I often feel like the proverbial canary in the coal mine, acutely aware of how broken medicine in the U.S. is and wondering if anyone else has noticed.
I’ve been an emergency physician for the last 18 years, but over the last several years, my job has felt different from what I trained to do. Emergency physicians are self-described adrenaline junkies. We thrive on trauma, stroke, sepsis and heart attacks. Little by little, however, the burden of disease we see has changed.
Even before the pandemic, it felt like the emergency department was shouldering the lion’s share of primary care: We’d provide treatment for hypertension, refill prescriptions when calls to the doctor’s office went unanswered and manage chronically elevated blood sugar. Behavioral health patients with nowhere else to go would arrive one after the other by ambulance. Eager to help our patients, we started to offer drug and alcohol treatment programs. Victims of our own success, primary care physicians now seem more likely to send someone to the ED for help than to try to treat them in their own office. And it’s understandable, given the inaccessibility of outpatient laboratory and radiologic testing for urgent issues.
Photos: COVID Nurses Recount Traumatic Experiences
When the Affordable Care Act was enacted in 2010, we were hopeful. The system was about to be overhauled and streamlined, with optimism that all patients eventually would have a primary care home with electronic records that would follow them everywhere and seamlessly interface with multiple systems.
Except that quantum leap never came.
Now COVID-19 has laid bare medicine’s house of cards. Those of us who worked through the pandemic were understanding at first. It seemed we were the only department with the lights still on. Primary doctors didn’t have protective gear. Surgeons couldn’t do routine operations for many reasons: fear of contagion, risk to staff and lack of beds for postoperative patients. At first, it seemed maybe this situation was temporary – that help would soon be on the way – but with each successive wave of COVID, the situation has worsened. We are now on the brink of disaster.
Most days in the ED where I work begin with 120 patients – most of them “boarding” or waiting for a bed upstairs in the hospital. We have only 53 beds in the ED to begin with. This translates into having nowhere to see the new patients who start to float into the waiting room which, if we are lucky, has just been emptied from the day before. By the time the floodgates open at 11 a.m., we are bursting at the seams.
These last few months we have decided to station physicians, physician assistants and nurses in the waiting room to see patients. We even see patients in the ambulance bay. Sometimes they stay there for hours, unable to move into the ED because of the roil of patients. Transporters take them to radiology almost from the door where they arrived. Because there is little hope a room will open anywhere in the ED to afford them the care they need, we start to care for them wherever we can – hallways, triage bays and waiting rooms included.
The other day, one of my colleagues joked that we would soon be caring for people in the parking lot. It isn’t far from the truth, and to be honest, it sounded like a decent idea: “At least,” I thought, “there will be ventilation.” We take chances when we send patients home, hoping their oxygen level will hold, that someone else can take a look at their skin infection the following day after starting antibiotics, that they understood our instructions on how to manage their high blood sugar.
It may sound like we have a local problem in our ED only. There must be a management issue, a quick fix that an astute hospital administrator can improvise, and we will be back to normal, caring for patients at the standard to which we are all accustomed. The truth is that this has become a national problem. Our ED is not alone. On social media, colleagues from all over the country are bemoaning the same situation.
The bottom line is this: The house of medicine in the U.S. is a house of cards that has already started its crashing descent into collapse. We didn’t go into emergency medicine to care for patients this way, and they certainly didn’t come to us expecting the care we are struggling to provide. So what are the solutions?
In order to tackle the problem, institutional leaders, insurers and lawmakers need to recognize emergency department crowding as a critical patient safety issue. Triggers that activate disaster protocols should be expanded to include indicators of crowding so resources can be directed toward minimizing boarding. Financial incentives must be aligned to encourage swift discharges with appropriate and timely follow-up. If the system is not able to accommodate adequate and timely outpatient testing for urgent complaints that are not life-threatening, then we need to find the pain points and create solutions. Capacity and turnaround times for outpatient labs and radiology must be examined and improved.
In addition, both public and private insurers must incentivize every one of their patients to have a primary care physician. In turn, primary care doctors’ offices must increase capacity and access for urgent cases. Primaries and specialists should consider judiciously whether to urge their patients to seek care in the ED for imaging and testing that could be accomplished as an outpatient. Patients themselves need to consider responsible use of the ED though it’s not simple, especially for those without easy access to medical care.
Our fundamental system must change, or the penalty will be the collapse of not only the system but the doctors, physician assistants and nurses who have been waging this Sisyphean battle as well.
Instead of waiting for someone to sound the alarm, I am doing it today. Consider yourselves warned.