Health care emergency in nation's ERs

The St. Louis Post-Dispatch carried a quasi-expose in its Sunday editions last weekend that used one local example to highlight the growing health care emergency in our nation's emergency rooms.

According to the report, an ambulance crew was forced to divert a patient from a local emergency room because the supervising RN said the ER was too full and could not accept more patients.

The paramedics reloaded the patient -- a women who had been involved in a motor vehicle accident -- back into the ambulance and headed for another emergency room 22 minutes away. While enroute to the second location, the patient had a heart attack.

She didn't die, and the "offending" hospital apologized to the patient, who is now in cardiac rehabilitation and may be there for some time. My guess is that, eventually, the offending hospital will at least cover the cost of this woman's therapy, though the ever-present threat of a lawsuit is, I'm sure, also a consideration.

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Was the RN wrong? According to Missouri state and federal laws, and according to the hospital's own ER admissions policy, yes. But as someone who spent 15 years as a paramedic myself, I can tell you that the RN was wrong only in the letter of the law, not in the spirit of ensuring that this woman received quality and timely care.

Why was she diverted in the first place? Because of a phenomenon that is all-too-common for ERs in urban centers and is becoming more common in suburban and some rural facilities -- emergency rooms are no longer strictly for "emergencies"; they are little more than 24-hour urgent care and routine medical clinics that, "by law," must see all patients who present, regardless of the emergency ward's primary mission.

In the St. Louis case, the RN in charge diverted the woman patient to another facility because he was already dealing with 79 patients: 42 were being treated; 20 had been treated and admitted and were waiting for beds on the medical floors; and 17 had yet to be treated and were waiting to be taken back into the ER to be seen.

And by the way -- patients waiting to be taken to floors still require monitoring and, in some cases, continued care by ER staffers, so just because they're ready to be admitted doesn't mean they don't require attention.

So, even one more patient -- one that could reasonably be considered a "priority" patient, even before her heart problem occurred -- was simply one more too many for an already overcrowded emergency department.

In St. Louis and every other major city across the country, emergency rooms have long ceased to be centers only for the critically ill and injured. In their quest to "be profitable," suits who have no medical training but spent years learning how to turn a buck earning a business or finance degree now run hospitals, and so they have mandated that all patients represent potential income and, hence, should be seen regardless of ability to take care of them.

As a consequence, federal and state laws have also supported and even mandated this insane practice of taking every patient that comes through the doors, whether they have a hangnail (this happens; believe me) or have had both legs amputated in a car or farm accident. Hospital marketing campaigns have even encouraged such abuses.

Generally speaking, it is against the law to refuse to treat any patient once that patient steps onto, or is delivered to, a hospital's property. Emergency departments have managed to "skirt" the law by diverting ambulances to other facilities (ambulance crews call in reports to hospitals prior to arrival, to advise patient condition, request medication orders, etc.) before they pull up to the doors.

Is that fair to ambulance patients, most of whom are (generally speaking) in worse medical shape than most patients waiting to be seen by ER staff? No, it's not, but it is a logical response to impossible conditions.

I remember being frustrated as hell on several occasions because I was "diverted" from the facility the patient requested. In a few instances, all of the local hospitals were "on ambulance diversion" because they had so many people clogging their ER. In those cases, my partners and I would simply go to the closest hospital and wheel patients in unannounced. That ticked off ER staffers, but we simply could not drive around forever with these patients; many of them could not wait to be seen in hospitals 30-40 miles away.

So what's the answer?

In the "business," so to speak, there is a saying: "Just because you think you are suffering from an acute, life-threatening medical emergency doesn't make it so."

In other words, the medical professionals need to be making the ultimate decision as to who requires legitimate emergency care and who can wait to see their own physician in his office -- not the patient, which current ER and hospital policies support and encourage. It is ludicrous to expect a medical layman -- a patient -- to know whether he is suffering from a severe emergent medical condition. Some patients can make the distinction, and some medical conditions (a severe cut or heart attack) are fairly obvious; but in most cases, patients haven't got a clue what is and is not wrong with them; they're not, after all, trained to diagnose such things.

Additionally, federal, state and local laws should reflect the reality that emergency rooms were never established for the purposes of becoming doctor's offices or clinics in the business of taking care of "routine" medical problems. Emergency rooms were established by hospitals for the sole purpose of treating emergency and life-threatening diseases, injuries and illnesses.

What would stop such reforms? Attitudes.

For years now, Americans who think they're too busy to wait in their own doctors' office for an hour or so have opted instead to head for the ER, because they liken "emergency" rooms to fast food joints in terms of time. Thanks, however, to the overcrowding, this isn't the case anymore, if it ever was. In fact, in many cities, you will wait longer to be seen by an emergency room than you will if you decide to see your own doctor or go to an urgent care or 24-hour medical clinic.

Medical personnel spend years educating themselves; emergency medical personnel -- doctors, nurses, paramedics -- specialize in determining what types of illnesses and injuries put your life at risk and what types don't.

They -- not faceless bureaucrats or empty suits with business degrees -- should be deciding who needs emergency care and who does not. They should have the power to say to patients not meeting this criteria: "I'm sorry, but you don't belong here. You should go see your own doctor or go to a non-emergency clinic; we need to keep our space open for patients suffering emergency injuries and illnesses."

If they had this power, then perhaps the St. Louis woman -- and thousands like her everyday -- wouldn't have to be turned away or suffer needlessly by an overburdened, abused and crumbling emergency care system.

The "business" aspect of medicine won't like this approach because, traditionally, emergency departments are money-losers. "We have to be able to turn a profit or we won't stay in business at all," these people insist.

That's true, and I have no problem with a for-profit medical system because, generally speaking, it promotes competitive pricing. However, when it comes to emergency room treatment, most of today's HMO-related insurance plans don't pay squat as it is, so the financial problem is only compounded when you try to cram as many people as possible into as few resources as possible. The only "revenue increases" are seen on paper -- in the hospital's "uncollectable debts" line item.

In the end, as it stands, overcrowding caused by high numbers of inappropriate medical cases means almost nobody receives quality care, and the hospital becomes even more liable for a crippling lawsuit.

Doctor's associations and medical lobbies ought to push insurance companies to also recognize this worsening phenomenon by reforming billing practices and ensuring that -- for the cases that are appropriate -- the hospitals get paid for the treatment they render. The policyholder patient expects that, and the hospital has every right to expect to be paid as well.

In the meantime, if nothing is done, expect ER overcrowding to worsen and patient care to suffer.

This problem is a classic case of Americans wanting it "both ways"; they want instant access to medical care but refuse to distinguish or even recognize that there are priorities to medical care. Politicians and hospital bureaucrats have compounded this problem by succumbing to these unrealistic whims.

Going to the ER for a headache you've had off and on for two years is not an emergency, yet under current rules and guidelines, encumbered ER personnel are supposed to hypocritically treat it like it is.

It's a joke, but a dangerous one.