vomiting and says she needs more pain meds.”
Cynthia, in Bed 5, recently completed a round of chemotherapy. She tells me her pain and nausea have been unbearable, just as they were two weeks ago, when she was here after her previous treatment. I examine her, check her labs to make sure there isn’t another reason she is dry-heaving and type in a request for a hospital bed.
Cynthia is on a state-of-the-art cancer therapy, available only at a few of the top centers in the world. It is also expensive, experimental and extraordinarily taxing on her body. The discussion with her oncologist must have been difficult: the possibility of improvement weighed against the risk that the treatment could cause her to spend most of her remaining days in hospitals, hooked up to IV drugs.
For the E.R. visit, Cynthia will be charged more than $1,000 plus about $600 in professional fees for the few minutes of critical thinking I expended on her. That is the thriftiest part of this arrangement: Her admission stay for several days in the hospital will be billed at about $10,000.
To the hospital’s finance department, each case like Cynthia’s is another base hit, a fuss-free bill to collect from the insurance company requiring minimal work from E.R. personnel. But to what extent will this hospital stay prevent Cynthia from returning in two weeks, when she is again due for chemotherapy?
Maybe a different regimen of cancer drugs would sit better with Cynthia. But finding it involves trial and error and is seen as work that doesn’t have to be done — work that could get the oncologist in trouble for rocking the boat, that exposes the hospital to liability. A plan focused on keeping Cynthia out of the hospital would require more frequent check-ins at her home, which the hospital isn’t set up to do. We are choosing the path of least resistance for us, even though it is the path of last resort for her.
One in five people who stay in American hospitals are on the same morbid merry-go-round as Cynthia and Jean-Luc and will wind up back in the E.R. within one month of leaving. We tell ourselves the E.R. is meant only to stabilize patients, that someone else will handle the rest. But the problems I punt in the E.R. are also punted by the hospital’s doctors upstairs and by primary care doctors outside. No matter where I send patients, these gaping holes in care fester, like bed sores tunneling to bone.
So I wait in the E.R. for the same patients to return even sicker and even more dependent on the hospital. I’m thinking about this when an overhead speaker calls me to the resuscitation room for a “Level 1,” the highest level of urgency in the E.R. I hang up on Cynthia’s oncologist and head to the north side of the department.
A young woman is gasping loudly through the oxygen mask that paramedics put over her face, screaming, crying and thrashing all at once. She swats at the nurses trying to hold her arm down to place an IV, and at the technicians cutting her clothes off with shears. Her sweat prevents the electrical leads we try to attach to her chest from sticking.
This is routine for us. Many things can make a patient acutely agitated: pain, drugs, rapid blood loss or a shortage of air. Until we know the cause, we carry on even when patients resist. With little explanation, we surround them on all sides, pin them down and undress them, placing probes and leads while we get our bearings.
Someone tries to calm the young woman down while I scroll through her electronic chart. Mariah is 23. She has severe asthma and has been to the E.R. many times. She has bipolar disorder. The last time she was in the hospital proper, two months ago, she left abruptly once her breathing stabilized, before we could send her home with an inhaler and a steroid regimen for her asthma.
As far back as I look in her records, I find no visit with a primary care doctor. Like many patients in the E.R., especially younger ones, she doesn’t see any other doctors regularly. In effect we have been her primary doctors, although we didn’t know it and didn’t do much primary care.
I close the screen and look back at her. She is now on the monitor, the beeping display of her heartbeats and respirations scrolling along in green and red like a stock ticker at the bottom of the evening news. The numbers are terrible. She isn’t resisting us anymore, and her breathing has slowed. Mariah is starting to look confused.
We had achieved a sense of control, but it evaporates in an instant. Everyone starts moving quickly, jumpily, trying to suppress the sinking feeling that this is not like the other asthma flares we see, that this person is too sick for us to save. We focus on our roles. I’m worried she will stop breathing, so I come to the head of the bed and tell her we’re going to sedate her and put her on a ventilator.
Through the breathing tube and the IVs, we give everything we have already given, again: albuterol, epinephrine, magnesium, helium, antibiotics, lidocaine. Nothing is working; her lungs remain stiff and in spasm. Her heart slows, then stops. We start chest compressions and push more medications. We probe her heart and lungs with the ultrasound, trying to find something we can reverse. Nothing.
I look at the senior doctor in the room. He knows I’m asking if there is anything else we can do, and he shakes his head. We record the time of death.
There is a silent pause in the room. Before it passes, the unit secretary hands me the packet of paperwork for the deceased.
