It's taken me a long time to write this piece. It's been sitting on my desktop for weeks, if not months, in various stages of completion; a thought added here or there, furious deletions of whole passages, and more hours than I can count staring at the blinking cursor, willing my fingers to follow through on the flood of emotions coursing through me.
The COVID-19 pandemic has been a complete disaster, both for the world at large, and for me both personally and professionally. I'm an emergency room nurse, and those of us that work in emergency and crisis services get to see firsthand how broken so many things are in the United States- the healthcare system, the political system, the way we treat one another, et cetera. We're the ones that stitch our communities and the people in them together. And since this crisis started last spring, my colleagues and I have had to do that entirely on our own, as it quickly became clear our government had no desire to help save us or our communities.
Most people don't understand how dire things are. It's hard to explain to people who aren't on the "front lines" of this fight, both because of how much background knowledge is required to explain some of these concepts and problems, and because, just as it took me weeks to write this very missive, we are all exhausted. Burnt out. Unable to muster the emotional energy to discuss what goes on, because doing so will inevitably cause us to relive it all over again- and getting through it the first time was tough enough.
I suppose it almost seems like a last will and testament. Like one of those "to read in case of my death" notes you see in the movies. As I finally finish this, we're a week out from the US Presidential election. But I know that even if our country survives the election this fall, and Joe Biden becomes President, that it will be January (and almost certainly weeks, if not months, later) that help will begin to arrive for my colleagues and I- and we're stretched thin now. And thin doesn't even begin to describe it.
And if Biden doesn't win, well...
I've known that for a long time, of course. But writing it down, I don’t know. Makes it more real somehow?
Sigh.
Before I get into the doom and gloom stuff, I supposed I should start by briefly explaining where we find the state of healthcare in the United States of America. I think most people understand there is something fundamentally broken about the way we approach healthcare in our country. Addressing that in earnest would take a War and Peace-sized dissertation, which nobody would read anyway, so I'm going to talk about just my little slice of it in emergency services.
One of the biggest problems is that emergency and acute services- EMTs and firefighters, emergency medicine, intensive care, and all the attendant fields thereof- don't make anyone money. In fact, they are giant money sinks. And this is a big problem, because whether you're talking about a public hospital (those owned by government institutions or universities, like the University of California San Francisco or the University of Michigan) or a private hospital (a "non-profit" entity such as Bon Secours, HCA, AdventHealth, etc), the goal of any healthcare institution in the United States of America is to make money. That's literally the bottom line.
Now, obviously, providing healthcare to people obviously requires an expenditure of resources. After all, you need to pay for staff, to keep the lights on, and all the other things that go into running a hospital, and efficiency of resource expenditure should always be a metric paid attention to.
But we have gone well beyond what I think most people would consider sane or healthy, if they only understood the depth of it.
There are several reasons for this. One is pretty evident- when we are trying to save people's lives and provide acute, emergent care to them, efficiency is often a secondary concern. We throw a lot of (often very expensive) resources at solving the problems presented to us, to be able to address them as quickly and effectively as we can. We are supposed to think of our patients and their well-being, first and foremost, to which all other concerns are secondary.
This is something we've sort-of agreed to as a country, in fact; it's codified into a law called EMTALA. EMTALA basically states that if you present to an emergency room in the United States of America, you cannot be turned away for an inability to pay. You have to be seen by a physician and treated, whether you have high-end "Cadillac" insurance, or nary a dime to your name. This isn't a bad thing, of course- everyone deserves emergent treatment if they need it, and it should not hinge on their ability to pay. But, consequently, that means emergency departments see an awful lot of people who simply cannot pay- whatever care is provided to them will be forever beyond their ability to compensate the hospital for.
And if you can't make money, well, you can't keep the doors open.
So, in that light, the question is: what can you do to make up the deficit that emergent and acute care settings impart onto a healthcare system?
There are a few things. One is to do whatever you can to push business to the places in healthcare that make you the most money, like elective surgeries and procedures, certain kinds of specialists, etc. This is one of the reasons you see so much vertical and horizontal integration in the healthcare field; if you can refer people to your own specialists, primary care providers, so forth and so on, you might "lose" money on some interactions, only to recoup it on others.
