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The evolution of emergency care in the United States is a fascinating story. Sadly, what became a hugely successful solution to an important problem in health care is now being eroded by its misapplication to another problem.

The modern U.S. health care system began with so much promise. After World War II, the economy was booming and employers were quick to provide health care for their workers. The addition of Medicare and Medicaid in 1965 further fueled a dramatic expansion in the quality and availability of health care services.

Throughout this time, emergency care was still in its dark days. Ambulance services were operated mostly by funeral directors, with minimally trained helpers. Emergency rooms were commonly staffed by a nurse whose job was to conduct an initial evaluation of patients and then contact the on-call physician — who may or may not have had any training in the management of emergencies.


Soldiers and health care personnel who served in World War II, Korea, Vietnam, and our undeclared wars had experienced how effective a well-organized system for taking care of acutely injured people could be. Their knowledge put pressure on hospitals to look for a new way to manage emergency care.

In that new way, hospitals contracted with physicians to ensure that there was always a doctor in the emergency room. Beginning in 1976, I was one such physician.


I was a pediatrician at the time, with little experience treating adult patients. Fortunately, I could call any physician on the staff for help. Equally important, when they came in to assume care for the patient, I was there to help. In that way, I learned how to care for all sorts of emergencies.

One day, an ophthalmologist taught me how to remove small bits of metal from the surface of a metalworker’s eye. His instructions were simple: put some anesthetic drops in the patient’s eye; use a “spud,” a metal tool with a point on the end, to scrape out the metal fragments; then use a small electric burr, like a tiny sander, to buzz off the residual rust granules. The patient did fine, and I learned how tough an organ the eye really is.

I did that procedure entirely by myself. I had to: The ophthalmologist stayed home and told me what to do over the phone. That was also a part of emergency medicine.

During the 1970s and early 1980s, professional organizations formed; leaders emerged; the science of emergency medicine developed; new emergency procedures and better techniques for old procedures were invented; textbooks were written; and examination and certification procedures came into being. Emergency rooms became departments of emergency medicine. In 1983, I took and passed the second Emergency Medicine Board Examination ever given, making me certified in the new specialty of emergency medicine.

Today, if you are acutely ill or have experienced trauma, you can go to an emergency department anywhere in this country and receive immediate, excellent, lifesaving care from people who have spent their careers learning how it’s done.

That’s the good news.

The bad news is that, in parallel with the rise in emergency medicine, health care costs steadily surged upward. Today, medical debt is the most common cause for personal bankruptcy, particularly in the elderly. At the same time, health care insurance is becoming increasingly difficult to afford.

Until health care reform happens, the stopgap measure is the emergency department. Why? Because it is like mom and dad: When no one else will take you in, the emergency department can’t turn you away. It’s against the law to do that. But using emergency departments to create access to health care is like putting a snow plow on a Porsche. It costs much more, does a bad job, and it trashes the Porsche.

Although emergency departments are set up to handle anything, they can’t handle everything at once. As more and more people turn to the emergency department for non-emergency care, it is common, especially in metropolitan areas, to have waiting times in them measured in large parts of a day and to have patients kept in stretchers in the hallways after they have been admitted to the hospital because they cannot get an inpatient bed.

Wealth does not make people immune to being swallowed up by the emergency department. Here’s a story for the one-percenters out there. Several years ago, while working in the emergency department of a busy metropolitan hospital, I cared for a middle-aged Wall Street stockbroker. Certain he was having a heart attack, I admitted him to the cardiac care unit. Two days later, when I returned to work, he was still in the emergency department, standing amidst a collection of gurneys in front of the nurses’ station. Wires attached to his chest tethered him to a monitor 20 feet away. He was still there because no bed had opened up in the cardiac care unit.

People sometimes ask me how long I think it will be before our health care system collapses. There certainly are signs that it is coming apart: Our legislatures routinely block attempts to create a rational health care system. Old people are regularly financially ruined by the costs of illness. Health insurance is becoming increasingly unaffordable. And politicians, while decreasing taxes for wealthy people, are crying that federal health insurance must be cut back.

I believe that one reason our health system still functions at all is because emergency departments are the chewing gum and duct tape holding it together. That may work for a few more years.

Or maybe it won’t.

Paul Seward, M.D., practiced medicine for nearly 50 years, mostly in emergency departments. He is the author of “Patient Care: Death and Life in the Emergency Room” (Catapult, July 2018).

  • You must look at the type of patients who utilize the ED. It’s glaringly obvious. Also look at the payer mix using things like Express (Immediate, Now, Prompt, etc) Care and it’s obvious. The latter generates revenue for hospitals and the former is a money pit. It’s all about the user.

  • Dr Seward: Thank you for your service to patient care. this country needs affordable healthcare for everyone! Other countries seem to manage it pretty well. Money is the issue. It is all about the money! I am a healthcare professional in my 70s and I have watched all this evolve since I walked into a Clinical Laboratory in 1969. First change, here comes the money-changers mandated to tell everyone how to save money. They bought mahogany desks, re-did the offices with custom drapes, hired assistants, and assistants to the assistants until they had a pretty hefty budget. Meanwhile, they recommended cutting staff, advocating for less of this, or that to be more cost-effective. Raises, except for nurses stayed at 2%. The money-changers did pretty well. Knowing nothing about medicine or patient care, they took over healthcare cutting as they went. Nursing staff who never wanted to draw blood, had to. Phlebotomists staff was cut. Laboratory scientists (called Medical Technologists then) had to help phlebotomists. Nurses had to learn some lab testing called point-of-care. The medical device industry began selling small POC instruments directly to Nursing. It didnt matter if they were accurate, or not. Other necessary departments suffered staffing cuts, offered less services than before. Drug companies began advertising on TV. Patients began asking docs for more drugs. It goes on and on, and the people “in the trenches” are fewer and fewer with less and less skill (older folks never got time to mentor). Training was also cut-docs, nurses, etc. Lab college programs were cut (nurses organized formimg unions (gaining more$$). Other allied professionals were cut to the bone. Allied care gleaned more reimbursement seeing outpatients. Services like lab & x-ray moved off-site.
    Bottom line- we let non-medical people tell us how to care for patients. “Medicine” needs to take back healthcare.

  • All true enough. As a recently retired Respiratory Therapist I’ve experienced what Dr. Seward describes from a direct care staff perspective.

    Maybe one solution is to create an Acute Care Department different from the Emergency Department. Acute accepts non-cardiac, non-trauma, non-respiratory distress, (to start).

    Instead Acute accepts simple fractures, sniffles, lacerations, VS-stable direct admit referrals, and those other things that drive ED staff crazy. Set-up may be short term expensive but long term efficient (hopefully). Goal is to keep the stable out of the ED, get treated, and out the door. Triage at the driveway with in-building connecting halls if transfers to “other side” required.

    • Hi Michael:
      We have “Urgent Care” here in N.E. where I live, and “Triage” is policy. However, the many UC sites are not near hospitals but in suburban areas making them more convenient.

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