I had to beg for my patient in his twenties, dying and previously healthy, to get the care he needed. Beg! Not because no one wanted to help, but because the latest wave of coronavirus had brought our healthcare system to its knees. As of mid-January, no intensive care beds could be found in any Richmond hospital system.
The challenge for PEs over the holidays was to keep up with the wave of patients seeking to get tested for COVID. This surge has finally peaked, thanks to more home testing kits and outpatient testing sites. Now the challenge has shifted from seeing large numbers of worried wellbeing to trying to find a place to admit seriously ill people. Either we don’t have beds, thanks to the Omicron variant that tore our communities apart over the holidays, or we don’t have staff, thanks to two years of a pandemic that kept healthcare workers away from the front lines.
The night I collapsed and begged, I had naively thought the ER landscape was prettier because people had stopped overwhelming us looking for COVID tests and work notes. I should have known better after two years than to underestimate the ability of the coronavirus to disrupt our healthcare system. That night, an unvaccinated patient in his twenties came in with fever and myalgia. He was COVID-positive, hypotensive despite vasopressors, and flaking. The transfer center said the only critical care bed available was at least an hour away by ambulance at another small community hospital only slightly larger than mine.
But the intensivist said he would take it, adding: “We are a small facility with minimal specialist inpatient services beyond a general surgeon and cardiology nurse practitioner. Looks like he needs more.
I explained my situation to him. “I agree with you, but I’m told my only options are to send him to you or keep him here where we don’t have intensive care, and I’m the only doctor in the hospital. He it’s just me and four nurses tonight, and we also have a full emergency department and waiting room.
Unfortunately, the overwhelming volume of Omicron patients had left the Richmond University Teaching Center in perpetual diversion. Their transfer center was doing its best to prevent doctors from outside facilities from talking to doctors about accepting more patients at their already overcrowded facility. Still, my patient needed to be there. I was on the verge of tears when their transfer center, as expected, refused my transfer request without letting me speak to a doctor. The mental distress of having a single critically ill patient for whom I could not find proper care far outweighed the stress of seeing 50 healthy patients with mild COVID symptoms in a single night.
I decided it was time to wake up the duty administrator. “I’m sorry,” she told me 30 minutes later after trying to use her administrative authority to help me. “Our sister hospitals already have several cases of intensive care in their emergencies and are diverting ambulances. Do you have friends you can call in other city hospital systems? »
My patient was decompensated despite the nurses increasing his norepinephrine. It was time to make friends. Abandoning protocol, I called the university referral center again and implored their ER clerk to let me speak to an EP rather than their obstructionist referral center. After a 30 minute wait, I got Michael Joyce, MD, the incumbent. I started with “I need help” and begged him to accept my patient. “He is in his twenties and previously in good health and is not going to sit well in my emergency department or go to a small hospital 50 miles away. He needs an infectious disease; he needs dermatology. PLEASE.” Long story short, Dr. Joyce is now my friend.
The victory was short-lived. While I struggled to get care for one patient, other patients stagnated. My little 13-bed ED was a parking lot, with nine patients waiting for upstairs beds, higher levels of care, or a mental institution. An unfortunate psychiatric patient had been held in the emergency room for more than a week. All the while, we were getting more and more EMS teams.
something must give
I received a call around 5 am from poor Brittany at our transfer center, whose work I definitely don’t envy. More than 30 hours earlier, the hospital that normally receives our surgical patients had promised the next available bed to our patient with an intra-abdominal microperforation. Now they were going back on that promise, using the excuse that they were a diversion. We were also on a diversion, like all the hospitals in the region. Unfortunately, unlike them, we did not have the level of care this patient needed. My head was about to spin around like the scene of The Exorcist.
It’s to the point where I pray that my loved ones don’t get sick now because I’ve lost faith in our medical system’s ability to care for them if they get seriously ill. EPs in small community emergency departments find that the most important thing we can do for our patients has little to do with our medical expertise and everything with our ability to roll up our sleeves and suppress it with the system to find these increasingly scarce beds at appropriate levels of care.
A paramedic recently told me, “Doc, it’s like the wild Wild West out there.” Storm Omicron will pass, but the repeated abuse of wave after wave of COVID-19 variants has left us in a lawless new frontier of nurse shortages and resulting bed deficiencies where EMTALA is useless, and people are dying. because no place has capacity. Something has to change.
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