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When most people think of emergency medicine, they picture trauma and STEMI and stroke and sepsis. The time-sensitive stuff. But the reality for today’s emergency physicians is far more complex.

Most of what we do is not acute or primary care. It’s frailty care, complexity care, and chronic exacerbation care. It’s social-behavioral issues, healthcare system failures, and risk stratification. This is what fills our beds and waiting rooms — and how eight of my 10 hour shifts are spent.

Textbook emergencies like “right lower quadrant pain in a 23-year-old” or “epigastric pain after a fatty meal” are increasingly rare. These straightforward cases are almost a luxury — what I call “Emergency Medicine Easy Mode.” Instead, every shift presents a new challenge of managing complex, chronically ill, and frail patients, often with an unpredictable combination of resources.

Every Day is a New Crisis

It’s easy for outsiders to say, “Just hire more doctors or nurses.” But in reality, every day brings a different shortage. Sometimes it’s a staffing issue, but often it’s a lack of beds, broken equipment, unavailable medications, or even system failures. This unpredictable landscape makes delivering care exhausting and frustrating.

Here’s a recent shift shared by a colleague in Chicago (details changed for privacy):

A 97-year-old patient with dementia had syncope and a ground-level fall. She weighs 82 pounds. She’s profoundly hard of hearing, doesn’t speak English, and is on Pradaxa. When she fell, she shattered both of her hearing aids, everything hurts, and she’s screaming in pain and vomiting in a c-collar.

Even after I pick the broken bits of plastic out of her ears, the Polish translator can't get loud enough for her to hear us. Because of her age, of course everything needs imaging. And even after we've imaged everything (that’s three CT scans and four plain films) and found only a broken clavicle, now of course we need a safe disposition, and her family isn't answering the phone. And it's a three-day weekend.

Next is a 68-year-old liver transplant who's supposed to be getting an outpatient endoscopy but he has a fever so they cancel the case and send him to the ER. He has indwelling hardware, was just in the hospital for two months, has numerous allergies, is immunosuppressed, has indwelling ports, and his last discharge summary is five pages long. I have about seven minutes to try to figure all of this out because …

Critical stroke alert patient (I'm being timed!) who may or may not have chest pain along with headache and a history of Todd's paralysis. They have lung cancer but no known brain mets. Oh and by the way, the nurse checks their temperature and they also have a fever. Their stroke symptoms either started when they woke up or three days ago. By the way #2: They had an outpatient sodium yesterday which was 118 that no one knew about until she was sent over to CT.

The Burden of Complex Patients

Emergency physicians (and our hospitalist counterparts) are overwhelmed by the sheer volume and complexity of cases. These patients take an enormous amount of time to assess, with layers of medical history, co-morbidities, and frailty to navigate. And as hospitals try to discharge them as fast as possible (to make more beds for the never-ending queue of these patients knocking at the ER’s doors), they bounce back just as quickly, too.

With each readmission and re-hospitalization, someone finds a new problem — maybe it’s a PE so now they’re on a blood thinner, or an incidental nodule now needs a biopsy — each time adding new complications and opportunities to oversaturate to an already overloaded differential and problem list.

Triage demands that high-risk patients be prioritized, which means the straightforward “rule out appendicitis” cases linger in waiting rooms. The result? These “easy” cases deteriorate and grow frustrated while we grapple with increasingly fragile, complex patients.

It’s easy to understand why some patients — and even other physicians— question the long wait times. “What’s taking so long? It’s just a laceration!” Unfortunately, the growing complexity of the patient population means that what once were quick, straightforward cases are now competing with a mountain of chronic medical issues, frailty, and unpredictability.

Join the Discussion

To my fellow physicians: I want to hear from you. Does the reality that I described resonate with you? If so, what do you think we do to improve our emergency departments to better serve the complex cases that come in? Also, what would you like to see change institutionally or systemically for this to happen? Let’s brainstorm solutions! Let me know in the comments and I’ll jump in and respond with my thoughts.

Graham Walker is the co-founder of Offcall and an emergency medicine physician in San Francisco, California.