Seizing the COVID-19 Spark to Catalyze Emergency Medicine Development

For the past 25 years, I've specialized in clinical and academic emergency medicine -- working and teaching in university and community hospitals, urban and rural hospitals in New York, Washington DC, Virginia, Maryland and elsewhere.  During this time, I've also completed 2 residencies, 2 Masters degrees and 4 subspecialty Fellowships in International Emergency Medicine, Health Policy, Public Health, EM Administration, and Heath Economics, Policy and Law.  During these 25 years, I've spent 3-5 months / year living, teaching and working overseas helping build emergency medicine, trauma and acute care systems in other countries--most countries are still in the process of building their emergency medicine, trauma and acute care systems, and I've been very lucky to help with this in over 40 countries around the world.  I'm also on the Board of Directors of the American Academy of Emergency Medicine (https://www.aaem.org/) representing over 8500 emergency physicians in the USA and abroad, and the Secretary of the International Federation for Emergency Medicine (https://www.ifem.cc/), representing over 70 national and regional emergency medicine professional societies from over 50 countries.

Over the last weeks and months,  this unfortunate but predictable (and predicted) COVID-19 pandemic and its crippling impact on our emergency care system and the health care system in general (not to mention the impact on nearly every other industry and facet of our society) has laid bare and provided yet another example of the common problem that underlies most of our modern corporate-run and corporate-beholden economic practices:   the practice of running every business and industry right on the knife-edge of the cliff, of squeezing out any and all overage, back-up, surge capacity, cushion and protection -- protections that are necessary for safe and proper provision of modern health care -- has turned this current situation into a near-extinction event for the national and global economy, for local and national health care systems, for global public health and health responses, and of course for the many millions of people around the worlds who will likely become infected and may die.

These common corporate practices of selling out long-term safety and stability in favor of short-term profits at the expense of health care workers and patients is glaringly evident in the current crisis with PPE, ventilators, medications and other emergency care resources, and many years of practices such as these have kept the emergency care system, the hospital system and the health care system running in the red, over-extended, under-staffed, under-equipped, under-trained, under-appreciated and misunderstood.

I'm sure you are aware of the many cases where emergency physicians, nurses and other health care professionals have been reprimanded, punished, sanctioned and even fired for speaking out to hospital administrators and on social media about the lack of adequate and safe PPE, of the lack of proper testing, of ventilators and other emergency equipment.  (See this article here: an emergency physician in Seattle was fired over the weekend for bringing attention to the inadequate PPE and safety equipment.  The physician was employed by a billion-dollar "contract management group" called TeamHEALTH, which engages in unethical and often illegal corporate practices of medicine, allows non-physician-owned medical corporations (illegal in the majority of States), all at the detriment of patient safety and public health.  The link to the article in the Seattle Times is below.)

This crisis of inadequate PPE, equipment and sacrificed emergency care and health care worker safety is just the latest example of corporate greed run unchecked in our health care system, and in our society in general--that the most important thing and often the only important thing is to make a profit at any cost, and that it is quite easy to make a huge profit as long as you don't mind doing things the wrong way.  Businessmen and the corporate elite are no longer satisfied at becoming and being obscenely rich--now they must be obscenely, cartoonishly rich--all at the expense of the average working citizen.  The corporate practice of medicine and the business mind sees any and all safety measures, additional capacity for surges, and other intentional excess measures as unnecessary redundancies to be chopped and eliminated and traded for profit.

