That's completely ridiculous. The bar is pretty high for me to go to an ER, I'm pretty sure anything on that list would need treatment faster than 6-10 hours.
Hell, its not recommended to keep a tourniquet applied for more than two hours and even then there's a specific protocol to follow as there's risk of what will be released back into your system.
What are people even going to the ER for when they can wait for 10 hours?
I'm an ER doc. I work 3 nights a week and see probably 5--10 patients a week who have waited over 3 hours.
The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.
We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.
The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.
Attach a regular urgent care clinic to the ER, and divert patients there. Medicine is anything if not statistical, and any ER should have a clear picture of what the care needs are for the incoming patients.
Some hospitals do this and it works OK. But patients often believe that they should go to the ER rather than the urgent care part in this situation "just to make sure" or due to other myths. Also, during the day both our main ER and our urgent care are totally saturated at my hospital system.
"Well then your silly system just needs to build more facilities! It's obvious!!" You say.
One thing people need to realize is that it is not necessarily in hospital admins' best interest for all the ER patients to be seen. If it was, they would spend more money on more efficient triage systems so that we could just rake in the bucks. But, in reality they would often lose money on such a gamble in my understanding, due to how patients of different coding levels are reimbursed by payors (and whether a patient is even likely to have a payor).
It is interesting to me that a system that had good social housing and guaranteed healthcare would not be affected by this specific problem, and would most likely (looking at places where this is true, like Austria) be cheaper than what we are currently doing.
If you add a level of mandatory screening you can filter out ER to Urgent Care. The problem is still the connotation that ER is for everyone. Just put up posters in the ER lobby that make people uncomfortable things that say ER is for like car accidents. No one wants a reminder, but no one wants to be that asshole cutting in front of the guy who got a broken clavicle from a seatbelt or other various injuries.
This has been suggested many, many times in my career. The problem in the US is that such posters would violate[0] a federal law called EMTALA, which prohibits an ER from turning away any patient for any reason until I or another provider has performed a Medical Screening Exam (MSE) to assess for A Real Emergency (TM).
EMTALA and confusion around it is another common reason why patients often stay in the waiting room for many hours when really it would be in their best interest to go home and go to a clinic during the daytime. It is the main reason I try to ~break all the soft rules at night and just go out into the waiting room and MSE anything that moves so I can send it home.
EMTALA was passed in the 1980s under Reagan I believe. Good luck repealing it or revising it to make sense in our current political environment!
[0] Or appear to violate the law in the optics of some administrator, insurer, healthcare bureaucracy maintenance organization visitor, etc. In this way, in large bureaucracies, magical thinking reigns, optics becomes objectivity, and 2 + 2 = 5 .
It isn't about turning a person away, it is about enqueuing them into another emergency type care, urgent care is still a high priority but it is urgent and not deathly required.
This would allow prioritization of people needing immediate care.
I happen to agree with you. I was writing not my opinion, but my experiences with the actual EMTALA law, or more accurately and importantly my healthcare administrators' perception of said law. I cannot change either of these things.
I think that admins' interests not aligning with that of patients/consumers or with those of professionals/practitioners is making millions of people sad in a lot of other fields in addition to medicine.
Ben Hunt has written some great essays about this nebulous concept. His phrases "industrially necessary" and "raccoon" come to mind.
Is there a general solution? Dunno. But I suspect crafting even more regulation would be kinda like trying to make Wikipedia better by firing all the content experts and making all the admin-type people write all the words. It wouldn't result in a very good end product.
I seem do my best work when I am left to my own devices and my contact with admin is minimal.
A few years ago my wife had a very high fever (105°). I took her to urgent care and they determined she was too sick snd needed to go to the ER. So we shrugged and went to the ER,’where she had to wait for 3 hours before she was given some more Advil and a cold compress (and tested for a few other things).
You're welcome! Basic answer: $250/h + benefits and 4 days/week "off". Plus, working in the ER at night is the most fun job I've ever had or probably ever will have. (Programming is second.)
