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Crisis in the ER

Connecticut's emergency departments are overwhelmed, but not for the reason you think

By Daniel D'Ambrosio

August 14, 2008

Eight-year-old skateboarder Sean Carroll lay stretched to his full 54-inch length on a bed in the Fast Track area of Bridgeport Hospital's Emergency Department. Dressed in knee-length shorts and a muscle shirt, Carroll sipped a cup of water and insisted he could walk despite his severely sprained ankle. But he wasn't going anywhere.

Thanks to a $15 million renovation that is still underway, Bridgeport's ER welcomes patients into a light, airy lobby with lots of glass and tile and a clean modern design. The waiting area is separated by a low wall from the main lobby and lined along its edges with comfortable padded chairs. An always-on TV mounted in the corner helps pass the time. In the morning the waiting area is often nearly empty, but by the afternoon, few of the several dozen chairs are vacant, filled mostly with quiet, somber-looking folks who don't require immediate attention, but clearly aren't feeling well.

Sean's bed was in a short hallway near the nurse's station, and hovering around him were his parents, Bill Carroll and Susan Syrotchen of Trumbull (not married but raising their son together). At a nearby computer monitor, Dr. Bryan Jordan, associate emergency chairman, examined an X-ray of Sean's ankle, and explained to a physician's assistant that even though the bones weren't broken, the boy's injury would be classified as a fracture.

There's a reason this serious but non-life-threatening case is unfolding in an ER, and not in a doctor's office. Syrotchen and Sean are on the state-run Husky A plan for low-income families, which Syrotchen says severely limits their options for care. Bill Carroll, a union carpenter, hasn't had any health insurance at all for nearly five years. But even patients with private insurance are being shunted to ERs by physicians who don't have the time, or the inclination, to see them.

Welcome to the wonderful world of medicine circa 2008, with the ER playing the role of a default universal health care plan for the nation. Dr. Jordan, in an interview after helping fix Sean's ankle, wonders if the ER's new role is in actual fact national policy. "President Bush made a very unkind remark in one of his speeches in the spring," Jordan said. "When someone questioned him about where people without health insurance are going to go [for care], he said, 'We have universal health care. Go to the emergency department.'"

In fact, that's exactly what the uninsured and the underinsured in Connecticut are doing in droves, flooding emergency departments across the state with decidedly non-urgent problems like colds, flus and aching muscles. "The new people coming to the emergency department often have private physicians and private insurance, particularly Medicare and Medicaid," said Jordan. "But community physicians are not accepting Medicare and Medicaid patients, who are instead being seen by government clinics or hospital clinics." A 2006 study by Families USA, a Washington, D.C.-based nonprofit advocating for better health care, found nearly 210,000 Connecticut residents between the ages of 25 and 64 who were uninsured. The study also found that they were sicker and died sooner than their insured counterparts. Families USA estimated three working-age Connecticut residents died every week because of a lack of health insurance—a total of about 150 people in 2006.

Nationally, the prognosis for emergency departments is every bit as worrisome as it is in Connecticut. A report issued by the Centers for Disease Control and Prevention released Aug. 6 found visits to emergency departments reached a record high of 119.2 million in 2006, up from 115 million in 2005. The CDC found that over the decade from 1996 to 2006, emergency patient visits increased 32 percent, at the same time the number of hospital emergency departments fell from 4,109 to 3,833.

A 2006 report from the Institute of Medicine reached similar conclusions, including the loss of 198,000 hospital beds from 1993 to 2003.

"The result has been serious overcrowding," says the IMN report. "If the beds in a hospital are filled, patients cannot be transferred from the [emergency department] to inpatient units. This can lead to the practice of 'boarding' patients—holding them in the [emergency department], often in beds in hallways, until an inpatient bed becomes available. It is not uncommon for patients in some busy EDs to be boarded for 48 hours or more."

Carroll rides his motorcycle more often these days, parking his gas-guzzling Chevy Blazer to save money. He injured his ankle in a recent spill on his bike, but gutted it out without seeing a doctor (despite severe swelling) because he has no insurance. "It sucks," he said. "I don't have enough hours in. I got to have 1,100 hours for a full year before I get insurance for myself."

Carroll was literally getting started on his first work in three weeks—a remodeling job on a Rite-Aid in Milford—when he got the call about Sean. It wasn't a good way to begin the week-long job. "I mean, I was right there with the foreman," said Carroll, a tall, husky man with wide-set blue eyes and curly hair. "He said, 'You got to do what you got to do.' I said, 'I'll see you in the morning.'"

Syrotchen can't get private insurance because her employer keeps her to 32 hours weekly, with no benefits. Despite the state coverage, she says she has a hard time finding physicians who will see them. "When you call their office and they find out what insurance you have, that's the end of the conversation," said Syrotchen. "If you're on the HUSKY program people get the impression you're less than acceptable."

