May 7th, 2008
04:24 PM ET

ER capacity and terrorism

By Miriam Falco
CNN Medical Managing Editor

How crowded is your neighborhood emergency room and could it handle the aftermath of a terrorist act? That's been the topic of two hearings on Capitol Hill this week. On Monday we learned that lawmakers had surveyed hospitals in seven cities (New York; Washington, D.C.; Los Angeles, California; Chicago, Illinois; Houston, Texas; Denver, Colorado; and Minneapolis, Minnesota) to see whether their emergency departments would be able to handle the flood of injures after a conventional terrorist attack, such as the subway bombing in Madrid, Spain, four years ago, which killed almost 200 people and injured more than 2,000.

Of the 34 hospitals surveyed on March 25 (a randomly chosen date, according to the House Committee), more than half of the hospitals said their ERs were already above capacity and only five had available beds in their intensive care units. Washington and LA hospitals were in particularly bad shape in terms of capacity.

The House Committee on Oversight and Government Reform, chaired by Democratic Rep. Henry Waxman, commissioned the survey and held these hearings because new Medicaid regulations are taking effect as early as May 26, which will cut tens of billions of federal dollars to public and teaching hospitals nationwide.

Today, Health and Human Services Secretary Michael Leavitt and Department of Homeland Security Secretary Michael Chertoff were grilled by the same committee.

Asked if they thought the nations' level 1 trauma hospitals had the capacity to deal with such a terrorist attack, Chertoff said he did, and Leavitt said repeatedly that even though some hospitals were not able to handle a terrorist threat, Medicaid dollars are not the solution. "The job of Medicaid is to take care of people who are poor, or indigent, or disabled," not institutions or hospitals, as Leavitt told the committee many times.

One ER physician I spoke with said he was "dumbfounded" when he listened to today’s testimony. Dr. Art Kellerman, a long-time emergency room physician at Grady Hospital in Atlanta and Dean for Health Policy at Emory University continued, "This is mind-boggling. It's deeply disturbing that the two cabinet secretaries most responsible simply are not going to take responsibility for the current crisis in our Emergency Departments."

For the American College of Emergency Physicians, overcrowded emergency rooms have been a concern for quite some time. "This is an EXTREME crisis, not just for surge capacity (in the event of a terrorist attack), but day-to-day capacity," the group's president, Dr. Linda Lawrence, told CNN following Monday's hearing.

A few years ago, my husband sliced his hand in the kitchen. Fortunately, I knew of a smaller hospital nearby. Its ER wasn't too crowded and he got in pretty quickly. I couldn't do that today. That hospital is closed. Today I would have to go to a different hospital with the potential of an overcrowded emergency room and a long wait.

Have you been to an emergency room recently? Did you have to wait a long time?  Are you concerned about emergency departments in hospitals in the city where you live being able to handle ordinary patient care, let alone coping with the disaster following a terrorist attack?

Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation.

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soundoff (15 Responses)
  1. Jersey Lou

    Considering that people are more at risk of injury or death by hitting a deer while driving than becoming a victim of terrorism, is this really even a necessary question? As many as 50,000 people may be dead as a result of a recent storm, a real danger, unlike a the exaggerated threat of global terrorism. Why not ask if hospitals are suitably equipped to handle that kind of influx?


    May 7, 2008 at 18:21 | Report abuse | Reply
  2. Michael

    AS an Emergency Department Physican Assistant, the overcrowding is paramount. It is a national concern, that sadly has not been addressed properly by those with oversight. Most of the patients I see, have common complaints that truly belong in a primary care office. But they often call their PCP only to be told that they are overbooked, and if they are concerned that they should report to the ER, which is a terribly inefficient and inappropriate use of resources. I just performed an I&D procedure on a patient who was seen less than an hour ago by his regular MD who recommended that he come here for treatment. This is not acceptable. It only creates further delays, and possibly increase morbidity in patients with more serious and pressing healthcare concerns. We need a serious overhaul on our current system.

    May 7, 2008 at 18:26 | Report abuse | Reply
  3. Jennifer

    I've worked in an emergency room for 5 year now. I've seen it grow from an average of 70 patients in a 24 hour period to 180 patients in a 24 hour period (Our senses has only grown by 3,000). The hospital has done a great job at enlarging the area to add more rooms and staff. It has also done many changes to establish a quick flow by adding a step down area for people with minor illnesses and injuries. We are also the leader in our area for disaster planning and drills.

