18 May 2012

The E stands for "Emergency"

Beating A Dead Horse

I can't believe we are still having this conversation. Really, it kind of makes me sick. I've been beating this dead horse for five years now, but I guess it's worth saying again.


Sorry to shout.

I'd like to thank Aaron Carroll & Sarah Kliff, who recently made the point (again) over at the Washington Post's Wonkblog:
The emergency room is not health insurance

and on CNN:
Why emergency rooms don't close the health care gap

And I'd like to expand on their points a little bit.

What the ER does (because federal law says we have to):

  • Examine every patient who walks or rolls through our doors.
  • Screen for life-threatening disease or other conditions which present an imminent threat to health and bodily function.
  • Provide necessary stabilizing care for the above.

What the ER does (because we are nice people and like helping patients):

  • Treat minor injuries and acute but not life threatening illnesses.
  • Treat exacerbations or decompensations of chronic illnesses.

What the ER does not do:

  • Provide comprehensive, integrated, longitudinal health care.
  • Provide screening and health maintenance services.
  • Manage chronic illnesses.
  • Provide guaranteed access to subspecialty care.

So, if you come in because you are pooping blood and it's serious enough that something needs to be done to stop the bleeding, you're in luck! We can do that. But if, say, you come in because you're tired and I notice that you are slightly anemic with a very low-grade lower GI bleed from your as-yet-undiagnosed colon cancer, well, that's unfortunate. Because I will be sympathetic, and I will tell you that you need to go get a GI doctor somewhere to agree to scope you, and good luck with that if you are not insured. Maybe you live in a county with a hospital for the indigent who can do that for you in six months, if you've the fortitude to stick with it through the byzantine process it will take for you to get into their clinic. Hopefully, they'll diagnose you before it metastasizes. But I'm going to give you a piece of paper and send you home. Regretfully, I should add. I care, but I can't give you the care you need in the ER.

Alternatively, if you come in with an acutely blocked and inflamed gallbladder, I can get you to the OR for a surgeon to take it out before you get septic from it. Yay us! If, however, you have the seventh attack of excruciating pain from an uncomplicated gall bladder attack, that's a pity. I can make you feel better and send you home with a piece of paper. Maybe you'll get lucky and it'll get bad enough that someone has to take care of it.

Further, if you come in with a hangnail and I notice that your blood pressure is sky-high, I may be able to give you a short-term prescription for a blood pressure medication. But I can't manage it forever through the ER (though some patients try), and unless you get into a family doctor's office to get it taken care of properly, I'll see you again in a few years when you have your heart attack/stroke.

So, Thank You, Sarah and Aaron, for making this important point yet again. Let us all scream it from the rooftops. The ER is for Emergencies. That's what the "E" stands for. We're a backstop — the option of last resort, the societal safety net. We are not the venue for universal health care, and I wish that for once and for all that policy makers (largely the conservative sort) would get that through their heads.


  1. You left out the part about providing free narcotics for drug abusers!

  2. My favorite example was when w was claiming everyone in America could get health care by going to the ER at the same time his spokesman, Tony Snow was dying of colon cancer. W was advising everyone to get their screening colonoscopy. I was screaming at my TV "you cannot get a screening colonscopy in the ER!"

  3. This is just what I've been looking for, a blog written by someone who knows what he's talking about. I found this article to be both informative and entertaining (horse beating image) -- Fine job. Thanks.

  4. This post is really true.ER- stands for emergency and it should be well equipped with all sorts of procedures and methodologies to attain any sort of true emergency cases.

  5. When will people understand what an emergency is?

  6. Last shift I worked there were just over twenty patients. One was an emergency. That may be a little lower than the average, but not much.

  7. I've long said that when i triage patients, i'd love to steal a line from the 911 operators and say "Welcome to our hospital, what's your emergency?" Sadly, lots of folks still wouldn't get it.

  8. Great examples! They are all so spot on!

  9. to be fair though, ER's couldn't stay open with just level 1 and 2 patients. We need those level 3s to keep us in business.

    Family practice and internists seem unable these days to handle anything beyond a "well baby" exam in their office. And lord help them if they had to arrange a direct admit if they actually figure out in the office if someone is sick enough to need admission. Its so much easier just to send them to the ER.

    That's why Monday's are our busiest days. Insured patients with doctors still can't get into to see them. Or else get seen and laterally turfed to us.

  10. Actually many hospitalists won't take direct admits. So the local FP/Internist has to send the patient through the ER unless they admit to themselves.
    So really blame CMS for not increasing pay for admissions in the last decade(though overhead has gone up 30-40% in that time frame) for the lack of direct admits.


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