An icy wind whipped against my khakis as I walked 3 blocks from the patient parking lot to the hospital on the crisp March day. The frigid air triggered an unexpected paroxysm of coughing. What is wrong with me? Why am I getting worse? I read my notes, neatly written on 2 small index cards, clutched in my hands. The mammoth medical center loomed menacingly in front of me. I struggled to catch my breath against the icy bursts of wind. While it was just another day for the doctors inside this hospital in Anytown, it was not for me. I was about to check myself into the emergency department.
Anytown is a city like many others. Multiple academic and community hospitals serve the several million inhabitants living within the city and surrounding suburbs. Competition between these hospitals is vigorous in spite of a desiccating pool of revenue derived from a seemingly endless flow of patients. The doctors, nurses, and other providers of Anytown are worried about the future of their hospitals, places they could almost call home. The shadowy threat of hospital closure seems anathema given the enormous mob of patients clamoring for help, but fears about job security, a preposterous concept when they dedicated their lives to medicine many years ago, creeps ever forward in their minds.
The stark reality of emergency medicine felt suffocating as I walked through the sliding doors at 1:12 pm. The walls bulged with a motley crew of people, mired in their paradoxic anonymity. Patients covered every available surface, from rows of plastic, short-backed chairs to surfaced end tables. Many were leaned over, doubled in pain, attentively nursed by a friend or family member. Bloody bandages and splints wrapped wounds and broken extremities. An old man sitting in a rusty wheelchair warily eyed 2 rambunctious children. A CNN broadcast of the war in Iraq beamed from a small television in the corner while a jaded row of waiting patients, little else to capture their attention, gazed half-heartedly at the images. Gritting my teeth, I trudged to the back of the line at the reception desk and took the deepest breath that I could muster, releasing it in a tired sigh. It was going to be a long wait.
In front of me, a middle-aged woman holding a plastic supermarket bag stuffed with old clothes hunched forward to speak to the uniformed young man at the desk. As I waited, I noticed a half-empty Sprite bottle several feet to my left, sitting prominently on the reception desk counter, reminiscent of a proud family displaying their child’s soccer league trophy. Behind the desk, jackets, purses, and backpacks were strewn about, giving me the disquieting impression that I might just have stepped into a private office, or the casual confines of a residence. Next to the chairs, 2 women, apparently nameless employees, were whispering with great amusement to one another. They stopped talking and looked at me as I approached, but neither acknowledged me nor spoke. I looked bravely back at them, wondering if it would be rude to tell them that I needed their help. They returned to their whispering. I waited anxiously.
“Can I help you?” the uniformed man asked me as the woman in front of me shuffled away.
“I had trouble breathing last night. I have been coughing all week,” I replied.
“Are you breathing okay right now?” he asked. I nodded. He wrote my name and my chief complaint onto a hospital data form. He told me to take a seat and that a nurse would call me shortly. It was 1:22 pm.
I claimed an open plastic seat in the corner. A filthy sign on the floor a few feet from me leaned against the wall, exhausted. It carried a cartoon picture of a patient wearing an N95 respirator with the caption, “You may be asked to wear a mask.” The dog-eared corners of the sign complemented its nicked and peeling, stained edges. For a brief second, I wondered if patients should be given masks to wear around that sign.
Although there was a small table to my left designed for children, the entire waiting room had turned into something of a play area. Napkin shreds and wrappers littered the floor. Magazines and newspapers in a nearby rack were crumpled and disorganized. A few brown, recycled napkins were sandwiched underneath one of the table legs. Patients and staff members looked on the mess with equal distaste. No one stopped to clean up the trash. A wave of anxiety suddenly passed over me. If they could not keep their waiting room clean, how would they possibly care for me?
I waited. As I struggled with my frustration over the wait, I was one of a number of witnesses to a fascinating daily name ritual. Approximately every 10 minutes, a nurse would come out through a set of double doors near the back and announce a patient’s name in a loud voice. “Mr. Jones. John Jones.” Usually, no one would answer. The nurse wandered around like a disappointed bargain shopper until his voice became an echo in the distance.
At 2:35 pm, a nurse named Mandy called my name. Two individuals accompanied her: a lean woman with dark hair and a tall man with a 5 o’clock shadow, both of whom were wearing improvised nametags—small strips of silk tape on which was carelessly written “Observer, R.N.” They did not introduce themselves. As I sat down, the 2 of them and Mandy looked at me with disinterest, apparently waiting for me to tell my story. Apprehensive of the observers, but fearful that I would be banished back to the waiting room empty handed, I described my symptoms. After I finished, Mandy asked about my medical history and took my pulse. Because I was probably not too sick, she said, she would put me in the “RapidCare” pathway. After all, RapidCare is, well, rapid, right?
At 3:05 pm, I went back into the waiting room. A new, half-empty coffee cup had been added to the mess in the culinary menagerie that stifled its space. More magazines were strewn about. Given the distaste with which everyone had been regarding the trash all afternoon, we were all somewhat surprised when Wanda marched smartly into the waiting area carrying disposable gloves and alcohol swabs. She proceeded to clean up the garbage. One patient looked on appreciatively, remarking, “You are a dedicated employee.” Everyone let out a small sigh of relief. At least some of the people here clearly care about the state of this place. Perhaps one of those people would care that much about us when we prostrated our lives and bodies to their hands.
I continued to wait. At 5:15 pm, I went up to the reception desk and asked if it would take much longer. The uniformed man, not presently dealing with anyone else, nonetheless seemed annoyed at my impertinence. Perhaps I had broken some unwritten oath of silence. He said that he could not tell me how long it would take and that they would call me when they were ready. But I’m a RapidCare patient, I argued, to no avail. Even the most poorly organized, unfriendly restaurant will tell you how long the wait is for a table, I ventured. He looked at me with a mixture of contempt and intense ennui. I backed away apologetically and sat down.
At 5:45 pm, with beads of sweat forming on my forehead, I suddenly felt a wave of anxiety wash over me. Why was this taking so long? Did they forget about me? What if I am really sick and something happens while I am sitting here? Why doesn’t someone just tell me what the hell is going on?
A nurse practitioner finally called me in at 6:09 pm. After a few minutes of getting settled into my room, she knocked, entered, and introduced herself. She made no mention of the nearly 5 hours I had just spent in the squalor of that waiting room and offered no explanation or apology. She stood over me and asked me what the problem was. I told her that I was not really sick. I am a consultant hired by her boss and am helping to evaluate their emergency department.
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