Wait Times

Slipping through the cracks in the emergency room

Early on a Wednesday morning, I heard an anguished cry—then silence.

I rushed into the bedroom and watched my wife, Rachel, stumble from the bathroom, doubled over, hugging herself in pain.

“Something’s wrong,” she gasped.

Timestamp: September 18, 2013. About 8 AM.

This scared me. Rachel’s not the type to sound the alarm over every pinch or twinge. She cut her finger badly once, when we lived in Iowa City, and joked all the way to Mercy Iowa City as the rag wrapped around the wound reddened with her blood. She runs marathons, loves the grueling challenge of it—and once, hobbled by a training injury in the days before the race, she limped across the finish line anyway.

So when I saw Rachel collapse on our bed, her hands grasping and ungrasping like an infant’s, her eyes screwed shut with pain, I knew it was bad. I called the ambulance. I gave the dispatcher our address then helped my wife to the bathroom to vomit.

Average ambulance response time for Brooklyn, New York, in September 2013: six minutes, twenty-nine seconds.

I cradled her body on the floor. “Oh, they’re going to take so long,” she whispered, her voice hushed with grief. “It’s going to take so long.”

We knew this was likely: once, in Fort Greene Park, Rachel and I watched a young girl fly over her bicycle handlebars and land on her skull. She lay on the ground in a terrible splay of limbs, still as the dead. We called 911 three times, but it was twenty minutes before we saw red and blue lights start to flicker though the trees.

I don’t know how long it took for the ambulance to reach us that Wednesday morning. Pain and panic have a way of distorting time, ballooning it, then compressing it again. But when we heard the mournful sirens wailing somewhere far away, we knew they were coming for us. My whole body flooded with relief.

I didn’t know our wait was just beginning.

I buzzed the EMTs into our apartment. They wore bright reflective vests and carried medical gear. We knew the answers to their questions. When did the pain start? That morning. Where was it on a scale of one to ten, ten being worst?

“Eleven,” Rachel croaked.

We knew the rough date of her last period, her medical history (nothing major). No, she’d never had a kidney stone.

We also knew we didn’t want to be taken to the hospital closest to our house, which was notorious for poor care and long wait times. A friend once fell off the top of a Bushwick brownstone roof and waited hours at that hospital with a shattered foot.

As we loaded into the ambulance, here’s what we didn’t know: Rachel had an ovarian cyst, a fairly common thing. But it had grown, undetected, until it was so large it finally weighed her ovary down, twisting the fallopian tube like you’d wring out a sponge. This is called ovarian torsion, and it creates the kind of organ-failure pain few people experience and live to tell about.

“Ovarian torsion represents a true surgical emergency,” says an article in the medical journal Case Reports in Emergency Medicine. “High clinical suspicion is important. . . . Ramifications include ovarian loss, intra-abdominal infection, sepsis, and even death.”

Approximate interval, from pain onset to surgery, for best chance of salvaging a patient’s torsed ovary: eight hours or less.

“I’m not going to make it. I’m not going to make it,” Rachel whispered hoarsely as we held each other in the back of the ambulance. “It’s going to take so long, so long.”

I whispered back, promising we were almost there. She squeezed my hand so tight it hurt, my wedding ring cutting into my finger—and I almost didn’t mind, as if that twinge put me somewhere within the outer reaches of her pain. After what seemed like ages, I risked my first glance out the ambulance window to see how close we were. I didn’t have the heart to tell her that a maze of one-way streets had funneled us in a long and pointless square, and we had only just passed our own street corner on the passage north, up Bedford Avenue towards DeKalb.

Another funny thing pain does with time: when the hurt feels like an epic voyage, you find out you’ve only just left home.

Estimated distance from narrator’s residence to Brooklyn Hospital Center, by car, without traffic: 2.07 miles. About ten minutes.

There is nothing like witnessing a loved one in deadly agony. Your muscles swell with the blood they need to fight or run. I felt like I could bend iron, tear nylon, as we entered the windowless basement hallways of the hospital.

And there we stopped. The intake line was long—a row of cots stretched down the darkened hall. Someone wheeled a gurney out for Rachel. Shaking, she got herself between the sheets, lay down, and officially became a patient.

Emergency room patients are supposed to be immediately assessed and treated according to the urgency of their condition. Most hospitals use the Emergency Severity Index (ESI), a five-level system that categorizes patients on a scale from “resuscitate” to “non-urgent.”

