Hospital Helper, Part II: The ER and the Changing Face of Practice
Visiting a friend in rural Connecticut recently, I was asked to see his son-in-law who was quite ill with a temperature of 103, and a nasty soft tissue infection (cellulitis) of the foot. A house call after a 20 year hiatus? Well, letís say home consultation. The family had called their own family physician, member of a group practice, the day before, a Friday at 4:15 pm, but couldnít get past the phone lady who followed the current litany with: "No appointment until next week," "no physician available until Monday morning," and, finally, "Go to the emergency room..." Sound familiar? Four hours later, counting travel and waiting time, the patient received treatement at a freestanding $100-a-visit clinic. A single injection of a "new antibiotic" was given, but no prescription for oral antibiotics. He was asked to return in 24 hours for "another shot" (and another $100 charge). By the time I saw him 72 hours had elapsed from the onset of his illness. Finally, on my advice the patient went to the nearby University ER, and was admitted to the hospital.
Another story comes to mind. A 67 year old man experienced sudden loss of vision in one eye and called his ophthalmologist. The office secretary was told the problem, but informed the patient he could not be seen for two weeks. When the doctor finally saw him he had complete and permanent visual loss in the left eye due to a retinal detachment. Neither the patient nor the secretary knew that sudden visual loss is a medical emergency.
Aside from mismanagement at the freestanding clinic and the resultant two day delay in proper treatment, there was, to me, the shocking fact that a family doctor belonging to a group practice had no evening or weekend coverage. When I was in practice, making 4 or 5 house calls a week and sharing coverage with other physicians on a rotating basis was routine. In those days emergency rooms overwhelmingly handled emergencies. Admittedly, there was a dark side to this picture. ER doctors, responsible for the most seriously ill or injured patients, were the least experienced physicians, usually interns and residents. Today, ERís are staffed with highly trained specialists in emergency medicine. Some things do change for the better.
In the second case, failure of the ophthalmologist to have a properly trained receptionist was a clear-cut case of negligence. Formerly, a doctor might be subject to a lawsuit based on the negligence of even his answering service. In the best of all possible worlds, every patient should have a primary care doctor who provides 24/7 availability for routine and emergency care, but nowadays this is no more than a distant dream. One bright spot is a growing number of specialty groups that make house calls. See The American Academy of Home Care Physicians.
When Should You Go to the ER?
There is no substitute for common sense and good judgment in deciding when there is a medical emergency. Trust your instincts. Itís obvious that when someone is unconscious or with severe chest pain or bleeding, the choice lies between a 911 call and an ER visit, whichever seems quicker. In questionable cases when you may be concerned about severe symptoms, it is best to call your primary care physician first to determine if a true emergency exists. Even if you end up going to the emergency room, contacting your doctor first is important, since he can meet you there or call ahead to give the ER doctors pertinent information about your medical history.
An excellent website belongs to the American College of Emergency Physicians and especially their subsite with links to nearly the entire spectrum of possible emergencies ranging from animal bites to wound care. Following are some general guidelines to help you decide when a trip to the ER is necessary: According to the ACEP, "Not every cut needs stitches, nor does every burn require advanced medical treatment." Among life-threatening emergencies listed by the ACEP are the following, with my additions or comments in italics:
Any chest pain lasting 2-5 minutes or more, especially unexplained frontal chest pain with or without radiation to the back, neck, head, shoulders or arms.
(Other) sudden or severe pain especially unexplained abdominal pain lasting more than an hour. Significant steady abdominal pain lasting more than 4-6 hours generally indicates an acute surgical condition.
Coughing or vomiting blood.
Severe or persistent vomiting or diarrhea.
Difficulty breathing, shortness of breath, persistent wheezing or uncontrollable cough.
Sudden dizziness, weakness, or change in vision lasting more than a few minutes.
Sudden onset of one-sided weakness of an arm and/or leg, or facial droop on one side.
The "worst headache ever."
Change in mental status (e.g., confusion, difficulty arousing) or unexplained loss of consciousness. A brief episode of fainting does not qualify as an emergency, particularly if relieved by recumbency.
Sudden development of any symptoms, such as hives, wheezing, or generalized itching, either spontaneous, following or an insect bite or ingestion of food.
Take immediate action, the ACEP suggests. "(This) can mean anything from calling paramedics, applying direct pressure on a (bleeding) wound, performing CPR, or splinting an injury. Never perform a medical procedure if you're unsure about how to do it." A good idea for all of us: take a course in first aid and CPR.
More About Emergency Rooms
Because of physician unavailability, lack of a family doctor, or simply a cultural shift in perception of illness, going to an emergency room has become a trend in this country. According to the American College of Emergency Physicians, Americans made more than 115 million visits to hospital emergency rooms in 2003. Among the most common complaints were chest and abdominal pain, fever, and cough. About one out of eight of those seen in the emergency room are admitted to the hospital. The National Center for Health Statistics estimates that more than 55% of these visits were unnecessary. Translated into dollars and cents this means at least 43 million Americans and their insurers, leaving out the 20 million uninsured driven further into debt, paid up to four times as much for routine care as they would have at a physicianís office. This cost has been estimated at between $15-$20 billion. It does not include the economic losses incurred by employers and workers for excess lost time in the work place, estimated to be on the order of 350 million work hours. This figure is derived from a mean waiting time of 3.2 hours. Ask your average ER patient if they were seen that promptly.
Not all this wasted time is the fault of the ER, which, after all, is not set up for care of routine illnesses like respiratory infections and non descript fever. Since emergency rooms really are intended for emergencies, they cannot work on a first come, first served basis as many people mistakenly believe. Once a patient arrives, healthcare workers make an immediate estimate of urgency, called "triage" (French for "sorting") to ensure that the most critical patients - those with heart attacks or stokes, or the seriously injured, are seen first. Everyone else has to wait. Thatís simply part of the menu.
Another big reason for long waits in the emergency room is overcrowding. The number of emergency rooms in the U.S. has decreased since 2001, but the number of patient visits keeps increasing. Moreover, in some parts of the country there is a serious shortage of nursing staff leading to even longer waits and more overcrowding. While ER physicians are available 24 hours a day, 7 days a week, an increasing number of other medical specialists, such as neurosurgeons, cardiologists, and orthopedic surgeons (let alone obstetricians) are melting or moving away because of skyrocketing medical liability insurance premiums and inadequate reimbursement.
The migration of medical care from doctors' offices to the ER and beyond is, as someone remarked during the French Revolution, "more than a crime, it is a mistake."
Martin F. Sturman, MD, FACP
Copyright 2005, Mathemedics, Inc.
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