The emergency room is a strange world. It’s both the best and worst of medicine all in one crazy area. In one room someone is getting impacted ear wax cleared from their ear, in another someone is being resuscitated after a cardiac arrest. Some people find their back pain was really a dissected aorta, others find that their back pain is a ticket to a few hours sleeping on a cot inside the hospital away from the cold NYC streets. The ER is the entryway to the hospital. Most people that end up in the hospital first have to go through the ER, “get processed” so to speak. It is also the safety net for the uninsured and those that don’t have access be it by choice or by circumstance (such as a closed clinic on the weekend). If there is one thing in my mind that is certain is that experience in the ER shows you the future of modern medicine and it is a grim one.
I have now worked in ERs on the west and east coast and they are all similar: bursting at the seams. Inevitably stretchers are lining the hallways as the ER gets put on “divert” meaning literally it is full. This is all under normal circumstances. There is no influenza epidemic, no massive plague, no terrorist attack. One can only imagine what would happen under those circumstances. The ER is about getting patients in and out as fast as is safely possible. Delaying may result in the next person getting sicker, or even dying. Yet, ultimately the ER is all about delay. Beds in nearly full hospitals are not ready. Patients wait hours, even days waiting for a bed to get admitted. This “wait” was what our non-nationalized system of medicine was supposed to be somewhat immune from. Consultants from various medical disciplines take hours and hours to see patients as they are stretched too thin. Yet those various disciplines are more competitive than ever to get into. You don’t see new medical schools popping up. You don’t see class sizes expanding even as demand for doctors increase.
The other day I had a 100 year old patient. He was a former doctor at the hospital. He had pneumonia. He was stable but far from well. He was throwing up left and right. The overworked nurses would get to him when they could but he had already soiled his clothes. His frail wife marched around trying to find out when he would get a bed. After all he had served for over 20 years at the hospital and here he was soiling his clothes and people were too overstretched. It was obvious she was becoming very exhausted. I went in the hall and stole a chair for her to sit on. What else could I do? It wasn’t as if I could magically make a bed open up. She came up to me, “You guys are fine but he served here for over 20 years, I never thought we would be treated like this.” I went over to his bed stretchers lining the hallways which were bursting at the seams. I stood in the center of a mass of stretches. I looked 360 degrees around me. They were all my patients. They seemed to all look at me: the women with anemia, the man with pneumonia, the lady with a shunt in her brain. They all had the same look on their face, that of exhaustion but I couldn’t help but think it wasn’t the exhaustion because it was 2AM in the morning. It was that same exhaustion I felt. Maybe it was frustration.
The other day as I was going to clinic for a meeting I ran into a man in the elevator who smiled at me “Hey you’re that doctor that took care of my wife. We’re here for the follow up appointment. ” He got off the elevator, “It’s nice seeing you.”
I love what I do but sometimes it feels like people don’t love each other and themselves. People lack insight into their disease, partially by their choice and partially by the fact that doctors cannot spend enough time with their patients as they are in such short supply for an ever aging population. If only it were about sore throats and coughs. It’s about people on dialysis, people with multiple stents, people with liver disease, people with med lists that have to be typed because who can remember 15, 20, 25 medications. I don’t understand society even though I see it at its most vulnerable. If a system is in such a dire state that if action is not taken it will collapse is it not society that should be compelled to fix it? If anything needs to be “bailed out” is it not this? Would doing so be any more “socialist” than funding banks that made poor decisions and coerced others in doing the same?
There is this notion of personal responsibility that many critics bring up with respect to people. I believe in this, to a point. Yes, many people by poor choices have caused or exacerbated their illness. There are people who took out loans when they did not have money. Fatty food is cheap, and loans by banks were cheap. It was their choice but it was other’s influence that had a large part in it. When the consequences of those actions come to fruition what do we do?
Is it not then a double standard when we chose to bail out one group and not the other? Have we not by our actions as a society put money as a higher cause to act on than our health? Is that the “choice” we are making? People have a responsibility for their actions, but as people in a society do we not have a responsibility to act to improve our society and help others make more sound decisions. Choice is not a simple a, b, c response. Doesn’t the 300lb man with diabetes know that white bread is bad for him? At first glance it is his “choice” that he eats white bread. But having been around enough people with disease I can tell you it is never that straightforward. That 300lb man may live in a certain section of Harlem where for wheat bread is nearly nowhere to be found. Then again maybe that same man has wheat bread and chooses not to eat it. This is despite the variable of mental illness which is much more prevalent than people can imagine. Is someone ravaged by depression, bi-polar, or dementia really making a “choice” that is the same “choice” as that of a mentally healthy person? Nonetheless at the end of the day if he spirals downward he will end up in the ER. There is no distinction between those that made poor choices and those that didn’t. He will sit right next to the 100 year old doctor. In making the assertion that you will chose to treat those who made the right choices and let those that made poor choices suffer, you are making a choice to judge without enough information. If in a court of law you have to prove beyond a shadow of a doubt is it different in a hospital? With such overburdened resources there is really no way to assess who made bad choices with appropriate options and access. That is the luxury of philosophers and those that aren’t on the frontlines. But every so often you will get a smile in an elevator that reminds you why you are on the front lines.
It’s a strange world indeed.