Full disclosure, I hate it when people go abroad then come back to the U.S. decrying the way life is for us here in America. That’s not what I am trying to do in this post. I think life in the good ‘ole U.S.A is pretty amazing and I wouldn’t want to live anywhere else. After my adventures in India last week, I discovered a new love for Tikka Masala but would still choose steak and potatoes over spicy curry any day of the week. That being said, while observing an emergency department in Jaipur on my vacation, I left with a few interesting take-aways.
In Jaipur, I visited the emergency department of 250 bed Fortis hospital, just a bit smaller than the hospital where I work here in Nashville, TN. The number of emergency department beds where I currently work? 32. The number of beds in the Fortis Hospital ED in India? 4. When I walked into the emergency department, which is really just one room with four stretchers, I was amazed. Where were all the patients? How did they fill the hospital floors without a bustling ED full of patients waiting to be admitted? I was perplexed.
I began to pick away at the discrepancy by asking questions of the staff. Most patients in India, it seems, are admitted by a primary care provider. Patients are seen in the clinic then admitted directly to the hospital floor at a much higher rate than in the United States. There is less paper-pushing and formality making admission much easier. The emergency department doesn’t get clogged with patients who have seen their PCP, been sent to the ED and had their labs and imaging repeated all to be admitted as their PCP initially knew was the best course of action.
A more prominent clinic-based system isn’t the only reason the emergency department in India only necessitates four beds. Patient’s in India don’t go to the ED unless there’s an actual emergency! Remarkable.
If you work in the ED you know that non-emergent patients are a big problem. People come to the ED in the U.S. for strep throat, bumps and bruises, cuts and scrapes that clearly don’t require suturing. Not to bite the hand that feeds me, if you know what I mean, but these aren’t actual emergencies and don’t warrant emergency level visits. But, with EMTALA and other legal concerns as well as the push for profits, emergency departments in the U.S. must treat these patients. I love my job and actually enjoy treating these types of patients, but sounding the emergency alarm for a bump and a bruise is a major drain on our healthcare system and a waste of resources.
As my day in the emergency department in India progressed, I noted a few patients stop by the ED for non-emergent problems. In these cases the triage nurse would pull the doctor aside and ask him to speak with the patient. The first “non-emergent” patient complained of tingling in both of his arms for a week. The ER doctor politely informed him this was not an emergency, ripped off the corner of a piece of paper and wrote down the number for the hospital’s appointment scheduling department. The patient could call this number to get an appointment with an internal medicine doctor later in the week. No physical exam, no blood work and no documentation was done. This is not how we do it in my workplace, folks!
Observing the non-urgent patients being politely but swiftly booted from the ED, I realized that in two hours we still had not had a single patient in any of the four ED beds. I asked the nurses what kind of patients usually go to the ED in India and are actually treated. “Cardiac arrests and major trauma” she replied. Those certainly qualify as emergencies.
I realize that while the philosophies behind how the emergency department is run in India aren’t flawless, but let’s just say they certainly aren’t wasting time and money on treating otitis media in the ER. I’m sure that sending abdominal pain patients in no acute distress has to lead to plenty of cases of missed appendicitis in India, but there’s no ER overcrowding at this Indian hospital.
Legal concerns, paperwork and red tape are all to prominent in our practice here in the U.S. In India, it was refreshing to observe a more “raw” style of medicine. Patient care in a practical manner, without as much concern of a malpractice lawsuit and a more efficient use of limited resources. Without non-urgent patients in the ED, I admittedly would not have a job, but it was nice to see the emergency department used as intended.
Left: The Fortis Hospital emergency department
Right: Ambulance at the entrance to the emergency department