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ER Hardship In The Big Easy

A nurse's assistant wheels a patient past a makeshift laboratory (L) to the emergency room to see a doctor at Charity Hospital's temporary emergency room in an old Lord and Taylor department store in a mall near the Superdome, 10 August 2006, in New Orleans, Louisiana. Charity Hospital, also known as the Medical Center of Louisiana at New Orleans, once housed one of the busiest emergency rooms in the United States, before it was flooded and closed last year following Hurricane Katrina. Now the emergency room is in an old Lord and Taylorís department store where a staff of 725 deals with around 4,500 patients a month compared with 6,000 a month when the hospital operated a top of the line facility with a staff of 4,000. Photo courtesy of Robyn Beck and AFP.
by Laura Gilcrest
UPI Health Business Editor
Washington (UPI) Aug. 23, 2006
Almost one year to the day that Hurricane Katrina pounded New Orleans and the surrounding Gulf region, a new survey of the area's emergency room (ER) physicians paints a grim scene of ERs struggling to treat growing numbers of uninsured patients with sometimes only half the number of beds and staff needed, dangerously long wait times for patients and a dwindling pool of specialists to whom ER patients can be referred.

Yet, the ER doctors say, the federal and state aid that poured into the region in the storm's aftermath seems to have largely passed them by.

"It's a very complex problem affecting emergency rooms across the country," Rick Blum, president of the American College of Emergency Physicians (ACEP), told United Press International, but Hurricane Katrina put a national problem "under a magnifying glass."

"There are no easy fixes, but there are even fewer easy fixes when the whole infrastructure is destroyed," said Blum, who works as an ER physician at West Virginia University Hospital in Morgantown.

ACEP released a survey Thursday in which more than 80 percent of Gulf-region ER physicians said that, in its present condition, the area couldn't handle another Katrina-scale disaster and that the long wait times in understaffed, overcrowded ERs are hurting their patients.

"The survey gives a good indication of what emergency physicians have been saying all along," Jim Aiken, director of emergency preparedness at Charity Hospital in New Orleans, said in a statement. "You survive and work through the hurricanes and the damage and you expect it to get better at some point. We're still waiting."

The poll also showed that more than half of the doctors surveyed felt there'd been "little or no progress" in the rebuilding of the emergency care system in their respective communities, while the same percentage reported that the need for specialists available for emergency care was greater than before the storm hit last August in "several" or "most" practice areas.

The New Orleans disaster is a microcosm of the problems that American ER physicians face day to day: low expectations of reimbursement for providing emergency care, and inadequate staff and beds to handle a growing patient load, problems that have cultural roots, Blum added.

Because the ER doctor's primary mission is to treat all patients regardless of their resources, he said, there's no motivation for policymakers to see that the providers in Katrina-ravaged areas and throughout the country have adequate reimbursement and resources. "People take the ER for granted; that it will be there if they need it," he told UPI.

Yet ER physicians were the "true heroes" in Katrina's wake, Blum said, with many doctors remaining in the region for weeks after the storm struck to take care of the hurricane's victims, despite having inadequate "food, water or linens," and even dodging gunfire as they moved patients out of the flooded Charity Hospital to dryer quarters.

Nonetheless, one year after the catastrophe, Gulf-area ERs are still fighting to remain up and running, the ACEP poll suggested, with more than 90 percent of the ER doctors surveyed saying they are working with at least 25 percent fewer beds than required to care for patients, while 30 percent said their bed inventories remained at only half what they need.

In fact, there are still just ten hospital beds in the entire city of New Orleans for patients who need emergency psychiatric care, Aiken told UPI, a dilemma compounded by a drain of doctors to treat them.

"We've lost 85 percent of our psychiatrists," he said, a loss the region can ill afford in the face of an alarming number of patients seeking treatment for depression and anxiety.

Other specialists badly needed in the ER who have fled the area include neurosurgeons and gastroenterologists, Aiken added. New Orleans-area ER practitioners have also seen the number of uninsured patients rise from a pre-Katrina rate of 15 percent to 20 percent or more in the wake of the hurricane, while ER patients have seen their wait times triple.