Recommended treatment intervals, by triage level, according to the ESI:

Immediate: immediately.

Emergent: one to fifteen minutes

Urgent: fifteen to sixty minutes.

Semi-urgent: one to two hours.

Non-urgent: two to twenty-four hours.

I knew which end of the spectrum we were on. Rachel was nearly crucified with pain, her hands gripping the metal rails blanched-knuckle tight. “Please,” she whispered. “Please, please, please,” as if to ask the walls, the halls, for mercy.

Her state, I thought, would surely grab someone’s attention. I flagged down the first nurse I could.

“My wife,” I said. “I’ve never seen her like this. Something’s wrong; you have to see her.” My eyes stung again as I heard my own scared voice, and the nurse’s face blurred through my tears.

“She’ll have to wait her turn,” she said, and turned from me and left.

I begged anyone who’d listen. Their reactions ranged from dismissive to condescending. “You’re just feeling a little pain, honey,” one of them told Rachel, all but patting her head.

We didn’t know her ovary was swelling, dying, calling out unseen in the starkest language the body has. I saw only the way Rachel’s whole face twisted with pain, as if she was trying hard to remember a melody she heard long ago and the world might come together again if only she could.

I asked her if we should leave, take a taxi somewhere else, but we both agreed it would be crazy to leave for an unknown situation somewhere else when we were there, inside the hospital, just feet from the entrance to the ER. Once we’d traveled that tiny distance, help would surely come.

And yet, I started to realize—in a kind of panic—there was no system of triage in effect. The other patients in the line slept peacefully, or stared up at the ceiling, bored, or chatted with their loved ones. Arrival order, not symptom severity, would determine when we’d be seen. No one was watching. 

As we neared the ward’s open door, a nurse came to take Rachel’s blood pressure. By then, Rachel was writhing so uncontrollably that the nurse couldn’t get her reading.

Approximate amount of time needed to take a patient’s blood pressure: forty-five seconds.

She sighed and put down her squeezebox. “You’ll have to sit still, or we’ll just have to start over,” she said.

A ragged voice, which I had never heard and hope never to hear again, burst out from some deep place in Rachel: “I can’t fucking help it.”

Finally, we pulled her bed inside. They strapped a plastic bracelet, like half a handcuff, around Rachel’s wrist. It contained her name, her intake ID, and her social security number. But let’s say it just read Patient X.

• • •

From an early age, we’re taught to observe basic social codes. Be polite. Ask nicely. Wait your turn. But during an emergency, established codes evaporate—this is why ambulances can run red lights and drive on the wrong side of the road. I found myself pleading for that kind of special treatment. The overworked nurses heard me begging, their faces, unmoved, like objects carved from wood. Rachel’s suffering was invisible to them. I kept having the strange impulse to take out my phone and call 911, as if that might transport us back to an urgent, responsive world where emergencies exist.

Average time, in 2013, a Brooklyn Hospital Center patient spent in the emergency room before being seen by a doctor: one hour, forty-nine minutes.

National average during the same time period: twenty-eight minutes.

Everyone we encountered worked to assure me this was not an emergency, and I had no choice but to trust them. “Stones,” one of the nurses had pronounced, shaking her head sadly as she watched Rachel gasp and writhe. That made sense. I could believe that. I knew that those calcium jags, pushing through the tiny renal tubes, caused agony but never death. She’d be fine, I convinced myself, if I could only get her something for the pain.

By 10 AM, Rachel’s cot had moved into the “red zone” of the ER, a square room with maybe thirty beds pushed up against three walls. She’d curled up into herself so tight I could barely believe the tiny lump she made under her sheets. She hardly noticed when the attending physician came and visited her bed; I almost missed him, too. He didn’t introduce himself. He never touched her body. He just asked a few quick questions and left. His visit was so brief and insignificant it didn’t register that he was the person overseeing Rachel’s care.

Approximate amount of time Doctor Y spent with Patient X: two minutes.

Then—just like that—someone came with an inverted vial and began to strap a tourniquet around Rachel’s trembling arm. We didn’t know it, but the doctor had prescribed the standard treatment for patients with kidney stones: hydromorphone (Dilaudid) for the pain, followed by a CT scan.

Timestamp: Wednesday, September 18th, 2013. Around ten forty-five.

Soon an IV rolled up beside her, its hanging sac dripping magic fluid. The pain medicine started seeping in. Rachel fell into a kind of shadow consciousness, awake but silent, her mouth frozen in an awful, anguished scowl. But for the first time that morning, her features softened, and she rested. For the first time that morning, I felt like I could catch my breath.