Emergency medicine is the first medical specialty that was pulled into existence from public health care seeking behavior, generated from the holes and cracks in the public health and health care system.  "Every patient who presents to the emergency department represents a failure of the public health care system", said Prof Lewis Goldfrank, grandfather of emergency medicine, Chair of Bellevue ED in NYC, father of poison control centers.  However, hospital emergency departments and emergency medicine specialists are treated like 3rd class citizens in the House of Medicine, and are not appreciated for the enormous value, quality, safety, efficacy, timeliness, cost-effectiveness and patient-reservedness that we provide to the hospital and to the health care system.  In the USA every year, US emergency departments see 151 million patient visits, which goes up by 6-7% every year.  53% of all hospital-based health care provided in the USA is provided in an emergency department.  60-90% of all hospital income is derived by profits from hospital admissions, and 50-80% of all hospital admissions come through the emergency department.  This means that 50-60% of all hospital income is from the services that are provided by the ED.  Studies have shown that every $1 spent in the ED generates or saves $7-8 in the hospital, and recent studies show that modern emergency departments generate $50-100 in down-stream outpatient services.  The emergency department is the true economic, quality, safety and diagnostic engine of the hospital, yet we are treated as if we are faceless, interchangeable cogs in the machinery, and are as usual understaffed, underequipped, underfunded and misunderstood.  

Over the past weeks and months, I have been up to my ears in working busy ER shifts taking care of sick, infected COVID-19 patients--putting my own health and the health of my colleagues and my family at risk--as well as taking care of all of our other ER patients who have not simply vanished into thin air.    I think it's important to highlight that the ER system in the USA is the safety net of the entire health care system.  The ER is there for every citizen and every patient who has been failed somehow by the health care system, who has been failed by our education system, by our insurance system, by our economic system.  Most human inequalities and inequities ultimately show up as human pathology, whether medically, psychologically, emotionally or all of the above.  

It's this practice of using the emergency system (and indeed many other aspects of the health care system) as an overworked overcrowded catch-all receptacle for all of the inefficiencies of the rest of the system that is causing the system to fail now during this crisis, that is causing so many patients and citizens to suffer, and that is causing so many physicians and health care workers to "burn out" and leave the field, intentionally or otherwise.  

However, we should stop using the term "burnout".  Burnout is a name that places the blame on the victim, when in actuality, burnout is the proper physiologic response to living and working in the wicked environment that is the modern emergency department.  Burnout is not because we have improper work-life balances, or because we don't use deep-breathing or meditation or that we're suffering from yoga-penia --we are burnt out because we are being abused.  

As famously put by George Carlin: In WWI, some people snapped psychologically because their nervous systems were exposed to bombing and shelling and the horrors of war, and these people were diagnosed with "shell shock"--two words, short, descriptive, a word that even onomotopeically mimicks the sounds of the bombs themselves. In WWII, this was replaced with "battle fatigue"; in Korea with "operational dysfunction" and in Vietnam with "post-traumatic stress disorder".  The impersonal trend these new terms are following has allowed a completely confused notion to be applied to these victims: these new terms place the blame on the victim. The same is true for "burnout"--this is blaming the victim.  Physicians and emergency physicians are not burning out.  We are being abused.  Systematically abused, overlooked, undervalued, undersupplied, underresourced, misunderstood and disrespected. This is why over 50% of emergency physicians are "burned out"--the same reason so many WWI and Gulf War and Iraq War and Afghanistan War vets were"burned out"--we live and work in a wicked, unsustainable, crazy environment, with sick, unscheduled, undifferentiated, undiagnosed patients, an environment kept in place by an exploitative hospital and medical system that uses the ED as an overflow pressure valve for a mismanaged hospital instead of a modern diagnostic and stabilizing medical unit delivering value through early recognition, stabilization, diagnosis, admission, proper patient streaming and patient advocacy.

I believe that the on-going global COVID-19 pandemic can shine a huge spotlight on our already crumbling overworked over-stressed emergency care system and our health care system in general, and should serve as the example of putting profits over patients, of building hospitals and health care systems in order to make a tiny percentage of people rich at the expense of peoples' health and well-being and their very lives.  While all of us who work in emergency medicine and in our emergency departments will continue to show up on the front lines, to staff our already overflowing ERs now literally bursting with sick and dying patients--we must turn this horrible and avoidable tragedy into a spark that could change and improve the entire emergency care system, that could transform our modern health care system into a system based on health, well being, patient safety, equality, efficacy, timeliness, efficiency and patient-centeredness.  We must not lose this opportunity to highlight this current crisis as yet another intentional bubble of need and exploitation created by short-sightedness and greed.