My trip to California took a bit of a downward turn a bit more than a week ago when I began to develop a fever and associated symptoms (headache, dizziness, fatigue, sleeplessness) while in the southern Sierra Nevada. After a third day of steady worsening of my condition, with my temperature spiking to 102.5 F/39.2 C, we decided to head for San Francisco, our next scheduled stop, a bit early, and to stop in Fresno the night before so that I could seek medical treatment.
I had my wife drop me at the ER just before 8pm. I was quickly processed through to see a triage nurse, which was the last quick thing that evening. My fever was a bit lower, around 100.5 F, but it had been spiking up and down all day without much relationship to the ibuprofen I had taken. As I reported my symptoms and stressed that I was travelling and lived on the East Coast, that I had interrupted a trip to seek medical care and felt very abnormally worse than I would in an ordinary ‘flu’, it was already clear to me that the triage nurse was uninterested in any of the specifics. I peeked at my information sheet. He wrote one thing: fever.
If my wife had looked at the odd rash and bump on the back of my leg that had worried us the night before, I would have been able to be considerably more specific. Later that night when she saw it, it had resolved into a clear bulls-eye, which to people living in the mid-Atlantic or New England means one thing: Lyme disease.
Probably the staff in Fresno would have spotted it too, but they never got the chance to see it.
It was the kind of ER that was very obviously used by many patients as their primary-care physician, the specific circumstance that has been so much in contention in debates over health-care legislation in the last decade. I would not call it overly crowded: there were perhaps twenty patients plus families or friends in the waiting room, about as many as I see in the main hospital of my health-care system at home.
After waiting two and a half hours, I began to get the picture. The nurse on duty repeatedly called patients who were not present, who had checked in and then left later on. At first I thought it odd that they kept calling and calling for almost thirty minutes for people who were very obviously not there while not calling cases of people who were present. Every once in a while, someone who was there was called and seen, though in a few of those cases, the nurse on duty simply took vitals again and sent them back to the waiting room. At the limits of my endurance, I finally went up to ask how long I might expect to wait. “We’re still seeing cases that checked in between one or two p.m. today,” I was told. Meaning it might be four in the morning before I was seen, I asked, stunned? Yes, that’s very possible, said the nurse. I gave up at that point: infection, disease, whatever it was, if I was going to continue to worsen overnight, I’d damn well go back and do it in my hotel room and hope for better in San Francisco. (Which I found, thanks in part to my Facebook friends.)
This was a Tuesday night. There was no city-wide crisis or emergency. Or perhaps there was: not a fire or earthquake or epidemic, just a localized case of national decline.
It became clear to me that as a matter of policy, the hospital was coping with a large number of local patients using its ER for ordinary medical care by passive-aggressive neglect. Unless you walked in with an immediately and obviously life-threatening condition, time would be your triage, not a medical professional. If you could endure waiting eight to nine hours, that was proof that your condition was sufficiently serious that you might need urgent care. The staff there don’t spend much time working up a more nuanced picture on initial evaluation because they don’t want one. They don’t efficiently discard the cases of people who’ve left the facility because they’re stalling the remainder deliberately.
The basic problem faced by this hospital and many others is structurally serious and requires a strong nationally consistent solution. Given that one political party struggled to formulate a fussy, detail-strangled series of half-measures to address the problem and the other party apparently thinks there isn’t any issue in the first place, I’m resigned to this situation happening again to me, my loved ones, my friends, my fellow citizens, for the rest of my life.
This is where we are at now. Decline is not something we need to fear or forestall, it has already happened. America is not in decline, it has declined. A nine-hour wait at a well-built, well-staffed, well-resourced medical center for treatment of a serious condition is decline. As a traveller seeking urgent care, I’ve been seen more quickly in similar facilities in both Africa and Europe.
However, even within the limits of the structural and systemic failure of the American present, I think individual institutions can do better by making smarter choices about ethical and professional responsibilities. My home hospital has some of the same demographic burdens as the hospital in Fresno, but it hasn’t chosen to show the same indiscriminate hostility towards any patient in its emergency room.
The challenge of the American present will be how to deal creatively and humanely with limits while continuing to sharply challenge the leaders who got us to this point with such indifference and disdain–all the while exempting a small fraction from having to join us on the journey.