PROVIDENCE — It is the state’s biggest hospital, with a name that suggests how important it is to the health care system here: Rhode Island Hospital.
And it is in crisis right now.
Sick and injured patients line the emergency department hallways in stretchers, begging for help that doesn’t always come right away. Frustration in the waiting room is so high that assaults have been reported. From ambulance triage to the intensive care units, nursing is short, but so are supplies, everything from needles to medicines to bedside urinals. Nurses sit in their cars after work and wonder, did I do everything I can today? Everyone’s burned out, and nobody knows where or when this all ends.
“Some days we come in feeling like ‘We’ve got this!’ This is an experience, this is a learning time, we’re going to get through this,” said Lindsay McKeever, a nurse and the director of emergency services at the hospital.
Other days they marvel in disbelief at the difficulties.
“We’re just like, ‘Wow, what is going on here?’” McKeever said.
The bottom line at Rhode Island Hospital: Nobody can really say that they are consistently delivering the same level of care they’re accustomed to.
“I’d be being untruthful if I felt like we had all the resources and tools to take care of every patient that came through the door right now,” McKeever said.
The staff at Rhode Island Hospital, the state’s only Level 1 trauma center, are experts in triage. So if someone comes in with trauma or chest pains or stroke symptoms, they get good, lifesaving care – an EKG in minutes if they need it, McKeever and her colleagues say. Health experts say people need to go to the hospital for true emergencies, though they should avoid it for things like routine COVID-19 testing. And, they stress, the best way to stay out is to get vaccinated against the virus.
But not even an optimist like hospital president Dr. Saul Weingart, who’s fond of wearing Santa hats and giving out candy canes and joking about having the only stocking with the name “Saul” on it, can say that things are normal. He recalls the hardest day recently, when he got an update from the medical director.
“We have over 50 people waiting for beds on the inpatient service,” he said the medical director told him. “There are no beds on the inpatient service. There are another 60 people waiting in the emergency room with an average wait of six hours. We’ve just had four assaults that security had to get involved in. And the nurses are crying.”
COVID-19 surely isn’t helping the situation, nor is the hyper-contagious Omicron variant, which is milder but is still causing swaths of the staff to go out sick. But the broader problems predate this latest wave of COVID-19, or even COVID-19 in general. Like a patient with a chronic illness, the state’s health care system was ill prepared to handle a viral shock. And then COVID came, and came again, and again, and again.
Nurses and other staff left for more lucrative travel jobs, or opted for less traumatic assignments in blood banks or urgent care centers. The staff who stayed and the temporary staff the hospital had to bring in are taking on new shifts and new responsibilities, while parts of the hospital are shuttered for want of workers, an eerie sign of the times: A crowded waiting room below wards filled with empty, unstaffed beds.
Right now, according to parent company Lifespan, about a quarter of ICU beds at Rhode Island Hospital are closed amid the staffing shortage. At the end of December, one out of every 10 patients was leaving the emergency department without being seen, which declined to 7 percent more recently. And the average wait time to see a physician in the ED has doubled since December 2019, to about two and a half hours for non-life threatening emergencies. Life threatening emergencies are still seen right away.
Rhode Island Hospital is grasping for every lever it can, from canceling all elective surgeries to combining units to getting a police detail for extra security in the waiting room. Weingart is still an optimist, and he knows they’ll get through it, but he also knows what they’re up against.
“Things were precarious, and then all of a sudden I need 100-plus extra beds for COVID patients, plus I just lost a couple hundred staff members,” Weingart said. “That’s what’s made it go from bad to terrible.”
It has gone from bad to terrible just about everywhere around Rhode Island, around the region, around the country. Not least in the state’s most important hospital, whose staff Globe Rhode Island interviewed over the past week to get a sense of what it looks like.
It starts, as a trip to the hospital often does, at the emergency department.
