Emergency Rooms

Last month, an essay posted by retired physician Ken Murray called “How Doctors Die” got a huge amount of attention, some negative but mostly positive. Murray tells the story of an orthopedic surgeon who, after being diagnosed with pancreatic cancer, chose not to undergo treatment. The surgeon died some months later at home, never having set foot inside a hospital again.

Los Angeles doctors are plentiful, and Angelenos have some of the highest rates of visits to doctors and specialists in the nation. So you’d expect Angelenos to get the very best health care. But do they really?

Overcrowding in emergency rooms and departments costs lives.  A 2009 Government Accountability Office report found that “emergent” ER patients – those who need treatment in 1-14 minutes – faced an average wait time of 37 minutes. Patients have to wait longer than recommended over 50% of the time.  One in four hospitals even diverted ambulances to other emergency departments at least once in 2006.  In New York City, periods of ambulance diversion increased the heart attack mortality rate by 47%.

This blog has covered the issue a number of times, looking at ambulance diversion, emergency care state grades, the multiple reasons behind ER crowding, ER “super users,”  and more.  But we were given a stark reminder of the delays plaguing many emergency departments across the country when we read Dr. John Maa’s article “The Waits That Matter” in this month’s New England Journal of Medicine.

In his piece, Maa describes the story of his 69-year-old mother with mild heart disease.  After feeling slightly short of breath and noticing an irregular heart beat one morning, she had her husband drive her to the local hospital – “one of the most highly regarded academic medical centers on the West Coast.”  At the ER, she waited an hour to be seen, eventually being diagnosed with rapid atrial fibrillation and admitted into the hospital.  She receives an IV for anticoagulation drugs and is scheduled for an electrical cardioversion procedure the following day.

U.S. officials say the nation’s health system is ill-prepared to cope with a catastrophic release of radiation, despite years of focus on the possibility of a terrorist “dirty bomb” or an improvised nuclear device attack.

The emergence of H1N1 or “swine” flu last year raised fears around the world of a severe pandemic.

In the United States, health officials planned for the worst. They were concerned that the number of patients needing artificial breathing support might far exceed the number of hospital ventilators available.

American health officials drafted emergency plans that set out which patients would, and would not, have access to life support.

Dyspnea. Nausea. Dementia. The deep relentless pain of metastatic cancer.

Young physicians entering emergency medicine may envision spending their careers mending trauma victims and restarting stuttering hearts but soon find that they spend as much or more time treating chronically ill patients who cycle in and out of the emergency department (ED) with high symptom burdens and a grim trajectory that no one has stepped up to explain.

A short but quite interesting item in Newsweek. Will coverage expansion under health reform boost costs, as some critics claim? A new study of hospital costs shows that Massachusetts managed to cover 93 percent of its population without excess cost increases. And FEWER people are using the ER for routine care. (Emphasis ours in the quote below):

On Sunday morning at 7:30, Dr. Stuart Weiss, the medical director of the New York City Marathon, was holding a coffee with one hand, gesturing with the other, and moving at the stereotypically brisk pace of an emergency room doctor. Walking in and out of the white medical command tent in Central Park, he was focused, he said, on "What's missing? What's missing? What's missing?"

So just how fast does that revolving door spin? The Kaiser Family Foundation this week released several reports on Medicare spending for people in nursing homes or other long-term care facilities.  Of course it's no surprise that these patients are expensive -- they wouldn’t be in nursing homes if they were in perfect health. But the reports shed a lot of light on just how expensive their care is -- and just how often they go in and out of emergency departments, the hospital, and skilled nursing facilities.

These patients cost Medicare $14,538 -- nearly twice the annual cost of the average Medicare beneficiary. (Remember that Medicare pays for doctors and hospitals and the like -- whether the person lives at home or in a long-term care (LTC) setting. Medicare does not pay for long-term care. Medicaid pays for the long-term care of low-income people.)

The piece I did for Slate last week on palliative care and the emergency room sparked quite a bit of blogging and emailing and chatter (gratifying). One theme that stood out for me is the people wondering why a palliative care physician (or nurse) had to deal with these tough decisions about treatment and goals of care in the emergency room. Why they asked, can't the primary care physician do this? And I realized there is a really strange cognitive dissonance, or a nostalgic time warp, between the health care that we think we are getting and what we and our family members actually get.