Long Stays in the Emergency Room are Dangerous to Your Health

An article in the Journal of the American Medical Association from November 6, 2023, shows that staying overnight in the emergency room is dangerous for an older person who is sick enough to be admitted to a medical ward.  Older individuals with signs of frailty may have their risk of dying double from staying in the ER waiting for a bed. An editorial in the same issue of JAMA reviews the issue and proposes some solutions.

This is something that I have personally experienced. As I have told you before, I get a partial bowel obstruction once or twice a year because there is a narrowing in my small bowel from scars related to surgery and radiation treatments for cancer. It causes  repeated pain like a kidney stone or gallstone. The pain can be very severe and it builds over 30 seconds or a minute. Then it eases over about the same period. I can usually take something for the pain, not eat or drink anything, and hold on until the bowel opens up again. Sometimes, the blockage persists so long that I begin to throw up. I have gotten very ill when that happens by getting dehydrated and tearing a small blood vessel and losing enough blood to become anemic. I have gotten dehydrated enough to become dizzy when I stand.

I am 77 years old. A few months ago, I had one of these episodes and I knew that I needed to be hospitalized. I also knew what I needed. I had to have IV fluids to overcome the dehydration and some IV medications. I also needed an NG (nasogastric) tube attached to suction to pull off the fluid that had built up in my bowel and stomach. An NG tube goes through the nose and esophagus to the upper low intestine.

I was miserable, in pain, and holding a vomit bag in the ER waiting room for a couple of hours. Then I was called back to be seen. I got my IV and my NG tube. I got IV medication and I felt better almost immediately. Patients like me must be admitted until bowel function normalizes but there was no bed available. I spent the night in the ER. I had not slept the night before because of the pain. Sleeping is almost impossible in the ER and that is a problem. Rest is an essential part of recovery. The guy next to me told his story about his injury repeatedly and he was loud enough that no one could sleep. Overcrowding is so severe some patients are treated in the hall. People are in and out frequently. My care was excellent. The ER doctor checked on me appropriately. Obstructed bowel is a surgical problem and I have an ongoing relationship with a cancer surgeon who works with patients like me frequently. The doctor on call for him came by and evaluated me in the emergency department. I was lucky. I was moved to a room early the next morning. This ER is in a teaching hospital in a busy metro area. It is a trauma center. It is extremely busy. Major accidents, injuries, and other catastrophes can result in several seriously ill patients hitting the emergency department at the same time. They have to be the priority and that can distract the staff from other patients.

Ok. So, the ER waiting room and the ER itself are unpleasant places that you would want to avoid if you can. I have a recurrent illness and when it reaches a certain point, I know that I will need to be admitted to the hospital. My surgeon recognized that also. As he was discharging me, he said: “If this happens again, call my office or the surgeon on call and we can admit you directly.” Many of you have recurrent problems that lead to repeated admissions also like congestive heart failure. If you contact your doctor, she may be able to keep you out of the ER and hospital by adjusting your treatment. Failing that, they may be able to admit you directly, and avoid the ER waiting room and ER.

There is another whole layer of this that is highly problematic. When we call our doctors, the first thing we hear is: “If this is a medical emergency, dial 911.” Dialing 911 will automatically take you to the ER. How are you to know if it is an emergency or not? You may vomit because you have a 24-hour bug, or you may vomit because you have a bowel obstruction that is a genuine emergency. If you dial 911, you will not be directly admitted. You will not be as safe, and your experience will definitely not be as good. That message does not serve us well.

The obvious place to determine whether your problem is an emergency or requires admission is with your primary care doctor, but we have a primary care crisis. New people to a community cannot even find a primary care doctor. Sometimes it takes months to get into a primary care practice, and even then your doctor may be so overwhelmed she cannot see you right away.  If you don’t have a doctor, every significant medical problem requires an ER visit. If you cannot pay for care, the ER must see you and many uninsured patients end up there for problems that are not an emergency. These problems are all related to healthcare policy. It does not need to be this way and it is one of the reasons our healthcare is twice as expensive as the European countries and four times as expensive as the care in Singapore. The ER is one of most expensive places in our system to receive treatment.

We work with Vestra Health which is a truly patient-centered worksite clinic company. They are a great example of how advanced primary care can keep you out of the ER and hospital. They provide care for the Coushatta tribe and employees of the Coushatta Casino Resort in Southwest Louisiana. They provide optimal medical therapy (OMT) for cardiovascular and related conditions. OMT dramatically reduces the number of heart attacks, strokes, cases of gangrene, congestive heart failure and other factors that would lead to an ER visit and hospitalization. They have a McKenzie Method trained physical therapist onsite to provide better treatment for strains, sprains, and other painful orthopedic conditions. That keeps patients out of the ER. They answer patient calls for urgent conditions and if required they see them right away to do everything they can to solve the problem in the clinic. When you combine these measures, the patients seen in the clinic are in the ER one third as often, they are hospitalized one fifth as often, and their care costs half as much compared to patients seen in the broader community and receiving the care that most of us get.

Our overuse of expensive, more dangerous, uncomfortable emergency care is related to healthcare policy and systems. We have a primary care crisis. Everyone has trouble accessing primary care because of lack of capacity or ability to pay for the service. Other developed countries have healthcare systems based in primary care in the outpatient setting. Our system is more focused on specialty and hospital care. The only solution that will work is to move much more powerfully to a system that relies on advanced outpatient primary care. Vestra Health makes recommendations to tribal leaders, but tribal leaders determine healthcare priorities for members of their community. Other county and municipal governments can follow that same path. Why wouldn’t you want to have care that is more responsive, more convenient, more comfortable, more effective and less expensive that leads to better health? That is definitely what I want for me and my family.