In 2022, Ballad reported a median ER time for admitted patients of about six hours.
In 2023, it reported the same statistic at seven hours and 40 minutes.
In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.
In 2023, it reported the same statistic at seven hours and 40 minutes.
In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.
Hell, its not recommended to keep a tourniquet applied for more than two hours and even then there's a specific protocol to follow as there's risk of what will be released back into your system.
What are people even going to the ER for when they can wait for 10 hours?
The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.
We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.
The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.
"Well then your silly system just needs to build more facilities! It's obvious!!" You say.
One thing people need to realize is that it is not necessarily in hospital admins' best interest for all the ER patients to be seen. If it was, they would spend more money on more efficient triage systems so that we could just rake in the bucks. But, in reality they would often lose money on such a gamble in my understanding, due to how patients of different coding levels are reimbursed by payors (and whether a patient is even likely to have a payor).
EMTALA and confusion around it is another common reason why patients often stay in the waiting room for many hours when really it would be in their best interest to go home and go to a clinic during the daytime. It is the main reason I try to ~break all the soft rules at night and just go out into the waiting room and MSE anything that moves so I can send it home.
EMTALA was passed in the 1980s under Reagan I believe. Good luck repealing it or revising it to make sense in our current political environment!
[0] Or appear to violate the law in the optics of some administrator, insurer, healthcare bureaucracy maintenance organization visitor, etc. In this way, in large bureaucracies, magical thinking reigns, optics becomes objectivity, and 2 + 2 = 5 .
This would allow prioritization of people needing immediate care.
Hang around an ER and I think you'll see this isn't remotely true.
>mandatory screening you can filter out
This would be great but is unfortunately illegal.
It's still a systemic problem, where admins' interests are not aligned with the health and experiences of patients.
I think that admins' interests not aligning with that of patients/consumers or with those of professionals/practitioners is making millions of people sad in a lot of other fields in addition to medicine.
Ben Hunt has written some great essays about this nebulous concept. His phrases "industrially necessary" and "raccoon" come to mind.
Is there a general solution? Dunno. But I suspect crafting even more regulation would be kinda like trying to make Wikipedia better by firing all the content experts and making all the admin-type people write all the words. It wouldn't result in a very good end product.
I seem do my best work when I am left to my own devices and my contact with admin is minimal.
I don't know how you manage to do that job, but thank you.
Despite this, I plan to pivot to my telemedicine business full-time within the next year. I know I am not invincible and the older I get, the more mistakes I am likely to make and the more working nights will become a risk factor for heart disease, diabetes, and the like. Plus, working nights wreaks havoc on the family, but it's the only option to work stable days each week in the ER. (Ie, most ER docs either work all nights or work a random rotating schedule of first, second, and third shifts.)
LATAM Subcontractor for Teleperformance/LanguageLine Solutions/Pacific Interpreters.
Most telemedicine roles I have interest in start with a very directed patient population and a limited set of interventions. Patients at risk for HIV, obese patients, etc. In this context, these subsets of patients are happy to accept special-purpose telemedicine, in my experience.
I personally would not want to see a primary doctor or surgeon over the Internet, and if I needed follow-up testing in the lab right next door anyway, I would prefer to go in person to both places in one "quick" trip rather than dicking around with the Internet before going out to the lab anyway.
Patients are right to be reluctant. Telemedicine offers a lot of benefits, but it can never be as thorough as time in person with a primary doctor. (But this in-person time is just not possible to get for your average patient in my experience.)
2. Decide I want to be, like, the Hagbard Celine of pharmaceuticals and cure death, or something.
3. Learn programming because I still need a job if I fail at (2) and anyway programming is fun and people are scary.
4. Double major in CS and Bio, do bioinformatics research for minimum wage.
5. Move to Berkeley, learn more programming working at a random startup for minimum wage.
6. Get a job as a bioinformatics programmer at a lab; learn lots more programming and some bench biology and publish papers, under the theory that I need papers and a PhD to start a pharmaceutical company.