The Emergency Department
When Brown Emergency Medicine physician Whit Fisher went down to his native New York City in the spring of 2020 to help at a hospital there, things were horrific. Amid the crushing wave of COVID-19, medical workers stuffed bodies into corners and bathrooms and literally knocked down walls to get medical equipment from one place to the next.
At that time, this chaos was mediated by the fact that everyone on the outside was rooting for them. Help was on the way. People banged pots and pans out their windows at the appointed hour, a musical accompaniment to the light at the end of the tunnel.
Nearly two years later, they’re not stuffing bodies into corners at Rhode Island Hospital. But it also seems like that light is gone. Working in New York in the spring of 2020 was dispiriting. Working in Rhode Island in the winter of 2021-2022 is dispiriting and embarrassing, Fisher said.
“Patients look to you, because you’re the person in the white coat, and you feel like a chump,” Fisher said. “You’re the one who’s supposed to be able to help people, and you can’t. And it’s demoralizing.”
The emotions for medical professionals like Fisher can be complex. COVID-19 hospital patients are generally unvaccinated, and to Fisher, treating these patients is like treating a drunk driver who got in a car crash. The staff does the best they can, because the credo is do no harm.
But “it’s impossible to feel deeply sorry for them after you’ve seen it enough times,” Fisher said. “And it’s disturbing when you realize that you can go home and go to sleep perfectly easily after watching people die in horrible ways. Normal people don’t do that.”
The days of the morale-boosting “Rocky” theme blaring over the PA system after every COVID-19 patient discharge are long gone, and although Caserta Pizzeria recently brought some free lunch, it can seem to people on the inside like a place society has forgotten, or is trying to forget. Medical professionals were treated like heroes in 2020. Now they’re resented, scolded for telling people to put their masks on even when they’re in the hospital itself, Fisher said.
Depending on the day, if you were to walk through the emergency department at Rhode Island Hospital, where Fisher splits his time with Newport Hospital, you’d first be greeted in a generally crowded waiting room. Some are waiting with broken bones but can’t get painkillers quickly enough.
Past the waiting room, the people who are sitting on stretchers in the hallway get little privacy. The lights are harsh, and so are the constantly blaring alarms. People who do get rooms can spend days there because there’s no room for them upstairs. And patients who otherwise could go home can’t, because they can’t get transportation or space in nursing homes, which are also short-staffed.
Fisher knows people are suffering because of the crisis. And in his opinion, people have died who would otherwise have been saved months ago.
There is, Fisher said, “more death, and more suffering – and it’s terribly unsafe.”
Why is this happening? It’s easy to point to simplistic answers. Fisher, who’s also a professor of medicine at Brown University, diagnoses larger problems behind the crisis, problems not unique to either Lifespan or Rhode Island: the replacement of experienced medical workers with younger, cheaper, more compliant ones. Misplaced financial priorities. And still, even amid the crisis, too much red tape locally. The system could, for example, allow doctors to administer certain medications themselves, instead of keeping everything, even Tylenol, under a lock and key that only nurses can access.
Still, Fisher added: “Even though the situation is terribly bleak, I’m very very proud of the people I work with for showing up.”
McKeever, the nurse, echoes that sentiment.
“They show up constantly, with a positive attitude, and they really support the staff,” McKeever said.
Dr. Stephen Traub, attending emergency physician at Rhode Island Hospital and a top doctor at Brown Emergency Medicine, the independent group that provides the emergency doctors for Lifespan, said he goes to bed every night and wakes up every morning checking on the emergency department. At times they may have only half a dozen beds available in a department that sees 100,000 patients in the course of a year.
“I don’t think that there’s any system that could take the sheer numbers of resignations that we had over the course of the last several months,” Traub said. “I don’t really see systemic forces at play here. I see a reaction to the pain that particularly the nurses felt during the early waves of COVID.”
But it’s the particular patient stories that stick with Traub, like the woman whose care took a lot longer than it would have under normal circumstances. She didn’t have a bad outcome, but she went through pain. The staff feels it, too, in their own way.
