Las Vegas emergency rooms ill-equipped for flood of patients

Stacy J. Willis

Saturday, Feb. 10, 2001 | 12:06 p.m.

How this woman ended up here is another story -- something to do with genetics or fate, maybe economics. But she is nevertheless here tonight, lying on this bed in UMC's emergency room, blood running down her neck, turning the sheet under her head from white to deep red.

A young doctor -- a resident in training -- is struggling to get a needle into the carotid artery below her jaw, and he is frustrated, and she is near death, and the two of them -- total strangers until moments ago -- are doing this urgent routine together with the common belief that medical science can stay the whims of mortality.

The woman, 38, has myasthenia gravis -- a disease in which the nerves stop communicating with the muscles. She is conscious and not mentally impaired, but she can't move her muscles to speak because she is in a myasthenic crisis. The imminent danger is that her respiratory muscles will quit, and she will stop breathing entirely.

To prevent this from happening, she needs to have a catheter inserted into her neck so that medicine can be quickly distributed through her veins. The doctor is trying, in these long minutes, to find that artery -- but he is not succeeding. A more experienced physician, Dr. Jeffry Greenlee, steps in.

"She's got so many scars on her neck from having this done before, it's like a little graveyard of scars where the central lines have been," Greenlee says. "It makes it nearly impossible to get in there.

"But the key is not to give up, not to get frustrated. This happens," Greenlee says. He finally decides to pull aside her gown and insert the needle into another major artery near the groin. He pushes the needle into her skin and blood begins running down her leg, too. "I'm sorry about this, sweety," he tells her. Her eyes are wide open. Her legs stick out from under the sheet; she is wearing white athletic socks. Her purse sits on the floor beside the bed.

Greenlee checks her vital signs and says, "I think she just crossed over. She's not responding. I think she's trying to d-i-e. Get her bagged."

A respiratory technician comes in and begins assisting her breathing. Soon there are five people around the bed working on her. You can hear her breaths amplified through the breathing bag -- they are strained and hoarse, and every person in the room is hanging onto them.

Like all area hospitals, University Medical Center's emergency rooms -- both pediatric and adult -- are overcrowded. On this particular Thursday night, as on most nights in recent months, the hospital is on divert status -- meaning ambulances are asked to take patients elsewhere first if possible.

But still the injured and ill turn up, and the waiting rooms are full. Some would-be patients have been waiting as long as 12 hours.

The 525 hospital beds upstairs also are full, so patients who need to be admitted instead take up space in ER. Furthermore, an entire section of the emergency department is devoted to "drunks and psychs" who need to be transferred to facilities better suited to deal with those problems -- rehab and mental hospitals -- but those, too, are backed up.

So doctors, nurses and support personnel handle the bottleneck in the emergency room, where a typical night such as this is a bizarre mix of the mundane and tragic.

"When a person walks into the waiting room and into triage, the decision tree starts with, 'Are you going to die?' " Greenlee says. " 'And if so, can we prevent it?' "

Managing

Twenty-two doctors, nurses and clerks are on staff in UMC's ER on this Thursday night, on rotating shifts. They and a few residents will see about 200 patients in a 24-hour period, rotating them through one of 39 adult ER beds.

Behind a curtain in Room 3A, a 38-year-old AIDS patient awaits news about his most recent problem: excruciating pain in the belly. The man's mother sits on a chair near him. Greenlee reviews the X-ray and other test results, and speaks to the mother.

"Your son's guts have ruptured, and he's got air inside. He's got some fecal matter spilled out in there. I will need to admit him and schedule surgery," Greenlee says.

The mother begins to cry. Greenlee tries to assure her that her son is in good hands, that things are under control.

Greenlee cannot, however, move the man from the ER into a hospital room because there aren't available beds. In fact, the man will stay here well into the night.

"We'll give you something for your nerves, and try to get you in as soon as possible," Greenlee says before leaving the two.

