I am writing this to ask for help. No, I'm pleading for help. This is a patently self-serving public service announcement (PSA), aimed at any physician or person sending someone to an emergency department. Because emergency departments across the land are overwhelmed. And as my patients have so often said, "something has to be done."
I am addressing my supplications primarily to physicians and advanced practitioners who depend on the emergency department as a back-up, a pressure-release valve for their practices. For my entire career I have been proud to be just that. To be available to help with situations that were medically, or just logistically, complicated or dangerous.
Those of us in emergency medicine are good at managing patients who are complex, very sick, and whose situations may require that we marshal different specialists and arrange transfers for specialty care. We like that role.
The problem is, we're just out of space and out of staff. And frankly, we're out of steam. All day long, patients walk in off the street or come to us via an endless line of ambulances, parked outside and eagerly awaiting the chance to deliver their human cargo. Their stretchers are parked in front of our desks, where they often wait and wait for pain medication, for evaluation of their fevers, for nebulizers, or for x-rays of injured limbs.
Our nurses have far too many patients to give safe care; but unlike the floor, there is apparently no limit to what they can be expected to do in our departments. And frankly, sometimes it feels as if there's a fixed limit to how many patients one emergency physician can handle when so many in our aging population have chest pain or shortness of breath.
Many of our patients meet septic criteria, or have mental illness or addiction issues. No small number have conditions that we track along pathways that measure metrics. How long until that EKG? They stack up like pink-tinged snowbanks on our desks, threatening avalanche. How long until that CT or thrombolytic, that antibiotic or decision to admit? That clock runs in the background of all we do.
In the midst of all of this, we often have patients sent from medical offices, who are told they should "get checked out," or "go and be admitted," or "I was told to come and get an MRI." Some are sent from nursing homes because their altered mental status was more altered than normal and it was "just easier" for them to be evaluated in the ER. Others are told by medical offices that if they come to the ER, we can admit them and help them get into a nursing home or rehab. Still others are sent because of their history of addiction, "to get them some help." Other times, it's a post-procedure issue: "I had surgery last week and I have some pain, so my surgeon said to come here and get checked out."
Frequently it's urgent care sending patients. The urgent cares of America are very important and do great work. But too many are staffed with physicians or advanced practice providers without adequate experience who are uncomfortable making decisions. "You should go to the ER to make sure," or "your 18-year-old with chest pain has an EKG that says STEMI," (it doesn't) "we're calling the ambulance." In one of the locations where I work, the very busy local urgent care doesn't do RSV testing, and directs their patients to the emergency department for testing where they wait hours upon hours. And some aren't infants or sick seniors, but adults without respiratory distress, with cough and fever for whom the definitive diagnosis doesn't really matter.
What I want to say is that we want to help, we really do. We love being able to help make the diagnosis. But the line is long and the number of very sick and often contagious patients in the department is very high. A patient sent to the ER faces certain hazards. Not only exposure to infection but also significant cost. This is particularly true of those who might be managed with an outpatient ultrasound, an outpatient transfusion, a simple recheck the next day.
The other, enormous problem is that of boarding. Because of the degree of sickness in our communities, and the lack of inpatient beds due to the lack of nursing staff (or physician coverage), patients are waiting days and days to leave the emergency department for inpatient beds. Our hospitalist colleagues are as beleaguered as those of us in the ER. I hear it in their voices when I call and say, "I'm sorry, I have another admission." They round in the chaos of the ER, and are as far behind as we are. Sometimes, 40-50% or more of our emergency department beds are taken up holding admissions. Of course, this isn't just inconvenient and difficult. It's dangerous, according to in The BMJ. Boarding in the emergency department is associated with higher mortality. We suspected this all along, but it seems the numbers agree.
So, we have no end of influx, no place for the truly sick (who are often parked in hall beds even in the ER), and certainly next to no place for the worried well. Frequently, due to lack of beds, the sick who require specialized care are also boarding, as they wait for transfer...to another place in the same bed crisis.
All this is to say, if you are a physician or advanced practice provider sending someone to the local emergency department, and if it isn't really an emergency, it might be wise to call ahead. Or to try to make some other arrangement to help treat, comfort, or reassure your patient.
The emergency departments of most hospitals are now disaster zones, best avoided if possible. We'll still be here when you need us. But if you can, show a little mercy until the dust settles.
This PSA is brought to you by an exhausted emergency physician, speaking for the entire tribe.
Edwin Leap, MD, is an emergency physician who blogs at , and is the author of and . You can read more of his writing on his Substack column, .