Why are there so many emergencies here? • LITFL • ER Doc Walkabout

American ER Doc Gone Walkabout Episode 001

Immediately I step off the plane I face questions without the same answers as in the US:

Which direction do I look to see the sun? (Can I ever see the sun in Launceston?)
When I step from the sidewalk, which direction do I look to avoid being crushed by a lorry? (In fact, what’s a lorry?)
How do I order something that resembles the coffee that I drink at home? (Wikipedia informs that a “long black” will do it, and that seems to work quite well.)

Then, on to the more substantive questions:

Will the waiting room be full? With folks waiting for over 2 hours? (OK, some answers are the same.)
Will admitted patients spend hours or even days in the ER? (OK, still waiting for a different answer.)
Will I have to take a pen in hand, and write on paper?
Will I miss my computerized electronic medication dispensing system (Pyxis)? (Fat chance of that.)
What will happen when I recommend that a discharged patient follow up with a GP, or a specialist? Any chance of that happening? (And, what’s a GP?)
Will I spend hours, and hours doing paperwork that has no medical purpose whatsoever, but is solely for billing and legal protection reasons?
What units are those strange numbers on the lab reports?
What do you mean, I can’t get a CT or MRI of that man’s toe at 3 am?
The neurosurgeon is how far away?
If my patient has no pulse or respirations, did he die? Or, did he “cark it?”
Will the psych registrar provide less help than the drunk in hall bed 3? (What’s a Registrar? I know what a drunk is, but it took me a surprisingly long time to really understand the difference between residents and registrars.)

And the more technical questions:

What do you call that stuff that you use for fever?
You do what for symptomatic bradycardia? Hmmm – that’s a bit different.
And how’s that you manage new onset a fib?
Tamsulosin? I don’t think we have that.
Really? You can write a prescription, and people can actually get the medication without becoming bankrupt? That would be unAmerican – to think people could actually afford their prescription medications.

Let me start with the most consistent, on a day to day basis, thing that I noticed in Launceston (no, it wasn’t the patients with 6 fingers):

First, a reminder: I work currently primarily in a large, urban, academic emergency department in Denver, Colorado, USA. I have worked for many years primarily in a smaller, non-academic ER in the rich, yuppie town of Boulder, CO. And, I work for at least a few weeks a year in a small 8 bed ER, in a 50 bed hospital with limited specialty backup on an Indian Reservation in rural Arizona.

The remarkable thing in Launceston, was that every day, repeatedly, we saw cases that were emergencies. They were emergencies by anybody’s definition. If I asked my non-medical cousin, she’d say it was an emergency. If I used a common sense definition, by the man in the street, it was an emergency. And, If I used my own more technical definition, it was an emergency: acute onset in a time-frame of hours to days, and needing some sort of intervention to prevent a bad outcome. More colloquially, I could ask myself, “Is this something that I’d expect to see on “ER” (or even on Scrubs) on Thursday night television?”True emergencies were a remarkably high proportion of our patient population at LGH.

At University Hospital in Denver, 90% of our cases are exacerbations of chronic disease that can’t — either for financial reasons, or because of lack of clinic appointments — see a GP or specialist in a reasonable time frame.

Doc, my COPD has been getting worse for months — and it’s still another month before I can get an appointment at clinic. So, I’ve waited 6 hours in the ER waiting room to be seen for my chronic exacerbation.

A large portion simply have no way to pay for an office or clinic visit — no insurance, and poor enough that they wouldn’t be able to pay the $50 or $100 or more needed to pay for the visit. But US law forbids turning these folks away from an ER (though, if I do the CT and find a cancer — it’s not an emergency and I can, and sometimes must, provide the diagnosis but not the treatment). Or, I even find the trimalleolar fracture, reduce and splint it, but can’t get my orthopedists to provide the operative fixation!!! So, the ER Docs at the University often are inundated with the workup of complex chronic issues — including the really complex heart, lung, liver transplant patients, and pulmonary hypertension patients on continuous prostaglandin infusions. Or provision of “social safety net” care to the poor and the homeless — generally, non-emergent. We face pressure from the “suits” to “move the meat”, to do the paperwork for billing, and I can’t help but believe that when the true emergency comes through our door, care suffers because they are lost in the herd and receive less than optimal attention because of the multiple competing priorities.

