Tuesday, September 23

From Emergency Room of the Future
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Friday 9/12/08 8:00pm-11:00pm

The waiting room was filled with patients, both young and old. The people waiting seem like they’re in discomfort and have been waiting for a while. I checked in with the receptionist and she let me inside without any questioning.

I think the ED was quite operating near, if not over, capacity. There were a lot of patients on hallway beds, and there was a nurse doing triage on these hallway patients. She used a portable and mobile computer which she pushed along from bed to bed. The patients were hooked up to a monitor, so their vitals were clearly accessible.

The ED was very noisy, with constant beeps and buzz and people chattering, discussing, calling out orders, responding to orders, etc. I asked a nurse where Dr. Ackerman was, and she radioed him. 30 seconds later his face popped into the nurse station. He was very busy.

Dr. Ackerman showed me the giant LCD screen showing all the patients and their status. Things were color-coded to indicate acuity level, and there were lots of other info including tests ordered, tests completed, doctor assigned, etc. It seems a bit complicated with all the different icons representing different things. But it is a good organization tool for defining a structural operation flow of some sort.

It’s 8:25p, and Dr.A has washed his hands (the quick anti-microbial hand sanitizing lotion) a lot of times. He does a good job remembering to wash his hands before and after every patient he sees. Dr. A has really good patient-doctor bedside manners, and despite the noise and chaos that goes on around him, he was still able to give every patient he sees his undivided attention.

There is a nurse trying to start a line into a patient lying in the hallway bed. He’s injecting the needle into her arm, and then there’s a bed (with a patient on it) moving down the hall. So the nurse had to get out of the way and temporarily suspend his procedure. There’s a very old lady (around 80+) lying on the adjacent hallway bed who every now and then would moan and scream out foreign phrases, calling to her daughter. There are all sorts of patients here with different needs; it is quite overwhelming.

I can’t express how crowded the ED is at this hour. There are so many different types of health professionals in here: nurses, tech, med students on rotations, residents, police officers, patients, students like me, etc. I can’t imaging how things get done around here at this level of capacity, but things do manage to get done and patients do get transferred to the floor and get admitted. It’s is amazing to say the least, even if the ED is not efficiently operated.

I looked at my watch and it says 11:00pm. I had originally thought to sign up with the ED nurse outside to get my health check, since I was quite sick (cold or flu of some sort). But seeing how crazy things were, I figured it was best to just go home and sleep, since I most likely won’t be able to see a doctor and would have to wait some ridiculous hours. I also figured that staying in the ED when my immune system is fragile is not a very good idea. So I bid Dr.A goodnight and left for home.

Saturday 9/20/08 8:00am-12:00pm

The waiting room was emptied except for a teenager who was sitting watching TV. The ED looks very different from the last time I came. Dr. Ackerman had already seen five patients since the last hour, so I’m guessing I missed the morning rush.

I had a chance to talk to a PRN today, and he was a very delightful person to talk to. He was quite passionate to say that healthcare is “insanely dysfunctional,” that at least in the army you know who you’re reporting to and what you’re expecting. But in healthcare, there is a complex hierarchal structure that it’s impossible to know. He also said that there is a traditional psychological abuse in the health care training process, where the old “eat their young,” and the new are hazed. It is better to look stupid than to ask questions, because as a newcomer you don’t want to get stepped on. Nursing is a tough position, a pink collar job that everyone looks down upon.

I felt a bit distraught after the interview, but I don’t think it’s that bad. But then again I’m not a nurse so I don’t know. I saw the nurse put in an NG tube into a patient (tube inserted through nose and passed down to the belly) – that was quite interesting. The patient was quite compliant in being a teaching object at the same time.

Because the ED was not crazy and hectic like the last time, I got a chance to talk to another doctor about his perspectives on ED. Dr. Armstrong is a relatively new addition to Emory’s ED docs. He had previously worked at Detroit Receiving Hospital, and he had many positive opinions about Detroit’s ED. He sketched a rough blueprint of Detroit’s ED and explained how the system was run. The details I will post up later.

So I asked Dr. Ackerman about modeling EDs after the most efficient existing ones, and he said that it’s not realistic to do such a thing due to variation in geographical setting, which means variation in diseases and distribution of diseases. One way of creating an efficient ED is to start from scratch and build the ED from the ground up. But since this is not a very practical option, modifications and improvements of sub-processes in the ED are important for improvement in ED health-care delivery. The ER Future Class is expecting students to offer solutions to problems that would have incremental changes, not necessarily the governing change that models the perfect ED.