Tongie Johnson, dressed in jeans, sneakers and a white tank-top, sits down gingerly in a chair near the nurse's station, and cants her body to the side, wincing and sucking in her breath. Her back is killing her. She injured it in a car accident five years earlier, but this week she reached down to pick up her cousin's baby at a Bridgeport family gathering and heard a loud, low-down pop. And that was that.

"I hate hospitals," says Johnson. "I would have to be in a lot of pain for me to come to any hospital. I don't like to see sick people."

After going without insurance for years, Johnson has been covered for the past four months by State-Administered General Assistance (SAGA) Medical, a program from the Department of Social Services for low-income people who don't qualify for any other state or federal programs. She says it took her two years to get the coverage.

"The only reason I got [insurance] is because I have psych problems," says Johnson. "I'm bipolar."

Johnson says she's heard rumors of a "spindown thing" with SAGA, in which the benefits get thinner and thinner and "they start giving you generic medications." But that hasn't happened to her yet.

Dr. Jordan introduces himself and stands over Johnson, examining her back as she sits. "Just tell me if it hurts," Jordan says.

It does. Jordan prescribes a "concerted effort" of pain medication around the clock for five days, icing and 24 hours of bedrest. Because Johnson has no regular doctor, he orders her back to the ER in a few days to recheck her back. "This makes me never want to pick no more babies up again," says Johnson.

The ER never slows down. Eleven-year-old Luis Hernandez sits stoically on a bench beside his mother Gigi with a short length of fishing line tailing off the fish hook that, while casting off a Bridgeport pier, he managed to embed in the top of his head.

"How'd you do that, you were fishing?" asks Jordan as he approaches Hernandez and his mother. "You know, the fish are in the water."

After briefly examining the boy, Jordan leaves to retrieve a special tool—a pair of snips he uses to remove fish hooks and rings from swelling fingers. When he returns, Hernandez is lying face down on the bench with his face in his hands, girding himself for the upcoming ordeal. Jordan numbs the area with several shots of anesthetic, deftly pushes the barbed hook all the way through the boy's scalp, snips off the end and removes the shank. All done, except for some antiseptic to stop the bleeding.

"I got one question for you. If you were fishing, how come there was no bait on your hook?" Jordan asks as Hernandez leaves with his mother.

That gets a smile.

Dr. A.J. Smally, medical director of the Emergency Department at Hartford Hospital, says boarding in his ER has been reduced dramatically over the past several years, thanks to new, more efficient procedures and better staffing. But he estimates that up to 40 percent of the people who come to his emergency department don't need to be there, and could easily be treated at a clinic or by a primary-care doctor.

That's a whole lot of people when you consider Hartford Emergency, one of the busiest ERs in the state, is on track to see more than 82,000 patients this year. That works out to an average of about 225 patients daily, except on Mondays, the busiest day, when as many as 280 patients might come through the emergency room doors.

Why Monday? Because that's the day people who were sick over the weekend are referred to the emergency department by private doctors who can't fit them into their tight schedules.

Smally explains that, as with hospitals, private doctors try to run their offices close to capacity to maximize profit. If there are three doctors in an office who can see 100 patients a day, they'll schedule 90. Once those 10 open slots fill up, the rest go to the emergency department, with the expected consequences for Smally and his staff.

"We are just really trying to keep up—we've never gotten ahead," Smally said. "This is true of most emergency departments in Connecticut and pretty much all big trauma centers. We just can't get caught up. It has been hopeless for the last 10 years or so."

Exactly right, says Dr. Patrick Broderick, chairman of the department of emergency medicine at Danbury Hospital, which will see some 69,000 patients this year.

"It's not the glamorous stuff that kills you, it's the day-in and day-out grind that can wear you out," Broderick said. "You may be built to handle 188 patients a day and staffed well, but throw in a couple of hours of 20 to 25 patients registering and you're on pace to see 230 or 240 patients that day. If you can't keep up with the flow you get behind the eight ball and patients accumulate in the waiting rooms."

On Tuesday afternoon last week at 4 p.m., Broderick checked the computer monitor in his emergency department and saw there were about 40 patients, sorted by the acuity of their medical problems.

At acuity level one—critical care—there were seven people being treated for respiratory distress, chest pain, severe abdominal pain, seizures or injuries received in car accidents. These folks have a high probability of being admitted to the hospital, accounting for about 18 percent of the total number of patients in the ER.

In the next category—acuity level two—there were 28 people waiting to be treated for problems like fever, headaches, a wrist injury or vaginal bleeding. These patients often wait 20 minutes to two hours to be treated, and account for 70 percent of the patients then in the department.

At acuity level three—low-level stuff—there were four patients being seen for a sore throat, toe pain, chronic back pain and nausea—only about 10 percent of the total.

"That's not bad, but I'll bet you that by 9 p.m. tonight we'll see the percentage [of acuity level three] get much higher," said Broderick. "In the evening you tend to get inundated with the walking well and minor stuff."

According to Broderick, the working poor and uninsured come in late because that's when they finally finish with their days. People are savvy about the emergency room, he says. They know that no one will be turned away for an inability to pay.

