Intensive Care 

4-26-17

I’m not sure what I expected when I walked through the doors of the emergency department at Beth Israel Deaconess Medical Center (BIDMC).  It certainly wasn’t the clunky, beige monitoring systems that flashed a series of lines and colors from inside examination rooms; the standing booths, used for triage, that looked more like ATMs than anything medicinal; the occasional patient sitting in a hallway chair, appearing completely commonplace except for a dangling IV; the television overhead flashing a college basketball game; the relaxed gathering of clinicians in the center room, eating ham sandwiches in front of screens displaying radiology results.  This was nothing like the gory landscape I was imagining — patients with limbs hanging off, screaming in pain as attractive physicians rolled them into steel-plated rooms for immediate surgery.  In some ways, the underwhelming reality was comforting: a lesson not to trust television dramas, at the very least.  In other ways, though, I wondered how the miracles of emergency medicine — the split-second decision making, the obscenely long shifts, the saving of lives — occurred in such a non-miraculous setting.

 

But our tour guide (whom I'll call Dr. L) seemed to think otherwise.  Dr. L had recently developed a software system that — with its intuitive interface, unique color coding capacities, and accessible patient profiles — supposedly revolutionized the efficiency and safety of care at BIDMC since its implementation several years ago.  As he walked us through his project, Dr. L noted the software’s low emphasis on financial data (something prioritized by the leading software Epic) and high emphasis on patient experience.  In addition to handy diagrams that “standardize care” based on symptoms, the portal stores valuable demographic data such as “language spoken” — information that, in combination with family history, readmission rates, and other notes, increases doctors’ sensitivity when treating patients .

 

To me, these efforts to improve patient-centeredness were crucial, yet woefully insufficient.  Sure, they give life to otherwise flat profiles, allowing doctors to prepare for and contextualize their future rounds.  But as we transitioned from our virtual tour to a real one, I couldn’t help but notice glaring transgressions of patient-centeredness throughout the emergency department.  Receptionists rolled their eyes at the frantic or unintelligible complaints of several incomers.  One attendant ignored a patient’s request for water as he lay in a hallway stretcher.  Most notably, the psychiatric ward in the department — a wing that, according to Dr. L, is severely undersized given the huge demand for beds among mentally ill patients — was comprised of six cube-like rooms with glass exteriors, housing solitary patients who stared back at our passing group with confusion and contempt.  Attendants, holding clipboards and pagers, sat sleepily in front of each room, noting periodically in their records that patients were alive and not self-injurious. 

 

Never have I been more uncomfortable with my own role as an observer — not just because the scene felt exhibitionist and zoo-like, but because I couldn’t necessarily think of alternatives to the systems in place.  Unfortunately, the same patients that could benefit from “patient-centered” initiatives — personalized accommodations and prolonged relationship-building with a provider — are those least likely to receive them due to the dire and time-sensitive nature of their conditions.  In fact, patient-centered care almost seems antithetical to the sterile, fast-paced, and overcrowded environment of an emergency room.  Is it even worth trying?

 

I was surprised, then, when Dr. L led us into one of the acute care units, housing complicated-looking machinery, and pulled out a set of beige blankets from one of the fridge-like structures.  “Feel them — they’re warm,” he said.  “You’d be surprised at how much of a difference that can make when you’re about to undergo a procedure.”  I immediately imagined myself in some compromised position, in pain and unable to advocate for myself. 

 

I think — in this situation, at least — Dr. L was right.