    However with all the changes and preparedness, I still believe in a true crisis we would have major problems. I believe the real reason for overcrowding has many factors. These factors are lack of affordable health insurance, lack of primary doctors( which stems from school costs and insurance costs), and a general disregard of what a true emergency constitutes by the general public.

    May 7, 2008 at 18:47 | Report abuse | Reply
  4. Dr. D. Hugelmeyer

    It is indeed astounding the lack of common sense and insight many of our so called "leaders"have in regards to the challenges faced by the crisis in emergency care the US is experiencing. It is correct that simply throwing more money at the problem is not a solution, but cutting Medicaid funding and support, especially for the very hospitals that act as a safety net for our failed primary care health system is not the solution either. “The job of Medicaid is to take care of people who are poor, or indigent, or disabled,” not institutions or hospitals"...yes, Mr. Leavitt, but it IS those very hospitals that do take care of these people! When I started in Emergency Medicine nearly 25 years ago a typical community hospital would see 25,000 or so patients/year in an ED...now, it is common for this to be in the 45-60,000 range. In the Netherlands where I work now, a big teaching hospital sees 25,000 a year in the ED...why? because a funded and utilised system of primary care and access to outpatient specialty care is the "safety net", not a crowded Emergency Department. There is indeed a crisis, and the solution is a total rethink of how best to provide a basic level of care to all Americans that is funded and efficiently utilises the resources we have. Simply slashing funding to the existing mess is not the answer.

    May 8, 2008 at 06:44 | Report abuse | Reply
  5. grace humphreys,lmsw

    It makes me sad to again realize that our legislators are so out of touch with the reality of the problems throughout the nation. The concern that the healthcare system is so insufficient and Medicaid benrfits so punitive is one I deal with daily. The overcrowded E.R.'s are at best a bandaid for larger problems and issues facing the elderly, the homeless, and the working poor.

    May 9, 2008 at 14:39 | Report abuse | Reply
  6. Jerry R Lucas RN

    In the issue of our emergency department and there use I find that we have allowed lawyers to dictate the course of care. I have seen so many repeat patients that have been seen at least two times in one week. The doctor’s office will send their patients to the ER knowing we have no beds in the hospital with inpatient orders in hand and we must keep them in the ER. The last thing is the nursing shortage. In the ER we hold patients awaiting a room for days sometimes. The nurses are asked to care of ICU, CVU, and Medical Surgical, and then the ER patients. It is no wonder why we have no good plan. Nothing will work without nurses.

    Jerry R Lucas
    Male Nurse Magazine

    May 11, 2008 at 14:59 | Report abuse | Reply
  7. greg

    This is typical from goverment. Slash from the bottom up until they get to something of value to them stop and then anounce job well done. I've worked as a ER nurse for 10 years, and this over crowding problem is not new. It's been increasing and getting worse every year. Rural city hospitals take the largest hit, and taking away money from the very people they say go to the ER for your care is stupid. ER Doctors are actually being put down on health questionaire as their primary doctor. That alone tells you the mind set of the patients that use the ER for runny nose, cough, and mosquito bites. The system needs a complete overhaul and to teach the general public what the ER is for

    May 11, 2008 at 22:45 | Report abuse | Reply
  8. M. D.

    I work in a hospital. Reference to the terrorrism/ car vs. deer comparison. It does not matter what the chances are, just that there is one. I do not wish there to be an attack, but preparation for such a situation allows preperation for any natural disaster or catastrophic scenario, as well. The problems are legitimate. Our ER has a typical weekday wait of two to four hours. Therer just isn't enough room. We do have to house lots of vagrant population, though. (By "have to," I mean they scam the system by calling EMS on cold days or feigning illness to get a room, ASAP. It is frustrating, but it's just the way things work out around here. Wolutions cost $ and no one wants to put any forward. "Don't raise my taxes," you scream, but they'll get your money from you one way or another.

    May 12, 2008 at 10:47 | Report abuse | Reply
  9. C. A.

