Saturday, June 24, 2006

Emergency Rooms, the New Primary-Care Centers

ErchildWith 48 million uninsured and a near-equal number underinsured, where are they to go when a child wakes in the night with whooping-cough or an asthma attack? Night or day, asthma, chronic earache or unending diarrhea, the local Emergency Room is the sole remaining available option. And it's becoming unavailable at an alarming rate.

“Long waits for treatment are epidemic, the reports said, with ambulances sometimes idling for hours to unload patients. Once in the ER, patients sometimes wait up to two days to be admitted to a hospital bed.”

ErdoctorinternSo writes David Brown for the Washington Post, in an article that takes a look at what has been swept under the medical-services rug. 25 experts conducted a study and, as studies almost always do, in their collective wisdom they determined that

“fixing the problems is likely to cost billions of dollars and will require the leadership of a new federal agency, which Congress should create in the next two years.”

Oh lordy, save us from another federal agency. What is needed is to keep this problem as far from the clutches of Congress as possible and work, immediately, with small and innovative solutions that are hospital-based. Even a cursory look would show that


  • Emergency rooms are for . . . emergencies. Duh! They are not prepared or staffed as out-patient clinics, although they are being used more and more for that purpose.

  • Since the 1986 law that imposed the requirement upon emergency rooms to evaluate and stabilize all who walked in, ER admissions have ballooned at more than double the increase in population.

  • ER’s lose money, big money. Because of that, hospitals regularly under-staff and make them unpleasant places to go. Non life-threatening emergencies wait hours, in a sort of grudging triage designed to discourage return visits.

Now I don’t want to knock the Institute of Medicine or the twenty-five experts they had studying emergency rooms over the past two years, but nationwide studies come up with nationwide proposals, it's the nature of the beast. Emergency rooms are not national, they are local. The ER at a big-city teaching hospital has problems, expectations and workloads that are not analogous to rural or regional hospitals.


ErambulanceI have, over a lifetime, come to believe that if one wants to know what’s wrong with an airline, a manufacturer, school district, courtroom, candymaker or lawn-care service, the way to find out is to sit down with the line-workers and ask. CEO’s can’t give you a clue, consultants are less than useless and legislators will unaccountably but consistently make things worse by a factor of ten.


It’s not in the rulebook of how to run two-year national studies, but if I were one of the twenty-five experts, I’d be inclined to hang out in the saloon nearest to whatever hospital had my attention. A quiet ‘what’s the matter with that joint?’ over a beer can bring a lot of useful information. But what’s learned by that method isn’t transferable.


And that’s the major thing to be learned; that hospitals and their ER’s are local in the extreme. One may have a steady stream of the poor and uninsured clogging the halls, because it’s located in a poor and uninsured neighborhood and the only other nearby hospital recently closed down. Another, close to the Interstate, may have a high proportion of head injuries and no resident neurosurgeon.


EradmittanceEmergency medical care in the United States is indeed on the verge of collapse. In a great many areas, it has already collapsed and unnecessary deaths are soaring. Also on the verge of collapse, is the single mother with two jobs, no health care insurance and a sick kid. Congress, besieged by unions and various lobbyists, knowing there’s no voter-pressure among the poor, can’t help but make a hash of such a situation.


One thing they might give a moment’s consideration to, in between fund-raisers, is why sixty or seventy million Americans have no options other than emergency care.
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See Taking My Country Personally on my personal web site.