“When I reflect on that, and the fact that we let her down, and we didn’t provide the care that we normally would have wanted to provide — we acknowledge that family’s pain, but we also as a group, we had to acknowledge that it hurts us to see that that’s how we’re operating,” Traub said.
The Intensive Care Unit
“I’ve been an ICU nurse for many years, and I have never seen patients this sick.”
This is Laura Wodecki, the clinical nurse manager at Rhode Island Hospital’s medical intensive care unit. It’s usually an 18-bed unit, but four beds are closed now amid the staffing shortage. Most of those in the 14 open beds are COVID patients, and most of them are unvaccinated. Since the pandemic started, the medical intensive care unit has never not had a COVID patient, Wodecki said.
Because of the staffing shortages, Wodecki is doing more hands-on work than a manager usually does. On Tuesday that meant helping another nurse. The nurse had been in the patient’s room for hours and hours and refused to leave, because the patient was not doing well and, if she left, might get worse. If something happened, Wodecki said, she would take care of it. Still the nurse refused to leave.
“No, you need to go eat now,” Wodecki told her. “It is 3:45. You’ve been here since 7.”
Wodecki recalled later: “Sometimes they don’t even recognize that they need to take a break.”
To Sherry-Ann Johnson, a nurse who’s part of the United Nurses and Allied Professionals leadership, working in the COVID ICU for months at the height of the pandemic made her fearful of the disease. She’s seen what it can do to people.
And now, working in the trauma intensive care unit, where COVID-19 is incidental to things like car crashes and burns, there’s a new feeling: guilt. She’s always been the type of person to wonder what they might have been able to do differently. It’s even more pronounced now, at a time when she also wonders sometimes whether someone will be there to relieve her at the end of a shift.
“I feel a sense of obligation to be there,” Johnson said. “But you just can’t – you just can’t always be there to provide the care.”
The union has asked for the hospital to scale back the amount of material they have to include in patients’ charts to make things work more efficiently – “disaster charting,” it’s called. And, in Johnson’s opinion, the atmosphere can feel punitive, rather than educational. But the broader issues aren’t unique to Rhode Island Hospital, Johnson said. They exist across the health care industry.
“People are feeling overworked, they’re feeling undercompensated, and so they’re angry, they’re upset,” said Johnson, who stressed that she was not speaking on behalf of the union. “When other opportunities come up, they’re maybe a little more willing to take those opportunities, and maybe feeling they haven’t fully been supported by their institutions.”
On a recent Tuesday, Johnson said, she was supposed to work from 7 a.m. to 3 p.m. But her unit would have been four nurses short. So she and three colleagues signed up for another shift, working until 7:30 p.m.
Compared to the bustle of the emergency department, it might seem like nothing is amiss in the intensive care units. On the surface the ICUs are generally quiet, almost peaceful places, imposing order on immense grief.
But “this feels markedly different than what we’re used to,” Dr. Debasree Banerjee, attending physician in pulmonology and critical care medicine, said in a phone interview Friday as she took a break from work. “It’s beyond what we hoped we could control.”
One thing that makes January 2022 harder for the staff there is that they’ve never really recovered from 2020, Banerjee said. Also, what they’re seeing is mostly preventable with a COVID-19 vaccine.
“It’s a shame we’re losing so many of our community members like this,” Banerjee said. “Leaving behind spouses, parents, young children.”
She worried about what would happen over the weekend. Not about whether any patients would die, because in the ICU death is an inevitable presence, but about how many would actually survive.
After work Banerjee will go to her home in Providence, greeted at the door with a hug from her toddler. She’ll put her scrubs in the wash, feed her son and put him to bed. Usually the workday hits after this. She has lost patients younger than her. She is 38. She has never had to call social workers so often to get fingerprints of dying patients, to serve as keepsakes for their young kids. All that goes through her head as her own toddler sleeps in another room.
“And then I have to prepare mentally for the next day,” Banerjee said.