Despite this, I plan to pivot to my telemedicine business full-time within the next year. I know I am not invincible and the older I get, the more mistakes I am likely to make and the more working nights will become a risk factor for heart disease, diabetes, and the like. Plus, working nights wreaks havoc on the family, but it's the only option to work stable days each week in the ER. (Ie, most ER docs either work all nights or work a random rotating schedule of first, second, and third shifts.)
Having worked as an MSI (Medical Specialized Interpreter) at $4/h, I've noticed that patients are still very reluctant to accept telemedicine for anything other than reviewing lab results.Do you possess a strategy to overcome this challenge?
LATAM Subcontractor for Teleperformance/LanguageLine Solutions/Pacific Interpreters.
The strategy I possess is to use telemedicine in novel and directed ways when it suits the purpose.
Most telemedicine roles I have interest in start with a very directed patient population and a limited set of interventions. Patients at risk for HIV, obese patients, etc. In this context, these subsets of patients are happy to accept special-purpose telemedicine, in my experience.
I personally would not want to see a primary doctor or surgeon over the Internet, and if I needed follow-up testing in the lab right next door anyway, I would prefer to go in person to both places in one "quick" trip rather than dicking around with the Internet before going out to the lab anyway.
Patients are right to be reluctant. Telemedicine offers a lot of benefits, but it can never be as thorough as time in person with a primary doctor. (But this in-person time is just not possible to get for your average patient in my experience.)
Completely understand if you don’t have the time or desire to answer questions, but I’m curious whether you went programming -> MD or the other way around, and how you made the transition.
1. Grow up in the 90s and play too many video games and read the Extropians list too much.
2. Decide I want to be, like, the Hagbard Celine of pharmaceuticals and cure death, or something.
3. Learn programming because I still need a job if I fail at (2) and anyway programming is fun and people are scary.
4. Double major in CS and Bio, do bioinformatics research for minimum wage.
5. Move to Berkeley, learn more programming working at a random startup for minimum wage.
6. Get a job as a bioinformatics programmer at a lab; learn lots more programming and some bench biology and publish papers, under the theory that I need papers and a PhD to start a pharmaceutical company.
7. Look around and decide I don't want to be postdocking in SF for $40k/y when I'm in my 40s and have kid(s).
8. Enter an MD/PhD program (MSTP, ie combined and debt-free degrees) as a lowish-resistance hedge even though I dislike premeds and also the entire bloated medical system.
9. (8 years later) Do residency in Emergency Medicine because it's really fun and all the other specialties bore me. (Except radiology, but that's no fun with chronic sciatica.)
(Writing this in the middle of the night from that critical access ER I mention.)
I just don't think there's any other medical specialty that has a job as action-packed and gratifying as my job is for me. Surgery would be gratifying, for sure, but also I hate formal clinic and I have a weak bladder, so no.
Yeah, I guess I see lots of sad things. But (1) often patients are sad about things that could've happened but didn't actually happen, and I can cheer them up just by telling them the truth. (2) Often I can make patients happier if actual sad things happen to them, at least in the moment, and that makes me happy too. And (3) if I got sad every time I saw a sad thing, I'd be too sad to do my job and then I'd get fired. So, like, these things don't really make me sad because I'm here to do my job, not to get big feelings?
Maybe not for you. If I had a medical emergency, I wouldn't want to be attended to by a mopey physician - no matter how dire my circumstances. The same goes for therapists and first responders. Yes, those people don't always see people at their best, and they've seen some shit - but it's just a job, and society works best if that job is done well.
ER doctors are the SREs of physicians - some folk are wired to enjoy the same high-tempo/unpredictability aspects that repels others.
I looked up the etymology of "fun" and you are right - Middle English fonne, fon (“foolish, simple, silly”).
That said, I'll take action-packed and gratifying over fun any day.
Also, emergency medical doctors are extremely foolish people during their down time - medicine has an old tradition of utter silliness when it is time to blow off steam from the job's pressure. So there, fun too !
When I was in ERs as patient, I did enjoy doctors with a good mood. People with a good mood are also usually doing a better job and if they have fun fixing my mess, good for them and for me. Optimism is quite helpful for recovery.
I mean, I am also a fan of black humor, so mixing jokes with blood works for me, even if it is my own blood.