Another thing that's been popular is to open "free standing" emergency rooms in high-income areas. These are ostensibly fully-functioning emergency departments that are simply not attached to a larger hospital, and sell themselves as being an extension of the community's emergency services network. If you're having a heart attack or stroke, you have a nearby facility able to treat and stabilize you before transporting you to a cardiac catheterization lab, or give you clot-busting medication before sending you to a stroke center.
While these facilities are more than able to do just that, their true purpose is to entice non-emergent patients with excellent health insurance coverage to choose to visit them over waiting in a "doc in the box" urgent care center or a general practitioner. Thus, they can charge for a full emergency visit for "easier" problems, such as putting in stitches, treating a sinus infection, or even referring a patient to a specialist (often in the hospital's own network).
You can get into an arms race with insurance companies vis-à-vis reimbursement. For example, a colleague of mine told me about their facility's "reimagining" of their patient intake process which put a physician, instead of a nurse, as the triage provider who a patient first sees when they arrive in the emergency department. This was sold to the staff there as helping get patient treatment started more quickly and efficiently, when in reality it was simply an attempt to lower the measured "amount of time" a patient had to wait from checking into the emergency department to when they actually saw a physician.
This process didn't actually change the amount of time patients stayed in the emergency department- these patients were often sent back into the waiting area for hours after seeing the physician in triage- but it allowed the hospital to legally state that patient saw a doctor within minutes of their arrival. This sort of thing happens all the time, and as insurance companies and Medicare become wise to it and change their billing requirements, hospitals respond in kind to find loopholes they can exploit. When they announced one of these changes in our ER, one of our nurses asked management what evidence-based research they were using to make those decisions. Hahahaha. If looks could kill... but, c'mon. We all knew it wasn't about evidence-based standards, but bending over backwards to capture reimbursement dollars; why try to pretend otherwise?
And, of course, there is the old ditty familiar to anyone in corporate America- labor costs. You want to do everything you can to limit labor costs while pushing productivity as high as you can. This isn't necessarily a bad thing, of course. You don't want hundreds of employees milling around, being paid to do nothing. The only problem is that, in reality, corporate America has been weaponizing this practice for decades, far past the point of simple "efficiency". And while not being able to find a Wal-Mart employee when you're looking for something in the sporting goods section is annoying, the same problem in a healthcare setting can be deadly.
There is a scene in the 1999 cult hit movie "Fight Club" where The Narrator is talking to a woman he's sitting next to on a plane, discussing his job as an actuary for a major car company. He says:
"A new car built by my company leaves somewhere traveling at 60 mph. The rear differential locks up. The car crashes and burns with everyone trapped inside. Now, should we initiate a recall? Take the number of vehicles in the field, A, multiply by the probable rate of failure, B, multiply by the average out-of-court settlement, C. A times B times C equals X. If X is less than the cost of a recall, we don't do one."
This formula is pretty much the exact same one used by the healthcare industry to decide staffing levels for healthcare providers. We want to avoid having what we call a "sentinel event"- an unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. And so we hire the bare minimum number of people that will keep our number of "sentinel events" manageable- out of excessive legal trouble and the sight of healthcare accrediting agencies such as The Joint Commission- and not one single doctor, nurse, technician, or pharmacist extra.
In the time I've worked in the emergency department, I've seen what we consider as "fully staffed" cut almost in half. The emergency department I work in, in a suburban area outside of a state capital, top-100 sized city in the United States, sees about 40,000 patients a year. When I met my husband (who also works in emergency medicine) near the end of the last decade, we would rotate through 6-7 doctors a day, in rotating shifts, with up to 12 nurses on duty at any given time. Now, we only have one doctor in our emergency department at any given time, working an eight hour shift alone, while the staffing level for nurses and technicians varies depending on what a computer at corporate has determined our "busy times" are, but maxes out at seven nurses and drops to as low as four (And that computer is using cherry-picked data from non-pandemic times!).
