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ED SFX: Footsteps in hallway, monitors beeping, gurney rolling
Dr. Brenna Farmer: Brooklyn Methodist, is uniquely situated in Park Slope.
This is Dr. Brenna Farmer chief of the department of emergency medicine at NewYork-Presbyterian Brooklyn Methodist Hospital. In the heart of New York’s most populous borough, the emergency department she runs sees over 250 patients every day. Up to 15 percent of those patients arrive in critical condition.
Dr. Brenna Farmer: The only predictable part is knowing that we're gonna have patients coming in and it may be the worst day of their lives.
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When a severe medical event occurs –
Dr. Brenna Farmer: We get a notification from EMS and it comes over a red phone. Some people would call it the bat phone because it's got a very annoying, loud sound. Very different than any other phone ringing in the emergency department. It's also got a light on top of it in case the ED is super loud. You'll see the light flashing.
SFX: Loud phone ringing, muffled voices.
On the other end of the line, EMS relays what kind of trauma is [00:01:00] coming in and how much time Dr. Farmer’s team has to prepare. But in the chaos of a medical emergency, they have limited information to work with.
Take, for instance, the case of a subway trauma.
Dr. Brenna Farmer: We are close to three or four subway lines that mean that we get trauma patients after being hit by trains or falling off the platforms.
When EMS calls in –
Dr. Brenna Farmer: A lot of times they only say a subway accident and we have to go from there
That could mean anything – from a mild concussion to a lost limb.
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This means that making split-second decisions with little-to-no-details, having tight operations and a multidisciplinary response team is critical.
Dr. Brenna Farmer: One of our recent cases required the trauma team, the vascular team, anesthesia, neurosurgery, OB/GYN, because it was very, very severe injuries. All from getting hit by a subway train.
ED/OR SFX: Monitors beeping quickly, hospital chatter.
When EMS arrived with the patient, they were in dire condition. Situations like this could unravel [00:02:00] quickly. But at Brooklyn Methodist, Dr. Farmer has established efficient protocols for coordinated care, which ensured there were no wasted minutes – or even seconds – addressing the patient’s multiple injuries.
Dr. Brenna Farmer: We have a team lead that's identified to help kind of bring everybody together because those roles and responsibilities help us not miss anything when we're at the bedside.
With skill, focus, and supreme levels of coordination, that severe subway case became a longshot success story.
SFX: Frantic hospital ambiance fades out
The patient was stabilized and taken to the operating room, where the multidisciplinary care team addressed all of their injuries at the same time – from a head injury to several near amputations.
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Dr. Brenna Farmer: She did tremendously well. And it was because of the coordinated care, all those services plus our nursing team, our chaplain service, to make sure there was support for the family, our patient services, our social workers, our rehab doctors, and all, all of that care was tremendous to get her to be able to go to rehab and [00:03:00] home.
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I’m Erin Welsh and this is Advances in Care, a podcast about groundbreaking developments in modern medicine.
Today, we’re going into the emergency departments at NewYork-Presbyterian’s busiest hospitals, to learn from leaders at the forefront of emergency medicine. Through their stories and insights, we’ll explore what makes New York City such a unique environment for emergency care, from its massive population and cultural complexity, to the severity and array of traumas that can come through the ED doors each day. And – we’ll get a window into how these leaders push their operations above and beyond, to deliver top-tier care to hundreds of thousands of New Yorkers.
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Dr. Farmer’s domain is NewYork-Presbyterian Brooklyn Methodist, where her team sees over 95,000 cases a year – a staggering volume. Across the East [00:04:00] River, her colleague Dr. Angela Mills oversees operations of another magnitude: she manages four Emergency Departments.
Dr. Angela Mills: Some people might call it controlled chaos, but I like organized intensity. You look around the team’s in constant motion, you know, high volumes patients coming in. We can get 10 patients all come at once, or even more.
As chief of emergency medicine at NewYork-Presbyterian and Columbia, she runs emergency care at Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, Westchester Hospital and Allen Hospital. And she thrives in these high-intensity environments.
Dr. Angela Mills: There's definitely a great sense of purpose and teamwork, a lot of communication talking to one another and trying to get the patients what they need.