Of course I view you as more than pph. My job would not be very fun if I only viewed you as pph. And another part of keeping my job involves minimizing patients complaining about me to admin, which they would a whole lot more if I only [acted like I] viewed them as pph.
And, in order to allow myself to continue viewing patients who are not you as more than pph as well (and thus keep my job), I also consider a lens of pph. Because if I'm talking to you for an hour about low-carb diets or whatever and you feel like I'm the best doctor in the world, but there are 5 more people in the waiting room in pain that I haven't seen yet because I'm totally focused on you... also not doing my job.
The fact that I use this lens does not limit the services I provide to you or the empathetic positive feelings I share with you as a fellow human. (Or not, if you don't want those feelings. As a certified weirdo, I distrust people who come onto me w/ big outward empathy, personally. But most patients like it in my experience. So I tailor it really depending on who you are.)
Agree that forum is very depressing. Bunch of old ER docs who aren't looking for a way out for whatever reason. Part of the goal of my posts in that thread was to get them to smile a little, but they're too crusty. If I hated my job as much as some of them, I would just quit immediately and go back to programming.
I do some radiology in the ER. I do find this fun. The core skill of radiology is to find stuff in pictures and then communicate these findings to others. Just like I did as a scientist, which I also found fun and exciting.
I also find it fun to do research in molecular imaging. I suspect I would further have fun researching AI techniques that may allow us to replace some or all of the human work of radiologists with computers. (I suspect "all" will never happen, for the same legal reasons that I suspect we'll never have real self-driving cars. Humans need, um, human scapegoats.)
However, yes, I also have chronic sciatica, or back pain. It gets worse the longer I sit. I don't like standing still enough to use stand desks and treadmills are distracting. Clearly being a radiologist and sitting in a dark room for hours at a time would not be good for this pain.
This is yet another reason I got out of full-time programming.
Thanks for sharing all of this. Your account of a night shift gives me hope that there are still micro-cultures out there that want to get it done. Reminds me of the best parts of active duty.
Main telemedicine gig right now is diagnosing and managing HIV and other STDs. Patients love it as it's super private, and even testing can be done discreetly at home with a mailed kit.
Currently completing an online fellowship in obesity medicine and plan to start my own online practice or collaborate with midlevels who do so. Will probably get into tele-urgent care as well.
I've learned a little about all aspects of medicine as an ER doc, and it's exciting to apply that knowledge to telemedicine. Telemedicine is the Wild West right now. COVID-19 just opened it up a couple years back. We don't really know how to maximally benefit patients with it, but there are all kinds of new models being tried. When it works, it really works, without all the bloat and entrenched rentiers that can make brick & mortar medicine awful for both doctors and patients.
Reminds me of the state of the Internet around 2000. Wide open.
That tracks with what I have I assume the average wait times are. Given that its the average, I can only assume the ratio between actual emergencies and everything is worse than 10:1.
For that, I apologize. Maybe it comes down to fundamental problems in healthcare and most people not having a primary care physician, but I just can't imagine going to the ER with anything less than a very serious traumatic injury.
> As I understand it, the ER cannot refuse patients without money or insurance?
That's true, and a whole other discussion. If our ER wait times are 6+ hours primarily because they are full of people without a way to pay for treatment that's a much bigger problem.
> Also people can get sick in the middle of the night or outside of regular clinic hours.
For sure, that can absolutely happen. Though I'd argue the bar should still be high with regards to when a person should go to the ER. Unless its a true emergency one could still wait until clinics open for regular hours.
I once went to a large professional building attached to a hospital because I lost my voice and I wanted to see a doctor, any doctor, on any time frame. They said the only thing they could do is send me to the ER. These days, I would go to a walk-in clinic like Carbon Health or One Medical I guess, if I was in an American city away from home, without my own doctor. But I find it hard to blame anybody who goes to the ER for "just a cough" since I know the system won't do anything else for them.
NB when I was in the military they had the entire problem of suddenly ill people completely solved. Socialism.
Yep. We’ve only ended up in the ER once for each kid (so far … knock on wood), but both times there were sudden onset symptoms that in my mind warranted urgent care but not the ER. Both times we called and were told that we could wait two weeks for an appointment or go to the ER, no in between.