In Greenlee's eight years as an ER physician, he has seen both the numbers and severity of patients at UMC get "much worse." Greenlee is the immediate past-chairman of the Clark County Medical Advisory Board and, he says, the medical community is struggling to find a long-term solution to the influx of patients.

In the short term, however, he and others juggle people and beds.

"You see these patients in the hallway?" he says about two men on stretchers parked against the wall inside the ER's front door. "I've already seen them. I've already ordered their tests and drawn blood, and they have never seen the inside of a room yet."

Hanging behind the busy nurses' station is a TV screen that displays the up-to-the-minute status of each Las Vegas Valley hospital, telling ambulances where to take patients. "Open" means a hospital is accepting patients; "divert" means it is full; and "super-divert," Greenlee says, means "really, really full."

"The diversion status helps to a point, then you're so saturated you have to go on super-divert," Greenlee explains. "The purpose of super-divert is to unload and give us some breathing room. But you can only be on super-divert for one hour, so you've got to figure something out because other hospitals are waiting to go on super-divert for their problems, too."

Growth

UMC is 70 years old. It was built in 1931 as Clark County Indigent Hospital, partially to serve workers who moved to the area to build Hoover Dam. In the 1940s the name was changed to Clark County General Hospital and later to Southern Nevada Memorial Hospital.

Finally in 1986 it was dubbed University Medical Center to reflect its teaching relationship with the University of Nevada School of Medicine in Reno.

The hospital currently has 525 beds, employs 3,500 people and is Southern Nevada's only trauma-ready hospital.

But obviously it doesn't handle all of Clark County's medical needs.

As the county's population has grown, so has the number of hospitals. St. Rose Dominican Hospital and the Boulder City Hospital also were developed to accommodate the needs of dam and defense-industry workers more than 50 years ago. Sunrise Medical Center was built in 1958; Valley Hospital and Desert Springs were converted from nursing homes into hospitals in the 1960s and 1970s; and Lake Mead Hospital was built in the 1960s. MountainView Hospital and Summerlin were added to the mix in the last decade.

That leaves 210 emergency-room hospital beds to serve Southern Nevada's population of more than 1.6 million people.

By last summer overcrowding reached its peak, and the hospitals and Clark County Health District went to the media to spread a communitywide message: Don't go to a hospital if it's not urgent.

Since then St. Rose Dominican has opened a second hospital, Sunrise has built a new emergency-room facility and UMC is scheduled to open an $18.5 million, two-story emergency room March 1 to help address the problem.

But many in the trenches, including Greenlee, say the problem is more than one of bricks and mortar.

On a five-minute break, Greenlee makes what some call quite possibly the worst pot of coffee ever made, and he talks about the crisis in emergency-medical services.

"A change in philosophy needs to happen here, in the administration and in the community," he says. "The ER is the only department in the whole hospital that tolerates overcrowding. Why can't they shift some of them upstairs? I'd like to see a change in the way the administration views it.

"And I'd like to see some more community education."

Las Vegas is not alone in hospital overcrowding, although its rising population exacerbates the problem. Emergency rooms nationwide are suffering from similar problems, owing not so much to a shortage of space, but more to at least a decade of managed care that, some argue, has changed the way in which health care is delivered and in which patients seek it.

In the 1950s the nation suffered from too few hospitals. By the 1980s the health care industry was fat and happy, leading to the managed-care squeeze in the 1990s.

Recent years of cost-cutting, along with nursing shortages and an increasing amount of uninsured patients, have put some communities' hospitals in a bind.

In 1998 27 percent of U.S. hospitals were losing money, up from 20 percent the year before, according to the American Hospital Association. In the past decade,about 500 hospitals have closed. And in the three-year period between 1993 and 1996 the number of hospital beds per 1,000 U.S. residents fell by 9 percent.

Rather than shutting their doors entirely, some hospitals simply closed their emergency rooms because ERs tend to be the doorway through which most uninsured or nonpaying patients enter.

