Like any tsunami, the wave started innocuously enough. Even disconcertingly calmly. Elective surgeries weren't scheduled over the Thanksgiving holiday anyway, and the glut of open beds meant that the emergency department, for once, had a manageable caseload. Of course, this was all relative: A half-dozen nurses and technicians were out with COVID-19 because a patient came in with a fractured shoulder (and no other symptoms). When the X-rays came back, boom: They showed the telltale sign of a COVID-19 infection: hazy "ground glass" infiltrates in the lungs. The patient was an asymptomatic superspreader who would never have known they had COVID-19 if they hadn't fallen off a ladder putting up Christmas decorations.
Beyond that, though, the department has been running on half staff for months now. The 10-year retention rate for ER nurses and technicians is around 5%, even when there isn't a global pandemic. The hospital's inability to hire more in the interim—a combination of budget constraints and lack of providers who want to take jobs on the very the bleeding edge of the COVID-19 crisis—hasn't helped any. But at least the staffing levels were merely woeful instead of critical. Over the next few days, however, things began to turn rapidly.
The phones began ringing off the hook: "I think I was exposed to COVID-19, and I am having some mild symptoms, can I come in for a test?" Apologies were made as no COVID-19 testing can be done without a patient being fully screened by an ER physician. Left unsaid is that thanks to federal mismanagement, the hospital is so limited in its testing capacity that for a while if you wanted to run a rapid COVID-19 test, you had to have the personal approval of the head physician of the hospital. Things aren't quite that bad now, but unless a patient is being intubated or needs emergency surgery, everyone is relegated to getting the results in three to five days, just like if they’d gone to CVS or their primary care provider.
Three dialysis patients are brought via ambulance within an hour of one another. There was an outbreak of COVID-19 amongst the staff at the dialysis center and these patients were unable to receive their normal treatments. Even worse, one of them turns out to be coronavirus-positive themselves. The same happens with an infusion center patient who arrives in dire need of a blood transfusion. An elderly Alzheimer's patient (whose daughter caught COVID-19 and as the sole caregiver for her ailing father, gave it to him) is brought in with extreme delirium, an underappreciated consequence of COVID-19 infections. His vital signs are stable, but he yells. Screams. Refuses to wear a mask. Kicks and bucks at the staff.
A classic COVID-19 patient on day nine of their symptoms arrives in triage. Their blood oxygen level is 60% and while they’re still able to talk, they are quickly worsening. It's determined that they will need to be intubated except the hospital's ICU is full; calls are desperately made to other nearby hospitals attempting to find an ICU willing to accept them. While half of the ER staff is assisting with the intubated patient and covering that nurse’s other patients, the Alzheimer's patient rips his IVs out and gets out of bed. He wanders maskless and infectious down the hallway, trailing blood, opening the doors to other patients' rooms. A scream brings the attention of a CNA who is "sitting" outside the door of a room with a 1:1 suicidal patient, who has been waiting four days for a bed placement; she and an X-ray technician, both only wearing surgical masks due to a critical shortage of N95 masks that hasn't improved since the pandemic started, call for help and attempt to corral the agitated patient.
In triage, the wait time has grown to a minimum of six hours, perhaps double that for "less acute" patients. Large, white surge tents are set up in the parking garage, but even that extra space can’t decompress the waiting area fully. The sardonic joke of flu seasons past—"if you don't have the flu when you go to the ER, you will by the time you leave"—takes on new meaning. Unlike during the summer, when patients and visitors could wait on a bench outside, it is now almost winter. The temperature at night drops well below freezing, with snow already on the ground and in the forecast. Environmental engineers have given it their all, having received the green light from the administration to do whatever is necessary to increase patient and staff safety. Eventually, they jury-rig the ventilation system to pull in fresh air instead of recirculating it and make the entire unit as "negative pressure" as possible to keep COVID-19 particles from aggregating dangerously. Yet without shutting down the hospital and conducting a wholesale gut of the building's HVAC system, no permanent solutions will be found in time for this pandemic.
The ER charge nurse gets a call from the nursing supervisor: The neighboring level-one trauma center is going on "divert," meaning that they have decided their emergency department is too busy to manage any more patients. If an ambulance tries to bring a patient to the level-one, they'll be instructed to take that patient elsewhere—and this is the only other emergency department within 50 miles. Indeed, within minutes of that notice, five ambulances have called in to report they were rerouted and will be arriving momentarily.
Except there are no beds to be had, so two of the patients are jammed into hallway beds in the back of the department. The other three are sent to triage, including a patient who is extremely intoxicated and seeking "detox" before they go into withdrawal; another, bruised and bandaged, wears a cervical collar after having crashed his motorcycle; and a crying elderly woman who is helped into a wheelchair and will eventually be diagnosed with a fractured hip and pelvis. But that will be hours and hours from now.
