The sad truth is that the ER has become the doctor of choice for the uninsured and underinsured. Go to any area ER and take a look at the people there. Immigrants and the poor comprise the majority of users. Many are there for maladies that are not emergencies which in turn clogs the system for people with valid immediate needs. Until we can remedy this with better health care coverage, the ER will remain overused by non-emergency patients.

My 2 y/o son fell down concrete stairs around 6 pm. Got to the ER by 7 (he wasn't bleeding, but wanted to check on a concussion per pediatricians orders). Got taken back from the waiting room at 12:30 am, doctor saw us at 1:15-1:20, didn't order a CAT Scan, sent us home. I don't know who was more cranky, me or my son.

The thing that really bugs me is that there were 4 other patients in the waiting room. They weren't swamped/overcrowded by any stretch.

After several trips to ERs with my son, now 15, I've learned a few things.

1. Make sure you bring a book. Maybe several; you'll be there a while.
2. Bleeding trumps almost nothing. When my son 'evulsed' the end of his toe via 50-pound weight, we sat in the ER for five hours while his smashed toe throbbed, bled and grossed out everyone else. Until we actually got in to be seen by a nurse, all we got was a paper towel--one-- to put on his toe. Nice.
3. But hey, a head injury will get you in fairly quickly as long as you remind the admitting people -- often -- that your 14 year old son got whacked in the head with a basketball and now resembles a stroke patient, with limited movement on one side of his body and a smile that only touched half his mouth.

After seeing a couple of flu-like symptoms get ahead of me, I pointed out that my teenager had a head injury, for crying out loud, and probably needed to be seen a bit more urgently than someone who had dithered around for a day or two with flu symptoms.

Indeed, he was seen and turned out fine in the long run (a shock to a facial nerve can look like stroke symptoms. who knew?)

Be a squeaky wheel when you need to, but otherwise, settle in and get comfy for a long and ugly wait

It's also not about the non- and under-insured.

When I used to work in a large ER (and I left just as "ER" was coming on the air, a show so actually unrealistic I could never bear to watch it), it never ceased to amaze me what people called "emergencies".

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"I've been having chest pain."

"How long?"

"A month."

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"My son has been having problems breathing."

"How long has this been going on?"

"Two weeks, but I felt like a doctor should look at it tonight."

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"I cut my hand."

>>ER staff opens up bandage to show a healing but infected laceration

"Why didn't you come in earlier?"

"Oh, I didn't have the time, but it looks nasty now and really hurts so I thought someone should look at it."

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None of this is hyperbole - I saw all of these situations countless times, and I only worked in an ER for about 18 months.

And the horror stories you hear about hospitals "refusing" care because you don't have money? Unless it's some sort of private clinic, that doesn't happen. Not for profit or public hospitals *must* actually treat anyone who walks in their doors, whether or not they have the ability to pay.

Many people misuse ER's for clinics or after-hours care. One memorable Christmas there was an unforecasted ice storm - staff could barely make it into the hospital, and even the ambulances were having accidents. One ambulance crew, the EMT's looking disgusted, wheeled a man holding his 4 year old daughter in his lap into Triage with barely a word and walked out.

The daughter had an ear infection with a slight fever. The child's pediatrician - correctly - refused to simply dispense antibiotics without taking a look at the ear first, and said he'd see the child in the office in the morning. But the father thought "it was horrible my daughter had to suffer on Christmas." He also decided that he didn't want to drive on icy roads, so he called 911 describing the fever, but not the ear pain.

The ambulance couldn't refuse to take him and his daughter, so they had to bring them into our busy, Level 1 trauma center (i.e. - where all the BIG accidents come) for a child's ear infection that could have waited until morning when the doctor was prepared to actually treat the child.

The triage nurse gave him a serious lecture on how that ambulance was now no longer in a position to rapidly respond to a *real* emergency in his neighborhood - a car accident, a heart attack, a stroke, etc. - since the roads were so bad it was going to take them an hour to even get back to their base of operations.

