Alexandra Ortego
DPCS Reflection Paper
Summer 2008
My Experience in the Bellevue Emergency Department
The best way to describe me on my first day in the Bellevue Hospital
Emergency Department is completely intimidated. As I stood in the Adult
Emergency Services I couldn’t help thinking that I was in over my head. The
Emergency Department was bustling with busy staff who didn’t have time to hold
my hand and frustrated patients who stared at me curiously. In the months before
my internship I pictured myself walking into the hospital, rolling up my sleeves
and beginning to help the patients there, but that image burst pretty quickly when
I couldn’t even find a place to stand without being in the way. Finally, I took a
chance and asked a tired looking man with only one leg if there was anything I
could get for him and was quickly sent to retrieve a glass of water. It took me at
least half an hour to figure out how to get that glass of water, but once I took that
first step, everything improved from there.
Bellevue Hospital is notoriously one of the busiest public hospitals in the
country. Located in midtown Manhattan, it is renowned for its Emergency
Department and draws some of the most talented medical professionals in the
country. However, what makes Bellevue stand out is its patient population, which
is one of the most unique and diverse in the world. Eighty percent of the 100,000
patients treated in the Bellevue Emergency Department every year come from
the medically underserved community and no patient is ever turned away due to
inability to pay. This policy in addition to the excellent quality of care that
Bellevue provides attracts many patients who are homeless, incarcerated, and/
or do not speak English. Many are unable to afford a visit to a primary care
physician and rely on the Bellevue Emergency Department for all of their care.
This patient population poses the additional challenges such as barriers in
communication and inability of the staff to relate to their patients. The doctors
and nurses of the Emergency Department are often so busy that patients may sit
for hours without an update, growing anxious without information or someone
with whom to talk. For this reason, the Emergency Department brings in
volunteers during the busy summer months to help provide better and faster care
to its patients.
As a Project Healthcare volunteer I was assigned to shifts in various areas
of the Emergency Department including Adult Emergency Services, Pediatric
Emergency Services, Urgent Care Center, Emergency Ward, Comprehensive
Psychiatric Emergency Program, Social Work, Operating Room, Cardiac
Catheterization Lab, and Recovery Room. In all these areas my main
responsibility was to serve as a patient advocate, spending most of my time
performing electrocardiograms, transporting patients, translating, distributing
food, water, blankets and clothing, and acting as a liaison between patients and
medical staff, providing information about their status. I was constantly moving
during most of my shifts and spent time in between performing structured tasks
talking to patients and doctors. I talked to many people who came from
backgrounds very different than my own which really expanded my horizons and
allowed me to learn a lot about other cultures and the challenges of poverty.
Assisting both patients and doctors also allowed me to earn their trust so I was
able to observe medical procedures while providing patients with a hand to hold.
Many doctors including my mentor were very willing to explain their diagnoses
and treatment of patients to me and I learned a lot about the compassion
required to care for this population through the conversations I observed between
the doctors and patients.
Another part of my internship included preparing and executing a large
health fair for the community in the lobby of the hospital. Two other interns and I
were responsible for researching smoking cessation and lung cancer, presenting
the information on a poster board, supplying pamphlets and talking to patients
about the importance and methods of smoking cessation. The fair was carnival
themed and each booth supplied an educational game for visitors. When I was
preparing for the health fair I didn’t expect a very large turn out and began to
wonder if all the effort I had put into my booth was worthwhile. To my surprise,
however, the health fair was visited by hundreds of patients and their families
throughout the day and I was constantly talking to members of the community
about smoking cessation and supervising my booth’s trivia game. Although I’ll
never know if my efforts led someone to quit smoking, I believe that the health
fair really taught me the value of educating patients and made me think about the
importance of promoting preventative medicine. I believe that placing a greater
emphasis on healthcare education will not only improve the health of the public,
but will also decrease the cost of their medical care.
Talking to patients with lives so different from my own did not come easily
to me at first. I had no idea what a middle class college student from the suburbs
could possibly have in common with a heroin addict from the inner city. Slowly I
found that simply introducing myself and asking if they needed anything was
enough to start a conversation. Many of the patients I talked to were so eager for
a distraction that they were excited to tell me all about their children, their jobs,
and their home countries and asked me lots of questions about myself, always
wishing me good luck with my future career in medicine. I believe that to many of
the people that I spoke with, knowing that there was a volunteer in the hospital
who showed an interest in their problems and a strong desire to make them feel
better was just as comforting as the treatment that they received.
