Emergency Room Series – Part IV: ERs

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Emergency rooms
It’s time. It’s dark outside and something’s wrong inside. Let’s look at emergency rooms (ERs).

The American College of Emergency Medicine, in a 2009 position paper, rated our country’s emergency rooms. It’s a C-. So when you are at your worst many ERs are too. This combination is bad for your health at a time when it’s already badly compromised.

There are few places that are sought out so eagerly, even desperately, that are, at the same time, so loathed and feared. In a very real sense you are twice victimized: once by the condition that brings you to the emergency room; and second by the conditions to which you’re about to be subjected.

Let’s look at what you need to do before the certainty an emergency, so that when the day comes you know where to go. The next ER blog will discuss what you must do to control your fate when you’ve arrived at your chosen ER.

Which ER?
In my upcoming book I divided ERs into tiers I call the 4 D’s. Demanded, Desirable, Disarming and Deal breaking.

Demanded

  1. Your doctor’s okay. Your choice may fulfill all the requirements I outline below, but if your doctor won’t go there, you probably shouldn’t either. Whether you’re in a big city or a small town, your physician may not have privileges in one or more of its hospitals. So, ask your primary care doctor which ER she services. This helps narrow your choices. Some of you may have to throw your doctor under the bus if her ER promises to do the same to you. Today, if you need to be admitted, she probably won’t attend to you anyway. It’s the age of the Hospitalist. I will direct your attention to this flawed health delivery model in a future blog. Hospitalists make your long night’s journey into day even more dangerous. If your doctor doesn’t abandon you to hospitalists, she’s a keeper!
  2. The ER should be staffed by physicians certified by the American Board of  Emergency Medicine. The American Board of Medical Specialties (ABMS) lists its American Board of Emergency Medicine diplomats online.  The registration is simple, free and open to the public.  It is one of the “must have websites.”
  3. Crucial Services Provided by Its Affiliated Hospital. The availability of invasive radiologists and key specialists (cardio-thoracic, vascular, neurosurgical and anesthesiology doctors) who are on-site or on-call can mean the difference between life and death. Who wants to make another 911 call –from the ER itself? It happens. (See Trauma hospitals below.)
  4. Proximity. Is your ER in the next county? Count the seconds. Seconds count in heart attacks, strokes and trauma.
  5. Trauma Level I or II status. If your ER choice is attached to a hospital that is a Trauma I or II level hospital, it’s almost all you need to know. Every state has them and if one is nearby, you can skip the rest of this blog. Their physicians are better trained and more experienced in emergency care than in other ERs. There is a greater availability of specialists than non-Trauma hospitals. A trauma center’s willingness to be inspected and the high volume of patients it attracts say it all.  Even survival rates for a Level I trauma center one year after the emergency room visit is 25% higher for its patients than for their poor cousins. Some hospitals claim that they have “trauma teams” and they may have “trauma directors.” This may be better than nothing but, unless they’re designated as Level I or II hospitals they are not trauma centers. They are usually housed within large, university-affiliated members of the Counsel of Teaching Hospitals and, therefore, best suited to treat a range of emergency conditions for patients who have multiple co-morbidities.  They are also attached to hospitals with more acute care beds and larger intensive care units. To be a trauma center, the personnel you need the most are on-site and ready to go. Level III’s are okay in a pinch and level IV and Vs are launching pads to higher level centers.

Desirable

  1. Unit Segregation. The separation of the critical from the casual has several advantages.  First, and most importantly, children, teenagers and the faint of heart will find them less emotionally disruptive. ERs are rated X. If it has a pediatric unit your family will get a PG experience and specialized staffers.
  2. Fast track Units. Urgent Care Centers (UCC) have one disadvantage. You are doing your own triage when you visit one. You may be on the wrong line in the wrong place waiting for the wrong doctor. It’s better to travel across a corridor than across town when the UCC is in a hospital.
  3. Short stay units. What happens once the ER staff decides you are sick enough to require admission? You are shoved against a wall and left all alone until a bed opens up. It’s called warehousing. 1,500 ER docs were surveyed. 80% disapproved of the practice. Half knew patients who suffered while deserted in hallways. Over 10% knew of patients who died. The short-stay unit may have a separate, dedicated nursing unit or be in a wing off the emergency department. Either way, you can anticipate privacy and ready access to both a doctor’s care and family support. You now have an address on the hospital’s computer.

Disarming
Recent renovations. We have already discussed how nice it is to have a sushi station, wandering minstrels, massage therapy and wonderful views when you might otherwise be treated as litter while lying in your ER litter. But, when you are stricken and saying your amens, amenities pale in importance to the features that count. They are valued only when housed in ERs that have all the requirements outlined above. A doctor’s style can mimic but not mirror his brains, communication ability and empathy. So too can amenities. They blind you from what counts most –quality.

Deal breakers
Doctor owned, for-profit hospitals, have advocates –about a couple of dozen of them. These hospitals and their ERs are cash registers. They are meant for the wealthy and provide services that generate profit, not results. Most have few ER beds and fewer doctors to supervise them.

This year an emergency will strike you or a family member. In my immediate family we’ve had five. When you throw the dice in a game of craps, 7 11 wins. When you dial 911 you better not be gambling.

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2 Responses to “Emergency Room Series – Part IV: ERs”

  1. Chris April 5, 2011 at 5:52 pm #

    My ER visit last year should have been video taped for “Are you kidding me!!” TV. I was there for a hip dislocation and the ER staff spent 2 hours pulling, pushing, twisting, flipping me every which way. Couldn’t get it reduced and back in place. Then the ortho finally came in and it was done in a short time. My other leg and hip that was used for “leverage” hasn’t been the same since. What do you do then?? Finally out of town and getting some answers. But it is a slow, slow process and discouraging.

  2. steven kussin April 20, 2011 at 12:32 pm #

    Several lessons. One: Ask for the specialist right away.
    Two: If, after a few visits your problem persists..go regional or national. Walking is a nice thing to do as painlessly as possible.
    Three: You have done well. The answers will come and time will pass and altho it may not be the way it was it will be better than now.

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