The clock reads just past noon, which is near the start of the busy time for the ED.

"Usually around 7 to 9 it is very manageable," says Roberta Coombs RN, director of emergency services. "It's a good time for staff to check their equipment and get caught up. Then around 10 a.m. things get busy. Invariably, if I want things to pick up, I'll say, 'Oh boy, it's quiet.'"

Coombs says the ED at LMH mostly services senior citizens with cardiac and respiratory cases. Sometimes trauma patients are rushed in from car accidents, but more often than not, these end up at Mass. General Hospital.

"We don't really get a lot of gunshot wounds," says Coombs. "Medford doesn't really have a lot of that."

Of course, one never quite knows what to expect in emergency medicine. That unpredictability is a big draw to many nurses and physicians in the field.

"This is one of those places where you can see anything," says Sheila Cangiano, RN. "Every patient is unique. We actually had someone come in with an arm in a bag. The patient was in a motorcycle accident and was sent to MGH."

"The other day I'm over in the triage and someone says, 'Someone cut his finger,'" adds Helen Maunsell, RN. "But he had cut it off. You never know what's going to be minor and what's going to be serious."

Patients are brought in throughout a busy Wednesday afternoon. At 1:40 p.m., a man is wheeled in with a neck brace. He is recovering from a seizure. Ten minutes later another man comes in with heart trouble and is given a cardiogram.

All around, hospital staff goes about their business in a smiling and efficient manner. Since January, hospitals in Massachusetts have no longer been allowed to divert ambulances when busy and Coombs says this has brought about some changes.

After being admitted, most patients are treated between two and four hours, says Coombs.

Looking back a year, this figure was closer to four to six hours, she says.

"That was pretty consistent last year through November," Coombs says. "We started working on no-diversion in September."

The biggest challenge in an ED is finding beds for everyone who needs treatment and Coombs says this can be problematic with psychological patients who need special accommodations without any potentially harmful items.

"If a patient really wants to commit suicide, they'll find a way," Coombs says. "And we have to keep them safe."

Since the no-diversion policy went into effect, hospitals have taken a serious look at discharging patients in an efficient manner.

"When a patient gets discharged, it's almost as much work as when a patient is admitted," says Coombs.

Under no-diversion, she says case managers have become even more skilled at coordinating whatever treatments and tests patients need before they can be discharged.

On average, Coombs says the LMH ED sees about 60 to 62 patients a day. The area has two major sections, commonly called the "acute" area and the "extension" area. In busy times, less sick patients will be directed to the extension side so they can be processed more quickly.

"It can get very busy," Coombs says. "The challenge is - the patients wait in the hallway and usually on a stretcher with family. We want to make them feel like they haven't been forgotten."

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