Cara M. squints and shields her eyes against the flood of hallway light, a blanket clutched at her chest, a vomit bag at the ready. She describes her migraine as an icepick stabbing through her right eye. At home, the glow from her laptop screen kicked off waves of nausea. Birdsongs landed like hammering spikes. For most of my ER career, I’d be examining Cara M. in a low-lighted, quiet-ish room. Not in today’s diluted version of health care.
She is parked in a gurney along a wall in a bright, busy, and noisy hallway, one in a long line of patients. For darkness, she pulls a blanket over her eyes. But it can’t protect against the assault of overhead announcements from a nearby ceiling speaker. So loud, we pause our conversation until we can hear each other and she can stop squeezing her ears. “What are we doing here?” I’m thinking, apologizing, fighting the urge to pull a blanket over my own head. A room number is taped to the wall above her, marking her bed assignment. Yet, if not parked in a gurney or a chair, patients like Cara M. would be counting the hours in the ER waiting room.
ER boarding is a pervasive and worsening national crisis for hospitals. As more patients spend longer times in the ER waiting for an open hospital bed, the number of available beds for new patients dwindles. The burden falls on ER staff, who must convert every available space — no matter how inadequate — into care areas for new patients. Physically, this means transforming hallways and corners into makeshift treatment zones; emotionally and ethically, it forces staff to question and even compromise their standards and ideals. If the trade-off for patients seeking timely care is enduring conditions that may make them worse, for ER staff, it’s practice patterns that demand they feel less. The burden freezes the heart.
For decades, hallway beds have served as both necessary and problematic short-term fixes for ER crowding. The emergency department can no longer serve as the community’s safety net while also serving as the hospital’s safety valve. The number of ER visits in the United States is rising, from 128.97 million in 2010 to 155.4 million in 2022. Meanwhile, hospitals struggle with rising occupancy rates and fewer available beds, and ERs are swamped with increasingly ill patients who have complex medical, mental health, and social issues. There is no safety net for the safety net itself.
Cara M. wanted to avoid the ER, but three weeks was the earliest available appointment with her primary care physician. Primary care, the foundation of the health care system, is crumbling under high workloads, endless bureaucratic obstacles, poor reimbursement, and burnout, driving away the most dedicated providers. Those who remain contend with guidelines so absurd in numbers that satisfying them all would require more hours than a 24-hour day allows. When Cara M.’s headache intensified, and she couldn’t keep her medications down, her overbooked physician group, like so many clinical practices, told her to go to the ER.
I promise to do my best to ease her pain. From her weary grin and the game nod as she absorbs it all, I sense Cara M. doubts meaningful relief is possible in a hallway bed. “I know,” I say, attempting an optimistic shrug that I can’t exactly pull off. There’s an implicit emotional tax patients and ER staff stomach to various degrees when they meet in a hallway bed. Shame.
Responding to unexpected challenges is built into the emergency medicine ethos. As crowding and hallway beds have become expected challenges, they have cut into the bones that sustain emergency medicine, shaving away layers of the moral tenets and high standards, the meaning and purpose that nourish staff through the difficulties, and the comfort and dignity of patients.
When my mother, who suffers from dementia and difficulty walking, fell in her memory care unit in New York, she landed in a hallway bed at the university ER near her facility. While we awaited test results, she needed to use the bathroom. Her calls for help went unanswered. I couldn’t flag anyone’s attention, either, and we were located directly across from the ER staff’s workstation. They were clearly overwhelmed, rushing around or scrolling their computer screens, phones nestled to their ears. My mom’s gown drooped off her shoulder as I sat her up. I tried to steady her while screening her exposed body with mine in a vain attempt to uphold the semblance of privacy. A young nurse veered toward us, breathless and effusively apologetic. I sighed, less upset than disgraced, rudely aware that patients see me not seeing them in the same way.
ER staff are the agents at the gate of dysfunction. With hallway beds, absorbing patients’ frustration and dissatisfaction is the prologue to too many patient encounters. I know what I’m in for when Mr. S huffs his heavyset body into a sitting position, rubs his thinning white hair and gray, flaking scalp, and stabs the air with three fingers. He takes straight aim at the half-clothed nursing home patient in the gurney at his feet, the angry man whacked in a bar fight behind him, and the foot traffic rushing by. “And now this?” He coughs a yellow plug into a tissue. “This isn’t right.”
“Yep. I agree,” I say, which lets the air out of his argument. I must hear him out, which includes his frustration about unreturned phone calls to his doctor, before redirecting the conversation to the symptoms that prompted his ER visit — fever, cough, and confusion. But hallway beds are in hallways, which still function primarily as hallways. When patients are parked along a wall, there’s less space for traffic to pass. My efforts to calm him are washed away as his disgust returns each time our conversation is interrupted. First, I must step aside to make way for a gurney carrying a patient to a CT scan. Minutes later, it’s a woman padding unsteadily to the nearby bathroom on the arm of an ER tech, who can’t quite hitch the gown to cover the bruises on her backside.
