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Emergency Measures

AIR DATE: Tuesday, December 9th 2008
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Oregon's emergency care system just scored below average on a national review of emergency medicine. The American College of Emergency Physicians is behind the study, and while they don't officially release results until Tuesday, they've already said that nationally Americans might not receive the lifesaving emergency care we've come to expect.

Oregon isn't alone. Emergency rooms across the country are overcrowded and under resourced. And with a troubled economy leading to unemployment and loss of insurance, more and more Americans are skipping on medical visits and using emergency rooms for health care needs.

What are your experiences with emergency rooms around the state? Do you work in emergency care, or have you recently gone to an ER for medical help? Where is the state?s emergency system working, and where is it falling short? How, ideally, should emergency care fit into the overall healthcare system?

Guests:

Tagged as: emergency room · hospital · medicine

Over the last ten years or so I've taken 7 different people, on many different occasions, to ERs at St Vincents and OHSU hospital. The wait times can be terrible, but once seen I don't know anyone who is unhappy with the care they received.

The hard part is being at home not knowing what's wrong, seeing a loved one falling to pieces and not knowing what to do about it. The wonderful part is finally getting to the ER and being treated competently, courteously, compassionately, respectfully, absolutely non judgmentally by the staffs.

Here is the trouble I've seen: I've taken in an elderly woman who had fallen and hit her head, elderly women with shingles, pneumonia, urinary tract infections, a cardiac crisis. I've taken in a 73 year old man with kidney stones and a kidney infection. I've taken in a young man who had cut himself working on a chain saw, a young woman who needed stitches, a middle aged woman with a rash. I've been everywhere, man.

Once out of the no man's land of the waiting room and into a treatment room I've never had the feeling there was a shortage of nurses, or a shortage of anything standing in the way of good care, including personal warmth from the staff.

I've also gone to the Providence Urgent Care facility on Scholls Ferry Road. The waits have sometimes been bad but I've felt good about the care. Once we were sent to the ER anyway because the Urgent Care doctor felt the elderly woman needed inpatient care. The only way to be admitted on a Sunday was through the ER.

I could rant until dark about the many failures of our national health care system and of most things about allopathic medicine, but ER performance in these hospitals in Portland is astonishingly wonderful in my opinion.

I lived in Washington DC for many years and regularly read in the paper that I didn't dare have a car accident near Suburban Hospital in Bethesda, because I could go in with a fairly minor problem and die from their incompetent care. I'm unaware of such scandals in this area.

Thanks for your show. You're doing such a good job.
SusieQ22 —
Our doctor's office isn't able or willing to see someone after a fall and order an outpatient CAT scan or X ray. I don't know why not, when the patient was an established patient and it was during office hours. Even if there had been an open appointment they said their recommendation would have been to go to the ER. Huh?

In 2007 an elderly woman waited all day to be seen at 3 in the afternoon in a doctor's office at OHSU internal medicine. The doctor's office recommendation was to go the ER because she could get the tests she needed faster (and that day, rather than waiting until the next day) through the ER than they could schedule them. This sounds like an obvious way to save a ton of money, doesn't it? Make it possible to get x rays, cat scans, blood work, you name it, done for outpatients and then Medicare and Blue Cross, her Medicare companion plan, wouldn't have had to pay thousands of dollars for her ER visit. I must be missing something because this solution looks so obvious to me.
SusieQ22 —
I worked as a "discharge planner" in the TRACU, a step down unit, for trauma patients at Legacy Emanuel Hospital, which is a level one trauma center. We received patients with the worst types of injuries. Being an urban inner city hospital we received our share of patients with stabbings, gunshot wounds, etc. Patients, of course, are treated whether or not they had health insurance or funds to pay. If they survived their injuries and were admitted they typically spent time in critical care ICU, and once improved they were moved to a bed in the unit where I worked, where nurses and therapy staff were adept at providing the sometimes specialized care that these individuals required. As a discharge planner there was great pressure from MDs and the hospital administration to discharge patients the minute they no longer required care in a hospital setting. This makes perfect sense, however many patients, in order to leave a hospital setting required care in Rehab., skilled nursing facilities or if they could be discharged to home would need access into their house (you cannot get into your house if you have stairs and you have two broken legs!) and someone there to care for them. Since many of the patients had no insurance or inadequate insurance and little or no family/friend support it became very challenging to discharge them. The hospital cannot just put them out on the street. Therefore, many patients ended up staying in a "trauma step down bed" until such a time when they were significantly improved or until we could get them onto the Oregon Health Plan via Title XIX. Needless to say, the trauma patients continued to be admitted into the hospital day and night and as those patients needed to come out of ICU there were often no beds available on our unit because there were patients who we could not discharge (because of insurance or whatever). This leads to MDs, administration and other staff continually asking the discharge planner "When is Mr. X going to be discharged? He's ready to go! Have you found a place yet?". The administration gets upset because hospital beds equate to money. When a patient is in the hospital who technically does not need to be there it costs the hospital money and it forces patients who are in ICU to either stay there longer or get transferred to another floor (Orthopedics, for example) where the nurses/staff are not accustomed to caring for those trauma types of injuries AND the trauma MDs get frustrated because they have to make a trip to other floors in the hospital in order to care for their patients (vs seeing them all in one unit). Needless to say it was a thankless job where expectations on the discharge planners was unrealistic. The corporate climate there was "frosty" with little or no support. Although the care provided was outstanding to the patient, many a staff suffered from that corporate environment.
Do not forget in spring of 2005 when the group of Trauma MDs at Legacy Emanuel threatened to go on strike if they did not receive increased salary and they offered to work for Free at OHSU emergency rooms! Talk about commitment.
opbgirl —
Having raised 3 children, I was a frequent visitor to emergency rooms for years. Highlights include:
Daughter 1: broken hand, appendicitis
Daughter 2: broken arm (trapeze)
Son: 2 separate broken arms, auto/bike crash with knee injuries.
Wife: appendicitis while camping.