Dr. Mills manages 150 faculty that see about 275,000 patients per year – that’s over 750 people daily. Systemwide, emergency departments represent about 10% of NewYork-Presbyterian’s [00:05:00] overall patient volume.
But while Dr. Mills thrives leading four different emergency departments, she didn’t begin her career expecting to work in emergency medicine.
Dr. Angela Mills: After I graduated from medical school, I actually went and started in a general surgery residency program and completed the first year.
During her residency, though, she did consultations on patients in the emergency department. And – like many ED physicians – once she entered that environment, she couldn't stay away.
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Dr. Angela Mills: The immediacy of emergency medicine, you know, we see things right away. The pace, fixing things quickly. The raw humanity of it, I think there's a huge privilege of being able to be the first contact for a patient and their family during a crisis.
In a similar way, Dr. Farmer also discovered she had an innate passion for emergency medicine. But she came from a different medical background – research.
Dr. Brenna Farmer: I was doing patient interviews as part of a research study and I loved it. Once I started talking to patients, and actually being able to [00:06:00] witness the care that was happening in the emergency department there, I was like, this is where I need to be. Patients come to the emergency department on the worst day of their life, and if I can make it a little bit better, that's a win.
Working in this high-stress, high-demand environment takes a specific kind of grit and talent – particularly in New York, where the caseload is nonstop.
When they’re building teams who will excel in this setting, both leaders seek out physicians who have a unique ability to –
Dr. Angela Mills: Think quick on your feet, make decisions quickly, and not just quickly, but with very limited information.
They need to be master diagnosticians, constantly assessing countless variables, and looking for answers outside of the box.
Dr. Angela Mills: Patients come to us – sometimes they're not conscious, they're not able to tell us anything about themselves. We don't have any history, we don't have anything available. And so it certainly puts us in a different space with patients, so you have to be comfortable in that space.
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They also look for people who understand that patient advocacy is a critical part of the [00:07:00] job. Working at a key medical hub for large, diverse populations means bringing empathy and humanity to the traumas and trials of community life.
Dr. Angela Mills: It's really one of the few places in medicine where you see the whole full breadth of life, you know, every single day. And every shift that you work. You have a patient with a heart attack, the next minute, delivering a baby, counseling a teenager for a mental health crisis and, and everything in between.
Laser focus, talent, and compassion – set against the backdrop of the city that never sleeps – is what keeps these teams humming and thriving.
Dr. Angela Mills: I think we really do work in one of the busiest, most complex environments in the country. And I think, again, we do it with excellence and I think that's what sets us apart. We try to lead by example. We set standards nationally. And so I think that that combined with the clinical care and excellence really leads to a special place, right? And I think people enjoy being here for that reason.
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But it’s not only the master [00:08:00] diagnosticians that keep these departments running smoothly. There are layers of other staff who fill critical roles, like helping physicians connect with patients. And in a place like New York City, that often means communicating across language barriers.
Three of the emergency departments that Dr. Mills oversees are located in Upper Manhattan, with patients coming from Washington Heights, Harlem, the Bronx, and other areas. At those sites, more than 50% of patients are not native English speakers. The majority speak Spanish. So, at one of her busiest departments, they have a Spanish interpreter available 24/7. But these interpreters do more than just translate language.
Dr. Angela Mills: Obviously there's a language barrier, but there's also understanding the cultural parts of it. Understanding their beliefs, their fears, how they view health. Our interpreters also work as liaisons with the family and be able to speak with them and work with them in a way that is most beneficial for us to be able to treat their, heart attack, their stroke, whatever it is that they're there.
[00:09:00] Dr. Farmer's team in Brooklyn also leans on a robust support system of staff to deliver holistic care for patients, beyond their acute medical needs. They work with community health workers called “patient navigators” who often speak a range of Chinese dialects and Eastern European languages, among others. Part of their role is to help patients navigate the healthcare system – set them up with primary care providers and other specialists. But they also assess patients for social determinants of health, and connect them with resources in the neighborhood for housing and food insecurity.
Dr. Brenna Farmer: Navigators work closely with our social work team to screen patients for social determinants of health to see if there's other ways that we can help patients that may be affecting their healthcare.
