Once every room is full, once the hallways are stocked with beds on which patients lie like so many cords of wood, once EMS continues to bring fresh faces, fresh injuries, fresh drama, the ER grinds to a painful, screeching halt.

At that point, a helplessness descends on the nursing and physician staff.   Wait times creep from two hours to four, four hours to eight, eight hours to ten.  Only those who are obviously the sickest come back for care.  Remarkably, on some of the busiest shifts ever, I discover that I have seen the fewest patients.  If the pace were like normal, I could burn through ER visits like crazy; so could my partners.  But when the numbers waiting climb, when the patients being admitted and held grow to legions, then speed is dead.

These are the dangerous times.  These are the times when the sickest sometimes give up and go home.  And the times when overwhelming amounts of data crush clear thinking.

Emergency departments are often accused of many things as we try to improve American health-care.  Despite the fact that we account for only 3% of American health-care dollars, we are accused of being too expensive.  Despite the fact that we have a very limited window for evaluation of highly risky patients, and the fact that admitting physicians invariably desire more, not less tests, we are accused of ordering too many studies. And we are almost always accused, especially by the public, of being painfully slow.

The problem, and I hope not to beat a horse too long dead, we’re held responsible for much that we shouldn’t have to do, and we are mandated to do far more than we are physically, temporally capable of doing.

An emergency department is for initial evaluation and stabilization of life or limb-threatening illnesses and injuries.  Yet, we have become:

Endless chest-pain centers, whether designated so or not.  I do not lie when I say that if I see 23 patients in an eight hour shift, I’ll do no less than 8-10 EKG’s.  Some of this is regional, but chest pain and syncope (passing out), shortness of breath and dizziness are ubiquitous in the modern ER, and all require at least a cursory cardiac evaluation.  And they are truly speed-bumps to physician velocity.  (Not that we don’t care about coronary disease; we do a bang up job of it. But as I alluded in a recent post, I suspect much chest pain is more a psycho-social phenomenon than a reflection of pathophysiology. )

Neighborhood health-centers.  We understand that many can’t find or afford doctors, but it adds to the cost, the testing and the delay.  Patients come to me daily with long sagas which involve months of cold symptoms, years of back pain or decades of arthritis.  It’s unfortunate, but it’s not the right place.

Pre-admission evaluation and holding areas where primary care physicians can stage patients safely without having to deal with them until office hours are over. I understand, but there has to be a better place.

Pregnancy test confirmation centers.  Everyone knows, if you need or desire a test or ultrasound, tell the doctor you may be pregnant, and are having pain and bleeding.

Chronic pain exacerbation centers:  even those with pain specialists come to us for ‘breakthrough,’ which sometimes happen, but usually means they broke through their last pain pill about 3 weeks early after the party, and need something to get them through.

Disability enabling stations, where every stout, strapping woman and man who could reasonably lift a mule out of a ditch needs more medicine for that chronic pain or anxiety which has left them entirely unable to do any work except ride motorcycles and make babies.

Drama-rodeos, in which every young or old victim of, or participant in, social drama comes to the emergency department to be checked out, checked in, eat crackers, suck on ice-chips, get a dose of Ativan and call/text their friends to come and visit.

Mental health holding centers.  A private, nationally known chain of mental health centers used to advertise:  ‘if you don’t get help here, get help somewhere.’  That is, the ER.  Call a suicide hot-line and you’ll be directed to an ER.  It doesn’t matter that many facilities (like ours) don’t have psychiatrists or even counselors (except by tele-psych).  It doesn’t matter that they take up beds, languishing in line for commitments (which seem to be growing exponentially in number).  It doesn’t matter that the law requires us to pay one on one observers (and if they are RN,’s they get RN pay to read novels at $25/hour).  It doesn’t matter that we don’t have the security to manage it.  We are the last common pathway, so that someone, somewhere can feel good that ‘at least he’s finally getting the help he needs.’  No, he isn’t.  He’s getting observed and largely ignored until we can send him somewhere else.

Guilt assuaging centers.  Call any doctor’s office.  ‘If this is an emergency, hang up and dial 911.’  All you need to do, to do the right thing,  is send someone to the ER.  No matter how many stretchers are lined up in the hall, or how many schizophrenics or arrested drunks are screaming and terrorizing the little children with fevers.

It’s just untenable.  Medicine has slowly, surely, rested it’s bulk on the emergency departments of America, which are given a vast federal mandate without the federal money.  Like telling the EPA to clean up the Gulf, but fund it with a bake-sale.

If reform will fall on our shoulders, we will need some relief.  We need less rules, more money, less well-meaning over-sight and some protection from litigation.

After my last shift, I came away thinking that, although I hate both ideas, I’d almost agree to make all ER’s part of the Public Health Service, or failing that, unionized.

Because as it stands, we have every expectation placed upon us, but no support from those who make the rules, and no love from those who daily search for mistakes, both malpractice and regulatory.

Why is the emergency department so slow?  It’s easy.  Because we’re doing way too much that we shouldn’t have to do, and we’re doing it with far too little.

All I can say, to those in authority, is this:  ”Shoot up her amongst us, one of us has got to have some relief!’

Listen to the following clip for a little laugh from the inimitable Jerry Clower.

https://www.youtube.com/watch?v=-AX9QoFhEhI

Edwin

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