Overwhelming demands stretch emergency rooms to the limit

They were there waiting for me when I came back this morning: the sick, the hurt, the scared, the unwise, and a few who knew exactly what they were doing, waiting all night -- for health care.

I am the director of the "Fast Track" area of Johns Hopkins Bayview's Emergency Department in Baltimore, but lately it hasn't been very fast. As is the case in many other hospitals, we see the patients who shouldn't need prolonged work-ups or admission. At Bayview, we see about one-third of the department's volume. The triage nurse sorts them out when the patients arrive, and sometimes even the ambulance cases go first to triage rather than directly to stretchers in the main treatment area. The less severe problems, the walking wounded and the worried well, come to Fast Track. Such subdivisions of emergency departments became popular as areas where patients can be quickly treated and discharged.

Now, like many such facilities across the country, we're often overstuffed with people who simply cannot get care elsewhere. And because hospitals are overcrowded and emergency departments cannot get those patients who are admitted into hospital beds, the sicker and more resource-intensive cases are spilling over into other units. So we, too, have backups, with long waits and stressed staff. People who can pay to get prompt attention in their physicians' offices don't want to sit for hours in my waiting room, so the proportion of my patients who lack the ability to pay increases. We don't have anyone to whom we can spread the costs of staying open, and we can't afford to expand facilities or personnel.

In too many hospitals, people who need inpatient care spend their whole stay in the emergency department because a hospital bed never opened up. Beds in intensive care can be hard to find, and so emergency departments often care for desperately sick patients over long periods. The stretchers can be tied up with these cases, turning a large emergency department such as Johns Hopkins' into one with few available spots for new patients, no matter how ill or injured they are.

Most of our patients do need medical attention. Some could go elsewhere and simply find this more convenient. But often we see patients who have appointments with their doctor or HMO but are afraid they shouldn't wait that long -- or they're just suffering too much. Many of the patients in emergency departments around the country are there because they let some fixable problem get worse -- often because they couldn't pay for the fix. Our patients are often employed but lack insurance and sufficient cash reserves to offer payment at the time of service at an office or clinic. Some are hurt at work but don't want to make a claim for fear of losing their jobs. And some know they can get what they need today and worry about whether or how to pay tomorrow. If you were broke or an illegal immigrant and your child was sick, what would you do?

How did it come to this? Easy. Imagine any system with shrinking supply and increasing demand for something important. Then imagine one source of relief in this system, one place where you can get what you need regardless of your ability to pay, where they have to and want to help you, and do so very well. Unless that one resource has infinite capacity, it will be overwhelmed.

I understand how health care planners with limited vision might have decided years ago that unoccupied hospital beds meant inefficiency. But demand fluctuates around an ever-rising curve. I understand that legal restrictions on hospitals' ability to "dump" indigent patients were needed, but we now have screening rules interpreted to require immediate and extensive evaluations of anyone at an emergency department who might have anything serious. I understand that consumer advocates and plaintiffs' lawyers are concerned about tort reform that might make it harder to sue, but the nearly random nature of that system leads some providers to feel that they have to do everything for everybody.

Regardless of where you stand on health care as a right, it's clear that lack of it is a wrong. Emergency services have at least some aspect of a public good. Even those of us who don't need the emergency department today want it to be there.

Don't worry, members of Congress and their families will be OK. They can go to Bethesda Naval Hospital or Walter Reed's emergency room, and the admiral or general in charge will come down and make sure they don't have to wait. But emergency medicine is fairly egalitarian otherwise, taking sicker patients first, with those in about the same category of severity waiting in turn.

I worry about the people in the waiting room. Are they getting sicker? Do they have some undiscovered dangerous problem? What will we do when the waiting rooms are full beyond capacity?

Your friends in the emergency departments are working as hard and as fast as they safely can. Both the people and the facilities have been stretched as far as they can. We hope you don't have to come and see us. We hope we can still be there when you do.

Hugh F. Hill III is on the faculty of the Department of Emergency Medicine at Johns Hopkins School of Medicine.

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