Early in my residency, I realized that like Pavlov's Russian dogs of yore, the other surgeons-in-training and I had developed a conditioned response to our electronic pagers. Our blood would rush and our breath disappear at the sight of one five-digit extension on our beeper's screen.
The emergency room was calling.
It wasn't that we disliked the E.R. Some of our most memorable training experiences occurred there. It was just the sheer crowding of that area of the hospital that made our stomachs drop.
Day and night, the hallways of the E.R. were lined with gurneys, sometimes parked two rows deep. Patients were forced to wait, or "board," on those flimsy narrow stretchers until a bed became free at the "Inn," as the E.R. staff referred to the rest of hospital.
Stuck for hours and sometimes entire days, these patients were surrounded by the groans, cries and hacking coughs of others who waited with them. Doctors and nurses did what they could, pinning curtains around two stretchers to create makeshift semiprivate rooms and dimming the lights to bring some sense of calm to the chaos. But there were always more new patients, and the "boarders" would be left to continue their wait, calling out to whoever approached to ask for water, a bedpan or an extra blanket to keep warm in the chilly corridors.
None of my colleagues were surprised when we heard one day that a patient had died in those halls waiting for a bed. "I'm not sure there's much more we can do about this overcrowding," an E.R. nurse later confided to me. "It's not like we can turn people away; that's against the law."
Since 1986, when Congress passed a bill that made emergency care a legal right, emergency rooms have served as the safety net of the American health care system. But providing such care has become increasingly difficult in recent years. More and more hospitals are being forced to close their emergency departments, a major source of lost revenue, even as the demand for them continues to rise.
Once seen primarily as a problem of urban medical centers that affected only the poor and medically underserved, emergency room closings and overcrowding are increasingly viewed in a different light. More and more experts now believe that the current crisis in emergency care is a canary in the health care coal mine, a warning of more vexing challenges ahead for medicine in general.
And those challenges have the potential to affect every single one of us personally, patient and doctor.
The far-reaching implications were made painfully clear last month in The New England Journal of Medicine. In an eloquent and moving essay, Dr. John Maa, an assistant professor of surgery at the University of California, San Francisco, and a national leader in improving emergency care, describes the all-too-familiar story of a 69-year-old woman who is admitted to the E.R. for a procedure to correct an irregular heartbeat. Her operation is delayed because she has to board for a full day while waiting for a real bed. During the delay, she suffers a major stroke and dies.
The woman, we learn, was the author's mother.
"Emergency room overcrowding and boarding are formidable challenges that even I, as a surgeon dedicated to emergency care, couldn't address for my mother," Dr. Maa said recently. "What about other patients who don't have a physician as a family member?"
The major challenge for any patient in the emergency room is a reimbursement system that offers little incentive to decrease crowding or minimize boarding. Hospitals prefer patients who come in electively for scheduled procedures, at least from a financial perspective. For one thing, they are far more likely to be well insured than those admitted through the emergency room. By boarding E.R. patients in crowded halls, hospitals can offer the required emergency care for all while minimizing the effect on their bottom lines.
"It becomes a question of who can keep our hospital afloat," said Dr. Renee Y. Hsia, an assistant professor of emergency medicine at the University of California, San Francisco, and an author of two recent major studies on theemergency care crisis. "Being an emergency doesn't necessarily move you up to the head of the line."
In the last few years, several initiatives have attempted to address the overcrowding and boarding issues. In England, a new law limits the length of emergency room visits to four hours. Some American hospitals are reserving beds for emergency admissions and "smoothing admissions," distributing elective admissions more evenly throughout the week rather than clustering them on Monday mornings. Dr. Maa has led a "surgical hospitalist" initiative in his hospital that has now spread to hundreds of other hospitals across the country; it ensures that emergency rooms have a dedicated surgeon who will see patients within 30 minutes of arrival to speed their admission, discharge or follow-up care.
As promising as these efforts are, they have also revealed one thing: Truly effective changes won't occur until we have addressed the lopsided repercussions of a system that allocates care based on insurance coverage rather than clinical status. "In emergency care, in order to be efficient, you have to be equitable," Dr. Hsia said. "But as long as elective admissions take priority over emergency ones, then we will see the kinds of consequences that Dr. Maa's mother suffered."