The guy had no remorse whatsoever, and complained most of the night that we weren't treating him "seriously" and he couldn't believe we were making him wait. The fact that we had numerous car accidents coming in from the ice storm (including several serious traumas) seemed not to matter.

To me, that's the horror story. Deep lacerations, concussions, strokes, heart attacks, broken limbs, serious asthma attacks, extremely high fevers, dehydration - all of those things and many more are what an ER is for. It is not about drop-in care for your convenience.

And there are only so many staff members and so many resources to go around - every time someone who goes to the ER because they don't want to wait for a doctor's appointment (which I will admit can be hard to get for some), then the ER gets clogged a little bit more. Don't just blame the uninsured - the insured have a lot to do with it as well.

To Concussion:

While I feel bad for you and your son (that *was* horrible service - I forgot to say that not all ER wait time issues are purely the fault of patients), an ER is not all about the waiting room.

If you went to a large ER, ambulances come in through the back doors. Serious injuries take precedence. If your son's vital statistics were good and he was stable, he was going to have to wait. The triage staff *should* have explained that to you, and told you to keep an eye out for certain symptoms to bring to your attention - I hope they did so.

Some nights are worse than others in ER's. It looks quiet out front but it's bedlam in back. The staff may have been dealing with other things and finally gotten them cleared out by the time they saw your son. Unlike on TV, you don't stabilize patients in minutes, and some you simply can't leave unattended. And if someone dies, well, there is a process for that that can take up a little bit of time.

On the advice of his pediatrician, we took our 4 month old son, who had a 106.5 fever, to the ER at 10:30 at night during the week. It was at an Inova Healthplex that maintained an ER but was not a hospital where patients could be admitted--they had to be transferred. The waiting room was packed. We were seen by the triage nurse, and since we had given him tylenol recently, she told us to come see her in 2 hours if we hadn't been seen and she would give him motrin. We returned to her after 2 hours and got the motrin. We continued to sit until about 2:30am. Not one person had been called back. We went back to the triage nurse to retake his temp and it was down to 103. We questioned whether we should just leave and see his pedi in the morning. She, as required, told us that she couldn't give us such advice, but when pressed admitted that all of the rooms were full of people who needed to be admitted but none of the local hospitals had beds. So until those people could be moved out, no one else would be seen. She said we would likely be seen around 5 or 6am (but no one else in the waiting room was told that). Insane. We left and one of us stayed up all night to be with our son and then we took him to his doctor in the morning. Likely an issue unique to that facility but still amazing.

After trying to untangle the many bills my uncle received after an ER visit (he had fallen on the broken pavement in front of the hospital), I was told by the hospital that in fact NO ER in the US is now owned by a hospital, that they are run by private drs who are not on the hospital payroll, that the hospital only makes money if a patient is admitted. Otherwise it is the many private orporations the various ER physicians are associated with who send the bills to patients, and who make the profit. I don't know if this is true of all ERs as I was told, I have no reason not to believe what I was told. Anyone else have information on this?

I am an emergency medicine physician in California. Dr. Schneider's study points out extremely important and sad effects of overcrowding in America's emergency departments. However, the problem of long delays, both waiting to be seen, and once seen is not caused by too many "non emergency patients."

The most common cause of emergency department (ED) overcrowding is the boarding of admitted patients in the ED. Boarding is the practice of keeping patients in the ED (after they have been stabilized and no longer clinically belong in the ED) because they need to be admitted to the hospital but a bed is unavailable. As the ED becomes saturated with patients no longer requiring emergency care, it creates a backlog and the ED's ability to care for all patients--including those arriving in the waiting room or by ambulance--is impacted. If EDs have resources (beds, nurses, space, doctors) we can quickly take care of the "non emergent" patient. Besides, patients should not be and often cannot be expected to know what constitutes an emergency and what does not. An illustration, consider a restaurant that offers take-out and sit down service. If none of the sit down diners ever leaves, the restaurant cannot seat any more diners. However, it can continue to serve the take-out orders, but not as efficiently or comfortably

