If this is an emergency, hang up and dial 911…

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Currently, in American healthcare, experts are wringing their hands in confusion.  I mean, people have insurance, right?  And yet, healthcare is still expensive and dang it, people just keep going to the ER.  Visits are climbing everywhere and I can speak from personal experience when I say that we’re tasked with more and more complex and multi-varied duties in the emergency departments of the 21st century.

I’m not a medical economist.  I do have some thoughts on the well-intentioned but deeply flawed Affordable Care Act. However, I won’t go there right now.  What I do want to address is the ‘go directly to the ER’ mentality of modern American medicine.

Call your physician.  If it’s after hours, the recording for any physician or practice of any sort in America will have a message:  ‘If this is an emergency, hang up and dial 911.’  It’s a nice idea.  But of course, it presumes that everyone really understands the idea of emergency.  In fact, they don’t.  We understand that, or we try to, but we see lots of things that come in ambulances, or just come to the ER, that really aren’t.

‘I feel fine, but my blood pressure is up.’

‘I was bitten by a spider and I watch nature shows and I know how dangerous they are.’

‘I have a bad cold and I have taken two rounds of antibiotics.  I have an appointment with my doctor tomorrow but I thought I’d just come on in to get checked out.’

The list goes on.  In part, it’s because we do a poor job of educating people about their bodies and their illnesses.  Online searches usually result in someone self-diagnosing Ebola or cancer, so that doesn’t help much.

But in part, it’s because the ER, the ED, has become the default.  Surgical patients are told to have wound rechecks in the emergency department.  Kids with fevers are directed there by pediatricians or family doctors or secretaries.  People who need to be admitted are sent in ‘just to get checked before they go upstairs.’  Or sometimes, so the physician on duty can do the negotiation with the hospitalist, rather than having the primary care physician do so.

Why is the ED the default? In 1986 Reagan championed and Congress passed EMTALA, the Emergency Medical Treatment and Active Labor Act, which says you can’t turn anyone away for reasons of non-payment.  Another well intentioned bit of government meddling, it never provided any funds for it’s expansive act of compassion so many emergency departments and trauma centers simply shut their doors.  You can’t see patients for free all day and still meet your budget.  I think something needed to be done, but it probably went too far.

Fast forward.  Insurance is expensive even when the government mandates it. Whether for fear of litigation or due to over-booked schedules everyone else can always send patients to the ED day or night for any reason.  We still function under EMTALA and that will never, ever change.  Patients have little to no expectation of payment when covered by Medicaid and know it (and thus use the ED for everything, and I mean everything.  We are seeing expanding life-spans for the elderly, but with more complex illnesses being treated and ‘survived.’   We have fewer and fewer primary care providers.

Who actually thought emergency department visits would decrease, and why?  Did they ask anyone who saw patients on a daily basis? Or only lobbyists, administrators and progressive academics with starry-eyed fantasies?

I want to take care of everyone. But the Titanic that is emergency medicine in America is sinking.  We really, honestly can’t bear the burden for all of the chaos of our national healthcare.  And don’t tell me that if we have a single payer system it will change everything, because it won’t.  EMTALA will go on and doctors paid by the feds will not be more productive than they are now, so everything will still flow to the emergency departments and trauma centers of the land.

This isn’t about rejecting the poor, or even criticizing Obamacare.  It isn’t about single payer or Medicare for all. It’s about entrenched behaviors and facing the reality of the system we’ve created which allows one part of the system to attempt to carry the limitations of the rest.

Herb Stein, father of Ben Stein, famously said:  ‘If a thing can’t go on forever, it won’t go on forever.’

And if its’ true anywhere, it’s true in the emergency departments of this great land of ours.

Where the answer to every crisis is: ‘hang up and dial 911.’

7 thoughts on “If this is an emergency, hang up and dial 911…

  1. Agreed, great article. One thing I started doing the last few years is asking patients (who are able to converse), “Did you call your primary care doctor before you came?” I was honestly shocked at how many actually did, but the office wouldn’t get them in. One poor gentleman, elderly, with CHF exacerbation, had called several times in one day but no one would return his calls, finally at 4 pm they advised him to go to the ED. I do think our community docs are maxed out, understandably, but was quite shocked at some of the folks they were sending to the ED instead.
    I honestly think there needs to be Public Service announcements like in the UK on when you should and should not go to the ED.

