• emergency care systems
• crowding
• quality
• emergency department
• clinical care

It was September 2001 when I spoke at a press conference in San Francisco arranged by the American College of Emergency Physicians. My colleagues and I had just written a paper on who uses the emergency department (ED) showing that most patients seen in US EDs had primary doctors and insurance, countering the myth that ‘ER’ (emergency room) patients were all homeless, alcoholic and poor.¹ Time Magazine was running a cover story that week shouting: ‘Crisis in the ER’. That headline was quickly overshadowed by the events of 11 September. But that is not the only reason that little headway has been made against the ED crowding crisis.

I fell in love with emergency medicine (EM) in 1982, in my third year of medical school. It was a 2-week stint on the ‘medical side’ of the ER of the Beth Israel Hospital in Boston, part of a 3-month rotation in hospital-based internal medicine. I had a wonderful supervising resident who, before I went to see a patient, would sit me down and go over the differential diagnosis of each problem I saw, what I should look for on examination and options for treatment. It was great teaching, there was a cornucopia of interesting cases, patients of all ages and some people got better before our eyes.

But this was a time where, as you might tell from where my ER experience fell in the curriculum, EM was not really considered a specialty, at least not by those teaching at my medical school in Boston. At that time, academics thought that people who worked in EDs were, as my kids would have said, slackers—backpacking, Birkenstock-wearing medics who did not train for a specialty and rolled into an ER every now and then to earn some money, then get back on the trail. And the patients? They were perceived as people using illicit substances (and over-using legal ones), ruffians, or individuals who were too lazy to make or keep their doctor appointments. So when it came to applying for a specialty, I was discouraged from looking at training in EM. Rather I was strongly advised to pursue internal medicine because I could ‘always practise’ EM anyway. Similar feelings about EM accompanied the birth of our specialty in the UK (now 50+ years old) and Europe (although even today some European countries do not acknowledge EM as a specialty).

In general, things have changed greatly. EM is indeed a specialty, we have EDs, not rooms, formal training programmes and a body of research that fills multiple EM journals every month. Our specialty is much in demand by patients and by other physicians. We built the better mousetrap. When physicians—be they general practitioners or ‘ologists’—cannot see patients due to full rosters, lack of tests or uncertainty about what to do, or when they recognise a patient needs time-critical care, they rely on us. We should be flattered. Our work is valued!

Unfortunately, our patients are not. For as long as I have been in this field, it has been clear that EM patients are not considered as worthy of dignified and expeditious care, of comfort and respect, as other kinds of patients. No other specialty or service manages its outpatients in the waiting room. While no one thinks it is good patient care, corridor care is accepted as standard practice in the ED but doing the same thing on inpatient wards has engendered great controversy and pushback. Somehow, the same patient who is treated in their own examination room in the clinic and in a proper bed in a room in a hospital is considered unworthy of that same comfort, privacy and respect if they happen to need evaluation in an ED. Politicians and administrators (without some looming target or financial incentive) seem ready to turn a blind eye to the fact that we see patients in the waiting room and in the corridors, and they wait for 12 or more hours often for a bed in the hospital. And blame for failure to meet targets still tends to focus on the ED, not recognising long ED waits and crowding is a whole hospital problem. Regulatory agencies who are quick to note the slightest irregularity in a patient’s consent form, delays in signing of discharge summaries or failure of a staff member to wash their hands appear resigned to the conditions our patients endure. We worry about disparities in medicine, but somehow this disparity has been historically overlooked.

The origin of this double standard is unclear, but I suspect it goes back to some sense of the lack of legitimacy of EM as a profession—the casual emergency doctor, with her motley intoxicated, non-compliant patients who are using the ED inappropriately. Really, there would be no need for EDs if everyone just went to their doctors and did as they were told. Indeed, as early as 1979, there are articles fretting about the rise in ED visits in the USA, largely attributing the trend to inappropriate use.2 3 Unfortunately, our own well-intentioned efforts to curb the current crowding situation by suggesting patients could be streamed elsewhere so we can handle true emergencies reinforce the impression of an undeserving patienthood.

Emergency patients have always been seen as ‘other’ to those who have not (yet) needed an ED. Yet, so many of the current advances in illnesses that someday most of us will experience rely on the acumen, speed and ability of trained emergency physicians to correctly identify the illness and initiate treatment within a few hours of the event. Those who currently ignore the plight of ED patients may think that crowding is simply a matter of everyone waiting a bit longer to see a physician. But time is muscle and brain and blood. Waiting could mean the difference between a myocardial infarction that leaves you with minimal damage or chronic heart failure, whether your stroke will have devastating consequences, whether your tranexamic acid or antibiotics are given in time. We in EM all know this, but I am not sure that those who wield the power of the purse truly do. And that is because we are good at our jobs and we prioritise the patients who need this time-critical care. But at what cost? And when is the breaking point?

If our departments are crowded, and understaffed, or even perhaps closed, who will be there to diagnose the myocardial infarction and call the cath team or deliver thrombolysis? Will offloading times for ambulances allow us to diagnose the stroke within the appropriate window, or start fluids and antibiotics in sepsis? Who will be the individual who fails to get the care they need in the nick of time?

It is time those outside our specialty understood that emergency patients are not them but ‘us’.