This has had a major impact on the care we are able to provide, both to our patients- and to ourselves. If even a single nurse calls out sick, that may be literally 25% of our entire workforce for that shift. If someone quits or otherwise leaves the emergency department (emergency medicine is a notoriously high turnover field), that "hole" can persist for weeks (or months!). I cannot tell you how many times in the last few years that we have only "held on" to situations by our metaphorical fingernails, trying to manage so many desperately sick patients at the same time, and only surviving by a combination of backbreaking work and blind luck.
In fact, that's sort-of our default mode. We have to make do with barely enough resources to survive, let alone thrive. And taken like an actuary, it sort-of makes sense. When we try to convince expecting mothers to choose our hospital, we showcase our birthing suites with color-changing mood lights, sound systems, and whirlpool tubs to win over their business. Once labor starts, of course, these mothers aren't going to be in the mood to use even a single one of those amenities- but it sure sounds cool when you're a few weeks out, doesn't it?
When you're coming in to have your scheduled elective surgery done, knowing you are promised to have a guaranteed bed waiting for you once your surgery is over makes deciding to give us your business easy. But the emergency room, well. You're having an emergency. If you have to lay in a hall bed for a day or two waiting for a bed on an inpatient unit to open up, what're you gonna do- go somewhere else? And the odds are that if you do leave in frustration after waiting eight, nine, ten hours in triage to be seen, you'll be a money sink to another facility- and, c'mon, you probably weren't even that sick to begin with, right?
Of course, this situation is hardly unique to the facility I work at. I've yet to meet a single one of my colleagues from anywhere in the country who didn't have a similar story to share with me. Combined with the fact that any emergency and/or acute care field is a high-stress, high-acuity one to begin with, you may be able to understand why burnout, compassion fatigue, post-traumatic stress, and suicide is endemic to our profession. But we press on regardless of the odds, with the implicit understanding that we are balancing on a knife edge, because we know how important the work we do is in keeping our communities safe and healthy.
And then COVID-19 happened.
I think people misunderstand the impact this pandemic has had on my profession. It didn't uncover any new deficits or problems in our system; it merely shone a supernova spotlight on the ones we've been desperately papering over and pretending don't exist.
Understand that this is the key reason for most of the lockdowns that have had to occur to date. We have spent the last few decades ruthlessly destroying any excess capacity our healthcare system may have possessed in the name of efficiency and profit. A hospital having it's beds 90-95% full is a goal most hospital strive to meet, because every empty bed is a revenue stream lost. To be fair, we are also incredibly concerned by the number of people who will potentially have long-term health consequences of being infected with COVID-19/SARS-COV-2. We've known for some time that over 50% of survivors of the SARS-COV-1 virus had permanent health problems, including persistent and significant impairments in exercise capacity and health status. The cost- social, economic, and emotional- of hundreds of millions of people worldwide with permanent, lifelong health problems has the potential to cripple and bankrupt entire countries if not mitigated.
But the bottom line is, even under normal circumstances, our emergency services systems can barely handle the load they're asked to shoulder day in and day out. It's only the hard work and dedication of those front line providers that holds the whole system together. That effort borders on the heroic on a regular basis, and surpasses that just as often... but, even so, that effort alone can only get you so far.
Start adding hundreds, if not thousands, of new patients to take care of? Well. It's just not possible.
I can tell you the culture of our departments has radically changed, too. You know, we're used to dealing with people who don't care about us, to whom we're easy targets to use and abuse. We're used to having to fix other people's mistakes. But to see thousands, if not millions, of people who not even just passively don't care about what we do, but are actively working to make our jobs harder- still expecting us to take care of them if anything goes wrong!- has really broken a lot of us completely. Because there are tools in places now- masking, social distancing, proper hygiene, ventilation, etc- that have been proven to limit the spread of COVID-19, and enable people to go about their lives with as little impact as possible until vaccines and therapeutics came online. But so many not only actively choose to not follow any of those, they work as hard as they can to convince other people to do the same shit.
