Life in Emergistan: Sometimes EDs are the Only Solution (but… : Emergency Medicine News


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EMTALA, health care, health care infrastructure

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EMTALA saved lives, without question. It’s hard to imagine what it was like before, when a hospital could just say, “Nope, move it on down the road,” and leave the sick and dying to their own devices. That, of course, was pretty much the story of illness and injury for all of civilization until not so long ago.

I wonder sometimes about the unintended consequences of the law that made emergency departments the epicenters of modern health care in the United States. It’s easy enough for us to applaud the good things we do when they look so clear, at least on the surface. No doubt those who drove EMTALA saw the tragedies that unfolded without its protection, and said, like we do for so many issues, “Something has got to be done.”

We live, however, every day with the results of what happened after the passage of this anti-dumping legislation. I’m not talking about the financial aspects, although they are certainly an issue, and I’m not even going to address the crowding in our departments. What I wonder is how EMTALA led to a situation where health care problems don’t have to be solved but just shipped to the ER.

How many times a day do we see people who don’t have primary care because they are uninsured? Subsidized public health clinics are few and far between. The old days of resident clinics seem to have vanished with the advent of private equity and increased emphasis on billing and collections in large centers, which are, at least on paper, nonprofits.

No Place to Go

Many of those without primary care have significant medical issues like hypertension and diabetes, and they have to come to the ED to manage those problems. Urgent care clinics are rarely a solution because they require payment at the time of service. I did some telemedicine during COVID, and I was shocked at how many people just wanted a refill for their inhaler or antihypertensive but couldn’t get anyone to see them except an ED. Many were even refused by their family physician because they worried the patient might transmit the virus during office visits.

Obstetric care is another issue because small hospitals continue to close their labor and delivery units. What happens to pregnant women in areas with no prenatal or L&D services because the hospital said it couldn’t justify the cost? They arrive in our departments with no prenatal care, in active labor, delivering infants at high risk.

Older people with illness or injury who can’t manage alone often can’t be admitted but absolutely can’t be cared for at home. We all used to know this and called them social admissions. Now, the best we can often offer is to hold them overnight and beg for someone to find them a place in rehabilitation or long-term care. This population will need even more care as it grows, ages, and survives significant medical crises. We aren’t equipped to provide it in the ED.

No Plan to Follow

Perhaps the most egregious side effect of EMTALA has been in the care of those with mental illness and substance use disorder. We evaluate their medical problems, address their breakdowns and psychoses, we order their telepsychiatry consultations, and hold them for days to weeks, but they still may not be admitted. Is a system in place to care for them? To manage them in follow-up? Not at all. Even less so since the brilliant move of closing most of our state psychiatric hospitals.

What about the exploding population of children and adolescents with mental illness? Placement in facilities or outpatient follow-up is even harder for them. Many of them are essentially orphans because of their parents’ illness and substance use disorder. I see no fix on the horizon.

COVID illustrated this because we had no national contingency plan for such an epic disaster. We simply had the same old refrain: “Just go to the ER.” That plan saved some lives but also cost lives and careers.

We should be proud of our care and the truly Herculean effort we make to do the best for those who need us most. I don’t resent that. I love what I do. The current system, however, creates unrealistic missions for EDs, and it is incredibly unfair to vulnerable populations.

now is the time

We as a nation don’t seem to be making a serious effort to look to the future to find evidence-based, cost-effective solutions to the tsunami building among the population. This is in no small part because of the pop-off valve of emergency medicine: It is always available to ease the crisis until next time, thanks in no small part to EMTALA.

This is the time for a national health care infrastructure plan. It won’t happen in the current economy, of course, but we can start thinking about it and make the connections.

We need hospitals and physicians and psychiatric and substance use disorder facilities (which would go a long way toward managing homelessness). We need access to specialists that doesn’t require hours-long transportation. We need case workers and counselors. We need a small army of people dedicated to caring for older patients.

We also need to stop expecting EMTALA and the nation’s EDs to manage all of our health care struggles. That well-intended law should help guarantee entry into the system, but it can never be the solution to problems so widespread and multifaceted.

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Dr Leappractices emergency medicine in rural South Carolina, and is the author of the column, Life and Limb (https://edwinleap.substack.com) and a blog (http://edwinleap.com). Follow him on Twitter@edwin_leap, and read his past MNE columns athttp://bit.ly/EMN-Emergistan.

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