Emergency Medicine at the Breaking Point….

2006-10-19T14:39:00

Emergency Medicine at the Breaking Point….

The following guest blog was written by Matthew Bassett, an Emergency Response Manager for a company located in Maryland, and an EMT-B. The viewpoints below are Matthew’s, and not of Emergency Medical Products.

We all have a horror story. Most of us have more than one. The triage nurse who simply refused to process our patient. A full-scale resuscitation effort that happened in an emergency department corridor because all the beds were full. The two-hour waiting times, the EMS supervisors called to the facility, the patients, sick of waiting, who tried to get off the cot and just go home.

And we all know that it’s getting worse. Relationships between hospital staff and EMS providers, once jovial and fraternal, have soured in many places. Emergency departments struggle to find beds and providers in the face of a never-ending stream of patients, and often, they take their frustration out on us. In turn, EMS providers grow increasingly restless in the emergency department hallways, sometimes with critical patients. More often, however, we wait with Priority 3s tying us down at the hospital while our colleagues run themselves ragged across large jurisdictions.

As both a volunteer EMS provider in a major urban area and an emergency management professional, I’ve seen the problem of overcrowded emergency departments from the top and the bottom. I’ve sat in meetings with fire chiefs and hospital administrators who floated grand schemes and focused on silver bullets, and I’ve stood in fluorescent hallways for hours, out of service and waiting for beds.

While there are many theories, I have encountered general consensus on one pivotal issue. EMS and the emergency department have become the new primary care providers, for the enormous (and growing) number of Americans who cannot afford “normal” health insurance. Regardless of your political views or your explanation for the problem, we all agree that it’s not going away. And federal law requires that no hospital turn any patient away based on their ability to pay (or just about anything else, for that matter. Yet the modern system of HMOs and hospital management is based on generating revenue.

In short, we have emergency departments who can’t afford patients being flooded with patients who can’t afford anything else. But this flood of primary-care patients, with rashes, colds and sprains, engulfs the beds EMS providers need for real emergencies. Cardiac, stroke, and trauma patients face longer transport times to hospitals which might be so clogged that their care could be unacceptably delayed.

The current situation is clearly untenable for us, as EMS providers. Lengthy ED waits strain response times, patient care, and morale. What may not be obvious to the general public, however, is the danger such overcrowding presents them- even if they’ve never been to the hospital and are in perfect health. To say that 9/11 changed everything is to restate the painfully obvious, but terrorist attacks and natural disasters like Katrina have reshaped our perception of the world beyond our ambulance doors. Tunnel vision on one particular threat, such as terrorist attacks or hurricanes, will not help us to prepare for the next “big one.” Instead, we have to adopt an “all-hazards” approach- ensuring our emergency response infrastructure is flexible and coordinated enough to approach any incident.

But in preparing for all hazards, we must acknowledge that our emergency medical system is at the brink. With overcrowded emergency departments, lengthy transport times, and thinly-stretched EMS coverage, a major disaster like Katrina, 9/11, or the Northridge earthquake of 1994 could cripple our ability to help.

We can’t ditch a call to the Priority 3 patient across town when, a few moments later, the dispatcher calls for mutual aid for the Priority 1 down the street. We can’t dump patients in the waiting rooms at a hospital and then leave- they have to be seen by someone. We can’t, in good conscience, encourage people who want transport to sign refusals instead.

To be blunt, the American emergency medical system finds itself in crisis because of the poor. Whether they are elderly Americans warehoused in cut-rate nursing homes, minimum-wage Wal-Mart employees in America’s rural areas, or illegal immigrants living on the fringes of society, their access to healthcare exists only through the door of an emergency department. Short of sweeping federal legislation (and a shocking drought of American compassion) these people will remain legally entitled to one avenue of healthcare- ours.

What can we do about this situation? The answer is, not much. As EMS providers, we show up for our shifts, transport our patients to the hospital specified by protocol, and generally do the best we can for these people. But as informed citizens of a free and open society, it behooves us to advocate for change in the environment of modern healthcare. To improve our capabilities in responding to true emergencies, and to prepare ourselves for a strong and flexible response to a major disaster, we must advocate for broad-reaching healthcare reform.

It sounds extreme. Our job begins at the scene and should theoretically end at the hospital door. But what happens after we arrive at the receiving facility- and more importantly, what happens before we are dispatched- is crucial to healing our emergency response system and alleviating the crushing load of low-priority, “primary care” calls.

Access to free clinics, neighborhood health outreach programs, and “urgent care” centers are working like a Band-Aid across a lacerated artery. Federal, state, and local governments must work together with health departments, community organizations, and public schools. The common goal should be comprehensive health education and access to primary care for those too poor to afford it, even illegal immigrants. We can have primary care systems in place, or we can take them to the ED.

A lot of American taxpayers would (understandably) balk at such a plan. It sounds like the national healthcare system that’s become the third rail of American politics. And it’s true. Such an effort would not be cheap. Nor should it be one-size-fits-all. Communities should decide for themselves how to implement it. But taxpayers would see significant savings at all levels, as government subsidies of overcrowded hospitals and ambulance transport for indigents would decrease drastically.

But this is not, and never has been, about money. Hospital overcrowding lays an intolerable burden on our ability to care for others. Overloaded emergency departments slow down everyday responses, and in doing so, could cripple our ability to manage a large-scale disaster like 9/11 or Katrina.

You might not agree with the solution I propose, or might have a better one. I’d be very interested to hear opinions in either case. But I think EMS providers can all acknowledge that we cannot meet this challenge alone. We need to advocate for ourselves and for our patients when it comes to this issue. In doing so, on a local or national level, we strengthen our country’s ability to stand ready.

As a friend and fellow EMS provider always tells me, I’ll see you at the Big One.