Armies always fight the last war, the old saying goes, which means that the strategies and tactics needed in the present day do not keep up with the times, at least not without sudden and devastating lessons. Unfortunately, this is also true in emergency medicine, as we continue to operate under old paradigms even as rapid changes occur.
This is evident on several fronts, perhaps most painfully on staffing. I don’t know who did the calculations, but they don’t work anymore. I look at job advertisements to follow trends and see “single doctor, two shifts a day and an APP” (probably the IP or AP is only available in the middle of the day). This goes for installations with visits ranging from 15,000 to 30,000 per year.
The problem, at least in part, is that our patients are much sicker than ever. People are living longer with more complex illnesses and less primary care than I will ever remember. How many people do we see who are five years away from their Whipple procedure? How many 85-year-olds tell us about their sepsis or pulmonary edema that occurred a few years ago? How many do we see who have survived major trauma?
Our beds are full, our patients need more, we have fewer specialists available, and we are keeping more and more critical patients in the emergency departments of small hospitals because transfers are nearly impossible. Thus, more and more falls rest on the shoulders of emergency workers.
Problems at every turn
The one doctor at a time method is not only miserable and drives people off the field when they can, it is also dangerous. Worn-out staffing is inexcusable at a time when we supposedly have an overabundance of emergency doctors. I suspect that additional staff could be funded at many facilities simply by preventing patients who leave unseen from, well, leaving unseen.
Nor does emergency medicine follow in the area of safety. A local deputy told me that our ED is the most dangerous place in the county; I don’t doubt he was right. The emergency room has become the only option as rates of substance use disorders and mental illnesses have soared to new heights, for those who want care and those who need it.
The emergency department is also the so-called right place for a number of private and government agencies to drop off patients and feel good about the loving care they provided until 5 p.m., when the few doctors and nurses are already struggling to manage classic emergencies. It’s madness of us to keep saying ridiculous things like “people who go through a psychotic episode aren’t dangerous”, “people who use marijuana are just cool”, or any of the other words we use to downplay the harsh reality that people with mental illness or substance use disorder can be dangerously unpredictable.
Violence is increasing in many regions, in communities and in emergency services. It’s fine to pass laws that prosecute abusers, but they’re a lot like cameras in some ways: a great idea, but they don’t stop the terrible thing from happening. Times are different and robust security measures can no longer include retirees who cannot save lives in a crisis. We can’t make stupid rules like “Don’t let them go, but don’t touch them” or cheap security like hospitals asking maintenance people to answer as security (a legal and ethical nightmare becoming, being sure).
And one more thing: thanks to endless clutter, our treatment of HIPAA is comical at times. Our EMR programs have two-factor verification, and we change our passwords with painful frequency. Our desktop computers shut down every five minutes to avoid prying eyes (although data breaches are all too common). But we have patients who languish in hallways or share rooms separated only by curtains, behind whom we ask for the intimate details of their illnesses and lives as if the fabric were somehow soundproof.
Finally, we have our old friend, EMTALA. I’m pretty sure COVID-19 has driven a stake through its legal heart despite our dedication to it. Of course we tried, but transfers were a disaster at the height of the pandemic as hospitalized doctors refused to take on patients with complications and hospitals with specialists told us they had no no ability to do the same. Consultants anxious about COVID-19 weren’t coming to the bedside, so we transferred laterally just for a bed. Even patients with STEMI and others requiring intervention were turned away because facilities said they had no inpatient beds.
I am in favor of transfer and reception hospitals. Everyone was at their wit’s end. But I remember calling nearby facilities and being told, “You can’t even talk to the obstetrician; we are full” or “We don’t do consultations and we don’t have beds; I’m sorry.” I know of an emergency department where an ambulance arrived from two states away, just looking for a place, any place, where care could be provided.
What will our beloved metrics look like in the retrospectoscope? It’s hard to say, but probably not pretty. People left, not because of neglect but simply because of math: zero beds, zero nurses, zero places to care for patients, however sick.
Our beautiful plans are falling apart, and it’s time we realistically reassess what we can and should do and how we can do better unless we want more unnecessary deaths, more burnout, fewer doctors and poorer care. The answer is no longer “Do the same thing but faster and with less”, especially when it’s simply a way of saying “Don’t spend more money”.
Dr Leappractices emergency medicine in rural South Carolina and is the author of the Life and Limb column (https://edwinleap.substack.com) and a blog (http://edwinleap.com). Follow him on Twitter@edwin_leap, and read his former REM columns onhttp://bit.ly/EMN-Emergistan.