• • •

Leslie Jamison’s essay “Grand Unified Theory of Female Pain” examines ways that different forms of female suffering are minimized, mocked, coaxed into silence. In an interview included with her nonfiction collection, The Empathy Exams, she discussed the piece, saying, “Months after I wrote that essay, one of my best friends had an experience where she was in a serious amount of pain that wasn’t taken seriously at the ER.”

She was talking about Rachel. 

“That to me felt like this deeply personal and deeply upsetting embodiment of what was at stake. Not just on the side of the medical establishment—where female pain might be perceived as constructed or exaggerated—but on the side of the woman herself: my friend has been reckoning in a sustained way about her own fears about coming across as melodramatic.”

Amount of time Patient X will reckon “in a sustained way”: Undetermined.

“Female pain might be perceived as constructed or exaggerated”: we saw this from the moment we entered the hospital, as nurses—predominately female nurses—downplayed Rachel’s pain, ridiculed it, criticized it, even plain ignored it. In her essay, Jamison refers back to “The Girl Who Cried Pain,” a study that identifies ways in which gender bias tends to play out in clinical pain management. Women are, in fact, “more likely to be treated less aggressively in their initial encounters with the healthcare system until they ‘prove that they are as sick as male patients,’” the study concludes—a phenomenon referred to in the medical community as “Yentl Syndrome.”

I assume it’s common for nurses to become numbed to the sight of pain in others, due to the nature of their difficult jobs, their constant proximity to suffering. But what we experienced went beyond mere jadedness.

A lab tech made small talk, asking me how I liked living in Brooklyn, while my wife struggled to hold still enough for the CT scan to take a clear shot of her abdomen. Nurses chided her continually.

“Lot of patients to get to, honey,” we heard, again and again, when we begged for help.

“Don’t cry,” another said.

Once, when lifting Rachel’s arm to take her blood pressure, a nurse laughed, bitterly, when she saw the way Rachel’s engagement ring sparkled in the light. “Nice ring,” she said.

They went out of their way to make her wait for medication—one nurse insisted she had to wait for another patient’s stool sample before she could help us. Frequently, our increasingly agitated requests for attention were responded to as though we’d said something impolite, spoiled, or pushy.

We were among the only white people in a crowded basement hospital in a gentrifying, complicated city. I’m not sure whether race or social class came into play, or what it would mean if they did. But I feel certain of this: Rachel was easier to ignore because she is a woman. The diagnosis of kidney stones—repeated by the nurses and confirmed by the attending physician’s prescribed course of treatment—was a denial of the specifically female nature of her pain. A more careful examiner would have seen the need for gynecological evaluation; later, doctors told us Rachel’s swollen ovary was likely palpable through the surface of her skin. But this particular ER, like many in the United States, had no attending OB-GYN. And every nurse’s shrug seemed to say, “Girls cry—what can you do? We see this all the time.”

Average time men wait before receiving analgesic for acute abdominal pain: forty-nine minutes.

Average time women do: sixty-five minutes.

Approximate length of time Patient X waited before receiving pain medication: between ninety and a hundred and twenty minutes.

“My friend has been reckoning in a sustained way about her own fears about coming across as melodramatic.” Rachel does struggle with this, even now. How long is it appropriate to continue to process a traumatic event through language, through repeated retellings? Friends have heard the story, and still she finds herself searching for language to tell it again, again, as if the experience is a vast terrain that can never be fully circumscribed by words. Still, she showed incredible bravery on that day; in the throes of debilitating pain, she tried to be good for the doctors, she tried to be patient, wait her turn, keep her chin up, bite her lip.

When I think how hard she fought to stay calm, to stay polite, to keep it all together, in the hope that it would ingratiate her caretakers—though all it did was make it easier for them to forget us—I want to weep.

• • •

Timestamp: September 18, 2013. About 2 PM.

They let us wait. For hours, nothing happened. No one spoke to us. No one checked in. Around three, we got the CT scan and came back to the ER. Otherwise, Rachel lay there, half-asleep, with her face twisted in an awful frown, suffering and silent. Later, she’d tell me the Dilaudid didn’t really stop the pain—just numbed it slightly. Mostly, it made her feel sedated, too tired to fight, and kept her from writhing and shaking so much, which calmed her down.

