9:05 p.m. As some patients start the triage screening process or begin medical treatment by disappearing through double security doors, an elderly patient in a wheelchair emerges from behind them. The patient asks a nurse when a doctor will be available; the reply is that there are several doctors on duty, and they're just waiting for one.
9:25 p.m. In a loud voice, the patient in the wheelchair shouts: "I want to know when I can go home!"
"I don't know," says the nurse.
"I'm not sick," shoots back the patient. "Who is my doctor?"
"I have no way of knowing," the exasperated nurse responds.
10 p.m. There are still about 25 people in the waiting room, including the patient in the wheelchair, but about half the faces have arrived since 8:30 p.m.
Emergency-room horror stories of long waits, misdiagnoses and impersonal staff are tattooed on our memories. But even emergency rooms produce satisfied customers.
Like every hospital ER in town, Tucson Medical Center has its supporters, one of whom wrote in a note last year: "I dreaded having to use an emergency room service, but was quite surprised at the experience I received at TMC. Everyone was professional, kind, courteous. I would use TMC again without hesitation."
St. Mary's Hospital received a letter of appreciation recently which said: "Please know that I feel the people in the area of the emergency room are not only very professional, but so caring and wonderful. They were so conscientious of my pain and feelings (even when we had to 'wait'), and they kept a constant watch in checking on me!"
At University Medical Center, a patient commented in a handwritten letter: "Thanks to all who attended to me after my motorcycle crash. I was very impressed with your professionalism and kindness."
Others' experiences, however, can be less praise-worthy. My friend Jerry Juliani went to the UMC emergency-room in 2000. Suffering from a cyst hemorrhage in his kidney, Juliani was in excruciating pain when he and his wife, Carol, rushed to the ER late one night. As he filled out the required paperwork, Juliani vomited all over the reception desk; he believes that got him immediate attention.
Even though he was screaming in pain, the ER staff at first wanted to send Juliani home. But his wife insisted he stay and used her hospital connections to ensure he did. She also had to battle to get him the proper medication.
"Vomiting and bleeding puts you at the head of the (ER) line," Juliani now observes, while gratefully adding about UMC: "They saved my life."
Nine years ago, a more disturbing event took place at TMC. The ER controversy involved then-state Sen. George Cunningham, who spent seven painful hours waiting to be treated for acute diverticulitis, an intestinal infection.
"I had a horrible experience," Cunningham told the Arizona Daily Star. "I think I was misdiagnosed, and I don't think I was treated well ... ."
As a result of that and other issues, TMC took a hard look at its emergency room procedures; that self-analysis continues today. The hospital last year completed a lengthy review of its ER services based on substantial data and a detailed analysis of the emergency room process.
10:20 p.m. A woman wrapped in a colorful beach towel, trying to keep warm, attempts to sleep in St. Mary's ER waiting room. Around her, a few small groups of people wearing visitor badges congregate; one older patient on oxygen sits in a wheelchair.
10:30 p.m. A man in his 30s wheels a silently sobbing companion up to the registration desk, near which hangs a crucifix. They are immediately escorted behind the double security doors.
11:05 p.m. Three seniors arrive looking for a friend from Green Valley.
11:25 p.m. A pizza is delivered to someone behind the double doors.
11:30 p.m. A patient holding an ice pack on a glistening shiner enters the room; meanwhile, a large family is told it will be two more hours until test results are back for the patient they are waiting for. Hearing that, three of the women head across the street to a 7-Eleven to buy coffee.
11:35 p.m. The elderly patient on oxygen is lying down on a bench in the entryway outside the ER as a nurse finally calls the woman wearing the towel in to be seen.
Almost a decade after Cunningham's nightmare experience, TMC's average waiting time to see an ER doctor is about an hour, the same as it was in 1998. As a hospital spokesman points out, the statistic may be that low because TMC includes children in its calculations.
In a rapidly growing community like Tucson, wait times of an hour are a genuine success, and TMC officials are proud of their ER accomplishments.
"We work really, really hard," says RoseAnn Garcia, director of emergency services at TMC. "We hope people come here because of shorter waits and better service."
TMC is also Tucson's busiest emergency room, and the wait times for other hospitals vary widely, ranging as high as more than four hours at UMC. (See chart.)
Even the much-longer waits to see a doctor at UMC, St. Mary's and Kino are shorter than the average time for all Arizona hospitals. In a survey done two years ago, ER patients in the state reported their typical wait was almost five hours, by far the longest in the nation.
A report prepared earlier this year by the Arizona Hospital and Healthcare Association (AHHA) listed 11 causes for the long wait times, including the fact that many patients use the ER as their source of primary medical care.
"People in our (health-care) climate today are less tolerant to wait two or three days to see a primary-care doctor," says Eileen Whalen, vice president for trauma, emergency and perioperative services at UMC. "Instead, it's easier to go to the ER."
