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"Crisis in the Emergency Department. What is the answer?"

 

It’s late November in New England. I’m standing in the middle of a lake on a paddle board. A steady wind pushes me to the far end as I soak in the stillness. Two seagulls circle over me in the grey sky, then land eyeing me suspiciously. Small waves tap at my board, rocking me gently. This is just what I needed. After a grueling stint in the Emergency Department, eight shifts in ten days, I am exhausted. The constant onslaught of patients, the hospital at capacity and the ED so full it is bursting at the seams. In the waiting room patients are being seen in rooms that functioned as something else in the past. In the ED they are stacked along hallways obscuring exit doors, bathrooms, and supply closets. Transport has to move one patient to get another through the narrow remaining hallway space. We do our best to take care of patients, some of whom have been there for over twenty-four hours, but in truth, this is not good or safe medical care. There is so much room for error in a system this overburdened.

How did we get to this place? It is not just the pandemic, though it surely has contributed by the delays that many have experienced in their medical care, and by making access to outpatient services, elective surgery, preventative procedures, and primary care, more difficult. Many patients have had to put off important treatments and workups and now present with complications and worsening of underlying conditions, leading to ED visits and prolonged hospital stays.

It is nearly impossible to see a primary care doctor for anything other than routine appointments. If you are acutely ill and you put a message in MyChart online, or leave a message with the answering service, you are lucky if someone gets back to you in a day or two. When my husband recently became ill, it was easier and safer to go to the ED than try and wrangle an appointment, sure to delay care. Delaying treatment would likely have caused significant worsening of the illness. This is true for many who come to the ED.

There are other factors in play as well. The corporatization of medicine and profit based insurance, with prior authorizations, denials, and increasing costs of medical care, have pushed people into more perilous health conditions, or they have become so desperate for a procedure or treatment that has been denied, they come to the ED. Primary care physicians and specialists send anything out of the norm to the ED including chronic medical conditions. They are under tremendous pressure to see patients in a limited time frame and anything unexpected or time consuming must be sent elsewhere out of necessity. The increasing use of mid-level providers also plays a role in our volume. NP’s and PA’s, have taken on an intermediary role, helping to care for primary care and specialty level patients. This can be helpful, lessening the burden of patient care and creating more outpatient access, but because mid-levels may not be as experienced, and have less training, they may have a lower threshold to send patients to the ED.

Mental health care, addiction treatment, homelessness, and the opioid crisis are also major contributors to the crisis in the Emergency Department. People who desperately need help and care, have nowhere to go. There are few mental health options, few addiction treatment centers, and a housing crisis. Care is so fractured many go without treatment, leading to an increase in violence, suicide, and a myriad of health problems. The Emergency Department is often the only access point many of these patients have.

All of this and more has led to the crisis in health care being playing out in many Emergency Departments across the country. The impact on ED providers is clear. Nurses are leaving the field. Physicians are exhausted and stressed, suffering from burnout and moral injury. It is death by a thousand cuts.

I don’t have the answers to all these problems, but I do know that standing in the middle of a lake, paddle in hand, fingers and toes numb with the cold, breathing in fresh air, is therapeutic. I start to move. The wind which had gently pushed me in one direction, is in my face as I head against it. I pull with long paddle strokes, knees slightly bent leaning into the wind. A group of migrating buffleheads take off skimming over the water as I go by. What a joy to feel myself moving forward, the waves tap-tapping on the bottom of my board, my feet firmly planted, arms working hard. This task I can do. I can paddle back to my dock, feel the shock of the cold water on my legs when I get off, haul up my board, and satisfied, head in for breakfast.

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Elizabeth Mitchell, MD

Emergency Physician, Clinical Professor, Singer-songwriter, Poet

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