A DIRE WARNING FOR AMERICA
When I began writing this blog on violence in healthcare I focused on the direct causes, which included EMTALA, hospital policies, loss of funding for mental health and addiction, and the number of alcohol and drug-related patients seen in our emergency departments. These problems did not appear to be unsolvable. As I began to dig further and further back into the history of violence in healthcare I began to understand its proper perspective. Please bear with me while I trace the history of this problem and why it is likely to get much worse before it gets better.
Violence in healthcare is only part of much larger problems. The first problem is best described as National Unpreparedness for Disaster. In 2003 Dr. Art Kellerman of Emory University clearly outlined that our nations EDs (emergency departments) were unprepared for any kind of disaster— natural, terrorist, or biological. In 2006, The Institute of Medicine’s Committee on the Future of Emergency Care released a similar report on the unpreparedness of America for disasters. As I studied these two articles I was stunned by the fact that the requirements for preparing our nation’s EDs to manage disaster have been identified for almost a decade. During that decade, our government has further increased our vulnerability to disasters.
There is an old saying, “Follow the money” when you don’t understand what is going on. In order to respond to national disasters, we must have some surge capacity within each hospital. In other words, we need more hospital beds. Trauma centers need more surge capacity than general hospitals. Unfortunately, our government has been on a three decade mission to reduce the number of hospital beds and psychiatric beds. While the number of patients visiting EDs has increased steadily, augmented by the concentration of potentially violent patients mandated by EMTALA, the number of hospital beds in America has decreased by hundreds of thousands. Between 1993 and 2003, the number of hospital beds declined by 198,000. There was a 25 per cent decrease in the number of hospital beds from 1980 to 2000. Most of these lost beds have never been replaced. In 2002, according to AHA, there were 5,810 hospitals. There are 5,754 hospitals in the U.S. as of 2012. The U.S. has a comparatively low number of hospitals per 1000 persons, 2.7, and physicians per 1000 persons, 2.4. The average among thirty other countries is 3.3 per 1000 persons for both hospitals and physicians. As the number of beds has decreased, the number of patients requiring admission increased, welcoming in the era of boarding admitted patients in the ED and diverting ambulances.
For three decades hospitals have been squeezed by the government to cut costs. To make sure that hospital beds decreased, the government began to steadily ratchet down reimbursement rates to hospitals and insurance companies. We must consider that the failure of hospitals to provide adequate security is at least partly due to cost control. Dr. Paul Biddinger, Director of Operations for the Department of Emergency Medicine at Massachusetts General Hospital summed it up in 2006, “Reimbursements to hospitals is structured in a way that it’s not financially possible for hospitals to add more beds.”
So, let’s get this straight. The government and its gaggle of health agencies have had the problem of nationwide hospital and ED unpreparedness pointed out to them repeatedly by researchers and emergency physician leaders like Dr. Kellerman and Dr. Billinger long before I showed up. These two emergency physicians screamed to our government in 2006 that it had achieved its goal of efficiency and needed to increase capacity for the sake of disaster preparedness. The reduction of hospital beds did improve individual hospital efficiency, but left America totally unprepared for any kind of disaster, not to mention the coming baby boomer surge.
Many hospitals have very high occupancy rates and essentially no surge capacity for disasters. Of course, not all beds in a hospital can be used as surge beds. During this long period of reduction of hospital beds, emergency departments have become more and more crowded. Remember that when a hospital closes, an emergency department closes. Psychiatric beds have decreased so dramatically that mentally ill patients have nowhere else to go but the local ED, where they frequently need one on one care during the long wait to find a psychiatric bed. Street drunks have been given a government VISA card to sleep overnight in the ED every night at no cost to them.
I think that if the terrorist attack of September 11, 2003 had produced 3,000 trauma patients instead of 3,000 dead, the inadequacy of our nation’s EDs would have been clearly demonstrated. I have worked in three trauma centers. None could handle more than about five or six major trauma patients requiring surgery at one time. There are not enough trauma surgeons or anesthesiologists or operating rooms or nurses or support personnel or CT scanners in any one city to accommodate such a disaster. Any plan to distribute 3,000 trauma patients to many hospitals would have exposed our inadequate number of ambulances and helicopters.
