Emergency room care, part one

"It’s just something we do and hope that it works."

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This week’s interview is with a nurse in New England, who works at a small-town community hospital. Today, we’re talking about the care he provides at his job. On Thursday, you’ll hear about his family’s experience on the other side of the equation, as a patient—and the debt he’s in from it. (I granted him anonymity to let him speak freely about his workplace and his debt.)

We talked about a much-discussed problem in US healthcare: patients showing up at the emergency room to be treated for non-emergency conditions. As we talked about, though, this widespread phenomenon is hardly a personal failing on the part of millions of individual patients. How many people do you know who would rather spend hours waiting in a crowded ER than a quick primary care appointment, if that option were available? Who wants to risk a bill for thousands of dollars? As our nurse friend said, the much bigger issue he sees is the lack of availability for other kinds of care. (This isn’t necessarily a “shortage” of doctors overall, but it is still an availability or ‘access’ issue. The ratio of doctors to patients is worse in rural areas than urban.)

The Bad ER Patient remains an easy scapegoat, a lazy, go-to explanation for high health costs. UnitedHealth Group released an analysis in 2019 showing that “avoidable” emergency room visits by privately insured patients cost $32 billion each year, which was written up by many news outlets; US News reported on this study by saying the US’ high health costs were “being driven in part” by these visits. But we spent $3.8 trillion on healthcare in 2019; $32 billion isn’t even one percent of that. This is like saying my quarantine weight gain is “driven” by the half-and-half I put in my coffee in the morning; I think it’s probably the 500 calories of ice cream I housed after dinner last night, not the 25 calories of creamer. (And it really all depends on what you mean by “avoidable,” with some studies concluding that just 3 percent of ER visits are truly avoidable.)

And yet you still get column-space wankers criticizing patients for “misusing” the ER, suggesting patients should pay for such incidents to “incentivize” them to “merely [go] to their primary care doctor.” It’s an easy way of shifting the blame away from the system we have, including how poorly resources are allocated and how hard it is for low-to-middle people to get the care they need, and onto individuals. As this week’s interview should demonstrate, this “If I were sick, I would simply go to the doctor” solution just isn’t an option for a lot of people.

The other half of our interview, which will run on Thursday, will shed light on another problem: People who are afraid to go to the emergency room because of cost—which includes nurses themselves. But just think of all the money this saves!

As always, our conversation has been lightly edited and condensed. One small note: Our interview happened in late November, so the parts about Covid-19 are a little out of date. Things are much worse now.

Sick Note: What kind of hospital do you work at?

Anonymous Nurse: It’s a smaller hospital that’s part of a larger healthcare system. So it’s not one of the big city trauma hospitals, it’s a smaller emergency room with 20-30 beds in it. It’s got its own kind of challenges that come along with it—you end up having a really sick patient in the emergency room or something, you have to call a helicopter to come take them to a city or something. So I’ve worked in larger city hospital emergency rooms as well, and it’s almost a little bit harder [here] at times, when it’s like, this person needs to get out of the emergency room as fast as possible, sitting with them for like, 3-4 hours waiting for a helicopter.

Sick Note: When you’re making a decision like that—when you’re like oh, we need to call a helicopter for this person—does their insurance status or anything like that ever factor into it? Do you ever have to think about cost or is it just like, this person needs this now?

Anonymous Nurse: From my point of view, as the nurse at the time, it never really enters my thinking. But I am exposed to it if we have the patient’s family in, even when it’s ground transfer for an ambulance, almost inevitably the patient or the patient’s family is like, well, I don’t want to take an ambulance to a different hospital, that’s gonna cost me this much, or something like that. That happens quite a bit. 

Sick Note: And what do you say in a situation like that?

Anonymous Nurse: I try not to really engage with it, just because I don’t even know how much it’s going to cost, personally, and I have no say in it. The patient really does have to go; if they’re going, it’s because they have to. As the nurse, I try to work on the outside of the financial aspects of healthcare, if that makes sense. The second I start worrying about cost is a time when I’m starting to make decisions based on things other than patient needs, which is not what I’m supposed to do.

Sick Note: That makes sense. And of course if you ask the hospital I’m sure they wouldn’t be able to tell you how much an ambulance costs as well.

Anonymous Nurse: Exactly, and you know, it always depends what contractor we work with, are you going to go with the city, are they going to be able to take you, if not are we going to call our backup plan—I mean, I’ve actually had experiences at work where our backup ambulance company was requesting payment before they would come and take the patient.

Sick Note: Jesus. 

Anonymous Nurse: Yeah, like, asking me for a credit card over the phone. And I’m like dude, I’m not even like, the customer, you got this all wrong, man. 

Sick Note: I’m not sure who they really expect to pay in that situation? Like, are you supposed to fish the patient’s wallet out of their pocket and say alright, here you go?

Anonymous Nurse: I know, and it’s, obviously the patient isn’t booking their own ambulance right now. It’s just… a kind of willful ignorance, like “alright, and we’ll take that credit card number.” Like yeah, I’m sure you will! I don’t know where I’m supposed to get it, or anything.

