Hilary Fairbrother, MD, MPH, on overcrowded emergency departments

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger talks with Hilary Fairbrother, MD, MPH, an emergency medicine physician in Houston, about overcrowded emergency departments—what she’s seeing, why it’s still happening and the impact on patient care.

Speaker

• Hilary Fairbrother, MD, MPH, emergency medicine physician

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're talking with Dr. Hilary Fairbrother, an emergency medicine physician in Houston, Texas, about overcrowded emergency departments and what she's seeing and why it's still happening. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr. Fairbrother, welcome back. Last time we talked to you, we were in the middle of the pandemic but I read an article not too long ago, talked about something different, which is overcrowded emergency departments and how they continue to be a problem. First, let's talk about the situation that you're in right now. What are you seeing down in Houston? Are you overwhelmed by patients?

Dr. Fairbrother: So, we are busy for sure, both on the adult side and the pediatric side. Our volumes are either at what they were before the pandemic started and sometimes even higher, so we are busy. The ERs are crowded and the hospitals are crowded and full.

Unger: What's driving it?

Dr. Fairbrother: I think it's a lot of different things. So we still have 70,000 cases of COVID in the U.S. a day and we still have a lot of people who end up needing the hospital and even the ICU for the coronavirus. On top of that, we have our normal number of heart attacks and strokes and other medical problems that cause people to come to the emergency department. And on top of that, we have our normal volume of trauma, car accidents and other kinds of violent trauma and assault, that lead people to have to seek care in the emergency department. All of that together means that we are busy, if not busier than we typically would find ourselves.

Unger: I think there was a moment in time, you can correct me if I'm wrong, where a lot of those things that you would normally see kind of ending their way up in the emergency department were not happening for a while during kind of the height of the pandemic. Is that changed?

Dr. Fairbrother: Well certainly when March 2020 hit and the country really locked down, everyone who could was staying home from work, people really weren't on the streets. I think all of us in urban areas saw that traffic just go, disappear. And so a lot of the trauma that would come from car accidents or from a lot of people being together et cetera, a lot of that just disappeared. And then we also just saw a lot of people being at home and not being exposed to the same number of people that they normally are, so our numbers of coughs and colds and influenza season really just didn't, it just didn't happen the way that we've normally seen it in years prior. And then unfortunately, I think a lot of people who probably should have come to the emergency department or who should have seen their doctor stayed at home and, in some cases, got sicker because they were worried about getting this new virus and so they stayed at home even though they were feeling sick and even though they were having medical problems.

Unger: So that's something that I have read about and I think it might be universal that people are arriving in these emergency departments sicker than you're used to seeing them. Is that a characteristic that is happening right now?

Dr. Fairbrother: I think we're still seeing effects of an increase in acuity or patients being sicker when they come to the emergency department and part of that is that we have most of our care in the U.S. is now overwhelmed or backlogged with cases. So if say somebody normally sees their specialist every three to six months and a bunch of those appointments were canceled, now all of those physicians are really trying to catch up and see people as urgently as possible. But there's a bit of a backlog and so people are not as able to get into their specialists and even into their primary care doctors in some instances. And so that always translates to patients getting sicker at home and patients being sicker before they come to the emergency department for care.

Unger: Now, one thing you mentioned previously was about the pediatric emergency department, that that is particularly intense right now. What's driving that surge? What issues are you seeing? Is it COVID driven or more?

Dr. Fairbrother: So certainly with Delta, we have seen more children get sick with coronavirus and that really makes all of us really sad. The coronavirus is not a particularly strong contagion, it doesn't make many children very, very, very sick and certainly needing the emergency department or the ICU but we were seeing so many children get sick at the same time that our pediatric care resources across the nation were overwhelmed. In general, we don't have as many pediatric inpatient hospital beds or pediatric ICUs or pediatric nurses or pediatric respiratory therapists as we do adult because there's just aren't that many children that get sick. So even though a very small percentage of children got really ill with COVID or with MISC after getting COVID, it still was too much for our systems to handle. And that also came at the same time, that Delta surge, came at the same time as a particularly strong RSV, respiratory syncytial virus, surge across the country and we really just were not able to ... we just didn't have enough beds to adequately take care of kids in every neighborhood and community that needed those resources at that time. We had to do a lot of shuffling and there's even stories of children being shipped to different states to get them to the appropriate level of care because that's the only option that we had.

Unger: We just talked with Dr. Paul Offit about pediatric vaccination and he did mention those complications in that younger age group can be pretty serious with COVID.

Dr. Fairbrother: Yes, unfortunately. That's why all children who can be vaccinated really should be vaccinated, so that means anyone five-years-old and older. And I think if any physicians or people in medicine are having any questions about pediatric vaccines and safeties, which is common sense to think, "Okay, is this going to be really safe for our children?" They should really go get some outside resources and really see how extraordinarily safe these vaccines are for children. It's actually ... it's exceptional. We've never seen a vaccine that is this safe be on the market for children. It's really inspiring.