  2. I agree with your thoughts about America’s mind-set in regard to ERs. For years, I’ve watched and wondered as I see people go to the ER for the most minor things. My ex-husband is a paramedic, and I remember the stories he would tell about the nature of some of his calls – one of the most memorable was the family whose young son swallowed an insect, and his mom dressed him in his Sunday best and called 911 to have him “treated.”

    I have always tried not to abuse the emergency system; unfortunately, this effort caused my family more harm than good recently. About a year ago, my son was not feeling well. There was a “bug” going around at that time, and his symptoms matched what I was hearing every day…headache, nausea, dizziness, weakness. I’d had it myself a week earlier. After several days with no improvement, we went to the doctor’s office. The doctor wasn’t in, but we saw a nurse and a PA. The nurse was sweet and helpful, and I felt awful for her when during the information-gathering part of our visit, my son suddenly reared up and vomited. She barely escaped the splatter. She moved us to another exam room, gave him a shot for the nausea, and left us to wait for the PA.

    When the PA arrived, she stood just inside the door, never approached my son who was on the table, at this point almost too weak to lift his head. She told us that there was a virus making the rounds and that it should “run its course” soon. She’d prescribe something for the nausea, and we should continue giving him fluids – she recommended Gatorade or something similar – and maybe some Saltine crackers to settle his stomach if the meds didn’t kick in soon enough. Then she sent us home with the instruction “if he doesn’t get better in a couple of days, take him to the emergency room.”

    I did as instructed and took my son home. He slept most of the rest of the day, only waking to take his medicine and drink liquids as instructed. Late that night, he woke me up; his headache was worse, he was weaker than ever, and he started to complain about chest pain. Eventually his breathing became labored, and within a short while he was incoherent. I tried to get him to the car to take him to the emergency room, but he collapsed and became dead weight so I called 911. The paramedic who responded made an on-the-spot diagnosis: DKA. Unknown to us, my son had become a diabetic, and he was now in trouble. He went into a coma and was in the intensive care for 3 days. His blood sugar reached 1600. I didn’t even know it could get that high! As the ICU doctor said to me, my son was “a very sick young man.” In fact, it’s a miracle he’s alive today. The hospital staff was wonderful, and I’m proud to say that my son took charge of his health and is now in great condition. He is completely off insulin and manages his blood sugar with diet and exercise. He is a walking miracle and he knows it.

    I tell you this story to make this point: I did what I thought was the right thing to do; I took my son to his doctor for help. That boy was right there in the exam room, and he could have been given tests and examinations that, I believe, would have let us know that there was more going on than just a virus. He could have been saved the trauma of almost dying. Instead, what we got was a pat on the head and instructions to go elsewhere. Not just go elsewhere, but go home make the situation worse…I mean think about it: sports drinks and crackers? Not exactly what a person with sky-high blood sugar needs, right? It infuriates me that the people with whom I entrusted my son’s care blew him off with such nonchalance. With that kind of mentality from them, it’s easy to see why a person would just skip the doctor’s office all together and go straight to the ER. I wish I had. But that’s not the way it’s supposed to be. ERs are supposed to be for EMERGENCIES. My son probably could have avoided the ICU if the PA had paid closer attention. He may have still ended up in the hospital, but it wouldn’t have been by way of 911 and a diabetic coma. What’s the point of doctor’s offices if they aren’t going to actually treat their patients?

  3. maybe a dumb question, but why isnt the hospital opening a 24 hour clinic – staffed with nurses and PAs and triaging people to the clinic instead of the ER?

    A patient could always be upgraded to the ER if they needed it.

