Emergency Room

A story of a patient and doctor. Both facing the ER.

Waiting Game

“She was 69 years old and, with the exception of mild heart disease, was in excellent health.

One morning, she noticed that her heartbeat was irregular and she felt short of breath. She asked her husband to drive her to the local hospital.

Early in my residency, I realized that like Pavlov’s Russian dogs of yore, the other surgeons-in-training and I had developed a conditioned response to our electronic pagers. Our blood would rush and our breath disappear at the sight of one five-digit extension on our beeper’s screen. The emergency room was calling.

“

The emergency room was calling.

After waiting about an hour to be seen, she was diagnosed with rapid atrial fibrillation around 8 o’clock on a Thursday evening. Given her age, the emergency department staff and the consulting cardiologist decided to admit her to the hospital.

We didn’t dislike the E.R. Some of our most memorable training experiences occurred there.

It was just the sheer crowding of that area of the hospital that made our stomachs drop.

Because no inpatient bed was available, the patient was kept in the ED overnight. The narrowness of the stretcher and the noise and bright lights of the ED hallway made it hard for her to get much sleep. The following day, shortly before noon, she was wheeled upstairs to a bed.

Day and night, the hallways of the E.R. were lined with gurneys, sometimes parked two rows deep. Patients were forced to wait, or “board,” on those flimsy narrow stretchers until a bed became free at the “Inn,” as the E.R. staff referred to the rest of hospital.

Early in the afternoon, the cardiologist stopped by to let her know that because her admission had been delayed, it would not be possible to complete her procedures before the end of the workday. Therefore, she would remain in the hospital receiving intravenous heparin and oral warfarin throughout the weekend

Stuck for hours and sometimes entire days, these patients were surrounded by the groans, cries and hacking coughs of others who waited with them.

Doctors and nurses did what they could, pinning curtains around two stretchers to create makeshift semiprivate rooms and dimming the lights to bring some sense of calm to the chaos.

But there were always more new patients, and the “boarders” would be left to continue their wait, calling out to whoever approached to ask for water, a bedpan or an extra blanket to keep warm in the chilly corridors.

Early in the afternoon, the cardiologist stopped by to let her know that because her admission had been delayed, it would not be possible to complete her procedures before the end of the workday. Therefore, she would remain in the hospital receiving intravenous heparin and oral warfarin throughout the weekend

None of my colleagues were surprised when we heard one day that a patient had died in those halls waiting for a bed.

The next day, without warning, she sustained a massive embolic stroke. The clot occluded her right common carotid artery and extended into the intracranial branches.

Within moments, signs of middle cerebral artery syndrome developed. A neurosurgeon rushed her to the operating room and attempted to extract the embolus. Unfortunately, the procedure tore her internal carotid artery. Because of the anticoagulants in her system, rapid intracranial bleeding ensued and led quickly to brain-stem herniation.

“I’m not sure there’s much more we can do about this overcrowding,” an E.R. nurse later confided to me.

For the next 2 days, she lay intubated in the ICU without evidence of neurologic recovery. Her family asked that she continue to receive mechanical ventilation until preparations for her funeral could be finalized. At that point, life support was withdrawn 112 hours after she

walked into the hospital.

Almost all ER doctors treat patients daily who have Medicaid, but who can’t find doctors who will accept their insurance.

Since these insured patients are more likely to use the emergency department, the number of visits to emergency rooms will increase as the new health law is implemented.

- Julie Rovner for Southern California Public Radio

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These stories are from John Maa, M.D., who wrote about his experiences with his mother’s death for the New England Journal of Medicine and Pauline W. Chen, M.D. who was featured in the New York Times.

Designed by Gabrielle LaMarr LeMee in 2011.Set in Vista Sans and United Serif Regular.