Portrait of an ER at the Breaking Point

It was Saturday night at Grady Memorial Hospital in Atlanta, and the emergency room was getting crushed. An unrelenting wave of severe head-injury cases was sucking up most of the trauma section's resources. Among the victims filling the four trauma bays: a middle-aged woman who had been shot in the left eye, a young man who had been shot in the right temple and a young woman whose head was pummeled when she was ejected from her vehicle when it rolled over in an accident. Doctors and nurses darted from one patient to another, medicating, bandaging and intubating them. Amid the tumult, one nurse exclaimed: "This is Lebanon! This is Afghanistan!" The neurosurgery team was overwhelmed. One resident drilled a hole into the female gunshot victim's skull, so he could insert a tube that would relieve the pressure on her brain. Another resident re-bandaged the other gunshot victim's head, which oozed blood and brain matter all over the sheets. Why all the head injuries? It turned out that most hospitals in the area at that hour had either no Intensive Care Unit beds or no neurosurgeons available, said Dr. Arthur Kellerman, the attending trauma physician. "So all the brain stuff is coming here."

But the night was about to become even more hectic. Just before midnight, Kellerman burst into the trauma room. Two more car-accident victims were on their way, he announced. He quickly scanned the four trauma bays, all of which were taken. Who could he move to make way? He selected the only patient not on a ventilator, even though her condition—six broken ribs and a lacerated liver—was precarious. "I would not have chosen to take her out of the room," said Kellerman afterward, "but I had other people coming in who were even more critical." That freed up only one spot, though. Minutes later, the two accident victims arrived simultaneously. So paramedics crammed both into the free space. The ER staff descended on the patients—clearing their airways, checking their circulation, cutting away their clothes—all the while struggling to avoid colliding with one another.

With so many ER personnel tied up in the trauma bays, patients in the rest of the trauma zone received only scant attention. "There's a catastrophe happening out there because we're so focused on this," said Kellerman, in a quick aside. Beyond the trauma-bay doors lay a multitude of the sick and maimed. Every ER room was taken. Overflow patients lay in gurneys lining both sides of the hallways. Scores more sat anxiously in the waiting room outside. Yet as chaotic as it all was, this was a typical Saturday night. "There's nothing unique about this," said Kellerman, who's the chairman of Emory University's Department of Emergency Medicine and currently a Robert Wood Johnson health-policy fellow in Washington, D.C. "This is trauma care in the U.S. today."

Grady is stretched to the breaking point. It lost more than $20 million last year, up from $13 million in 2005 and $10 million the year before. In 2006, it incurred around $170 million in costs to treat uninsured patients, including both outpatient care in the ER and inpatient care in the hospital. As a public institution, it receives about $105 million annually from Fulton and DeKalb counties, but that figure has remained flat for years and covers only 17 percent of its operating budget (the bulk of the remainder comes from Medicaid, Medicare and commercial insurance). It's hard enough for such a strained system to handle the routine flow of patients. How would Grady deal with a major disaster or terrorist strike? In the midst of the Saturday-night crunch, Kellerman evoked the 1996 Olympics bombing in Atlanta, which flooded Grady with scores of victims. Back then, he said, the ER was less burdened. "Imagine what we would do with an Olympic Park right now."

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.

Plenty such people poured into Grady on Saturday night. Just before 2 a.m., about when the hospital was considering going on trauma diversion, the waiting room was choked with some 50 patients and another 30-odd relatives and friends. Many slumped in their seats, staring despondently at the blaring TV sets. Others paced anxiously, accosting anyone with an air of authority. One woman who had just spoken to a nurse reported back to her family, "They've got a lot of trauma back there and it's going slow." Wait times at Grady regularly reach eight hours and can sometimes stretch to 12 hours or more. A growing number of patients give up long before then. According to hospital figures, walkouts increased from around 8 percent of patients in 2001 to about 12 percent in 2006.