The triage nurse is overwhelmed. She has no help and is now expected to watch over 30 patients, deciding who goes first. Every time a bed opens in the back, instead of moving the waiting line forward, another ambulance comes in and takes it. A nursing home patient who is septic from an infected indwelling foley catheter, an actively seizing epileptic—their arrival requires her to start her priority list over from scratch. While the triage nurse scrutinizes her patient board again, checking the vital signs on a emotionally stricken woman who is suffering a miscarriage, she is accosted by another patient demanding to know why they've been made to wait for hours to get stitches put in. She tries to politely apologize but is interrupted by the patient spewing a litany of insults who tells her she must not know how to do her job and that her hospital is the worst they've ever been to.
Meanwhile, in the main part of the ER, a facility across the state finally agrees to take the intubated COVID-19 patient, but only if they are transported by air. If the patient survives their ICU stay, they'll find a $25,000 helicopter bill awaiting them along with an ICU bill that will easily be in the six digits. It's unlikely they'll be able to pay that even if they do have health insurance, which means that cost will get spread out amongst everyone else in a sort of "stupid single payer", as opposed to the system just a couple hundred miles across the border in Canada. Socialize the losses, privatize the gains, and bankrupt the patient—basically, make sure to cost society the highest possible amount in the least efficient way possible.
Right now it's an all-hands-on-deck evolution to try and make space somewhere, anywhere, in the hospital. But with all inpatient units already full, the ER charge nurse is told some of the patients there will have to wait until tomorrow at the earliest for beds—if not beyond. By the end of the day, the emergency department will be down to a mere three rooms (out of the original 35) where patients can actually be seen by ER physicians. All the other beds will be taken up by "boarders" waiting for a room. Administration attempts to open a makeshift unit to house these patients using admit—recovery and post-anesthesia care unit rooms to take some stress off the ER. New patients simply fill those spots as soon as they open and no headway is made whatsoever.
A half-dozen people leave the triage waiting room. The patient needing stitches angrily screams they will be going to another hospital; unfortunately, there are no hospitals in the area in better shape, meaning they will arrive elsewhere only to find themselves at the back of a new 10-hour wait to be seen. Another patient who suspects they have had COVID-19 for a few days but with only mild symptoms is looking for a prescription for an inhaler. They will leave ... only to return by ambulance in the middle of the night in cardiac arrest. It turns out COVID-19 had given them a constellation of massive pulmonary embolisms—blood clots in their lungs. Before acute intervention can be done, they go into cardiac arrest. While the harried emergency department team is able to resuscitate the patient, they will eventually be discharged to a nursing home, requiring full-time care for the rest of their lives from the anoxic (lack of oxygen) brain injury they suffered while arresting.
This goes on all night. Administration offers unlimited overtime, time and a half, even double-time pay for anyone who will pick up a shift anywhere in the hospital. Coronavirus-positive staff are allowed to work even if ill as long as they are able to stand and walk. Maximum shift lengths rules are ignored, as are the number of consecutive days one is allowed to work without a break. Every manager in the building is told they will not be allowed to leave until the hospital decompresses and they’re on the "other side" of this surge, because if their employees don't get a break, they don't, either.
Dawn breaks. It’s Thursday, Dec. 3. COVID-19 takes two to five days to manifest symptoms after exposure, and the window for acute symptoms requiring hospitalization is between Days Eight and 10 after symptoms start. Which means there are another five to seven days to go before the people who became infected on Thanksgiving Day will be showing up to the ER, critically ill.
Today was only the beginning
This emergency department will fail. Patients will die who, a year before, would never have been in any jeopardy whatsoever. Others will survive with chronic health problems that will make them "frequent fliers" to the ER and other health services for the rest of their lives, dramatically impacting their quality of life and incurring an incalculable toll on themselves, their family, and society as a whole.
The emergency department staff, from the hospital administrators who will roam the hallways to take vital signs and set up rooms to do everything they can to help, to the housekeepers cleaning rooms to keep patients and staff safe and healthy, everyone will absolutely wreck themselves trying to hold the line. Of all the tragedies to come, the cost to front-line staff will have one of the biggest impacts. Because these emergency service providers will carry every failure with them for the rest of their lives. And it's not their fault; they will do everything they can. A third of the staff that make it through the pandemic will leave nursing altogether once on the other side of the crisis. Marriages and relationships will be destroyed; substance abuse problems will become manifest, and compassion fatigue almost universal.
None of them will ever be the same.
And it's not fair. They will internalize every failure, every patient who suffered or died and think, ”That was my fault. What should I have done to save this person?’ The truth, of course, is that the problem was always beyond their capacity to solve alone. That effort needed to be led and managed at the federal level.
No emergency department anywhere was designed to be able to handle a mass casualty event lasting for days or weeks
Effective intervention from the highest levels was needed from the get-go. A coordinated message to push for masking. Using the Defense Production Act to make sure there was enough personal protective equipment to go around. Onshoring critical national security supply lines. Keeping schools and teachers safe. Not forcing working-class folks and small business owners to choose between paying bills and getting sick or dying.
And while these front-line providers may recognize that federal failure logically, their conscience will never allow them to believe that.
This story is not hyperbole. It has already happened, this spring and summer, in a number of places in the United States of America. It will happen again in the coming days. Some places won't be as bad as what’s described here; others will be worse. Regardless, we had a chance to avoid it. We could have done so with a modicum of national effort and competency.
But that chance is gone, and the price will be paid in blood.
The only question now is how much.