Wednesday, May 09, 2007

The Face of Crowding

I coded a patient yesterday for seven hours. He arrived at the very beginning of my shift. The department was packed, as usual, with about thirty percent of the beds filled with patients waiting for an inpatient bed assignment. EMS brought this (young) 47 year old man to the Shock/Trauma bay in severe distress, sweaty, pale, and unable to draw a deep breath to speak.

The patient was last seen by his family 24 hours before he came to my emergency department. He had been complaining of a cough, and had gone to his mother’s house to ask for cough syrup. When his sister called him the next day, he did not answer. Responding to the sister’s 911 call, the paramedics found the patient lying on the floor in his apartment barely conscious.

The patient was HIV positive and had not been taking his antiviral medication. He drank to inebriation daily and smoked a pack of cigarettes per day. The family thought that he had high blood pressure, but could not be sure.

He had a pneumonia completely obliterating the left lung. His kidneys and liver were failing. He had an overwhelming infection in the blood stream, also known as sepsis. I placed him on a ventilator, gave him antibiotics and fluids, and ordered all the usual tests.

Now, so far, this is a sick, but not unusual, patient. Then I called the Intensive Care Unit for an admission. There were no beds. There was a waiting list with three other patients on it. At my hospital, the ICU doctors don’t take care of the patient until there is a bed available, so I was destined to be his doctor until then.

Then his heart stopped. We did CPR, we gave drugs and we successfully resuscitated his heart within 5 minutes. His family had now gathered en masse, and my hospital encourages families to be at the bedside during CPR. I talked with them about his poor prognosis, then had to leave to take care of a heart attack, a stroke, and two people with very high blood pressure.

Thirty minutes later his heart stopped again. We did CPR again. We gave drugs again. This time it took ten minutes to regain a heartbeat. I explained everything we had done for the patient to the family. They only wanted to know when they could get to the ICU. I left to take care of the other six patients who arrived during the code, plus the first four, plus the ten waiting for beds upstairs.

Thirty minutes later his heart stopped again. We did CPR again. We gave drugs again. It took 15 minutes to regain a heartbeat. By now the family started to realize that this patient might actually die. The crying and wailing upset my other six Shock/Trauma patients, including one child……..but what could I do? I left to take care of the eight new patients, the ten patients in the middle of workups, and the ten patients waiting on beds in the hospital.

Thirty minutes later, his heart stopped again. I realize that this story begins to sound like that famous children’s book, A Fly Went By, by Dr. Seuss, that adds a new item to long list with every turn of the page. Every time the patient’s heart stopped, we did more, it took longer, and more patients piled up in the department.

Finally, after seven plus hours and ten episodes of CPR, the patient’s heart finally gave out. As I pronounced the time of death, his family expressed their grief. Why were we stopping? Couldn’t we do more? What about the ICU? Why did he have to die today?

I know that the questions come from a place of deep loss, but I couldn’t help but wonder about the losses of the other patients who were seen in the ED that day. One nurse and one tech were with the patient all day, leaving us short in the department. Our social worker/patient advocate spent her whole shift with the family. I spent more than three quarters of my day in that room, with that patient. Only one quarter of me took care of the other fifty-two patients we saw on my shift.

My dying patient deserved better than dying in a crowded Shock/Trauma bay in the emergency department. My other patients deserved more time and attention than they received. The dedicated health care professionals deserved better than spending their entire day doing the impossible.


Val Jones, MD said...

Thanks for sharing this tragic story. The bed crisis is terrifying... a reporter recently asked, What would the overcrowded EDs do in the case of a terrorist attack?

Anonymous said...

I don't know that this is always a "bed scare." Betcha dollars for doughnuts that there are plenty of beds but not plenty of staff. Patients need doctors and nurses and this country has a short supply. Until the public and private sectors wake up and smell the bedpans it is only going to get worse...