Each year in the United States, adults aged 50 and older make more than 40 million visits to the emergency room. Older adults often have complicated and multiple conditions and so their care requires both coordination between multiple healthcare providers, and more follow up services. When deciding where to go for emergency care, more than 85% of older adults said it depended on their health insurance. If they have none, and many do not, then the nearest facility turns out to be their sole healthcare provider. Although the satisfaction with services provided in the ER ranked above 60%, many users complained or were concerned about cost of services, long wait times (both to be admitted to the ER and then to see a doctor), lack of communication, lack of privacy and personal care. All of this comes from a University of Michigan National Poll on Healthy Aging conducted in 2020.
A study done in Ireland in 2019 found that many older adults wanted a segregated emergency room for them so that they could access specialists for their more complex needs more easily. However, most emergency rooms in this country and in Europe are general emergency rooms, that is, facilities where everyone is treated, regardless of age, ability to pay, or special needs.
The following is an example of one older adult’s recent round of visits to one emergency room within her insurance plan. It is not meant to expose ineptitude or wrongdoing, or to condemn the system based on three visits, but to tell one story of what emergency care for an older adult looks like today in the United States.
I spend three hours in Kaiser Permanente’s Richmond emergency room on Saturday October 22 with a persistent cough I think is probably related to my recent covid diagnosis. I am seen by an emergency room doctor within 15 minutes of my being admitted. I know this is just the luck of the draw and depends on how busy the ER is when I arrive. He reads my history before coming in to talk to me, so he has already read that I have chronic lymphocytic leukemia, emphysema, heart disease, covid and now this crazy cough. Talk about complex diagnoses. I tell him I can’t stop coughing and that while the cough is “productive” it doesn’t seem to help clear my lungs. He listens to my lungs, then orders blood tests and an EKG (I have recently had surgery for atrial fibrillation). He comes back about an hour later (I have brought a book and a nurse has covered me in warm blankets), with news that the blood tests all look good except mild anemia which I should call my oncologist about, and that my covid has morphed into bronchitis. He gives me a prescription for a cough suppressant and sends me home. I contact my oncologist about my anemia. He says “Don’t worry about it.”
The following Friday as I’m talking to the advice nurse on the phone, I start to vomit blood. I’m immediately more frightened than I have been since my covid diagnosis. The nurse asks me if someone can drive me to the emergency room and I say yes, knowing that my daughter is teaching a class and my husband is in the next town for a meeting. I snag my husband just before he gets to the meeting, and he agrees to come home and take me (though he’s about 30 minutes away). We arrive at the ER at about 10:30 in the morning. There is a considerable line ahead of me to be admitted.
I wait an hour to be admitted. After looking at my throat, the admitting doc says right away that I’ll have to see an ENT surgeon and that the only one available is in the operating room. I wait 3 hours for a surgeon to appear and tell me what is wrong with me and what we were going to do about it. What is wrong, it turns out is that, due to more than a week’s worth of deep coughing, there are two blood clots in my throat that have to be removed.
When the surgeon comes he looks down my throat and says he needs to consult with his colleagues. He does this three times — back and forth from my emergency bed to a phone at the nurse’s station. (This makes more sense when I learn later that he is an intern.) He comes back. He says that because I am “elderly,” and the dangers of anaesthesia are greater the older the patient, he will consider doing the procedure, which involves suctioning out the blood clot, without anaesthesia. He leaves the room again. The nurse shows up with a metal kidney shaped dish and sterile instruments. “Here?” I ask. “Yes,” she replies. “Anaesthesia?” I ask. “Maybe a local,” she replies. He comes back a few minutes later and says, “I’m going to sit on your bed, next to you. You are going to sit up facing me. You will gag. I will suction out the clots. Tell me when you can’t stand it and we’ll take a break.” Eeek!
It takes 15 minutes. He shows me the prize (the second clot). He leaves the room again and returns a few minutes later with a pitcher of ice water. “I want you to drink as much of this as you can. It will help to seal the wound.” “Nothing else?” I ask. “No,” he says.
Both he and the admitting doc who comes by at the end of his shift, tell me that I must stay overnight for observation. I tell my husband, who has been sitting with me since noon, to go home. Emergency room beds are uncomfortable; the department itself is noisy. It will be a long night.