  4. One major problem is that we cannot turn anyone away – no matter how minor – because of a bastardized EMTALA law. EMTALA was designed to ensure that no one was turned away from the ED for the inability to pay and also states that an ED can’t just send someone to another hospital either because the patient can’t pay or because the ED is too busy, or just wants to “dump” a problematic patient on another facility. Somehow, this got twisted into “every patient who presents to the ED MUST receive a medical screening exam.” It’s even more twisted that, in many ED’s, nurses can’t triage a patient with a very minor and NON-EMERGENT problem at the window and tell them to go to their doctor the next day. This is very nice for the hospitals because they are getting paid either by the insurance companies or the Feds for the uninsured or Medicaid recipients. It sucks for the ED’s because now a non-emergent patient is taking up both a bed and the doctor’s and nurse’s time for something that should be seen in a clinic. And here’s the rub….hospital administrators aren’t going to put a stop to this abuse of the ED because they are getting paid. And worse yet, the higher-ups in the Emergency Medicine world are proclaiming that the ED will take everyone! Hooray, we are the heroes of the primary health care crisis in the US! But here’s what these people are missing: The burnout rate among Emergency Physicians (EPs) is steadily growing. One study cited a seven year burnout rate. Over the past ten years, there has been a ten-fold increase in the number of Emergency Medicine residency trained physicians. EM was the number one residency choice in the mid to late 2000’s. We did not go through 3-4 years of EM training to do primary care. The abuse of the ED by patients and, in my community….the clinics who tell patients that they can’t get them in that very day so they send the patient to “Convenient Care” (yes, that’s what they call it here…makes me want to puke. Convenient for whom? Oh yeah, the clinic!), is exacting a heavy toll of many of us. In 10 – 15 years, we are likely to see a shortage of EP’s, as we are seeing now in Primary Care specialties. And then, ironically, it will be Family Practice docs or mid-levels (Np’s, PA, LPN’s) staffing ED’s again and the EM world will rail against them stating that they have not been properly trained to provide quality emergency care.

  5. ***We understand that, or we try to, but we see lots of things that come in ambulances, or just come to the ER, that really aren’t.

    You don’t know that. Too many times patients are on gurneys and left in a hallway, ALL DAY without as much as a howdy do. You’re trained, I know that. Is compassion part of your training? I doubt it.

     “I have a bad cold, and I have taken two rounds of antibiotics.  I have an appointment with my doctor tomorrow, but I thought I’d just come on in to get checked out.”

    On this one I will agree that if they have an appointment the next day, they should wait. BUT……bottom line, we don’t want to die. If we feel something is not right, and think our problem has gotten worse, what do we do?

     Online searches usually result in someone self-diagnosing Ebol’a or cancer, so that doesn’t help much.

    That’s it! That is where you are assuming we are idiots. You must know how awful it is to go to the ER, personally, I will never go to another one, as long as I live. WE HATE THE ER!

    Ebola? Really?

     Herb Stein, father of Ben Stein, famously said:  “If a thing can’t go on forever, it won’t go on forever.”

    Well, he’s an ass, and WHAT??

    It won’t go on forever because it will kill you!

     90% of the medical community are so burnt out, we have no choice but to hope we aren’t dying.

     The last time I was in an ER, I was on that gurney, against a wall for 10 hours. When I was finally seen they said I would have to stay because I needed s blood transfusion ASAP. 2 hours before the transfusion, oops, we mixed up your records with someone else’s, you can go. Yeah, can’t wait to take a trip to the ER again. I would rather die, what’s worse, I think they would rather I die too. So the next time ER people bitch about us, we’re probably bitching just as much about them. Difference is, its your job and I’m sick. If you did yourself jaded, you owe it to everyone to get out of that field.

  6. I’m old enough to remember there used to be PSA announcements as to what constitutes an emergency; they ran perhaps once a day on our local channels, with a reminder that emergency room care is very costly and you showing up with a non-emergent condition could cost a true emergency patient their life.

    Of course, those were the days when ERs could charge more for a non-emergency visit. And when hospitals weren’t enticed by added revenue from diagnostics and ER interventionists’ services.

    I have been in the healthcare documentation field for over 30 years and it appalls me that so many people go to the ER for a headache! A severe, crushing, once in a lifetime headache, yes, but a run of the mill, tired, hungry, stress headache–really? Or with a child with a runny nose and perhaps a slight fever–I don’t think so.

    I think at least part of the answer to this is education. Yes, of course, basic anatomy and physiology for everyone, starting in elementary school, but also education on common medical conditions and which of these is serious and which not, with emphasis on when to report to an emergency room. Most states have a physician contact system for after hours; use it! The healthcare system in general and the pharmaceutical companies in particular have made many people afraid to trust their own body’s ability to heal, to weather a cold, to recover from a headache or other aches and pains, without seeking immediate attention and often overkill (pun intended) diagnostics and treatment.

  7. Is it a California law that physicians must leave on their voicemail, the option for the member to call 911, i.e.:
    The answering service or recorded message should instruct members with a life-threatening emergency to hang-up and call 911 or go immediately to the nearest emergency room. After-hour answering service or recorded message must provide a clear instruction on how to reach the physician or the designee (on-call physician) during after business hours. Physician or the designee must respond to urgent after -hours phone calls, messages, and/or pages within thirty (30) minutes.

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