'We're At Our Breaking Point'

Grady is the only Level I trauma center (the highest designation, with 24-hour trauma surgery coverage) in a 120-mile radius. Staffed by Emory and Morehouse School of Medicine faculty, it's also a teaching hospital that trains one quarter of Georgia's physicians. The vast ER, which is spread out over nearly 1.5 acres, is divided into a Red Zone that handles trauma cases (injuries) and a Blue Zone that deals with medical cases (such as diabetes and chest pain). Beyond the ER's 80 beds, there are now 30 "holding spots" for patients in the hallways, but all of these are routinely filled. In recent years, the overcrowding has worsened. While Atlanta's population has grown by double digits in the last 10 years, three area ERs have shut down during that period and another hospital is due to drop out of the trauma system this summer. The result: those facilities that remain are reaching their saturation point more quickly, and diverting ambulances to other facilities more frequently.

Grady hit that threshold at around 2 a.m. on that Saturday night. When Kellerman headed over to check on some patients awaiting a CT scan, he learned that the machine was down. Now all those head-injury cases would have to rely on the only remaining machine, which was two floors up and across the building. Before long, six patients in critical condition were backed up awaiting CT scans. If additional trauma patients arrived who needed a scan as well, they could face a potentially fatal delay. So at 3:30 a.m., Grady went on "trauma diversion"—an alert to ambulance and helicopter services that for the time being, the ER couldn't accept any more trauma cases. Unfortunately, at that point, nine other hospitals in the area were also on some form of diversion; some had reached trauma saturation, others ICU saturation and others general ER saturation. Since diversion can't be enforced—it's more like crying uncle—and since practically every other facility was on it as well, patients continued to roll in to Grady.

By now, the ER's hallways were jammed with patients. Some had gaping wounds and were spilling blood. Others moaned in agony. A note taped to one wall—"No procedures in hall"—seemed like a pointless plea. In the hallway outside the trauma rooms, resident Lee Ocuin treated a drunk man teetering on a stretcher who had slashed his middle finger on a beer bottle and severed an artery. Blood streamed down his arm, soaking the stretcher and drenching a sheet that Ocuin was standing on. "This is not nice," one nurse observed as she walked by. Only months before, the Joint Commission on Accreditation of Healthcare Organizations, which regulates hospitals, had ordered Grady to cut down on patient "boarding" in hallways. Grady responded by trying to limit gurneys to one side of the hallway. But during Saturday night's onslaught, that proved impossible.

The frenetic pace was exacting a toll on the ER personnel, who looked frazzled and exhausted. Some overstayed their shifts—by eight hours, in one nurse's case—to help ease the pressure. That helps explain the difficulty Grady and other hospitals have in recruiting nurses. With a 25 percent nursing-vacancy rate in the ER, Grady is almost always understaffed. Nurses burn out quickly on the conditions—caring for 10 or 12 patients at a time when half that should be the norm, racing from one crisis to another, feeling guilty for taking a bathroom break. "You want to give quality care but you can't," said Charge Nurse Sherika Kimbrough. "We're at our breaking point." Same goes for the physicians, who also have malpractice suits to worry about. Two years ago, Kellerman received a resignation letter from a top-notch doctor. "I can't take it anymore," she told him. "I am so afraid of making a mistake that I'm vomiting in my driveway before I go to work."

To better understand the ER crisis, however, you have to look beyond the ER itself—starting with the floors above it. The ICU beds on Grady's seventh floor are regularly as packed as the ER. For a variety of reasons, including medical advances that permit people to live longer, patients are arriving in the ICU in greater numbers and in worse shape. Many are admitted through the ER, which supplies the ICU with most of its patients. Others are transferred from smaller hospitals ill-equipped to handle the hardest cases. And still others come for elective procedures. The resulting congestion forces patients down in the ER to wait hours and sometimes days for a bed upstairs to open up. Not only does that clog the ER (it's common to have more than 20 patients at one time waiting to be moved), but it also taxes an already harried staff, since admitted patients are in grave condition and require specialized attention. "The last place you need admitted patients is hanging out in the ER," said Dr. Leon Haley, Grady's chief of emergency medicine.

Other factors contribute to the overcrowding as well. As the ranks of the uninsured grow, many resort to ERs for primary-care needs, like filling prescriptions or dealing with back aches. One day during NEWSWEEK's visit, an uninsured woman, Rashdat Adebowale, came in for what amounted to little more than a headache (she was given some Motrin). A friend told her she'd receive professional attention at Grady and wouldn't be charged. In fact, she was charged—about $300—but when it comes to the uninsured, which represent about 55 percent of Grady's ER visits, the hospital says it recovers only about five cents on the dollar. Part of what's driving up patient volume at Grady and other medical centers is actually the insured population—people, for instance, who can't find a primary-care physician who will accept them or who recoil at the thought of waiting three months for an appointment. "They're coming because for whatever reason, they're having difficulty accessing the system," said Haley.