“I Wanted to Come in Early, Before It Got Busy.”

In July 2007, while on a visit to Cleveland, OH, President George W. Bush made an eerie but significant statement on his view of health care in the United States. He stated, “The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”1 Then ENA President Donna Mason eloquently answered President Bush’s statement by pointing out that even though federal law mandates that we examine and stabilize all patients who present to the emergency department, the ability to provide primary care services will and can strain already overcrowded, understaffed emergency departments.1 It is important to note that this statement was made before the onslaught of the current recession, which includes job and insurance loss. If we thought this impacted us before, we have only begun to discover the consequences of what this recession may mean to emergency nursing and emergency care.

“I wanted to come in early, before it got busy” was the declaration of the wife of a patient I was caring for in the emergency department. Her husband had been having diarrhea and abdominal pain and could not be seen by a gastroenterologist for 6 weeks, even though he was not having with any acute problems at the time.

Another patient came for a neurologic workup because she could not be seen by a neurologist for 12 weeks, and she knew that she could obtain magnetic resonance imaging and electroencephalography studies through the emergency department. After an 8-hour stay in the emergency department, she had her neurologic workup.

Finally, I recently triaged a family of 4 who presented with multiple complaints including the need for teeth extraction, school vaccines, and workers’ compensation evaluation paperwork.

I am sure many of us are seeing an increase in patients—insured and uninsured—who need primary care services, services that used to be more available in the communities where we live. Over the past 2 years, the Journal of Emergency Nursing has accepted and published (or will publish) over a dozen papers that address the issue of “crowding” in the emergency department. (See Journal of Emergency Nursing at http://www.sciencedirect.com and search for “ED Crowding.”) There are multiple solutions proposed. However, most focus on moving patients out of the emergency department. I would challenge that we look again at the issue from the “ground up.”

The “ground up” begins with basic health education, prevention, and access to services that many of us grew up with—school nurses, community health departments, and health hygiene. It is fascinating that “simple” things are usually the first to be cut in any budget. I think back in my management days, we called it “low-hanging fruit.”

We have become a victim of our own success related to emergency services. We can provide timely, comprehensive evaluations for life-threatening illnesses and injuries. We have also applied these techniques to complaints that may not be life-threatening but are just as agonizing to a patient or family who needs health care.

We are in a crisis of ethical, economic, and emotional proportions. The ENA 2009-11 Strategic Plan identifies practice priorities that include crowding/boarding, workplace violence, and psychiatric emergency patient care.2 As emergency nurses, we are on the frontline of this national crisis, and who but those involved should be the primary ones to propose and test solutions?