But when the drugs started to wear off, her eyes again began to widen, agonized and bright. Then I’d beg the nurses for more painkiller. Eventually, if I was persistent enough, someone would dawdle to her bedside, carrying the tiny, sacred vial.

Timestamp: September 18, 2013. About 5 PM.

The doctor—the man who’d come to Rachel’s bedside briefly, and just once—packed his briefcase and left. He’d been around the ER all day, mostly staring into a computer. We only found out later he’d been the one with the power to rescue or forget us.

A younger woman came on duty: I watched her go from bed to bed. Somehow, I sensed that she could help. There was something in her face I thought I could reach.

“Please,” I said. “We’ve been waiting all day. My wife’s so sick, and no one’s told us anything. I have no idea what’s happening to her.” I told her we were waiting on the results of a CT scan, and I hassled her until she agreed to see if the results had come in.

She brought me to a computer station in the middle of the room and reluctantly pulled up Rachel’s file.

Her eyes widened.

“What is this mess?” she said. She scanned the page, the screen reflected in her eyes.

“Oh my god,” she murmured, as though I wasn’t standing there to hear. “He never did an exam.”

I saw I’d made a terrible mistake: I had trusted that someone was watching when no one was.

We’d slipped through the cracks.

The male doctor had prescribed the standard treatment for kidney stones—Dilaudid for the pain, a CT scan to confirm the presence of the stones. In all the hours Rachel spent under his care, he’d never checked back after his initial visit. He was that sure. We were just a box that he’d checked off. As far as he was concerned, his job was done.

If Rachel had been alone, with no one to agitate for care, there’s no telling how long she might have waited.

It was almost another hour before we got the test results, but when they came, they changed everything.

“She has a large mass in her abdomen,” the female doctor said. “We don’t know what it is.”

That’s when we lost it. Not just because our minds filled then with words like tumor and cancer and malignant. Not just because Rachel had gone half crazy with the waiting and the pain. It was because we’d been asked to wait our turn all through the day—longer than a standard office shift—only to find out we’d been an emergency all along. 

Suddenly, the world responded with the urgency we wanted. I helped a nurse push Rachel’s cot down a long hallway, and I ran beside her in a mad dash to make the ultrasound lab before it closed. It seemed impossible, but we were told that if we didn’t catch the tech before he left, Rachel’s care would have to be delayed until morning.

Number of minutes, at time of Patient X’s arrival, before the ultrasound clinic was scheduled to close: ten minutes.

“Whatever happens,” Rachel whispered while the tech prepared the machine, “don’t let me stay here through the night. I won’t make it. I don’t care what they tell you—I know I won’t.”

Soon, the tech was peering inside Rachel through a gray screen. I couldn’t see what he saw, so I watched his face. His features rearranged into a disbelieving grimace.

Whatever was on the screen, it wasn’t good.

By then, Rachel and I were grasping at straws. We thought: cancer. We thought: hysterectomy. It was one of the worst outcomes I could fathom. A week earlier, I think Rachel would have felt the same. But lying there, in the dim light, she almost seemed relieved.

“I can live without my uterus,” she said, with a soft, weak smile. “They can take it out, and I’ll get by.”

She’d make the tradeoff gladly if it meant the pain would stop.

That was the closest I came to glimpsing the fullness of her hurt.

After the ultrasound, we led the gurney—slowly, this time—down the long hall to the ER. By then, the ER’s open floor was completely crammed with beds. Trying to find a spot for Rachel’s cot was less like medical care and more like navigating rush hour traffic.

Then came more bad news. At 8 PM, they had to clear the floor for rounds. Anyone who was not a nurse, or lying in a bed, had to leave the premises until visiting hours began again at nine. Of course, I pleaded with them. Made my case.

It was no use.

I held Rachel as long as I could until they forced me out.

Outside the hospital, I thought about calling family, friends. But what could I tell them? There was a large, ambiguous mass—that’s all we knew. It seemed cruel to call anyone to say so much and so little.

So I wandered around alone, down Ashland Place, along Fulton Street. An evening drizzle came and went, and the dark streets shone with rain.

Amount of time Patient X and narrator spent apart: about one hour.

Then they let me in again, to see how much I’d missed.

Timestamp: September 18, 2013. About 9 PM.

I found Rachel alone in a side room of the ER, a place I hadn’t seen before. So much had happened. The mass was her ovary, she told me. She had something called ovarian torsion—the fallopian tube twists, cutting off blood.

There was no saving it. They’d have to take it out.

