Late last Thursday evening I found myself alone at Mt. Sinai’s ER. I had been running a low grade fever for about a week and I also knew something else was desperately wrong but was frankly afraid to have it addressed. By Thursday night I had no choice.

MY HOSPITAL – always and forever till the end of time – The SINAI

Mt. Sinai is my hospital in so many ways. Nearly 40 years ago I had extensive surgery there related to an auto-immune disorder I’ve had since I immigrated to Canada as a preteen. My surgeon had pioneered the technique that saved my life ultimately as a 20 year old and I named my son after him. Indeed, both my kids were born at this hospital and I received high-risk prenatal care there, all spectacular.

Now I’ve been fortunate not to have needed admission to hospital in a very long time, the last really being to give birth, and since that all went fine, those were happy visits. This was the first time I had to seek emergency care in an actual, sort of dire feeling emergency, in ages. But of course back in my teens and early 20s I had spent a huge amount of time in hospitals, years ultimately including one year straight. I know a lot about medical care – I work in the field of health care and mental health law. I’ve seen a seemingly endless volume of medical records and reviewed thousands of interviews of patients, myself included, over the years. I have more extensive experience with all this than most, fair to say.

THINGS HAVE REALLY CHANGED – BOTH WAYS – OVER THE LAST 40 YEARS

Things have changed so fundamentally in medical care and emergency care that I barely recognized it.

Some for the better, so many for the worse.

Let’s cut to the chase. Medical and nursing care at Mt Sinai were spectacular, to say nothing of the dental care, which against all odds I also ended up needing – which was like the cherry on top of my ice cream sundae of excellent medical attention in a serious emergency.

But the hospital infrastructure is horrible. The public facing shiny neon lights announcing the donors with $5 MIL or more or whatever, are really a frank misrepresentation of what you get inside. I expect that money goes largely to research or equipment or salaries of administration or something. Perks like there is a CT scan especially designated for the ER which means you can get a scan in an hour in the ER – that’s great.

But it would be a mistake to discount the importance of physical infrastructure in how it shapes the patient experience. How awful things are in many places inside Mt. Sinai in my own view is seriously detrimental to patient care and likely adversely affects outcomes in the aggregate and long term. In other words it’s not really a case of “who cares what it looks like so long as the treatment is appropriate?” as perhaps you might imagine. Comfort and confidentiality are important aspects of wrap-around standard of care. Both are often and sometimes grossly lacking sadly at the Sinai.

GENERAL WAITING ROOM – MAIN EMERGENCY DEPARTMENT AREA

The main ER waiting area generally functions well — the triage system is expert and efficient. I was seen by an actual doctor within two hours of arrival on each occasion. I found that reasonable and when I came back the second time, I had trust and confidence in the system working well. That was a good feeling, empowered by a recent visit, being in the know and feeling reassured.

Some odd things though. I couldn’t believe the number of security guards I saw – my first night about five — many are the least intimidating security I’ve seen — tiny women mostly. And they are invariably kind. I saw them dealing with very difficult situations of people in altered states, consistently kindly and gently. Albeit I did also see the application of restraints in plain view of everyone gathered in that large ER main waiting area. That was something I am still processing and it likely was not necessary. It escalated the patient who probably was just drunk and ultimately OK to go. I did find a lot of private conversations between patients and their attending physician happened in that pretty public area. I heard many of them and learned the medical histories and presenting problems of complete strangers to me.

As a for instance, one of the conversations I literally could not help but overhear was an ED Dr. telling his patient that he had tried to get her an ultrasound but “was getting push back about using ultrasound resources in this situation at this time.” You know what the situation was? A young racialized woman whose English was not great, who was working a couple of jobs, attending with her Mom, because she was in early stages of pregnancy and was spotting. The tone of the whole “push back” message to my lawyer ears suggested that this was something being floated to see if it was accepted by the patient. Like if I had intervened and said “that’s ridiculous, ultrasound her belly right now, this is what emergency medicine does”, they would have just done it. But the patient and her mom just agreed to attend an early pregnancy clinic the next evening after work instead. It was all I could do not to insert myself into other people’s healthcare moments as I heard over and over again why something couldn’t or wouldn’t be done because of concern about appropriate and inappropriate allocation of resources.

But back to how I kept learning all about everyone around me. None of that should ever have happened.

