(July 29, 2006)


      In 1969 while working in southern California, I needed to be able to fly my family home to Nashville for visits. Because I did not have the money to pay for our flight I did what many young doctors often did in those days, I signed up to work two 24 hour shifts in a nearby hospital's emergency room. In those days, you see, there were no doctors who specialized in Emergency Medicine so emergency room positions were filled with doctors needing or wanting to make some extra money. How times have changed!

      The first residency programs to train young doctors to become specialists in Emergency Medicine began in the mid 1970s and have grown ever since. Today the field of Emergency Medicine has become an equal to other specialties such as Surgery, Medicine, Pediatrics and Obstetrics and Gynecology.

      Emergency rooms are now staffed by men and women who are highly trained to care for the critically ill and to handle the most complicated of emergencies. American medicine is the better for this relatively new specialty. Despite all this expertise and professionalism, however, Emergency Medicine Departments in this country are in trouble.

      In many ways emergency rooms can be compared to canaries in a coal mine. A canary that dies in a mine is an early warning to working miners that the air is dangerous and that they should immediately exit. Emergency rooms are dangerously troubled today and represent an early warning sign that indicates our health care system is dying and that we must exit our current way of administering medical care and begin making significant changes.

      The reason is clear. Patients are coming to emergency rooms for minor medical conditions as well as serious problems. Because so many Americans do not have a primary doctor, they must rely on emergency rooms for routine care. This has created a serious problem for doctors and nurses as they attempt to decide who needs urgent treatment opposed to those who could wait.

      Due to the large number of Americans without health insurance and huge cost increases in medical care, emergency rooms are seriously over crowded and close to the breaking point. The number of patients seeking care in emergency rooms has increased from 90 million in 1993 to 114 million in 2003. It is even higher today. In addition, 423 Emergency Departments throughout this country have closed.

      All this has resulted each year in over half a million ambulances being diverted from emergency rooms that are full to others further away. It is estimated that many people have died as a result in a delay in treatment as well as not receiving treatment in the chaotic environment of an overcrowded ER.

      Vanderbilt Medical Center recently doubled its ER capacity from 23 to 46 beds because of an increasing need for more ER beds. The Chairman of Vanderbilt's Department of Emergency Medicine, Dr. Corey Slovis reported that on most days his department is totally full and there are as many as 20 patients waiting to be seen. Dr. Slovis explained how Vanderbilt has had to hire doctors just to take care of patients in the waiting room. Their job is to make sure that waiting patients are not so ill that waiting will bring possible harm. The over crowding of emergency rooms is expected to get even worse.

      We are witnessing a large influx of patients who are seeking routine medical care and are uninsured or on Tenn Care and cannot find a doctor to take care of them. They have no place to turn for help and so they come to the ER. By law, hospitals cannot turn away any patient seeking care regardless of whether they can pay or not.

      Considering all this, one wonders how we are going to be able to deal with a major disaster such as a mass casualty or influenza epidemic. How will we be able to get the kind of emergency care we need when the time arrives.

      It is time to respond to the canary's demise in our emergency rooms. We need to put together a system that will allow all citizens to have health care insurance and thus be able to obtain primary care outside the ER. We need to increase the number of doctors graduating from medical schools and make it attractive financially for more to chose primary care specialties as well as to practice in poor neighborhoods.

      We also need to stop diverting real emergencies and begin diverting those who are seeking non-emergency care to neighborhood clinics staffed by round the clock doctors or nurse practitioners. All this will require a will to act as well as money. Yet we must act if we are to save our emergency departments.