The Place Where They Have To Take You In

Days and nights on the front line at Minnesota's busiest emergency room.

Not everyone who walks into triage ends up being seen in the emergency room. Like every hospital, HCMC has made efforts over the years to divert patients who aren't in danger of life or limb; it operates six primary-care clinics and has affiliations with a dozen more. There's also an Urgent Care Center, two doors down from the ER, which sees people with rashes, sore throats, and the like. Psychiatric patients go to a separate mental-health emergency room, the Crisis Intervention Center, which began in the 1970s as a suicide line.

None of these things has significantly stemmed the flow at the ER--not because they don't work, but because the need keeps growing. Some services tap into a whole new market; the Crisis Center is now on the answering machine of just about every shrink in the county. Others barely make up for what's being lost elsewhere. A number of other hospitals in the city have closed or consolidated. A few have simply done away with their ERs in favor of urgent care centers that charge cash up front.

Generally, emergency rooms aren't popular among health executives, in part because, unlike any other unit, they can't perform what's known as a "wallet biopsy." The reason goes back to the mid-1980s, when "patient-dumping" began to make headlines. In one high-profile incident, a Texas ER sent an uninsured woman in high-risk labor on an almost two-hour ambulance ride to a public hospital. She delivered on the way. Elsewhere, patients with minor injuries developed complications during transfer and ended up disabled for life.

Congress's response was an amendment to the 1986 Consolidated Omnibus Budget Recon-ciliation Act (COBRA), prohibiting emergency rooms from sending a patient away unless the person was "stabilized." It sounded obvious, and few people paid much attention until the lawsuits began. Eventually, court rulings made it clear that with one little amendment, Congress had created a kind of last-ditch national health care guarantee. The reasoning, as assistant Hennepin County attorney Ann Russell summarizes it, goes like this: "The decision whether a person truly has a medical emergency in most cases can't be made at triage. They have to be seen by a physician in a thorough exam. And since the exam makes up 90 percent of any medical encounter, it basically means once they're in you might as well do the treatment too."

Health administrators grouse a great deal about this "unfunded mandate," and there has been a lot of experimentation with COBRA loopholes for "appropriate transfers." The act has not been aggressively enforced, and few hospitals or doctors are ever punished under it. Studies estimate that a quarter-million patients still get dumped from private ERs around the country every year.

Dumping, though everyone in the HCMC ER has a story or two to tell, isn't as common here as in a lot of places. But Minnesota has had no respite from ever-tightening insurance rules on who gets to go to an ER, for what, and where. At Hennepin County, says Russell, "We see cases all the time where men will come in with chest pain, freaked out, and Group Health or whoever will say 'send them on over.'" Usually, she says, the hospital will take its chances--treating first, and worrying about the proper justification later. So far it's worked out. But the policies are always being revisited.

Past triage, and down a couple of corridors, is the kids' emergency room--pediatrics, or Peds for short. It's a bright place, with mobiles hanging from the ceilings, colorful stickers, and a few private rooms. One of them, with a dinosaur on the door, is also used for sexual assault exams. Some 16,000 patients came through here last year. The most common complaint was ear infection, with respiratory problems a close second

At 5 p.m. on a weekday, Peds is in high gear. There's a six-year-old with stomach pain, a pregnant 15-year-old, and the intrepid who stuck his tongue on a metal railing at 20 below. An eight-year-old is coming down the corridor, his arrival heralded by furious sobbing as he struggles to get air into his lungs. He's placed in cube four, from which he can see the TV monitor in the waiting room. The movie is The Lion King.

An hour later the doc is still standing outside the cube, talking softly to the father. The kid is quieter now, sucking on a nebulizer and winking at anyone who'll catch his eye from the nursing station. Someone's moved the bed out from the wall so his mother can sit next to him and hold his hand. The worry in her eyes seems out of proportion to an asthma attack.

"When you have a minute," the doc says to the social worker, "I need you to talk to this family. We're in the middle of a financial crisis." Debbie nods and heads in. Another hour goes by.

The little boy, it turns out, is one of five children. His mom works full-time at near-minimum wages. His dad does odd jobs for $50 here, $100 there. They don't qualify for Medical Assistance. They've applied several times for state-subsidized insurance under MinnesotaCare and were turned down each time. Apparently it has something to do with being unable to document the father's income. So when the doc suggested that the kid be admitted overnight, both parents panicked.

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