"It's not unusual for a patient to wait 12 hours" before receiving care, Aiken noted, while three to six hours is typical. But even after the patient is finally seen, those who require overnight stays could easily find themselves in a facility like one in which Aiken said he has often treated patients post-Katrina; a "retooled" department store stocked with tents supplied by emergency mobile units.

Or doctors often have to search for accommodations outside the city. "We're sending people outside the city for hospital beds all the time," Aiken said.

Still, there are no simple solutions, said ACEP's Blum, adding that policymakers and government agencies need to do more to ensure adequate reimbursement, protection from medical malpractice liability for doctors treating disaster victims -- perhaps under a sort of "sovereign immunity" rule where ER doctors are acting as agents of the government -- and adequate healthcare infrastructure. Simply put, "We need to build the facilities for the patients we have," Blum told UPI. "I don't know if it's (the Federal Emergency Management Agency's) job, but it's got to be somebody's."

For its part, FEMA said it can only provide funds for rebuilding state-owned or state-controlled infrastructure that was damaged by the hurricanes --for example, damaged hospital beds, but not additional beds -- and by law, can only provide reimbursement rather than upfront payment.

Moreover, applicants for aid must petition the state of Louisiana, which first must approve the building contracts and invoices before sending the application on to FEMA, James McIntyre, a spokesman for FEMA, told UPI.

"If you just sit down and do the work, it can get done," he said. "If you work through the process, it goes fairly quickly." FEMA picks up 90 percent of the tab for rebuilding efforts, while the state pays the balance, he said.

Dept. of Health and Human Services officials told UPI that a major problem that effectively ties that agency's hands is the way current federal regulations are set up, so that once a disaster passes out of the immediate-aftermath "response" phase and into the "recovery" phase, the primary responsibility for giving aid shifts to the local and state governments.

"The basic authorities don't exist for the federal government to intervene (beyond the response phase), at least in our department, they don't," Rear Admiral Craig Vanderwagen, HHS's assistant secretary of public health emergency preparedness told UPI. "There isn't any specific authority for us to expand manpower in emergency rooms or hospitals."

He added, "Secondly, should the federal government intervene where local and state folks are going to have deal with the realities of that environment?"

But since Katrina's aftermath moved into the recovery realm, HHS has played a secondary role, Vanderwagen noted.

"There is a Gulf Coast recovery authority identified for the events of the last year, and they do have some funding and authority for recovery activities. We provided advocacy to them about what the ongoing health issues are, including the manpower shortages and the facility capabilities that are deficient.

However, he added that rebuilding the Gulf-region health system should involve treating not just the immediate symptoms, but the underlying problem.

"I don't know that the solution is to just throw up more beds in the ER as much as I think they need to invest more directly in ambulatory and primary care and take the pressure off the ER."

Vanderwagen said that the response phase following the storm was as unique as the magnitude of Katrina itself -- extending months instead of weeks -- adding that HHS officials did a lot to prop up the area's frayed healthcare system until February of this year.

"(The agency supplied to the region) nurses, pharmacists, environmental health officers, physicians, dentists, and hospital and clinic administrators. I had in my command down there in October and November 1,300 (personnel)from HHS plus 1,200 federalized civilians (and) close to a couple of thousand emergency room-type folks," he said.

But one year out from the hurricane's devastation, "I don't think it's a lack of dialogue, discussion and analysis of what the problems are, Vanderwagen added. "It's finding the legal means to utilize federal funds to address the issues that have been raised."

HHS chief Michael Leavitt this week traveled to the Gulf region to discuss with local officials long-range solutions to the area's healthcare challenges, he said.

But the federal agencies' role in the emergency care system's agonizingly slow road back is only one piece of the puzzle.

Along with a major chunk of New Orlean's healthcare infrastructure, Hurricane Katrina seems to have taken with it the region's political will and leadership, Charity Hospital's Aiken told UPI. "We feel the plans for (rebuilding) are already there, but we don't have leadership," he said. "We just keep going from one task force to another. The next step is to take the plans, put money into them and decide how to move on. It's not rocket science."

And there's no time to lose, ACEP's Blum noted. "When the ER is over capacity and closes down, it closes for everybody," he said.

Source: United Press International

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