When Will Emergency Rooms Go Back to Being Emergency Rooms?

The University of Chicago hospital made headlines this week when it was criticized by the American College of Emergency Physicians for a plan that tries to get non-emergency patients out of its emergency room.

I’ve been fortunate to have only made one visit to the University of Chicago emergency room in the five years I’ve lived in Hyde Park. My youngest daughter Sophie was the reason for the visit. What had seemed like a run-of-the-mill kid’s illness had taken a turn for the worse. She had become extremely lethargic. She wouldn’t eat or drink and she had been vomiting, so we figured she was likely dehydrated. I took her to the University of Chicago emergency room at about 9 a.m. on a Sunday morning.

My visit started like most other visits to emergency rooms. When we arrived, there must have been 30 people in the waiting room. All of them were African-American. I filled out some paperwork and waited for the triage nurse to call my name to hear Sophie’s symptoms. At least half an hour passed and nothing had happened. I’m not usually very aggressive, but Sophie was looking worse and worse. So I went to the triage nurse and tried to do anything I could to see a doctor. I started by describing a set of symptoms that sounded like meningitis, even though she didn’t have all those symptoms. The nurse seemed unmoved. I then told her I had a son who died of meningitis. That definitely got her attention; but when she asked when he had died, and I said five years ago, she was much less impressed.

I guess she originally thought I meant he had died yesterday of meningitis. I told her that Sophie had become nonresponsive (and Sophie complied, staring off into space absently). I told her I was a professor at the university. I told her I would get my pediatrician on the phone. I’m not sure which of these strategies actually worked (I think it was being a professor), but within 10 minutes I was in to see a doctor. It turned out Sophie was badly dehydrated. They put an IV in her and she sprung to life. Our visit still took four to five hours. As we left, I was shocked to see that most of the people sitting in the waiting room when I arrived were still in the exact same spot, not yet having seen a doctor.

I don’t know the full history of emergency rooms, but I can’t imagine that the folks who designed them ever imagined they would turn out the way they have: a place where patients with no health care go to first wait six hours and then get routine care.

It is a system that makes no sense. If you read the description of what the University of Chicago hospital is trying to accomplish with its Urban Health Initiative that is being criticized, it does make sense.

Or you can do what my grandfather did and just avoid emergency rooms altogether. My grandfather was a doctor who practiced into his 80’s. I heard the following story from my father, so who knows what part of it is true, but this is how the story goes.

One day, while at home, my 80-something grandfather realized that he was likely having a stroke. He called in a prescription to the drugstore around the corner for some clot-busting drugs and sent my grandmother to the pharmacy to pick up the drugs. He crawled upstairs and got into bed. When my grandma got home, he took the drugs and just waited to see whether or not he would die. It turned out that he lived, with no noticeable side effects, which makes me wonder how true the story really is. One facet that I know is true, however, is that a man who spent 60 years of his life practicing medicine would do anything in his power to stay out of the hospital.


Jim

I understand your frustration. I have had similar experiences to yours in an ER. But after thinking about it, what is their incentive to provide good service?

If they had taken care of you and gotten you (and everyone else) in and out in 30 minutes or less, that would only exacerbate the problem. More people would use ERs to get good, fast medical care.

So it is in their best interest to provide limited customer service and try to match it to the seriousness of the illness.

Mike

I assure you, whatever point you were trying to make here has gotten lost. I leave this post thinking of a guy trying to pull every string he can (including flat-out lying) in order to get his daughter a drink of water. I hope no one you cut in line was seriously hurt by having to wait behind you as well.

Jon Luke

Tragedy of the ER--commons.

Scott Wentland

I've long wondered why they don't put free clinics NEXT to the emergency rooms. When someone comes in for routine care, they can just point them next door (or even connected to the emergency room if you'd like).

Problem solved. All emergencies go to the ER, free healthcare patients (who do not have urgent symptoms) go to the clinic next door. Does anyone know why this doesn't happen more often?

K

#2 If you read the post, it's clear this was not just a matter of "needing a drink of water". Severe dehydration can cause quite a number of serious side-effects. It's also pretty easily treatable most of the time with IV fluids and monitoring. The amount of time the doctor probably spent on this case was negligible, but clearly essential for Sophie.

Neil (SM)

#2 Except he was there with what seemed like an actual emergency. The long holdups are undoubtedly caused by the non-emergencies, ie, the masses who are using the ER as primary care.

John

How is the fact that everyone in the ER waiting room was African-American germane to your point?

edel

In Spain it has published that around 75% of patients' in ER are in no need of Emergency care. Two are the main reasons for that:
1) Hospitals do barely ever offer non-standard hours for medical procedures so patients on tight schedules don?t have a choice.
2) Even with the line queues, you still can save time* than doing the calls and appointments for a regular visit.
*In the US would be interesting to know if the monetary cost is different too.