The irony that military healthcare, while far from perfect, has many advantages like it's part of the benefits to servicemembers and dependents, some retirees.
A surprising number of people, especially prior to the Affordable Care Act, would call expanding public healthcare "Socialism", even though many in Congress are veterans. The late Sen. John McCain (R-AZ), A Vietnam veteran A-4 pilot, and POW, cast the deciding vote against repealing the ACA. He earned his military healthcare, and then some.
There's a strata of use cases that left in limbo in your argument.
Im a basketball player. I may have a microtear of a ligament from a 9pm game. The ortho guy, the pain doc, the sports med and my pcp are closed at 9pm.
I have no options but to go to the ER. I know because I've been there. Multiple times.
My kid is breathing and I can see his ribcage from forced breathing? If its past 5pm, its definitely an ER trip.
I pierced my hip with a chain link fence and need irrigation for the wound? ER trip
None of these injuries are life threatening.
I'm not poor. My time is super valuable. i charge some clients $700/hour. Yet in each case, I spent > 4 hours in ER !
Now- I will literally wake up MD friends and ask them to write me a script to the 24hr pharmacy instead of waiting in ER for meds.
There's nothing in my post that disagrees with anything that you're written.
Everything you've written is correct. I was not trying to argue anything and I think I hedged my words above quite carefully. I was mainly trying to answer OP's question and in passing explain a few things that make it look to patients like me that the ER is even more messed up than it actually is. (And it is actually pretty messed up!)
I love the people with microtears who can't get into the office. I love reassuring parents that they don't need to spend $10k for their viral toddler to be admitted and get treated with nothing all day and then get discharged, but slowly and passive-aggressively. I love helping people who are in the ER for legitimate reasons. I understand that the medical system is broken and most people who are in the ER should, in a halfway sane system, not be in the ER. I understand that way too many people wait for way too long in the ER and it makes me real sad, because as I've written elsewhere on this thread, I do think there are usually fixes that are possible and even easy, from my POV as both geek and JAFERD.
Telemedicine does offer some solutions to some of these problems, but not all of them by any means.
None of those sound like ER visits, except maybe the chain link fence if you're worried about infection if you wait?
It sure sounds like your justification here is that you have to take up time in the ER because you or your time is that important - I hope I'm just misreading that and your point was different.
In Sweden there are two types of ER, real ER and "närakut" which roughly translates to "near care". It works pretty well, the few times I had to go to närakut I waited less than an hour to talk to a doctor.
Just wondering, why does an ER doctor read hackernews?
In the local ER - not your ER, probably - they only scoop up the dying. As I recall, one person near me had been in a car accident and was sitting there with very painful, unset broken bones for 9+ hours. They couldn't get painkillers until they were seen.
Everytime I've gone I see regular people spend 8 hours+. No one is looking for a roof over their head or a doctors note. The ability to pick and choose who requires care sooner is overrated.
I can assure you if you come via an ambulance you will get pushed to the front of the line over a walk in.
Easy to triage things gun shots are not so easy when the problems are internal. Easy to introduce bias. Parent poster thinks homeless and poor are only there because its warm or they have nothing better to do. It's okay to keep them waiting over someone who looks rich. They must have a serious problem, look at how well dressed they are.
In hundreddaysoff fantasyland, the solution is to fire all the bureaucrats and triage everyone immediately. But, then nursing primaries and secondaries and all the other required paperwork wouldn't get done and CMS would come shut down our hospital.
There is no shortage of practitioners, ie ~medical middle managers such as myself and other MDs/DOs/NPs/PAs, willing to work in the ER.
(In the narrative of one faction, the suits have in fact created a surplus of us, including docs, that will only get bigger in the next 5 years, possibly hitting n=10,000+ surplus ER docs by 2030. If that happens, a major reason for that in this narrative would be that the suits have directly funded more Emergency Medicine residency slots opening in that time than there are interested American medical students applying to the specialty.)
There is no shortage of bureaucrats willing to shuffle paper and create more work for themselves in the name of Quality or whatever. See this doc's blog for a relatively balanced take on this growth, but I do think there is truth to his first graphic: https://investingdoc.com/the-growth-of-administrators-in-hea...
