A Night At the ER

I remember the night our teen-age son complained about terrible stomach pains and then he said he had trouble breathing. It was on the weekend, the netherworld of medical care. Should we go to the nearby hospital emergency department? Should we wait, or leave a message on the family physician's answering service?

Not much debate. We went to the emergency department.

It's no secret that some people use the emergency room as a quick cure all, when they should be going to see their primary care doctor, me included. Such action balloons medical costs. But when your child feels sick, it's a different story and you don't have that immediate power of hindsight.

But questionable ailments don't stop with children. Sandra Schneider, MD, had a bad stomachache, too, around 2 a.m. on a Thursday night. But she decided to wait it out. She waited to see her primary care physician when the doctor could see her. That was 14 hours after she first felt pain. Looking back, she wonders if she should have just gone to the ER. And that's not only because she's president-elect of the American College of Emergency Physicians.

I talked to her about emergency care in the wake of a Excellus BlueCross BlueShield report that says in Upstate New York, two out of five non-overnight visits to hospital emergency departments are unnecessary. My colleague Cheryl Clark quoted criticism of the report by Gerard Brogan, MD, president of the New York American College of Emergency Physicians, as well as Schneider. They said the report lacked data and was inconclusive and unfair.

The Excellus report, issued May 25, focuses on 640,000 trips to emergency rooms that patients made for such ailments like sore throats, ear aches, upper respiratory infections, and other minor medical problems in 2008, saying that many of these patients could just as easily have gone to a primary care doctor for treatment, at much lower cost.

The report said that one of four ER visits in which the patient was treated and released in the same day turned out to be for a medical issue in which care wasn't needed in a 12-hour period. Some treatments, such as ear infections, should have been treated sooner, but easily could have been done in a primary care setting, the report states.

The report itself displays a big hole, simply by its language. It says the analysis covers the "number of potentially unnecessary hospital room visits" that it says led to overcrowding and wasteful spending.

Potentially? That leaves too much room for, er, potential variables. Schneider agreed that the term was ambiguous. "It says potentially–potentially something your primary care physician could handle? But it could be potentially something your primary care physician couldn't handle, and if you didn't come to the emergency department, you could have lost valuable time," she says. "The report doesn't look at what the patient could have had."

In my conversation with them, officials of American College of Emergency Physicians were quick to summon other studies that they said contradict the Excellus findings, at least on a national level, about the usage of emergency departments. For instance, the The CDC's National Center for Health Statistics noted last month in a report, Emergency Department Visitors and Visits: Who Use Emergency Rooms in 2007, that 10% of emergency department, or ER visits by persons under age 65 were considered non-urgent, far less than the 25% figure in the Upstate New York study.

Schneider says primary care physicians are referring patients to the emergency department, and have been doing so for some time. In 1993 a study performed at Schneider's hospital, Strong Memorial Hospital in Rochester, showed that 88% of patients had a primary care physician and that 50% of them "had called their physician before coming to the emergency department and were told to come to the emergency department," she says. "This was an unpublished study involving 2,000 patients coming into our hospital. . . . We are in the process of repeating that study in our institution. To date, it appears that 80% of the patients have primary care physicians and that about 40% of them have been told to come to the emergency department.

When Schneider suffered the stomach ailment, she was convinced she had gallstones. Her doctor never determined what she had, and eventually she felt better. Ironically, she later treated a woman in the ER who had a similar ailment, and her condition really was gallstones. After the quick diagnosis, the woman eventually was treated, and recovered.

Looking back on her own condition, Schneider said, "Why should I have suffered for 14 hours? When I saw what happened to the woman, I said to myself, 'you fool, you sat at home, feeling nauseated and in horrible pain for 14 hours and you could have had some relief.' That's why in these situations primary care physicians are sending their patients to the emergency department. We can work through it, very quickly. We have the ultra sound, the blood tests, and the medications right there."

Various studies have focused patient usage of emergency departments. An Urban Institute study found that even after Massachusetts adopted universal coverage, visits to the emergency department remained high, with some people just finding it was more convenient. In looking at the uninsured use of emergency departments, the NCHS report said "uninsured persons are not more likely than others to assess the ED (emergency department) for non-urgent visits."

Schneider says she understands the focus of the criticism of emergency care. "We are doctors for the uninsured." But questions about "appropriate treatment" can be spread across the medical spectrum, Schneider says.

"We don't hear about cardiologists, or allergists, or plastic surgeons, or psychiatrists or anyone else, whether they have appropriate treatments. I strongly suspect that not everyone who goes to those places has an appropriate visit," Schneider says. "Emergency departments are the low hanging fruit, the cause célèbre."

As to my son's condition, he spent about 45 minutes in the emergency department where he was watched closely and given fluids. Apparently, earlier in the day he drank much too much soda, and the food he ate didn't agree with him, either. We never really got an explanation for the breathing problems.

When I talked to Schneider about my son's ER visit, she said, "That would have been considered an unnecessary visit. But should you have waited until Monday until you see a doctor? I don't know how you have would slept at night."