7. Look around and decide I don't want to be postdocking in SF for $40k/y when I'm in my 40s and have kid(s).
8. Enter an MD/PhD program (MSTP, ie combined and debt-free degrees) as a lowish-resistance hedge even though I dislike premeds and also the entire bloated medical system.
9. (8 years later) Do residency in Emergency Medicine because it's really fun and all the other specialties bore me. (Except radiology, but that's no fun with chronic sciatica.)
https://forums.studentdoctor.net/threads/patients-per-hour.1...
(Writing this in the middle of the night from that critical access ER I mention.)
I just don't think there's any other medical specialty that has a job as action-packed and gratifying as my job is for me. Surgery would be gratifying, for sure, but also I hate formal clinic and I have a weak bladder, so no.
Yeah, I guess I see lots of sad things. But (1) often patients are sad about things that could've happened but didn't actually happen, and I can cheer them up just by telling them the truth. (2) Often I can make patients happier if actual sad things happen to them, at least in the moment, and that makes me happy too. And (3) if I got sad every time I saw a sad thing, I'd be too sad to do my job and then I'd get fired. So, like, these things don't really make me sad because I'm here to do my job, not to get big feelings?
Does that make sense, or too facile?
Some of the people you see in ER are having the worst time of their lives (I was once), so it would be great to be viewed as more than “pph”.
Btw, that forum you linked to, it’s depressing. Yes, the system is broken, but it also seems everyone has just given up.
Maybe not for you. If I had a medical emergency, I wouldn't want to be attended to by a mopey physician - no matter how dire my circumstances. The same goes for therapists and first responders. Yes, those people don't always see people at their best, and they've seen some shit - but it's just a job, and society works best if that job is done well.
ER doctors are the SREs of physicians - some folk are wired to enjoy the same high-tempo/unpredictability aspects that repels others.
I looked up the etymology of "fun" and you are right - Middle English fonne, fon (“foolish, simple, silly”).
That said, I'll take action-packed and gratifying over fun any day.
Also, emergency medical doctors are extremely foolish people during their down time - medicine has an old tradition of utter silliness when it is time to blow off steam from the job's pressure. So there, fun too !
I mean, I am also a fan of black humor, so mixing jokes with blood works for me, even if it is my own blood.
And, in order to allow myself to continue viewing patients who are not you as more than pph as well (and thus keep my job), I also consider a lens of pph. Because if I'm talking to you for an hour about low-carb diets or whatever and you feel like I'm the best doctor in the world, but there are 5 more people in the waiting room in pain that I haven't seen yet because I'm totally focused on you... also not doing my job.
The fact that I use this lens does not limit the services I provide to you or the empathetic positive feelings I share with you as a fellow human. (Or not, if you don't want those feelings. As a certified weirdo, I distrust people who come onto me w/ big outward empathy, personally. But most patients like it in my experience. So I tailor it really depending on who you are.)
Agree that forum is very depressing. Bunch of old ER docs who aren't looking for a way out for whatever reason. Part of the goal of my posts in that thread was to get them to smile a little, but they're too crusty. If I hated my job as much as some of them, I would just quit immediately and go back to programming.
"Hospital wants us to admit dead patients"
https://forums.studentdoctor.net/threads/hospital-wants-us-t...
ER is fun because, eg, https://forums.studentdoctor.net/threads/patients-per-hour.1...
I do some radiology in the ER. I do find this fun. The core skill of radiology is to find stuff in pictures and then communicate these findings to others. Just like I did as a scientist, which I also found fun and exciting.
I also find it fun to do research in molecular imaging. I suspect I would further have fun researching AI techniques that may allow us to replace some or all of the human work of radiologists with computers. (I suspect "all" will never happen, for the same legal reasons that I suspect we'll never have real self-driving cars. Humans need, um, human scapegoats.)
However, yes, I also have chronic sciatica, or back pain. It gets worse the longer I sit. I don't like standing still enough to use stand desks and treadmills are distracting. Clearly being a radiologist and sitting in a dark room for hours at a time would not be good for this pain.
This is yet another reason I got out of full-time programming.
My impression as well.
And I admire it way more when the attitude is maintained even when surrounded by those having lesser motivation.
