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Waiting Doom

How hospitals are killing E.R. patients.

By Zachary F. Meisel and Jesse M. Pines

Posted Thursday, July 24, 2008, at 6:54 AM ET

Last month, Esmin Green, a 49-year-old mother of six, tumbled off her chair and onto the floor of the Kings County psychiatric E.R. waiting room in New York City. Members of the hospital staff saw her lying there but did nothing for about an hour. When Green was finally brought into the E.R., she was dead. An autopsy revealed that she died from a pulmonary embolism, which occurs when a blood clot forms in the leg, breaks off, and travels to one or both lungs. This can also kill long-haul airplane passengers who sit in one spot for hours: The blood sits stagnant in their legs for so long that it clots. You could say that Green, too, had been on a plane ride of sorts. She'd waited for a psychiatric-unit bed to open up for more than 24 hours, roughly the same time as a trip from New York to Tanzania.

The surveillance video of Green collapsing and lying untended, as hospital staff at Kings County fail to respond to her collapse, is inexcusable by any stretch. And so Nancy Grace, for one, focused on the negligence. But what's largely missing from this story is the likely cause of Green's pulmonary embolism. The answer lies in a far more systematic and widespread danger in hospital care: E.R. waits. Why was Green sitting and waiting while blood pooled in her legs? Despite increasing evidence that crowded E.R.s can be hazardous to your health, hospitals have incentives to keep their E.R. patients waiting. As a result, there has been an explosion in E.R. wait times over the past few years, even for those who are the sickest.

A major cause for E.R. crowding is the hospital practice of boarding inpatients in emergency departments. This happens when patients who come to the E.R. need to be admitted overnight. If there are no inpatient beds in the hospital (or no extra inpatient nurses on duty that day) then the patient stays in the E.R. long past the completion of the initial emergency work. This is what happened to Green, and it has become widespread and common. The problem is that boarding shifts E.R. resources away from the new patients in the waiting room. While E.R. patients wait for inpatient beds, new patients wait longer to see a doctor. As more new patients come, the waits grow. And an E.R. filled with boarding patients and a full waiting room is an unhappy E.R.: The atmosphere is at once static and chaotic. If you or a loved one has waited for hours in an E.R., you know what we mean. The environment can be unsafe and even deadly. A recent study found that critically ill patients who board for more than six hours in the E.R. are 4 percent more likely to die.

What hospital would promote such a practice? Potentially, those that profit more from boarding, particularly in poorer communities with high numbers of uninsured and Medicaid patients. Imagine you run a hospital. There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits. The second source is E.R. patients, who are more likely to be uninsured or have pittance-paying Medicaid and less likely to need high-margin procedures. Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money.

In effect, then, E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor. E.R.s are safety nets: By law, we who work in them see any and all patients, regardless of their ability to pay. But as more E.R. beds are devoted to boarders, the E.R. has less space for new patients, which keeps a lid on the number of un- and underinsured. So unless you are having a heart attack and can jump the line, your emergency

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I haven't had to go to a hospital since I was 7 or so. At that time, the crappy doctor had me waiting, when my dad showed up he was livid because the doctor was grossly incompetent. My father is a doctor and knew the staff, so when he confronted someone it got taken care of quickly. But if it takes a doctor to see the incompetence and get something done, most people are going to be out of luck. Obviously the doctors doing the initial diagnosis are garbage.

I have a friend in medical school who has told me 95% of residents kill a patient. Doctors are an extremely powerful lobbying group, and the general public is apparently extremely gullible, so they've managed to push tort reform through to the point that it is becoming near impossible to sue a doctor. They can leave sutures or fixture devices in causing you crippling pain, and you'll be completely out of luck. Medical malpractice kills more people a year than all automobile accidents and homicides combined, but the doctors have you convinced that their is a "crisis" for their insurance premiums, so you should make sure they can't be sued while they sit back and charge you an arm and a leg and still kill you.

I'm guilty of falling for this too. I haven't had to go to a doctor in a decade or so, but who knows how long my health will hold out like this. If you find a good doctor, make sure to stick with him or her. Same idea with a good mechanic. Because the good and honest ones are really, really rare.

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Early on in my wife's pregancy, about 13 weeks in, she began bleeding profusely one night. We were terrified that she had a miscarriage and called her doc, who said to go straight to the ER immediately. He told us to tell the ER doc to call him once we got there. Anyway, we told the ER doc what happened, and the doc "looked" in her vagina to see what was going on. He basically admitted he had no idea how to tell if she had a miscarriage or was experiencing bleeding on the outside of her cervix. He ordered a D & C (abortion) and then called our doctor to ask if he wanted to do the procedure, or if the ER doc should just go ahead with it himself. Thankfully our doctor refused to allow him to do anything and demanded that the ER doctor wake up the ultrasound technician (it was about 3am by now) to come in and perform an emergency ultrasound to see if the fetus was harmed at all. Sure enough, my son was doing just fine and the bleeding was coming from a small lesion on her outer cervix (we went to a gynecological oncologist later on to make sure it wasn't cancerous).

Had our doctor not insisted on the ultrasound the ER doctor would have performed an abortion without even knowing whether our child was alive or not. He didn't really care, he was just assuming blood meant miscarriage. I'm sure my wife and I still would not have allowed the procedure ourselves without knowing 100%, but even still it makes you wonder how many babies may have been wrongfully aborted just because the mother had some bleeding early on.

Now you know why I haven't had sex since November 21st by the way :)

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