Hartford Courant -- March 4 2007

By HILARY WALDMAN, Courant Staff Writer

Emergency Rooms Across The State Are Feeling The Pain Of Too Many Patients

WILLIMANTIC -- Lynn Daros is lying on a gurney in Room 5 of the Windham Hospital emergency room, waiting to be seen. Her husband, Mike, sits beside her, bouncing their baby girl on his lap.

Lynn woke up with a fever of 102. Her body ached, her throat was sore, her head felt like somebody was hitting it with a hammer. The baby, 1-year-old Kaley-Lynn, had been a little fussy too, coughing, sneezing, not taking her bottle.

Mike figured they both needed to be checked out.

He doesn't get health insurance through his job as a part-time roofer, so the family relies on Generations, the overcrowded free clinic on Main Street. This morning, the clinic hadn't opened yet when they called, so a receptionist directed them to the emergency room.

It's 9:45 a.m., the beginning of Dr. Gregory Shangold's 11-hour shift in the ER. Dressed in chinos, a casual, button-down shirt, a bright silk tie and worn suede Merrell slip-ons, he walks into Room 5 - and head-on into one of the most persistent symptoms of the nation's health care crisis.

Shangold suspects Lynn has the flu and simply needs rest, but she has asthma so he can't take any chances. He orders a chest X-ray and calls a respiratory therapist to bring a nebulizer that will blow medication and moist air into her lungs. A nursing student gives Lynn an injection of Torodol, a painkiller that will ease her muscle aches.

Meanwhile, Shangold examines Kaley-Lynn, who by now has downed a bottle of kiwi-strawberry Hi-C and is bobbing happily in her baby-size hospital gown printed with pink elephants. Her dark hair is pulled into a fountain of a ponytail.

Shangold, 35, and the father of three young children, pronounces the baby good to go and moves on to examine a woman with chest pain, then another uninsured man who thinks his shingles have returned.

At Windham, and at hospitals across the nation, emergency rooms are overflowing with patients such as Daros. They are hurting and need care, but they are in the wrong place.

Overburdened emergency rooms have become the symbol of the trouble with modern American health care. The problem is not just about jam-packed waiting rooms and Shangold's busy days, though. It is about a health care system whose problems, according to experts across the nation, have reached the breaking point.

The ER has become a refuge for 46 million people nationwide - 400,000 in Connecticut - who do not have health insurance. Emergency rooms are the primary care clinic of choice or necessity for low-income people on welfare. And they can be a savior for anyone who suffers a catastrophic illness or injury.

Above all, they are the nexus where so many links in the country's fragile health care system are threatening to fall apart.

UConn Health Center researcher Thomas Babor compares overcrowded emergency rooms with coal mine canaries. Babor served on the Institute of Medicine committee that last year released a chilling assessment of America's emergency care system.

"You see that canary die," Babor warns, "and you know the rest of the system may be broken as well."

Located in the center of a tired mill town where the broad lawns of Eastern Connecticut State University roll up against homeless shelters, drug treatment centers and low-rent apartments that are magnets for a rich state's poor, Windham Hospital is in many ways a microcosm of the national crisis.

Stacked Up

Shortly after noon, Lynn Daros is still in Room 5, receiving fluids through an IV. Her flu culture is negative, but her blood pressure is precariously low.

Down the hall, an ambulance pulls up carrying Virginia Smith, 70, a resident of a nearby nursing home. Smith had a bad night. Her leg is swollen, she is coughing and a nasty rash is spreading across her stomach and back.

Smith, disabled for the past five years, suspects she might have a blood clot. Shangold thinks the cause of her discomfort is more likely cellulitis, a bacterial infection beneath the surface of her skin. Either way, she must be admitted to the hospital.

And that is easier said than done.

Shangold immediately calls Smith's doctor, but the patient is still a long way from a bed. Although emergency room physicians are employed by the hospital, they cannot admit patients. So Smith waits in Room 7 for more than four hours.

The phenomenon is known as boarding - holding patients in the emergency room until they can be admitted to the hospital. At large city hospitals, where inpatient beds are usually filled to capacity, boarding patients can wait up to two days. Boarding is a major contributor to the nation's emergency room crisis, according to the Institute of Medicine,

On one unusually busy night in January, when all of Windham's inpatient beds were full, Shangold had 11 patients lined up while they waited to be admitted; an additional six mentally ill patients were waiting for transfers to psychiatric hospitals.

Altogether, those patients filled 17 of the emergency room's 24 beds, forcing other patients seeking care to stack up in the waiting room.

