The Unraveling Safety Net



all of American medicine, the only place that Federal Law guarantees Americans

the right to a physician 24-7 is in the Emergency Room. This is because of the

1986 "anti-dumping" law, the Emergency Medical Treatment and Labor Act, known as

EMTALA. The Health Care Finance Administration enforces it. This law was tested

recently in the 9th Circuit in California. A divided panel said that hospitals

could not turn away ambulances not owned or operated by hospitals after radio

contact is made, unless they do not have the staff, facilities or equipment to

treat the patient. It reminds me of Frost’s definition home in the Death of the

Hired Man "Home is the place where, when you have to go there, they have to take

you in." Because of widespread extreme overcrowding and the strain put on the

healthcare system nationwide, a special meeting May9 2001 was called aptly named

"The unraveling safety net."


are called "boarders", these patients who are stuck in health care limbo. They

can’t be sent home because they’re too sick. They can’t be moved to an impatient

unit because the hospital is full. In a survey of 575 emergency room directors,

more than 90 percent reported overcrowding as a problem, according to a study by

researchers at the University of California’s Davis Medical Center. In the

typical scenario, hallways are packed with boarders, waiting rooms are full of

the sick and injured and ambulances are diverted to other facilities because

there’s no doctor, no nurse, no inch of space available to deal with another



situation is acute in all types of hospitals – academic, public and private – in

urban and rural areas. Emergency departments full of "inpatient boarders…are

commonplace across America," notes physician Mark C. Henry of the State

University of New York. The losers are acutely ill patients who like "stateless

refugees, are kept in makeshift accommodations in the ER," with little if any

regard for privacy, dignity or personal hygiene.


presence of boarders in the ER hallways is the latest symbol of a broken-down

health care system. Emergency rooms have been in crisis before. But today the

overcrowding problem is not confined to emergency medicine. What is new is that

the entire medical system is headed toward gridlock because of a lack of staff

and available beds, a shortage of nurses and an antiquated of work rules that

guarantee that everyone will be operating on a short fuse due lack of sleep.


course managed care can take the blame for a big part of this chaos. They are

avoiding reimbursement for emergency procedures, including intubations and

cardiopulmonary resuscitation, and are not complying with state and federal laws

designed to ensure coverage for patients in emergency situations, threatening

America’s healthcare safety net, according to the Annals of Emergency Medicine.

According to this study many patients who were denied coverage were unaware of

the need for pre-authorization. Almost half of those denied coverage did not

receive alternative care within 24 hours. During the 7 month study at a large

urban hospital (36,000 annual emergency) visits) 151 were denied authorization

for emergency care by their managed care plans and chose to leave without

receiving care, This may change, but don’t hold your breath. This (2001) is the

fourth Congress in which a bill has been introduced requiring health plans to

pay for ER visits "if a prudent layperson" thinks his or her condition requires

it. Of the 104 people who participated in the study, 86 of them (83%) said they

came to the ED (emergency department) because they believed their problem was an

emergency, and 63% said they were not aware of their need for preauthorization

for coverage. There is such a breakdown in communication, which was not the case

pre-managed care.


live every day with almost the complete failure of a system to meet the basic

needs required to do the job. Nurses are demoralized, not paid enough, supplies

are lacking – unimaginable a surgical ICU with no tape at all on the stocked

cart." Chaos is the rule" as one nurse recently said. "I worked in an academic

research world with lots of grad students and post docs moving in and out and it

didn’t hold candle to the indifference and lack of caring from most of the

ancillary support staff. We run a 300+ bed hospital with 1-2 phlebotomists

usually. We figure we are lucky to get our stats within 2 hours. As a nurse, I

work hard to forge alliances with other departments so that when I call for an

emergency it is listened to, and I don’t bother them for routine stuff."

Another nurse is quitting because (1)" can’t find things when needed in a hurry,

e.g.needed a wheelchair. I had to locate one by roaming about several floors and

when I did find one the floor didn’t want to give it up. Gurneys, tubes, masks,

gloves, tools of all kinds were simply in short supply and a distracting chore

to find. ‘no one put anything back, and there is not enough stuff."


Dealings with the pharmacy. Wrong drugs sent at wrong time. Drugs not there when

needed. Pharmacy wants the nurse to deal with docs, dumping this on top of

regular duties with patient care. Rarely could I give drugs at the ordered time.

I had to console myself. Well, I guess it’s Ok to miss by an hour.


Patients with acute needs being placed upon routine medical floors." They sent

us patients with tubes and vents and timed meds and all kinds of special needs.

They should have been kept in the ICU.


Too many rigid nonsensical rules. For example, I allowed BOTH worried parents to

stay in room with a sick kid one night. The next day I was chewed out by one

senior nurse because the rules say, "Only one parent can stay in the room. Only

one chair allowed, don’t you know that?"


are others, such as too little staffing and too much verbal abuse from doctors

and too little pay.


male nurse wrote to me recently exclaiming that even with his 19 years

experience he had decided to leave nursing. He related some of his reasons to

one of my recent commentaries wherein I related how the patients are now being

"blamed" for any medical errors. He went on to say that in the beginning when he

just started as a nurse’s aide the one thing "I loved more than anything was

being able to take the time to help the patient understand what was going on in

terms they could understand – in a way that could make sense for them.

Thanks to the increasing focus on healthcare as a business and the ever present

focus on "bottom line profits (even in the case of public or private

"non-profit" hospitals) decisions have been made over the past decade to cut

back many positions at the bedside."


went on to say "I finally made a decision that I could no longer continue

working in a situation that resulted in my constantly being on the verge of

tears. I felt so angry and impotent after continuous rejection about any of my

suggestions made to the administration as to ways to improve the system. How

many times was I reprimanded that I just did not understand the "economics" of

the situation.’

Overcrowding on the ER hits doctors, interns, residents – everyone. And

accidents are happening too often and in more and more hospitals. Up until a

year or so ago, ER rooms faced this nerve-racking logjam for only few days or

weeks in winter when the flu and cold viruses turn into potential fatal

pneumonia, babies fall prey to respiratory and intestinal viruses, depression

fills the psych wards and slippery ice keeps the orthopedists busy. Now we’re

seeing mini-surges in the spring, summer and fall.


Call to Action: Single payer Hearing in Congress May 1,2001 will start, I hope,

the ball rolling. The Congressional Black Caucus and Congressional Progressive

Caucus sponsored this hearing. The group produced a 27-page white paper that is

easy to download. Just send me a quick note and I’ll explain it, just for your

information the URL to the site is


group of nearly two-dozen nationally prominent physicians- including Dr. Marcia

Angell, former editor of the New England Journal of medicine, and a host of

others testified before Congress that only comprehensive reform of America’s

ailing system will address the nation’s health care crisis.


have engaged in a massive experimental failure (if it were really as innocent as

that). Rhetoric about the benefits of competition and profit-driven health care

can no longer hide the reality: Our health systems in a shambles. I think we

have started a nice little grassroots movement here – let’s keep it up. I feel a

tad optimistic since 1999 when I started to write on this issue for

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