by AintMuchToDo
Hi. I’m an ER nurse, and I want to talk about what you can expect to come in the arena of emergency medicine in the United States, because I think it’s important that we are well-informed on how grim the future looks for every American. I posted a musing on this over on the Nursing subreddit, but decided it needed a full writeup, because this is something that will affect every single person who may have a medical emergency and doesn’t have their own concierge health team.
“Unfortunately”, of course, emergency services have never been a profit-generating system. Because of this, the stark truth is that most hospitals and most communities, left to their own devices, wouldn’t even provide emergency services — which is why closing a hospital in a rural community can be a death sentence for so many. This is why organizations that provide emergency care rely largely (dare I say, almost entirely) on federal dollars and regulations for the things we do. From 911 centers, to EMS and Fire/Rescue departments, to Medicaid/Medicare/ACA dollars and regulations, to laws like EMTALA- the Emergency Medical Treatment and Labor Act of 1986, signed into law by that notorious socialist Ronald Reagan- it all governs and affects our ability to provide care to you.
For instance, EMTALA stipulates that we have to treat all patients regardless of their ability to pay, which, while being an unfunded mandate that has probably cost an aggregate of multiple trillions of dollars over the last forty years, is still a good thing. People forget that prior to EMTALA, you could literally be in active labor or bleeding to death, and if you couldn’t pay, the emergency department could legally turn you away- and often did.
I’d been mulling over writing something like this but had ultimately demurred. There are hard rules in this sub in re posting about politics, about “conspiracies”, etc, and while this post is neither, I’m certain there’ll be a flood of people who mark it as such. And I didn’t want to write this all out, only to have it yanked for that reason.
Then I read that the richest person in the world joined on a national security call for no apparent reason. If there was any doubt in my mind that person would be a key player in setting policy, very, very soon, it ended right there.
And that person has pledged to cut “two trillion dollars” from the federal budget, alongside the admission that “everyone is going to have to hurt” for at least the next “two years”.
That means many things are going to happen… none of them good.
When the Affordable Care Act/Medicaid/Medicare are gutted and/or repealed entirely, tens of millions of people (if not more) will lose their ability to access primary and specialty care. That diabetic or dialysis patient that is managing with quarterly appointments, the person getting regular skin checkups once a year for melanoma, the person who is having weird right lower quadrant pain (unbeknownst to them, appendicitis) who would call their family doc to check them out- they’re not going to have access to any of that anymore.
Interestingly, this is why Monday is generally considered to be the worst day of the week in the ER. Everyone who couldn’t see their non-ER providers over the weekend tough it out until they can see someone on Monday. That provider discovers this patient is now in dire straits, and refers them immediately to the ER- which totally slams us.
Now: imagine that, multiplied by a factor of ten.
Every single day.
Without end.
Let me outline a scenario for you.
You break your arm, or you have a kidney stone, or your mother falls and breaks her hip. First, you call 911, and if you can get through, you may find it is literally hours before an ambulance can pick you up. The ability of that fire/rescue department to continue operating has been jeopardized by the loss of federal funding. What little funding they have left means that, particularly in rural communities, one ambulance may have to cover the area of a small European country. And it doesn’t matter how many ambulances you have, you can’t run them without maintenance and crews to operate them- provided by Federal dollars.
Instead, you manage to get to the ER, where you find the waiting room has spilled out into the parking lot. The harried triage nurse, you find, is actually a basic EMT, who has twenty hours of training and just qualified for their boards. Since overtime pay was fundamentally changed- the required hours per week raised from 40 to 50 and requiring overtime pay to be calculated over a cumulative month instead of a week- there are no experienced ER nurses to staff triage full-time. You find out there have been people waiting for twelve hours (and longer) to be seen.
Not only is there no triage nurse available, the inpatient units in the hospital haven’t been able to keep nurses on for staffing, meaning that it doesn’t matter how many beds there are- there aren’t nurses to see those patients. The nurses that are left are watching a staggering six to ten patients each, who they aren’t able to keep up with as it is. In a cascading effect, that means anyone in the ER who needs to be admitted to the hospital has to wait until a bed comes open, which now may be days if not longer.
So you’ll sit in the waiting room for hours. I don’t know if you’ve had a kidney stone, but every woman I’ve ever seen that has had both those and given birth have said kidney stones are worse. If it’s your mom with a broken hip, she’ll lay on an ER cot in the waiting room with everyone else, in agony and incontinent because she can’t even move her hip to pee into a bedpan. “What?!” you might say, “You can’t make people wait that long for serious stuff!!” Well, we’re not going to have a choice.