In my understanding, there is a critical shortage of RNs willing to provide the actual hands-on patient care, for pay that will still turn a profit for the hospital.
This includes skilled ER triage nurses.
But the other side of the coin from labor shortage in this problem is, again, that hospitals simply are not reimbursed sustainably to serve many ER patients, particularly self-pay patients, in the non-literally-emergent ways that those patients should be served, would like to be served, or deserve to be served medically.
Ie, in my understanding the ER is often a loss-leader for a hospital that serves to get patients into higher-total-reimbursement clinics such as GI, cardiology, and orthopedics.
Again, I'm not trying to argue for any faction here including doctors/midlevels, RNs, hospital admin, or even patients. I'm just trying to describe the system from my view down my periscope over 8+ years of doing this.
In the past year I've gone to the ER with my late 70s dad almost once a month including multiple waits in the 6-12 hour range.
* Any time a senior (I guess anyone, really) falls and hits their head doctors want a head CT. Only place to do that is the ER, but if you aren't showing any symptoms of a brain bleed or similar problems, you're low on the priority list.
* Dad had IBS and problems with severe constipation. Twice he was having significant abdominal pain and we were told by his GI doc to go to the ER for a CT to make sure there wasn't a serious problem going on. But again, pain with a history of constipation and no other immediate symptoms lands you low on the triage list. And indeed both times he was just constipated.
* The worst time - the 12 hour wait - he was experiencing severe altered mental state. His neurologist, who normally has a 2-3 month wait for an appointment, thought it was serious enough to see him the next day. After examining asked if we could go down to the ER (their office is attached to a hospital) for a lumbar puncture and other tests to rule out a brain infection. Again, apparently the ER docs disagreed, so in the waiting room we sat.
In general though my observation from all of those hours sitting in ER waiting rooms was that a significant portion of the people there were really just sick and probably should've been at urgent care or their PCP.
My wife is a pediatric ER doctor. The majority of the patients she sees shouldn’t be there from a strictly medical perspective.
But parents can’t get off of work while anything else is open, first time mom doesn’t realize that a slight temperature and a cough isn’t an emergency, dad is finally fed up that his teenage daughter has been complaining of a tummy ache off and on for 6 months and Sunday at 2am is when he finally decided he had to have answers.
While I personally am okay with giving a pass for new parents that are scared for their child, I don't get burdening our emergency system just because.
I'd chalk new parents up to a learning experience in a new and uncertain time. For anyone going to the ER because it fits better with your work schedule, don't clog up the system for anyone that's truly in need and increase prices for everyone else.
It's not 'our' emergency system, it's the healthcare provider who now is often a for-profit. If they have a mismatch between supply and demand, the fix is obvious. It's not your problem, it's theirs.
Fairly often, a doctor told you itnis fine and then things escalated quickly. Or, you have appointment but it is weeks away. nope, people do not prefer to wait 8 hours in ER if there is an actual choice. Problems is, actual choice is often unreachable and just used to blame patients for bad system.
Like with OP, 2am tummy ache means the pain massively escalated from something undistinguishable for run of the mill cramps doctors normally don't do nothing about. (As in, cramps you walk in with, they charge money and they won't do anything at all with and fonsider minor)
> Like with OP, 2am tummy ache means the pain massively escalated from something undistinguishable for run of the mill cramps doctors normally don't do nothing about.
... and then, on average 7 years [1], later, the desperate daughter finally learns she had endometriosis all the time, and she could have been spared of years of suffering had one of the completely overworked doctors she had seen before actually had the time to delve deep into the issue rather than just hand out painkillers.
> Hell, its not recommended to keep a tourniquet applied for more than two hours
Minor note: this is somewhat outdated. They've determined now it's more like 4-6 hours before it causes any damage at all.
Per Stop the bleed, Mayo Clinic, etc.
But yea faster than 6-10 hours that's for sure. I bet if you went into that ER with an average time of 9 hrs and a tq stamped hour ago on your arm, they'd get you in pretty fast though. Triage is still a thing
I actually had 6 hours for the tourniquet limit at first and did a quick sanity check online to find the 2 hour stat. Thanks for the clarification here, I could have sworn I had seen slightly longer times more recently but haven't gone through training in a while now.
