During a recent emergency room shift, I treated a 12 year old boy for a swimmer’s ear. During the visit, I learned he from the South and was in the area visiting relatives before starting school in a couple weeks. It turns out he’s been battling this pain for a couple weeks and his mom is convinced it’s because of all the swimming he’s done this summer. Instead of rushing him to his own pediatrician at home, she has been “riding it out” to see if the pain resolved on it’s own.
This was true music to my ears! Most parents rush their kids to the doctor at the first sign of ear pain, even though the current recommendations are to not use antibiotics in this age group unless the pain persists or worsens past the first few days. So, if his exam were abnormal, my decision making process would be much simpler.
What wasn’t music to my ears was learning I was the second physician to see the boy that week. The grandmother took him to see her physician when she had a scheduled appointment a couple days earlier, “just for a curbside” and learned that he did in fact have “an ear infection”. No medications were given or appointment facilitated with a pediatrician or other physician. This was truly just a curbside. The family was left with no alternative but to use the ER.
The ER often ends up being our only option when visiting an area out of town, isn’t it? If staying at a hotels, many do have a cool option that provides a physician call service so a physician will come to you, as I learned a couple year’s back in Disneyland. And, some cities do have free-standing urgent-care centers that can help with these sorts of non-911 situations. But, by and large, the ER is it in most areas and for most people.
What a backwards situation! The majority of people sick have situations that do not need the ER yet find themselves having to because there are simply no other options. Think about how much time and money would have been spared for this family and the system had that first physician just seen the child as an office visit and written the same prescriptions I wrote 2 days later during the ER visit. Think about the healthcare savings to the system and personal savings to families if we had the same theoretical options to the hundreds of thousands of annual after-hours urgent care visits our system sees each year but is current seeing in the wrong setting!
In the big picture, seeing a basic sick visit after hours in the ER is like trying to crack a nut with a sledgehammer. It makes about as much sense, too. The truth is we just have no place for the after hours regular sick people, which, by the way, are the majority of people who get sick after hours, especially if their doctor is in another state!
It’s really not a shock ER wait times are so long…ERs are over loaded with patient’s just like this boy. Until we find a better system, better take along your iPod and a good book should you find yourself heading to the ER. You’ll be in very good company waiting to be seen so may as well come prepared for the wait.
Thanks for writing about this very important topic! I am glad this patient was able to receive after hours care from a pediatrician, even though unfortunately it was in the emergency setting.
Your blog post brings up several considerations. First, the grandmother's physician may not be trained in treating children and as such did not see the boy as a patient and write the prescription. Second, practices may not accept insurance from out of town and may require cash payments that families may not be able to provide and so they are forced out of primary care practices. Third, after hours urgent care clinics do not always have staff trained to treat children. Finally, in an ideal world, the boy's health record would be available so an out of town physician such as yourself would be able to see his drug allergies, most recent antibiotics, current medications which may interact, etc.
I do hope that current healthcare discussions will cover after hours phone calls, email/web communication and patient care.
Dr Gwenn,
You are half right here: the use of the ER for urgent-but-not-emergent problems is a huge driver of cost. I agree with your entirely that it would be preferable if there were an urgent care center or some such thing where these folks could go, if they have the means to pay. (If they do not, then the ER may be their only option.)
However, these folks are not the cause of ER congestion, by and large. (At least not in the adult/general ERs — if you work in a peds ER that may differ.) The greatest cause of ED overcrowding is boarding of admitted patients in the ED. If the ED has eighteen beds but six of them are occupied by admitted patients, then your throughput capacity has been reduced by a third. So the waiting room backs up, largely with the acute-not-not-urgent stuff. This creates a perception that it's the ear aches that cause ER overcrowding, but they are just the most visible symptom, not the cause.
Lack of adequate inpatient capacity, and poor utilization of existing capacity are the more fundamental causes of ER congestion.
You're article is so true, but if you are like this boy and not near your home and not near an urgent care location, or after hours what are you to do? Is it best to wait until the next day and go to urgent care?