Alexis Carter was nearly in that group. That Saturday, she arrived at the ER at 4 p.m. with pelvic pain and bleeding (she had started a new job and her insurance hadn't yet kicked in). Hours later, as her pain grew unbearable, she retrieved some Ibuprofen from her car to try to relieve it. Around midnight, Carter's mother, who had been calling to check on her, blew in like a tempest. She marched up to the nurses' station, pitched a fit and demanded that her daughter be treated. Nothing happened. At 3 a.m., a sympathetic nurse practically smuggled Carter back to the triage area, leapfrogging her over other patients. When Carter reached the Blue Zone, she received a bed in the hallway—and waited some more. Finally, at 5 a.m., 13 hours after she arrived at Grady, a doctor came to examine her. "I just think it's crazy you could leave people waiting that long," said Carter. "It's pathetic."

In an attempt to speed things up, Grady has introduced a number of reforms. Three years ago, using grant money from the Robert Wood Johnson Foundation, it created the Care Management Unit, a seven-bed annex aimed at treating patients with ailments like diabetes and congestive heart failure who might otherwise be admitted to the hospital. Then, on the eighth floor, Grady took over some unused space to set up the 17-bed Care Initiation Unit, designed to pull admitted patients out of the ER and start their lab work and feeding while they wait for a bed to open up. And just off the waiting room below, the hospital established a fast-track section staffed by physician assistants and nurse practitioners to treat mild conditions like cuts and coughs.

As much as that might facilitate patient flow, however, the bottleneck remains. Last year, Grady spent 3,600 hours on some form of diversion, compared to 1,400 hours in 2001. Other hospitals are increasingly diverting patients as well, though Kellerman carps that their standards are sometimes questionable. Some will go on what they term "case by case" trauma diversion. "That term drives me crazy," said Kellerman, who speculates that it's a way for the hospital to conduct what's known as a "wallet biopsy"—accepting paying patients while rejecting nonpaying ones. Whatever the reason, the bottom line is, if everyone else is turning a patient away, chances are he'll wind up at Grady.

Few experience the stress of diversion more directly than the paramedics charged with rushing patients to treatment. Scott Cathcart, a Grady EMS supervisor, said it's common for an ambulance to be forced to bypass a closer hospital because it's on diversion. He recalled the case of an 8-year-old hit by a car who was turned away from two ERs before arriving 20 minutes later at a third that could take her. Often, as soon as one hospital begins diverting ambulances, others quickly follow suit. In which case, "we've got a rule," said Cathcart. "Once all are on diversion, none are on diversion." (By federal law, an ER must accept a patient brought to its doors.)

At 4:30 a.m., an hour after Grady went on trauma diversion, Kellerman took a phone call. A doctor from Chestatee Regional Hospital in Dahlonega, Ga., a mountain town 70 miles north of Atlanta, wanted to transfer a patient who needed more sophisticated care than his medical center could offer. The patient, who was in a vehicle crash, had a fractured femur and possibly a brain injury. Unlike some other states, Georgia lacks a coordinated statewide trauma system to help distribute patients to the appropriate facility. That leaves physicians to shop patients around themselves. Though the Chestatee doctor had contacted North Fulton Regional Hospital in Roswell, Ga.—which was closer to Dahlonega—he told Kellerman that an ER doctor there had hung up on him. Kellerman sympathized, but explained that one of Grady's CT scans was down. "I'll make a deal with you," he said. "Let me talk to my trauma surgeon. But could you try North Fulton again? They're not listed as being on diversion."

The doctor called back an hour later. He said North Fulton had rejected the patient, even though the hospital wasn't on diversion and was 20 miles closer to Dahlonega. "That was not an appropriate decision," said Kellerman, fuming. (A North Fulton spokesperson said afterward that the trauma surgeon on call that night insisted that he never heard back from the Chestatee physician after an initial conversation and did not reject the patient.) Soon thereafter, Grady officials reluctantly agreed to take the patient. At 7:30 a.m., as the sun rose over the city, a helicopter buzzed into view and landed on Grady's rooftop. Paramedics and Grady staffers unloaded the patient onto a gurney and rushed him down to the trauma bay, where the next shift of doctors and nurses was already getting deluged. As stressed as it was, the system somehow worked and saved the man's life. But what if Grady were to collapse? Or what if, as hospital executives have contemplated, it were to downgrade to a Level II trauma center? "Can we continue to be all the things people want us to be?" asks Haley, the chief of emergency medicine. "No, we can't. … Society has to decide what it's willing to support." And, he might have added, it will have to live with the consequences.

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