"CRISIS IN THE ER" and "CODE BLUE" are the headlines on the cover and on the feature article inside in the September 10 issue of U.S.News & World Report . Masked doctors work frantically over a dying man, a car accident victim in Fairfax County, Virginia. An emergency medicine resident, with beads of sweat standing out on her face, works intently over a patient. A physician's assistant injects an anesthetic into the spine of a woman whose face is contorted with pain. A lab tech draws blood from a patient lying on a gurney in a hallway, while a doctor fills out eternal paperwork and the ER scene whirls around him. A mother, trying to get seen at an ER, comforts a son who got choked on a stick.
A picture is worth a thousand words, and all these pictures accurately describe the hectic daily routine at Emergency Departments across the United States. When we watch this kind of turmoil on TV shows like "ER", we imagine it is the creation of writers just for dramatic purposes, that doctors under that kind of stress, with patients that volatile and critical, would need medical care themselves after more than a few hours of that kind of pressure. But it is not a writer's dramatic license, according to the U. S. News article. It is everyday life, and not just in big inner cities. Most of the article concentrates on Fairfax County, Virginia, a high-technology mecca with a median household income of more than $90,000, home to Colin Powell and Sam Donaldson and other high-income residents of Washington's annulus.
"It used to be that ERs got swamped just during winter flu outbreaks, or just in inner-city neighborhoods on Saturday nights. But now emergency departments are overwhelmed year-round. They're maxed out in world-class institutions that consistently land on this magazine's honor roll of Best Hospitals-including Johns Hopkins Hospital . . . the Cleveland Clinic, which last year turned away ambulance patients almost half the time.", the article contends. "When there's not enough room, there's not enough room", one emergency department chairman stated.
The article recites a litany of delays and frustration, one woman stating she spent five hours lying in a busy hall with excruciating back pain without even an aspirin or a drink of water before she saw a doctor. "The national ER crisis has doctors and nurses feeling desperate, dreading the day when the crush and chaos will create the conditions for a fatal mistake. . . 'We get yelled at on a daily basis', says Fairfax nurse Elizabeth Ireland. She recently went to court because an 18-year-old traffic accident victim, angry that he had to wait, grabbed her by the throat and yanked her off her feet."
ER visits number 103,000,000 a year in the United States. Patients arrive with a "dizzying array of complaints: asthma attacks, stomach aches, horse bites, psychotic breaks, earaches, the flu. In some ways, emergency medicine is a victim of its own success. That success has been built by decades of public health campaigns urging people to call 911; the sophisticated care available in emergency departments, which are a far cry from the 'accident rooms' of decades past; and the lure of the glamorous EMTs and nurses portrayed on Third Watch and ER. But a real emergency department is anything but glamorous. 'Do you think people have fun sitting in our ED for six hours?' asks Tom Kirsch, an attending emergency physician at Maricopa Medical Center in downtown Phoenix. 'It's horrible. It's awful. But people need healthcare, and our country has chosen to make EDs the providers.' " Many people use ERs as clinics, for illnesses that are not critical; some go out of frustration because they are unable to get appointments soon enough with their primary care physician, if they have one, or find that many doctors on insurance lists allowed by their providers will not accept new patients. "People come to the ED because their doctors won't give them an appointment for 3 days . .. . For a kid with a fever, 3 days is too much", stated an ER physician in Maryland.
Other factors creating the problems are nursing shortages, technician shortages, and the frustration of doctors who are working 12-15 hour shifts because these professionals are in such short supply. Many hospital EDs are not staffed by Emergency Medicine Board Certified physicians because the long hours and high pressure of the job turn many medical students away from that specialty.
Between 1994 and 1999, more than 370 emergency departments in hospitals across the country were shut down. About 4,200 remain. And the demand for that shrinking capacity is growing, as high technology medicine keeps sick people alive longer. The number of emergency departments in rural areas dropped by 11% in the last decade, leaving the remaining EDs with a much larger volume of patients. "There is no more flex in the system", the article states.
"Nurses, doctors, and paramedics fear that this winter's flu season will overwhelm a system close to the breaking point. 'We're going to move from a crisis to a disaster', says . . . the director of the emergency department . . .. in Concord, Massachusetts. Hospitals there are working on a statewide disaster plan."
In suggesting solutions, one item the article highlights is to "build more urgent care centers". A boxed side bar headlines "Urgent-care clinics take some pressure off the ER". "I've never been in and out of the ER in less than four hours. I didn't want to sit and wait", is why one mother stated she prefers urgent care clinics to ERs-"for convenience".
More families like hers are opting for medical care at Urgent Care Centers for pressing, yet not life-threatening, health troubles-such things as strep throat or a cut that needs stitches, according to the article. "Increasingly, families are using them as alternatives to their primary-care physician's and pediatrician's office when they can't make quick appointments."
According to the article and the North American Association of Ambulatory Urgent Care, there are about 16,000 urgent care centers in the U.S. and the number is growing. "Patients like the centers for their convenience and affordable cost. 'We usually never wait more than a few minutes', says .. . . a former nurse and mother of four."
Urgent Care Centers can take some pressure off the ER, according to a medical director in Springfield, Virginia.
In much of the country, insurers have warmed to the idea of reimbursing urgent-care visits. "And because staff at these clinics are often less stressed, they can spot things a busy ER triage staff might miss."
"'We received a family here who had waited for hours in a local ED. Their young child had abdominal pain', says Steve Whitson, vice president of ambulatory services" at a Fort Worth urgent care center. "The familiy finally headed to the UCC. The diagnosis? Acute appendicitis; the child was rushed into surgery, just in time to prevent a rupture."
This article in U. S. News & World Report is available online at www.usnews.com.
This last link states that you should head to the ER for:
Uncontrollable bleeding
Poisoning (but call the Poison Control Center first)
Severe allergic reactions
Severe difficulty breathing
Possible signs of a heart attack or stroke
Other symptoms can be handled by urgent care. Some urgent care centers, like MedExpress Urgent Care at the Wharf, have Emergency Medicine physicians as their staff. The 4 doctors at MedExpress are all Emergency Medicine Board Certified/Board Eligible and have experience at emergency departments in 4 counties in West Virginia. They are qualified to handle any emergency, however they do recommend in the above instances, to go to the hospital first. MedExpress physicians Dr. Frank Alderman, Dr. Kevin Blankenship, Dr. Christian McCarter, and Dr. Bryan Stuchell stress the qualifications of the doctors and nurses, the convenience of the hours, the convenient location in the Wharf District, the onsite Xray, lab and minor surgery, and the acceptance of most insurance including The Health Plan.
Source: Shute, Nancy and Marcus, M. "Code Blue; Crisis in the ER."
U.S. News & World Report , 10 Sept., 2001, p. 54-61.
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