State of Emergency Medical Care in the U.S.
I've only had to visit the emergency room once in my life.
I was about 9 or 10 years old and I was wrestling with my step-father. He picked me up to slam my back gently on a mattress but instead I landed on my neck. For about 15-to-20 seconds I could not breathe, and my parents told me later that my face was turning blue from lack of oxygen.
My step-father carried me down the stairs and to the car, because when I tried to walk pain shot through my chest like someone was stabbing me with a flaming piece of the sun. Onward we sped toward the emergency room, as my parents felt that haste was important.
Unfortunately, haste was not the word of the day in the ER when I arrived. I sat for an hour waiting on someone to see me as I inhaled air that seemed to be filled with tiny shard of glass, shredding my lungs and chest.
Turns out that I had a crack in my sternum, something I learned after the hour wait and another hour of testing and diagnostic imaging. I should not have had to sit and wait for an hour to see someone, especially when I was having trouble breathing and was experiencing an extraordinary amount of pain.
Emergency care has not gotten any better, and in recent years, may have gotten even worse. The American College of Emergency Physicians (ACEP) produces a report card on emergency medical services in the U.S. every year. In 2009, the report emergency services in the U.S. came out with a grade of C- minus. The latest report states that the grade has fallen to a D+. This is based on 136 measures that were broken down into five different categories, each with their own grade:
Access to emergency care: D-
Quality and patient safety environment: C
Medical liability environment: C-
Public health and injury prevention: C
Disaster preparedness: C-
Why is emergency care suffering?
Many factors have contributed to the decline in emergency care. First, the number of people who go to emergency rooms for care has increased at twice the rate of the growth of the population. Many people who lack health care do not visit a doctor for problems until they become too much to deal with. It is at that time they seek care in an emergency room. The ACEP report says that from 1995-2010 there was a 34 percent increase in the number of people who visited an emergency room, totaling 130 million in 2010.
In addition to this increase in patients, there is also a problem with the medical liability system in the U.S., according to the ACEP. Each state has different policies that impact doctors, causing them to eliminate procedures or move to other states. Liability costs have been estimated to add about 100 million dollars to annual spending on health care in the country. This extra sum is passed onto the public in the form of higher health care bills and extended waits because of lower numbers of practicing doctors. And every doctor practicing in an emergency department is important, as only 4 percent of active physicians in 2010 were emergency ones.
All of these problems outlined in the ACEP report may have contributed to an 11 percent decrease in the number of emergency departments. If the status quo is allowed to continue, the problem might only get worse.
The passage of the Affordable Care Act has added millions of people to insurance rolls and Medicare, but the number of emergency care professionals has risen dramatically in response. Primary doctors add to the number of people heading to the emergency room as well. In 2013, RAND released a study saying that 80 percent of people who called their doctor complaining of a serious medical issue were told to go to an emergency room.
What can be done about the state of emergency care?
In an effort to better understandthe problem, I asked two emergency care professionals, Christopher Hanifin and Charles Pollack, to answer a few questions about the current state of their field . Hanifin is the chair of the Department of Physician Assistant Program at Seton Hall University. while Pollack is a professor of Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania and Chairman of the Department of Emergency Medicine at Pennsylvania Hospital in Philadelphia.
Both men agree that emergency care is absolutely necessary. Hanifin said that "emergency care is essential to the health of the nation. Even though the system is overburdened, it remains our healthcare safety net. Presently the only legal right we have to healthcare is that if you show up at an ED they are obligated to assess and stabilize you. "
Pollack mirrored that statement, telling me that "emergency care in the US serves two vital roles : (1) provision of life-, limb-, and sight-saving medical and surgical care to patients with severe illness and injury, and (2) maintenance of society's healthcare safety net, providing emergent, urgent, and even routine evaluation and care to patients 24x7 and regardless of ability to pay."
While they agreed on the essential nature of emergency care, both men had different ideas on how the Affordable Care Act would impact ER's around the country.
"The effects of the Affordable Care Act remain somewhat unpredictable," Hanifin said. "One of the goals is that if more people can be linked with a primary care provider they will not need to seek care in the ED for routine issues like upper respiratory infections and minor injuries."
Pollack had a much more definitive opinion of how the ACA would affect emergency care.
"The Affordable Care Act will likely increase demand for emergency care as more patients gain health insurance coverage, but there is no increase in the number or availability of primary care physicians to see them."
If both these professionals see problems in our existing system, what are their suggestions to fix it?
Pollack pointed out that we should "improve collaboration with outpatient providers (including more innovative services such as home health care, visiting nurses, case managers, etc) and inpatient (primarily hospitalists) providers. We can also improve the consistency of ED care around evidence-based pathways."
For Hanifin, the solutions included the idea that "increasing access to primary care is essential to improving emergency care." Because access to primary care is not universal "emergency departments are frequently flooded with patients with very routine problems that would be better handled in another setting. Care in the emergency department is expensive and it lacks the same continuity that is possible in a primary care setting."
Is there anything we can do?
How can we help emergency care professionals like Pollack and Hanifin fix our broken system besides placing pressure on government officials? The answer may be to join the emergency care workforce. There are a number of health care positions in emergency departments that you might be able to pursue to help alleviate the burden that overcrowding has produced. These positions include:
Emergency Medical Technician (EMT) - Respond to 911 calls and administer immediate emergency care in order to save lives. The Bureau of Labor Statistics (bls.gov) estimates the position to grow 23 percent nationwide from 2012 through 2022.
MRI Technician - Take images of patients in order to help doctors diagnose medical problems. Bls.gov estimates this position will experience national growth of 24 percent from 2012-2022.
Registered nurse - Work in collaboration with doctors and physicians in order to provide care for patients by recording medical information, administering treatments, and monitoring medical equipment. Growth for this position is expected to be 19 percent nationwide from 2012 to 2022, according to bls.gov.
Physician assistant - Usually supervised by a physician, these professionals prescribe medicine, diagnose illnesses, order tests for patients, and keep patient records. Bls.gov estimates growth potential for this career to be 38 percent nationwide between 2012 and 2022.
As Pollack and Hanifin agree, emergency care is vital to our overall health care system. It needs more funding and more practicing professionals to help it recover.
When lives are at stake, care cannot be substandard.
America's Emergency Care Environment Report Card, American College of Emergency Physicians,
Physician Assistants, Occupational Outlook Handbook, Bureau of Labor Statistics, 2012,
Registered Nurses, Occupational Outlook Handbook, Bureau of Labor Statistics, 2012,
Emergency Medical Technician, Occupational Outlook Handbook, Bureau of Labor Statistics, 2012,
MRI Technician, Occupational Outlook Handbook, Bureau of Labor Statistics, 2012,
Interview with Christopher Hanifin, chair of the Department of Physician Assistant Program at Seton Hall University, conducted January 24, 2014
Interview with Charles Pollack, Professor of Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania and Chairman of the Department of Emergency Medicine at Pennsylvania Hospital in Philadelphia, conducted January 31, 2014