Eve Purdy is a PGY5 in emergency medicine and who recently earned her Masters in Applied Anthropology after completing thesis work related to the culture of high performing teams in critical care environments.
In March 2020 I treated a patient I’ll call Mr. Jackson*. He was an elderly gentleman who’d had 2 hours of chest pain that he thought was heartburn but when it didn’t go away he came to the ED where he was brought immediately to a bed in the resuscitation section. Although the initial ECG was normal, a repeat 15 minutes later showed subtle ST depression in the anterior leads. Both his pain and the ST-depression improved with nitroglycerin. The first troponin came back slightly elevated and I explained to Mr. Jackson that he was having a heart attack. I started antiplatelets and anticoagulants and contacted the cardiology service. Less than an hour later he was admitted and moved up to the inpatient unit.
While this may seem like a standard case, the interaction was actually a profound moment for me as a fifth- and final-year emergency medicine trainee. It made me question my previously held notions of quality care. It was the moment that an era of deviance was unnormalized.
Of course, that was not the first time I’d seen a patient with a myocardial infarction. I have cared for hundreds of patients just like Mr. Jackson. In fact, as I approach transition to independent practice, I like to think I am pretty good at it. But, having been a Canadian medical trainee for the last nine years, I have “grown up” in the era of “hallway medicine”.
Prior to March 2020 it would have been perfectly normal for Mr. Jackson to sit in the waiting room as we awaited the results of his troponin test, and then be moved onto a hallway stretcher for further assessment after a game of bed tetris. It would not have been unusual for me to return for another shift 24 hours later and find him on the same hallway stretcher still waiting to be transferred to the inpatient unit. I’d thought “hallway medicine” was just a part of how I was supposed to do my job.
Yes, I felt uncomfortable when I saw patients having catheters placed in hallways behind flimsy curtains, or when I noticed elderly “long stay” patients becoming confused in our windowless environment. I had read that overcrowded EDs were dangerous and representative of problems with access. Yet, I couldn’t ever see past the only reality I had ever experienced. I now recognize that my learned acceptance of “hallway medicine” represents a near completion of the normalization of deviance within our system and our profession. With a whole generation of doctors like me never having experienced emergency medicine any other way, the slow cultural drift towards lowered expectations of what is acceptable and of what is humane was almost complete.
However, our health system’s response to COVID-19 resulted in an immediate and dramatic shift in how I provided care. We prepared fervorously for the potential arrival of patients with COVID-19 increasing hospital capacity through a variety of mechanisms. However, unlike more severely affected areas in Canada and around the world, our region fortunately did not see the expected influx of COVID-19 patients it had feared. An empty hospital and decreased Emergency Department (ED) volumes meant available ED stretchers and vacant inpatient beds. So for most of March and early April, like on the day that Mr. Jackson arrived, our waiting room was almost empty. Patients like him were brought immediately into available rooms. When admitted they moved to the floor with what seemed like miraculous, but what was is probably just reasonable, speed. Older patients awaiting crisis placement did not languish in the ED for days. It was a brief glimpse into an alternate, better reality I never knew existed. My resident colleagues and I cannot ‘un-see’ this new ideal. The deviance has been unnormalized.
But another type of deviance started to emerge.
I asked Mr. Jackson whom I should update about his condition. He told me his wife was waiting in the car outside. I exited the department to “the ramp” and found the blue Ford he’d described. It was cold outside, and raining. Drops of rain fell down the visor of my mask. I was having difficulty seeing the driver and she had no idea what I looked like. I apologized for the way we had to speak…in a parking lot, like this was some kind of drug deal…I said I was sorry she could not see her husband. I explained about the heart attack and asked if she had any questions. “What time should I be back to take him home?” she responded. I emphasized the words “heart attack” and that he would need to stay in hospital but she could not visit. “Oh, I see…,” she said. I knew she didn’t. She couldn’t see the urgency of the care we were giving him. She trusted me, but it was blind trust. I suddenly wondered if she would see him again, if this heart attack would have a heartbreaking ending. I made my way back into the ED, wet and cold from the rain. I wiped off my visor and saw the next patient with the heaviness of this interaction weighing me down.
I think back often to this moment and how much it bothered me. After just a few weeks of the “no visitors” policy, I’m already finding myself less saddened for patients and their families as I walk back from conversations on “the ramp”. Now I am mostly frustrated with how inefficient care is without families at the bedside. Questions answered in a minute by a family member in the ED now take three extra phone calls. Without non-verbal communication cues from a worried family member it takes longer to understand the situation. Having a conversation about goals of care is nearly impossible. We cannot normalize this new form of deviance, but already I see the system, and myself, rapidly accepting and adapting to it. Experiencing this drift in real-time contextualizes for me how quickly we can collectively come to accept the extremely abnormal – how things like “hallway medicine” can happen.
Over the past few weeks the acute threat related to COVID-19 has dissipated somewhat in our region and we are already trending back towards “the way things were”. Our wait times are slowly increasing. Despite infection control guidelines, in order to manage the waiting room pressure, stretchers are creeping back into the hallways. There are delays when patients are transferred to inpatient beds. Without extreme collective vigilance, “hallway medicine” will be rapidly normalized by our system again. It is only in the last months of my nine years of training that I truly came to understand that “hallway medicine” is not normal, that it is not humane, and that there must be a better way. A perspective that came just in time. A perspective that took a pandemic.
*The names, dates, details, and medical facts of this case, while founded in truth, have been altered significantly to protect patient confidentiality.