Currently completing an online fellowship in obesity medicine and plan to start my own online practice or collaborate with midlevels who do so. Will probably get into tele-urgent care as well.
I've learned a little about all aspects of medicine as an ER doc, and it's exciting to apply that knowledge to telemedicine. Telemedicine is the Wild West right now. COVID-19 just opened it up a couple years back. We don't really know how to maximally benefit patients with it, but there are all kinds of new models being tried. When it works, it really works, without all the bloat and entrenched rentiers that can make brick & mortar medicine awful for both doctors and patients.
Reminds me of the state of the Internet around 2000. Wide open.
Sometimes it's the best option.
For that, I apologize. Maybe it comes down to fundamental problems in healthcare and most people not having a primary care physician, but I just can't imagine going to the ER with anything less than a very serious traumatic injury.
Also people can get sick in the middle of the night or outside of regular clinic hours.
That's true, and a whole other discussion. If our ER wait times are 6+ hours primarily because they are full of people without a way to pay for treatment that's a much bigger problem.
> Also people can get sick in the middle of the night or outside of regular clinic hours.
For sure, that can absolutely happen. Though I'd argue the bar should still be high with regards to when a person should go to the ER. Unless its a true emergency one could still wait until clinics open for regular hours.
NB when I was in the military they had the entire problem of suddenly ill people completely solved. Socialism.
A surprising number of people, especially prior to the Affordable Care Act, would call expanding public healthcare "Socialism", even though many in Congress are veterans. The late Sen. John McCain (R-AZ), A Vietnam veteran A-4 pilot, and POW, cast the deciding vote against repealing the ACA. He earned his military healthcare, and then some.
There's a strata of use cases that left in limbo in your argument.
Im a basketball player. I may have a microtear of a ligament from a 9pm game. The ortho guy, the pain doc, the sports med and my pcp are closed at 9pm.
I have no options but to go to the ER. I know because I've been there. Multiple times.
My kid is breathing and I can see his ribcage from forced breathing? If its past 5pm, its definitely an ER trip.
I pierced my hip with a chain link fence and need irrigation for the wound? ER trip
None of these injuries are life threatening. I'm not poor. My time is super valuable. i charge some clients $700/hour. Yet in each case, I spent > 4 hours in ER !
Now- I will literally wake up MD friends and ask them to write me a script to the 24hr pharmacy instead of waiting in ER for meds.
Everything you've written is correct. I was not trying to argue anything and I think I hedged my words above quite carefully. I was mainly trying to answer OP's question and in passing explain a few things that make it look to patients like me that the ER is even more messed up than it actually is. (And it is actually pretty messed up!)
I love the people with microtears who can't get into the office. I love reassuring parents that they don't need to spend $10k for their viral toddler to be admitted and get treated with nothing all day and then get discharged, but slowly and passive-aggressively. I love helping people who are in the ER for legitimate reasons. I understand that the medical system is broken and most people who are in the ER should, in a halfway sane system, not be in the ER. I understand that way too many people wait for way too long in the ER and it makes me real sad, because as I've written elsewhere on this thread, I do think there are usually fixes that are possible and even easy, from my POV as both geek and JAFERD.
Telemedicine does offer some solutions to some of these problems, but not all of them by any means.
It sure sounds like your justification here is that you have to take up time in the ER because you or your time is that important - I hope I'm just misreading that and your point was different.
Just wondering, why does an ER doctor read hackernews?
Easy to triage things gun shots are not so easy when the problems are internal. Easy to introduce bias. Parent poster thinks homeless and poor are only there because its warm or they have nothing better to do. It's okay to keep them waiting over someone who looks rich. They must have a serious problem, look at how well dressed they are.
Our medical system is still in the stone age.
In hundreddaysoff fantasyland, the solution is to fire all the bureaucrats and triage everyone immediately. But, then nursing primaries and secondaries and all the other required paperwork wouldn't get done and CMS would come shut down our hospital.
(In the narrative of one faction, the suits have in fact created a surplus of us, including docs, that will only get bigger in the next 5 years, possibly hitting n=10,000+ surplus ER docs by 2030. If that happens, a major reason for that in this narrative would be that the suits have directly funded more Emergency Medicine residency slots opening in that time than there are interested American medical students applying to the specialty.)
