The ER Shifts: A One-Sided History of the PGH ER
My own account of how the PGH ER evolved from when I was a medical student to today. This is by no means an extensive history, but still something I hope many can relate to.
“Respectfully referring an ER patient for co-management…” says the text.
I push the heavy metal double doors forward as I enter the PGH emergency room. With my free hand, I scroll through my phone, reading the details of this newly referred ER patient. I quickly skim through the long wall of text for the history, physical exam, lab results, and assessment. When I’m truly in a hurry, there are only two vital details: name and location. In this case, that’s Patient Santos (not their real name), a 55-year-old male, Airport A.
The Airport is by no means a true airport, a helipad, or any other transportation-related location. The Airport refers to the rows of airport-style metal chairs (which are called “gang chairs,” apparently) at the ER lobby. As you enter the main entrance, Airport A is on the left and Airport B is on the right. This “airport” is meant to be a waiting area, a transition space before being transported to a new location, preferably a room, a ward, or a bed, but more likely will be a stretcher, or possibly a wheelchair. Space is limited in the ER, definitely disproportionate to the number of patients who come in. Some patients—nay, many—end up sitting on these metal chairs for the entirety of their stay.
I stand in the general vicinity of Airport A, take a deep breath, and shout, “Santos? Patient Santos?” Someone’s hand shoots up, like a student confirming their attendance to class. Patient Santos is seated next to another male patient, their IV bottles sharing a pole stand to hang from, and their respective companions sharing a seat. I make my way to the raised hand, give my salutations, and commence my history-taking.
I’ve done this whole routine—receive referrals, find patients, interview patients—more times than I can remember, as a student, a resident, and now a fellow-in-training. Doing the whole routine in the ER is always particularly challenging, what with all the squeezing through the hordes of people before you find who you’re looking for. The routine itself has not changed, but in my years of medical training, I’ve seen at least four iterations of the PGH ER, each of them strikingly different, but also uncannily the same.
I was a medical clerk in 2016 when I first stepped foot in the ER. Quite befittingly, it was an Emergency Medicine rotation. Back then, the ER was a sticky, humid hell. Even when you sit completely still, you still manage to sweat uncontrollably. It was a tight, confusing maze, made even tighter by the quantity of patients. When you’ve been there long enough, you realize that there’s a method to the madness. The ER can be divided into several parts: the triage area is where patients are received and assessed; the resuscitation area (simply called “Resus”) is where critically ill patients needing life-saving interventions are brought; the acute care unit (ACU) is where the sicker patients are taken after resuscitation; while the observation unit (OU) is where you find more stable (i.e. less “bantayin”) patients, including those we intend to send home soon. The surgical ER team has a separate table, and the pediatrics team has a separate wing, including a triage area. There’s a separate room for certain specialty services, including orthopedics, otorhinolaryngology, and ophthalmology. Still, no matter how much we try to arrange the ER into neat little compartments, by sheer necessity and circumstance, the lines eventually blur. You find patients spilling over to the hallways, resuscitated in the triage area, or getting intubated in the observation unit. I’ve seen several CPRs done in the hallway, sometimes on the floor.
I soon learned the fine art of locating patients, which included shouting patient names loud enough to rise above the chaos, or creating descriptive and specific names for patient locations—Bed 16.5, IFO triage (in front of the triage area), IFO Iwata (in front of the big Iwata fan), ACU hallway, the Oven (precisely because it feels like being inside an oven)—only illustrating just how much we try to make do with the space. Locating patient charts was a whole other ordeal, as this was a time when electronic medical records were unheard of and assumed never to be heard of. At least thirty minutes were spent just looking for the coveted patient record. It was a daily scavenger hunt for every nurse, intern, resident, or fellow handling the patient. Nurses got creative, too. They marked their charts with brightly-colored paper, with a color assigned to each nurse on duty. The charts themselves could be anywhere—in drawers, pantries, the nurses’ station, the interns’ table, and sometimes in a distant callroom. Each time we found the chart in someone else’s possession, we would ask for it ever so nicely, promising we would return it as soon as we were done.
As we were promoted to internship, there were rumors of renovating the ER. These rumors were often shrugged off, with no one believing that such a project would materialize, what with the many issues of funding and red tape to maneuver through. Much to our surprise though, a few months before the end of our intern year, we were all asked to relocate the ER and all its contents — stretchers, beds, patient charts, and of course patients themselves — to a temporary, makeshift ER. It was like a grand exodus, transferring to a temporary oasis while the promised land was ongoing construction. The “new” ER was in a separate wing of the hospital, where previous wards and clinics were transformed into a makeshift ER. The isolation rooms became Pay rooms, the trauma ward became the new acute care unit, to be shared by all medical, surgical, ophthalmology, orthopedics, otorhinolaryngology, and pediatric services; and what used to be a perinatology clinic became the new resuscitation area. As was inevitable, overflow patients found themselves in hallways and corridors outside the designated space. We found new names for patient locations, too: ACU hallway (the hallway outside the ACU), Radio hallway (the hallway outside the X-ray room), and perhaps the worst: the ATM hallway (the hallway near the ATMs) which was very, very far from the actual ER.
This entire complex served as the ER throughout my internship and most of my three years of residency. It was still incredibly chaotic, but as with most chaotic changes, we soon settled into a steady state, creating new routines and even memories in that makeshift ER. It was in that ER where I bonded with blockmates and co-interns, where I learned how to suture a laceration (I don’t know how to anymore, but it was nice while it lasted), where I charted new referrals in the wee hours of the morning, and where I fell asleep on random stretchers and tables. It was also here that I found out that I passed the physician licensure exam. I was doing my pre-residency in internal medicine then, and when the news of the board exams came out, I remember distinctly that I was ordering tranexamic acid for a patient whose gums were bleeding—a memorable albeit anti-climactic, non-cinematic moment.
