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And I'm Linda Wertheimer. Today in Your Health, why you'll almost always have to wait when you go to a hospital emergency room and why it's likely plenty of people will be waiting along with you, some for as long as two days. That's the finding of a new report on emergency care in the United States by the Independent Institute of Medicine. NPR's Joanne Silberner spent a night in a very busy ER to see what's causing the problem.
JOANNE SILBERNER reporting:
It's 8:30 p.m. We're in the waiting room of Grady Memorial Hospital in downtown Atlanta with Dr. Arthur Kellerman.
Dr. ARTHUR KELLERMAN (Chairman of Emergency Medicine, Emory University School of Medicine): I'd estimate we probably have 80 or 85 people out here right now spread out among the benches. The earliest check-in we have at this point was 10 hours ago. Some of these people just arrived minutes ago.
SILBERNER: Kellerman is chairman of Emergency Medicine at Emory University School of Medicine. He also practices at Grady, and tonight he is taking us around. If anyone knows how to negotiate in an emergency room, it's Arthur Kellerman.
Dr. KELLERMAN: The first thing that is important is it's important to tell the triage nurse and the staff exactly what your problem is. Be honest, be truthful, be factual. That's the best insurance you have that the nurse and the doctor on duty will make the right decisions and get you into the queue in the proper way and as fast as possible.
SILBERNER: If your wait turns into many hours or even all night, Kellerman says it's okay at that point to be politely assertive.
Dr. KELLERMAN: It is very appropriate to go back to the nurse or back to the clerk or back to the volunteer and say, I'm feeling worse, or something is going on, or have they forgotten about me, my name is Jones, could you please check and see where I am in the queue.
SILBERNER: Kellerman is 6'2" and in his white coat he is something of a target in this waiting room. People grab at his sleeve as he walks by. He kneels to talk to some of them to get a sense of how long they've been waiting. As he stands to leave, a blonde woman tugs at his jacket and asks if there is anything she can do to get seen.
Dr. KELLERMAN: So I'm checking to see where her chart is. Is it over there? Is it here?
SILBERNER: The look on her face tells Kellerman she is hurting. She says she has fibromyalgia, a painful condition but not a life threatening emergency. She is not bleeding and she is not short of breath. Even so, Kellerman looks almost as pained as she does about the wait, and he asks the ER staff to do what they can.
Dr. KELLERMAN: She is hurting all over. She has been in a chair for many hours. She wants to lie down.
SILBERNER: The reason for the backup in the waiting room can be found through the swinging metal doors around the corner.
Dr. KELLERMAN: We are going into the main emergency department now. We just came through the triage. Excuse me, ma'am, I'll help you.
SILBERNER: There are patients everywhere, in rooms and in the wide hall, sitting on chairs or lying on gurneys.
Dr. KELLERMAN: Welcome to my world.
SILBERNER: Kellerman checks with the charge nurse to see if any space is available.
Dr. KELLERMAN: No patients in those areas or no vacant beds in the area.
Unidentified Woman (Nurse): No vacant beds.
Dr. KELLERMAN: Okay. All right. So in other words, we've got no critical care beds. All the resources of the emergency department are occupied.
SILBERNER: It's 10 p.m., and about 2/3 of Atlanta hospitals have temporarily closed their emergency rooms due to crowding, which means despite the crowding here, more ambulances are coming to Grady Memorial.
(Soundbite of ambulance)
SILBERNER: An unconscious and very old woman is rushed off of an ambulance. Her heart is essentially fluttering, not beating. She is taken into a special resuscitation room, kept free for people with life-threatening heart problems.
Dr. KELLERMAN: Did they have rhythm on-scene, or was it (unintelligible) on-scene?
SILBERNER: Kellerman watches as his interns, residents and nurses do everything they can.
Unidentified Woman #2: Clear. Is everybody clear?
Dr. KELLERMAN: All clear.
SILBERNER: They try two defibrillations. Both fail. There is nothing more to be done.
Dr. KELLERMAN: Was family contacted?
Unidentified Man: Not (unintelligible).
Dr. KELLERMAN: Okay. So we'll have to take care of that, and we will have to get the social worker involved. All right. Thank you all very much.
SILBERNER: Kellerman has to move on. There is so much to do for other patients.
