Emergency medicine is a public service

I recently treated what looked like one of those unnecessary patients in one of our emergency departments. You know the ones. The ones that don’t need to be there because they should have gone somewhere else to receive care. She was a 28-year-old woman who presented with lower abdominal pain. Her pain started abruptly in her left lower abdomen. She had no nausea or vomiting or fever.

After my evaluation and several rounds of pain meds she was feeling better but still uncomfortable. Her pregnancy test was negative, urine and white blood cell count were normal. Normal labs, so therefore she should have been seen somewhere else. Right?

If only medicine were that simple.

She had a lot of pain during the pelvic exam, so I ordered a sonogram which demonstrated a left ovarian cyst with good flow to her ovary. Still concerned, I asked the OB/GYN to evaluate her because I was concerned with an ovarian torsion. After some discussion (and skepticism) the GYN doctor took her for laparoscopy where she had a 720 degree torsion of her left ovary (rotated around itself two times), requiring removal of the ovary as it was unable to be saved.

When we talk about unnecessary ER visits, the prevailing wisdom is that a large percentage of visits seen in the emergency department can more appropriately receive treatment in an urgent care or a private physician’s office. Let’s say 30% of all the patients we treat in emergency departments nationwide could be seen in a lower intensity (and lower cost) setting. Let’s do the math. There are about 140 million ED visits in the US. Reducing that by 30% brings us to 100 million visits. Of course it’s not total savings. The patients will go somewhere. Let’s say an urgent care center or primary care doctor.

Seems like a no brainer. Cost savings to the patients and the system.

Not so fast. What about the cost of the urgent care centers popping up on every corner? What’s the cost of running them 24 hours a day? Because if you are going to compare one to another and save the overall costs, patients don’t just arrive between 10am-10pm. They come in all hours of day and night. How would the cost model change if you had to run your office or urgent care center 24 hours? The response would be that is crazy, that it does not make economic sense to do it. And you would be right.

The ER on the other hand has to be there, ready to serve with all capabilities 24 hours a day. What was necessary for the woman above to get the care she needed at the time she presented? She needed a fully functioning emergency department (emergency physician, emergency nurses, technicians and support staff) and that includes other critical services such as lab and radiology. Not to mention an appropriate consultant with a surgical suite that was capable and ready to take care of the problem at hand.

The real question is what is the cost of being truly ready to serve your community? I do not know the answer to that question. I know it is high and I know it is necessary. Whether you are the patient mentioned above or one who presents with signs of a stroke, acute MI, a surgical emergency, severe trauma case or someone with a time sensitive condition, you need your local hospital emergency department to be ready to provide that care.

According the American Hospital Association, between 1991 to 2010, emergency department visits rose from 88.5 million to 127.2 million. Meanwhile, over roughly the same period, hospitals have eliminated one in four emergency departments. Writing for Atlantic Monthly earlier this year after the Boston Marathon bombing, Jason Silverstein noted that the capabilities of Boston’s emergency departments and trauma centers were expected to help every single patient who was treated after the bombing to survive:

At all times, they have the full roster of emergency services available: the entire spectrum of surgical specialists; respiratory therapists; laboratory services; nurses; and radiologists. They can land helicopters. They can treat burns. And they’re ready to support patients through rehabilitation. If you’re severely hurt, this is where you want to be.

We have evolved our system of care since I began practicing emergency medicine 20 years ago. We now have more clearly defined trauma centers, although there are fewer today and in some parts of the country they are in danger due to lack of funding, and clearly designated centers for patients who present with acute MI or strokes. We have seen the rise in pediatric emergency departments to bring higher level specialty care to children. These have all been advancements, although some wonder if all this focus on accreditations and certifications has contributed in some communities to the lack of access to basic high quality emergency care.

Emergency medicine is a public service. It is one of the tenets of my specialty that we care for anyone who walks through the door regardless of social status or ability to pay. There is a cost associated with that readiness. While we all agree that more patients should have access to good primary care (and as the recent RAND report states, many of those patients with a primary care physician are referred by their PCP for care in the ED), I would also argue it is and remains essential to have access to high quality emergency care.