A death certificate differs from other medical records. It presents not one lone diagnosis field but four nested together, each line asking for the proximal cause of the line above. In the first line I write the diagnosis: cardiac arrest. I consider why her heart stopped, and in line 2 — “CAUSED BY” — fill in: respiratory failure. Line 3, CAUSED BY: severe asthma exacerbation. I am ashamed, but I know the cause of this as well. In line 4 I write, CAUSED BY: no medications at home to control her asthma.
This is the first patient all shift for whom the modern E.R. and I have acknowledged the root cause of illness. Our failure was not today but a few weeks ago, when she was last in the E.R. and we didn’t find a way to get her asthma inhalers to her at home. Maybe we assumed the medical team upstairs would handle it; maybe that team expected a primary care doctor would do so. Now our failure is the bottom line in black ink, pressed into the carbon-copy pages that will accompany Mariah’s body to the morgue.
Should the emergency room treat only emergencies? More than 80 percent of our patients arrive without sirens blazing, by walking in or after parking their cars with the valet out front. A rash that won’t stop itching, a lower back that won’t stop aching, a child who won’t stop vomiting. If their problems aren’t in our manual of emergency conditions, we say they are misusing the E.R. and try to dispense of them as quickly as we can. But here they are, having waited six hours to see me, asking for help. What to do for them?
I click a few perfunctory buttons in their charts. I say there’s nothing life-threatening going on as I hand them boilerplate discharge paperwork to sign. Someone calls me to see my next patient. I send them back to their families, jobs and responsibilities equipped with little more than these unceremonious goodbyes.
Almost one in 10 — 8.2 percent — of these discharged E.R. patients return to an E.R. within three days. What I leave unaddressed — persistent pain, nagging uncertainty about a diagnosis, a social dilemma — tends to stay that way, begetting yet another visit. An E.R.’s success is measured by how fast it sees these patients, not by whether it breaks these cycles.
The waiting room is empty now. I review the labs on an elderly man in Bed 3, enter the admission details for Cynthia and Jean-Luc, check that the woman with the migraine feels better and print her paperwork, and look at my watch: 7:00. My shift is over.
Although the E.R. was built to quickly get the sick “up” into the hospital, it has exposed, better than anywhere else, what patients lack while “out” in their otherwise private lives. Patients like Cynthia and Jean-Luc will survive devastating diseases under our care “up” in the hospital, but we send them “out” unable to sustain their precarious conditions without us. Patients like Mariah make their needs clear in the E.R., but we are too busy to meet them, and by the time they come back it’s often too late.
From 2012 to 2014 the federal government, recognizing that neither up nor out was solving the problem for a growing group of patients, financed an experiment at the University of Colorado. The typical E.R. has surgeons on-call to treat patients with broken bones; following that model, the E.R. in Colorado set up a team on-call for patients with broken homes.
Disadvantaged patients who kept returning to the E.R. were matched to social workers, health coaches and doctors who visited them where they lived and kept in touch for several months. By staying involved after the E.R. visits and not letting details fall through the cracks, the team reduced these patients’ need to revisit the hospital by 30 percent compared with the need of those in a control group.
The E.R. at Yale, where I work, addressed a different group in need. Elderly patients who came to the E.R. after a fall were offered a follow-up at home. There, they were screened for risk factors that might lead to another fall, such as loose rugs, medications that increased their risk of balance problems, or lack of necessary equipment or support at home. Over the next month, those who received such visits called 911 about half as often as similar patients who did not participate in the program.
Programs like these are not considered the E.R.’s core business, so they often rely on grants — and they end if funding dries up. Of the slim resources that E.R.s do set aside to address patients’ barriers outside the hospital, most are put toward hiring social workers and care managers. But these employees, stymied by mountains of paperwork and unrealistic patient loads, never get outside the hospital to see their patients, either.
The programs at Colorado and Yale succeeded by framing the E.R.’s resources differently. They recognized that the E.R. staff could identify problems that were destined to arise after discharge — and empowered those employees to help. Both programs orchestrated follow-ups outside the E.R; those teams worked on the day-to-day problems at home that go unaddressed in hospitals and clinics and can cause catastrophes.
As I zip up my bag, I head to Jean-Luc’s room to talk to him about urinary catheters. But when I arrive I find only our custodian with a mop, pulling the crumpled sheets and throwing out the extra tubes of blood. Up or out; Jean Luc is already up. His fate is out of my hands now, and I worry that he won’t keep his spirits up, that his bed sore will never heal.
Only a few minutes have passed, and the waiting room has filled up again. A man with a nosebleed has arrived. A nurse hands him a nasal-compression clip and a basin to spit in. He and his wife look around, wondering how long they will have to wait. By now, Jean-Luc’s bed is freshly made. For this couple, his quick move upstairs was a blessing. It means that, on my way out, I can tell them that they will be called back soon. A room just freed up.