A thousand cuts to our healthcare system.

For the past few months, hospitals everywhere have been operating just below a point of crisis. It's become my new regular when working in the emergency department. I see it written about in newspapers and people I talk to who aren't in healthcare seem to be aware, but I'm not sure people get it. I mean, I know people realize things aren't great - but things haven't been great for a couple of years now, and it seems it's a challenge to recalibrate what bad means.

Dysfunction is a gradual process.

Here's what I've seen:

In July 2021, we seemed to enter a pandemic stage where people were getting sick. Like our emergency department filling up with the most critically ill people I've ever taken care of in large numbers. Not from COVID necessarily, though that was there. But sick with heart attacks, strokes and infections, and even terrible traumatic injuries like bad car crashes, there seemed to be more violent injuries like gunshots.

So I would spend my shifts that month and the months after trying my best to stabilize people on the brink of death and get them to our intensive care units. Except we had no ICU beds open because they were full of people who had COVID and were on ECMO (a machine that takes over the work of your heart and lungs). So they stayed in our department for much longer than usual. They joined the other patients who were already admitted to our hospital, awaiting a bed on the other floors. Those patients are called boarders - they board in the emergency department because there are no open beds elsewhere in the hospital for them to go. It's not unusual for our emergency department to be 50% occupied by patients boarding. At its worst, we may have one or two rooms in our department open to see new patients - the rest full of people already admitted to the hospital.

A hospital will initiate something called "ambulance divert" in these instances. It's a status that tells ambulances in the area, "we can't currently safely take new patients," and routes those ambulances to the other nearby hospitals. In theory, it's useful. Its usefulness fades when everyone is on divert, leading to "zone management." Emergency departments near one another then take patients in round-robin style. So not only is each hospital stretched past capacity, EMS then transports patients to the healthcare systems they may not usually get their care. So imagine someone with a long surgical history, with a likely surgical complication, not being taken to the hospital where they've had all their surgeries aren't as well known. They still get good medical care, but it's another slight erosion of the possible best care for that person.

Our waiting rooms are filling with patients who sometimes wait 8 or 9 hours to be seen. A lot of patient care has shifted to the waiting room.

Emergency department or primary care?

I've started to see - or maybe now just taken note of - another trend that has me even more worried lately. I've heard people say and have said it myself a lot recently, "it's almost impossible to get any outpatient follow up". It's a subtle thing, though it has me worried about how the next 12-24 months may look.

Here's the usual process of what emergency care in our healthcare system looks like:

• I see you for some complaint, chest pain, abdominal pain, etc
• I do a big workup focused on the most dangerous problems that could kill you or hurt you
• I find something and either:
• Admit you for treatment
• Discharge you with treatment and follow up
• Or don't find something specific and have you follow up with your primary doctor
• and tell you to come back if anything is worse or worrisome

With the healthcare system, we've decided to value in the U.S., many people are either under or uninsured. There is no follow-up system for patients after they leave the emergency department in many cases. Worse, lately, it seems that even adequately insured people who are already connected with a primary care physician have had a very challenging time being seen in the clinic after they present to the emergency department. The increased use of telemedicine and video appointments has likely helped buffer this some, but even that tool has not quite panned out the way we've hoped it could. Really, how could a video appointment suffice for something like a wound check to make sure it's healing, or substance use counseling, or anything else that takes an in-person visit to be effective?

The real challenge in our outpatient care system has been referrals to subspecialists who are often necessary to evaluate challenging to diagnose or manage medical issues. Patients have to wait months, like 6 months, to be seen in the clinic right now. Imagine you have a painful skin rash across all of your arms, legs, chest abdomen that isn't responding to the usual stuff we try; lotions, creams etc. You've been seen in your primary care clinic, been to an emergency department a few times, and nothing is really getting better. It's not truly an emergency, but you need a skin expert who can take a skin sample and send it to the lab and make a diagnosis and start the proper treatment. That will be three months from now.

I'm seeing it more and more now. It's undoubtedly multifactorial.

• There are nursing shortages everywhere - it seems to be a matter of a wage race as experienced nurses are getting burnt out and deciding to either leave more stressful jobs or are taken advantage of very competitive wages that come with travel nursing contracts.
• Elective surgeries have often been canceled or slow due to COVID restrictions. Every patient getting a procedure gets a COVID test - especially challenging when our nation doesn't have enough tests. If a patient tests positive, the procedure is rescheduled, meaning the person could be asymptomatic or even a false positive test. This is a particularly tricky area considering patients with COVID seem to have worse surgical outcomes. Worse yet, elective surgeries are sometimes canceled when the hospital is under particular strain. It's a short-term fix that you pay for later on. Or as my mom says, "you're robbing Peter to pay Paul." This leads to a backlog of work for the specialists - the difference between their clinics and the emergency department is they're allowed to have a set schedule. It's hard to schedule people's heart attacks six months out.

The healthcare butterfly effect

So now imagine you're a physician in the emergency department, seeing a patient who feels miserable though maybe not experiencing an emergency. You do some testing, rule out life-threatening causes for how they're feeling, and counsel them that they can likely go home. They already have follow-up with the right specialist scheduled, but not for another two or three months. They can't get in to see their primary doctor for at least two weeks. How could you reasonably tell them you won't do more to help them? So you order the MRI or make the additional phone calls and ask a consultant to come to the emergency department to see them. They're in the department longer, and the physician on call is taken away from doing other work for patients elsewhere in the hospital.

The emergency department absorbs all the other inefficiencies in the healthcare system.

Do I prioritize the patient in front of me and serve as their primary care doctor or do I prioritize the population and preserve the emergency department for true emergencies?

While the omicron variant may cause less severe disease from COVID, it's still going to cause huge issues in the healthcare system. By sheer volume, each relatively healthy 30-year old I see who "just wants a COVID test" takes time, energy, and resources away from the other patients I care for in the department each day. Compound this over days, weeks, months, and years in the context of everything else I've mentioned; you can see why people in healthcare are reaching a state of burnout and troubling rates.

At the start of the pandemic, we were flooded with free shoes, meals, and nightly ovations in the communities we serve. Now I have to plead with people to keep their masks on in the hospital. We have to ask ourselves, "what do we want our nation to be?" If we want to make it out of this in one piece, we must move away from putting ourselves first and decide that a small sacrifice for the greater good is the best investment for a meaningful future.