Homeland Security incorporates FEMA (Federal Emergency Management Agency). You remember FEMA; the folks who could not bring water to the Astrodome for five days after Katrina struck and had no evacuation plan. The management of disasters is FEMA’s reason for existence, yet they have done nothing about ED vulnerability to disasters. ED security is no priority to them. I have been searching for some plan from FEMA, CMS, or JCAHO that addresses emergency departments, the point of intake for most victims in a disaster. So far, I see none. The fight over Obamacare has only taken our eyes off of the big picture.
I never intended for this blog to be any kind of political statement. I could see no reason why Democrats and Republicans should not agree that our nations EDs need better security to protect the caregivers as well as prepare for disasters. But, as I have worked on this problem, and struggled just to arrange a meeting with agencies like FEMA, it has become clear just how dysfunctional our government is. Currently, it appears that Democrats and Republicans cannot sit in the same room and have a civil discussion. Nobody is interested in anything except the coming election. The agencies controlled by our Congress have, in some cases, thrown up their hands and stopped trying to fix problems. Every course they take results in a partisan fight or a fight between two powerful lobbies. Good ideas cannot be voted on because no one wants to be identified as a legislator who cooperated with the enemy. This limits what OSHA, CMS, and JCAHO can do about healthcare violence.
Even if I could blast my way through all this hatred and mistrust and daily bickering between people who publicly express their contempt for each other, I would still have to overcome the lobbyists from AHA, who oppose hospital and ED security for reasons that I have already dealt with in other posts. The point I want you to appreciate is that this congress is incapable of overcoming the huge divide between the left and the right on anything, including a budget for our country for the last three years. This divide is tearing our country apart right before our eyes.
The next elephant in the room that you must prepare for is our country’s suicidal fiscal policy. If you are looking for a source of civil violence in the future, look no further. We are living in a surreal nation that refuses to alter its course no matter what the obvious consequences. Our president and his economic team appear comfortable with the fact that no nation has ever debauched its currency like the USA without precipitating anarchy, civil wars, hyperinflation, and/or depression. The same president refuses to enforce federal laws that he does not like. I have heard a president of the United States stoke the fires of class warfare and envy even as he single-mindedly pursues his own agenda at all costs and against all warnings. I have never seen anything like this in my lifetime.
Even if the members of Congress did not act like they hate each other, they are hopelessly corrupted by corporations and special interests. They have excused themselves from the very laws they heap on the people, creating a new class of aristocracy. The elimination of aristocracy was one of the cornerstones of our nation’s fight for independence. This ruling class is not what our founding fathers had in mind. Our founding fathers did not give the executive branch the authority to make up its own laws when frustrated by Congress. But this is exactly what we see in the newspapers on a regular basis. Our president is governing by executive decrees. Would you have ever predicted that individual states would sue the federal government? Would you have predicted that Congress would charge the chief law enforcement officer in the country with criminal contempt?
I could not imagine our country sending thousands of guns into an already unstable Mexico for any reason. But the ATF did just that even before Obama took office. The current attorney general’s refusal to answer questions about Fast and Furious and our president invoking executive privilege to keep documents concerning the operation suggests that he has something explosive to hide. When have we seen individual states prevented from enforcing federal laws by the federal government? The ineptitude and corruption of our government and our national bankruptcy are creating a perfect storm for disaster.
The Republican candidate is really not much of a choice, another aristocrat who cannot change the culture in Washington or the divide between left and right. We, the people, are not the right stuff who built this country, a country that most of the world once admired. We are divided into narrow interest groups who want to use the government to force our views onto those who disagree with us. We have long since forgotten President Kennedy’s charge: “ask not what your country can do for you; ask what you can do for your country.”
