The most common misusers of the ER are those without health insurance or access to other health care services.

The sooner you get to the hospital for treatment of a heart attack or stroke, the more likely you are to survive...with the fewest disabilities.

How often do you use the emergency room? Ask that question to a large, representative group, and you’re likely to get a variety of answers.

Some Americans visit the ER only a few times in their lives–to treat a broken leg after a fall from a bike perhaps or because of chest pains in the middle of the night that turned out to be indigestion. Others may get treatment in the emergency department several times each year.

Why such a big variation? Some individuals are more prone than others to have accidents. In most cases, however, the difference is due to different views about the role of an emergency department and what constitutes a medical emergency.

Getting treated in an emergency room generally costs two to three times as much as the same care delivered in a doctor’s office, a clinic or a freestanding outpatient center. In one study the average cost of treatment in a freestanding outpatient clinic was $70 compared to $170 for the same kind of care in an emergency department three miles away.

Improper use of emergency facilities moreover means that highly trained emergency physicians may be treating children with a runny nose and fever when they are needed to administer life-saving care to trauma victims or persons having a heart attack or stroke.

Emergency room visits jumped 14 percent during the 1990s–reaching 103 million visits in 1999–while the number of emergency rooms remained about the same. Recent surveys indicate that 40 percent of emergency departments consider themselves overcrowded, and 26 percent say they often have to divert emergency patients elsewhere.

In an effort to control health care costs, health maintenance organizations (HMOs) frequently establish strict rules about ER use–generally refusing to pay for such services unless the patient has received prior authorization. These rules are controversial. Patients say they don’t always have time to get authorization; nor do they know whether they have a medical emergency until they get an opinion from a doctor.

If in Doubt, Don’t Go Without
The idea, of course, whether you’re in an HMO or not, is to avoid unnecessary trips to the emergency room–just because it’s more convenient.

Some emergencies leave no doubt. If someone in your family is choking, has stopped breathing, or has suffered a severe burn or electric shock, the first thing any reasonable person will do is ring 911. After any accident that might involve a head or neck injury, it’s also important not to move the person until trained emergency medical personnel arrive.

But what if your child falls off a swing and you think her leg might be broken? Or suffers a deep cut on her leg? A call to your pediatrician or family doctor can let you know whether you should head for the emergency room or the doctor’s office, but if the accident happens after office hours or on a weekend, you’re going to have to make a judgment call.

In most cases, it depends on where the injury is and how serious it seems to be. If a bone is jutting out in an odd way or if there’s a sagging arm, an emergency department is probably the best place to get quick x-rays and deal with complications.

Many cuts can be treated at home, but a deep cut usually requires stitches to heal properly without scarring. And many pediatricians prefer that cuts on the face be stitched by an emergency physician or a plastic surgeon. Cuts on the hand may also require special attention because of the many tendons, nerves and muscles in a small area.

A burn larger than the size of a child’s palm or any burn on the face, hands, feet, genitalia or over a joint probably requires emergency treatment. Anyone who has inhaled significant amounts of smoke, toxic gas or carbon monoxide also needs to be in an emergency medical setting and monitored closely.

Allergic reactions (such as from a bee sting or eating peanuts) can strike quickly and with deadly force. Signs include trouble breathing, swollen lips and tongue, vomiting or nausea. The sooner these symptoms develop, the more serious the problem is likely to be.

Adult Emergencies
For older adults, the most likely reason to call 911 is for a heart attack or stroke. The sooner you get to an emergency room for treatment of either, the more likely you are to survive with fewer complications and disabilities.

The classic symptoms of a heart attack are viselike chest pain (like an elephant standing on your chest), often radiating out to the arm, trouble breathing, sweating and anxiety. But there’s no requirement that the symptoms be dramatic. Sometimes, it’s hard to tell the difference between a heart attack and indigestion, and many times they occur together. If you’re not sure, it’s better to be safe than sorry.

If you already have heart disease or risk factors for it, you have more reason to be cautious than if you have a strong history of upset stomach. And while you’re getting to the hospital, chew on an aspirin tablet to help prevent blood clots.

A sudden attack of mental confusion may be the first sign of a stroke. Jack dropped his car keys and when he stooped to get them, just couldn’t pick them up. Nor was he able to talk clearly to explain what was happening. He was suffering a stroke and needed immediate medical attention.

Sudden blindness in one or both eyes–even for a brief period–may also signal a stroke. Another common symptom is a headache–the worst of your life and different from any you’ve ever had. The headache could be caused by bleeding in the brain caused by the rupture of a blood vessel. Or in rare cases, it could be related to a brain tumor or other serious neurological problem. Don’t waste time wondering.

One reason–often overlooked–for getting emergency medical attention is a blood clot in the leg. This is usually seen as a swollen, inflamed leg–red, hot and painful but with no obvious cause such as an athletic injury.

If the swelling is caused by a blood clot, it will compromise blood flow to other parts of the body and there is a distinct risk that part of the clot will break loose and travel to the heart or lungs.

The swollen, inflamed leg could also be a sign of kidney disease, heart failure or a severe infection–any of which require immediate medical attention.

Fever–Yes or No?
A high fever that doesn’t go down when you take aspirin or fluids is to be taken seriously, but you should probably call your doctor first before rushing to the emergency room. A high fever in the summer, when the temperature and humidity are high, on the other hand, could signal a life-threatening heat stroke–a definite emergency.

Most Americans realize that the ER is not a place to go for a runny nose or an upset stomach. Many who misuse emergency facilities, however, do not have health insurance and have nowhere else to go.

Studies show that the most common users of ER services for non-emergencies are “medically and socially vulnerable”: Medicaid and Medicare recipients, the uninsured, the mentally ill, persons dependent on alcohol or other drugs and those without families or adequate social support.

Emergency rooms are convenient and accessible–open 24 hours a day and offering care to those in need. As long as significant numbers of Americans lack access to health insurance or affordable health care, the ER will continue to fill that need.

REFERENCES:
Robert Brown, “Variations in Prudent Laypersons’ Perceptions of the Need for Emergent Medical Care,” JAMA, April 5, 2000.
“Emergency Room Visits Jump 14 Percent,” AP Health, June 25, 2001.
“Healthcare Workforce shortage Already Serious,” Reuters Health, June 5, 2001.
Kathryn E. Livingston, “10 Times To Go to the Emergency Room,” Redbook, March, 1997.
Peggy Morgan, “Call 911: These Symptoms Could Cost You Your Life,” Prevention, May, 1998.
Daniel B. Moskowitz, “Emergency Care: In Search of Balance,” Business & Health, April, 1999.
Kathleen F. Phalen, “ED Capacity May Be Reaching Its Limits,” American Medical News, January 15, 2001.
I.R.S. Robertson-Steel, “Providing Primary Care in the Accident and Emergency Department,” British Medical Journal, February 7, 1998.
Karen MacDonald Thompson and Doris F. Glick, “Cost Analysis of Emergency Room Use by Low-Income Patients,” Nursing Economics, May, 1999.