In the US, it’s not strictly financial issues that drive people to the ER. Even in a rich town like Boulder, we had large populations coming to the ER with chronic problems because of poor access: “Grandma has been deteriorating for months, and for the past week she can’t even walk, but we can’t get a time see her internal medicine specialist for 3 weeks – so we came to ER”. Or, sent to the ER for high-tech diagnostics (I called my Doctor on the phone, told him I had abdominal pain, and he said I might need a CT scan, so go to the ER) that “might” be needed. And, in a rich town, many trivial complaints are perceived as requiring immediate care – the trivial ankle sprain, the single vomit in a 2 year old, etc. — the worried well.

30 years ago, most of my acquaintances in primary care scheduled 4 patients an hour, and left an hour a day unscheduled for urgent walk-ins. But, in the last 20 years the suits have told the clinicians that they need to be efficient, so the offices schedule 6 patients an hour with no unscheduled time. So, an urgent issue, even if it could and should be handled in an office by a doctor who already knows the patient, is often sent to ER for convenience and scheduling reasons.

At the Indian Health Service hospital, it is often much the same — the clinics (no financial barrier because it’s a federal government paid system) are often overloaded – especially during the winter respiratory season — and rather than overloading the clinic system, patients are sent to the ER where they wait for hours in the waiting room, and leave the Emergency Medicine specialists caring for chronic disease, minor respiratory illnesses, etc. I’m not clear on why overloaded ER’s are more acceptable than overloaded clinics.

So, despite the differences in those US settings, the ER Docs time and expertise are rapidly diluted by the large volumes of patients who would not fit anyone’s (not even my Aunt Matilda’s) definition of an emergency. In the non-academic setting it contributes to skill deterioration. In the teaching hospital, it means that our residents (comparable to Australian Registrars) get limited exposure, despite heavy loads during long work hours, to the true emergency requiring active intervention.

The notable difference in Lonnie was the generally low levels of such non-emergency care. On a daily basis we saw a large proportion of patients who required an intervention for an acute trauma or acute illness. It might be a minor intervention — sewing a laceration, or a little oral zofran and oral hydration for a vomiting child. Or it might be major: a stroke, a STEMI, a major trauma, a sepsis resuscitation, a cardioversion for new onset atrial fibrillation.

It was, compared to home, rare for a patient with a chronic disease, or with subacute symptoms to show up at the ER without having been in contact with, and often seen by, a GP. And, often he’d have in hand, a brief letter from his GP. Truly unheard of in my experience.

In the setting of seeing fewer patients per day than at home, I placed more chest tubes, did more electrical cardioversion, sepsis resuscitation, managed more major traumas, had more positive bedside ultrasound exams, etc. during 3 months at LGH – than I would in several years at any of the hospitals where I work, or have worked, in the US. Each shift provided the volume of true emergent care that I would expect to see in several months (really!) at home. In many ways Launceston reminded me of emergency departments in the US of 25-30 years ago – before the shift in social paradigm: from ER’s are for emergencies, to “it’s OK to go to an ER for a chronic condition, they’ll take care of you, no matter what.”

I tend to prefer caring for sick patients, doing procedures, using technology and I was in heaven at LGH. And, I wish that I could have brought some of my own residents with me because they would have gained far more experience in a short time than they do at home.

And, they would have the opportunity to search for pathognomonic physical findings, like 6 fingers.

Here’s the caveat: I don’t have any good way, except by hearsay, to compare my experience at Launceston with anything else in Australia. Was Lonnie unique? And if so, why? Because it was bigger than, or smaller than, or more rural than, or better than, or worse than — other ER’s in Australia? Or was it similar — because of payment systems, or because of the broader office-based medical care system, or the lack of a social construct to allow patients to self-refer non-emergent illnesses to the local ER?

Over the next couple of months, I’ll plan on a bit more focused review of my time in Launceston and comparisons with care back in the US.

Next time: What is that stuff you give for a fever?