Thursday, December 11, 2008

A visit to an emergency room

No, nothing to be alarmed about: I did not visit as a patient. My research focuses on developing methods that can make healthcare run more efficiently, and I’ve just begun to explore how emergency room (ER) operations can be improved. For a country that is the leader in just about everything – especially medical research, technology and innovation – the United States has a lamentable health care delivery system. And nowhere is it more evident than in emergency rooms across the country. Patients, even patients who have had a stroke, may have to wait hours before getting care. Some wait seven to eight hours. In major cities, ambulances carrying patients to an emergency room are diverted to other emergency rooms, simply because there is no capacity and queues are long. (Queues again! Haven’t we talked about queues before?)

The ER I visited is in Baystate Medical Center, in Springfield, Massachusetts. In terms of volume, this is one of the largest in the country. About 110,000 patients use it each year; about 300 patients come to the ER every day, 80 of them brought by ambulances. Others just show up by car, accompanied by friends or relatives.

Some have ordinary ailments, like a cold or sore throat. Instead of going to visit a primary care doctor, they use the ER. They do this probably because they don’t have a doctor. And that in turn is probably because they don’t have insurance. The statistic that crops up in just about every major discussion about the US healthcare system is that there are about 45 million uninsured patients in the country – a colossally high number; indeed an unforgivable number if you compare with other developed countries. Massachusetts is a bit ahead of the curve and has tried to fix the problem, but other states lag.

So if you don’t have insurance, and if you have a medical condition, you end up using the ER and pay a huge bill. But even if you have insurance, you might use the ER because you could not obtain an appointment with your doctor. ERs cannot refuse care; they have to treat everyone who shows up, irrespective of whether the patient has a trivial condition or is uninsured.

ERs, thus, are a safety net; they soak up the consequences of inefficiencies whose root causes lie elsewhere.


At the Baystate ER, patients with minor ailments are sent to a Fast Track section. That way they do not interfere with the more critical patients who are sent to the main area. But the name Fast Track has become something of a joke. Waiting times for getting into Fast Track can be very long. So to pacify patients and ensure they don’t feel mocked, the Fast Track area was recently renamed the General Treatment section.

Needless to say, only the name has changed; the waiting times have not.

When I visited the Baystate ER, it was about 2 pm in the afternoon. It was crowded. Early mornings are the least busy hours; but by noon things start picking up. By late afternoon, early evening, the ER is packed. This too is a US-wide trend – and perhaps true worldwide as well.

In the waiting area, there were patients and their relatives and friends. A couple of the patients were in wheelchairs; they were elderly, clearly sick, and their faces had a resigned and faded look to them. Their faces told also of the passage of time: seconds had become minutes and minutes hours, yet they were still waiting. If sicker patients arrive, they tend to preferred, thus increasing the waits for less sick patients. But assessments of sickness are to some extent subjective, inevitably so.

The main emergency area – entered from the waiting area through double doors – was a world apart. It was a buzz of activity and felt surreal. Constant activity and motion: like a video on fast-forward. There was a central square, the inner portion of which consisted of staff working hastily with computers, records, paperwork. On the outside, doctors, nurses, assistants swirled around immobile beds with prostate patients. These beds are supposed to be in rooms, but to create capacity, beds had been added to the hallway. Monitors displayed constantly changing information: how much time each patient had been in the ER, whether the tests that had been ordered had returned, which resident or doctor was assigned to the patient. The charge nurse, who was in charge of operations, had tough decisions to make. Whom to admit next? Which nurse to assign to which patient? Should another bed be added to the already overcrowded hallway?

The staff, even though busy constantly attending to something, seemed cheerful enough; their cheer was much needed, considering the bleak faces of the patients.

Patients, once they are treated, are either discharged or admitted to the nearby Baystate Hospital. And here too there is a crunch. Hospital beds are a scarce resource, and generally there is no availability. So the patients continue to wait in ER beds, effectively denying beds to other patients waiting for hours for treatment in the waiting area. Such as the elderly patients I'd seen upon entering, waiting in wheelchairs and with tormented looks.

So it goes. Emergency rooms are not supposed to be pleasant places. The nurses and doctors who work there know there is no room for sentimentalism. Work just needs to be done. But ERs are also a barometer of the larger issues that ail a healthcare system. The US healthcare system is badly fragmented and inefficient; and a large part of the cost is borne by ERs.


Krishnan said...

Hari, time and again we do read that US health care system is in shambles. Why is it so ? Is it because of managed care that I often hear about in Robin Cook's thrillers ? On the contrary, Britan's National Health Service is often quoted as a good model to be emulated.

Hari said...

Hi Krishnan,

There are a variety of reasons; I haven't understood all of them yet. Part of the answer - an admittedly simplistic one - lies in the United States' unwillingness to give up the market system in healthcare. This creates some strange incentives for doctors and insurance companies. Insurance companies, for instance, gain very little by providing insurance to patients with preexisting medical conditions. So very sick patients may have trouble getting coverage.

Other western countries with greater government involvement in healthcare are doing much better. Outcomes are better and achieved at lower costs.

The hope is that Obama will be able to change some of this. We'll see how effective his policies are or if he is able to bring any change at all.