Adding to my embarrassment, his physical exam is done mainly through his clothes. Hallway beds have transformed the patient examination — once sacrosanct, undebatable, and integral to diagnosis — into a moral dilemma. Exposing the patient is critical, and yet, in a hallway, the call for exposure competes with the duty to honor patient privacy and dignity. How far should I go? Raise Mr. S’s shirt just enough for an abdominal exam? Sneak my stethoscope under his sweater to listen to his lungs? Do I ask him to remove his pants under a blanket? How about taking off his shirt? Every situation is different, and I can judge only in hindsight whether my rationalizations for each action are defensible.
With Mrs. G, a defiantly independent spark plug in her 80s who lived alone, I missed a telling flank bruise. She possessed a sharp mind and a scratchy voice that adamantly denied she had fallen. I believed her, especially when I pressed around her belly and down her back, and she wasn’t tender anywhere. Out of respect, I didn’t raise her blouse to inspect her skin for bruising. In my calculations, the odds of finding anything were slim and not worth risking exposure in the hallway.
But I was wrong. When she returned from X-ray, I learned of healing flank bruises from prior falls that she had hidden from her family, who believed she could no longer care for herself.
It’s an inexcusable oversight for a medical student and unconscionable for an ER physician with decades of experience. I would have examined her fully from head to toe if she were in a room. I should have pushed her gurney into the sea of hallway traffic to thoroughly explore the bruised “wall side” of her body. But given the circumstances, the diligent act also felt cruel.
Privacy breaches existed before the widespread use of hallway beds, in triage and waiting areas, as well as in areas near nursing stations. Sometimes, personal health-related information even reached patient rooms. But hallway patients offer front-row seats to these conversations, and for long stretches of time. However, to be close to the action also means to be seen by others; their fragility, dignity, and pain on the same stage. Here, a deeply personal, life-changing moment doubles as a public event.
With Mrs. V, I had no choice but to break the news about the new abdominal masses on her CT scan, likely a malignancy, in her hallway bed. ER crowding was severe, with no private area to move her to. I lowered my voice, hoping to fly below the earshot of others. The tears poured down her face. Her sobbing was raw and insuppressible, I couldn’t help but notice all the people staring, then quickly turning away. The stream of tears soon soaked the wrist of her sweater that she recruited to wipe her cheeks. I just stood there, biting my lip, aghast, angry that I had put her in this position, disappointed in myself. Everything about that moment felt wrong.
Breaking unexpected bad news, a life-changing diagnosis, is one of the hardest yet most profound tasks in emergency medicine, even under ideal conditions. In the hallway, it feels inhumane, far from ideal, and forces me into a fresh dilemma I had never encountered before the age of hallway beds. Remain by Mrs. V’s side, my hand on her trembling shoulder so she wouldn’t feel alone amid this crowd of strangers, or leave to grab her a box of tissues? There are times when offering a box of tissues becomes a necessary expression of caring. If we were in a room, I could do both, fish out a box of tissues from the bedside cart while sitting, not standing like I was, beside her. However, there is little space for hallway carts near hallway beds.
When I shared this conundrum, a young emergency medicine resident told me she always brings a box of tissues in situations like this. She describes never knowing a time without hallway patients. For her, and other physicians whose medical school training overlapped with pandemic conditions, her normal isn’t a new moral space. When I finally returned, Mrs. V looked cried out and lost and was inconsolably alone.
These moments force me into hallways of my own, dark recesses in my mind and soul, where it’s impossible to ignore the slow erosion of the ethical and clinical standards that now pass as my “best.”
Back to my shift with Cara M.: Hours later, she remains cocooned inside a blanket, and though she claims to be a little better, her flinching eyes speak otherwise. Mr. S’s anger has waned enough to reveal hints of fear.
There’s an argument that eyeballs on patients in an imperfect setting is better than the alternative, a chair in a crowded, unmonitored waiting room. After endless hours there, would Cara M. leave without ever being seen by any physician to suffer in peace at home? In the post-pandemic period, the number of patients who left without being seen (LWBS) by a physician increased sixfold. And should they return, many patients are sick enough to require hospital admission.
When Mr. S suddenly spikes a fever and his breathing becomes labored, the nurse notices, and he’s hooked to a monitor. Quickly, he’s moved to a critical care area. Is it a suboptimal event? But what if his clinical status had deteriorated in a waiting room? Was it a fortunate coincidence that the nurse happened to be walking by, or a well-conceived strategy to position him in a high-traffic area? I can’t say. Catching his downturn early feels intentional, lucky, and unsettling.