This is exactly what happened during the height of COVID. This is why places where it was the worst, like Florida, were offering ER and COVID ICU travel nurses up to a staggering $250/hour. This time, though, there’ll be no Federal COVID support to pay those nurses- the exact opposite, in fact.
You’ll sit there waiting alongside a 42-year old gentleman whose face is ashen. He lost his health insurance coverage, and couldn’t see a PCP or dermatologist- which is worrying, because this morning he discovered a multicolored and very weird asymmetrical mole on his back, which he’s going to find out is malignant melanoma that’s already metastasized, when it could have been lopped off at Stage IA for $100 in health insurance copay and a pathology test.
You watch as a 56-year old lady gets wheeled back urgently, furious that you’re having to wait and they don’t, not realizing that person is a diabetic who had no access to insulin, who is in diabetic ketoacidosis (her blood sugar is now around 1200 at the moment). She won’t make it to the ICU; they’ll have to put her on a breathing machine in the ER and hope she doesn’t die before an ICU bed comes open; the ICU, which normally operates on a one nurse to one patient ratio, is running around 4:1 at the moment.
You gaze nervously as two kids, a brother and sister by the look of it, fidget and itch and scratch the red/brown blotches that seem to begin at their hairline and extend down their face and to their body. You don’t know what that is, because you’ve never actually seen measles before. And you also don’t know that it’s an “airborne” disease and significantly more contagious than the Flu or COVID. They probably shouldn’t be sitting in a packed waiting room filled with sick and immunocompromised people- but they are.
You vaguely hear screaming from the back, which you have no way of knowing is the husband of a mother who was rushed into the ER, unconscious, her untreated preeclampsia becoming worse and contributing to her throwing an amniotic fluid embolism into her lungs, requiring the ER staff to do an emergency c-section- not in the OR, but at the bedside in the ER. With time of the essence for any chance to save the baby, and with blood flowing by the liter onto the floor, frazzled ER nurses are using their own hands as pressure bags to push uncrossmatched blood through an IV in a desperate, but ultimately futile, attempt to save the mom.
If you have a kidney stone, you might get seen sooner; four or five hours instead of twelve or longer. Seen by an NP or PA who is exceptionally talented, but has had a patient load 3-4 times what their normal “busy” day was. You get a prescription for narcotics and nothing more, and will be sent out the door. If you’re there because your mom fractured her hip, well, eventually she’ll get seen, and medicated into oblivion with IV narcotics. But hours later, when the ER doc has a chance to touch base with you, she’ll tell you the x-rays say she not only broke her hip, but her pelvis, and that if/when she gets an inpatient hospital bed, they will have to discharge her back to a total care unit, IF space is ever available, and entirely at your expense.
Except the case manager that would have helped you find somewhere for your mom to go after being discharged (a short term disability facility, rehab, etc) is gone. The federal funding for her job is gone. Not only the funding to pay her, but all the assistance to find the exact kind of help your mom is going to need. Mom’s your problem now; you’re going to have to take her home, you’re going to have to turn her, you’re going to have to put her on a bedpan 6-8 times a day or more because there simply isn’t help out there anymore to do anything else.
But don’t worry- after all, Elon said “everyone is going to have to hurt for two years”. Well, the “two years” of pain is enough to make American nurses and doctors not want to be nurses or doctors anymore; not in those kinds of conditions. The crisis of not enough nurses/doctors worsens after a systemic effort to “root out the woke mind virus” craters funding to colleges and universities across the country. The best and brightest have fled to the EU, to Australia; heck, even Dubai is offering unheard of incentives for talented American providers, wanting to take the best and brightest away while they can.
Even if the flip switches magically at the two-year mark, the damage done will last a generation or more.
Whether you realize it consciously or not, emergency services are something you consider every single day. Are you looking at buying a house? Going hiking in the mountains? Driving to work? Taking your kids to soccer practice? Letting your elderly parents or grandparents live in their own home? You rely on the safety net my colleagues and I in emergency services provide. We’re a foundational part of what makes modern life possible.
If you can’t rely on it, you are going to have to make some very hard choices in the very near future about what you need to do to keep you and your family safe.
If a system that every American relies on is going to collapse, if we can’t rely on it, you need to know about it now. So you can see this through, going forward. So you can do the very best you can by you and your family.
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