Armies always fight the last war, the old saying goes, meaning that the strategies and tactics necessary for the current day don't keep up with the times, at least not without sudden, devastating lessons. Unfortunately, this is also true in emergency medicine because we continue to operate under old paradigms even as rapid changes occur.
This is evident on several fronts, perhaps most painfully in staffing. I'm not sure who does the calculations, but they aren't working anymore. I look at employment ads to follow the trends and see “single physician, two shifts daily, and one APP” (presumably that NP or PA is only available in the middle of the day). This goes for facilities with visits ranging from 15,000 to 30,000 a year.
The problem, at least in part, is that our patients are much sicker than ever before. People are living longer with more complex illnesses and less primary care than I can ever recall. How many people do we see who are five years out from their Whipple procedure? How many 85-year-olds tell us about their sepsis or pulmonary edema that happened a couple of years ago? How many do we see who survived major trauma?
Our beds are at capacity, our patients require more, we have fewer available specialists, and we're holding more and more critical patients in the emergency departments of smaller hospitals because transfers are nearly impossible. So, more and more falls on the shoulders of emergency physicians.
Trouble at Every Turn
The one-physician-at-a-time method is not only miserable and driving people to leave the field when they can, it's also dangerous. Threadbare staffing is inexcusable in an era when we supposedly have a glut of emergency physicians. I suspect that extra staffing could be financed in many facilities by simply preventing patients who leave without being seen from, well, leaving without being seen.
Emergency medicine also isn't keeping up in the realm of security. A local deputy told me that our ED is the most dangerous place in the county; I have no doubt he was correct. The ED has become the only option as rates of substance use disorder and mental illness have skyrocketed to new heights, for those who want care, and those who just show up needing it.
The ED is also the so-called right place for any number of private and government agencies to drop off patients and feel good about the loving care they provided until 5 p.m., at which time it is assumed by the few physicians and nurses already struggling to manage traditional emergencies. It's folly for us to continue saying ridiculous things like “People experiencing a psychotic episode aren't dangerous,” “People using marijuana are just chill,” or any of the other words we use to minimize the hard reality that those with mental illness or substance use disorder can be dangerously unpredictable.
Violence is growing in many areas, in communities and in emergency departments. It's fine to pass laws that prosecute assailants, but they are much 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 can't save lives in crises. We can't make silly rules like “Don't let them leave, but don't touch them,” nor can security be done on the cheap like hospitals asking maintenance workers to respond as security (a legal and ethical nightmare in the making, to be sure).
And another thing: Thanks to endless crowding, our treatment of HIPAA is sometimes comical. Our EMR programs have two-factor verification, and we change our passwords with painful frequency. Our desktop computers time out every five minutes to prevent random prying eyes (even as data breaches are all too common). But we have patients languishing in hallways or sharing rooms separated only by curtains, behind which we ask 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 drove a stake right through its legal heart despite our devotion to it. Sure, we tried, but transfers were a disaster during the worst of the pandemic because inpatient physicians refused to take care of patients with complications and hospitals with specialists told us that they didn't have the capacity to do the same. Consultants anxious about COVID-19 wouldn't come to the bedside, so we transferred laterally just for a bed. Even patients with STEMIs and others needing intervention were refused because facilities said they didn't have inpatient beds.
I'm sympathetic to transferring and receiving hospitals. Everyone was at wit's end. But I remember calling nearby facilities and being told, “You can't even talk to the obstetrician; we're full,” or “We don't do consults, and we don't have beds; sorry.” I know one ED where an ambulance pulled up from two states away, just looking for a place, any place at all, where care could be provided.
How will our beloved metrics look in the retrospectoscope? It's hard to say, but probably not pretty. People left, not because of neglect but simply because of mathematics: zero beds, zero nurses, zero places to take care of patients no matter how sick.
Our beautiful plans are falling apart, and it's time we did some realistic reassessments about what we can and should do and how we can do better unless we want more unnecessary deaths, more burnout, fewer physicians, and worse care. The answer is no longer “Do the same but faster and with less,” especially when that is simply a way to say, “Don't spend more money.”
Dr. Leappractices emergency medicine in rural South Carolina, and is the author of the column, Life and Limb (https://edwinleap.substack.com) and a blog (http://edwinleap.com). Follow him on Twitter@edwin_leap, and read his past EMN columns athttp://bit.ly/EMN-Emergistan.