Inside the Emergency Room

Real-life drama unfolds every day in ERs around the state

photo by kendal j. bush The hallway at Catholic Medical Center’s emergency department is occasionally used for overflow.

It’s noon. Lunchtime for most people. But here, at the hospital, it’s surge time — one of two times each day, the other around 6 p.m., when the emergency room suddenly fills up.

A car accident, chest pains, stroke, burns, stubbed toe — whatever it is, the medical team at Manchester’s Catholic Medical Center is ready for it. They move from bed to bed, figuring out who needs what care and how fast. Blood tests, X-rays, CT scans, MRIs are ordered. They first stabilize anyone who needs it, then diagnose and treat, one patient after the other. Sometimes, life-or-death decisions are required, quickly and in the midst of chaos.

An ambulance pulls up outside. No doubt there are more to come.

“The biggest challenge is where to put all the people coming through the door,” says Dr. Jon Vacik, director of emergency medicine at CMC, which handles close to 35,000 emergency room visits a year. At times, all 30 beds are filled, there’s an overflow into the hallway and people still in the waiting room.

High volume is only part of the problem. Most of the people who arrive at the CMC emergency room, a Level III trauma center, have a serious illness or injury. The hospital ranks high on the ESI, or emergency severity index. “On most shifts, you usually have two or three patients who are very sick,” Vacik says.

At night, the ER sees more overdoses and intoxicated patients, as well as a higher percentage of the mentally ill and homeless populations. “Oftentimes, these patients can be quite agitated and may require sedation or restraints for staff safety,” Vacik says. “I’ve been punched, spit on and called nasty names. You have to stay ahead of the curve.”

Staying ahead of the curve in emergency medicine means its doctors have to know a lot. It is the one specialty that requires knowledge of all the other specialties.

“It takes an incredible breadth of readiness to take care of anyone at any time,” says Dr. Todd Morrell, emergency medicine section chief at Dartmouth-Hitchcock in Lebanon. “There’s a quip that we will do the first 24 hours of any disease.” Specialists — cardiologist, neurologist, orthopedist, psychiatrist among them — are brought in if needed.

Dartmouth-Hitchcock’s 38-bed emergency department, which is the state’s only Level I trauma center, has trauma surgeons on call at all times. They’re needed for the “high acuity,” or level of severity, of injury and illness the hospital deals with. “Probably only 10 percent are low acuity,” says Morrell. “Ninety percent have acute medical issues.”

Some of those patients are transferred from other hospitals and accident scenes throughout northern New England — the most critical flown in by Dartmouth-Hitchcock’s helicopter, part of its advanced response team (DHART) — to get the hospital’s high level of trauma care.

photo by mark washburn courtesy of dartmouth-hitchcock Dartmouth-Hitchcock’s helicopter is a part of its advanced response team (DHART).

The Dartmouth-Hitchcock ER sees more than 30,000 patients a year. Just to the north by about 75 miles, the number of ER visits at Littleton Regional Healthcare is just 11,000.

“What we see here are mostly recreational injuries — skiing, snowmobiling, hiking injuries in the summer, and falls and scrapes,” says Dr. Edward Duffy, the medical director of the emergency department.

Note that the term “emergency room” is shifting to “emergency department,” a distinction that some emergency physicians care about while others don’t. It is certainly more than a room; it’s a whole complex of curtained cubicles, nurses stations, and rooms with diagnostic equipment and offices.

“It used to be just a consultation room off to the side that was used sparingly,” says Duffy. “A nurse would assess you and call a doctor if she needed help. Hardly anyone came for a routine problem.”

What’s also changing — the level of stress. It’s gone up as the volume of patients has gone up (no, the advent of urgent care and Affordable Care Act, aka Obamacare, hasn’t reduced the volume). Part of the increase is drug overdoses from the opioid epidemic; another is the long stays — “boarding,” it’s called — by mentally ill patients who cannot get into the few treatment centers in the state.

Having higher patient volumes means more times when critical patients must be dealt with simultaneously. “It can be a quite chaotic, loud environment, with lots of moving parts, lots of distractions,” says Dr. Joseph Leahy, medical director of the emergency department and associate vice president of emergency medicine at Nashua’s Southern NH Medical Center, a Level III trauma center with 42,000 visits a year. “It’s a challenge to make quick and effective decisions in that environment.”

Another layer of stress, he adds, is doctors having to make those decisions with limited information, especially if the patient cannot talk. Knowing a patient’s medical history, what medications they’re taking and so on can be vital.

In recent years, medical records have been made electronic, but the system isn’t perfect. “Access to information is easier,” says Leahy, “but, if you’re dealing with an outside organization, sometimes the EMR systems don’t talk, or the information you need is buried and access to that information is harder to obtain.” The flow of information can also be constrained by the federal HIPAA privacy laws. 

With emergency physicians working in such stressful conditions, there is always the chance of making a mistake. As with all doctors, the threat of a lawsuit looms large.

Also stress-inducing, emergency physicians are acutely aware of the people sitting in the waiting room. “We recognize that no one wants to be there,” says Dr. David Heller, emergency department medical director at Portsmouth Hospital, a Level II trauma center with 25 beds and 27,000 visits a year. “Most people didn’t expect to be there, and they don’t want to wait a long time. We try very hard to see patients within 10 minutes, but if a bunch of patients come in with serious problems, that’s going to affect the wait time.”

photo by kendal j. bush People are always in motion in Catholic Medical Center’s emergency department.

The average time spent in New Hampshire emergency department waiting rooms is 26 minutes, according to recent data from the Centers for Medicare and Medicaid Services gathered by ProPublica, a nonprofit public interest news agency. The average time spent in the emergency room before being sent home is 2 hours and 15 minutes.

Wait-time statistics are just one of several metrics on which emergency departments and their physicians are judged — by the financial people at hospitals, as well as by state and federal agencies.

If physicians also have the duties of department administrator, as is the case with all the physicians interviewed for this story, those metrics are always on their mind. As administrators, these doctors must oversee their department, attend meetings and sit on committees, pushing up the number of hours worked and the stress level.

Burnout. It’s a big issue for emergency physicians. “After four or five years, some feel they’re been there, done that; they’re ready to move on to something less stressful,” Heller says. “People who have been in this business for a long time have figured out how to manage stress.”

Heller is one of them. He’s been at work in emergency rooms for 29 years and still loves what he does. He adds, though, as do all the doctors we talked to, that he couldn’t do it without the support of his staff — nurse practitioners, physician assistants, nurses and technicians among them. As Heller says, “I might be the quarterback, but I have a whole team helping me.”

The camaraderie, unmatched in most other professions, is one reason emergency physicians stay at it. Another is that the hours they work are predictable. After their shift, be it 8, 10 or 12 hours, they go home. After-hours phone calls are rare. 

They say it’s also “the excitement,” “the hustle,” “the variety.” And, as Dr. Duffy of Littleton Regional Healthcare says, “There’s the immediacy of getting patients to feel better. If someone has a dislocated finger, you fix it and they’re happy.” Another plus, says Dr. Vacik of CMC, is the ability to take control in dire circumstances: “It’s nice to be the calm head in a crisis.”

Most important of all, and for all, they are helping people.

“It is a very privileged, sacred space to be trusted by someone in that genuine moment of critical need,” Dr. Morrell of Dartmouth-Hitchcock says, “It is an honor to have them look to us for help and wonderful that we can make a difference.”

And what a difference. Few people can say they’ve saved a life. Fewer yet can say they’ve saved the life of a stranger. These doctors — and their teams — can say they’ve saved many.