While Smith waits, a city public works crewman in a fluorescent yellow T-shirt, work pants and boots walks into the emergency room through a back door. He is cradling his hand, wrapped in blood-soaked gauze. His body is starting to quiver.

The nurses quickly guide him into a room across from the nurses' station and eases him onto a stretcher.

Reuben Eddy, 34, tells medical technician Nancy Knapp that he was using a truck-mounted vacuum to pick up leaves when he caught his right hand in the city truck's pneumatic tailgate. It only hurt for a second, but he knew he needed help.

Less than 15 minutes after Eddy arrives, Shangold parks beside him, suturing the gashes that have caused a painful wound but no permanent damage.

While Shangold tends to Eddy's hand, new patients arrive.

One is a student named Katie, wearing a gray UConn sweat shirt, who complains that her contact lenses have been bothering her for two days.

The Life Star helicopter airlifts a heart attack patient from Windham to Hartford Hospital. Virginia Smith rides the elevator up to an inpatient bed.

And Shangold is grateful for small favors.

By the time his shift is over, Shangold will have seen about 70 patients. But today, at least, he didn't have to wrestle with his conscience as he did a few days earlier when a repeat patient, sometimes called a "frequent flier," demanded painkillers. It is a perennial problem.

About 70 percent of the people who seek care at emergency rooms complain of some kind of pain. It's difficult, Shangold says, to sort out the patients who are genuinely hurting from those who are addicted.

And it's not Friday night, so there's nobody passed out in the trauma room. There have been nights when as many as 10 dangerously drunken college students have been packed into the glass-walled room.

The Sink

Shangold compares the nation's emergency medical care system to an overflowing household drain. Pipes can back up at many points, but no one really notices until the mess bubbles up into the kitchen sink.

From 1994 to 2004, emergency room visits nationally rose 18 percent, according to the federal Centers for Disease Control and Prevention. In 2004, they totaled 110 million patient visits.

Many of those patients, the Institute of Medicine has concluded, are being treated in the wrong place.

At Windham Hospital last year, doctors handled about 25,000 visits, an increase of almost 10 percent from 2005. The increase was recorded even without large flu outbreaks in 2006 or this year, so far.

"There's been no flu, which is scary," Shangold says. "If we had a severe accident or flu outbreak, that would seriously hamper Connecticut emergency departments."

A native of Fairfield County who was trained at the University of Pennsylvania, Shangold chose emergency medicine because he likes the detective work sometimes required to diagnose patients he barely knows.

He is active in the American College of Emergency Physicians, the professional association pushing for more money and other reforms to ease the burden in emergency rooms. He also sits on a state legislative task force looking for ways to ease the gridlock.

Shangold gets frustrated when flaws in the system interfere with his ability to provide the best care.

One afternoon, Shangold answers a call from nearby Backus Hospital in Norwich. The emergency room there is full, and the hospital wants to send its ambulances 20 miles northwest - to Windham.

The practice of sending patients from one hospital to another to compensate for overcrowding is called diversion. In 2003, the Institute of Medicine estimates, 500,000 ambulances were diverted from hospitals across the nation, an average of one a minute.

"Ambulance diversions," the Institute of Medicine states, "can lead to catastrophic delays in treatment for seriously ill or injured patients."

Windham is almost full this afternoon, with 18 patients and no end in sight.

"No," Shangold says tersely into his cellphone, to the Backus Hospital request.

A Cutter

One of the 18 is Chris Lathrop. His left arm is bloody with scores of razor cuts that darken the skin from his wrist to his elbow. Beneath his hospital gown, a self-inflicted, blood-crusted red "X" scars his abdomen.

He has been waiting on a stretcher in the hall for several hours since Shangold used Dermabond, a type of super glue for the skin, to close his newest wounds. Lathrop listens to a portable CD player to ease the boredom.

Lathrop, 26, is the kind of patient at the core of the emergency room crisis. Low state payments to public outpatient psychiatric clinics and critical shortages of inpatient psychiatric beds make emergency rooms the dumping ground for people with mental illness.

Although the crunch for adult patients is dangerous, the shortage of services for children is far worse. Recently, a child waited in one of Windham's drab and unfurnished psychiatric holding rooms for seven days before an inpatient bed was found.

A frequent visitor to Windham, Lathrop knows he could be in this hallway for days before a more permanent hospital bed opens up.

A month earlier, Lathrop arrived at the ER at 3 a.m. bleeding profusely from about 45 self-inflicted cuts. Shangold was the only doctor on duty overnight and knew he could not afford to devote three or four hours to suture Lathrop's arm. Even using the quick-fix Dermabond, the job took 40 minutes.

Shangold says he was lucky nobody else needed his attention that night.