Unger: And I imagine that it must be a challenge for you and your colleagues to be in a situation where you're experiencing all of this overcrowding when there is a safe and effective vaccine, that this is preventable, serious illness, for the most part, using vaccinations. Does that kind of weigh on you emotionally?

Dr. Fairbrother: For sure. I think it weighs on all of us emotionally when we are taking care of patients who are very sick and dying of a preventable disease. And it's a choice, obviously, for almost everyone to whether to get vaccinated. In fact, I'd say it's a choice for everyone. There might be some consequences but we are seeing that this is a disease of the unvaccinated and it's, simply put, it's heartbreaking. It is heartbreaking to look into my patient's eyes as they struggle to breathe, knowing that it doesn't have to be like this anymore. It was scary enough at the start of things when we really had no treatments and we were doing everything that we could and it was terrifying to watch patients come in with such low oxygen levels and multiorgan failure and it was simply just awful to watch. And we worked really, really hard to try and protect our patients and treat our patients and protect ourselves. But now when I see patients come in and I find out that they've chosen not to be vaccinated and yet are coming in so sick or even dying of this disease, it's just heartbreaking. It's preventable. It doesn't have to be like this anymore.

Unger: Dr. Fairbrother, emergency departments are made for, obviously, for short stays. Patients usually treated, sent home with instructions on how to follow up with their primary care physicians or they get admitted to inpatient, or worse, intensive care units. Has overcrowding in other areas of your hospital changed? Are patients staying longer in the ED requiring longer term care?

Dr. Fairbrother: So, we are seeing overcrowding in the emergency department and we are seeing patients stay longer in the emergency department before going to their assigned bed once an admission decision is being made. And this affects that patient's care but it also affects everyone's care in the emergency department. So as the emergency department fills with patients who have already been admitted to the hospital or to even another facility and they continue to have a bed while they're waiting for that transition, patients who are in the waiting room or new patients coming in by EMS are either put in the hallways or they are double boarded in a room. There's obvious space constraints. We can only operate within the physical space that each emergency department exists within and as that space fills up, that affects our ability to see new patients and to have effective throughput and effective waiting to be seen times. And all of those things, they start piling up, they start adding up and patient care always suffers when emergency departments are overcrowded.

Unger: I take it you're not at that point where you're having to make difficult decisions, or at least where you are right now, in terms of care.

Dr. Fairbrother: We are very thankfully not at a place where we've had to make direct decisions about rationing of care, deciding who gets what resource. We've been there or been close to that at points in this pandemic but I'm thankful that we're not there right now. We've certainly seen a decrease in cases across the country and in new cases and a decrease in patients who are requiring hospitalization for this disease.

Unger: I'm sure that none of us imagined, outside of some kind of tragedy or catastrophe, this image of just the hallways across America's emergency departments just stacked with patients who are seriously sick. I mean, when you think about this situation in general, what you've experienced over the past year and a half, I'm sure you've heard people talk about reimagining care and issues that are broken with our health care system. How do we relieve the stress on emergency departments and our health care workforce in general?

Dr. Fairbrother: So I think this whole idea of the strain on this broken medical system is really complicated and it's multifactorial. I do think that as our country hopefully continues to increase the rate of people with insurance and, even more important than insurance, access to quality care, access to preventative care. I think we can see overall it as our population is aging, that we are going to have to look at how we get care to patients across the country and that the emergency department, as we know it, as a resource, is great as a safety net and I'm really proud to be a part of that safety net but it can quickly get overwhelmed, particularly in times of pandemic and in times of crisis. So with that in mind, I think an embrace of getting patients access to care, whoever they are, access to quality care and timely, efficient care.

Also, looking at the harnessing technology. Telemedicine during this pandemic has been the biggest gift to U.S. health care that I have ever imagined. I actually now see patients via telemedicine and I largely help patients within our system coordinate care after they get discharged from the hospital or after they've been to the emergency department and they have questions and they want to know, "Should I go back to the hospital or can you help with a prescription or a follow up appointment?" And in doing so, I get patients the care that they need safely, effectively, and sometimes patients don't need to go back to the emergency department. So I think that we've seen advances during this pandemic, most notably telemedicine, and hopefully with a continued focus on access to quality care and care efficiency, telemedicine, the use of artificial intelligence and other technologies to really improve and streamline health care, we can really make advances in supporting our health care system and fixing some of those systemic problems.

Unger: Well, Dr. Fairbrother, it's a pleasure to get to talk to you again. Maybe when I talk to you in the future, it'll have nothing to do with COVID. We'll look forward to that future.

Dr. Fairbrother: That would be amazing.

Unger: Thanks again for joining us. That's it for today's Moving Medicine video and podcast. We'll be back with another segment shortly. Be sure to click subscribe on the AMA's YouTube channel, Apple, Spotify or wherever you listen to your podcasts. You can find all of our AMA videos and podcasts at ama-assn.org/podcasts. Thanks for joining us. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.