I wish I could pinpoint one moment during the summer when I had an
epiphany, but learning about community service in healthcare was more of a
gradual process for me. Looking back however, I can measure part of my
learning experience by how my attitude toward one patient changed throughout
the summer. This patient, who I’ll call Mary, pays at least one visit each day to
the Emergency Department and was on a first name basis with all of the staff.
She is one of New York’s many homeless patients who suffer from alcoholism
and psychiatric issues. I met Mary on one of my first shifts in the Adult
Emergency Services when the head of the Emergency Department asked me to
sit with her and make sure that she didn’t leave her stretcher. This turned out to
be much more difficult than I had anticipated. I had never met anyone who
looked as dirty or smelled as terrible as this woman and it took a tremendous
amount of willpower just to keep myself from running from the room. Trying my
best to help I stood next to her rubbing her back and trying to calm her down as
she begged for yet another set of clothes and not to go to the psychiatric
emergency room, requests I had no control over. I began to get frustrated that
she refused to stay in her bed and that I had been asked to handle this situation
that seemed out of my league. As I stood in front of her stretcher to prevent her
from getting up I felt guilty that there was nothing I could do to help her and that I
was in fact doing the exact opposite of what she asked. I was relieved when I
finally helped transport her to the CPEP, the psychiatric section of the
Emergency Department, and could move on less difficult patients.
I saw Mary many more times over the summer both in the Emergency
Department and sleeping on the sidewalk while I was walking to the hospital, and
each time grew a little less nervous and frustrated around her. I started thinking
about why this woman would come to the hospital every day only to beg to leave
again and not be sent to the psychiatric emergency room. Slowly, I began to
understand that the hospital was really the only place she could go to receive any
kind of compassion or attention. When she arrived she would be given a place to
sleep, clothing, and food and was treated in the same manner as every other
patient that entered the Emergency Department. Interacting with Mary gave me
an increased sense of compassion and understanding for patients trapped in a
life of poverty, especially those who suffer from addictions and psychiatric
diseases, and showed me the need for increased support for these patients. I
learned that physicians that work with the medically underserved face the
additional challenge of providing social support in addition to medical treatment
to ensure their patient’s wellbeing and that this social support is often difficult to
provide.
My internship at Bellevue presented me with many challenges that I had
never before encountered. I had trouble communicating with patients that did not
speak English or Spanish and often had to resort to body language to find out
how I could help them. Even when interacting with the patients with whom I could
communicate I often would struggle to find the right words to comfort them and
wished I could give them more information about their treatment. In the beginning
I was intimidated about talking to patients who were very different from me,
especially the psychiatric patients, prisoners, and addicts. It took me awhile to
learn that listening and showing an interest was the most helpful service I could
provide for these patients and eventually looked past their reputations and
handcuffs to approach them in the same way I would any other patient.
One of the more challenging tasks I was asked to perform was to offer
free HIV testing to all of the patients in the Emergency Department. HIV is a
sensitive subject among many of the patients and I had to try my best to offer
testing to every patient regardless of whether or not they fit a stereotype so as
not to make patients feel that they were targeted. Many patients feared being
tested because they were afraid to see the results and it was my responsibility to
explain the importance of early diagnosis and the support that’s available to
patients with HIV. Although I was a little uncomfortable talking to patients about
such a sensitive subject it was very rewarding to know that because of me
people could know their HIV status. This assignment reinforced in my mind the
importance performing less glamorous tasks in order to help others even if they
require me to leave my comfort zone.
My motivation to help with testing for HIV was also influenced by a woman
I met a couple of times in the Adult Emergency Services who suffered from AIDS
dementia. She was constantly talking in an incomprehensible manner and
begging to return home to her children and there seemed to be nothing I could do
to comfort her. One day a nurse asked me help restrain her while she changed
her diaper which was one of the more emotionally challenging things I was asked
to do. I knew that I was helping her, but holding her down while she was
screaming left me feeling guilty for causing her more anxiety. From her I learned
how terrible a feeling of helplessness can be for a doctor and how at times they
are forced to do difficult and emotionally draining things to treat their patients.
