Doing time: Hallway medicine is out of hand

Amy’s back pain reached a crescendo in the early dawn hours of Oct. 6. Our daughter was never one to complain. After two weeks of progressively increasing pain, without an acute antecedent provocation, things became intolerable. The standard analgesics and non-steroidals barely scratched the surface. The decision to seek emergency care was made without hesitation, despite the anticipated wait times in most hospital settings across the province. There was no viable alternative. Our son-in-law, Stacey, drove with haste and purpose. The hospital of choice was well-known to Amy. She had delivered her daughter, our granddaughter, 21 years earlier during SARS, in the same hospital. On arrival, Amy was quickly evaluated by triage nursing and soon thereafter by the attending ER doctor. His initial assessment was thorough and thoughtful. Immediate CT imaging was ordered. When the doctor returned, he patiently reviewed the findings, “unexpected” his emphatic opinion. He described a “burst fracture” of L1 and the plethora of clinical investigations that would immediately be undertaken. In Amy’s case, time was truly the critical variable. He ordered an MRI, he said, but would immediately proceed with a referral to CritiCare, a complex triage undertaking which would identify a tertiary care hospital with a spinal emergency surgical team. In Toronto, the triad of choices was Sunnybrook Health Sciences, St. Michael’s Hospital and the Western Division of the UHN. The recipient institution would need a surgical team available and willing to accept the transfer, emergency operating room accessibility and a soft landing in a postoperative surgical bed. We received Amy’s text informing us of the decision to go to the ER for her severe back pain in the early hours of that morning. We were asked to await test results before rushing out the door, no sense waiting in a room of the same designation. The next eight hours, however, were spent waiting for the CritiCare decision. Amy was somewhat comfortable, the therapeutic benefits of intramuscular opioids. The initial ER doctor’s shift ended with him signing off her case to his replacement and, checking on Amy prior to leaving, further reassured that his colleague would scrutinize care until the transfer was confirmed. At 3:30 p.m. that afternoon, Amy was transferred by ambulance to the designated tertiary care hospital. We were given the go-ahead to meet at the emergency department where we situated ourselves in the waiting room until allowed access to the hallway where Amy would languish for the next 27 hours. Amy was triaged from the ambulance stretcher to a spot in the hallway adjacent to the ambulance bay. They could have used a stoplight or at the very least a pedestrian crossing for traffic control. Her initial vantage was in a cluster of three stretchers bearing male patients “experiencing homelessness,” one of whom was secured to his conveyance by handcuffs. Not an environment that would by any definition provide for the privacy needs of most female patients. After numerous requests, Amy’s stretcher was repositioned to an alcove of sorts, near a busy thoroughfare of broken flooring tiles and exposed underlying concrete. To emphasize the normalization of healthcare in the hallway, Amy’s repositioning space had a small plaque affixed to the back wall identifying her temporary digs in the central hall as “CH-F.” Amy was reminded by the nursing staff that she was in a “trauma centre” and from our physical perspective somewhere between the ambulance bay and the helicopter delivery area to the trauma ER, there was little doubt. The volume of traffic in the hallway was reminiscent of an average Toronto rush hour on the DVP.Amy had company in her spacial confinement. To her right was an elderly female, let’s call her “Suzanne,” propped up in/on her stretcher, uncomfortably positioned but somehow asleep, mouth agape. To Amy’s left, was “Mafalda,” mid-80s by best guess, with nasal prongs in situ, clutching an adjacent clear plastic bag revealing copious blood-stained tissues within, evidence that her lung cancer was sadly no longer in remission. She had only left the hospital three days earlier. When Amy required ‘topping up’ of her Hydromorphone because of surging breakthrough pain, it was up to us to advocate on her behalf. Nursing care was hardly routine or timely. Some hours later, a resident physician arrived, introducing herself as one of the members of the “Spinal Team.” With my assistance, she wheeled Amy to a spartan exam room across the corridor. The examination complete, Amy was returned to her cubby. We were told that blood work and further imaging would be ordered, specifically CT and MRI scans. At the time, no further explanation was given as to the clinical indication for these investigations, having already had similar imaging early that morning prior to transfer. Ellen and I went home at 11:30 p.m. and would return early the next morning. The additional imaging was done in the wee small hours. When we arrived the next morning, Amy was resting, uncomfortably. No doctor had come to see her, assess her or offer any explanation as to how much longer she would wait until the surgery, a foregone conclusion, would be done. Amy asked the attending, yet relatively inattentive nurse when she could expect a doctor to enlighten her. After several more hours, another request was made for medical input. Our collective frustration was growing and palpable. Later in the afternoon, a doctor arrived, introduced herself as the intern on the “Spinal Team” and proceeded to admonish Amy for precipitating this visit. She reminded her/us that we were in a “trauma centre.” We did not need