We all want the emergency room to be firing on all cylinders when disaster strikes, or even if a kidney stone decides to pass. If you have been to an ER recently, you can probably attest that this was not the case. Patients in ERs across the country experience waits well in excess of four hours, and then they often have to endure being placed in a hallway where short-staffed teams struggle to give them the care they need.
As an emergency physician for over 20 years and the medical director of an emergency department, I want to explain why the ER is broken. I hope you’ll understand the challenges ERs are facing, but mainly I hope that our country will start to address these problems and save our ability to respond to true emergencies.
Recently I spoke with an emergency physician who works in one of the most revered hospitals in the world. I had called this doctor in an effort to transfer a critically ill patient from my smaller community hospital to his, where a higher level of care is available. The shocking answer I received was: “Sorry, we can’t accept that patient, we just don’t have the space.” I have been transferring patients there for years, and this had never happened before. It is an ominous sign. His ER was stuck holding at least 100 patients who had already been admitted to the hospital and should have gone upstairs to a hospital bed. But the hospital had no beds available, so these 100 people were crammed into the ER.
Just imagine for a moment that your mom falls, breaks a hip, and goes to the hospital, but rather than getting her own room, she sits in the ER hallway, asking for a warm blanket to deal with the cold, exposed to the 24/7 noise and chaos of that environment. She’d be daunted; you’d be angry, and, as her doctor, so would I.
You know who else is angry? The 46-year-old guy stuck in the waiting room because the ER is full. He is writhing in pain with a kidney stone and wondering why on God’s green earth he isn’t being taken back into the ER to get some relief. He’s cursing the ER out loud and on social media, incredulous that it is so damn slow, looking for answers. Is it the workers? Are they just lazy, or don’t they care about his pain? I get the sense that there are people who view the ER much the way do the DMV.
But don’t blame the staff. These health care workers, who have persevered through years of school and training to care for people, could have chosen to work in a lush cosmetic surgery suite with banker’s hours. Instead they have chosen to dedicate their lives to helping people in a setting where they see the worst of the worst working nights, weekends, holidays; being exposed to COVID and countless other infectious diseases; often skipping meals and I won’t even use the word “breaks” because they have no idea what those are. They aren’t slow; they are some of the fastest and most efficient people on the planet.
Remember the excitement of the hit 1990s series “ER” with Dr. Carter and Dr. Ross pumping on chests while being urgently rushed down hallways? They went from room to room saving lives! That’s what attracted me and many of my ER brothers and sisters to this field. And the ERs we joined back then were designed for medical and surgical emergencies that were life- and limb-threatening. This is still part of what ERs do, but increasingly, ERs are asked to function as the “safety net” providing backup care for 330 million Americans who currently use the ER for a vast array of non-emergencies that our health care system does not have an alternative destination for.
Today we don’t actually call the space “the ER” anymore; instead we use the broader term Emergency Department, with various sections including express care units for bumps and bruises, geriatric care units for our blossoming baby boom population facing increasing difficulty staying in their homes, psychiatric units for our society’s explosively growing psychiatric population, as well as areas consumed by patients with substance abuse. Add to this all of the admitted patients who do not have a room available in the hospital and there is frighteningly little space left for our patient with the kidney stone who is still in the waiting room.
So how did we get here? It was not by chance, and the forces at play make it a mathematical certainty that it will get worse. The first of these forces is that America asked, well actually, it demanded, through a 1986 act of Congress called EMTALA — the Emergency Medical Treatment and Active Labor Act — that ERs care for everyone, no matter what. Emergencies. Non-emergencies. Just need a note for work. Homeless and it’s cold outside. Don’t want to wait a week to see your doctor. Everyone.
Add to this mandate the more recent and ongoing staffing crisis in the health care field. There has been a mass exodus of nurses, patient care technicians, and paramedics. The number of nurses in the United States fell by over 100,000 in 2021 — the largest decline in 40 years. Even though staffing levels may be rebounding in some places, at least one-third of all nurses report that they are considering leaving their jobs. This is hurting nearly every field of medicine, but the impact may be harshest in the ER, where minutes make a difference in how many heart cells die off or whether we are able to salvage brain tissue in a patient having a stroke. Elsewhere in the hospital, in an intensive care unit, there may be only one or two patients per nurse, while on a normal medical floor nurses can care for four or five patients each. There are nights in ERs where nurses are asked to care for twice that number, some of whom are critically ill. No matter how hard that nurse works, they often leave feeling defeated, like they failed, or anxious about errors or oversights they may have made. Can you blame them for scrolling through job opportunities in other fields?
Emergency physicians are also leaving ER jobs for less stressful work that often does not involve patient care, and fewer young doctors are choosing a career in emergency medicine. Given how full our ERs routinely are, a combination of fewer emergency-trained doctors and fewer nurses has catastrophic implications.
The ER was meant to be a place where patients go, get stabilized or fixed, and then move on. Today, patients can be stuck in the ER for days or even weeks. In addition to admitted patients who are “boarding,” i.e., waiting for a bed to open in the main hospital, psychiatric and elderly patients are occupying ER beds for profoundly long periods of time. They have nowhere else to go. Most psychiatric facilities and substance-abuse centers are not profitable enterprises, and therefore we have to rely on state-subsidized centers. But there are not enough of them, especially in states that have been battling deficits and looking to save on health care expenses. Many of these facilities have been outright closed.
I love my job, and I am immensely thankful for the opportunity to work alongside the nurses and patient care techs who continue the struggle of caring for people in their darkest hours. But I want to sound an alarm that our health care system is set up in a way that makes emergency rooms doomed to fail to meet patients’ expectations. We as a country need to decide that it’s important that our ERs function well enough to care for any of us when an emergency strikes. We have to develop and support new strategies and settings, outside the ER, where care can be more appropriately provided for non-emergency situations, especially for substance-dependent, psychiatric, and aging populations. Otherwise, the next time you go to an ER, bring a book and be prepared to settle in, because no matter how hard the staff works, there’s a good chance that they are overwhelmed. Our health care system has decided that it is OK for you to wait.
Dr. Brian McGuire is an emergency physician in Connecticut.