Emergency Rooms

USA Today ran two pieces the other day about the crisis in ERs. An editorial told an alarming story about a toddler having a seizure. The ambulance was diverted from a nearby but too-crowded ER where the family's doctor was waiting. The piece called for changes in how ERs are run. The other was an opinion piece written by the head of a leading hospital organization saying the way to solve the ER crisis is to cover the 47 million uninsured.

Both are right. But even if we followed all their recommendations, we'd still have a missing piece—adequate primary care in the United States.

The story of 23-month old Bella Nannini and her seizures, (she has insurance, by the way) is not a rare occurrence. Thankfully she was not harmed. Not everyone is so lucky. In Houston and Los Angeles, for example, the average hospital waves away or "diverts" ambulances away about one-quarter of the time. Nationally one ambulance is diverted from an emergency room a minute. Diversion is not always benign.

Picture an urban hospital where 67 languages are spoken, the Chinese food is glatt kosher, and the most exotic ethnic species is a blond Nebraskan surfer named Davey doing his medical residency in the E.R. Welcome to Maimonides Medical Center, in Borough Park, Brooklyn.

In HOSPITAL: Man Woman Birth Death Infinity Plus Red Tape Bad Behavior Money God and Diversity on Steroids author Julie Salamon gives rare insight into one year in the life of a large, complex, urban hospital (Read Jackie Judd's interview with Salamon about her new book here). In 2003, Maimonides admitted 38,667 patients, 127,319 were seen in its outpatient clinics, and 81,190 passed through the Emergency Department. More than 6,000 babies were born; more than 1,000 people died.

You may have seen the reports this week, on a recent journal article that the crowding we keep hearing about in emergency rooms is not the uninsured poor after all. That doesn't mean that the uininsured aren't going to the emergency room because, all too often, they don't have anywhere else to go. But everyone else is going too. After all, if you call your doctor at night or on weekend, doesn't the voicemail prompt caution you: "If this is an emergency, please go to the nearest emergency room"?

The number of people who visited U.S. emergency departments began to surge in about 1996, and visits have not decreased since then. From 1992 to 2002, the U.S. experienced a 23 percent increase in emergency room visits -- at the same time as the number of emergency rooms dropped by 15 percent. The population, meanwhile, grew by roughly 10 percent.

Increasing financial strains are pushing Level I and II trauma centers to the point of breaking, according to a recent article on Grady Memorial Hospital— the only Level I trauma center serving Northern Georgia, which loses over $40 million a year on trauma care. The problem is simple: the trauma services rendered to the uninsured are uncompensated, and the revenue generated from treating the insured is not enough to cover the deficit. The solution is clear: we must cover all Americans to financially stabilize our trauma care services in this country.

What happens when your local emergency room is full? For a troubling number of Americans, the ambulance is put on diversion and forced to seek the nearest hospital with open beds. These diversions were the focus of a recent article in Seattle Times and, more importantly, are a warning of the troubling times ahead for our over-burdened health care system.

The Seattle paper told the story of  Sara Nakagawa, who had complications 10 days after gall bladder surgery. She waited in an ER for six or seven hours,without being seen, went home and dialed 911. The ambulance then spent 20 minutes parked near her home trying to find a place that would take her. Later, the same thing happened to her 12-year-old stepson in the midst of an acute diabetic crisis. 

Ambulance diversion was rare before 1999, but it has since become increasingly prevalent and dangerous. Every minute, one ambulance is diverted from a U.S. hospital, according to a 2006 study in the Annals of Emergency Medicine. A study of New York City hospitals found that periods of ambulance diversion were associated with a 47 percent increase in the mortality rates for heart attacks.