Boom in Emergency Rooms

The biggest boom in U.S. medicine does not involve antibiotics or even contraceptive pills; it is the fast-growing popularity of hospital emergency rooms. Across the country they are flooded with an unprecedented number of patients. Since the end of World War II, the number of emergency-room admissions has jumped 500% , although the number of accident patients -- formerly the bulk of all emergency-room cases -- has remained stable at about 35 million a year. The U.S. public, says Manhattan's Dr. Robert H. Kennedy, director of a John A. Hart ford Foundation study group, is rapidly turning hospital emergency departments into community medical centers.

It is easy enough to explain the startling statistics. In the days when the local G.P. owned one of the few horse-drawn buggies in town, the doctor did most of his business in the patients' of his home. In an in era the of sprawling suburbs, when patients and doctors alike travel everywhere in autos, every car is a potential ambulance, ready to rush the victim of a real accident or a simple case of bellyache to the nearest emergency room.

These days, more and more doctors can afford long weekends and longer vacations; more and more of them are unavailable for late night calls. Even the better-heeled patients soon come to see no social stigma attached to a trip to the emergency room when their own physician cannot be reached. Poorer patients who once took their non-emergency sniffles, coughs and diarrhea to daytime outpatient clinics now tend to wait for evening and treatment in an emergency room. Such a visit usually means no time off from work. Today, says Dr. Kennedy sardonically, an emergency is "anything from which the patient is suffering when he cannot reach his regular doctor."

Separate Entrances. Trouble is, most emergency rooms are not organized to handle their burgeoning business. Many of them are out of date and ill-equipped, even for treating genuine accident cases. Many are understaffed; often enough the intern on duty is a foreign-born doctor whose language difficulties become almost insurmountable for the patient or his overwrought family. And the emergency room's new popularity is likely to cram it with cases of infectious disease--which is hardly to be desired for the accident victim brought in with an open wound. It is an unhappy situation for patients, doctors and hospitals.

Instead of trying to stem the tide, Dr. Kennedy and his study colleagues concluded that the thing to do is to organize emergency care properly to produce good medicine for all concerned. A prototype of what they are looking for is the emergency pavilion opened recently by Manhattan's New York Hospital. There, change from old emergency-room procedures begins at the entrance. To keep patients with open wounds waiting on stretchers away from others with infections, there are now two emergency-room doors--one for routine cases and most adults, one for children (who have most of the fevers). Inside are separate waiting rooms. A child with a broken leg but no fever can be quickly sent to the proper room.

New York's emergency pavilion is almost a complete hospital in miniature. It has full X-ray facilities, its own laboratory, a suite of three operating rooms, a modern plaster room for prompt immobilization of fractures, a room for ear-nose-throat cases and dental emergencies. The only major demand not met on the spot is for "something in the eye": ophthalmic examinations require expensive and delicate equipment that would be uneconomic to duplicate, and patients are sent to the regular eye department on another floor.

Growing Pains. The unit takes care of the traditional run of daytime emergencies. Every patient is seen by a doctor--either a medical or surgical resident--regardless of how minor his complaint may seem. After 4 p.m., when the regular outpatient clinics are closed, business flourishes. This is when Dr. Kennedy's definition of an emergency is proved true. As night deepens, there are proportionately more problems presented by hypochondriacs, alcoholics and potential suicides. New York Hospital's emergency traffic runs to more than 25,000 patients a year.

A few cities have even more elaborate setups than New York: San Francisco has five emergency hospitals organized into a comprehensive service. But in most places, the emergency service has grown haphazardly and with the expectable growing pains.

So busy are the emergency rooms, many physicians argue bitterly that they represent unfair competition. A physician writing in Medical Economics under the pseudonym of Roswell Porter complains that he has to serve three or four mornings a year in his hospitals emergency room. "Doctors on hospital staffs should refuse to be exploited any longer," he says. "We should agree to continue serving only . . true medical emergencies. Hospitals shouldn't be permitted, under the deception of maintaining an emergency room, to lie, cheat and falsify the truth to compete with private practitioners."

Around the Clock. Fortunately, some hospitals have found a satisfactory compromise. At the Alexandria (Va.) Hospital, where there is no medical school to supply interns or residents to man its emergency room at cut rates, the hospital's regular staff doctors were restive --though not so disturbed as "Dr. Porter." Led by Dr. James D. Mills Jr., four men on the hospital's staff decided to go on emergency duty fulltime; among them, they now man the room around the clock every day of the year.

Dr. Mills explains in Medical Economics that each of the doctors gave up his private practice to work under contract to the hospital. The payment system is complicated, but none of the four has lost any income despite the fact that all of them now enjoy regular hours and scheduled vacations. For the patient, a trip to the emergency room is like the first visit to a private clinic; the doctors might well be the family physicians of a group practice unit. The difference is that in the Alexandria emergency room, each patient is seen and treated only once for each "emergency." If he needs further treatment, he is referred back to his own doctor if he has one, helped to find one if he hasn't. For any treatment, the hospital charges $5 for use of the room, plus a minimum of $5 for the treatment.

Fees charged, and the intensity of efforts to collect them, vary widely among hospitals. Many, like Alexandria, collect a nominal fee from the city for treating indigent patients. Whatever the system, though, the business in emergency rooms seems certain to continue to boom, and as more and more model units like New York's and Alexandria's are set up, the quality of patient care is sure to improve.

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