The evolution of the emergency department

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Anyone who knows me has heard me say many times that primary care as both a medical specialty and the way it is delivered is a failure. More than a few souls have also heard me say that the emergency department is the modern version of primary care.

So why am I writing it here again? Because there are still people out there who haven’t got the message yet…

Every day from providers being angry they are for real emergencies in the US, to billboards in the UK, and every blog that comes across my screen from EMS, to medicine, to nursing, seems to have an abundance of supposedly scientific people who do not believe in evolution.

Not the Charles Darwin theory of evolution, though that certainly applies, because anyone who thinks they exist to only take care of life and death emergencies would not only ideologically, but also economically put themselves out of existence. Let’s have a closer look shall we?

The emergency room, or emergency department today was developed in a time when medical science was not very advanced. Rooted in symptomatology medicine as a profession really didn’t have much clue on how the body worked until the explosion of the sciences of biochemistry and molecular biology. (Roughly 30 years ago now.) Unfortunately, many providers and even clinical guidelines, still attempt to use symptomatology for the diagnosis and treatment of diseases. I see it most often in what I call “cop out” diagnosis; a diagnosis of a clinical symptom as an actual disease process rather than a symptom of an underlying pathophysiological process.

Cancer is a pathophysiological process. Symptoms include tumors, weight loss (from catabolic metabolism), etc. Cancer is a diagnosis. Cellulitis is a symptom. There are many things that cause the same symptoms, but successful cure requires identification of the underlying pathology; vascular insufficiency, from various causes like diabetes, fungal infection, bacterial infection, etc. Cellulitis is a cop out diagnosis. Treating like a symptom is only good if you are using your patient to make your car payment. You give a treatment that temporarily resolves it, do no further investigation, and sometime later it returns, forcing your patient to also return and pay you again for the job you should have done prior. Atopic dermatitis is perhaps the most abused of the cop out diagnosis.

Let me explain how this applies to the evolution of the Emergency department? Sudden cardiac arrest (the epitome of cop out diagnosis), stroke, myocardial infarction, ruptured aneurysms, severe trauma, etc. are common life threatening emergencies. They are not the only life threatening emergencies, but generally regarded as something worthy of a visit to the emergency department. Providers, specialists or otherwise, do not really treat these diseases. They call the people who do; surgeons, cardiologists, neurologists, and the like. The reason for this is simple, advancement in medical knowledge has led to the understanding these are not random, unfortunate, things that cause people to get sick and die. There are even predictors to major trauma.

You often hear providers talk about “stabilizing” before definitive treatment, but this is not something that cannot be done by other experts. Providers in emergency departments as well as other medical environments, whether they are emergency specialists or not, have the knowledge and ability to institute life-saving treatments specific to their practice.

When I hear emergency doctors and nurses complain they exist for true emergencies, it is fairly clear they do not. After all, you won’t find PCI going on in the ED. They are not fixing aneurysms down there. Stroke teams consist primarily of neuro-specialists, neurologists and surgeons, the ED is not doing direct arterial TPA, or craniotomies. Delivering a baby in the ED means unfortunately the patient could not be taken to OB fast enough. Even if you consider the volume of “true emergencies” it is so small, that it can be conservatively estimated to account for less than 10% of all ED visits. Most of the statistics I hear are less than 5%. In every medical system I know of, money is driven by patient census. The fewer patients you see, the less money you get. That doesn’t change in single payer or private payer systems.

How would your organization look if your census was only 5% of what it is today? Would you have as much equipment? As much staff? How many emergency departments would even exist in your city? In your region? In your country? I strongly suspect far fewer than do now. Would you even have a job? Would you even be employable as “an emergency expert?”

This leads to one conclusion. Life or death type emergencies are not why the emergency department exists. So what do they exist for? Well, if you look at what emergency departments actually do, it is clear they provide effective primary care. They have a fair range of diagnostic equipment on site which permits relatively accurate diagnosis, which results in the patient treated and released, with or without follow-up, or a referral/transfer to the appropriate specialist. EDs are also open 24/7. Let’s face it, the fine upstanding members of society will probably only require an ED a handful of times in their life; perhaps only once.

