The Guy in Room 20
A Sensible Medicine Guest Post
On a recent shift, I received sign-out for Room 20, a 46 year old man with a history of schizophrenia as well as alcohol and cannabis abuse. He came to us from a nursing home where he lives. He accidentally set his room on fire with a cigarette, prompting the nursing home to kick him out for being a risk to the facility. Although he had no acute medical issues, he was sent to the emergency department so “the health care system” could find him a new home. He arrived on a Friday, ensuring that he would live in room 20 all weekend, waiting for social service programs to evaluate him on Monday to arrange new accommodations.
Room 20 was recently renovated as “the psych room”, retrofitted to have specially locked storage and features to prevent patient self harm or “elopement”. (Elopement is a favorite term — most people picture running off to Vegas to get married while ER docs associate it with running out of the ER to be “free”.) A large screen TV behind plexiglass dominates room 20. I suppose the architects were aware that patients might have long stays in this room and hoped that a giant TV would help pass the time.
There used to be a character on David Letterman, The Guy Under The Seats. He was played by actor-comedian Chris Elliott. The Guy Under The Seats lived under the audience stands. He would occasionally arise to utter updates about life under the seats as if dwelling in the studio was a commonplace event.
Although taught never to refer to a patient as “the diabetic in room 5”, I started to fondly refer to my new patient as The Guy in Room 20. He would stand at his door, watching the rush of ambulances and staff moving from room to room or ask for something to eat. He reminded me of that vintage Letterman character. The Guy in Room 20 was jovial and cooperative, occasionally popping up to stand at his door. Ironically, the change of scenery in the ER seemed to be a mood booster for him.
The long term ER "boarders" have become victims of the bizarre tragedy of our safety net system with specialty rooms designed for “comfortable” long stays. Since EMTLA was enacted in 1986, Emergency Departments cannot refuse care. The law was passed to address private hospitals refusing to treat patients without insurance, “dumping” them at public hospitals. This safety net is a critical and humane necessity for our healthcare system, however, the unintended consequence is turning the ER into a destination to solve ever more complex social problems like housing for the mentally ill (or those unable to smoke safely).
That the ER is a short term hotel for psychiatric patients has been normalized. The demand for housing for the mentally ill has outstripped supply for generations. Now a growing cohort of non-elderly, mentally ill patients, with chronic medical conditions (especially diabetes or COPD) have made long term nursing home residence a common occurrence. The ER Boarder, classically describing admitted patients waiting for a bed in the main hospital, now more often includes the psychiatric ER Boarder who can wait days for an inpatient psychiatric bed, or, like my patient in Room 20, a bed in a new nursing home as a permanent residence.
Healthcare investment is biased toward sexy technological solutions that promise to “save money and provide better care”, but after a long weekend with the Guy in Room 20, investments are needed in low tech solutions like nurses to staff beds, case managers to help navigate new placements, and social service staff to manage problems on the weekend. And, of course, actual housing.
I ended up signing out the patient twice and received him back twice at shift changes during a three day stint. The Guy In Room 20 spent nearly 70 hours in the ER before being transferred to a new nursing home.
Carrie Mendoza is an Emergency Medicine physician practicing in Chicagoland.
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Great story that reflects a longstanding and frustrating situation for both patients and staff. After many years as a nurse, it still seems crazy that hospitals, theoretically 24-hour facilities, shut down many services after 5 pm and all weekend. This includes numerous clinical and support services that cannot be foisted onto the backs of overburdened bedside nurses, a decent selection of food for anyone not working 9 am - 5 pm, and many other things. Holding this patient in an ER is expensive. It's a penny wise and pound foolish choice.
As the CMO at a large healthcare system, my entire morning would be spent trying to “move” ED patients.
The vast majority needed beds in the hospital as inpatients. The most frustrating were the psych holds. As mentioned, the disparity between the total extant county psych beds and needs was a chasm.
IMHO there are two major reasons for all ED’s being overwhelmed and under capacity.
1. Urgent patient access to their outpatient doctors is difficult to impossible.
2. The primaries, when confronted with someone asking to disrupt their schedule, themselves, tell the nurse “send him/her to the ED/ER”
I have listened to recordings on PCPs’ answering machines stating “ go to emergency room if you need to be seen urgently” (words of substance)
I have nothing but admiration for ED docs. It’s the toughest job anywhere in medicine. Remember the adage about anesthesiology?
95% boredom and 5% chaos: emergency room medicine is 20% boredom and 80% chaos.
I am a PCP and to use a sports analogy, primary care doctors have become punters, not quarterbacks.
Ben Hourani, MD MBA.
Board Certification, Internal Medicine Geriatrics-retired