Over at "Home of the Brave," Annie calls attention to the following Las Vegas Sun story about a man who suffered a heart attack and went to the nearest ER for help:

    "But even as Linda Scheinbaum - Morton's wife of 24 years - was screaming [in the emergency room] for medical attention to save his life, the MountainView Hospital nurse was insisting on getting his Social Security number, emergency contact and insurance information.

    "'I'll give you all the information later!' Linda Scheinbaum yelled at the clerk.

    "It would be Scheinbaum's tragic misfortune to [go] to the emergency room on the night of Nov. 4, 2005, when it was busy and hospital officials said there were no open rooms. The Scheinbaums were told to take a seat and wait - even though a delay of just minutes can make the difference between life and death during a heart attack ...

    "The precise timeline of the events of that desperate night is in dispute, but hospital records show that it was at least 41 minutes from the time Morton Scheinbaum arrived to the time he collapsed, blue in the face and foaming at the mouth. Only then was he rushed into the emergency room for treatment.

    "And that's where he died, his admission paperwork completed."

    There are many reasons to feel outraged when reading this story. But the tragedies of this tale are part of a larger - and just as depressing - picture in American emergency care. The staffing and overcrowding issues that Linda and Morton Scheinbaum faced three years ago are becoming the rule, rather than the exception, when it comes to emergency departments (ED's) in the United States.

    Begin with the seeming villain of this tale, the pigheaded nurse who forced paperwork on the Scheinbaums in a time of crisis. Blogger Annie has some issues with the Sun's less-than-probing characterization: "Is the 'nurse' cited an unlicensed admission clerk?" asks Annie. "A secretary? ... or a licensed registered nurse who is obligated to perform triage and intervention to conform to state regulations and to the hospital's accreditation agency standards?"

    This is important - if the nurse in question is a registered triage nurse, then it's her job to prioritize patients based on the severity of her conditions. This would make her failure to recognize Morton's condition all the more scandalous. Though the Sun isn't specific on the matter, the nurse probably wasn't a triage nurse, since Linda was screaming that her husband needed to see a triage nurse and got no response.

    Sadly, it really wouldn't be surprising if MountainView didn't have that many registered nurses on staff. RNs are increasingly scarce in emergency departments. In fact, the Committee on Pediatric Emergency Medicine notes that, "among all the supply shortages in health care professional groups, the greatest deficiency is found within the ranks of registered nurses."

    As I discussed in a recent post, medicine faces a dramatic nursing shortage, and EDs are not being spared. In fact, the supply of nurses is particularly unstable in high-stress practice settings like emergency rooms, which see an annual nurse turnover rate of more than 30 percent.

    This is a big problem: as the Committee puts it, "experienced ED nurses are truly the backbone of emergency care." When nurses leave too quickly, it's harder to accumulate experience - and the intuitive knowledge that would lead a nurse to realize that Morton Scheinbaum needed immediate aid, just by looking at him.

    As I argued in my earlier post, America's nursing shortage can be solved by encouraging: innovative partnership programs across nursing schools, providing higher pay for nursing faculty and clinical nurses who work in high-stress situations, and - perhaps most importantly - improving working conditions for nurses through better benefits and greater voice in hospital decisions.

    But EDs face a number of other issues which have little to do with staffing. Every day, millions of Americans put up with the same long wait time that doomed Morton Scheinbaum to an early grave. In fact, an August report from the Centers for Disease Control (CDC) found that average ED wait time was about 56 minutes in 2006, up from 38 minutes in 1997 - even longer than what the Scheinbaums experienced in Nevada.

    These long waits aren't due to testy nurses. As Maggie wrote in a recent post, the real issue is that more people are visiting EDs - even as the number of emergency departments in the U.S. is decreasing. Between 1996 and 2006 ED visits jumped more than 32 percent, hitting 118 million two years ago. Yet from 1993-2003, the U.S. saw a 17 percent decline in hospital beds and a 9 percent decline in hospitals with EDs. There's no more straightforward way to illustrate these trends than the graph below, pulled from a 2006 New England Journal of Medicine article by Dr. Arnold Kellerman, a professor at Emory School of Medicine.

    The math here is simple: more ED visitors plus fewer facilities equals longer wait times. The key word is "overcrowding." For Morton Scheinbaum, this meant that there were no beds available to him when he needed care. Even in cities like New York City, which boasts an embarrassment of hospitals, ED overcrowding has become a major concern: 69 percent of NYC doctors say they've personally experienced an ED patient suffering harm because there was no hospital bed available; 28 percent said a patient died as a result.

    So what's driving Americans' great migration to emergency rooms? "The likely cause is there are just fewer and fewer primary care physicians," Dr. Stephen Pitts of Emory University told the San Francisco Chronicle last month. "If you were to get the flu and your doctor says, 'Sure, I'll see you in two weeks,' you may not be able to wait. It's hard for even insured people to get quick appointments and be seen quickly."

    As Health Beat has noted recently, the evidence on primary care backs up Pitts' hunch: it's people who have insurance - and thus already have, at least in theory, access to doctors - who are making up a greater share of ED visits than in the past. Over the years, America has seen primary care physicians who must take on more patients. As generalist doctors have become less accessible to insured Americans, they're substituting doctor's appointments for non-emergency care with visits to the ED.

    When so many patients use emergency physicians as primary care physicians the people who actually need emergency care may wind up taking a backseat to everyone else: At MountView hospital, one of the bed that could have gone to Morton was already taken by a patient who was constipated.

    With such increases in ED visits, why do we have fewer EDs, when in fact we need more? Emergency rooms just aren't very lucrative for hospitals. Indeed, hospitals often lose money on emergency care.

    This is in large part because, whether or not they are insured, all American citizens have a legal right to emergency care under the Emergency Medical Treatment and Labor Act (EMTALA) of 1986.

    EMTALA is a noble idea, but there's a big problem: it's an unfunded mandate. The federal government orders medical professionals to provide care for everyone, while never instituting a mechanism to compensate them for delivering that care. And that care gets pretty pricey.

    The American College of Emergency Physicians estimates that EMTALA requirements cost emergency care professionals more than $425 million annually; the growing ranks of America's uninsured, who also tend to use EDs as doctors' offices, add another $1 billion in uncompensated care to emergency physician services. All in all, according to the Centers for Medicare & Medicaid Services, fifty-five percent of emergency care in the U.S. goes uncompensated.

    Such generosity also eats up time: American College of Emergency Physicians reports that one-third of emergency physicians provide more than 30-hours of EMTALA-related care a week - which leaves less care for other insured patients who could cross-subsidize EMTALA care. With little in the way of financial support to help them navigate a sea of new patients, 500 hospitals and more than 1,000 EDs have closed over the past ten years.

    It would be wrong to argue that emergency departments should turn away more people in order to save money. The answer is to rebalance the U.S. health care system so patients don't feel that EDs are their best resort for medical attention. That means expanding health coverage for Americans and making sure that those with insurance have better access to primary care physicians. The "medical home" model, centered on collaborative, coordinated care, could go a long way in helping patients feel like they had more options for everyday care.

    What happened to the Scheinbaums was tragic. Unfortunately, so long as emergency care in the U.S. continues to be under-staffed, under-funded, and over-crowded, these stories will become more common.