by Patrick Appel

A reader writes:

How do we decongest our overcrowded and dangerous emergency departments? 

I am a pediatric emergency room physician.  The vast majority (statistics say about 75%) of our patients do not need to be in the emergency room.  Ask anyone who does the job--we routinely see children for colds, for diaper rashes, even for pimples. I once treated a 6 year old girl for gum stuck in her hair, and last week I treated a teenager with a sore throat who had an appointment in 30 minutes with her doctor but couldn't wait that long. 

The law (known as EMTALA) states that we must see everyone who presents to the department, regardless of the frivolousness of the complaint.  We can declare them "medically stable" and discharge them without treatment, but then we have unhappy patients and even more unhappy hospital administrators (who have to deal with patient/parent complaints and who make more money if we order expensive tests and treatments even for people who don't need them), and we are more likely to have complaints and lawsuits filed against us.  Patients come to us because we are more convenient than their regular physicians (open 24 hours, no appointment needed)--and, despite the prevailing myths most of our patients DO have primary care physicians (thanks to SCHIP)--and we accept patients regardless of their insurance status or ability to pay.  EMTALA was created for a good reason-- to prevent the "dumping" of uninsured patients on other facilities-- but it seems that some incentive to go to a primary care physician rather than the emergency department is needed.    

The problem is easily identified, but the solution is not.  If we stop accepting everyone, chances increase that someone with a real emergency will be turned away by a secretary, a nurse, or by EMS personnel.  As it stands, chances are increased that someone with a real emergency will be forced to wait too long to be seen as their condition worsens or that mistakes will be made because of the increasingly chaotic environment.  Despite President Bush's statement 2 years ago that “people have access to health care in America, after all, you just go to an emergency room,”  the system is completely overwhelmed.

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