I believe that we are witnessing the last days of the USA as we have known it post WWII. This life was based on individual hard work and initiative, which reaped rewards in proportion to how hard we worked. We are now a nation dependent on a corrupt and dysfunctional government. I fear that our country has reached the limits of democracy, the point where the government can no longer give us what we demand or honor its commitments of the past. Our individual interests have become more important to most Americans than our country. We must bear a large part of the blame for our broken society. We did not limit government’s power. We showed no restraint with our demands for more and more benefits. We made bribery legal for our elected representatives by renaming the money campaign contributions. I doubt if any government agency or Congress will address violence against healthcare workers. They will be too busy trying to control the angry mobs in our own cities. We are a broken nation facing a future as indeterminate as the one President Lincoln spoke of in the Gettysburg Address. I do not think that we can long endure.
I will continue to pursue congressmen, senators, and government agencies about healthcare violence, but the fact that no government agency has addressed the vulnerability of our nation’s emergency departments to disasters despite a decade of clear warnings is profound and discouraging. The healthcare violence problem is a tip of the iceberg of a dysfunctional government in denial. While we fiddle with the latest smart phone, our experiment in democracy is rolling toward a giant waterfall. Our president is sitting in the canoe “America” facing backwards, totally preoccupied with his own agenda, as “America” plunges into the abyss. At this point, I don’t believe we can avoid the outcome of generational fiscal irresponsibility by both parties. I see no leader who inspires me to think that we can avoid a worse fate than Greece. In many ways, we have been even more irresponsible than the debtor nations of Europe. Think it can’t happen here? American cities are lining up to declare bankruptcy. At every level of government, politicians promised too much and spent too much.
If I am correct in my assessment of the need for armed, uniformed security in our nation’s emergency departments based on the current vulnerability of our ED staffs, imagine the need for security when our streets are filled with angry people whose green checks are worth less every day. Interest rates only have to tick up a few points and we will be unable to fund the interest on our government debt and pay out government entitlements at the same time. Even if the government taxes every American who has an income over $250,000 at a rate of 100 percent, we would be unable to balance a budget and our national debt would continue to climb. Our government has created multiple unsustainable expenditures that represent people who will likely resist violently when their entitlements are decreased or inflated away. This is not just my assessment. This is the history of the rise and fall of nations worldwide. Our house of cards is shaking. Mr. Obama is reassuring us that we will be the first nation in history to tax and spend its way to prosperity through dependency on larger government.
Romney wants to see Obama’s college grades and Obama wants Romney to “come clean” about Bain Capital. This is leadership? The Republican presidential candidate and the current president are arguing over the arrangement of the deck chairs on the Titanic. As important as managing healthcare violence is, I believe that the next person who is assigned to maintain order in most emergency departments is more likely to be a member of the National Guard than an employee of the hospital. I sincerely hope that I am wrong, that somehow we can re-invent America. It was good while it lasted, but I fear that it is gone with the wind, as gone as the old South.
As a student of history, I’m betting against a bloodless transition to smaller government and individual responsibility. I am reminded of General Buford, the Union cavalry officer who arrived first on the battlefield at Gettysburg. He spoke of the anguish of ordering men to make a fruitless charge, knowing in his heart that the charge would fail and his men would be slaughtered. As a career soldier, he could recognize the signs of impending disaster. Ironically, it was General Longstreet, the Confederate Corps commander, who had to live General Buford’s nightmare. General Lee ordered Longstreet to plan Pickett’s charge on the last day of the battle. General Longstreet knew that the charge would fail, but he could not refuse to follow an order from General Lee. He was doomed to watch his own Corps decimated in predictable fashion. It was the beginning of the end for the Confederacy. I feel this same anguish and helplessness as I watch the demise of my own country. There is nothing I can do about it except warn you of very hard times ahead. I can’t predict the future, but I can tell you what has happened when other countries have tried Mr. Obama’s and Mr. Bernanke’s formula for prosperity. Every single effort has failed, with catastrophic results. There is no one who can bail us out. The results of the coming election won’t change our fate. Our own debt and the printing presses have already inflicted a mortal wound on America. I am so very sorry.
Charles C. Anderson M.D. FACP, FACEP