Worst than that is that, some seven or eight months into this crisis, our supply chain problems have not only not improved- they've gotten worse. We're asked to reuse personal protective equipment up to thirty times before we can replace it because nothing has been done to improve the quality or quantity of it's production. We don't have enough tests, swabs, and reagent to be able to test as much as we need to. The rapid testing machine we have at our hospital can only run ten tests per day for the entire facility. That's it. We can't source enough reagent to procure more than that. The rest of our tests have to go to an outpatient lab, where it might take two or three days to get a result. Miracle therapeutics are easy to get if you're the President of the United States, but everyone else just has to take their chances.
We're told that, because of the pandemic, the hospital doesn't have the money to hire more staff. Our attrition rate hasn't changed- if anything, it's gotten worse- but it doesn't matter, human resources won't budge. We've got a hiring freeze, and the ER doesn't make the hospital any money, so we apparently "can't justify hiring anyone else". We started 2020 with just under a hundred nurses, CNAs, EMTs, and the like employed in our emergency room. As of today, we have 54 left.
To solve the staffing problem, administration has instead started looking at other avenues. For instance, one of our nurses was infected with COVID-19, and rather than ask her to stay home, the hospital told her she should keep working if she was asymptomatic or mildly symptomatic, and to just to make sure she never took off her N95 mask or go into the breakroom at any time. Another was asked to wait and take a COVID test after he had an exposure outside of work (at an event with a known outbreak that made the national news) until after that he'd worked that week's shifts. That way, it wouldn't impact our staffing levels, and if he turned out to be positive, well, he wasn't scheduled to work again until next week anyway, outside the quarantine window. Problem solved!
Colleagues in other parts of the country have told me worse things. One had a patient admitted to their Cardiovascular ICU who initially tested negative, but surprise! Turned out to actually be COVID positive, and so infected their hospital's entire cardiology team- doctors, nurses, etc. For a few days, they had only two doctors and three nurses well enough to handle heart attack patients who needed a cardiac catheterization. Somehow- by the grace of God- they had a slow period during that time, and so that hospital was able to keep that particular crisis under wraps. Another told me that during their COVID surge this summer, they had a 1:1 suicidal patient- who required a healthcare provider to stay in constant contact with them to keep a constant watch on them. But they had to "abandon" them when a patient in cardiac arrest, another patient with a stroke requiring clot-busting medication, and a COVID patient in respiratory arrest came in almost simultaneously with a waiting room that was overfull with ten plus hour waits. There wasn't enough staff to manage all of that, and so they just had to hope this patient wouldn't do anything while they were doing chest compressions, putting a breathing tube into the COVID patient, etc. Again- by pure luck- nothing happened.
But that's all it is. Luck. It's only luck. And the thing is... luck eventually runs out. Now, we can- and do- stretch "luck" over with enormous, backbreaking, PTSD-inducing effort. We can tie things together by burning ourselves out. Destroying our home lives, our health- both physical and mental. And of course, when the worst happens, it'll be our fault. Not the hospital administration, no. No. They'll shake their heads sadly and find a scapegoat or three to fire, and use the money they save to put up a few more "HEROES WORK HERE" signs. Not the federal government- if you die, it was clearly your own fault anyway. I mean, stop being a fatty with pre-existing conditions. Not a healthcare system predicated on profit over all other concerns- what do you want, SOCIALISM? No. Instead, it'll be our fault. They'll blame us. And, even though we should know better... we'll blame ourselves, too.
I think that's the central premise to my piece here. This is the only reason the COVID crisis isn't worse in our country; why the death rate isn't as bad as it was this spring. It's because of us. Of our hard work. And we're barely making it through. I think the only thing keeping us going because we recognize what will happen if and when the bottom falls out.
We're not "heroes". None of us. We don't want to be. We just want to help keep our communities happy and healthy. We want to be the backstop for when the worst happens. We don't want to be the one thing keeping the country from imploding. We just want to make it through this crisis.
One way or another, though... I'm afraid many of us won't. I suspect in the years to come, the suicide and PTSD rates for essential workers- already a crisis pre-pandemic- will worsen by an order of magnitude. That’s baked in at this point. The only question now is how bad it’ll get.
Anyway.
Those are the stakes.
Please do everything you can to help get us through Tuesday and beyond.