Problems With Requesting a Hospital

April 17, 2002 -- Imagine suddenly experiencing a searing chest pain, accompanied by sweating and nausea. Your left arm is numb.

You are having a heart attack, or what doctors call an acute myocardial infarction (MI). Your sense of weakness is overwhelming as you gradually become more short of breath.

But you are prepared. You have already discussed the unthinkable in advance with your doctor. You calmly reach for an aspirin tablet and chew it as you were instructed.

A family member or co-worker notices you appear very ill, and you acknowledge saying, "call an ambulance," as those around you appear very worried.

"It will only be a few minutes," sounds reassuring, and you briefly recall the reports of two major medical studies released this month that showed overall improved outcome for acute MI patients with urgent cardiac catheterization — that is, if they are able to meet the two-hour "door to balloon" guideline for performing angioplasty.

An editorial published this week in the Journal of the American Medical Association even suggests that Emergency Medical Services (EMS) bypass local hospitals in favor of the nearest cardiac center, using the "trauma center model, in which patients with major trauma are triaged not to the nearest hospital but to the nearest trauma center."

Yes, you want to get help ideally at a nearby facility capable of aggressive cardiac therapy like angioplasty, stents and even coronary bypass surgery.

Paramedics arrive promptly. Oxygen in your nostrils makes your breathing easier. Nitroglycerin under your tongue eases your pain, and you feel good enough to inquire about the nearest cardiac center, as the ambulance crew lets it slip your EKG monitor does not look good.

Still, everything goes smoothly as you are now on a stretcher being taken to the ambulance, and then you are told that your neighborhood emergency departments are themselves on bypass.

"You mean they are sending us to another hospital?" you ask incredulously. "Yeah, we'll have to take you to..." Immediately you toy with the foolish idea of jumping off the stretcher and asking someone, anyone to drive you to your destination of choice by car.

But that means no oxygen, no IV, no more nitroglycerin, and who knows what else you might need. A trip like that, you might not survive.

Alternatively, you could just simply demand in language that ranges from emphatic to obscene to go to your choice of hospital anyway.

It might help to mention all those toll-free lawyers you could call that advertise legal services (incessantly) to make life difficult for the EMS team. "Then again, it might not," you think to yourself, "these people have already helped me a great deal."

Your EMS team is experienced at the diversion game. They explain it has been going on, quietly at first, not so quietly the last two years. And it is ridiculous to go to an emergency department that does not have an empty bed, an unoccupied cardiac monitor or enough nurses and doctors to care for you right now.

Overloading Hospitals

There is one more report I would like to draw to your attention as you contemplate how you would handle the above scenario.

The American Hospital Association (AHA) surveyed more than 1,500 hospitals nationwide, representing 36 percent of all hospitals with an Emergency Department (ED). The data were collected November 2001, and results were reported this month (April 2002).

You'll note on closer inspection the aforementioned cardiac studies that have been trumpeted in the media collected their data largely in the late 1990s before ED overcrowding and ambulance diversion became commonplace.

The AHA report says that 62 percent of all hospitals surveyed nationally perceive they are at or over operating capacity and that includes more than 75 percent of urban hospitals and a staggering 90 percent of Level 1 Trauma Centers and hospitals with more than 300 beds.

This unfortunate reality argues strongly against implementation of "the trauma center model" for acute cardiac emergencies any time soon.

It makes no sense in 2002 to bypass hospitals open to EMS for special centers that temporarily (one hopes) are simply inundated with emergencies and cannot safely accommodate more.

The AHA report also catalogues the continued increase in demand for emergency care across the country. ED volume is up by 5 percent in the past year alone, yet we have allowed hundreds of hospitals to close such services in the last 10 years.

In fact according to the American College of Emergency Physicians, more than one in three Americans is seen in a hospital emergency department each year. And that only begins to describe the myriad of reasons for overload in the health care system. There will be no quick fix.

Until we the people decide to accommodate everyone who needs immediate specialty care, in the case of severe symptoms, patients must be taken to the nearest appropriate emergency facility. In 2002 that facility may vary from hour-to-hour, depending upon your location.

Dr. Richard O'Brien is an emergency medicine physician at Moses Taylor Hospital in Scranton, Pa.