II have worked on it National Health Service for more than 10 years and I have never seen it as bad as now. Urgent and emergency services are overwhelmed and primary care is also overwhelmed. It is a very sorry state for all concerned. The last few weeks have been beyond terrible and it was all predicted by those on the ground months ago.
Before Covid, our ED could handle 30 patients at a time, but would “flex” that number up to 50 if necessary. During Covid we increased the number of bed cubicles and went from 14 to 23 standard beds and from three to seven resuscitation spaces.
However, despite that, we now often have more than 100 patients in the department at the same time. Between 40 and 50 of them are “ready to transfer”, that is, waiting to move to a bed upstairs.
But there aren’t enough beds, and discharging patients who are medically ready to go can be difficult. As a result, the wait time for a hospital bed is around 48 hours and has recently been as long as 72 hours.
We are now in a position in our A&E where we are taking care of a ward and a half of inpatients, occupying the spaces with beds, while at the same time running an emergency department out of the hallway and waiting room. Having to manage the very sick in inappropriate areas is now becoming the norm.
An emergency department (ED) is not a safe place. It’s full of some of the sickest people in a hospital, in a chaotic environment. There is a lot of coming and going, patients move frequently, and staff see multiple patients. It’s a recipe for things to get lost.
Add in the fact that ER staff work rotating shifts, so new staff come on duty every few hours and don’t necessarily know the patients, and there’s more chance of potentially vital information being lost.
Waiting rooms can be dangerous places if you spend a lot of time there. That’s because they’re not monitoring him often, and if he didn’t present as sick initially and then deteriorated, then that may not be resolved for some time. People tend not to openly announce it before passing out, for example.
Our overflow corridor never has fewer than 20 patients; people who are too sick to sit in the waiting room. The corridor is made up of patient carts lined up, head to toe, along one wall. It’s busy, it’s loud, and there’s no dignity there. The patients trapped there are being cared for behind the staff holding the sheets in the hallway.
Fortunately, we haven’t had an unexpected cardiac arrest in the corridor yet, but that’s a matter of time.
As an example of the intense pressures that emergency services are under, we recently had to move a patient from a cubicle into a hallway. That was so that the person in the corridor, who was more seriously ill, who was in fact dying, could die somewhere other than a corridor.
It is about a frail old man who, in the triage, found himself with an irreversible pathology. We knew they would die, and quite imminently. From a compassion point of view, the corridor would have been a terrible place to die.
As emergency physicians, we have always tried to provide the dying with a place of privacy, where their loved ones can be with them in relative peace. I would expect the same degree of compassion to be present in all A&E, but it’s getting harder to deliver.
A patient with severe respiratory problems was recently brought to our emergency department by a GP as there were no ambulances. His oxygen saturation level dropped to 80%, which is very concerning.
But there was no oxygen available for the patient when he arrived. Sometimes we run out of portable oxygen in the ED because we have so many patients in the hallway.
That patient waited all night and the next day in the waiting room even though he had what we call a national early warning score (News) out of 10. That’s a measure of how bad they are, based on monitoring their heart rate, blood pressure and other vital signs. Anyone with a double-digit News score is dead wrong. Generally, patients presenting with a Notice of seven or more should be managed on a resuscitation bed.
I am suffering more moral damage now than at the height of Covid. That’s the feeling of helplessness people get when they abandon their moral beliefs in high-pressure situations.
Covid was hard. We had oxygen shortages and had to decide to turn off oxygen for some patients we couldn’t save so we could ration what we had, and telling family members that their loved one had died became normal.
But what we are seeing now is much worse. I feel like the boiling frog.
A&E staff try to do their best in an extremely challenging set of circumstances. But we have accepted for some time that we are providing a service that is way below standard. It is a pity that there seems to be no political will to try to salvage the situation.
As told to Denis Campbell
