Semper Paratus: Our Decisions About Emergency Care

When I read Trudy Lieberman's recent piece, Rehabilitating the Image of the Emergency Room, I was reminded of a not-too-long-ago ER decision dilemma:

Nora misjudged the height of the stair outside the restaurant, stepped down too hard, jammed her knee and tore her meniscus. Not that we knew this at the time. All we knew then was that she was howling from the pain.

There we were on a dark, empty, wet street in lower Manhattan, not a cab in sight, with a wailing, immobile woman. What to do? Call 911? Find a cab to take her home and contact her primary care doctor for advice? Take her home, put ice on her knee, feed her Advil and call her doctor in the morning?

Sometimes it is clear that the only response to a health crisis is to call 911 and head for the emergency department (ED). But in this case and in so many others we encounter with our kids, our parents, our co-workers and on the street, the course of action is less obvious while the demand for some action is urgent.

The question “Which action?” has become more complicated of late because:

• In some communities, there are alternatives to an ambulance or a drive to the nearest ED, such as Urgent Care centers.
• Disincentives exist for going the route of the ED: in many cash-strapped municipalities we are charged for the cost of the ambulance ride; we risk not having our ED visit covered by insurance if we make the wrong decision or fail to notify our health plan in a timely manner. Or we don't have insurance and the ED care is expensive.
• Some of us have a number of clinicians who could guide us about ED versus self care on any urgent health matter, plus our health plan may have a nurse advice line that could do the same. Which among them to call? How long will it take to get an answer in the middle of a busy workday or a late night?
• Many of us have no primary care clinician to call.

What hasn't changed is that sense of panic. We don't know enough to judge how serious this is. We feel tremendous pressure to do something to resolve the pain and don't know how to do it ourselves. We don't want to be responsible for underestimating the problem and causing additional harm.

Efforts to help us problem-solve quickly about urgent health events have been going on for a while. For example, The HealthWise Handbook, distributed to more than 33 million people since 1975, walks readers efficiently through such decisions. The Handbook information is available to everyone for free on WebMD and HolaDoctor at http://www.healthwise.org/Questions.aspx. The American College of Emergency Physicians Foundation has a good list of general indicators for when to go to the ED, which is posted on its site and elsewhere. Other large health sites provide varied levels of advice about responding to specific health emergencies. But informed action depends on our ability to already know about a good source for relevant information, to find  the book or the search term or advice-line number FAST, then to be able to apply it to the situation at before us.

Twenty (20!) percent of U.S. adults made at least one visit to the ED in 2011, and a good number of these visits were not for urgent conditions. It's true that the ED is the only place that some of us can get health care, and considerable attention is directed toward reducing visits by frequent users, despite the fact that the blame does not lie with us alone: A recent RAND study found that some doctors say they use the ED as their “overflow valve. It’s where I send complicated patients. It’s becoming my diagnostic center.”

But none of us is immune to making the wrong call. Our decisions about where to seek care for a health crisis are made largely in the absence of knowledge or expert advice, and as a result we often end up wasting our time and money as well as that of professionals and institutions.

Health crises are common in the population, but rare among individuals. Regardless of our experience, when one happens to us, to a family member or a co-worker or in front of us on the Little League field, we know we must act. Right now, despite all the options and disincentives for doing so, the default action for most of us is calling 911 or getting ourselves to the ED. We would benefit from a little help here.

So come on, those of you who have a stake in making health care more patient-centered! This is an easy win.

If you are a primary care clinician in a practice or a medical home, tell your patients how you and your staff handle emergencies both during the day and after hours. Who should they call? What can they expect? Post this information, send it to them, remind them about it when you see them.

If you are an employer, make sure your employees know what services you have purchased for them as part of their insurance benefit to help them respond to an emergency. Show them where this information is located on the premium information website or in the handbook; remind them about that nurse advice line.

If you work for a health plan, communicate directly, clearly and consistently with members about their specific benefits: what must they do to ensure care is covered? Where on the plan website is there information that could help in making decisions about emergency care?

If you work on patient-centered care for the government, form a partnership across agencies and with private industry to gather the lessons from the 911 experience to inform the development and promotion of a self-triage emergency app for (web-enabled) smart phones. Create something that every single one of us could turn to when a health condition turns serious or an accident occurs; something that provides guidance to distinguish ED-level emergencies from “put some ice on it and take some ibuprofen.” By the time you do this, smart phones should be in the hands of most Americans.

Ideally, care that is patient-centered is organized to enable us to act to optimally benefit from the knowledge, services and technologies available to us. Each of these strategies would help us do so.

So what happened to Nora? She figured that since she wasn't bleeding and probably didn't break any bones, going home and getting advice from her primary care physician might save her a cold night on a hard chair in the local ED.  She's hobbling but healing.

This post was originally published April 20, 2011.