At about 7:30 PM my nurse tells me I will be transferred to another larger facility within the system by ambulance some time in the next two hours as there are no hospital beds available at this facility. “No,” I say. “I’m going home.” I had agreed to stay for observation overnight as a bleedout would be very dangerous and require immediate surgery by the doc who had gone home an hour earlier. “I cannot sleep here. I finished my book hours ago. I can hear everyone who has come in all day on either side of me. I can’t hang around for hours waiting for an ambulance to take me to Oakland where I will have to go through the whole damn admitting process all over again. If I go home, I’m 10 minutes away and can come back in that time. I may not be able to sleep, given the pain I’m in, but I’ll be a lot more comfortable than I am here.” I go home against my doctor’s medical advice.
The next day, Saturday, I’m the second in line at 7:30 when I have agreed to meet the Ear, Nose, and Throat surgeon from yesterday. I sit at the nurse’s station with a young man, black cap pulled down over his ears, RN identifier hanging around his neck. He wears a short- sleeved T-shirt over a long-sleeved T-shirt, and with the cap these clothes seem like a kind of nurse’s uniform as I watch other nurses arrive and remember how the nurses in the ER yesterday were dressed. Slowly, very slowly, it becomes clear that the surgeon is not here and that I will need to go through the whole process again — wait, admit, be assigned an emergency room “bed” and wait some more for a doctor — not the doctor I was supposed to meet at 7:30, not the doctor who made me commit to 7:30 because he had to be in Oakland by 9.
I’m finally admitted at 8:20 after several short conversations with the black cap. He wants to check on the surgeon’s name. I can’t remember. Cavallo, Carillo? I say I know it begins with a C and has double lls in the middle. He finds it after asking me about five other names. I remember that the doc is an intern. Bingo. Black cap finds him immediately.
I sit on my “bed,” swinging my legs. I have brought another book — longer this time. If we’re going to repeat yesterday, I want to be prepared. But I can’t concentrate on it. I’m furious. A doc appears after about 20 minutes.
“I feel like this is bait and switch,” I say, barely in control. “I promised to be here at 7:30 and he (my ENT surgeon) never had any intention of being here.” This new doc calmly responds “I think it is a little early in the process to be so angry.” He looks in my mouth/throat. He asks if he can take pictures. “Of course,” I say. Two more photos of my angry, raw throat are sent to the surgeon. Perhaps 20 minutes later the Saturday doc returns to say that the surgeon is satisfied and I can go home. I say, politely “Thank you. You see, I can be nice.” He says nothing.
My husband and I are there for an hour and a half — so much better than the day before. I’d asked both the surgeon and the Saturday doc if I could have some medication for my throat, which still felt like it was on fire. “Ice water,” they both said. “And Tylenol.” Three days later the follow-up doc prescribes a “magic mouthwash” that numbs my fiery throat. “It’s what we give people after a tonsillectomy. That — and ice cream (which I’ve already figured out on my own).” It takes three days to fill the mouthwash prescription as it has to be compounded.
What’s the lesson here, if there is one? I think there are several. First, emergency care in the United States is hit or miss, depending on several factors including the load on the department at any given time. If it’s busy and you’re not dying, you wait, sometimes for hours. I don’t know if it’s better in other countries. I only know that I asked one of the nurses during my longest ER stay if it was always this busy and chaotic. She answered, “This is healthcare in the United States.”
Another lesson might be that if the diagnosis is complex, as it is for many older adults, experts outside of the emergency room must be called upon and included in any treatment plan. My oncologist was not consulted during my first visit. When he was, he was relaxed about my anemia. It got much worse and had to be treated later.
The last is one that sticks in my craw and is certainly partly about my vanity, but mostly about a widespread assumption on many physicians’ part. They see a number rather than a person, perhaps especially in the emergency room. The young intern described me as elderly. At 79, that is one accurate description of me. But I’m more than my age and would like to have been in on the decision not to use anaesthesia. Instead, he assumed, based on my age, that I would tolerate the pain and discomfort of the procedure rather than tolerate any medication. In a way this is flattering. I’m a strong and courageous woman. But I don’t take foolhardy risks, at least knowingly. I think I would have chosen to have the procedure as implemented. But I would like to have had a choice, based on my own intelligence and experience.