Although the challenges of Bellevue’s patient population often left me
frustrated, these challenges allowed me to learn a lot more than medical
information. I learned the importance of having equal compassion for all patients
regardless of their background and that it is not the responsibility of a physician
to judge his or her patients for their actions but rather to give them the best
medical care possible. My summer at Bellevue also reinforced my belief that the
ability of a patient to pay should not play a role in the quality of medical care that
they receive and that all people should be entitled to help if they are sick. I
discovered how powerful information is to patients, the importance of involving
patients in the decision making about their medical care and keeping them
informed of their treatment status to alleviate their anxiety and ensure they
understand that they are receiving the best care possible.
While working with an underserved patient population I couldn’t help
thinking about how the healthcare system could be improved so that quality care
is available to everyone. In the United States and many other countries, people
without health insurance cannot afford to see a primary care physician on a
regular basis which limits their access to preventative medicine and may delay
the diagnosis of health problems. These patients tend to wait until their health
problems are more severe before seeking treatment in an Emergency
Department due to fear of the cost of care. The lack of preventative medicine
usually leads to more illness which in turn leads to more medical bills and more
missed days of work, leaving many of the uninsured trapped in a cycle of
poverty. Bellevue Hospital is unique in providing high quality care to the
medically underserved; however many of Bellevue’s patients may have avoided
a trip to the Emergency Department had they been able to see a primary care
physician on a regular basis. Though I don’t know the solution to America’s
healthcare problems, I believe that the first step is to increase patient education
to promote preventative medicine and increase access to primary care, which
may improve health and lifestyle while ultimately decreasing medical expenses.
The most extreme case I saw of the detrimental effects of delayed care
was a homeless man who had somehow obtained minor wounds to his legs three
years ago. His injuries went untreated and were never cleaned which caused
maggots to start eating away at his legs. He finally came to the Bellevue
Emergency Department this summer, three years after the maggots had started
to devour his legs. His shins which had swelled to size of basketballs had been
eaten down to the bone and the maggots were developing into flies as he sat in
his stretcher. The doctors and nurses were forced to wear masks to combat the
smell of rotting flesh while they tried to pick the maggots out of his wounds and
attempted to treat them with chemicals, but eventually they were forced to
amputate his legs. Although this is an extreme case, had this man sought
medical attention earlier he may have escaped with a few minor scars rather than
face a life in a wheelchair.
My experience in a medical setting and interactions with patients
throughout the summer also helped me to better define my career aspirations
after graduation. While I know that all of the science classes I have taken at
Dartmouth will help me to find medical solutions for my future patients, I believe
that my hands on experience in the medical field will do more to make me a
better doctor. At Bellevue I learned a lot about how to interact with patients from
diverse backgrounds and that every patient deserves the same quality of care
and compassion regardless of their social situation. My experience has led me to
think more seriously about pursuing a medical career focused on the care of
those with limited access to healthcare and showed me how prevalent poverty
remains within the United States. I’ve also developed a stronger desire to explore
public health and ways of improving the healthcare system, especially as
demand for medical care increases with an aging population.
Project Healthcare solidified my desire to pursue a career as a doctor and
has motivated me to explore other areas outside of emergency medicine that
involve more continuous patient interaction. When I first started working in the
Emergency Department I was most excited to see the care of the major traumas,
but by the end of the program I enjoyed working in the Urgent Care Center
(which is similar to a walk-in clinic for minor problems) more because I was able
to spend more time talking to patients there and thought it was interesting to treat
even the most common ailments. I’ve come to value establishing a relationship
with a patient and believe that seeing a patient on a regular basis to prevent
problems rather than treat immediate problems would likely have a greater
influence on their health. I enjoy hearing about their background and can
appreciate how a patient’s medical history has been influenced by their family,
environment, and life decisions.
On my last shift in the Emergency Department I couldn’t believe how
quickly the summer had gone by and how much I had learned. I went from
feeling helpless and intimidated to ready to face whatever difficult task that I was
asked to perform. I could stand by and assist doctors in suturing wounds,
perform flawless electrocardiograms, and no longer bumped into walls when
maneuvering patients on stretchers to other floors. Though I learned a lot of
medical terminology and saw incredible medical situations from gunshot wounds
to open heart surgery, I think the biggest lesson that I took away from Bellevue
was how to talk with patients. Project Healthcare really taught me how to interact
with many different kinds of people and helped me to develop my compassion for
the medically underserved. I know that no matter where I end up practicing
medicine or what type of physician I become I will always think back on my
experience at Bellevue and all that this summer has taught me.