COVID-19 Update

Over a period of about 13 years, I spent a lot time in Emergency Departments and Trauma Centers doing sales demos and inservice, and I can tell you from direct observation that when things go wrong, those people are amazing to watch.

While every job has some kind of stress attached to it, life in the ER is different.

You and I may be under the gun because we have to come up with a 10 minute PowerPoint thing for the boss tomorrow, and maybe you start to feel a panic attack coming on. Or maybe you're the one who has to go out and break up a street fight.

But the docs and nurses at the local ER have to deal with the immediate consequences of the sometimes really stupid shit we do. They have to clean it all up, and put people back together. 

And too often there's just not enough they can do to fix it. When they "fail", it means somebody's dead, and then they get to tell the family about it.

It's just fucking different from anything we can even imagine.

WaPo: (paywall)

We’re used to stress in the ER. But omicron has made our jobs impossible.

We can’t provide the right care at the right time anymore — and after two years, we’re exhausted from trying

Walking into a shift in the emergency department these days feels a bit like entering a disaster zone.

There are 50-odd patients in the waiting room needing to be seen. A number of beds are closed in the emergency department and across the rest of the hospital because of a lack of staffing. We’re holding a half-dozen acute mental health patients who desperately need care, because there’s no room in psychiatric hospitals. A few bed-bound patients are ready to leave but don’t have a ride to wherever they’re going, so they’ll be spending the night with us; there’s no one to drive the ambulances to transport them. And a couple dozen more patients have been waiting on emergency department stretchers for hours after evaluation, until an intensive care unit, medical or surgical bed becomes available. Meanwhile, we can’t use these emergency department staff or beds to care for those sitting in the waiting room with yet-to-be-diagnosed problems. Instead, I’m scanning the waiting room list to try to find the needle in the haystack — someone with a life-threatening illness that we haven’t identified yet.

By the time the patients make it to me, I’m playing catch-up on their pain, their illness and their frustration.

As an emergency physician, I thrive in challenging situations. In the best emergency care, I work with my team to quickly stabilize a sick patient, create trust with them and their family, and then come up with a clear diagnosis and therapeutic plan. I think about what needs to be done today to make sure they’re safe — and what needs to be done tomorrow, or in a month, to keep them from coming back.

In pre-pandemic times, I was usually able to do this. The system sometimes worked against me, most often because a patient lacked the right insurance to get the tests and treatments they needed. And sometimes we struggled with an acute surge of patients. For example, on a rainy night, we’d get overwhelmed with folks who’d been in car crashes. During flu season, we’d be crowded with influenza patients for a week or two. These surges were frustrating but usually relatively short.

Depending on how you count, though, we’re currently on our fourth or fifth surge of covid cases. As our health-care system is pummeled by yet another wave, it’s just too much. We never recovered from the last wave. Our bulwarks cracked, and then they were breached. It has become nearly impossible for us to take the right care of the right patient at the right time.

Across the country, emergency departments, intensive care units and ambulance services are overwhelmed. According to data from the Department of Health and Human Services, almost 80 percent of inpatient beds and 83 percent of intensive care unit beds are being used; other data sources suggest that these estimates do not fully account for staffing limitations and that even fewer staffed beds are available. Hospitals in almost half the states have paused or stopped non-emergency surgeries because of staffing shortages and hospital overcrowding, resulting in further stresses on the system, on patients and on providers.

As the severe cases accumulate, the distress among providers does, too. It’s certainly because of the exhaustion of caring for horribly sick covid patients yet again — especially now that the disease is so preventable. But even more, it’s the moral harm from the other cases, the ones that have nothing to do with covid except that they’ve been overtaken by the pandemic. It’s knowing that an elderly man was on a stretcher for hours with a broken hip, lying in his own urine, because there was no one to care for him. It’s the patient whose inflamed gallbladder smoldered while they waited. It’s the emotional exhaustion from assuaging the understandable anger of families calling for updates, only to be told that their loved one has not been evaluated yet after many hours in the waiting room.

“I just don’t think I can go back again tomorrow,” one friend texted me after a particularly demoralizing shift. Another friend told me: “I feel like we’re rats on a sinking ship. Do I jump off now or hope that someone saves us?” And every staff member who leaves causes a domino effect.

One small example: There are not enough emergency medical technicians. As a result, a patient might wait more than 12 hours for transportation after they are ready for discharge to a nursing facility or back home. That patient waits in a bed that could be used for someone with chest pain that might be a blood clot, belly pain that might be appendicitis, or a broken arm that needs pain meds.

Of course, this isn’t just about the coronavirus. Rather, the pandemic has laid bare the myriad inefficiencies and frank failures in our health-care system that we had managed to paper over until a real crisis came along. Emergency departments and hospitals have worked on a thin edge for a decade. We have been the last resort for mental health and dental care; we have routinely asked nurses, doctors and techs to work overtime during swells of trauma patients or influenza; we have tolerated threats and violence against our co-workers in the name of providing care. We have served as the safety net for a broken system. But with the serial surges of covid, we simply can’t do it anymore.

Two years in, and our health-care workers and systems have been beaten down, again and again. At no point have we stopped to take stock of how we survived the last wave, much less what’s needed to withstand another one. So let me be clear to my colleagues: This is not our fault. Our exhaustion and frustration are valid. We can’t change this alone.

We already have answers on how to fix and rebuild. They’re straightforward things, like subsidizing the training of more staff across all levels of the health-care system — from unit assistants to certified nursing assistants to physicians — and providing emotional and financial support for those who have stayed. They’re more complex steps, like setting up a public health emergency response system that is robustly funded, based on accurate data and resilient. And they’re big-picture things, like making sure that people can access care when and where they need it, and that our testing infrastructure, telehealth system and home-care network are intact. Ultimately, we also need to change the system’s incentives, so that prevention of a hospital stay is valued as much as end-stage treatment is.

Two years ago, I hoped the pandemic would help us marshal resources and political will to finally fix this system. But now, I worry that the fixes are not going to come. Health care in the United States was never perfect, especially for those who live at the margins of society. It increasingly seems that after the pandemic we’ll be left with something far worse: scarcity, inaccessibility, compassion fatigue.

So yes, I will celebrate like everyone else when the omicron wave passes. But I know there will be another one — probably another coronavirus variant, but possibly something else. At the very least, all those delayed surgeries, postponed preventive-care visits and untreated mental health problems are going to show up, and patients will need care that is simply not there.

My colleagues and I will keep showing up for work. Because if we don’t, who will? But we have been changed — and not for the better.