I was working in our after-hour clinic last night. Technically, we are the step before the emergency room, since most of our patients are classified as having “urgent” problems – things that need addressed now and cannot wait until morning. Emergency rooms are supposed to be used for serious and life-threatening problems, such as a heart attack, stroke, certain lacerations, serious head injuries, potential fractures, or injuries sustained motor vehicle accidents. Only two of the dozen patients that I saw last evening had urgent medical problems. Ten patients could have easily waited until the next day during normal office hours.
Why do people continue to use the ER for non-emergent problems? I have several theories:
1. Some people do not know if their problem is serious or not. If you are having chest pain or severe abdominal pain, you often think the worst. What if I am having a heart attack? Acute appendicitis? These can’t wait for a next day appointment. Personally, I would much rather see a potential heart attack that turns out to be “just gas”, than to know that they delayed treatment in order to research their symptoms on the Internet. When in doubt, use the ER. For potential life-threatening situations, call 9-1-1. Time and time again, I hear of patients trying to drive themselves to the ER in order to save the ambulance costs.
When people need advice, they often need it in a timely fashion. In defense of some people who show up with non-emergent problems, they did try and call and get advice. Either the doctor-on-call did not return to the call, or the ultra-conservative approach of advice nurses advised them to go to the ER.
Periodically, I have someone getting miffed because it takes me longer than expected to respond to their question on one of WebMD’s message boards. As much as I try to explain that WebMD is not your doctor’s answering service, or that health experts are not on-line 24/7, they are not pleased. I will still get an occasional message about someone thinking they are having a stroke. For Goodness sake people, if you think you have a life-threatening issue, get off of the Internet and go to the ER!
2. People do not have any alternative for care. Even knowing that their medical problem is not life-threatening, such as an itchy rash, many people will use the ER anyway. They should be going to a primary care medical office, but many people have not established themselves with one. They don’t know where to go. When they need medical care for a current illness, even if it is not considered an emergent problem, they are unable to get an appointment. It is easy to get discouraged when the receptionist tells you that the doctor can see you for a sore throat in two months.
But I am still puzzled why someone would want to pay thousands of dollars for ER care, when they can go down the street, find a more-appropriate urgent care facility and pay less than a hundred dollars. Many “Doc in a Box” medical facilities are popping up in chain pharmacies and big box stores. In some communities, you can get your throat examined, eyes checked, teeth cleaned, tires rotated, and stock up on toilet paper and hot dogs all in the same visit. Of course, if your community does not have an after-hour or urgent care facility, you may be stuck with the ER, if you are medically unable (or unwilling) to wait until your doctor’s office opens the next day.
3. Convenience. If you have nothing better to do for several hours and you have a non-emergent medical issue, using the ER is going to be an ordeal. ERs are fast, if you have a true emergency, but painfully slow when it is determined that you do not. ER nurses are trained to triage – treating the most critical cases first. Your itchy rash will not only be at the end of the list, it will most likely stay at the end of the list as other more critical and urgent cases arise.
Many people still feel that the ER is a “first come/ first served” facility. Many will even ask where they are on the list, like a number at the bakery. Although ERs are obligated to see anyone who comes through those big doors, they are under no obligation to hurry, or put the itchy rash in front of someone who has just been in a serious car accident. True, you can go to the ER at 3 AM and be seen, but it is far from convenient care.
4. Insurance Issues.Some insurance companies cover ER visits, but do not cover outpatient medical visits. Typically, ER use requires a higher co-payment ($75-$100), whereas a person may have to pay the full cost of a primary care visit (about the same). An ER visit for a simple, non-emergent problem can cost THOUSANDS of dollars – money that someone has to pay, either the insurance company or the patient. Some patients with non-emergent problems who go to the ER without prior insurance authorization have been faced with paying these bills. You need to read the fine print of your policies, especially if you have a penny-pinching HMO.
5. No insurance.There is a growing trend for the uninsured and undocumented (illegal) immigrants to use the ER. If they have no assets, the state will pick up the tab (assuming the state has any money). Billions of dollars are spent each year for care of undocumented aliens – one of the reasons for California’s financial crisis, and often one of the reasons that bankrupt hospitals who are struggling to stay in the black. When hospitals charge $20 for a Tylenol tablet, or $32 for a “dressing” (just a band-aid) to the insured, this is often to offset the free care that must legally be provided.