These were mostly Kaiser around Portland with one at Providence, one in Medford and another in Burns. In each case I was impressed by level of care, competence and compassion of staff, and by effective triage where wait times corresponded with the level of need,. For instance, my wife waited in pain with appendicitis behind a gunshot wound, diving accident with neck trauma with paralysis, and a heart attack.

My last visit was on Thanksgiving 2006. I broke my face playing football (a 40+ year tradition of Turkey bowl). I?m nearly 60, so maybe my reactions were a little slow. I initially denied serious injury, but by the time my wife arrived I was in shock, shaking with cold, nauseous with an extremely high BP. She took me to Kaiser Interstate where after a few brief questions that she answered (I could not speak or walk much at this point) I was whisked back to a room and given shots for nausea, wrapped in hot sheets and ex-rayed. I had broken the 3 major bones of the face. I was taken by ambulance to St Vincent, given adequate pain treatment and surgery the next day. The surgeon did an outstanding job and today you cannot tell I was injured or have two plates in my face. Pretty good with a $5 co-pay.

When I was young in Portland I can remember long waits, crowded waiting rooms and over worked staff. In the late 70?s Kaiser opened Sunnyside and the attitude and service were a 180 degree difference. I have been very impressed since that time.
lARreilly —
In the summer of 2005 I was taken to the emergency department at a major hospital in Portland. I had a high fever and had chest discomfort that became an MI while in the hospital. The emergency department that night was busy and I had wait in line to be screened by a clerk who checked your insurance coverage. There were several people in front of me. After about 10 minutes I was shocked to find out that 6 of those people were standing in line to get a pass to go back into the emergency department to be with friends or relatives. When I got to the front of the line the clerk took great care to see to it that my insurance was in order and that I was covered. Then she called for a triage nurse who examined me and I was told it would be a two hour wait to be seen by an emergency physician. As I sat in the wheel chair my chest discomfort became more severe and I was finally taken back to get proper help. This inane situation continues as far as I know. I am very concerned that real emergencies will continue to wait unnecessarily for needed medical care. There needs to be a better system to triage patients and handle visitors.
Phrogs —
When I took Portland's Neighborhood Emergency Team training, during the class covering first aid and triage, there was a lot of discussion about how ill-prepared our emergency medical system is for mass casualty situations. We were told to be prepared for worst-case situations where people with truly life-threatening injuries would need to be marked as "terminal", as there would be no hospital capacity for them.
EthanPDX —
When called to the country in E Multnomah county to care for my husband lying on the road beside his bike. The ambulance crew determined he had a head injury and that they were too far from a trauma ER to transport him (criteria >20 mins?). They called LifeFlight and transported him to the school football field for pick up.
The issue: insurance initially (2 yrs) refused to pay the ambulance because they "don't pay for transport except to an ER." Their words. Even after the ambulance co. contacted the insurance co. and got coding directly from them, they refused until we intervened. How can you provide services if it takes 2 years to get paid?
BTW care at Legacy Emanual was top-notch. The trauma doc knew his stuff. Obviously, if you come in by Life Flight, you don't do much waiting. When I got there, the waiting room was a zoo.
KarenR —
I've spent most of my adult life in Boston, though an Oregon native, returned now for about 3 years. The last two encounters our family has had with emergency rooms (both St. Vincents) have both been disastrous:

1. My father fell about 10 feet while trimming a lilac. In his early 70's, he was taken via ambulance to St. Vincents. He was ambulatory, but complained of pains in his torso. My mother and he requested an Xray. Emergency room staff demurred, then at my mother's insistence called his regular doctor, whose staff they said did not OK the procedure. Dad went home. As a person who was never ill, he did not follow up with the doctor. He never slept in a bed again, due to discomfort. He was dead within 6 months.

