The emergency department waiting room was jammed, as it always is, with patients sitting for hours, closely packed on hard metal chairs. Only those with conditions so dire they needed immediate care — like a heart attack — got seen immediately.
One man had had enough. He pounded on the glass window in front of the receptionist before storming out. As he left, he assaulted a nurse taking a smoking break. “Hard at work?” he called, as he strode off.
No, the event was not real, but it was art resembling life on “The Pitt,” the Max series that will stream its season finale on Thursday. The show takes place in a fictional Pittsburgh hospital’s emergency room. But the underlying theme — appalling overcrowding — is universal in this country. And it is not easy to fix.
“EDs are gridlocked and overwhelmed,” the American College of Emergency Physicians reported in 2023, referring to emergency departments.
“The system is at the breaking point,” said Dr. Benjamin S. Abella, chair of the department of emergency medicine at Mount Sinai’s Icahn School of Medicine in New York.
“The Pitt” follows emergency room doctors, nurses, medical students, janitors and staff hour by hour over a single day as they deal with all manner of medical issues, ranging from a child who drowned helping her little sister get out of a swimming pool to a patient with a spider in her ear. There were heart attacks and strokes, overdoses, a patient with severe burns, an influencer poisoned by heavy metals in a skin cream.
Because this is television, many of the thorny problems get neatly resolved in the show’s 15 episodes. A woman who seems to have abandoned her elderly mother returns, apologizing because she fell asleep. Parents whose son died from an accidental fentanyl overdose come around to donating his organs. A pregnant teenager and her mother, at odds over a medical abortion, come to a resolution following a wise doctor’s counsel.
But over and over again, the image is of a system working way beyond its capacity. There is the jammed waiting room and the “boarders” — patients parked in emergency rooms or hallways for days or longer because there are no hospital beds. (The American College of Emergency Physicians calls boarding a “national public health crisis.”)
There are the long waits for simple tests. There is the hallway medicine — patients who see a doctor in the hallway, not in a private area, because there is no place else to put them.
And there is the violence, verbal and physical, from patients with mental problems and those, like the man who punched the nurse, who just get fed up.
“‘The Pitt’ shows the duress the system is under,” Dr. Abella said. “Across the country we see this day in and day out.”
But why can’t this problem be fixed?
Because there’s no simple solution, said Dr. Ezekiel J. Emanuel, co-director of the Health Transformation Institute at the University of Pennsylvania’s Perelman School of Medicine. The problem, he said is “multipronged and there is no magic wand.”
Part of it is money.
Having patients jammed up in emergency rooms guarantees that no bed will go unused, bolstering revenues for hospitals.
Then there’s the problem of discharging patients. Spaces are scarce in nursing homes and rehabilitation centers, so patients ready to leave the hospital often are stuck waiting for a space to open up elsewhere.
Schedules are another difficulty, said Dr. Jeremy S. Faust, attending physician in the Brigham and Women’s Hospital Department of Emergency Medicine. Many rehabilitation centers admit patients only during business hours, he said. If an E.R. patient is ready to be discharged to one during a weekend, that patient has to wait.
In “The Pitt,” as in real life, patients often show up in emergency rooms with problems — like a child with an earache — that a private doctor should be able to handle. Why don’t they just go to their own doctor instead of waiting hours to be seen?
One reason, Dr. Emanuel said, is that “primary care is going to hell in a handbasket.”
In many cities finding a primary care doctor is difficult. And even if you have one, getting an appointment can take days or weeks.
Many do not want to wait.
“The modern mentality, for better or worse, is: If I can’t get it now, I will look for other solutions,” Dr. Abella said.
That often means the emergency room.
Even building larger emergency rooms has not helped with the overcrowding.
Dr. Faust said that his hospital opened a new emergency room a few years ago with a large increase in the number of beds. A colleague, giving him a tour, proudly told him there was now so much space there would probably be no more hallway patients.
“I looked at him and said, ‘Bwhahahahaha,’” Dr. Faust said. “If you build it, they will come.”
He was right.