One thing I have never come across is a prioritization scheme at the door of an ER department. This will solved three problems:
1) The "real" emergencies will be treated sooner
2) The injustice of selfless people (sorry Steven) be allowed to cut in line in front of others that follow the norm at their own expense
3) Discourage those with no real issue, since now their time may not be comparable to doing the regular appointment.

Eric

"I don't know the full history of emergency rooms, but I can't imagine that the folks who designed them ever imagined they would turn out the way they have: a place where patients with no health care go to first wait six hours and then get routine care.

It is a system that makes no sense."

It makes perfect sense. Emergency care is easy to get without insurance or ability to pay; routine care is hard to get without those things. The reason for this is that--rightly or wrongly--we care more about (dramatic) rescue than about prevention, even though this priority uses resources inefficiently.

In other words, a foreseeable, if unintended, consequence of giving free emergency care while not requiring payment for routine care is that people will crowd the ERs.

Beth

In my experience, ERs are actually pretty good at gauging how long a patient can/should wait, which isn't the same as our comfort level. When my son went to the ER for a dog bite, we waited over 3 hours. When we came in to confirm that he had developed Type 1 diabetes, we never even sat down in the waiting room (because the admitting team spotted signs of a life-threatening complication called DKA we were unaware of) and walked straight to an exam room with a waiting physician.

Generally, the severity of your need (from the ER team's perspective, not the patient's) is in inverse proportion to your wait time: the longer you are there, the better shape you must be in.

Zach

I'm not usually one to prance about and proclaim my country's greatness, however, In Canada we have a semi-socialized health care system and I have never had such a problem with a trip to the ER. Ive waited for upwards of 4 hours to see a doctor, but within 10 minutes of showing up with a non life-threatening in jury ( a broken ankle) a nurse came to check on me and make sure it wasn't anything worse. Another time when I came in with CO poisoning I was sent into the Intimidate care line by the front desk and was on oxygen within a couple minutes of showing up. When the system cares about making people better and not making(or saving) money.

Jesse

Reminds me of a Bush quote Paul Krugman uses often (quotes someone else saying the same thing here: http://krugman.blogs.nytimes.com/2008/08/28/let-them-eat-cake-and-go-to-the-emergency-room/). No one is uninsured because they can always go to the emergency room. I'm assuming your point is that clearing emergency rooms is another reason we should have universal (ish) healthcare.

michael

I've been in the ER twice in the last year - for myself and my daughter. Without knowing the true inner-workings, I did feel that most people there were the poor and uninsured who for the most part were waiting a long time for routine treatment.

That isn't to say there were people with genuine and immediate problems - and they, like me and my daughter, were waiting.

prfx

Health care has gotten pretty messed up in this country. There is a bizarre, perverse and incestuous relationship between pharma corps, lawyers, insurance, docs, academia, hr and bureaucracy that leaves most Americans with unreasonably high cost of healthcare in terms of time and money (which progressively more and more Americans can afford). Check out the cost of healthcare as a percentage of household income (double digit growth every year for the last decade, wtf?) Very dysfunctional.

VEH

Setting aside the fact that he did pull strings (and what parent wouldn't if they were alarmed by their kid's condition?), he's right. This is no way to run an airline.

To everyone who shrinks in horror at state supported health care, shouting about the evils of socialized medicine, I say--how can it be worse than the pathetic "system" we have now?

Fred Anon

Of course, if there was universal health care in the USA, most of those that were in the ER would be seen by a regular walk-in clinic, leaving the ER for real emergencies

Nic

Wow, I knew that one could do pretty cool things with instrumental variables but i didn't know that they were used in emergency rooms as well!

JM

As much as we would like to avoid emergency rooms, it has been a necessary evil two times in the past year (and we have excellent health coverage). The key is the triage nurses and process. Some hospitals are better than others obviously. We have walked into a ER with at least 50 people waiting and been seen within 30 minutes of our arrival....rightly so, as our situation turned out to be urgent but the key was triage. How quickly they evaluate and with a can-do attitude. Hats off to St Rose Hospitals in Southern Nevada!

Lewis

Mike:

http://www.mayoclinic.com/health/dehydration/DS00561

"You can usually reverse mild to moderate dehydration by increasing your intake of fluids, but severe dehydration needs immediate medical treatment."

And given that the treatment is so simple, what exactly is wrong with dealing with it pronto?

Basically, the problem with admitting teams is they don't think you know what you're talking about. If the professor thing is what did it, it's because it convinced them that the person insisting so much may in fact be on to something regarding the severity of the condition.

Jenn

Check for Urgent Care facilities or No Appointment Needed doctors if you have a non-life-threatening emergency.

These typically move faster and I've always had great care from them.