reminding. She further stated that repeated calls from the nurses only served to disrupt the members of the “Team” who were otherwise engaged in other traumatic matters of spinal urgency. She might as well of had a “do not disturb” sign hanging from her lanyard instead of a photo ID. We watched Amy as tears welled up in her eyes and she began to quiver in distress. Amy boldly responded, once gaining control of her emotions, and told the doctor that she was deeply offended by her disrespectful and uncaring attitude and how dare she diminish Amy’s spinal crisis. The crisis of communication failure had already been well-established. The doctor paused in silence and then offered a vacuous and meaningless apology. Amy continues to revisit this unforgivable failure in judgement and professionalism.A few hours later, the “fellow” on the “Spinal Team” appeared. He was considerably more diplomatic, professional and understanding. He explained that the additional imaging had been done because a “burst fracture” in a 49-year-old female is highly unusual. Although benign causes are more common, such a destructive fracture could be on the basis of an underlying occult neoplastic process. The “team” was apparently still reviewing the imaging. What he did confirm, without equivocation, was that Amy would have surgery later that evening or during the night depending on when an OR freed up. There was finally clarity and resolve. The waiting was about to end. As the afternoon transitioned into evening, we learned more about Amy’s ersatz neighbours. Suzanne was visited by a nurse who offered her a “good news and bad news” scenario. She had been a hallway resident for five days and kept NPO, awaiting surgery on a fractured ankle. The good news was that the nurse was going to bring her dinner, the bad news, her surgery would not take place the next day, but two days hence, following transfer to another surgical facility. Mafalda was in her second hallway day, the hemoptysis unrelenting and no bed in her near future. The conversations and dialogue defied the rules of privacy, an unfortunate hallway imperative.Suddenly, after 27 hours in a claustrophobic alcove and with the knowledge that she had a critical vertebral fracture needing emergency surgery, the surgical fellow arrived, announcing imminent departure to the OR. Our son-in-law, Stacey, Ellen and I accompanied Amy in the elevator to the doors of the OR. We said our goodbyes, told her how much we loved her and reassured her that she had the very best surgeon quarterbacking her spinal surgery. We retreated to the surgical waiting room and sat, mostly in silence, occasionally standing to stretch and frequently checking the time on our respective devices. Monday, Oct. 7 ended with heightened anxiety levels, and at 00:30 hours on Tuesday morning, Amy’s surgeon suddenly appeared. He squatted down level with our seated positions and began to speak. We listened intently to his every word. He was optimistic, encouraging and provided a positive prognostic picture, enthusiastically describing what he and his team had accomplished over the previous five hours in surgery. He described Amy’s vertebrae as severely osteoporotic, likely the underlying cause of the fracture. Amy is 49-years-old but for 30 of those years, has had MS. In the early years, her frequent exacerbations/attacks were managed with high dose pulse steroids, five days of Solumedrol IV followed by a 10-day course of oral Prednisone in doses tapered down from 60 mg daily. The surgery itself was complex: an L1 vertebrectomy, removal of fragmented bone, one wedge-shaped piece dangerously impinging the thecal sac at the L1 level, spinal shortening, and stabilization and fixation of the spine from T11 to L3 with Titanium rods and screws, further reinforced with bone cement. The surgeon looked amazingly fresh despite the protracted and complex surgery. We looked disheveled and were physically and emotionally exhausted. Amy went to the Recovery Room where she spent the night. She would spend another full day and yet another night in recovery, not because of surgical complications but because there were no postoperative surgical beds in the spinal unit. That bed finally materialized on Wednesday afternoon. With a holiday weekend looming, and we all know where not to be over a holiday weekend, Amy was discharged home Saturday morning, Oct. 12, on her fifth postoperative day.Over the course of the past month, I have had sufficient time to process Amy’s clinical course from ER to ER to OR to RR to home. There was far too much “hallway time,” the environment of which was dismal, inhospitable and at times inhumane. The incessant fluorescent fixture above the hallway stretcher was klieg-like in intensity, a rendition ensuring sleep deprivation. If we must accept wait times as a fact of life in today’s healthcare, let us never accept lack of resources, lack of communication and lack of compassion. Someone must advocate for the medically compromised when they are unable to do so themselves. It’s the outcome that matters at day’s end. It’s the journey, however, that will be embedded in our memory, a post-traumatic stressful reminder that hopefully will dissipate with the passage of time. Amy is currently four weeks postop, recovering well at home, gaining strength and mobility and function every day. There is finally light beyond the darkness of the hallway. Quoting the lyrics from an iconic Tom Petty song, “The Waiting is the hardest part”. Just ask anyone who has done time in an inhospitable healthcare hallway.

Doing time: Hallway medicine is out of hand

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HOWARD GOLDSTEIN

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