The frequent use of the ER as a fast-track alternative to seeing a primary-care physician is highlighted by a report prepared on Maricopa County hospitals by Arizona State University. The report found "that nearly half of (emergency department) patients seen from July 2004 to June 2005 were there for nonemergent health issues such as headaches, backaches or colds."
To address the primary care versus ER issue, St. Mary's is now conducting a pilot project to encourage uninsured people to use two clinics in town for primary-care services instead of the emergency room. They are also working closely with 15 urgent-care centers around the community to do the same thing.
"As a (hospital) system, we're encouraging individuals to find a medical home," says Letty Ramirez, the hospital's chief marketing and planning officer, "and to use primary care appropriately."
The AHHA report also lists a severe shortage of physicians and nurses as a problem. The association's director of regulatory affairs and policy, Debbie Johnston, believes this is the major issue "by far." Others point to the high job stress and frequent burnout as significant contributing factors to this shortfall.
Johnston adds that the state Legislature is addressing the staffing shortage through additional funding for Arizona's universities and community colleges. When it comes to physicians, she says: "Sixty percent of those who go through residency here, stay here. So we can grow our own talent."
A Phoenix registered nurse offered a different perspective last year in a letter to The Arizona Republic, blaming the troubled emergency room situation on the provisions of the national Emergency Medical Treatment and Active Labor Act, enacted in 1986.
While he understands that frustration, Paul Kappelman, CEO of Northwest Medical Center's Oro Valley hospital, thinks the law is worthwhile. "The overall spirit of the legislation is a good-faith effort, about what this country stands for."
UMC spokeswoman Geraldine O'Neill elaborates: "That law entitles people to a medical screening. It was intended to prevent patient-dumping by hospitals. So people with small problems make all ER screenings longer, but they will wait the longest and fill the seats up."
This law affects every ER in the country, but Arizona has its own special emergency room circumstances. Hospitals here have a hard time, both with staffing and physically keeping up with skyrocketing ER demand, thanks to the state's nation-leading growth.
Another potential problem is the state's medical negligence laws. Some doctors avoid the ER, claiming that the laws don't protect them enough from litigious patients. Despite that, the Arizona House of Representatives recently turned down a bill to revise the standard for emergency department negligence, a proposal supporters hoped would bring more doctors back to practice emergency medicine.
Information supplied by a sample of local hospitals indicates the major problems that bring people to the ER are abdominal pain, respiratory distress and flu-like symptoms.
Most patients get themselves to the hospital, or get help from friends and loved ones, with only a small percentage of patients being transported by ambulance. After arriving and registering, a triage nurse quickly assesses the patient's medical condition. This is done using a five-point scale, with one meaning extremely serious, and levels four and five being better handled at an urgent-care facility.
After this initial screening, the patient will usually wait in a reception area before being shown to an ER room. Once there, another wait will ensue until a doctor is available and a course of treatment determined. For these patients, it is mostly tedious boredom, not TV drama, which they encounter while waiting.
Statistics supplied to the state in 2005 from 16 Southern Arizona hospitals, a majority of which are in Tucson, show that almost 40 percent of ER patients are less than 25 years old, and 55 percent are female. The data indicate that Mondays are the busiest day; 95 percent of patients go home after being seen; more than 60 percent of them have bills of $1,000 or less, while another 22 percent are charged between $1,000 and $2,000.
The vast majority of these patients have medical insurance. Even given that high figure, Whalen from UMC believes the uninsured can cause ER delays.
"Private medical offices don't have to take them," she says, "so they sit in an ER, because they're underinsured or have no insurance."
12:30 a.m. Two blaring television sets dominate the large, Santa Fe-style waiting area of the Northwest Medical Center's emergency room on La Cholla Boulevard. One of the TVs is showing Crocodile Hunter with the late Steve Irwin; meanwhile, a small area with children's games sits empty. An older man in an ASU shirt strikes up a conversation with a younger guy about the perils of marriage, proudly proclaiming he's twice divorced. With that, the younger man asks: "Know why divorces are so expensive? Because they're worth it!"
12:50 a.m. A woman leads a patient whose eyes are covered with a towel into the reception area. They quickly disappear into the ER.
1 a.m. A man in his 20s lies across three chairs trying to get some sleep. "If I start snoring, wake me up," he says to a stranger. But before he has a chance for slumber, his cell phone rings, and he instantly reports--"The patient's still back there, and probably will be for a while."
1:30 a.m. A different young man is the lone occupant of the waiting room, while a group of four stands outside in the cool morning air.
This fall, St. Mary's will introduce an electronic patient-care tracker system.
"It will give us real-time information," proclaims Dianne Foster, emergency department director for the hospital.
Foster adds that the system will help determine if the medical goals for the patient are being met in a timely fashion, as well as follow the person's "throughput" in the hospital. That could result in either discharge or hospital admission (the destination of 27 percent of St. Mary's ER patients).
