Opinion: Mrs. J wanted a blanket in the emergency department. Saying no chips away at my soul

What upsets Mrs. J isn’t the six hours she’s waited in the emergency department to see a doctor for a growing and surprisingly painful inflamed area on her leg. Or that she’s being examined in an ad hoc space in the triage area because the department’s rooms are filled with patients waiting to be admitted to the backed-up hospital wards upstairs. What’s she’s upset about is that when she asked the triage nurse for a blanket a few hours earlier while still in the waiting room, she was told, “I’m sorry. I can’t give you one.”

“A blanket!” cries Mrs. J. “That’s all I asked for.”

The triage nurse, who is with us, fights back tears. She wanted to give Mrs. J a blanket, but the 60 patients in the waiting room complicated the situation. Previous experiences left her little choice but to say no, even though by denying a cold patient’s request for a blanket she denied herself the compassionate gesture she desperately wanted to give, leaving her to feel chilled as well.

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Why is an emergency physician like me ruminating about blankets, especially hospital blankets that are a little rough on the skin, when sick people overflow the country’s emergency waiting rooms, emergency departments, and hospitals?

Each wave of the pandemic has exposed major, well-reported fault lines in the health care system, including lack of beds in hospital wards and intensive care units, shortages of skilled staff, unfortunate outcomes resulting from boarding and wait times, and the emotional toll on health care workers. But there are less obvious challenges, seemingly minor, that are harder to articulate and devastating in their own way.

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The triage nurse later told me she found it hard to tell Mrs. J about a night in the emergency department before the pandemic when giving a few blankets to patients in a packed waiting room blew up in the staff’s faces. More patients asked, then demanded, blankets. Family and friends stepped forward. Blankets walked out the door. Once one was given out, drawing the line became impossible. And when the supply dried up, patients didn’t believe it. The staff faced anger and verbal abuse.

Restocking the empty carts with blankets would eventually happen. It takes a phone call and time. But this experience and others like it chip away at the soul of health care workers, and there are no ready repairs. The default response to preserve what’s left of our compassion involves emotional retreat, which we’ve discovered erodes compassion further.

Our blanket problem isn’t really about blankets. It’s a failure of something core that any system that has health and care as part of its title or mission should be able to uphold regardless of the challenges.

I can’t talk about blankets without considering the benefits of the simple act of giving. Kindness and generosity are linked to parts of the brain associated with happiness and altruism, producing physiological and emotional benefits to the giver, from a warm glow to increased activation of brain regions and neurochemicals like oxytocin and endorphins that are associated with reward and trust.

If giving is its own reward, I can’t resist wondering if there’s a cost when doctors and nurses want to give something like a blanket and aren’t able to do so. I might be powerless to create more hospital beds or staff, but a blanket belongs to the lowest level of Maslow’s hierarchy of human needs, on the level of food and warmth and shelter.

My encounter with Mrs. J happened during an earlier pandemic wave. The pressures from then have only deepened during Omicron, or it feels that way to those staffing emergency departments and ICUs and hospital wards. That’s partly because it’s been a grind, emotionally and physically, and partly because this surge grew on the backs of the unvaccinated.

Long before Covid-19 began changing the world, terms like “moral distress” and “moral injury” had sprung into the larger conversation about health care workers’ struggles. Meant to capture the “mental, emotional, and spiritual distress” that results from being unable to uphold deep values and moral beliefs, and being unable to provide high quality health care, I find these terms a bit baggy. Used often to describe and label the consequence of a range of challenging experiences on health care workers, it risks putting at a distance the complex and overlooked situations responsible for it.

I hold onto my moment with Mrs. J because I’m discovering that I’m losing the part of me once troubled by what it meant not to give a cold patient a blanket. I’ve come to feel so overwhelmed and powerless by everything I can’t do that I’ve erected a shameful line of self-defense: I’ve become emotionally vacant.

Sometimes it’s easier to pretend I don’t see the needy faces and walk blindly past the swell of moaning patients waiting for hours and hours in hallways. I pretend I don’t hear the frail man with dementia screaming, “doctor, doctor.” I speed by the otherwise well-appearing silver-haired woman who fell and quietly lies on a stretcher in pain because the stiff neck collar immobilizing her cervical spine is digging into her chin.

I walk by because I’m busy with other patients, because I don’t want to give the impression that I’ll be their doctor when there are many patients ahead of them, because I know that stopping to care for one person can precipitate other worthy calls for my attention. I walk by enough times and this protective line of defense becomes who I am.

A cherished emergency colleague recently asked me, “Does everybody expect that we’re going to come out of this OK?”

We stood there, lost in silence, not because we didn’t know the answer but because it didn’t matter. Many health care leaders work at a safe remove from blanket problems and might not realize why these seemingly small issues are profound and perilous for clinicians and patients.

My apology to Mrs. J includes an explanation for why she isn’t given a blanket. She brushes the tears from her cheeks and nods. She expresses sympathy for the stresses facing hospitals and the ER staff. The blanket, however, is another matter. “Is it too much to give me a blanket?”

I am ashamed and angry to be part of a system that puts health care workers in positions where satisfying a basic human need becomes a form of risk management.

Not long ago, a woman who sat in the waiting room for a half a day screamed at me when she finally was put in one of the emergency department’s rooms, and I felt nothing. I let her scream. I told her in a calm, defeated tone that she could yell at me all she wanted. I’d be screaming, too, if I were in her position. I’m surprised patients don’t yell more often, even though we are doing the best we can. But we’ve been at it for two years, and most of us are shells of who we once were, and more yelling won’t make things better. And there’s a possibility — unlikely but possible — that a day might come when she pulls up to the emergency department only to find it dark because there’s no one to staff it. That’s how gone we are.

I couldn’t believe I told her what I was experiencing when her problems should be the focus of this interaction. I felt guilty, disobeying the one-way road sign of the doctor-patient relationship.

She stared at me, swallowed, then apologized. And I apologized to her. No, she said. She felt terrible. No, I insisted, I felt terrible. Soon, we got into a verbal sparring match over who deserved to give the apology and who should receive it.

The pandemic has exposed what most of us working in emergency departments and hospitals have known for years: The house of medicine is collapsing. As standards and duties of care crumble, and health care workers struggle to make the “best, bad decisions,” it’s hard to lose sight of what’s possible, to ask, “What can we do in this cataclysm of can’t?”

One adaptation that has emerged from this pandemic crisis is to leverage technology like digital health and telemedicine. But connectivity through a video screen isn’t the answer when there’s a connection problem at the level of blankets, when conditions transform blankets into a moral crisis.

Meaningful work to repair health care must begin here, by investigating those blanket problems that data and graphs inadequately capture. They might appear simple, but they’re far from simplistic. These rocky moments contain opportunities for stability, and sources of comfort and control. I find hope in knowing that some critical system solutions are only an arm’s length away, though the answer isn’t more blankets. It’s recognizing and meeting the basic needs of the humans belonging to those arms: frontline workers who want to deliver compassionate care and patients who, even in a crisis, deserve to receive it.

Jay Baruch, M.D., is professor of emergency medicine and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University and author of the forthcoming book, “Tornado of Life: Constraints and Creativity in the ER” (MIT Press, Fall 2022). The patient’s name and identifying details have been altered to protect the patient’s privacy.

Source: STAT