Crash Cart: Boarding in overcrowded hospitals, transgender patients, and police related injuries


This week: Boarding is “as bad as ever” in the ED, #transhealthfail is an unfortunate ER reality, and police-related injury stats. Join in as our editors discuss the week’s headlines.


In addition to giving a short history on demands on ERs have grown in America, Yale professor, Howard Forman, says that is time ERs stop boarding patients

90% of ERs report frequent overcrowding and boarding results in poorer patient outcomes, but several solutions are possible, he argues. Original Article by The Wall Street Journal.

Jaime Hope, MD: Boarding is a big problem for docs, hospitals, and especially patients! These boarded patients are sometimes getting their home meds and routine non-stat tests while lingering in hallways waiting for a room but it is hard to argue that they are getting good care. We EM docs help ‘put out fires’ on any sick patients but after admission, most orders are deferred to the inpatient docs as if the patient were upstairs. They are the ‘invisible’ patients – ‘out of sight and out of mind’ in the ED and inpatient units.  And I’ve never seen a boarding patient get things like PT or OT to help improve any impairment. I certainly wouldn’t want to be parked in a hallway like some piece of equipment waiting for a spare place to store it! The solution is complex and involves many different changes and I agree with the article – if other industries had problems like this, they would be working hard on solutions!

Nicholas Genes, MD, PhD: To me there’s no worse administrative failure than widespread, prolonged ED boarding. It especially pains me because the patients expect me, the doctor, to get them out of limbo, to put them close to the team that’s caring for them, to move things along. But I can’t. For years, for decades, EPs have been sounding the alarm, and performing research that demonstrates that boarding patients get worse care, and ED patients have worse outcomes as a result of the crowding. We’ve been proposing solutions. Yet over the years, hospital administrators and The Joint Commission pursue dozens of other (usually much less important) measures of quality. Maybe the fact that this article appeared in the WSJ, and was written by a radiologist (!), means that we’ve reached a tipping point. I’m not going to hold my breath, though.

Seth Trueger, MD, MPH: I agree with Nick- it’s great that we’re (maybe?) reaching a tipping point about awareness that crowded EDs are not an ED problem – they are a symptom of a system-wide problem which hospitals are good at turning into an ED problem. Ultimately I don’t think it will be fixed into we address bigger issues – particularly overpayment for procedures, and our inability to address long term & post acute care – and hospitals continue to flex their muscle to keep upstairs problems downstairs.


Transgender patients are less likely to have health insurance and four times more likely to live in poverty, which makes ER care a vital safety net for them

Yet medical schools are failing to address their needs, with one study showing half had to teach their docs about transgender health issues. Alarming statistics as well as places making progress are offered. Original Article by The New York Times.

Jaime Hope, MD: Yes!! After co-authoring an article on this issue for EPM, I have continued to educate myself on the unique needs of transgender patients. As a result of this, I’ve been asked to do grand rounds for primary care as well as EM docs on this very topic. These patients are often hidden and marginalized; they have the ‘delay fear dismay’ triad and often wait unnecessarily long to seek medical care because of prior negative experiences and overt harassment in the medical system. WE are experts in taking care of all who come through our doors, it’s time to improve our education about these patients!

Nicholas Genes, MD, PhD: Yes! Jaime Hope just gave Grand Rounds at our institution on this topic – it was a great start. Unfortunately on Twitter and other platforms I still find physicians with abhorrent attitudes towards transgendered patients; even extending the simple courtesy of addressing a transgendered patient by their preferred name was compared to accomodating a schizophrenic’s delusions. We have a long way to go.


With near constant reports of crime, violence, and police brutality on TV, the stats on police-related injuries in the ER may surprise you

Among the findings: More than 80 percent were male, the average age of the injured person was 32, and 20 percent of cases involve mental illness. Also interesting: the South and the West each accounted for about one-third of all visits, while the Northeast and Midwest accounted for the remaining third. Original Article by Live Science.

Jaime Hope, MD: Law Enforcement Officers have a dangerous job. They are sometimes in high-threat high-adrenaline situations in which they are pursuing or detaining a person deemed to be a threat to themselves or others. Some have well-honed skills and keep cool and rational in extreme situations, using only the minimum amount of force necessary to protect themselves and others. These officers do not make the news, they are the everyday heroes who keep us safe and are essential for the survival of a law-abiding and civilized society. The newsmakers are the ones who go to far, get caught up in the sympathetic surge, and use unnecessary or even deadly force. The book Blink by Malcolm Gladwell gives an intense account of officers shooting a completely unarmed man, I recommend the audiobook version for maximum impact. The officers in this situation were primed by biases, adrenaline, and confirmation bias from each other. In EM, we understand intense, life-and-death fast decisions that need to be made. We have training, SIM, practice, supervision, and mentor ship. Focusing on these things for officers in training and even experienced officers can help give them the tools they need to protect society from bad guys and from good guys gone bad.

Nicholas Genes, MD, PhD: I think in New York, perhaps in contrast to other parts of the US, the police have a tendency to take complaints seriously and, as a consequence, we have a significant number of patients who are brought to the ED for truly minor injuries. Another variant is the patient who develops chest pain during their arrest. Finally, there are so many people brought in because they’re high on drugs in public. Just like I hate being second-guessed by a consultant over the phone, I give police the benefit of the doubt; if at some point their perp  looked like he or she needed an ED, I’ll respect that and launch an appropriate workup. I haven’t noticed an uptick of police-related injuries over the years, even as we’re seeing more illicit drugs and associated belligerence.



  1. Derrick Lowery on

    I am so happy to see health issues for transgender patients addressed! One side note, language is very important, and the term used by Dr. Genes (“transgendered”) is just as offensive to many as the term “colored” is. The word I think he was looking for was “transgender.”

  2. I think that the police are doing a great job in pursuing and detaining a person but it should be done in way that the person will not be seriously injured. It’s better to change their methods so that the person will not end up in ERs.

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