Yup, paramedic here. Several hours is entirely fine. We'll document the time of application. But (and admittedly different circumstances) ortho surgeons will regularly tourniquet limbs for several hours while doing their work.
There's some practical limits as neurons start to have irreversible injury after 6 hours of ischemia and 8 hours on muscles.
Usually we don't put tourniquets for more than 2h30min in lower limbs because after circa 2h we start to have some reperfusion injuries, lesser time on other segments.
The usual protocol is to not use tourniquets unless necessary, for ER care have the tourniquets removed each 30min for a few minutes to reduce reperfusion injuries. For surgery we generally follow this with the intervals no bigger than 2h.
(source: Ortho and Trauma surgeon)
Most people go to the ER for non-emergencies. The good news: if they have you sitting around for hours then it means it was not an emergency and you (probably) won't die.
Be worried if you check in and they hurriedly shuttle you into an exam room. That means they think you have an actual immediate life threatening emergency.
Unfortunately, at least in some regions, there is no other place to receive urgent (but non-emergency) care. Waiting a week or more for a doctor's appointment isn't going to cut it if you've broken your arm or if you've been bitten by a possibly rabid animal, and so you're stuck waiting all day or all night in the ER.
It was a revelation to me when I moved from the US to Australia. Not only do I not have to pay for insurance, but it's so much easier to receive non-emergency urgent care as well. I can typically book a doctor's appointment for the next day (there are no insurance networks to worry about, so I have my pick of doctors), or if I need care sooner than that, my local ER usually has a wait time of under 30 minutes even for super minor treatment, like removing a sliver of glass from my foot (the high availability of doctors means the local is pretty quiet).
You're seeing public GPs or what kind of doctor? In Melbourne, public bulk billed GPs are hard to book for the same day, the best ones are regularly 1 week away. Private specialties (Endocrinologist, Psychiatrist) are months away. What you're doing that I'm doing wrong?
There are also the intermediate cases. I had a blood clot in the leg. Not immediately life threatening, but certainly so over a couple of days. I waited something around 1-2 hours, which was not fun, but completely understandable.
We have private healthcare so you need medical insurance for treatment - if you don't then they stabilize you and send you to the nearest state hospital if it is warranted.
State hospital - lots of folks who got stabbed or shot due to alcohol or crime related violence - apparently overseas medical students love to come here to learn all about trauma surgery and getting to stitching people up.
Private hospital - people with babies who have fever or crying and folks with chest pains and in my case a kid who just had seizure - she got first dibs to ER because they triage cases.
That's a very different discussion. Personally, I think its bullshit if ERs are stuck with 6+ hours wait primarily with non-emergencies only there because they don't have insurance and want free care.
Don't get me wrong, its bullshit both because they're clogging up the ER resources and because they're in a position where they may be unable to get or afford insurance. Its also bullshit that insurance is effectively a must-have today. The whole system is very, very broken.
I'm not sure why at that point it's even considered an ER visit.
Clearly if you can wait 10 hours for something, it wasn't an actual emergency. Are hospitals just gambling that these people won't die in the waiting room? What's actually going on?
Is there a perverse financial incentive to drag it out?
ERs prioritize on severity, not first-come-first-serve. If you go for stomach pains and while you're waiting, someone else comes in with a severed limb, they will get seen right away and your wait just got longer.
More notably, more serious problems may require more staff. If the nurses are busy cleaning up bio material, you get to wait a little longer too before you get triaged.
The incentive is not to drag your wait out, so much as to have the minimum staff needed to keep patients stable. Stabilizing people in critical condition is literally the one job of the emergency room.
On the other hand, people go to the ER for all kinds of reasons that are more urgent than urgent care, but less than true emergencies. Sometimes, they even go because they can't be denied admittance for lack of ability to pay, when a general practitioner at regular practice would have been a more appropriate physician to see.
All of that said, a 10 hour wait either means there's an absurdly high number of non-emergencies, or they're facing severe shortages (self inflicted or otherwise).