2. I took my mother to the emergency room one night with considerable chest pain and dizziness. The lobby was mobbed, with patients lying on the floor, all chairs full. It looked like a refugee center. It was during flu season, though there was no other unusual event going on. The staff did a brief billing interview, during which no query as to her symptoms was made, though we volunteered some information (which was not written down). In the course of a 1 hour wait with no treatment, we saw only 2 patients go into the medical area. When I asked, I was told there would be another 5 hours wait. I took my now-weakening mother home. In over twenty years in Boston, some spent working in a hospital, I'd never seen anything like it.

So in our experience, Oregon emergency rooms are either ineffectual or deeadly, take your pick.

p.s. Though it shouldn't be relevant, both these patients had Medicare WITH supplemental Blue Cross coverage.
Justmy Thot —
If you think there are issues related to regular emergency rooms in Oregon, then try going to the emergency room at the VA hospital here in Portland. About 8 months ago, I had to take my partner to the VA emergency room as he is a VA patient, and we waited 13 hours before seeing a doctor. He suffers from a broken hip sustained in the Iraq War, and he had a muscle tear away from the bone. We were told the 13 hour wait was due to one doctor being on duty and 10 people ahead of us. VA hospital waits are getting worse and worse with more and more injured troops returning from the Middle East, and their treatment is getting ignored.
mydogatemyemail —
I once cut my finger rather significantly while working on a remodel project. I was alone, so I managed to drive myself to the Emergency Room on my own.
The person at the desk barely glanced at me, only enough to slide a clipboard of paperwork at me. As my right hand was disabled, I was having a hard time writing with my left hand. The person once glanced up and witnessed my plight, but made no attempt to help. Blood was dripping all down my front, as I had to let off pressure with the left hand to try and write. I commented to the person that I was having trouble, and she said "do what you can".

Then I was told to sit and wait. I waited in a full waiting room for 1 1/2 hours, and only one person was called back for treatment during that time. There were many many more ahead of me.

I finally gave up, and left. Shaking in mild shock I drove myself home and asked a neighbor to help me clean and dress the wound.

Ridiculous.
BlueBottle —
The results of this study are surprising to me in one way as Oregon is one of only 8 states that have a credentilled trauma system. Although hospital ERs will receive trauma patients whether a hospital is a designated trauma center or not, having a credentialled system in place means that there are the resources and the communication systems in place to get these patients stabilized and then transported to an appropriate facility where they will receive the best care for their acuity level. The survival rates for trauma patients cared for in a trauma center are so much better than for those treated in regular ERS without trauma resources.
CHEENA —
My Canadian father-in-law visited the emergency room at our local hospital. About 18 months ago, while visiting, he became concerned with his elevated heart rate. Both of the in-laws went to the hospital, were checked in, were greeted by several physicians and specialists in turn, and were attended to in a timely manner.

These two Canadians were thrilled by the quality of care they received compared to the treatment they expected from their system of medical care.

Will Perkinson
Pendleton
Will Perkinson —
Sandra can you expand on the quality improvement that WA state conducts for paramedics. I think a important note to your listeners is that just because the state does not conduct this does not mean quality assurance is not being done. As a medic for Bend Fire we have a committee that pulls reports monthly to review treatment and assure protocols are being met. This occurs for all of our medics. Our physician adviser also reviews cases monthly for 2 hours with us on major medical cases we had. During case review care is critiqued and discussion on outcomes and improvements ensues . On top of these measures we have monthly training online/lecture on all branches of paramedic emergency care and advances in emergency field care. I suspect most EMS in Oregon conducts similar quality assurance programs.
planck —
I worked as an ER nurse for years in many hospitals throughout Oregon and it bacame increasingly difficult as it was obvious we had and still have a broken healthcare system. As a result the ER became the safety net for all our uninsured and underinsured people. With over 45 million people uninsured and a lack of providers who are accepting these patients as well as patients on Medicaid and Medicare the ER has become the primary care provider for a lot of people. As was mentioned on the program this is a very costly and inefficent way to provide priamry care. Another problem is that these people with chronic conditions do not seek ongoing care as they do not have access and so they end up in the ER with exacerbations of these conditions costing the system a lot more money than it would have taken to prevent the exacerbation in the first place and resulting in poorer outcomes for the patient involved.
CHEENA —
I was raised the child of a physician and think back with fond humor of the vacations we had to postpone or cancel due to emergencies or patient in labor and dad just had to go back to answer the phone.

I also remember taking patients to Bend to specialists because they were not healthy enough to drive themselves, some were admitted and never came home while others were fine within a few days.

Urgent care centers are great, just 20+ miles away from Prineville. When it can take 3 to 5 weeks to get into my primary care physicians, that drive is nothing if my child is injured or sick. I've never had a problem with the treatment at an emergency room, just at times the long wait if its after hours for the clinics. We are very lucky here in Prineville to have just good physicians, clinics and ER.
janbony —

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