As the county hospital, charged with caring for the indigent, UMC suffers from that influx of uninsured patients. A study released last month by the Access Project, a nationwide health care initiative, shows that uninsured Las Vegans use the emergency room for routine health care at a high rate: 84 percent. There are about 44 million uninsured people nationwide and more than 250,000 in Nevada.

Other cities have considered a variety of tactics to combat emergency-room overcrowding.

In Boston, medical task forces have recommended preparing the National Guard to help emergency rooms in crises; in Syracuse, N.Y., a plan has been implemented that would allow the use of nursing homes when hospitals overflow; and in Charlotte, N.C., some have considered sending mobile health centers into underprivileged neighborhoods to head off emergency-room visits.

UMC already has a "Fast Track" medical service, located in a trailer outside the ER doors, that is meant to siphon off "urgent but not emergent" health care problems such as fevers and lacerations.

On this Thursday 51 patients were treated in the Fast Track trailer, and another 50 were treated in the pediatric ER.

Children's care

Standing in a hallway decorated with Tigger wallpaper, Dr. Larry Satkowiak, a UMC pediatric ER physician, is viewing a CT scan of a 2-month-old's head. One side of the child's brain is underdeveloped and water has filled the skull; the child's future is bleak.

Satkowiak shakes his head. He will need to get a Spanish-speaking nurse to accompany him to the exam room, where he must convey the problem to a teenage mother who has neither a family doctor nor insurance.

"If you're an illegal immigrant, you are afraid to come to the hospital because you are afraid you'll be turned in to (Immigration and Naturalization Service)," Satkowiak says.

About 30 percent of uninsured Las Vegans polled by the Access Project reported that they needed an interpreter at UMC and were not provided one.

"And we get a lot of teen mothers like this, and people who haven't seen a doctor during their pregnancy, and now they have sick babies."

UMC is one of two local hospitals (Sunrise is the other) that have a pediatric ER separate from the adult ER.

Much of Satkowiak's work is treating infants with respiratory problems, children with sprained or broken ankles and the occasional someone-threw-a-rock-in-my-eye accident.

"It's very rewarding work most of the time," Satkowiak, who has two small children of his own, says.

Last year UMC's pediatric ER served 28,707 children, up from 18,384 in 1995. In December 2000 the pediatric ER served 3,201 children, up from 2,634 in December 1999.

There are 23 pediatric ER beds at UMC, and eight doctors, nurses and clerks working at any given time.

"We're full. We're full most of the time," Satkowiak said. "We just try to make the best use of bed space."

Limits

On the adult side, behind a curtain in Room 4B, an old woman is slumped in a bed. A metal clamp is smashing her limp bicep to keep pressure on a small hole her arm.

She has been in the ER for 10 hours -- since she had dialysis treatment this morning and her vein failed to close. She will need a vascular surgeon to stitch up the hole, but there is no room in the hospital to admit her, so she sits, clamped, waiting.

Next to her, separated by a curtain, a uniformed Metro Police officer lies in a bed, his ankle twisted from a spill he took while chasing a suspect. He awaits results of an X-ray.

Down the hall in Room 6A, a homeless woman is complaining of injured ribs.

She is 43 years old and has long, brown hair and seems very comfortable in this bed. She says she fell off the toilet and hit her ribs.

But the X-rays show no rib injuries. Greenlee looks at her unhealthy lungs and curving spine in the image and shakes his head in frustration.

"You need a place to sleep. Where will you go when you leave here tonight?"

She shrugs.

"Do you have any friends you can stay with, or do you need to go to a shelter?"

"I have a friend. On the other side of town, but I can't get there."

Greenlee puts his hand on her shoulder and says, "You need to take better care of yourself. Your ribs are fine. But you need to stop smoking, your lungs don't look great. And you're getting osteoporosis prematurely."

He writes something on her chart.

"I've prescribed a bus token, OK? That's all I can do. We'll give you a bus token so you can get across town," he says.

"But then it's up to you to take care of yourself."

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