Case 9: Wait Times.

[Triage Note: Fever x few hours. Patient received three units of blood this morning. Pale. Unwell. Chemo January 5.]

In a few years, I will lose my enthusiasm for overnight shifts, but tonight, I’ve slept well, I have a Venti Pike from Starbucks, and I’m ready to move. I’ve arrived for my shift ten minutes early, but it won’t make a difference; the tracking board tells me there are dozens to be seen, many of whom have been waiting at least three hours. There’s a thirty-eight year old with chest pain who’s been waiting almost five hours. It’s said that time is muscle, and if this guy is the real thing, he might as well go straight to the transplant list. A sixty-year old on chemo has been hunched over a barf-bucked for four hours in the waiting room. She’s still retching.  And there’s a sixty-nine year old who is actively bleeding from her gut; a nurse will grab me by the arm and pull me into her room, telling me that the doctor before me didn’t want to see her – that he’d told her it could wait for the overnight guy. My colleague has walked away from this chaos and gone off to see sprains and strains. It is written in our E.R. manual – when I arrive, he can go to “fast-track”, no matter how many critically-ill disasters he’s left behind.  In my first 88 minutes, I’ll see these three patients and fifteen others, barely slowing to sip the coffee that will keep me awake until seven am.

It’s been like this, lately. A few months earlier, our group of E.R. physicians received this email from one of our colleagues:

Just now, at 03:00, do I find the time to note, via email, that again the department is overcrowded and unsafe. I arrived at 23:00 for my overnight to find a full waiting room, many patients waiting, and wait times in excess of seven hours.

My nineteenth patient, Karen Holcomb*, is the sickest person in the department. She’s thirty-one, listless, and emaciated. Her skin is pale, and her lips crack like elephant skin. Her temperature, the chart says, is thirty-nine degrees, and she can barely speak when I ask what brings her in. Her husband is at the foot of the bed with two small girls. He is dark skinned, and the sisters, standing on either side of their father make me think, for a fleeting second, of my own young children. There are many people in the department that are supposed to be sick – seventy year olds with heart disease, eighty year olds with cancer, ninety year olds with dementia – but she isn’t supposed to be sick, and these two kids aren’t supposed to be in the Emergency Room at twenty eight minutes after midnight.

Karen has leukemia – she was diagnosed just a few months ago, after visiting the doctor for what she thought was the flu. She’d just finished her first round of chemotherapy, and earlier in the day, presented to the cancer clinic feeling weak, barely able to lift her arms over her head. Her red cells were critically low, and she’d spent much of the day at the clinic, receiving three units of blood. She returned home, but just an hour after dinner, she felt nauseated and chilled. Her husband, as instructed by her doctors, checked her temperature. Thirty nine degrees. He put jackets over the kids pyjamas, wrapped his wife in a comforter and drove to the hospital, arriving just after nine pm.

Several months after Karen’s visit, I would meet Dr. Marko Duic, an overweight fellow in his fifties with a chronic slouch and a lumbering gait. I’d sit in a conference room with low ceilings and listen to this stranger lecture our group of twenty E.R doctors about his “trilemma” of physician staffing.  At the time, we had a fixed eight-week schedule. For instance, I knew, that during each cycle, in week five, I’d be working at seven pm on Tuesday night. It was in my calendar, and set on repeat, so that I could tell my wife whether or not I’d be home for dinner on any given night, in any given month, in any given year.

This schedule was predictable. And it worked. For us.

The trilemma entailed three criteria, that if fulfilled, would make a perfect physician schedule. The first, is something we already had – predictable shift times – with a fixed start and stop. With this, I could plan work, family duties, social events, and even managed to schedule a few hours a week in family practice. The second criterion, was maximal physician efficiency – the idea that physician staffing at any given time, would match, or attempt to match, patient volume. On days that we had this, it was only by fluke. Most times, we failed miserably. And the third, was something we were nowhere near: short patient wait times. The problem, Marko said, was that we could only satisfy two of these criteria, and short patient wait times had to be one of them.

I question Karen’s husband, searching for a cause for her fever. She isn’t short of breath, nor does she have a sore throat. She denies urinary frequency or burning. She has no rash, no stiffness, and no pain, other than a slight discomfort in her legs, which has been there for weeks. I step close and examine her.  Her eardrums and throat are clear.  Her neck is heavy, but moves easily from side to side. Heart sounds are normal, and her chest is clear. Her abdomen has a small scar over her appendix, but other than that, it too is unremarkable. As I begin explaining that we will have to do blood work, and that she will likely be admitted, I lift the covers away from her legs and notice a small red patch just above her left ankle. I tap it gently and she winces. This is cellulitis – an infection of the skin. In a healthy person, it isn’t a big deal. But in someone with leukaemia, on chemotherapy, it can be fatal.

