August 15, 2011

IN ANY large urban public hospital's emergency room, the intersection of medical problems and social problems is a given--and the resulting collisions are often tragic. Almost every day, already bad situations are made worse for people who are without insurance, without a job, without a home.

On one recent weekend workday, three cases stood out to me as typical of the patients treated at this hospital, and the problems they suffer.

The day before, a patient came in saying he'd had difficulty swallowing for six months. In his late 50s, both he and his wife had been laid off--by the same employer--almost a year ago. Unable to find work or afford insurance, the man had tried ignoring the problem, hoping it would solve itself. When he couldn't even eat soup anymore and had lost 30 pounds, his daughter convinced him to come in.

A CT scan showed a mass in his esophagus. An immigrant from Poland, he nevertheless felt he had survived much worse than this, and despite his plight, he tried to make light of the situation.

The next morning, when I come back to work--16 hours later--he's still in the hallway, waiting for a bed upstairs, and his wife is attempting to sleep in a plastic chair next to him. They say there will be a biopsy sometime later on, and the earliest appointment they can get to discuss treatment with an oncologist was in a week and a half.

Another man, also in his late 50s, is brought in by his wife and 14-year-old son. According to the family, he's an alcoholic and had been drinking for eight days straight. The wife takes off, leaving the son alone with his intoxicated father in the emergency room. The patient soon has to be put in leather restraints because he is disorientated and keeps trying to climb off the gurney--we simply don't have enough people to monitor him directly.

The teenager seems to be completely detached from the situation, and it's clear that this is not the first time this has happened. He sits on the bare floor, legs stretched out and stares at his phone as we pretend not to look at them and wonder what to do. Should we call social services on the mother for neglect of her son? Would that even help or just further complicate things?

Meanwhile, a young man in his late 20s has been vomiting with abdominal pain for several days. Once he makes it back to see us, he waits hours more before the CT becomes available to scan him--they have been busy with trauma patients, mostly victims of violence.

The CT shows a mass in his stomach. By the time his test is done, the emergency room is overflowing, and he has been "upgraded" to the hall. His mother has accompanied him the entire time, and the news is devastating. His wife carries two small children in from the packed-out waiting room to be close to him. The kids can tell something is up and are visibly nervous. It is difficult for the family to process what they will be confronting, as they are smack in the middle of a crowded hallway.

Up and down this corridor, heroin addicts are withdrawing, psychotic patients are hallucinating, and people needing assistance are calling out. There is no privacy, no space to deal with this. I pull another patient out of a station into the hall, and put the young man and his family into it. The only way to provide someone with privacy is to take someone else's away.

THIS ALREADY stressful context is further compounded by the chronic short-staffing of nurses.

Unlike failing banks, failing public hospitals aren't seen as deserving of government money. A lack of funds means cuts, and cuts in a public hospital mean cuts in staff, cuts in services, cuts in patient care. The head of the county government here, a Democrat, had already instituted 10 furlough days for the system's clinics. Crowded schedules are now even more crowded, and needed appointments are pushed further back.

Because of cuts in services and the increasing number of people without jobs or health insurance, flow into the Emergency Department (ED) has increased--and at the same time, we have seen a decrease in the number of staff.

Short-staffing an ED is very dangerous. When you already have a patient population that is sicker because they are poorer, it's never clear how many things are going wrong with them when they enter the front door. Fewer nurses on the floor means a greater chance that something won't get done, and the results can mean the difference between life and death.

The nurses are angry because of what this means for their patients and the stress it puts on them, but they've felt powerless to act. This has been going on since the start of the new year, and it's only gotten worse. When management says, "You're lucky to have a job," and you look at the 20 patients lining up to be registered at the front desk, some having to lean on a family member to stand and wait, it's easy to think that they're right, and we shouldn't complain.

Because of an embarrassing article in a local business magazine about how many hours of overtime these "greedy public-sector union workers" were getting, upper management decided to cap the hours. The article ignored the fact that they won't hire anyone to meet the obvious need, and that excessive overtime is a problem created by management.

A dozen nurses were told they were no longer allowed to work more than 40 hours a week. This cap meant that nurses who were willing to work weren't allowed to, and the staffing situation went from ridiculous to outrageous. Where we had been short two or three days a week for the past six months, the problem became an everyday occurrence.

In the area for the sickest patients, with active heart attacks, strokes, acute respiratory failure and so on, the schedule calls for three nurses and an emergency room technician to care for four very sick patients. Every day for over two weeks, only two nurses were scheduled in this area, and no tech.

It got so bad that nurses who never called in sick started doing so, too stressed out from the daily avalanche of patients and without adequate staff to help them. We had been giving notice to management about staffing problems since January, but nothing ever changed. A petition protesting short-staffing was circulated, and 75 percent of the 90-plus RNs who work the three ED shifts signed it within a week.

FOUR ED RNs showed up unannounced to a safety committee meeting of the independent board that governs the hospital. We presented the petitions and testified about how we had informed management months ago about this problem, and nothing had been done. All the nurses spoke about how this situation endangered their patients. The chair of the committee thanked us for coming and said he would investigate the matter.

When we got back on the floor, one of the nurse managers went off on us at the front desk of the ED, with the line of patients watching. In a completely unprofessional manner, she threatened us with discipline and yelled that there would be hearings because we "didn't have permission to leave the hospital."

I told her that her bosses knew exactly where we were, we never left the hospital, and if she really wanted to spend her energy on attacking nurses who had advocated for patient safety, that was fine with us.

A week and two days later, the overtime ban was lifted, and as of yet, not one nurse has been disciplined. The nursing director of the ED, who most of us never see hide nor hair of, has held six "town hall meetings" over the three shifts because she has now decided that she wants to hear our concerns. At the meetings, she promised that nine new ED positions have opened up for this fiscal year, and three more are slated for next.

In a department where our union hasn't been strong, this struggle has been a big step forward, not just because we won our main demand, but because it involved many nurses who distributed petitions, testified at a public forum and now see the union as a vehicle for defending our ability to provide safe patient care.

The problem of short-staffing hasn't been solved by lifting the ban on overtime, but nurses now feel more confident to fight for what is right.