Research paints caution signs around hallway beds. Patients are less satisfied with their care and at greater risk for diagnostic error and suboptimal history taking, especially when expected to communicate tender concerns about suicidal ideation, intimate partner violence, and elder abuse. Logistical challenges complicate electronic monitoring and nursing attention. And an assignment to a hallway bed may reflect triage bias against patients who are on Medicaid or who self-pay.
I acknowledge that alternative strategies to hallway beds are far from easy when nearly one-third of Americans don’t have ready access to a primary care clinician, and a rising percentage of adults and children in need of management of chronic disease, like Cara M., lack ready access to care.
Even if hallway beds are a necessary evil, that doesn’t mean they are, or should be, accepted as a new normal. “What are we doing?” is a frequent chorus from fellow ER colleagues, usually accompanied by a shaking head, a guttural sigh, or a slam of a pen. Hallway beds bear an undeniable human weight. To feel it fully, stare down a line of hallway patients with want in their eyes, a vacancy of spirit, a resignation to their fate, and test whether the heart can argue otherwise.
In one study, a patient in a hallway captured the distressing paradox of feeling exposed, in full view of others, and yet invisible. Their sense of invisibility is a fundamental human failure. I’m a cog in the hallway model, but an on-the-ground cog, and thus ultimately left to bear culpability.
However, my attention is a responsibility within my control. Unflinching focus on each patient might sound trite or overly simplistic; it’s a surprisingly strenuous and uncomfortable exercise. The effort to describe what I see, plainly, using simple, objective, nonjudgmental language, cuts through metaphors and justifications to expose the human heart.
For example, I see an older woman with dementia in a hallway bed calling for help. I see a man urinating into a plastic jug half under a blanket, a physician holding an end-of-life conversation with a patient and his wife in the middle of the ER hallway traffic, a young physician suturing a bloody scalp laceration as foot traffic moves around him. Each shift, I take 30 seconds and practice using language as a method of immediate and particular attention, and as an act of resistance, an antidote to methods that distance each patient’s experience behind rationalizations, images, and numbers.
The EHR (electronic medical record) computer screen is one culprit. The icon that represents a patient such as Cara M. in hallways is a box with a number assignment on the computer screen — exactly as those for patients in rooms with walls. Instead, these figures should depict their place with greater honesty, perhaps as exposed figures without borders. Remove all doubt for anyone facing the screen, from ER staff to hospital leaders in their offices, that Cara M, chief complaint “headache,” is in a noisy, bright hallway for endless hours.
Similarly, data and statistics that track key outcome measures can deemphasize the patient experience and fuel moral distress. Physicians are recognized and rewarded for better numbers when more hallway beds result in fewer LWBS patients and shorter door-to-doctor times. However, the actual care doesn’t feel better. It feels less. The unexamined pursuit of better metrics rewards shortcuts, alters behavior, and, ultimately, shifts our values. Left behind are core unmeasured and unmeasurable qualities, such as connection, trust, and the recognition of vulnerability; the human acts central to quality care and even clinician well-being.
Describing those patients along that wall in the hallway often hurts. However, this pain is the result of nerves coming alive, nerves I need to feel. By standing there, taking it all in, I’m also exposing myself. I’m reminded of what I’ve lost in the effort to do my best. Wrestling to speak the painful parts out loud, the tiny moments that cut like shards, is to struggle to gain agency at the gates of a broken health care system. Or, at the very least, to become a more empowered and empathic double agent.
Sometimes I ask ER patients in hallway beds what they see. By asking them outright, I acknowledge them, their situation, and do not pretend it’s in any way acceptable.
During that busy evening, when Cara M. and Mr. S were merely two among a sea of hallway patients, the use of hallway beds struck me as life rafts, keeping patients perilously afloat. But then I wondered, maybe the ER staff are the life rafts? Without their commitment and moral fortitude, these ad hoc models wouldn’t float nearly as well, if at all, and patients would be at greater risk. However, hallway beds are a drain on the animating human energy that sustains staff. It’s an idea that eats itself, a crisis of policy colliding with a crisis of conscience, a solution that creates new problems. When the hallway marks a destination, ER staff and patients can’t help but spin around and ask the walls, “Where am I?”
Jay Baruch, M.D., is professor of emergency medicine and director of the Medical Humanities and Bioethics Scholarly Concentration at the Warren Alpert Medical School of Brown University in Providence, R.I. His latest book is “Tornado of Life: A Doctor’s Journey through Constraints and Creativity in the ER” (MIT Press). The patients’ names and identifying details have been changed.
