I know, I know. We here at REBEL EM are normally very clinically oriented. We take recent articles or hot topics and give you the breakdown and clinical take home points. But a recent event happened that made me look at my own practice, and now on the other side, I feel that I am a better doctor. The hospital I was working at as medical director of the Emergency Department (ED) closed its doors. This was a hospital that had been in the community for more than 60 years. I won’t go into the reasons for closure, but rather, I would like to tell the story from the side of the ED provider and what I had to change until the lights were turned out.
I began working at this hospital on June 3, 2015 as medical director and Chair of Emergency Medicine. We knew that the hospital was in trouble, but not beyond the point of saving. The hospital, my group, and I were all confident we could turn the ship around. We were on pace to see just under 40,000 patients a year in a 17 bed community hospital. We had good specialty back up with the exception of neurology, neurosurgery, cardiothoracic surgery and trauma. We also did not due interventional cardiology, but we did have an active cardiology service. Things initially were going well. Patient satisfaction was going up, as well as admissions, which made the hospital happy.
The first inclination of the oncoming storm was the decision to close our Women’s Center. This included all OB/GYN, Labor and Delivery, and pediatric services. This was followed by the decision to suspend OR services, meaning no more anesthesia, general surgery, orthopedic surgery or gastroenterology (since general surgery covered this).
A couple of weeks later, while trying to sleep after a night shift, I received a call from our Chief Medical Officer and ICU director. We were closing the ICU effective immediately. The result of this was the loss of pulmonary, cardiology, and renal/dialysis services. I could no longer admit patients who had the possibility of being “sick.”
At this point, an announcement was made publicly that the hospital would close in 30 days unless an agreement could be made on the sale of the facility. Visits dropped off. Admissions were dwindling as well. As a result, the decision to close the inpatient floor was made. Inpatients could still be admitted, but they were physically relocated to one section of the ED, taking 5 of my beds away. A former 159-bed hospital had been reduced to a 12-bed ED and 5-bed inpatient service.
The end came quickly. On November 27, we stopped admitted inpatients (although we could still admit for observation). On November 29, EMS and law enforcement were instructed to divert mental health patients to other facilities (we would still see those that walked in the door). December 1 saw the end of observation admissions and the doors were closed and boarded up at 0700 December 4.
The progressive loss of services led to an increasing loss in ED visits. Tough personnel decisions were being made by the hospital, and by me as well. A decline in ED visits from almost 90 patients per day to 40 patients per day forced to me reduce the coverage of PAs and NPs from 20 hours a day to 10 hours a day. Truth be told, I was having a hard time justifying those 10 hours as well with such a low census. The final 24 hours before closure only saw about 22 patients in the ED. The last of those patients was discharged around 9 pm. The ED saw no patients for the last 10 hours it was open.
So what did this do to me as a doctor? While I was in a semi-rural environment, I really felt akin to great FOAMed docs like Casey Parker (@broomedocs) in Broome, Australia and Tim Leeuwenburg (@KangarooBeach) on Kangaroo Island. My resources were limited, but the patients still needed top-notch medical care. This forced me to spend more time with the patient to really parse out what they needed. I had to become more creative to provide the best care possible to these people.
Communication with the patient and family became the most important part of the encounter. Many of these patients had been coming to this hospital their entire lives and couldn’t believe the doors were closing. Often as doctor’s we feel we are communicating with the patient when we explain things to them. What about the listening side of communication? Just by listening to our patients more will help us understand the real reasons they visit the ED and what we can do to help, even if it is just listening or holding a hand.
Speaking of hands, the healing power of touch has been touted throughout the ages. This extends farther than the holding of hands or the gentle touch of the shoulder. Our hands as clinicians are powerful tools for diagnosis as well as patient comfort and care. Several patient complaints I have heard over the years included the phrase “and the doctor didn’t even examine/touch me.” How many of our diagnoses are clinical? Performing a more thorough focused physical exam not only makes the patient happier, but can also direct you to the use of diagnostic studies if needed, such as labs or imaging.
The gradual closure of the hospital also impacted patient care, with limited diagnostic modalities available. Remember, it’s not just direct patient care jobs that are being lost. Near the end, I only had one laboratory tech and one radiology tech at night. If I had more then one patient needing their services, someone was going to have to wait. Bedside ultrasound allowed me to bypass some of this. We had an older machine with curvilinear and linear probes, but one probe had to be disconnected to allow the other to be connected in order to use it.
I have listened to and watched Matt Dawson and Mike Mallin, Mike Stone, Vicki Noble, and others for years. Now I could really feel the benefit of what they have shown us with ultrasound. The rapidity of its diagnostic usage was one thing, but to be able to connect with the patient by allowing them to see what I saw was an added bonus. Now the patient and family could be more of a part of the team.
Bring the patient and family into the fold of the team is one of the most important things we can do in medicine. Gone are the days of paternalistic medicine, for the most part. The idea of shared decision-making really must be employed when you are resource strapped. By sitting down and talking with patients and families about the diagnosis, treatment, and disposition options, I was able to connect more and everyone was happier. Through this, I was able to discharge the low-risk chest pain patient with two negative troponins and low HEART score. I also had the 72-year-old hyponatremic patient with double pneumonia sign out AMA, but left with her prescriptions and thanked me.
Listening to the patient, performing a more thorough physical exam, increased use of bedside ultrasound, and shared decision making were only part of the changes in my practice. I’m not sure if “back to the basics” is really what happened, but more awareness of what I was doing is perhaps a better way to put it. I was much more satisfied with my patient encounters and heard “thank you” from patients and families more in those last 30 days, than in the preceding 5 months. I even had several ask where I was going to open my office once the hospital closed.
I feel I have gone back to what I wanted to be when I first became a doctor. With all the advances in technology, diagnostics, and the ubiquity of the electronic medical record, often we become removed from the patient experience. The humanistic part of medicine gets pushed out. Don’t get me wrong, I love my ultrasound and CT and EMR (not really). But I also love the feeling of making a difference for someone in his or her time of suffering, uncertainty, and fear.
For the “take home point” that we usually give: With all of our diagnostic bells and whistles, don’t forget there is a person sitting or lying in the bed in front of you.
Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)