The solution to the problem is to stop boarding admitted patients in the ED. This will require system wide changes in the way hospitals operate. In 2007, the Institute of Medicine published a report titled "Hospital Based Emergency Care: At the Breaking Point." In that report, the IOM wrote: "because the practices of boarding and diversion are so antithetical to quality medical care, the strongest possible measures should be taken to eliminate them." I urge policy makers, physicians, nurses, hospital to look at the full capacity plan, implemented at Stoney Brook Hospital in New York, where admitted patients are moved promptly to in patient areas as the first step in finding a solution to overcrowding and boarding in EDs. Let's make sure the ED is available for all who perceives themself or their child as needing emergency care.

Dr. Sugarman makes an excellent point. Dr. Schneider told me that one solution to the problem that some hospitals are trying is to move patients upstairs as soon as possible -- even if it's just to have them wait in the hallways there instead of in the emergency department. It's quieter there, and patients tend to get more attention than in the emergency department. And that frees things up in the emergency department.

In 2003, my toddler son stopped eating and drinking, and became very weak. After a few days, his ped sent him to the ER of a very wellknown children's hospital here in NYC, suspecting kidney failure. We sat, literally on the floor, of the very overcrowded pediatric ER for hours before he was finally seen. He was admitted after a couple of hours, and then spent 5 days, absolutely ignored, as an inpatient. Discharged without a diagnosis. He became sicker and sicker, his belly was bloated, and he stopped walking. He could do nothing more than cling to me. We went back to the pediatric ER, and sat for 8 hours, again on the floor, before being seen for 15 minutes by a neuro intern who refused to run an MRI. A few days later, after begging and pleading, a CT scan was finally done, revealing a large abdominal tumor. We transferred him immediately to Sloan-Kettering, where they started chemo on an emergency basis in their observation unit because they were afraid he wouldn't make it another few days. My kid was fricking dying while we sat, ignored, on the floor, in a sea of coughing feverish kids in the pediatric ER. Happily, my toddler recovered and is now healthy and in kindergarten (despite being given odds of 30% when he was dx'ed). As for me, I will never set foot in that well-regarded children's hospital again. Four years later, I am still furious.

I went into the Washington Hospital Center's ER at about 4pm on a Tuesday for suspected appendicitis. I never even got out of the waiting room until about 6:30pm (they don't let friends and family wait with you there, they have to be in a separate room, so I was alone and scared).

Once they finally got me into the ER, I then waited another 10 hours before they figured out what was going on with me, half of that time in excruciating pain. Then entire time that I was moaning and crying in pain the nurses were all rolling their eyes at me as if I was putting them out.

Finally, at 6:30am on Wednesday they took me to surgery. But because they waited so long my appendix ruptured, spraying my entire abdomen. So I had to be in the hospital for 10 days to be sure that I didn't' get an infection and out of work for 6 weeks after that.

If I hadn't have had insurance I would have truly been screwed - my bill was over $60000. But even with insurance, the long term effects of such devastating trauma to my body has been incalculable.

I forgot to mention that when I went to WHC it was because my general practitioner had sent me there. She had been observing me for 8 hours and saw that my white blood cell count was rising and very strongly suspected it was my appendix going bad. She sent a note to that effect with me, which I gave to the admitting people and they promptly ignored.

Donna- A friend of mine is an ER Doc and she is employed by a private ER staffing firm. That firm handles all of her billing, etc. I also cannot say if this is true of all hopspitals, but it is true of several I know of in my area.

I used to work for an answering service that answered for several doctors and I have to back up the experiences of people at the ER who say that people have a very wide definition of the word "emergency". We had a call at 10:30pm from a mother who's son was experiencing double vision...and had been for 3 days. Why it was suddenly an emergency then, who knows. Several parents had children with fevers that had had them for literally 3 or 4 days but decided to wait until Saturday afternoon to call the pediatrician; and then had the nerve to get upset because *their* doctor wasn't on call for the practice that weekend, or they didn't get a call back within 5 mins of calling the service. There were women who would call Friday or Saturday night for their gynecologist to refill their birth control prescription. Those things are packaged to tell you exactly when you'll run out. No gyn considers you running out of your BC pills an after hour emergency.

