Your message has been successfully sent to your colleague.
I had to beg to get my dying, previously-healthy, 20-something patient the care he needed. Beg! Not because no one wanted to help, but because the latest coronavirus surge had brought our health care system to its knees. Halfway through January, an ICU bed couldn't be found in any hospital system anywhere in Richmond.
The challenge for EPs during the holidays was keeping up with the wave of patients seeking COVID testing. That wave finally crested, thanks to more home test kits and outpatient testing sites. Now, the challenge has morphed from seeing high numbers of worried well to trying to find somewhere to admit the critically ill. Either we have no beds, thanks to the Omicron variant tearing through our communities over the holidays, or no staff, thanks to two years of the pandemic driving health care workers away from the front lines.
The night I broke down and begged, I had naïvely thought the ED landscape was looking prettier because people had stopped overwhelming us by seeking COVID tests and work notes. I should have known better after two years than to underestimate the coronavirus's ability to bedevil our health care system. That night a 20-something unvaccinated patient walked in with fever and myalgias. He was COVID-positive, hypotensive despite pressors, and desquamating. The transfer center said the only available ICU bed was at least an hour away by ambulance at another small community hospital barely bigger than mine.
But the intensivist there said he would take him, adding, “We're a small facility with minimal in-patient specialty services beyond a general surgeon and a cardiology NP. Sounds like he needs more.”
I explained my predicament to him. “I agree with you, but I'm being told my only options are to send him to you or keep him here where we have no ICU, and I'm the only doctor in the hospital. It's just me and four nurses tonight, and we also have a full ED and waiting room.”
Unfortunately, the crushing volume of Omicron patients had left Richmond's academic teaching center on perpetual diversion. Their transfer center was doing its best to prevent doctors at outside facilities from speaking to physicians about accepting more patients to their already overburdened facility. Yet my patient needed to be there. I was on the verge of tears when their transfer center, as expected, denied my transfer request without letting me speak to a physician. The mental distress of having just one critically ill patient for whom I could not find appropriate care far outweighed the stress of seeing 50 well patients with mild COVID symptoms in a single night.
I decided it was time to wake up the administrator on call. “I'm sorry,” she told me 30 minutes later after trying to use her administrative pull to help. “Our sister hospitals already have multiple ICU holds in their EDs and are diverting ambulances. Do you have any friends you can call in other hospital systems in town?”
My patient was decompensating despite the nurses titrating up his norepinephrine. It was time to make friends. Abandoning protocol, I called the academic referral center back and implored their ED clerk to let me speak to an EP rather than their obstructionist transfer center. After a 30-minute hold, I got Michael Joyce, MD, the attending. I led with “I need help,” and begged him to accept my patient. “He's in his 20s and previously healthy and not going to do well sitting in my ED or going to a small hospital 50 miles away. He needs infectious disease; he needs dermatology. PLEASE.” Long story short, Dr. Joyce is now my friend.
The victory was short-lived. While I was fighting to get care for one patient, other patients were stagnating. My little 13-bed ED was a parking lot, with nine patients waiting for beds upstairs, higher levels of care, or a psych facility. One unfortunate psych patient had been an ED hold for more than a week. All the while, we were still getting more EMS squads.
I got a call around 5 a.m. from poor Brittany at our transfer center, whose job I definitely don't envy. More than 30 hours earlier, the hospital that normally takes our surgical patients had promised the next available bed to our patient with an intra-abdominal microperforation. Now they were reneging on that promise, using the excuse that they were on diversion. We were on diversion too, like every hospital in the area. Unfortunately, unlike them, we did not have the level of care this patient needed. My head was about to spin all the way around like the scene from The Exorcist.
It's to the point where I pray 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 become critically ill. EPs in small community EDs are finding 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 scrap it out with the system to find those increasingly rare beds at appropriate levels of care.
A paramedic recently told me, “Doc, it's like the wild, wild west out there.” The Omicron storm will pass, but the repeated abuse of wave after wave of COVID-19 variants has left us in a new lawless frontier of nursing shortages and resultant bed deficiencies where EMTALA is useless, and people are dying because no place has capacity. Something has to change.
Share this article on Twitter and Facebook .
Access the links in EMN by reading this on our website: www.EM-News.com .
Comments? Write to us at [email protected] .
Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD , and read her past columns athttp://bit.ly/EMN-ERGoddess .
Your message has been successfully sent to your colleague.
Your message has been successfully sent to your colleague.
This website uses cookies. By continuing to use this website you are giving consent to cookies being used. For information on cookies and how you can disable them visit our Privacy and Cookie Policy.