Statistically, MI’s occur before primary care opens. Trauma happens after it closes. People cannot miss extended periods of work to see a doctor. As the knowledge of the human race increases, individuals become less diverse. As an example, even healthcare providers are not able to keep up with things like vaccination science. But chances are, the average economist doesn’t know much about medicine. Many may not even know simple things like how to treat a fever, when, and why. (why being mostly for comfort) Imagine how little the less educated know. In the modern world, people need and demand answers to their questions almost instantaneously. Am I sick? Do I need an x-ray? Do I need a medication? Is it serious or not? What should I do to help my kid? Are they serious? Am I a bad parent for ignoring and not investigating or seeking help for their potential medical problems? Did I hit the gym too hard? Did I drink too much? Did I overdose on my recreational drugs? Why does it burn when I urinate?

The alcoholic does not need a 9am appointment with the primary care provider. He probably can’t even make it to an appointment before 1pm.

What’s more, in medicine experience counts. How do you know if somebody is serious or not? From seeing lots of non-serious patients…Even in respective education you learn what is normal before abnormal. You learn what is easy before what is complex. What many are dismissing as “bullshit” is actually the basis of their expertise!

Primary care on the other hand is not 24/7. Most providers have only basic, if any, diagnostics. They cannot answer the questions people go to the ED for. Not only that, but routine cases have prescribed, scientific based guidelines. The cases are so simple they do not even require a doctor. That is why many nations are adopting the Nurse practitioner and Physician assistant. They cost less to produce and pay and can follow guidelines as well as anyone.

In Western society, the major illnesses are now acute exacerbations of chronic disease or acute on chronic disease. A myocardial infarction, sudden cardiac arrest, pneumonia in CHF, decompensation of COPD are not magic, unpredictable acute conditions. About the only ones that exist that way are infection, trauma, and poisoning to some degree.

EMS providers often mimic the attitude of “emergency” professionals. Their whole training and purpose is based on that 5-10% of “real emergencies” as they existed in the 1960s and 1970s. But the economics and value to society is the exact same as those in the emergency departments.

Knowledge has changed. Society has changed. What is considered an emergency has evolved. Why is there resistance to evolving with it? Why do people not realize or accept this evolution? I find it hard to believe emergency providers are that ignorant. So if it is not ignorance it must be stupidity; knowing and intentionally not accepting. What value does somebody who can only address the concerns of 5-10% of their patients, customers, John’s, whatever, provide? Who could stay in business doing that? Why would anyone allocate massive resources to it? Bottom line, nobody should. It is not worth it.
When you publish your blog post, Facebook post, editorial, public service campaign, billboard, etc. talking about “abuse of the system”, the real reason emergency exists, etc. you demonstrate just how fucking stupid you really are. You have no idea what your purpose or value is. What your knowledge and experience is. You do not see the forest from the trees; because if you do, you are purposefully acting in contra to it. either way, you are hopelessly out of date, and you no longer have any value. Do the rest of us a favor and retire or find some other line of work. Tell your boss you are only doing 5-10% of your job. Let me know how that works out for you. How do you think it would work out for somebody in an industry other than healthcare? How would it look if McDonalds put up a sign and advertising campaign they only wanted to serve 5-10% of the population?

The problem with emergency is not the “patients” misusing it; it is the providers not wanting to do their job. The reason it is such is because of the ineffectiveness of primary care, not because people do not want to use it or don’t know about it. But it doesn’t change reality on the ground. The ball of primary care has been passed to “emergency.” The only choices now are to quit, fumble, or try to score. Said another way, you can quit your job, you can be incompetent at your job, or you can try to be great at it. It is never going to be your fantasy of only life and death, “real” emergencies.

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One thought on “The evolution of the emergency department

  1. S. Benson, EMT-P

    “Well, if you look at what emergency departments actually do, it is clear they provide effective primary care.”

    I agree that EDs are effectively providing primary care but not that they provide effective primary care. EDs don’t really coordinate care once the patient is gone, don’t follow that patient over time (even the “frequent fliers”), and don’t really address preventive care.

    I would also add that, despite frequent comments by ED and EMS providers to the contrary, our patients are smart.
    When access to “real” primary care may take four weeks of waiting for an opening on the schedule and that opening is in the middle of the work day (and many people don’t have “sick days”), they know if they go to the ED they’ll be seen.

    For providers and patients: follow the incentives.

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