I think I know why it did and continues.

It’s because THERE IS NO SPACE FOR PRIVACY, OR COMFORT OR REASONABLE CARE MEASURES IN THE ED AT MT SINAI – IT’S BULGING AT THE SEAMS – IT NEEDS URGENT INTERVENTION BEYOND THE FLASHING LIGHTS OF $$$ AND WHO GAVE WHAT CHAIR.

I should flag at this point that from Thursday night through to Monday night I ended up cycling through more than one service, had an operation, was discharged home, came back the next night with a different emergency, was sent home, came back the following morning and had another surgery. So much blood was drawn, no vein was left standing and I had two separate CT scans on unrelated body parts both done almost instantaneously through the ED’s special machine. So a rather eventful 90 hours or so, to be sure. But in the process, I was triaged as different levels of care and intervention needed, so I got a pretty intense exposure to at least GREEN and BLUE exam and waiting areas in Mt. Sinai’s ER.

THE COLOUR-CODED TRIAGED EMERGENCY DEPARTMENT SUB-WAITING AREAS

It is shocking actually that throughout many of the internal designated areas within the ER, you cannot get anywhere to sit comfortably or god forbid lie down, when you are unbelievably ill and in fact you’ve been triaged as pretty seriously unwell. That’s not good. You feel sick as a dog and they agree with you that you’re very, very unwell, so you get triaged into a colour-coded area commensurate with your triage designation.

But the lack of appropriate facilities make this visit to the ER an incredibly unpleasant experience once you’re admitted inside those doors from the main waiting area. And it’s not the staff – it’s the space. There is not enough space, either in the ER or anywhere in the hospital – it needs a new home. It has long ago outgrown this home turf. It’s stifling patient care – the facilities are dated, dirty and desperate for a modernization, upgrade, humanization.

What’s wrong? Almost everything. There are precious few exam rooms, strikingly few, a handful per designated colour-coded section of the ER – and in some of those areas the rooms are pretty dated and old and sparse anyway. You get your actual private exam in there for 5 minutes or less and then you’re booted into a tiny, cramped “waiting room” that’s really a few chairs in a narrow hallway by the blanket cupboard and that’s where all the super sick people sit on top of each other coughing up a lung onto each other.

It was, I’m not gonna lie, excruciating. I had a fever. I had a medical issue that made it very difficult if not impossible to sit – and it was absolutely freezing in there. Getting through the first night was a living hell – it was torture.

The good news was that doctors and nurses came and with the exception of one first year resident who had no idea what was going on but would not readily admit to that – without cross-examination — poor thing – apart from her, the nurses and docs were universally fantastic. Absolutely brilliant, insightful, direct and clear communicators and diagnosed and recommended action appropriately – obtained just stunningly good informed consent at every turn. A+++ throughout for medical and nursing care.

GENERAL SURGICAL TEAMS, SURGEONS, NURSING AND OVERALL CARE – A++

The General Surgery Team who operated on me were absolutely flawless – from diagnosis to treatment intervention recommendation, to the informed consent, the surgical skill, the follow up, the discharge process and meds. All fantastic. And they somehow also had personalities, which is rarely seen in this department and was much appreciated. They quite frankly went above and beyond for me and their efforts to link me back to services I likely desperately need will probably prove to be life-changing over time. I couldn’t be more grateful.

Nursing on the General Surgery ward, also exceptional. All patient and accommodating. I had a room-mate, who was a very nasty, terrible person. Staff had the patience of Job. I don’t know how the heck they did it. More power to them.

THE GENERAL SURGERY WARD ITSELF

But the ward itself and the semi-private room I was paying for, were grossly inadequate. The bathroom in my room was filthy. It had not been cleaned when I arrived. There was a chunk of dark hair in the sink. The toilet wasn’t clean. The floors were disgusting. So was the shower area. There was nothing to dry your hands with even tho you obviously wash them constantly in hospital. Only one person came to sweep on Sunday and they moved around some dirt and left. Nothing else was ever done in the way of “house-keeping” while I was there.

