when you have to wait

Sunday, April 8, 2018

There is no word to describe the photo. Three survivors of the bus wreck that killed 14 of their Humboldt junior hockey teammates and their coach, holding hands while waiting to be helicoptered to a larger hospital in Saskatoon. Did they know that so many had died? Did they see the bodies, or did somebody tell them while they lay on the stretchers in the hospital? And who was that somebody? Who was there to help them hold hands while they waited. Teenagers with no family at their bedside.

Every hospital is required to have disaster drills that includes triage at the front end, sorting victims, and then making certain the hospital staff shows up at their designated spot. Like a life boat drill on a boat, once everybody gets to their spot, it’s over, everybody congratulates themselves on a drill well done and the day goes on. There is no part of the drill that involves breaking news to three teenagers about their friends and who lived and who died. And there is no drill that looks after those who cared for the victims.

Looking after patients who are extremely ill or injured is why most people work in the ER, providing critical care and making a difference in the first few minutes is what defines emergency medicine. There is a ying-yang to the adrenaline rush that comes during a patient resuscitation. Win the battle, the patient survives and the team celebration can last for the rest of the shift; lose and the patient dies, but there is no time for remorse or grief. The family now needs care and there is a waiting room full of patients, all waiting, some not so patiently. Winning makes it easier to deal with a frustrated waiting room but losing makes it much harder.

When the ambulance radio goes off with a trauma notification, everybody’s ears perk up. The trauma nurses hand off their patients to others to ready for battle in the resuscitation room. The ER docs try to plan care for their other patients when they will be drawn away to look after the soon to be arriving victim. The team gathers (lab, x-ray, respiratory therapy, pharmacy) and starts to prepare. But in the back of their minds, they want to know…where is the ambulance coming from… how old is the victim… and where is my family? Just checking.

Even with the best of care, some people die. Bodies are too damaged or too diseased, and death may be declared quickly, or it may take hours of care. The options for people at the bedside to process the unexpected death are limited. One can pretend that the victim wasn’t a real person becoming numb to events, or they may not be able to let go and disconnect the death they have just witnessed from their own life. When it’s a child who dies, it can sometime become overwhelming for the staff. The ability to pause for a few minutes and process what just happened is an important need for hospital workers, but that never gets practiced in a drill and not commonly in the real world. Time for reflection rarely happens because of the pressure to see a continuously filling waiting room.

Patients and family get frustrated when they have to wait, especially when they don’t know why. Newer hospital architectural designs insulate the waiting and treatment areas. In older buildings, people could see ambulances arriving, staff running to meet them and the noise of the care provided. Now, sitting in a quiet waiting room, the patient can only imagine doctors and nurses staff working at a leisurely pace with the urgency that they expect.

After a busy shift, and a less than polite patient or two, the ER staff have been known to gripe over a beer…the time to pause sometimes comes later than it should…and say things that they never would in front of a patient.

  • Can you believe the guy who complained that he had to wait for two hours? Doesn’t he have a clue?
  • We’re sorry that you had to but be glad that we thought you could wait. It means that somebody else was more damaged.
  • You had to wait because the doc was looking after a teenage trauma victim, and even though we did everything that we could for 45 minutes, he died.
  • The nurse and the doc had to tell family and sit with them until the chaplain came. The nurse stayed behind to talk about organ donation, while the doc talked to medical examiner and then had to go in back to change scrubs and coat because of blood contamination.
  • Meanwhile, housekeeping had to clean up the mess in the room. Central supply and pharmacy had to come down and restock so it would be ready for the next trauma patient.
  • So yeah, you had to wait and you’ll be seen when the doctors, nurses, techs and everybody else who makes the ER run, gets their heads together about what just happened because they have feelings and emotions too.
  • Welcome to the ER. now do you want to fill out your satisfaction survey?

By the way, there are three boys holding hands waiting for a helicopter, and somebody has to tell them that their teammates and coach are dead.

 

image: mirror.co.uk

 

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waiting to be seen

Sunday, November 15, 2015

Making the decision to visit the ER is never taken lightly. Aside from obvious injuries that need attention, think lacerations or broken bones, most other illnesses have the undercurrent of disaster. Is the chest pain a heart attack? Does my child have appendicitis? Is a tumor causing my headache? And worse yet, it’s the waiting, first in the waiting room and then finally being placed in an actual exam room, only to wait again. And then disaster strikes, but you don’t know about it.

Most hospital ERs, are staffed with doctors, nurses, lab and x-ray technicians, housekeeping and cleaning people, for the expected rush of patients that happens at different times of the day and different days of the week. Planning for the surge of patients on a weekend evening shift is no different that retail stores who prepare for Black Friday or Christmas Eve, expecting more customers. Hopefully, in the ER, the number of people working is enough to care for the number of patients walking in the door.

All that planning goes away when disaster strikes. In the Paris terrorist attacks, 129 people died (at the time of this column) and more than 350 people injured with almost 100 critically. These victims needed emergent care and many needed the services of a trauma team to provide care. But think of that number of patients. There are 13 hospitals in Paris, according to the Paris Tourism Office. Not all are capable of caring for these victims, but if each hospital took their fair share,  the “regular” emergency patients would be bumped and their wait to be seen extended. To be fair, hospitals have disaster plans and their whole staff would be mobilized to care for patients, both from the disaster and for those “routine” patients whose emergency visit was unlucky enough to happen at that same time.

People are very tolerant of waiting when a disaster happens. They see the carnage and they hear the news. Patients are less tolerant when waiting happens and they don’t know why. Many hospitals have waiting rooms that cannot see the ambulance bay and the steady stream of patients being dropped off. That said, arriving by ambulance does not necessarily let a patient jump the queue. Triage happens every time a patient gets touched, whether it is the person who walks in the ER door, or who arrives by ambulance, or who is found to be sicker than initially thought. First come, first serve is not the ER mantra.

A rush of patients doesn’t need to be the cause of the patient flow in the ER coming to a halt. It may be that the inpatient beds in the hospital are full and patients who need to be admitted from the ER have no place to go. They may be boarded in their ER bed, causing a logjam and the next patient up in the waiting room has no place to be seen. Or it may be there is one significantly ill patient that takes the time of many of the ER staff, leaving others to wait. Or it may be that a death has caused a doctor and nurse to spend time with a grieving family. Or that death caused the same doctor and nurse to take a few minutes to regroup emotionally for the next patient.

There is some sadness when hospital administration decides to use waiting times to lure patient to the ER by posting “real-time” waits on billboards or websites, or promising a patient will be seen within a certain amount of minutes. All those promises go away when a chest pain patient arrives at the door. To meet national standards of care, an EKG needs to happen within 10 minutes and if a heart attack (myocardial infarction) is happening, they need to be in the heart cath lab in less than an hour. If a stroke patient presents, they have less than 4 1/2 hours from onset of symptoms to get treatment and save their brain. Children with suspected meningitis need antibiotics immediately. A trauma patient who is in shock gets bumped to the head of the line. The waiting time listed on a website is old news if a disaster arrives before you do.

Waiting to be seen is difficult in the ER because of lack of control. There is the worry of the unknown about a headache or belly pain. There is the lack of choice as to what doctor or nurse will be providing care. And there is often a lack of information provided as to why the wait is happening in the first place. It is of little consolation to hear that somebody else is more sick or injured; there can be some perverse comfort in knowing that somebody else has it worse, but in the end, there is no joy in waiting.

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