Foster says her goal is to have 75 percent of St. Mary's ER patients into a bed within 45 minutes and to be seen by a doctor no more than 30 minutes after that, although she says she doesn't believe an ER's average wait time to see a doctor is a meaningful statistic because of all the variables involved.
Those objectives may have already been met at TMC, but that hospital's officials admit that patients can sometimes be delayed up to eight hours for emergency room service. Some patients, they say, even walk out of the ER before receiving medical attention.
"Walking out used to be common," Garcia says, "but now we talk to patients (about what's going on), and it has dropped dramatically." A paid patient representative often handles that responsibility at TMC, she adds.
But if people do leave without being seen, Garcia says, the hospital makes a follow-up phone call, a practice other hospitals use as well, or sends a registered letter asking for input. They also mail a questionnaire to a sample of ER patients requesting feedback.
The emergency room at TMC has 52 rooms, with another 15 specifically designated for children younger than 18, in a unit which opened in 2002. It additionally has a separate waiting room for patients who because of their medical condition shouldn't be sitting in the lobby.
Last year, the hospital also established a 10-room ER annex to handle an overflow patient load of less-serious cases. This building is in use up to four times a week.
2 a.m. Three Spanish-speaking people, one holding an 18-month-old child with a fever, are the only ones in the plainly decorated waiting area of Kino Hospital's emergency room, a space dominated by the reception desk secured behind six large windows.
2:10 a.m. A young couple enters. Grimacing in pain, one of them has a crude bandage around a finger. After registering them, a triage nurse quickly interviews them behind the windows and professionally wraps the finger.
2:40 a.m. The adult with the child tells the couple they have been waiting for 90 minutes. "That's crazy," the person with the bandaged hand declares. "I'd better go home, but I slammed my finger in a door and need some stitches."
2:50 a.m. Both the people with the child and the patient with the cut finger disappear behind the double doors into the ER. That leaves only one waiting person, who eats some left-behind food, then cleans up the mess before being called.
3:15 a.m. The waiting room is empty.
To achieve its short waiting times despite a large patient load, TMC has done several things besides opening the ER annex. About six years ago, it combined its urgent-care functions with its emergency department to allow for a single triage process.
"It makes it easier to provide an appropriate level of care," Garcia says, although the system may end up costing some patients more in copays.
In Oro Valley, Kappelman indicates his hospital hopes to keep its short waiting times, even as the area increases in population. "We've got to grow our staff at the same rate (as population growth)," he says, "and keep ahead of the curve."
To do that in a difficult labor market, the hospital's CEO says: "It's all about the work environment and giving the staff the tools they need to do their job." For the Oro Valley ER and hospital, Kappelman talks about focusing on the "throughput" of patients.
"It's engineering in many ways," he says.
More in the center of town, St. Mary's, for the fifth time, recently participated in an annual campaign to medically insure children. As a result, hundreds of local youngsters will be enrolled in the state's health insurance program, KidsCare. In addition, two years ago, the hospital technologically improved and physically expanded its ER, which now provides a separate waiting area for children.
University Medical Center is about to embark on a similar course of action--in a big way. The hospital currently has 18,000 square feet in its emergency department, including the adjacent urgent-care facility. By the fall of 2009, the hospital plans on completing a new emergency facility which will almost triple the number of square feet.
Whalen says UMC has made other changes to improve its ER.
"We're adding more staff in triage," she says, "because we know people are waiting. But we reassess them every two hours to insure they're stable."
Whalen says UMC is also trying to speed up the time it takes to get lab results to a doctor. She adds they are also addressing the issue of a lack of hospital beds, which sometimes results in ER beds being occupied by hospital patients, thus delaying admission to the emergency room.
This flow of patients from ER to hospitalization can be a particular problem for facilities such as St Mary's and UMC, because a majority of their hospitalized patients actually start out in the emergency room.
"We'd like to see everybody on a timely basis," Whalen says. Until that can happen, the hospital has patient greeters to explain what is happening.
"When people know what is going on," she says, "they are more reasonable about waiting, so we try to tell them."
4:05 a.m. A quarter moon brightens the morning sky above University Medical Center's empty waiting room. Tucked in the bowels of the massive concrete edifice, outside the ER entrance, six wheelchairs with oxygen tanks attached sit ready for service. Inside, a sign on the wall states: "We apologize for your wait ... ." Nearby, three vending machines are available, along with copies of Bear Essential News and the Tucson Weekly.
4:20 a.m. A person with their arm in a sling enters and is soon shown into the ER.
4:35 a.m. Two people, one on crutches, depart.
4:40 a.m. A nurse exits the ER and yells into the darkness: "I'm looking for Susan." Nobody responds.
Birds start loudly chirping outside the V-shaped waiting room as a few more people enter and leave.
The waiting room is empty again as a middle-age, black-leather-jacket-wearing biker emerges from the ER and asks what the smoking rules are near the entrance.
The sun peeks out above the surrounding cityscape as another day dawns.