In government hospitals, we’re so used to change either being impossible or taking too much time, so we assumed that the construction of the new ER would take forever and that the next big adjustment would take a while. Back then, the makeshift ER was the actual ER, and it would remain that way for a while.
But just when we found a steady rhythm, the pandemic came upon us.
Needless to say, a lot of changes happened. We didn’t relocate the new ER, but we did make several workflow arrangements, and as COVID policies changed, so did the ER policies. Everything was in constant flux. The previous ER setup fell apart, and the whole ER was designated as a COVID area. Every patient that came in was assumed COVID-positive until the swab proved otherwise. The workforce was limited to limit COVID exposure. Students were pulled out of their posts and skeletal duty schemes were implemented. Contingency plans were in place every time a healthcare worker got infected. Donning and doffing personal protective equipment became routine. As second-year IM residents, we were assigned everywhere—the COVID wards, nonCOVID wards, the ER, and the COVID ICU. For our ER shifts, we were assigned an ER callroom to stay in, separate from the rest of the department. At one point we were even required to take a shower after each ER consult. We couldn’t afford to repeatedly go back, because that would mean a whole other round of donning and doffing (and showering). That meant each visit to the ER had to be carefully calculated, and you had to know exactly what you were going to do, from patient interviews to blood extractions to swabbing patients and relatives.
While all these changes ensued, renovations to the new ER carried on as soon as it was safer to do so. Again, we didn’t expect much; we assumed it would take a long while. Not until we started transferring patients to the new ER did I believe it was coming to fruition. I was a third-year internal medicine resident when this newly renovated ER opened. It started gradually, initially opening only one wing, which we called the Holding Area, intended for stable, non-critically-ill, non-COVID patients, something like the Observation Unit of years past. Then, more wings were opened, and before we knew it, the new ER was in full swing. We now have bigger patient beds and more oxygen ports. There were again new names to familiarize ourselves with — the Acute Medical Unit (AMU), Critical Care Unit (CCU), Pay Room A, Treatment Bay, plus three nurse stations labeled A, B, and C—all in air-conditioned glory. Plus, a hospital electronic medical record system is in place now, so there’s no need for scavenger hunts or Hunger Games in search of the patient’s chart. There is also a master list of patients now, so whenever we need to find a patient, their location, or their corresponding nurse, we just CTRL+F’ed our way through a Google Document. Magic!
Of course, this new ER is not perfect. The magical Google Doc isn’t always updated. The waiting queue to get admitted still takes forever. Even with the newer and bigger patient areas, there are still more patients than the space can handle, hence giving birth to, again, more creative names. Now we have names like Airport A and B, IFO Nurse St. C (in front of Nurse Station C), IFO Treatment C (in front of Treatment Bay C), and AMU 16.5. Even with the new patient beds and equipment, we still see long triage queues, still find patients on wheelchairs and metal stretchers for days, and still have an indecent shortage of laboratory tests, glucose strips, and medications.
Progress is progress, of course; It’s a step up from what it used to be. Again, it’s air-conditioned now, sometimes so cold that patients shiver under three layers of clothing. A patient of mine came in wearing a knit bonnet as if she were going to Baguio, not getting admitted for uremia. The ER has come a long way from what it used to be when I was a medical student, but in many ways, it’s also the same. There are still droves of ambulances parading out front. There’s still a long queue for admission, with patients waiting for hours before the lone triage officer gets a chance to assess them; there are still stretchers and wheelchairs and IV poles inserted in all nooks and crannies; and here I am, years into training, still shouting a patient’s name with all the air my lungs would allow.
I will be honest: the ER is not my favorite place. While some people thrive in its unpredictability, I squirm at the inevitable chaos. I have always dreaded ER rotations, and I always have to mentally prepare myself when a new ER referral comes along. That being said, the ER is a fascinating place to examine, with all its transformations and rebirths. I stand in the ER sometimes and suddenly find it hard to imagine what it looked like before. The ER will continue to evolve, be it in the infrastructures it sets up or the policies it implements. Just as one eight-hour shift transitions to the next, so each iteration of the ER will adapt and make way for its successor, carrying the old and the new together.
Of course, this is just my account of the ER’s history, which doesn’t even reach ten years in total. I’m sure other doctors, nurses, paramedical staff, students, security personnel, and especially patients have their own stories to tell. I am not privy to the meetings that transpired or the planning that went into each change. Plus, I’m limited by my own memory and recency bias, so I don’t pretend to know the whole story. Still, this is my perspective and my experience, and perhaps this is an invitation for you to examine your own. To tell your own story, to share your memories, of how the ER used to be, of how it changed, of how it operates now. I often find that helpful, to look back at how things were, then stand back and observe how things are. I watch as the ER continues to evolve, sometimes forward into the modern era, and sometimes backward into archaic policies. To protect progress, keeping watch is precisely what we must do, even when we don’t like what we see—especially when we don’t like what we see. Let it be known that we are watching and that we will speak up when something is amiss. To comment on the system does not mean dismissing the progress made; it’s a way to ensure that progress continues forward. Granted, our opinions and observations will not always be heard, but I still find it’s worth being part of the conversation. It means we are hopeful that there’s still something better to aspire to. Change should be like that, a step toward something better.
Such is change, I think: It is never simply a forward march. it’s a series of missteps, detours, going backward, and running in circles, yet still putting one foot in front of the other. Nothing can ever transform overnight, of course, but there is value in pulling ourselves in the right direction, always a step toward something better.