There is no shortage of bureaucrats willing to shuffle paper and create more work for themselves in the name of Quality or whatever. See this doc's blog for a relatively balanced take on this growth, but I do think there is truth to his first graphic: https://investingdoc.com/the-growth-of-administrators-in-hea...
In my understanding, there is a critical shortage of RNs willing to provide the actual hands-on patient care, for pay that will still turn a profit for the hospital.
This includes skilled ER triage nurses.
But the other side of the coin from labor shortage in this problem is, again, that hospitals simply are not reimbursed sustainably to serve many ER patients, particularly self-pay patients, in the non-literally-emergent ways that those patients should be served, would like to be served, or deserve to be served medically.
Ie, in my understanding the ER is often a loss-leader for a hospital that serves to get patients into higher-total-reimbursement clinics such as GI, cardiology, and orthopedics.
Again, I'm not trying to argue for any faction here including doctors/midlevels, RNs, hospital admin, or even patients. I'm just trying to describe the system from my view down my periscope over 8+ years of doing this.
* Any time a senior (I guess anyone, really) falls and hits their head doctors want a head CT. Only place to do that is the ER, but if you aren't showing any symptoms of a brain bleed or similar problems, you're low on the priority list.
* Dad had IBS and problems with severe constipation. Twice he was having significant abdominal pain and we were told by his GI doc to go to the ER for a CT to make sure there wasn't a serious problem going on. But again, pain with a history of constipation and no other immediate symptoms lands you low on the triage list. And indeed both times he was just constipated.
* The worst time - the 12 hour wait - he was experiencing severe altered mental state. His neurologist, who normally has a 2-3 month wait for an appointment, thought it was serious enough to see him the next day. After examining asked if we could go down to the ER (their office is attached to a hospital) for a lumbar puncture and other tests to rule out a brain infection. Again, apparently the ER docs disagreed, so in the waiting room we sat.
In general though my observation from all of those hours sitting in ER waiting rooms was that a significant portion of the people there were really just sick and probably should've been at urgent care or their PCP.
But parents can’t get off of work while anything else is open, first time mom doesn’t realize that a slight temperature and a cough isn’t an emergency, dad is finally fed up that his teenage daughter has been complaining of a tummy ache off and on for 6 months and Sunday at 2am is when he finally decided he had to have answers.
I'd chalk new parents up to a learning experience in a new and uncertain time. For anyone going to the ER because it fits better with your work schedule, don't clog up the system for anyone that's truly in need and increase prices for everyone else.
It's not 'our' emergency system, it's the healthcare provider who now is often a for-profit. If they have a mismatch between supply and demand, the fix is obvious. It's not your problem, it's theirs.
Like with OP, 2am tummy ache means the pain massively escalated from something undistinguishable for run of the mill cramps doctors normally don't do nothing about. (As in, cramps you walk in with, they charge money and they won't do anything at all with and fonsider minor)
... and then, on average 7 years [1], later, the desperate daughter finally learns she had endometriosis all the time, and she could have been spared of years of suffering had one of the completely overworked doctors she had seen before actually had the time to delve deep into the issue rather than just hand out painkillers.
[1] https://www.york.ac.uk/news-and-events/news/2024/research/di...
Minor note: this is somewhat outdated. They've determined now it's more like 4-6 hours before it causes any damage at all.
Per Stop the bleed, Mayo Clinic, etc.
But yea faster than 6-10 hours that's for sure. I bet if you went into that ER with an average time of 9 hrs and a tq stamped hour ago on your arm, they'd get you in pretty fast though. Triage is still a thing
Be worried if you check in and they hurriedly shuttle you into an exam room. That means they think you have an actual immediate life threatening emergency.
It was a revelation to me when I moved from the US to Australia. Not only do I not have to pay for insurance, but it's so much easier to receive non-emergency urgent care as well. I can typically book a doctor's appointment for the next day (there are no insurance networks to worry about, so I have my pick of doctors), or if I need care sooner than that, my local ER usually has a wait time of under 30 minutes even for super minor treatment, like removing a sliver of glass from my foot (the high availability of doctors means the local is pretty quiet).