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Dr. Farmer says that this collaboration, between community health workers and social workers at NewYork-Presbyterian, actually helps reduce unnecessary admissions, because patients learn about other resources beyond the [00:10:00] emergency department, so they don’t have to come back when they’re in crisis.
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But along with the uniquely large and diverse patient population that cycle through these departments, there’s the sheer complexity of cases to contend with — from subway traumas to cardiac events and gunshot wounds.
Dr. Angela Mills: Overall, we have a very high, what they call case-mix index, or again, the severity or how sick, ill patients are. It's reportedly one of the highest in the country, and the complexity of the patients that we see that just, you don't find in, in most, I'll say, emergency departments around the country.
Refining systems and services to meet the demands of the complexity they see is a process of continuous advancement. One standout area is emergency cardiology.
Dr. Angela Mills: We see many patients with, very significant, severe congenital heart disease and come to our hospital for the latest and, and newest groundbreaking treatments. And so we take care of those patients, in our emergency department.
NewYork-Presbyterian is a nationwide leader in cardiology. A multidisciplinary, hand-in-hand [00:11:00] collaboration between emergency medicine and cardiology teams means that patients with complex cardiac needs can come to the ED for care that they can’t find elsewhere. The LVAD – or the left ventricular assist device program – is one such groundbreaking treatment offering.
Dr. Angela Mills: We have an excellent program there. And so in our emergency department we see many patients obviously who come to our center because they have an LVAD. You know, many EDs just don't see those patients. And so we have a great system where we collaborate very closely with cardiology and the teams there to be able to care for those patients, in a coordinated fashion.
But cardiac-related medical emergencies are just one kind of scenario that NewYork-Presbyterian’s ED staff have to be prepared for. They’re also at the cutting edge of mental health emergency care.
Take opioid abuse, for example. In New York City, someone dies of an opioid overdose every four hours. And Dr. Farmer says that the latest synthetic opioid on the street is making matters even worse.
Dr. Brenna Farmer: There’s a new type of drug around New York [00:12:00] City and around the country called nitazenes, that is a more potent opioid than fentanyl. And so what I am doing is making sure I'm educating my team, but also talking to patients and seeing if they've recognized any difference in their drugs that they're buying on the street, but also making sure that they’re going home with Naloxone.
That type of harm reduction is a crucial offering among every New York ED. A few years ago, the city launched a program called “Relay,” that connects non-fatal overdose patients with support in the community for education, medication-assisted treatment, and even health insurance. Essentially – on-call health advocates that staff can activate when an OD patient comes in.
Because of the specific volume and case-mix in one of her EDs, Dr. Mills had an opportunity to become an early adopter.
Dr. Angela Mills: Our Columbia Adult Emergency Department was the very first hospital in the city to be able to offer this service. The city chose hospitals based on the volume of patients we saw and [00:13:00] obviously we had a higher volume. And since that start we've been able to do a lot of things in our emergency department again for the larger patient population, not just people with non-fatal overdose, but other patients who come with substance use disorders.
Providing emergency care in New York City means upholding an inclusive philosophy and meeting all patients where they are. Dr. Farmer and Dr. Mills are constantly pushing the envelope to evolve and offer top-quality treatment to everyone who walks into their emergency departments.
Dr. Angela Mills: Our goal is that we're able to offer these types of, of services that just aren't in as many emergency departments. So we're proud of that and being able to give patients what they need.
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Next episode, we dig deeper into mental health emergencies, and the increasing incidence of behavioral decompensation.
Dr. Brenna Farmer: We're in the midst of a behavioral health emergency epidemic in the US and coordinating that care can be difficult.
Since the pandemic, rates of mental illness have nearly doubled in New York City, and [00:14:00] every year 34% of New Yorkers report unmet mental health needs. But city resources have dwindled. More and more patients – suffering from everything from severe intoxication to psychotic episodes – are seeking care in emergency departments.
Dr. Angela Mills: There are significantly less outpatient resources available for patients.
Dr. Brenna Farmer: Just like any medical condition, mental health medical conditions like substance use disorders or depression, suicidality, et cetera, takes a lot of effort and a lot of teamwork to be able to take care of those patients.
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I'm Erin Welsh.
Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the [00:15:00] pioneering physicians at NewYork-Presbyterian, go to nyp.org/ advances.
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