Sick Note: I want to talk a little about Covid. How has it been the past couple weeks? [Note: This interview was conducted just before Thanksgiving 2020.]

Anonymous Nurse: I'd say this last week I am definitely seeing probably more patients with Covid than I’ve seen the whole time. [...] The other day in the emergency room I took care of three or four just in my own assignment in a single day. One was really sick, an older guy. Some people it’s this weird disconnect where a young person is positive for covid, they get their test, they’re like, alright, I’m gonna go home. And then in a couple days they really start feeling worse, and they come to the hospital again. I don’t know what we’re supposed to do, because we’re just going to discharge them again, they’re not going to be admitted to the hospital for their fever, they’re still not hypoxic, they don’t have pneumonia. They still just have the mild illness. But every time they start to feel worse, they come back to the emergency room, and it’s kind of rough. 

Sick Note: Do you have any sense of what’s missing there? In a more ideal healthcare system, what would there be for that person? Would there be more beds, more availability to treat that person, or is it more primary care, house calls, or what?

Anonymous Nurse: That’s actually one of the biggest problems I notice in the emergency room, the way we use healthcare resources in America, specifically emergency resources because that’s my focus, is just so out of whack. It’s because of an unavailability of an alternative most of the time. Yes, we would have more primary care, we’d have more community healthcare, more urgent cares, so that emergency rooms are not overrun with mild illness. I mean, realistically, the only people who should be coming to our emergency room would be needing to be admitted to the hospital, for the most part. Occasionally you can splint an injury or something like that, but true emergencies aren’t necessarily discharged from the emergency room, and I discharge 90 percent of my patients.

Sick Note: Do you see a lot of patients who, you know if they had a primary care doctor—you know that care is missing elsewhere in their life?

Anonymous Nurse: Yeah, that is kind of the thing where a lot of the people, they don’t have a primary care doctor. And it’s related to lack of availability, I suppose, where, would they go to the primary care doctor for this today if it was available, instead of coming into the emergency room? More than likely. A very small amount of the people have things like, malingering—it’s a common thing that I see where it’s like, a psychiatric illness where people exaggerate their own illnesses because that’s like, a source of attention or something. It’s relatively common in emergency rooms unfortunately.

When you’re not taking everyday care of your illnesses, you inevitably end up at a crisis of your chronic illness, right? So if you’re not treating your diabetes or you’re not treating your hypertension, eventually you have an acute phase of a chronic illness. So that is the kind of endless bounce of, especially the people in poverty around, where you can’t afford your medicine. Or another common occurrence in emergency rooms is substance and alcohol abuse, where you lose sight of priorities, and yada yada yada, you end up out on the street. And a lot of times police, ambulances, whatever municipal services they are, they just pick the people up and bring them to the emergency room. That’s a great example of what you’re talking about where like, there is no emergency for this person, they’re intoxicated, out in public. They could definitely benefit from healthcare, but not mine, unfortunately. There’s nothing I can do for these people right now, other than comfort and nurse, and that’s kind of the approach for a lot of those patients. 

Sick Note: If you have a patient like that, or let’s say that it’s not even an extreme example where it’s a homeless person, where it’s someone who you know is not getting routine care for something like hypertension—what do you say to them? Can you say, hey, you need to go to the doctor? How do you even address that?

Anonymous Nurse: I definitely will do my best to try and educate for the current situation where it’s like, this is the third or fourth time I’ve seen you in the emergency room for a similar complaint, and we’re also not even answering your questions, unfortunately, because in the emergency room we’re doing the same thing over and over again, we’re making sure your appendix isn’t about to burst. It’s not, and it’s still not, but you still might have something going on that you need to see a regular doctor about, not an emergency doctor. Because they know more, they can do different tests that we don’t do here, that kind of thing. You get a lot of lip service from repeat customers, because they’re there for satisfaction, or just a couple of different reasons that someone keeps returning to the emergency room, and inevitably one of them is going to be, like, I don’t have anyone else to ask, or access to the proper professionals, and so here I am again. 

Sick Note: If you’re in situation like that, if they literally tell you, I can’t see a doctor because I don’t have insurance or something like that—I can imagine that puts you in a weird situation where you kind of have to be a social worker as well as a nurse, where it’s somehow your responsibility to know like, well, if you’re poor, you can get this Medicaid thing, or whatever. But that’s not a medical thing in any way.

Anonymous Nurse: No, so I’ll often try to get the doctor to do a referral to a primary care physician. One of the problems with primary care physicians is, yes they’re accepting new patients but they break up their day into like, sick visits from established patients and new patient visits. So if you’re a new patient they say yes, we’re accepting new patients and the first appointment we have is six weeks or eight weeks out. Which long term is good but for the person who doesn’t feel good right now that’s not helpful. So I don’t know how successful this is, but a lot of the time if a doctor can do a referral to a primary care doctor, they might be able to get them in as like, an emergency room referral earlier. 

But then of course I have no follow up on that—I have no data, no metrics. It’s just something we do and hope that it works.