A frail 50-year-old woman lies on a stretcher, clutching her stomach. On the wall above her is a sign that reads “Hallway bed 7.” Most passersby in the crowded narrow corridor seem to be ignoring her. As I draw near, I hear her moan softly.
This is the 13th time she has presented to the emergency department in the past year since being diagnosed with metastatic ovarian cancer. Her abdominal pain has never been this bad—she has not had a bowel movement in days and tells me that all she wants is an enema to end her pain.
I try to find any available room, some semblance of privacy; however, the ED is overcapacity, as it is on most nights. I am told that the earliest we can get a room is in two hours and the single portal folding curtain sometimes seen in the ED is nowhere to be found. The idea of attempting an enema in the hallway crosses my mind. She looks at me while still writhing in pain, and mumbles “not here,” as if she has read my mind. An hour later she resignedly agrees, but soils her stretcher, unable to make it to the washroom in time.
One strategy to cope with the dramatic increase in the number of people seeking medical care in the ED over the past two decades has been the use of non-traditional beds and spaces for patient care. Hallways, conference rooms and storage areas are hurriedly converted to clinical space, using portable oxygen tanks and makeshift nursing stations to make do. In some places, paper signs on the wall designating a hallway bed have become permanent fixtures, and questions such as, “Where’s hallway bed 7?” are part of the usual vernacular in hospital.
I have also fallen into a consistent routine.
When I see a patient in the hallway, I start by trying different versions of a quiet apology. “I’m sorry that you have to stay in the hallway, without any privacy. Sorry you will not be able to sleep. I’m sorry we’re still waiting, waiting for a bed to open up.” None of them seem quite right. No words feel sufficient to excuse the indecency of providing care in an open space, filled with strangers and noises.
Next, I stand beside the stretcher and ask questions relevant to the patient’s specific presentation. “Is there a way you can be pregnant? How long have you been struggling with increased alcohol use?” Sometimes, in the middle of a question, I awkwardly move to the side as another patient stretcher passes by. If I need to take a sexual history, I will quickly glance around, then attempt to whisper.
Without any curtains in sight, I ask permission to complete a physical exam. I do my best with blankets, trying to balance being thorough and not exposing their naked body to the world. Older patients often joke, “Oh, the world won’t mind, not much to see here!”
For patients who are being admitted, I often try to rush their paperwork, hoping for a more comfortable bed on the unit. But the next day I find them in a wider hallway on the ward, right in front of the hustle and bustle of the nursing station.
If my patient is lucky, the nurse will be able to find earplugs and an eye-shield in the back corner of the supply closet. However, for most sleep is hard to come by. Some of my patients become increasingly confused due to lack of sleep in the hallways and wind up staying in hospital longer. Others leave too early, defeated by their hope of getting a bed, only to come back sicker. History repeats itself and I see them again in the emergency department hallway. I apologize again and the cycle continues.
It has been suggested that one of the primary drivers of ED crowding is the fact that patients who have been admitted to the hospital end up staying in the ED until a bed becomes available on the unit. Some say that patients may even prefer a hallway bed on the ward to one in the ED and it has the potential for spreading the burden on hospital staff evenly. Subsequently in some hospitals, hallways on the wards have opened up to decant the emergency department. But the slightly wider hallways are hallways nonetheless.
I am disappointed in the care I provide daily in the busy cold hallways. I feel defeated and angered by the very design of our health care system that allows for care to be provided with such indignity.
I can only image how my patients feel. How do they feel to hear and see everyone that passes by as they are trying to heal from an illness? Do they get used to the sound the elevator makes every time someone gets off on their floor? Is it possible to fall asleep with only slightly dimmed lights in the hallway? Do they feel a cold breeze in the corridor when the doors open and close? What is it like to stand in line to use a washroom already shared by four patients in a room? How do they cope with having to be exposed in front of passersby so a physician can examine them? What if a physician forgoes the exam completely to ensure their privacy?
Emergency room crowding will only grow with an aging population and there is a real need to come up with realistic and creative solutions. The answer is not as simple as increasing the number of hospital beds. We need more long-term care beds, better hospital design that takes into account crowding, increased community resources and nursing support and ongoing investment in initiative such as hospital at home that aims to provide care of chronic illness within the comfort of people’s homes.
Health care providers need to stand side by side with patients and the community at large to demand better solutions because I refuse to believe we cannot do better than our hallways.