Overcrowded, understaffed and underfunded

American ER Doc Gone Walkabout Episode 012

My spontaneous memories of working in Tasmania focus on interesting cases, minimal amounts of safety net non-emergency work, delightful colleagues and staff. It came as a bit of a shock when I went back and read again the blogging that I did contemporaneously while in Tassie. Words like “chaos”, and “crushing” seem to have been quite prominent.

Hmmm. Time appears to not only heal wounds, but also erases bad memories.

I have had similar experiences with terrifying mountaineering near-death experiences, horrifying bicycle death marches, God-awful ski tours in white-out blizzards. A few months later, those awful experiences become life-enriching epic trips. Like Tassie.

A few observations might be of interest.

Why is it that, no matter how the medical system is financed, ER’s are so horribly underbuilt and understaffed? The US academic hospitals, and the Indian Health Service Hospitals, and many of the large city hospitals, and the Canadian hospitals where I have acquaintances, and every Aussie Hospital that I have any familiarity with — they all spend much of their time overcrowded and understaffed. More so than most of the inpatient services. Outside of medicine, one rarely if ever sees a private, or even a governmental business model that seems to have such routine mismatching of capacity to demand. There may be occasional day or hours of operation when the business is overloaded, but not day after day after day as is so common in ER’s throughout the world.

Business models often have built-in redundancy and excess capacity. Sure, sometimes when you go to the bank you have to wait for service but you don’t have to wait every time you walk through the door. Or to a restaurant – sometimes you wait, but not too often. Even (or, especially) at McDonald’s. And, hotels often have many of their rooms unfilled — so that they have capacity for most of their customers during peak times.

Why can’t we do that at ER’s?

Plan so that we can handle comfortably some of our busier (if not the busiest) times, even if it means having empty beds and idle staff at less busy times.

I’d like to think that it would be possible to build enough beds — ER and inpatient admission beds, and hire enough staff to adequately cover something like 90% of our loads, while not being too overstaffed at less than peak, and not achieving levels of pure desperation at our truly peak times.

What makes that goal unattainable?

Well, there’s little ability to shift loads. People may choose to eat a meal a little earlier or a bit later to avoid the noon rush, but few of our Footy players will be able to dislocate their shoulders earlier or later in the match in order to beat the rush. And restaurant patrons may choose to walk down the street if the first choice for pizza is overcrowded – not usually reasonable when searching for ER wait times.

And, most other businesses have much shorter average turnover times than ER’s, so can balance capacity to loads over shorter time periods. Perhaps long stay hotels approach ER turnover times?

And, for a restaurant, adding a few cooks or servers may be a short training program and a relatively low wage away from reality. And temporary staff can be added for busier times of year, and then let go when not needed. Adding a few more ER nurses or Docs is a many year training program and high wage away from reality. Not gonna happen. Not gonna hire enough ER Docs (even if you could find enough) to have them, at high hourly salaries, sitting waiting for that 10% peak load. This may be one reason that using more techs and paramedics and PA’s is likely to help beat the understaffing problem.

The only place where I’ve seen a staffing and capacity pattern that really seems adequate (and in some cases, excessive) is in the highly competitive sphere. 2 or 3 hospitals in close proximity, and with a well-insured patient population. There, allowing large overloads to develop shunts paying patients down the road to the alternative hospital. The business model requires overstaffing during low load hours in order to have adequate staffing at peak hours, so that you don’t lose patients to the competition. Nice work if you can get it. Though, I have to admit, I went bat-sh!t crazy after pitching too many “no hitters” on night shift at one place. (For you Aussies, an American baseball pitcher throws a “no hitter” by not letting a single batsman successfully get to base by hitting a ball, for an entire game. If I had ever worked an entire shift at Lonnie, seeing no patients, I suppose I could say I’d been bowled for a duck).

So, I’ve circled around…

I neither understand cricket, nor do I understand why so many ER’s in so many different systems are routinely overloaded and understaffed with inadequate facilities. But, I fear that the economics and availability of trained staff, and the inability to shunt off excess demand to alternative settings will survive all of our complaint.

At University Hospital, we’ve recently added a position called RME — Rapid Medical Evaluation. He’s really the Waiting Room Doc (Editor’s note: Welcome to Utopia Rick!). I did it today for the first time. Try to short stop the simpler cases (another baseball term, maybe like a slip or even one of the silly positions) and pre-order labs and imaging on some of the tougher cases, all out in the Waiting room and our little mini-exam room next to the Waiting Room. After 4 days of never getting below about 10 in the waiting room, and often 20-40 waiting, we cleared it out completely for about 10 seconds (literally). Good on us, mates.

Next time:  No emergency? No, thanks…