Dr. KELLERMAN: For example, in this corridor now we have one, two, three, four, five, six, seven patients who were admitted waiting for beds, many others that are in the process of being admitted. But those seven had been stabilized, worked up, admitted and could be moved to an inpatient unit if an inpatient bed were readily available.
SILBERNER: Kellerman says this is what is backing up his emergency room. Only a few beds in the main part of the hospital open up at night, when someone is moved from the ICU to a bed in another department, when a family member can be found to pick up a patient to go home.
Dr. KELLERMAN: In Denver, in New Orleans, in San Diego, in New York, in Philadelphia. In city after city, it's the sickest, the most injured, the most severely ill, that are the biggest challenge, because we were designed to treat, to stabilize, to admit, or to send home. When you take away the option of admitting the patient because the beds are filled and we can't move the patient upstairs, that system grinds to a halt.
SILBERNER: Upstairs, surgeon Grace Rozycki in the ICU says she's got the same problem Kellerman has. Her 50 beds are almost always full. So are her spillover beds.
Dr. GRACE ROZYCKI (Surgeon, Grady Memorial Hospital): While we're waiting for beds to open, the patients have to wait downstairs in the emergency department. Not infrequently, but rather frequently. This is a crisis.
SILBERNER: The emergency department is losing money, in no small part because it's seeing more and ore uninsured patients. Hospital officials are reluctant to open more beds in other parts of the hospital because they say they can't afford to keep nurses and doctors on hand to service what might sometimes be empty beds. And so the emergency department gets backed up, especially at night. And people have to wait.
Dr. KELLERMAN: I'm sorry ma'am, but I've got no space right now. We're going to find a space, but I have nowhere that I can put you.
SILBERNER: It's near midnight, and the blond woman who was tugging at Kellerman's sleeve at the beginning of the evening has burst through the middle doors and is begging one of the residents for a bed.
Dr. KELLERMAN: We'll try to find space just as soon as I can, okay?
SILBERNER: But a helicopter has just landed on the roof with a car crash victim. That patient gets right in to a special trauma room. The distraught woman with the less severe condition has to wait.
Dr. KELLERMAN: Let's use this spot here at least.
SILBERNER: To limit the wait, Grady has set up a fast-track for people who aren't likely to need a bed after they're treated. But even that unit is backed up. People without a doctor or without insurance fill this part of the ER every night.
Kellerman stops by and flips through a few files.
Unidentified Woman #3: Hey, Dr. Kellerman.
Dr. KELLERMAN: Hi. Looks like we have a few. Tooth abscess, (unintelligible) swelling, med refill...
SILBERNER: What's a med refill doing here?
Dr. KELLERMAN: Well, I'm about to find out.
SILBERNER: It takes him just a few minutes to find out the middle-aged woman is out of blood pressure medication. The local free clinic wasn't going to be able to see her for a couple of weeks.
Dr. KELLERMAN: She came in at noon. We're now nine hours later. I'm rewriting her prescriptions.
SILBERNER: As it gets later, the crowding eases a little.
Dr. KELLERMAN: It's 1:20 a.m. We now have seven patients in this unit waiting for beds. And happily, three of them have bed assignments.
SILBERNER: With three patients moved out, the woman in pain in the waiting room finally gets a bed.
Dr. KELLERMAN: Good.
SILBERNER: And at 2:00 AM, Kellerman passes through the waiting room on his way out. There's still plenty of people here, and the fact that many evenings are this busy worries him.
Dr. KELLERMAN: If we're struggling to deal with tonight's 9-1-1 calls in city after city across the united states, how in the world are we supposed to handle an epidemic, a pandemic flu, or a major terrorist attack, or the next natural disaster?
SILBERNER: And because the ER is so crowded all the time, he worries about whether some night he and his overworked staff won't notice the beginnings of a heart attack in someone waiting on a gurney in the back hallway.
Dr. KELLERMAN: When I come to work, as I get ready to leave my driveway, I say, Dear Lord, help me not to make a mistake tonight. And when I leave the hospital, I say, dear God, thank you for getting me and my patients through another night.
SILBERNER: As he pulls out of the parking lot you can see the blue and white bumper sticker on the back of his car. It says, if I'm injured in a crash, take me to Grady.
Joanne Silberner, NPR News.
WERTHEIMER: A report by the Institute of Medicine says the nation's emergency rooms are at a breaking point. You can read key findings at npr.org/yourhealth.
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