State hospital - lots of folks who got stabbed or shot due to alcohol or crime related violence - apparently overseas medical students love to come here to learn all about trauma surgery and getting to stitching people up.
Private hospital - people with babies who have fever or crying and folks with chest pains and in my case a kid who just had seizure - she got first dibs to ER because they triage cases.
Don't get me wrong, its bullshit both because they're clogging up the ER resources and because they're in a position where they may be unable to get or afford insurance. Its also bullshit that insurance is effectively a must-have today. The whole system is very, very broken.
Clearly if you can wait 10 hours for something, it wasn't an actual emergency. Are hospitals just gambling that these people won't die in the waiting room? What's actually going on?
Is there a perverse financial incentive to drag it out?
More notably, more serious problems may require more staff. If the nurses are busy cleaning up bio material, you get to wait a little longer too before you get triaged.
The incentive is not to drag your wait out, so much as to have the minimum staff needed to keep patients stable. Stabilizing people in critical condition is literally the one job of the emergency room.
On the other hand, people go to the ER for all kinds of reasons that are more urgent than urgent care, but less than true emergencies. Sometimes, they even go because they can't be denied admittance for lack of ability to pay, when a general practitioner at regular practice would have been a more appropriate physician to see.
All of that said, a 10 hour wait either means there's an absurdly high number of non-emergencies, or they're facing severe shortages (self inflicted or otherwise).
I refuse to work day ER shifts because along with just a couple motivated RNs, I can often clear all the patients from the waiting room at night that have been there for many hours. Often, we just need a break from new patients and we need to work as a team and just focus on getting one patient out at a time. OTOH, day shifts often make me powerless as a doc just because there are so many other bodies around, each with competing agendas and pressures.
I'm not sure wait time is an informative metric, vs something like survival rate for different kinds of conditions.
Seems to be a good metric for a dysfunctional triage system. How else does a type 1 diabetic with a known non-functioning insulin pump on the verge of going into coma get labelled as non critical.
I’m not defending the hospital in TFA, per se, but my wife recently had an ER visit on a miscarriage. She was immediately admitted and tended to be a doctor for the fact that she was hemorrhaging.
During the course of our 12 hours I came and went from her room through the waiting room and to my vehicle. Saw folks waiting hours and hours. For all I know they had a faulty pump.
When it came time for dismissal, we waited hours and hours. The attending staff were handing a GSW and a head trauma on a child. While I didn’t go full-Karen I had to drop the “my wife suffered a miscarriage and is having a mental breakdown, are we going to be banned from your hostile system if we just leave?” to receive final clearance to leave.
Triage is just… complicated. You can’t plan and staff accurately for random tragedy.
Sometimes things happen that we can't control, but I sure do get tired of ER docs/PAs/NPs overlooking common sense stuff like this. Especially since most good ER RNs would have bugged your provider multiple times to just get y'all the hell out of there!
Also, ER isn't really the place to handle DKA, those patients will cycle quickly through the ER to endocrinology or the ICU. It won't be "give me some insulin manually so I can get on with my day".
How did the rate of increase change?
If people were permitted pay directly for emergency visits, and new hospitals allowed to open then it would be ridiculous for there to be a general problem with trending wait times. Someone would add more emergency capacity somehow. That isn't even in conflict with keeping a public system either, there can still be a public system. Just let people who can afford their own emergency care fund their won care.
The problem here is precisely that deliberative bodies trying to work out how much emergency care is required instead of creating an easily-joinable class of people who benefit financially from providing care and leaving decisions up to them. That works well for almost literally every service out there and there is no reason to think it would fail for emergency healthcare. These people attending clearly have hours to shop around.
Since then, the hospital in question increased to 10 hours 45 minutes.
Worse, the federal government stopped tracking this metric, and now, among hospitals that elected to share the number, the median is over 5 hours.
So, if you live in the US, you’re probably screwed, regardless of whether you live in appalachia.