United States emergency services are justifiably celebrated. These extraordinary theaters daily display feats requiring skill, technology, and nerves of steel. But the costs of maintaining round-the-clock readiness and marquee talent is high. Also, federal law mandates that the nation’s 4,100 ERs keep their doors open 24/7, and they must at very least screen anyone who presents, regardless of their ability to pay. As a result, American emergency rooms are the country’s medical safety nets, offering care of last resort. Recent years have seen stabilization: programs like Washington’s Basic Health Plan linked families with primary-care doctors. But the weakening of those initiatives again heightened pressures on hospital emergency teams.

Harrison Hospital’s Emergency Services staff share the challenges of colleagues across the country. After ER use on the East Bremerton campus spiked to 45,000 visits several years ago, hospital officials redoubled efforts to ease the crunch. The openings of new facilities in Port Orchard in 1995 and Silverdale in 2000 were expected to better redistribute care. These satellites — both of which treat less serious conditions than the main campus, the county’s emergency hub — have indeed lessened congestion. But Harrison leaders stress that more — much more — remains to be done.

Don’t look for changes in the practice of medicine to match the speed of those at Microsoft, however. As Dr. Mel Belding, Harrison’s Vice President of Medical Services, explains: “Human beings are creatures of tremendous variation. We can only properly take care of them one at a time. To a certain extent we’ll always be reminiscent of the village tailor, who crafts one pair of pants at a time. Medicine shouldn’t ever be like working on an assembly line.”

The backstage aspects of emergency care are almost Byzantine, and that complicates the effort to streamline, Dr. Belding adds. Processes of registration, coding, laboratory and X-ray tests, documentation and many other steps have be coordinated. Accuracy, privacy, and safety are also critical. “To make the system run more smoothly, you can’t just isolate one piece. Facilities, staff, and processes all have to be scrutinized together.”

Harrison has always looked for ways to improve care and self-examination, says ER director Susie Rankin, RN. She notes that the struggle to address the community’s constantly changing needs has generated such unique successes as a chest-pains clinic and sexual-assault center. “Like most ERs, we’ve been limited by our physical space, which was designed for many fewer individuals than we see today. But I need to stress that there isn’t a relationship between how long people wait and the quality of care they see. Our patients receive excellent service, and I am very proud of those who work here.”

Current staff in Harrison emergency services number over 100 across the three campuses, with the majority working in East Bremerton. There are approximately 20 board-certified emergency physicians. Nationally, fewer than one-half of the doctors working in emergency rooms are board-certified in emergency medicine. Additionally, not all Americans have access to sophisticated emergency services — it’s estimated as many as 40 percent live in areas far from centers like Harrison.

As a level III trauma center, Harrison provides all types of emergency care short of neurosurgery and open-heart surgery. The hospital is completing the process necessary to provide some of these services, however. Harrison hopes to offer open-heart surgery in the summer of 2002.

Public expectations of emergency services can be unrealistic and cloud the picture of their caregivers. “We live in a fast-food culture, and patients are often frustrated when we can’t perform in the same way,” comments Harrison RN Jody Colleto. “Unfortunately, that’s not the way it works in this or any other ER. We have no choice but to treat each individual according to the magnitude of their problem. The man who walked in ahead of your child may look in the pink of health. But very likely he suffers from a respiratory problem or other difficulty that makes his situation more acute than yours.”

The quick-witted calm called for in emergency work isn’t to everyone’s tastes, including other healthcare professionals, Judy McDannold says. The Harrison RN, whose expertise includes stints in emergency departments across the nation, admits she thrives on the ability to manage crisis. Patients venture into the ER not only in states of physical disarray but also suffering emotional confusion. Offering emergency care involves the ability to assuage a wide range of issues, McDannold says.

Societal heartaches including mental illness, alcoholism, drug abuse, and domestic violence are also flooding American healthcare, making social workers key players in the modern ER. Not all of these situations warrant expensive hospital care, staff say, but many times no other place is available to take them. “These cases don’t represent a large number, but they do take up significant staff time, and they can be highly upsetting to other patients,” says Dave Olson, hospital planning director. “This is an example of something that really isn’t exclusively a Harrison emergency services problem. The whole community needs to find solutions together.”

A sense of urgency propels today’s ER planning efforts, as national trends point toward a harsher climate. “In the past, we tended to have periods of slack times followed by busier ones. Now, busy times are much more frequent,” Olson says.

Hospital staff will next month begin a period of exciting redevelopment in the emergency area, including the creation of larger spaces, Olson says. “The old model for emergency areas was the open trauma room. But that’s no longer satisfactory. Staff and patients both need privacy for optimal care.”

Specifics concerning improvements to emergency services will be announced this summer, Olson says.

Innovation doesn’t just make life easier for patients and staff, it ensures the hospital won’t lack for first-rate nurses. When critical shortages hit, they tend to affect emergency services especially hard, Rankin says. “Veteran emergency nurses bring immensely rich experiences to the table. When real crises happen, it’s with awe that you watch them draw upon that background. There’s simply no replacement for that kind of talent.”

It’s anticipated that advances in emergency services won’t end there, Dr. Belding says. “When you begin this kind of regeneration it creates ripple effects throughout the institution. That’s our goal.”

Any discussion of emergency services needs to keep the miraculous ahead of the mundane, Rankin says. “I confess I still feel awed every time we save someone’s life. And you know what? We do it everyday.”.