The schedule would have to change, Marko told us, from a fixed schedule, to one with flexibility – one with variable start times, and stop times. “If you don’t call for help during your shift, and it’s busy, it’s not fair to patients to just up and leave and let them wait,” he wrote in one of his first emails to the group. “That’s not what the best Emergency Department in Canada would do, and that’s where we’re going.”

Marko speaks with a hint of Eastern Europe, leaning heavily on biting words like ‘egregious,’ ‘unfathomable,’ and ‘incomprehensible.’ When he speaks, his hands are stretched out, as if he’s picturing our heads being crushed within the vice of his palms. His initial rants were delusional, as he painted a picture of one doctor lined up behind the other, waiting like cabbies to be dispatched to their next fare, to ensure that every patient would be seen the minute they walked through the door.

“I just can’t help but comment on the ridiculous nature of what we are doing,” one of my colleagues wrote. “We are going to…try to see every increasing number of people…while we purse the goal of ‘one hour waits for everyone.’

So, we did what any established group of emergency physicians would do, when faced with the idea of sweeping change. One beautiful Sunday afternoon, fifteen of us gathered and planned how we would band together and get rid of Marko.

What makes Karen so sick, as her blood work will confirm, is that she has Febrile Neutropenia – a complication of chemotherapy that leaves patients’ white blood cells so depleted, they can’t fight off infection. Looking over her chart, I see that she is already on two antibiotics – Ciprofloxacin and Penicillin – which are doing nothing to keep the redness from ascending up her left leg. I will never forget, during my residency, watching an oncologist publicly berate and blame an ER doctor for not getting a neutropenic patient antibiotics fast enough. The patient had died, and, the oncologist said it should have never happened – that it was the E.R. doctor’s fault. Patients with the lethal combination of leukaemia  and febrile neutropenia have a reported mortality as high as ten percent. Looking at Karen, I have the feeling that she may not survive the night. Her eyes are neither closed nor open; her breaths are shallow and quick; her blood pressure is low and her pulse is thready. I scribble orders and order the strongest IV antibiotics I can think of. I take another look at her husband, and he thanks me. I wonder if she’d been this sick four hours earlier, when she’d first arrived to the E.R.

The Monday after we planned our coup, I was called into the Chief’s office in the middle of my shift. There was a rat in our group. I was pissed off, I told Marko, as he stood there, staring at me – blue eyes bulging through bifocals – in his wrinkled non-wrinkle chinos and his over-washed flannel shirt. “Sometimes,” Marko said, “I get carried away with my ideas, and come off too strong.” He let out an unnerving chuckle, and we shook hands. As I walked out, I wondered whether or not I’d still have a job in the weeks to come.

Marko began moving like a speeding steamroller, one that leaves small animals – limbs splayed, eyes agape – flattened in the asphalt. First, he eliminated the waiting room, telling us that patients couldn’t be ignored if they were actually in the department, in plain sight. He replaced stretchers in our rapid-assessment zone with examining tables, to be used for assessment only.  “If they can walk in to be seen, they can walk over to a chair and wait for re-assessement while others can be assessed.” Once, he asked us to go to the waiting room and see patients right when they arrived. This didn’t work, and the ensuing conflict between physicians took months to resolve.  Physician hours increased as we were told to be ready to arrive for our shifts when volumes necessitated. Cursing doctors were asked to sign hourly reports on wait times.  One afternoon, I was called at two p.m. for a seven p.m shift, and was forced to leave my bewildered father with a crying baby, two bottles, and a handful of diapers. Rumours of dissent circulated through the hospital. The Chief of Staff called a meeting,  gathering each and every emergency physician into a conference room, demanding that we sort out our differences.

While we, as physicians, had the opportunity to modify our hours, the nurses, as salaried employees of the hospital, did not.  When the floodgates of patients opened, many experienced and skilled nurses retreated to different areas of the hospital. A cloud fell over the department as friends departed, one by one. One afternoon, Marko brought brownies and left them in the staff room. “Don’t touch them,” the nurses said. “They’re from Marko. They’re Blood Brownies.” At times, nurses refused to move patients, filing formal claims of unsafe working conditions. Tension rose. Factions formed. Tempers flared.