All this is not wrong. Also, there's another huge factor: frankly, most ER triage systems are not very efficient and they don't hire enough RNs or other front-line workers.
I refuse to work day ER shifts because along with just a couple motivated RNs, I can often clear all the patients from the waiting room at night that have been there for many hours. Often, we just need a break from new patients and we need to work as a team and just focus on getting one patient out at a time. OTOH, day shifts often make me powerless as a doc just because there are so many other bodies around, each with competing agendas and pressures.
Yes, a large fraction of ER visits aren't emergencies. Typically they triage new patients, take the actually critical ones immediately and everyone else waits.
I'm not sure wait time is an informative metric, vs something like survival rate for different kinds of conditions.
Seems to be a good metric for a dysfunctional triage system. How else does a type 1 diabetic with a known non-functioning insulin pump on the verge of going into coma get labelled as non critical.
I’m not defending the hospital in TFA, per se, but my wife recently had an ER visit on a miscarriage. She was immediately admitted and tended to be a doctor for the fact that she was hemorrhaging.
During the course of our 12 hours I came and went from her room through the waiting room and to my vehicle. Saw folks waiting hours and hours. For all I know they had a faulty pump.
When it came time for dismissal, we waited hours and hours. The attending staff were handing a GSW and a head trauma on a child. While I didn’t go full-Karen I had to drop the “my wife suffered a miscarriage and is having a mental breakdown, are we going to be banned from your hostile system if we just leave?” to receive final clearance to leave.
Triage is just… complicated. You can’t plan and staff accurately for random tragedy.
I'm sorry this happened to you. I don't know what happened, but good ER docs and nurses prioritize getting people out before they get people in. (No beds left = no new patients can be seen... not that hard of a concept!)
Sometimes things happen that we can't control, but I sure do get tired of ER docs/PAs/NPs overlooking common sense stuff like this. Especially since most good ER RNs would have bugged your provider multiple times to just get y'all the hell out of there!
I assume because DKA usually takes 24-72 hours to develop. So unless said diabetic waited the good majority of that time with their non-functioning pump before showing up at the ER, then that might be their assumption (though if a BGL wasn't done, that's a problem, but not of the triage system).
Also, ER isn't really the place to handle DKA, those patients will cycle quickly through the ER to endocrinology or the ICU. It won't be "give me some insulin manually so I can get on with my day".
As someone who has far more reason to interact with ERs than the normal person, if you have a problem that needs to be seen within the next week by a specialist and not just a GP, you have to go to the ER to actually get it addressed. Otherwise you won't be seen for months.
The fact that this is even a point of investigation is very frustrating. Wait times at local restaurants in my area are basically constant and will remain so, because if there is an observable queue, someone opens a new restaurant or an existing one puts on more staff and finds space for more tables.
If people were permitted pay directly for emergency visits, and new hospitals allowed to open then it would be ridiculous for there to be a general problem with trending wait times. Someone would add more emergency capacity somehow. That isn't even in conflict with keeping a public system either, there can still be a public system. Just let people who can afford their own emergency care fund their won care.
The problem here is precisely that deliberative bodies trying to work out how much emergency care is required instead of creating an easily-joinable class of people who benefit financially from providing care and leaving decisions up to them. That works well for almost literally every service out there and there is no reason to think it would fail for emergency healthcare. These people attending clearly have hours to shop around.
The article is hazy on this point, but the monopoly agreement set an slo of 220 minutes (3 hours 40 minutes), and it was fairly stable, but worsening by tens of minutes per year.
Since then, the hospital in question increased to 10 hours 45 minutes.
Worse, the federal government stopped tracking this metric, and now, among hospitals that elected to share the number, the median is over 5 hours.
So, if you live in the US, you’re probably screwed, regardless of whether you live in appalachia.
In addition, depending on how you model ER admissions using queueing theory - the wait times very quickly goes exponential with even relatively small changes.
I imagine all the signs about don’t abuse the staff and incidents of abuse against hospital workers went up at the same rate as the wait times. Abusing the staff is wrong but you have people that have come there because they think they are about to die without attention, they really don’t have a choice
In 2023, it reported the same statistic at seven hours and 40 minutes.
In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.