The Mystic Portal Awaits

And waits, and waits, and waits……

The ER is the portal of admission to the hospital for what we might call undifferentiated illness.  Shortness of breath.  Chest pain.  Fevers with localizing symptoms (like pneumonia, appendicitis, or gall bladder infections).  “Changes in mental status”–confusion, delirium, or dementia, caused by Alzheimer’s, strokes, and many other diagnoses.  Of course, other emergencies are usually well taken care of in the ER: fractures, lacerations, bleeding, etc.

Why do we have to wait so long to get seen and treated in the Emergency Room?

Well, crowding is one problem.  You’ve heard endless commentary about ER crowding.  Too many people using the ER for non-emergency issues: colds, sprains, back pain–all things that could be better treated in the office or over the phone. Too much difficulty getting seen by your primary care physician.  There are simply more people waiting to be seen than can be accommodated in a “reasonable” time frame.  [Of course, this all depends who is defining ‘reasonable.’]

The ER is a victim of its own success.  The ER “brand” if you will, is sexy.  Start with those TV dramas that glorify the gritty heroes who work on the front lines.   Then, the simple message of an ER’s mission:  “We’re always open, and we can’t turn you away.”  For people who don’t have insurance, or who are frustrated by lack of access to their (or any!) doctor’s office, the idea that the light is always on makes the ER an attractive beacon.

It wasn’t always this way. Emergency Medicine has only been a recognized medical specialty since 1979. Emergency rooms evolved out of the perceived need for medical services at all times of day and night and for all conditions.

ERs were (and in many places still are) staffed by internists, surgeons and family docs before doctors began training specifically in Emergency Medicine. Like Hospital Medicine, which will no doubt someday become an independent specialty, Emergency Medicine harbors the idea of medicine practiced in a specific location, rather than on a specific body part or group of organs. Approving such a specialty took some convincing of the medical establishment.

When ERs first came about, your personal doctor might meet you there and handle your assessment.  The ER doc would just hold down the fort until your doctor could come.  No one would dare overstep your own doctor’s wishes.

But soon office doctors realized that they could see more patients by staying in the office.  This gave more and more ground to the ER docs.  The ER docs would do their own assessment to decide if you’re sick enough or not to be admitted to the hospital.  Thus, the ER became the portal of entry.

If you come to my office and you’re sick, or I don’t know what’s going on, I may very likely now send you to the ER.  The ER is set up to do quick lab tests and x-rays, even advanced scans if necessary. Everything in my world moves more slowly.  You have to get from one place to the next–head to the lab, the radiology suite, then the pharmacy.  In the ER, they do it for you or come right to you—the blood tests, placing an IV, even bring a portable x-ray machine to your gurney if you need one.

The ER bundles you.  If you need a specialist of some kind to see you, they call that specialist in.  It can all happen so fast.

Can, I said.

The down side of this clever system is that so many individuals choose to receive care there, that the system breaks down.  People wind up waiting for hours.  An old man literally died waiting in one Chicago ER.  They don’t show you that on Chicago Hope.

It’s not really hopeful if you have to wait so long that you die.