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Redrawing the Boundaries: Conceptualizing Emergency Medicine as a Complex Communication System
Unformatted Document Text:  3 Wentworth, W. (1980). &RQWH[W DQG 8QGHUVWDQGLQJ $Q ,QTXLU\ LQWR 6RFLDOL]DWLRQ 7KHRU\ New York: Elsevier Appendix: ED Cultural Narrative “The world shows up at our doorstep”: The Tale of the CHC Emergency Department Some stories are great fun to tell and some are painful, and this one is a little bit of both. So you think you want to work in an emergency room? You had better be crazy, and then some. Nothing about this job is easy: not the patients, not their families, not dealing with the hospital administration. All EDs are having some version of this experience now; a recent issue of U.S. News and World Reports declared “ER in Crisis.” Nurses everywhere are in short supply, and nurses who can work effectively in the emergency environment are even more rare. Each day it seems things get a little busier as we see more and more people coming through the door. Some primary care physicians are so overscheduled that they send their patients to the ED—where they sit and wait. The growing ranks of uninsured patients join them. Moreover, each person comes in with higher expectations for care and service than ever before. So we try to sort things out in triage, and then we send people to sit for hours in the waiting room where they become angrier each passing minute. And all it takes is one vocal angry person to enflame the mood of the entire waiting room. But hold on—while surely true, this is sounding too negative. We chose to work here, after all, and there is something we love about the place. The best part of the job is when we get to use our training in dealing with “real” emergencies. Nothing feels better than rising to the occasion during a code and saving someone’s life, to feel the adrenalin rush and the miraculous way we manage to work as a team in the midst of a crisis. This is when we are at our best, but how much of the job is this way? Not much. Unlike how it looks on television, the number of real emergent cases is dwarfed by a litany of minor injuries and complaints better seen in a clinic or doctor’s office. It’s called an “emergency room,” but this is increasingly a misnomer--only a small percentage of what we deal with each day is truly emergent. But it’s not just the increased workload that is so hard to take—it’s also the daily inequities and frustrations that have led many of our former colleagues to leave. Six nurse managers in three years? That should tell you something. The people here are good, but the institutional support is lacking. Like some insane ticket-taker, we just keep packing patients in the door, but we haven’t developed an infrastructure to support these people who are counting on us—there’s nowhere for them to go, no available beds in the hospital. It’s not out of the ordinary that we have over half of our beds filled with patients on hold waiting to go upstairs. And the bed management system! There simply has to be a better, more automated way to track the availability of beds than the archaic paper system we use today. Given this level of overcrowding, some of us wonder about the overall growth plan for the hospital. We are pleased to see resources going to grow the Women’s Center and Heart Institute, but we are concerned about our ability to provide comparable levels of care in the ED. In theory, patients who come to CHC through these newer centers will develop a lifelong relationship with the hospital, and will come to rely on us for all of their medical needs. But if they visit the ED, they will find a different situation from how they were treated elsewhere on campus; we are overcrowded, and understaffed.

Authors: Eisenberg, Eric., Pynes, Joan. and Baglia, Jay.
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3
Wentworth, W. (1980).
&RQWH[W DQG 8QGHUVWDQGLQJ $Q ,QTXLU\ LQWR
6RFLDOL]DWLRQ 7KHRU\ New York: Elsevier
Appendix: ED Cultural Narrative
“The world shows up at our doorstep”: The Tale of the
CHC Emergency Department
Some stories are great fun to tell and some are painful, and this one is a little bit of both. So you
think you want to work in an emergency room? You had better be crazy, and then some. Nothing
about this job is easy: not the patients, not their families, not dealing with the hospital administration.
All EDs are having some version of this experience now; a recent issue of U.S. News and World
Reports declared “ER in Crisis.” Nurses everywhere are in short supply, and nurses who can work
effectively in the emergency environment are even more rare. Each day it seems things get a little
busier as we see more and more people coming through the door. Some primary care physicians are
so overscheduled that they send their patients to the ED—where they sit and wait. The growing ranks
of uninsured patients join them. Moreover, each person comes in with higher expectations for care
and service than ever before. So we try to sort things out in triage, and then we send people to sit for
hours in the waiting room where they become angrier each passing minute. And all it takes is one
vocal angry person to enflame the mood of the entire waiting room.

But hold on—while surely true, this is sounding too negative. We chose to work here, after all, and
there is something we love about the place. The best part of the job is when we get to use our
training in dealing with “real” emergencies. Nothing feels better than rising to the occasion during
a code and saving someone’s life, to feel the adrenalin rush and the miraculous way we manage to
work as a team in the midst of a crisis. This is when we are at our best, but how much of the job is
this way? Not much. Unlike how it looks on television, the number of real emergent cases is dwarfed
by a litany of minor injuries and complaints better seen in a clinic or doctor’s office. It’s called an
“emergency room,” but this is increasingly a misnomer--only a small percentage of what we deal
with each day is truly emergent.

But it’s not just the increased workload that is so hard to take—it’s also the daily inequities and
frustrations that have led many of our former colleagues to leave. Six nurse managers in three
years? That should tell you something. The people here are good, but the institutional support is
lacking. Like some insane ticket-taker, we just keep packing patients in the door, but we haven’t
developed an infrastructure to support these people who are counting on us—there’s nowhere for
them to go, no available beds in the hospital. It’s not out of the ordinary that we have over half of
our beds filled with patients on hold waiting to go upstairs. And the bed management system! There
simply has to be a better, more automated way to track the availability of beds than the archaic paper
system we use today.

Given this level of overcrowding, some of us wonder about the overall growth plan for the hospital.
We are pleased to see resources going to grow the Women’s Center and Heart Institute, but we are
concerned about our ability to provide comparable levels of care in the ED. In theory, patients who
come to CHC through these newer centers will develop a lifelong relationship with the hospital, and
will come to rely on us for all of their medical needs. But if they visit the ED, they will find a different
situation from how they were treated elsewhere on campus; we are overcrowded, and understaffed.


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