Lathrop says he was abused while growing up in Chaplin. He was 10 the first time he drove a blade into his skin. He spent most of his childhood in state hospitals and residential treatment centers. Now, he lives in Willimantic, between psychiatric hospitalizations.

Lathrop cannot explain what compels him to cut himself, but somehow, he says, it makes him happy.

"The help I need," Lathrop says, "people are not trained to give me."

Just A Virus

Four hours after arriving, the Daros family is still camped out in Room 5. Mike is feeding spoonfuls of vanilla pudding to Kaley-Lynn.

A huge tumbler of orange juice and IV fluids failed to increase Lynn's blood pressure, and Shangold suspects dehydration. But it is also possible that Lynn has a life-threatening blood infection.

Perhaps, the doctor thinks aloud, he should admit her to the hospital.

Shangold says it is important to remember that most people who seek help at emergency rooms are sick - or at least think they are. Sometimes, symptoms that appear mild can turn out to be a sign of serious illness. It's a delicate balance.

But Lynn is worried. Her baby has only just turned 1 and has never been away from her mother overnight.

Mike Daros, still wearing the hunting cap he walked in with this morning, stops at the nurse's station to ask if his wife can go outside for a cigarette.

Instead, the family is told they can go home. Another check determines that Lynn's blood pressure has rebounded and Shangold signs the discharge orders.

"It's probably just some kind of virus like we said it was three hours ago," he shrugs.

Incoming

Late in the afternoon on another day, the crackle of a police scanner alarms nurse Annette Beatty.

"Uh-oh, this isn't good," Beatty says. From the radio chatter, she figures that someplace in the city, somebody has been hit by a car. Before the siren sounds in the ambulance bay behind her, the piercing screams of a baby propel Beatty in the opposite direction, toward the front door.

Frantic parents cradling a baby rush toward her.

Tense, but composed, the mom says she was cooking dinner as her 9-month-old girl crawled on the floor nearby. Before anybody noticed, the baby apparently pulled herself up on the platform of a woodstove. Unsteady on her feet, the baby grabbed at the hot stove for balance, scorching her palms and forearm.

Cold compresses will stop the skin from burning. She needs IV fluids. But the baby's flailing makes it impossible for doctors, nurses or her parents to do much of anything.

Shangold orders an injection of morphine and waits for the powerful narcotic to soothe the little girl. Once she is calm and stable, an ambulance will transport her to Connecticut Children's Medical Center in Hartford, where plastic surgeons can assess the damage.

At the other end of the hallway, the ambulance delivers Jose Mendez, a 42-year-old man who was hit by a car in the parking lot of a nearby Burger King. Other than a gash on his head, he does not appear to be seriously injured. But he speaks no English, and a hospital housekeeper called to translate has not arrived yet, so it's impossible to know for sure.

Dr. Karl Markuszka, the other physician in the emergency room this evening, pulls up a stool and begins to stitch the first of many sutures into the injured man's forehead. At the nurse's station, Shangold is on the phone, describing the baby's burns to the plastic surgeon at Connecticut Children's.

Since his day began, Shangold has had time to eat two graham crackers and a slice of yellow birthday cake with white frosting that somebody baked for a nurse. There's an apple-cranberry cake at the nurse's station, the offering of another staff member. Soon he'll slice into that. A college student with possible appendicitis is waiting in another room. Shangold's head is starting to throb.

Sarah March approaches the desk, angry. Her mother-in-law has been waiting an hour for somebody to check her aching back and not one person has even stopped into the examining room.

Beatty, a veteran of the emergency room is unruffled. "We have had a person with a sore throat come up to us in the middle of a resuscitation and say something nasty to us," she confides.

In Exam Room 8, Cindy Green is flat on a stretcher. Her back has been hurting since she had a car accident four days earlier. When she stands up, she says, the pain travels down her leg. She came to the emergency room after the accident but insists the doctors did nothing.

Now, she's back. And she's getting impatient.

"Nobody's come in and asked me my name, nothing," Green says.

When Shangold arrives a half-hour later, Green tells him that after the accident only her pelvis was X-rayed. Shangold checks her chart. "No, they did your spine," he tells her. "Dr. Grant said your vertebrae looked fine, so the bones are OK."

When she was discharged after the accident, Green was told to make an appointment with the free clinic where she gets her care.

"Did you make an appointment with Generations?" Shangold asks.

"No," Green answers.

He exhales, and orders a shot of morphine for the pain.

"There's not much we can do for this," he says, closing the door.

Contact Hilary Waldman at hwaldman@courant.com.

Copyright 2007, Hartford Courant