I did my first shift of duty of the new year this week, in an NHS which is apparently not in crisis and you are getting all the financing you need.
For the first time, I went in in the morning and found patients on our medical admission list who had spent the night still waiting in ambulances. These patients, one of whom had arrived more than eight hours earlier, would have been attended to by an emergency nurse, blood samples taken and observations taken, and evaluated by a doctor and the medical team to confirm that it was indeed entry necessary. They were all in the rear ambulances, with teams of paramedics unable to get back on the road. I have never seen patients go this far in the hospital system without physically entering the building.
We have had to define new locations in our electronic system to be able to keep track of patients that we are entering but are still in the parking lot.
Even once you’re through the door, things may not get better. I took a woman to a procedure room to examine her. He was mortified when she began cleaning a dirty cart herself. She had been sitting in a chair in a corridor for more than 14 hours. I could only apologize as we took her blood before putting her back in the corridor to wait for her results so we could clear the procedure room again.
Even being seriously ill doesn’t guarantee you a place these days. I checked on an older man with severe pneumonia who had been in a chair overnight in a busy testing area off the waiting room. He needed admission for intravenous antibiotics that were being given every eight hours while he was sitting in his chair. I examined him in the hallway, apologizing again.
Emergency departments were not set up or staffed to care for sick patients for days on end. Its purpose is to see patients as they are admitted, initiate care, arrange admission, and transport patients to the hospital for definitive treatment to be administered by others. And yet, at one stage we had over 50 patients in the department (two full wards’ worth, some for more than two days) receiving care from the A&E team who also need to see incoming patients. This is not a safe situation.
In general, we have all had to increase our tolerance for taking and minimizing risk. For example, the head nurse who took twice as many regular patients under her care in the triage area because she felt he was safer than leaving them in the ambulance. Or the ward teams caring for patients who really should be in intensive care but there aren’t enough beds there. Or the nurse monitoring the man with pneumonia in his peripheral vision as he continues to assess new patients.
I have had to consciously adjust my own risk threshold, and it has not been easy. I now often send home patients who in days gone by would have been admitted or kept in the hospital for another day or two. Some will go back in. I’m keeping my fingers crossed that I don’t cause any lasting damage. However, I am concerned about the example this sets for our medical trainees and try to justify the decisions I make to reassure them, and myself, that I am not practicing dangerously. Maybe if I am. My insecurity makes me doubt my judgment.
Pressure affects the way we interact with each other. Yesterday I had a colleague apologize for being abrupt while caring for 12 sick medical patients alone, in an area usually used for stable patients awaiting transport home, even though she wasn’t even trained to administer their IV medications. Colleagues who are usually supportive and collaborative attack. In this environment, none of us can weigh our decisions with a clear head. These human factors only increase the risks to patients as our communication deteriorates.
And all the while we apologize to our patients and to each other, acknowledging how chaotic it is that we can’t even provide a place to lie down, a pillow, a toothbrush, some privacy. These people are only here because they are not well and we cannot offer even the most basic dignities. And yet, constantly apologizing for factors beyond our control is exhausting, as is repeatedly listening to completely justified complaints and anger without feeling the temperature rise. Sometimes the best I can do is stay calm all day; unfortunately, it often leaves when I get home.
Pressure has always been a feature of what we do, but not at this level for so long. A colleague described coming to work at the time as being repeatedly punched in the arm until it finally went numb. We are getting sleepy; more and more is needed to shock us. On my shift I saw several patients who had been in the ER for 30 or 40 hours; that would have been shocking in days gone by, but as it stands now, it’s okay because at least they’re on a cart in a cubby. Today it was the guy trapped in the ambulance that surprised me. Maybe tomorrow it’s someone dying in the waiting room. We can only shrug our shoulders and do what we can.
However, just as his arm might go numb after being punched, it still hurts when he thinks about it. I hate the fact that this is the best we can offer.
Declaring that this is not a crisis is the first step in acknowledging that the level of care we are providing at this time is acceptable. It surely isn’t. We must recognize that we all deserve better than this.