    As someone chronically ill, and well-connected with a PCP, I have also been in the position where I've been told by my PCP's office to go to the ED for treatment. I was ill with the flu 2 months ago. Due to the severity of the illness, as well as several pre-existing chronic issues I have, I immediately contacted my PCP's office for an appointment for treatment. I was told I needed to wait for four days for an appointment to see her, and if it was that serious, I should go to the ED. I've used the ED before under other circumstances, such as broken arm and broken back, but I wanted to wait for my Drs appointment, rather than sit in the ED for seven hours (the typical time I've had to wait). I managed to stick it out for four days, but hallucinated for two of those days with a 105 degree temperature, making the illness far worse than if I could get it treated in the early stage.

    Fact is, the system is badly in need of an overhaul. The ED, as well as most of the medical system, functions in crisis mode. This cannot work under any circumstance, let alone a major event, such as terrorist attach or natural disaster (think Katrina). Any cuts in funding, or lack of attention to change, will spell disaster for all.

    May 12, 2008 at 15:11 | Report abuse | Reply
  10. EL

    Do we need a plan? Absolutely. It could happen. Do we need to have enough beds that that everyone could fit in the hospital at one time. No that's stupid. And a waste of money. But definately a plan. Could more people come in, could you make a make shift hospital or transport people to another location. It may need to be worst case senario, but the truth is most places are unprepared for any type of major crisis.

    May 12, 2008 at 16:33 | Report abuse | Reply
  11. Stephen Schueler MD

    I have been an emergency room physician for over 20 years and the problem of overcrowding is only getting worse. Sure terrorism would make matters worse, but nothing need explode for us to recognize that we have a real problem RIGHT NOW!

    I think Andy Grove, of INTEL fame hit the nail on the head with:

    Part of the problem is education. I was lucky enough to spend a dozen years in school learning what an emergency is, what symptoms it may cause, and how to handle it. Perhaps it is unrealistic to hope that consumers can do this with little more than: "If you think you are having an emergency dial 911" Is this all we can offer people?

    Here is another thing that worries me: the aging of America. The people showing up in our ER's are getting older. No surprise, as the baby boomers become the new geriatric (believe me, I'm on deck), getting old is getting popular. Every ER doctor knows that the turn time (time from triage to getting the patient either out the door or upstairs in a bed) is significantly longer with the older patients. Why? There are simply more things that need to be considered diagnostically, and these things take time and resources to exclude.

    How are the health care innovators responding to all this?

    We have decided to fragment care more. In other words, we are creating more points of service for primary care. The idea here is to better match the problem with a location that has "just the right number of resources and intellect to handle the problem" The problem with the "Goldilocks paradigm" is that it requires the active participation of the consumer in deciding where to go....and it only works if the right decisions are made.

    REALITY CHECK: We are talking about the same health consumer, who uses the ER for non-urgent problems 30-40% of the time and then show up at the doctors office (2 days late) having a stroke. The tragic reality is that most peole don't have a clue WHEN to seek care, and now, the WHERE to seek care decision is going to up the ante.

    In the old days, it was either the doctors office or the ER....Over the next several years, here is your expanding list of "point of care" options. Note that several of these are innovations:

    * ER (serious problems; can handle admissions)
    * Free-standing ER (serious problems, but no admissions please)
    * Urgent care (more diagnoistic resouces than the office; some minor surgical problems)
    * Doctor's office
    * Nurse retail clinic (set in stone list of conditions that can be treated)
    * Doctor video interaction (e.g. American Well)
    * Telephone doctor (e.g. Teledoc)

    Ok, given you are a diabetic with pain during urination and nausea where do you go? YIKES!

    The bottomline: Going to the wrong point of care wins you both delayed care (which can give you an additional bonus of a worse outcome) and a double bill.

    Don't get me wrong, I like these innovations and if implemented correctly, can absolutely save money. My concern is that consumers have still not figured out the old chess game and now want to throw 3-dimensional chess at them!


    Yes, I am with a company that is actively working to solve this problem, however, WE SHOULD NOT BE the only ones working on a solution.

    Here is our approach:

    Please give me your thoughts-I welcome your comments.

    June 15, 2008 at 10:40 | Report abuse | Reply
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