Contrary to a popular myth, Broderick says, his department is not being overwhelmed by undocumented workers and other immigrants, who he says make up less than 20 percent of his patients overall. "If you're an upper-class citizen and you're sitting in the waiting room next to a family of folks you suspect are undocumented, that's where you get exaggerated anecdotal [evidence]," said Broderick. "People are a little hasty to make those kinds of judgments."

The psychiatric wing of Bridgeport Hospital's emergency department has not yet seen the benefit of the current $15 million upgrade, which is modernizing and expanding an ER that was built in 1979 to handle half today's patient load.

The three lock-down rooms, where potentially dangerous patients have been known to spend as much as 10 days, are grim, windowless spaces with drab beige walls and shabby single beds. In a small outer room, two women snore loudly as they sleep off the effects of drugs and alcohol. Security guards and other staff sit around a desk and computer monitor a few feet away.

In the secure rooms, another woman patient, homeless and uninsured, struggles without success to wake up and respond coherently to Dr. Jordan's questions about the previous night, when she was found wandering around a parking lot without a shirt after crashing into a parked car. She ended the night in restraints.

"Come on, please, bear with me for five minutes I just want to make sure you're OK," pleads Jordan, sitting on the edge of the bed. "Just tell me what happened. Were you drinking, using coke or something? The doc who saw you last night said you needed restraints. You were fighting. You were delusional."

After another mumbled reply over her shoulder, Jordan gives up and says he'll come back later.

"So that's a person who looks like she's using cocaine, or she just has a personality disorder and doesn't want to talk," says Jordan. "When she's good and ready, she will."

In the hallway, a small, balding man lies on his side in a bed, his head down and his knees drawn up almost in a fetal position, his eyes closed. A thin blanket covers him.

Waking him, Jordan asks how the man is feeling.

"Shitty," comes the reply.

Although just 43 years old, the man has had a triple bypass and angioplasty. He's diabetic, without a family of his own. He's on disability and has coverage from both Medicaid and Medicare. His use of cocaine is considered a sure sign of depression, and it means he might be suicidal. Cocaine is a stimulant that makes your heart beat faster and demand more oxygen, explains Jordan, a condition this man can't tolerate.

"How often do you use cocaine?"

"I haven't used it in a long time."

"What made you use it this time?"

"Because I'm depressed."

"What are you depressed about?"

"Pain. Life."

All of the patients Jordan has seen in the psych ward will be admitted to the hospital for treatment. By 5:30 p.m., the man in the hallway has waited more than 14 hours. He'll wait longer still.

Last April, Governor Rell announced Connecticut had received an $800,000 federal grant to "promote the use of community-based health centers by patients who go to hospital emergency rooms for routine medical needs, clogging the urgent-care system and driving up costs."

Evelyn Barnum, chief executive officer of the Connecticut Primary Care Association in Newington, which is administering the grant, said the money will be spent on a Web-based program that will allow emergency departments to schedule appointments for non-urgent patients in one of the state's 13 federally qualified health centers.

Those patients will be given directions to the health center in the language of their choice, along with the time of the appointment and the bus route that will take them there, according to Barnum.

"It's all geared to getting the patient to a more appropriate setting than the emergency room," said Barnum. "We are trying to link them to a medical home and that will prevent them from coming back to the ER. That's the concept of this."

But Barnum said a critical piece of the overall plan—$4.5 million in state funds that will be divided equally among the 13 health centers to accommodate expanded hours—has not yet been released by the state Department of Social Services.

Ironically, all three emergency department heads the Advocate spoke to agreed that the federal grant, meant to address the flood of non-urgent patients into the ERs, is not the real problem. People with colds and sore backs understand they're not a priority.

"They're very appreciative; they don't mind waiting," said Smally. "We push them in different places, they're quick and easy."

In fact, all three hospitals worry more about failing to help seemingly non-acute patients with hidden conditions. "There's going to be a handful that might have some sleeper diagnosis that could be dangerous," said Broderick. "It's not appropriate to divert those people away. Every once in a while they look pretty good but have something that's potentially dangerous. You can't let your guard down on folks who appear fairly good but could have a stroke or atypical heart attack."

The real problem, say the ER docs, is a shortage of hospital beds. Smally would like to see a hospital that was an "infinite sink," with an emergency department that could immediately admit patients as it deemed necessary.

"If someone wasn't dying, I could just say, 'Zip! Upstairs!' and there always would be a place for them," Smally said. "If that happened we could see everybody, including can't pay, don't pay, don't want to pay, have insurance, don't have insurance, shouldn't be here, might should be here, thought twice about being here. We could see all those people."

But as the report from the Institute of Medicine noted, the trend in hospital beds is down, not up. And nowhere is that more true than in provisions for psychiatric patients.

Despite all the challenges ER physicians and staff face, they're proud to serve—and do a difficult job under pressure. "You know what?" said Dr. Broderick. "I'm proud that no matter what the need is, we help people. And it's not based on whether they have six figures in the bank."