By Elise Takahama
The Seattle Times
PUYALLUP, Wash. — Jerae Goldsby is a blur in purple scrubs as she whips around fluorescent-lit halls, like a worker bee on the move.
It’s 2 p.m., and the emergency department at the only hospital in Puyallup is filling up.
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An older man with a hip fracture needs help using the bathroom. A 57-year-old woman has mounting pressure in her eyes, and parts of her face are drooping. A third patient needs an urgent blood transfusion after breaking her back and ribs this summer.
The registered nurse has seen all sorts of patients in her 20-plus years working in the ED at Good Samaritan Hospital.
Today, Goldsby is also serving as a float nurse, which means she’s looking out for all the other emergency nurses, too.
Goldsby hollers to them as she power walks past, making sure they take three breaks every four hours.
“Did you break? No?” she asks one nurse. “Go now.”
Once she’s sure all 25 nurses on shift have had a breather, she pauses and lets out a small exhale. Then she’s off again.
In truth, honeybees seem less busy.
The team that runs Good Sam’s emergency room is big — but not big enough, hospital leaders say. It’s staffed to see 190 patients a day. On this particular Wednesday, there will be 231.
When everything runs smoothly, the floor hums with energy as providers perform a spectrum of everyday medical miracles. They address shortness of breath, chest pain, burns, vomiting, broken bones. Patients move seamlessly into and out of hospital beds. On a good day, it can be a satisfying balancing act of teamwork, communication and grit.
It’s not always a good day.
Many end with more patients than open beds, hallways housing people instead of rooms and a waiting area still full.
Good Samaritan runs, by some measures, one of the busiest EDs in Washington state, according to emergency department leaders. They worry it’s only going to get busier, with shrinking access to primary care and looming Medicaid changes expected to push hundreds of thousands of Washingtonians off health insurance by the end of 2027. Good Sam isn’t alone; for the past year, state health officials have warned that hospitals, especially emergency departments, are nearing a cliff.
While hospital managers constantly look for creative solutions to keep them from tumbling off, medical providers — from physician associates to technicians — focus on catching patients.
Dr. Scott Taylor, an emergency physician, begins his day with a drive over two bridges, from the small and picturesque Fox Island in southern Puget Sound. Charge nurse Patience Fontaine comes from Tacoma, where she lives with her two beloved and massive dogs. Steve DeLong, an emergency room tech, heads in from his home on the outskirts of Puyallup.
They step through the emergency room doors, and prepare for another shift.
Around 2:30 p.m., Jennifer Cochran’s blood transfusion is underway. In July, Cochran got into a car crash and ended up in a ravine.
The 43-year-old from Wilkeson, a small town in central Pierce County, now gets her blood drawn once a week. This week, results showed something was off, so her doctor told her to go to the ED.
“I can barely walk,” Cochran says.
Goldsby, who moves fast and talks faster, leans against a counter, and slows.
“You’ve been through it,” she says to Cochran.
For 15 minutes, Goldsby stays in Cochran’s room to keep an eye on possible side effects from the transfusion. The two, both longtime Pierce County locals, chat about the Fairfax Bridge closure and an upcoming football game between rival high schools.
The time passes quickly, and with no apparent side effects, Goldsby wishes Cochran well. Then she’s on to the next person.
It’s 4:30 p.m., and an ambulance carrying a seizure patient is two minutes away.
Steve DeLong hustles to prepare a room. He makes the bed and wipes down equipment within seconds.
Just after 4:30, two EMTs roll a patient in on a gurney. They head straight for the prepped room, and nurses get to work.
DeLong slips out and circles back to the charge nurse’s station, a spot nearly everything in the unit seems to orbit.
There, Patience Fontaine is directing traffic.
She’s on the phone with someone from Covington Medical Center in King County, which is transferring a patient over.
Other hospitals are sending two additional patients.
Meanwhile, the crowd in the waiting room has at least doubled in the last three hours. There are 30 nurses on shift, along with 16 techs, eight physicians and two physician associates.
Fontaine’s eyes are glued to her computer screen, where she’s tracking incoming and current patients, their conditions and available beds.
Where is everyone going to go?
Christi McLane is in a hallway bed. Her husband, Chad, sits in a wooden folding chair by her feet, squeezed into a space near a crash cart and an EKG machine.
About five years ago, Christi started experiencing episodes of intense sleepiness, spiked by chemical imbalances, that require her to be hospitalized.
“Sometimes she can’t stand upright on her own,” says Chad, 54. They live in Eatonville, Pierce County. “It’s a mystery what’s causing it.”
She’s ended up in the emergency department six to eight times, and has been in a hallway bed once before.
“It’s busy today,” Chad notes softly, as his wife sleeps.
The two would stay in this spot, more or less, for eight hours.
Good Sam’s emergency department is divided up by hot spots.”
One section for the most critically ill, another for admitted patients boarded in the emergency department until an inpatient bed opens up. Mental and behavioral health patients are in another area.
And then there’s something you don’t see in every ED.