I felt relieved—not cancer—but I was devastated, too. I’d spent all day thinking about kidney stones. This was just so extreme—a whole ovary, half of all she had, gone.

But Rachel seemed confident and ready. “He’s a good doctor,” she said. “He couldn’t believe they left me here all day. He knows how much it hurts.”

I wanted a second opinion. By then, the hospital seemed so wildly incompetent I barely trusted them to take her blood pressure. While Rachel called her mother to give her the news—someone had stolen the cordless phone, the nurses said, so Rachel had to hobble to a wall phone behind a row of desks—I tried to reach her gynecologist, without luck.

But when I met the surgery team, I saw Rachel was right. In their eyes, the words we’d used all day—excruciating, emergency, eleven—registered with real and urgent meaning. They cared. They felt. They wanted to help.

An OR was prepared within an hour. Impossibly, the ER lost track of us again, and the head surgeon eventually called down, fuming, to ask why we hadn’t been brought upstairs.

By ten thirty, everything was ready. Rachel and I said goodbye outside the surgery room. She wept to leave me, and I wanted to hold her longer—but I let them take her from me, push her through the door toward the table where she’d finally, finally, find relief.

Approximate amount of time Patient X waited between first experiencing symptoms and entering the Operating Room: 14.5 hours.

Approximate duration of Patient X’s laparoscopic surgery: four hours.

It was almost morning when they let me into the recovery room to see her sleeping: Rachel, looking tired as a child, lighter by the weight of one beautiful organ.

Life span of Patient X’s right ovary: twenty-nine years, five months, twenty-seven days.

Total time Patient X spent in the hospital: Approximately twenty-two hours.

Amount of minutes in “a long time”: Undetermined.

I watched her for a long time. I thought our long ordeal was finished.

• • •

Amount of time Patient X missed from work: three weeks.

Rachel’s physical scars are healing, and she can go on the long runs she loves, but she’s still grappling with the psychic toll—what she calls “the trauma of not being seen.” She has nightmares some nights—I wake her up when her limbs start twitching. I know the pained expression on her sleeping face. She’s dying in her dreams, she tells me, and as she cries out, no one hears.

Amount of time Patient X experiences as passing during certain pain-related dreams she has, when she hurts and no one helps: Undetermined. But it feels like many, many hours.

Real-time length of human dreams: two seconds to thirty minutes.

And the nightmare continues for others, too, at the city’s crowded hospitals. I hope the people I saw that day—a woman screaming for her stomach medication, a man who stormed out after waiting all morning with a bloated, rotting foot—are home again and well, but they’re replaced daily by others who suffer and plead and wait. And sometimes it ends tragically, as it did for Tabitha Mullings in 2008, when she went to the same ER with a life-threatening infection. She was diagnosed with kidney stones, like Rachel, and sent away with painkillers. When, in agonizing pain, she called 911 again the next day—twice—she was not taken back to the hospital. Ultimately, she lost both hands, both feet.

We wait to see when Rachel’s physical scars will fade from her body. Sometimes, we inspect them together, looking at the way the pink raised skin starts blending into ordinary flesh. Maybe one day, they’ll become invisible; maybe they never will.

We wait to see how many new medical bills will arrive at our home, like birthday cards or anniversary cards reminding us of that day and its costs.

We wait to see whether we will have trouble conceiving a child since Rachel has just one ovary now. The doctors say we should be fine, but you never know—we’ve lost nature’s backup, and we don’t want to wait for something else to happen.

Amount of time Patient X’s surgery has accelerated the parenting timetable for her and the narrator: several years.

Time it takes, on average, for a couple to conceive: six months.

Rachel still daydreams, sometimes, about telling off her nurses—the women who told her, in so many words, to grin and bear it. She wants to confront their dismissive faces with everything we know today, with all she’s suffered then and since. There are comebacks she’s rehearsed, rejoinders she likes feeling in her mouth. I wait to see how long she’ll play, replay, these interactions. I wait for her bad dreams to go away.

Amount of time Patient X will continue to experience pain- and hospital-related nightmares: Unknown.

They happen less and less frequently now. But still, sometimes she wakes me, crying, whispering words like pain and hospital, and doctors, and again. When that happens, I simply hold her in the darkness, as long as I can, the whole incalculable length of time a full recovery takes.

About the Author

Joe Fassler

Joe Fassler is author of Light the Dark: Writers on Creativity, Inspiration, and the Artistic Process and the forthcoming novel The Sky Was Ours (Penguin, 2022). He lives in Denver.

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