There’s a kind of meme on the internet. There are various iterations of it, often applied in reference to the medical community. They generally go like this: “No one is coming to help” or “We’re all alone, nobody is coming to help us” or “No one is coming to save you, it’s up to you to save yourself.” It can be found on mugs and shirts; no doubt on tattoos. Currently ink-free, I have to admit it has an appeal.
It’s a little dark, I’ll grant. But it does speak to my Appalachian, Scots-Irish ancestry and our love of a good, hopeless last stand, with flags waving, drums beating, pipes blowing, axes pounding on shields, and all that.
Sadly, however, hopelessness has been all too real during the COVID-19 pandemic. And while every hospital and everyone involved in the care of the sick has felt hopeless at times, I write specifically from the perspective of small, rural hospitals and physicians like myself who staff them. Because indeed, when it goes bad, no one — and I mean no one — is coming to help.
Without a doubt, large regional referral and teaching centers are crushed by volume and acuity. I have every respect for the staff of those facilities. But those of us in smaller hospitals, the rural and critical access hospitals, are also fighting a losing battle. Not only due to volume, not only because people are extremely sick on a baseline of poor health, but because of a stunning lack of resources and options.
In the past, sometime around 2018 BC (Before COVID), we could often transfer the sick and dying. But here in 2022 DC (During COVID), we find ourselves uniquely situated for tragedy. This is because the large centers where we would typically send our critically ill and injured patients are no longer accepting them, except for a few very specific cases. Transfer coordinators inform us, “We’re closed to transfers except for trauma, stroke, STEMI, OB, and pediatrics.”
This means my patient with the relatively boring NSTEMI, rising cardiac markers, and ongoing chest pain will have to wait as we hope for the best. The completed but severely impaired stroke patient will not be seen by a neurologist but will lie in an ED bed where a neurologist is a mythical creature far away and a nurse practitioner will do his or her best to manage the patient’s complex illness overnight…if he gets admitted rather than held in the ED.
The list goes on of those conditions we should transfer but can’t. We have to hold things like post-operative complications recently discharged from other hospitals, serious vaginal bleeding when we have no OB, or new onset leukemia with sepsis. In fact, I have even been told, more than once, that I was not even allowed to consult with a specialist at a referral center; presumably they were just too busy with the pandemic chaos.
Much of our time as physicians in small hospitals is spent managing these complex patients while now simultaneously talking with transfer lines, telling the same story over and over only to be told “sorry.” We keep searching, asking for a hospital 1 hour, 2 hours, 4 or 8 hours away to give us a bed for the hypoxic child who needs an ICU with ECMO capacity, for the overdose with seizures, or for the patient with necrotizing fasciitis when I have no OR due to lack of surgical nurses at night.
To make things much worse, to place us squarely betwixt devil and deep blue sea, there’s the issue of paramedics and ambulances — which is to say, there aren’t enough of them. They’re frequently understaffed and when they have staff, it’s sometimes only an EMT basic doing his or her best to manage complex patients outside their level of training, or all too often the ambulance is out of town taking a patient 4 hours away, leaving them out of service for an entire shift.
“But what about the helicopter?” families ask. Sometimes they can’t come because they have insufficient crews, or need mandated rest periods. Where I work, it’s often mother nature that says “no bird for you!” Rain, fog, wind, snow, or ice can leave that magnificent piece of equipment grounded and unable to take our patient over the Appalachians to the care needed. When I go to my shifts I always look to the sky to see if air transport might be an option that day.
I know I’m not the only one who has seen patients slowly die in the ED; patients who in days past were salvageable and would have been transferred and then walked out of the hospital after a short admission. However, as good as we are in the ED, there are procedures and therapies we can’t offer, and so we do our best and keep seeing who walks through the door (which of course never stops), even as we manage whatever conditions need to go elsewhere but simply cannot.
In the midst of this we just keep hearing colleagues and administrators say, “well, just do your best. Try to transfer them.” I get it; they’re in the same boat we are. They have no answers. But all we can say in response is, “I get it. I’ve tried, over and over, but there aren’t any beds anywhere. And if there were I may not have an ambulance tonight.” We hear families say, “I don’t know what you mean by ‘no ambulance!’ Surely there has to be an ambulance?” In response we try to explain, no, there isn’t; nor is there a bed in Big Teaching Center Memorial Hospital.
An elderly patient’s son, who was intoxicated, looked at me and said of his aged, injured mother, “she needs to be in a bed, not a hallway, right now and I’ll call a (expletive deleted) helicopter myself.” I firmly, politely explained that we were literally doing all we could and had no other options yet. And that he should go to the waiting room.
For years we’ve all done disaster drills and read our yearly competencies, which included the disaster plan. We took online tests on them. We had badges with “code blue” and “code orange” and “code stork,” and all the rest to help us plan for bad days.
But they were meant for bad days, not bad years. And now, when we flip that badge and call the on-call administrator, all they can say is “I don’t know.”
I believe every hospital affected by COVID-19 should have a 24/7 command post, detailed with helping get whatever clinicians need that might distract from patient care. The federal government should also have established a national website and command center to help with locating specialists, beds, resources, and transportation. Large hospitals should “adopt” small hospitals with firm commitments to help when things fall apart, just as small hospitals should learn to keep more and transfer less whenever possible. Ultimately, we need to think long and hard about how to do this in the future, because another pandemic or similar existential crisis far worse will emerge one day.
This disaster has been brewing for decades. COVID-19 only brought it into the light. We have always needed more beds, more staff, more specialists, and in many remote areas, more hospitals. But these things cost money, and systems gambled that the worst wouldn’t happen. But in the end, as in the casino, the house always wins. This is to say, the population has lost.
Hopefully we’ll have a better plan and a better system and will have learned from this dark time.
Until then, however, the hard fact remains. For many of us “nobody is coming to help.”
Edwin Leap, MD, is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test and Life in Emergistan. He recently launched a new column on Substack called Life and Limb.