COVID-19 and the Bursting Bubble of ER Management

Terrence M. Mulligan, DO MPH FAAEM

My name is Terry Mulligan. I’m on the Board of Directors of the American Academy of Emergency Medicine (AAEM), and I’m currently the Vice President of the International Federation of Emergency Medicine (IFEM). Over the last 20-25 years or so, I have been deeply involved in emergency medicine, international emergency medicine, and global emergency medicine development. I think all of us are up to our ears with working in the ER and taking care of all of our emergency patients – a job that’s been increased and intensified especially the last six or eight months because of the unfortunate COVID-19 pandemic. I say this is unfortunate because a lot of this overwork and high stress for emergency physicians and for the health care system potentially could have been avoided.

I think over the last weeks and months, this pandemic and its crippling impact on our emergency care system within the health care system has pulled the curtain aside and laid bare the already overwhelming, overworked, overstressed state of emergency medicine, the emergency departments of hospital care, and the health care system in general. I think it’s obvious that this pandemic has had a huge effect on almost every aspect of our society – not just health care. It’s also shown how many of these different systems previously looked at as standalone or disconnected are deeply connected. For example, the economic impact of the pandemic is directly affecting the health care system and its proper functioning because so much of the United States’ health care system problem even before the COVID-19 crisis, but I depends on the state of the general economy, think the pandemic really put this into the forethe state of people’s employment, and the front of our minds. The pandemic has served insurance that often comes with the people’s as a stress test for the health care system. It employment (or the lack thereof. I think this shows the system was already running in the pandemic has the chance to pull the curtain red. Under standard circumstances, it is not aside on a crisis we’ve been facing safe to keep an engine running in the red, in emergency medicine for and we are running at 7000-8000 probably 15 or 20 years. RPM. Then, when a crisis The crisis is that in lots such as the pandemic of areas of medicine The health care system comes along, it becomes and in health care in general, but in the is looking to the emergency clear there is not any extra capacity in the emergency depart- department as a cleanup crew the system left over to take ment specifically, the current busi- emergency department serves a care of even a small surge, much less a ness and economic multiple layered safety net. giant surge like what has structure of the health happened here. Maybe care system forces us one of the only good things to run health care on a very to come out of this is the giant thin margin. Now, it is being laid spotlight now shining on how the health bare and made obvious to almost anybody who care system and the emergency system has wants to or cares to look at it. been running on very low resources. Hopefully, This pandemic has hit the emergency departpeople outside the field of Emergency medicine ment in a multitude of ways. In a material will see how the system can really improve sense, the effects include shortages of peritself after we get through the current crisis. sonal protective equipment (PPE), of ventila- In the next 6 to 12 months, we will probably tors and medications, and other emergency have some sort of vaccine. Within the next 12 care resources. Interpersonally, effects include to 18 months, we could potentially be out on the staffing problems with physicians and other other side of this crisis. Between now and then, health care workers becoming sick and risking I hope we will continue to shine the spotlight on their lives along with those of their family, and the emergency care system’s vital role in hosrisking being fired for speaking out against pitals, the greater health care system, and the patient safety issues or PPE issues. Being fired general economy. or transferred for this is unfortunately common Training people to take care of acute unschedfor us. It is important to show how the corporate uled emergencies is a relatively new concept. practice of medicine has crippled emergency services in the USA. This was an obvious >>

Emergency medicine is just about 55 years old go to their primary care doctor or didn’t take in the United States and the United Kingdom. In their medicines, so they come in with an acute most other places around the world, it is much emergency that potentially could have been younger than that. This skillset has not been prevented with good primary care coverage. We adopted around the world, but unfortunately are also the safety net for patients who have has also been abused in the USA. conditions their primary care services cannot One of the books that has been written about care for. We do not know everything about emergency medicine history in the USA by medicine yet, so sometimes when you have an Dr. Brian Zink is entitled “Anyone, Anything, acute medical emergency it does not matter if Anytime.” The book explains how we have you’ve had good primary health care: you still prepared ourselves to take care of all emerneed acute care now. If somebody has chest gencies. I think we have done this very well pain or breaks their arm right in front of their clinically, scientifically, and academically. After a primary care physician’s office, those people very initial, short period of inquisitiveness often still go to the emergency department. and resistance from the rest of In each sense, we are the primary the health care world, It has safety net for patients. turned into a harsh remind- I like to imagine the The second layer of the er to “be careful what you ask for, because you just emergency department as the safety net is for other specialists. Almost might get it.” When we cleanup crew following behind the everywhere, inside and asked for “anyone, any- Mardi Gras parade, sweeping up debris outside of the U.S.A., thing, anytime,” the rest and the refuse left behind after there is a huge shortof the health care system eventually said, “Fine, take the parade goes through. age of other medical specialists: neurosurgeons, it! You want the nights, you neurologists, orthopedists, want the weekends, you want the cardiologists, pediatricians, etc. holidays, you want social problems, you Not only do patients have trouble getwant the behavioral health problems, you want ting timely appointments, but specialists are the patients who have fallen through the cracks few and far between, with restricted hours. of the rest of the health care system – you can They often cover multiple hospital systems have them!” The health care system is looking and patients must wait weeks or months for an to the emergency department as a cleanup appointment or a referral, even from the emercrew the emergency department serves a mul- gency department. In turn, we act as a safety tiple layered safety net. net for the other specialists.

I think a lot of people might be familiar with how the emergency departments serve as a safety net for patients: patients who have nowhere else to go. These are patients who might not have insurance, patients who have no insurance or are underinsured and therefore did not To me, the most important part offered by emergency department services is the third layer: we are really the safety net for the cracks and the holes in the health care system. Our health care system is not perfect. We have tens of millions of people who are underinsured or uninsured. The health care system does not give equal health care to people from different types of socio-economic status and different geographic areas. The system has a lot of cracks and people who are not treated well either intentionally or unintentionally by the health care system often come into the system as emergencies. This completes the triple safety net: we’re the safety net for patients with nowhere else to go, we’re the safety net for the specialists, and we’re also the safety net for the hospital and for the health care system in general. We are there to catch people who fall through the cracks.

I like to imagine the emergency department as the cleanup crew following behind the Mardi Gras parade, sweeping up debris and the refuse left behind after the parade goes through. I think our health care system is surprisingly good, but it doesn’t serve everything. The system does not serve patients in the emergency department. In one sense, we are victims of our own success. We have accomplished a significant amount, well: critical care, emergency care, acute episodic care, and streamlined patient entry into the health care system. In fact, we have done it so well that the rest of the hospital system relies on us. They take advantage of us.

Transcribed and edited by L. Esther Hibbs, Managing Editor, EPi Magazine.

This article was first published by Emergency Physicians International and is reprinted with permissions. ©2020 EPi www.epijournal.com/ about

Dr. Mulligan also runs the the Global Emergency Medicine Initiative blog. Learn more at www.gemi.health/blog. 