Nobody ever came to change linens or offer towels or suggest you wash up or offer help. I asked for a second “pillow”, which was a paper outfit of sorts, not a pillow at all, actually, but I was told they were very hard to come by. Basic supplies were simply not available. To get an extra blanket or towel to prop up a body part post-surgery became a treasure hunt for staff who brought you things they scored like a prize. It was heart-wrenching in a way. And the severity of the shortage and resource-limitation culture didn’t dawn on me until I got home. It stands in stark contrast to what the hospital projects in a public facing way, which is modern, clean, sterile, state of the art infrastructure and facilities. As I say, maybe the machines or research or something benefits directly, more than likely that’s the case as the money does have to go somewhere – but otherwise, the facade is just that – it is not real. The allocation of donated or other funds does not appear to be happening in a patient care centred way. Certainly not a patient experience centred way.

The hallways on the Surgical Ward where I was recovering for two nights were crowded with equipment discarded or unused in all the common spaces — huge clunky things that left almost not enough room to breathe, crowded narrow hallways all over the place. At one point my IV machine ran out of battery time and rather than plugging it back in to charge for hours, because I was told I had to walk around, I asked if we could swap it out for a machine already fully charged or more so. Nurse looked at me like I had three heads and announced there was no chance of a spare machine on the ward, charged or uncharged.

NURSING AND MEDICAL CARE – THE PERSON vs THE PROBLEM PRESENTING

But like I say the nursing care was consistently and universally spectacular on my unit. My family left some donuts for the staff as I took my leave and it really didn’t sound like they were used to being acknowledged at all – broke my heart. Nurses have been through a lot since the onset of the pandemic. Everyone treats them poorly. They don’t get paid enough for all this. They are heroes and deserve a medal.

As for the training that medical staff are getting these days, I noticed patterns. Once upon a time they’d take a history that included things about you like oh, how old you were, what you did for a living, if you had kids or a spouse, before they got to the issue of the day. No time for any of those niceties now. Literally nobody ever asked me anything about me apart from what’s the problem they’re to address today, right now even. Not earlier today or later on perhaps. What is it NOW??!!!?

And if you heaven forbid strayed for a second to editorialize your answer, you’d be brought back to the main point with a Pozner Dodd like cross-examination by the doc who would repeat their question in smaller and smaller bites until you said “yes” or “no”, rather than “it depends what you mean by a fever” etc. It was jarring in many ways to be interviewed with the whole “just the facts ma’am” approach, because it is fairly dehumanizing. And you’re certainly left with the impression that it’s a lean, efficient, resource conscious regime, which simply does not have the bandwidth to care about you or your family beyond your whatever is infected or needs to come out of you now bits.

EMERGENCY DENTISTRY – A BRUTAL PROCEDURE THAT ENDED UP BEING FUN

When I returned over the next two days after discharge post-op I was presenting with a likely unrelated but equally emergent problem that remains somewhat unresolved. But in between there I was seen by and operated on by a Dentist – who is studying to be a facial reconstruction surgeon. And he was just adorable. Smart as a whip and terribly charming, he’s a great dentist who will go on to do brilliant things. A special young man I felt fortunate to receive care from.

ALL THE COLOURS OF EMERGENCY

There is no red zone, I learned, which is probably good. Green meant pretty sick, but apparently could be worse – could have been tagged yellow, which I blissfully was spared on this occasion. Blue I got to know better than most because that’s where your visit is expected to be closer to an outpatient consult, a quick in and out is hoped for. In my case, that turned out to be a slight miscalculation, overly optimistic in hindsight, but it was a calculated best guess certainly. What makes almost no sense to me, however, is that this general area is in much better shape (everything being relative) than where you’re housed when you’re much worse off.

All I know is I was glad that Purple was not in the cards for me during this particularly turbulent time. At moments I felt close to making it over in that direction, but held it together somehow and avoided the dreaded purple designation – Psychiatric Emergency. Which is not to say the Mount Sinai Emergency Department did not get its fair share, if not more, of all that too in the overnights I spent camped out there.

My first night, a very polite young woman wearing brightly coloured cheerful clothing, her life’s belongings with her in her shopping cart, had a very sweet dog close by her side at all times. She came through three times that night. Each time she was triaged through with intake nurses asking her the same thing: “What do you hope to accomplish with this visit?” As a gaggle of security guards was escorting her out, quietly and with dignity, the third time, I was outside taking a breather. I walked back with the group and commented: “That was the third time she came in this evening.” And one of them said: “People sometimes just need somewhere to sleep.”

She was back again two nights later. So was I.