So I imagine that those same idiots who called us nights and weekends with symptoms that they had been having for days but *suddenly* turned into emergencies are the same idiots who go to the ER because they've been having chest pains...for a month.

At first I wondered why dome doctors started charging patients who called after hours for anything other then a brief list of symptoms. After about a week, I totally understood.

This column shouldn't even concern horror stories encountered in emergency rooms. It should address the fact that they have become the family doctor for hundreds of thousands of people in our area. Thirty years ago you could walk into the ER at Suburban or Holy Cross and find two people waiting to be seen. Now the waiting rooms of some of the ER's are hell holes with unwashed people with all kinds of ailments that could easily be addressed at a family doctor or at a walk-in care facility. But many immigrants have learned that ER care is free since they don't have insurance and for the most part they have no intention of paying whatever bill they might receive. ID is not required and they give whatever address that is made up ahead of time and receptionists don't have the skill to spot a fake address. Nurses are terribly overworked and have to deal with the dregs of society all night long and the legitimate cases are hidden under the crush of humanity. Its a tremendous problem and I don't see how hospitals remain solvent.

For those who are insured - there are lots of urgent care centers. Chances are your hospital co-pay is what you will pay to be seen. Many have labs, and x-ray. Some are open as late as 10 pm. There is a pharmacy that has nurse practioners available for quality, non-critical care.

I can think of one that is open all night, advertises itself for children, that will also see adults. (and you can call ahead, make an appointment so you're not sitting around for hours!)

and about that clown forcing his kid to the ER in the ice storm: a little research on the internet would have revealed a boatload of home remedies, as well as the fact that 50% of ear infections are viral, therefore, antibiotics won't resolve them.

Patients: educate yourselves first.

The last place I would ever want to be is a hospital ER! BLECH!

My ER horror story is this: I have had an off-and-on c. difficile infection for a while. I had one memorable relapse while I was pregnant. After having had diarrhea every 10 minutes for several hours, my doctor sent me to the ER with instructions for an immediate IV. To the ER staff, "immediate IV" meant "have her lie on the floor undisturbed, in her own waste, for 2 hours". Yes, the place was full of pillseekers and those being boarded.

When they finally got to me, they decided that I didn't need an IV and stool sample, I needed a vaginal exam and an ultrasound. Because (according to the nurse) greenish, watery, frequent, foul diarrhea is obviously the first sign of an ectopic pregnancy and NOT a relapse of c. diff. Apparently I've had an ectopic pregnancy for years, during some of which time I was not even sexually active.

Contrary to the assertions of some posters here, a study published in Annals of Emergency Medicine last week shows that the rate of uninsured patients in the emergency department has actually dropped, from about 15.5% to 14.5%, while the percentages of patients with higher incomes jumped from 22% to 29%. The percentage of patients with a regular physician jumped from 52.4% to 59%.

hospitals suck:

I have to agree with you on their rather unusual notions.

I went into the ER for hemorraghing from the vagina. It turned out that I had a large fibroid in my uterus that was causing my lining to slough off in record time (ie. seconds). Before they would do anything, the took blood from me in order to perform a pregnancy test.

What part of... I haven't had sex in over 9 months... didn't they understand? I was highly pissed that they basically called me a liar and chose to disregard what I said and do their own thing. Amazingly enough, I wasn't pregnant.

I went to the ER after breaking my nose at 4PM on a Friday afternoon. My doctor's office was already closed, and I did go to an urgent care clinic first, but they sent me to the ER. I only had to wait two hours to be seen, but once I was, the doctor who saw me was skeptical. He insisted that since I wasn't rolling on the ground crying from the pain, I couldn't have a broken nose. Well, the xray results came in, and he had to eat his words.