6. Inexperienced Parents/Oblivious Adults. Adults, who routinely ignore their own potentially-serious chest pain, will call 911 for a minor cut, fever, or nosebleed. With sirens blazing, hook and ladder trucks along with a cadre of ambulances often show up at residences with panic parents running around aimlessly. Not to waste a paying visit, many ambulances will simply transport them to the ER. People who arrive by ambulances will be promptly examined and roomed – a fact that many frequent-flyer ER users seem to know. You may be roomed, but once it is determined that you do not have anything serious, you will lie around for quite some time before being examined, treated, and released.
7. Presumption of Expertise.Many people feel that ER doctors, like those on television, are the cream of the crop; the highest trained and most skilled of all clinicians. Don’t’ get me wrong, if I am in a major car accident, I want to be in the ER. Those trauma docs are amazing and save countless lives and limbs. However, ER docs are not Jacks (or Jills) of all Trades – they are not pediatricians, ENTs, or dermatologists. They do see a lot of pathology, but when it comes to basic, primary care issues, many miss the boat.
A child seen in the ER with ear pain is most likely going to be diagnosed with a “middle ear infection” and given amoxicillin. This is the classic “treat ‘em and street ‘em” approach. Many times (not always), the diagnosis is wrong and the dosage is sub-therapeutic. ER docs may not be up on the current treatments recommendations for kids, so they will dose a child like we did in the 1980s. They may diagnose a middle ear infection without even seeing the eardrum! When I end up seeing a chi
ld the next morning and find their ears completely occluded with wax, there is no way under the sun that this child was properly examined (or even treated).
When a child with ear pain does NOT have a classic ear infection, it requires a more thorough and time-consuming medical evaluation. Sadly, it is easier for some overworked ER clinicians to just shoot from the hip, hand the patient a prescription for an antibiotic, and send them on their way – quick, easy, and harmless. But is it? Putting a child on an antibiotic without a clearly established diagnosis is never good medicine.
I testified as an expert witness on a malpractice case in Chicago a few years ago where a child was diagnosed as having an “ear infection”. He ended up being admitted just a few hours later with meningitis and nearly died. This child is now seriously brain-damaged. The hospital is a few million dollars poorer, but money for lifelong care doesn’t bring back this child to normal… ever.
8. Patients are advised to go to the ER. Call your doctor’s office about an hour before they are ready to close, perhaps on a Friday, and try and get an appointment for your sore throat. The receptionist, with little or no medical training in most cases, will send you to the ER. Call after hours and get the answering service, tell them of your problem, and the doctor will call you back (eventually) and tell you to go to the ER. Advice nurses hired by our own medical office for after-hour issues tend to err on the conservative side and send many people to the ER when they could have easily waited until the next day.
9. The Worried Well.All medical practices have a cadre of “frequent flyers” – worried patients with good insurance who have a lot of time on their hands, are perhaps a bit of a hypochondriac, and use the ER frequently. A headache is a brain tumor until otherwise proven by an MRI – the ER is good place to get a quick MRI. Belly pain is not gas, but a ruptured aneurysm. Neck pain is meningitis, of course. All of the convincing on the phone by clinicians can not discourage them from heading to the ER. Knowing that even hypochondriacs get seriously ill sometime, many medical providers are quick to dump them on the ER.
10. Those that truly need emergency care.The last time that I used the ER was for a kidney stone. I diagnosed myself in the clinic and decided (bad decision, incidentally) to drive myself to the ER. I barely made it, stopping frequently to vomit, scream, etc. I was so out of it by the time I made it to the ER that I couldn’t remember where to park or the location of the front door. In my pain-laden stupor, I walked through the ambulance entrance and loudly announced, “I have a kidney stone. Can someone please help me?” In a flash, I had an IV, pain medication, and a CT scan to confirm my self-diagnosis. Great care, I might add.
I then waited another three hours for my wife to finish her own patients and take me home. She has no problem making me wait, knowing that I was in good hands.