A space where individual patient areas are separated by curtains, with a cushy recliner, but no bed, sitting in each bay.
This is the hospital’s advanced treatment program, or “fast track,” meant to more quickly treat and discharge patients not in need of critical care, explains Matt Hooper, emergency department nurse manager. For example, a teenager with a sprained wrist or someone with a bad cold might not need intensive blood work and lengthy scans, or a bed.
So a nurse in the waiting room will triage patients as they arrive, assessing their level of medical urgency. Some go straight back through the double doors.
Others might go to the fast-track area, where they can get some initial care, like receiving medication or having a test ordered. Then, if the patient is feeling well enough, they’ll go back to the waiting room until the next step, freeing the bay up for someone else.
The fast-track system, sometimes known as a vertical care model in other hospitals, functions almost like high-level urgent care, Hooper says.
“It’s the saving grace of the ER,” he adds.
Kris Kirkevold, from Edmonds, sits in a beige recliner in Bay D, a corner of the fast-track area. She’s at the ED with ongoing dizziness, facial drooping and pressure in her eyes.
Kirkevold is fairly alert, but her vision is slightly blurred and her speech is slurring a little. She needs a neurological exam, some blood work and a CT scan.
She’s able to make her way through a brief oral and visual exam, and get her blood drawn, while sitting in the bay. “I’m just grateful to be seen,” she says to her nurse.
“It’s hard because it’s not the care that we want to give, but it’s the care that we have to give,” Taylor, the emergency physician, says later about the fast-track system. “We would prefer to have people be seen in a room with, like, a door and privacy.”
But he also knows many patients favor receiving care faster, even if it means having to boomerang back out to the waiting room in between seeing providers.
Developing the fast-track system was a response to the growing demand for less critical, yet still urgent, care, says Shannon Pulley, the clinical director of the emergency department at Good Samaritan, a MultiCare-affiliated hospital.
“Outside of us, access to primary care has dwindled,” Pulley says. A good chunk of patients now “come in due to conditions that have worsened because they haven’t gone to primary care.”
This summer was especially jammed, with the average number of daily visits rising every month. Things have been busier in general since the COVID pandemic, Pulley says.
That’s true for most hospitals in the state, according to Mark Taylor, senior associate administrator at Harborview Medical Center. But he agreed the Level III trauma center in Puyallup is known to have particularly high volumes.
During the pandemic, he was responsible for tracking hospital capacity and moving COVID patients throughout Washington. He became acutely aware that hospitals in Pierce County are more spread out than in King County.
“We have the Tacoma hospitals,” Mark Taylor said. “But then you skip over to Puyallup — and you have Good Samaritan, and then you have nothing for a long time.”
“A huge swath of the population really is supported regionally by Good Samaritan.”
It’s just after 6:30 p.m., and a flurry of activity has descended on the charge nurse station. Fontaine is, at times, alternating between talking on four different phones, while directing EMTs and providers around the department and handling questions from families.
Beds are nearly full, and three pairs of firefighter-EMTs have just shown up with more patients. One because a medical device in his abdomen malfunctioned. Another for an alcohol problem.
Fontaine is supposed to be off at 7 p.m., but she often leaves late. She also picks up a lot of extra shifts.
“Most of my best friends work here,” she says later. “If they’re having a rough time, and I’m not doing anything, why would I not come help the cause?”
Plus, she likes earning days off and being able to take trips, especially to places with sunshine.
As an emergency tech, DeLong handles nearly anything that doesn’t require a physician, nurse or advanced practice provider. Sometimes that means cleaning rooms. Other times it’s taking patients’ vitals or checking their blood sugar. At the moment, he’s busy wheeling patients out of the department as soon as beds open upstairs.
DeLong is also a float tech today, which means checking in on other emergency technicians, as well as doing whatever he can to help “keep the flow of the ER,” he says.
As he transfers one person to the sixth floor and rolls their gurney out of the elevator, the patient’s younger family member trails behind.
After exchanging notes with the nurse there, DeLong heads back down to the ED.
DeLong said he likes the job for the “instant gratification when you make people feel better.” He also likes the camaraderie.
He gets back to the emergency department and checks in with Fontaine. How’s it going? She’s upbeat and calm.
“I wouldn’t say it’s ideal, but it’s going,” she says.
It’s almost 8 p.m., and things have quieted down a little.
Taylor, the emergency physician, notes another packed day, including an uptick in flu and COVID patients. He prepares for his two-bridge drive home to his wife and one son; the other lives in Pullman.
Taylor still loves the work after nearly 20 years.
“There’s an element of chaos that’s always kind of going on in the ER,” he says. “Everybody looks out for each other.”
Outside the hospital, the doctor is a “boisterous fan at his teenagers’ ice hockey games.
Fontaine is, at last, about to head home. Jake Crosby, the night charge nurse, is captaining the unit now.
Only two codes today, Fontaine remarks, referring to the number of resuscitation efforts. It could have been worse, she says.
She’s off for four days next week, with plans to travel to Arizona.
The week after she returns, she’ll pick up two extra shifts.
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