Karen’s blood results are worse than expected. Her total white blood cell count is close to zero, her neutrophils (a crucial element in the immune response) are exactly that – zero. Her platelets also, are almost non-existent – and she’s menstruating. Even though she’d received three units of blood that morning, she’s still severely anemic. I order blood and platelets for infusion. Forget the infection – I’m lucky she didn’t bleed to death waiting for a me to assess her. Two additional intravenous antibiotics are ordered by the Internist.

In the coming weeks, Marko would send several emails per day, detailing how we would achieve the shortest wait times in the country.

Six months after Marko’s arrival, a senior physician sent out an email lauding wait times of less than four hours the previous day. Nurses rallied and re-organized our rapid-assessment zone, and doctors tried to get used to the idea of calling in hours before their shift – in some cases, making arrangements with their colleagues the night before they were scheduled to work. Slowly, but steadily, wait times dropped.

As the sun rises, Karen is still alive, but she doesn’t look any better. Her daughters have taken off their thick coats and used them as sleeping bags. Her husband is still standing, unmoved at the foot of the bed as he stares blankly at his wife. I can barely keep my eyes open, and when I get home  I try to calm my thoughts as I lay, eyes closed on my pillow.

Over the next four years, Marko would continue to crunch numbers, send lengthy emails, and lecture us on the importance of wait times. He’d implement a Physician Navigator program, pairing doctors with smart young assistants that would become invaluable real-time assessors of patient waits, accompanying us on shift, directing us to those who needed us most, those whose wait times put their lives at risk.

Three and a half years after my overnight shift with Karen, Marko will send me an email, asking me to explain why wait times were so long the night before. I’d been on shift with a junior physician, and the long waits, he’ll say, are my fault, and not the fault of my young colleague. I look at the numbers from the night before – three hundred and twenty patients – the usual these days  – about a hundred more than the daily average before he arrived. The wait times in question, were the longest waits of the month; At 8 pm, the longest wait was 115 minutes. At 9, it was 85 minutes, at 10, it was 105 minutes, and at 11, it was 135 minutes.

He’s been relentless about wait times, and this isn’t the first time I’ve gotten an email like this. I’m accountable to him, I’m accountable to my colleagues, and I’m accountable to the department. Our individual performances are being watched, not only by Marko, and management, but by our physician colleagues. Every six months, we are asked to rate each other. Marko, in his evaluations, has been called a genius, tireless, fair, and brilliant. He has also been called forceful, deceitful, and untrustworthy. He’s been accused of fostering a culture of blame, fear, and hostility. He’s been called great, he’s been called a visionary, and he’s been called corrupt.

I take responsibility, chop out a response on the keyboard, and feel my blood simmer as I try to sleep that night. At times, Marko has the charm of a charging rhinoceros, and this isn’t the first time I’ve been angry at him; It won’t be the last.

At 2pm, about five hours after falling asleep, I wonder if Karen is still alive. I get up, shower, eat something, and play with my son. Several hours later, after he falls asleep, I go back into the hospital and find that she’s still in the same room. It’s been almost twenty four hours since she first arrived, and her temperature, despite tylenol every four hours, has not dipped below thirty-eight. She is still listless, and was vomiting bile earlier in the day. She is worse than the night before, and her family is still by her bedside. I catch up on paperwork, then head home.

After her third day of antibiotics, her fever finally abates. She’s received more blood, and more platelets, and her lab results have improved. By day five, she’s out of bed, able to walk the halls, and by day seven, she’s able to go home. A month later, her leukaemia is in complete remission.

After that admission, she never came back to our hospital. I looked periodically, as her name stayed on my list of poignant cases. Before writing this blog, however, I typed her name into Google. There she was, smiling, beautiful, her three-year old on her lap, her six year old standing, cheek-to-cheek, with her mother. Her obituary. Karen died less than two years after I saw her.

On May 23rd, 2015, we saw three hundred and ninety five patients, eclipsing the old single day record by almost twenty percent. For those of us working, it was chaos, and at times, it seemed like patients would never stop coming through the doors. A few days later, those who were working received the following email:

I have to ask myself whether there was opportunity to do even better. Unfortunately, from 11:00 to 16:00, patients waited over 100 minutes. If any of my colleague Chiefs were to see an email bemoaning a day, in which 90% of patients waited less than 98 minutes, when volumes reached about 100 more than we expected, they would lock me up for an involuntary assessment. Seriously. They’d be thinking that I have the best Emergency Team ever – and in this last thing, they’d be totally right. 

This past month, our team – nurses, doctors, clerks, navigators, porters, security guards and many others –  looked after over nine-thousand patients. Of those, ninety percent were seen in less than eighty minutes. The thought that sick patients once had to wait five, six, even seven hours before being seen and treated is incomprehensible, unfathomable, and egregious.

*Not her real name

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