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CLEAR Temp: 57 °F Wind: CLM at 0 mph Friday, October 3, 2003 SECTIONS Home Page Local News Sports Business Obituaries Life Opinion - Politics AP News Weather Classified Archives Site Map EXTRA HomeLife Magazine Joy Magazine Tempo A & E RogueValleyAutoFinder RogueValleyHomeFinder Real Estate Showcase Wellness Connection Newspaper in Education Prime Times Outdoor Journal Personals Movie Times TV Times E The People CLASSIFIEDS Find a Car Find a Home Find a Job Find Everything E SOUTHERN OREGON Automotive Communities Entertainment Publications Recreation Calendar ABOUT US FAQ What's New Advertise Home Delivery Classified Ad Employment Contact Us Media Kit Email Story to a Friend August 31, 2003 Thayne Browning, 2, of Central Point, cries as he gets blood drawn by Jennifer Williams, a registered nurse in the emergency room at Providence Medford Medical Center. Thayne's mother, Cynthia Browning, right, and her friend Annette Wilson, left, look on Mail Tribune / Jim Craven ‘The clinic of last resort’ As health insurance costs rise and more people lose their coverage, Rogue Valley residents increasingly take ordinary medical problems to emergency rooms bound by law to treat them Stories BILL KETTLER Mail Tribune There are eight patients in the emergency room at Providence Medford Medical Center as the swing shift begins. If a television scriptwriter were to drop in on this hot August afternoon, hoping to find some small-town medical drama, she would have a long wait. The patients are ordinary, and so are their ailments. A man in Room 1 has neck pain from a motor vehicle accident. A woman in Room 2 has some problems related to long-term alcohol abuse. An elderly woman in Room 3 is too weak to get out of bed, and a man in Room 4 has chest pains. There is another neck pain case in Room 5, and the person in Room 6 has an ankle injury. A woman in Room 7 is having an anxiety attack, and a man in Room 10 has a laundry list of medical problems that have left him weak and debilitated. "The main thing is to make sure patients get cared for as quickly as we can," says Terri Polyniak, the charge nurse. It’s her job to keep the work flowing — to get patients treated and clear the beds for the next wave. Advertisement Three of the 11 treatment rooms are empty, so the doctors and nurses are busy but not frantic. "During the week there’s no pattern" to the work volume, says Polyniak. "You never know which days are going to be busy or slow. "Some days are wonderful," she says. "Some are horrendous. Lots are in-between." Even the in-between days are busier than they used to be. Emergency room use increased at an average rate of 8 percent in Jackson County’s three hospitals in 2002, the fifth consecutive year of steady growth. Doctors, nurses and hospital administrators expect the trend to continue as more people lose their health insurance and can’t find medical care anywhere else. ERs can’t turn people away or stop taking new patients, like a doctor’s office can. Federal law requires hospital emergency rooms to treat all who seek admission, regardless of their ability to pay. People who can’t get in to see a doctor, or don’t have a doctor to see, take their problems to the emergency room. "The growth in ER use is a manifestation of a delivery system for primary care that’s breaking down," says Ken Rutledge, president of the Oregon Association of Hospitals and Health Systems. "People don’t have anywhere else to go." Dr. Martin Tice, a veteran of 22 years in the Providence ER, puts it more succinctly. "The ER," Tice says, "is the clinic of last resort." 4:10 p.m. A 30-ish woman from Central Point is admitted with a pair of puncture wounds on her right ankle and some angry cuts and scratches on her hands. "There were five dogs fighting with a cat," she says, eyeing her wounds and waiting for the anesthetic to kick in. "I tried to get the cat out of the way. That’s gratitude for you." "Eighty percent of our patients don’t have true emergencies," Tice says. "They have pain, or a symptom that worries them and we take care of it." As more people bring their troubles to the ER, hospitals have to add staff and space to keep up with the demand. Both Medford hospitals are expanding their emergency rooms to handle the growing volume. Providence will double its ER space over the next two years; Rogue Valley Medical Center will triple the size of its ER during its three-year expansion and reconstruction project. Unfortunately, emergency medicine is not a money maker. Reimbursements from insurance companies and state and federal governments don’t cover the hospitals’ costs of providing care. Providence wrote off more than $7.25 million of emergency care during 2002, and is on pace to write off $8 million this year. RVMC wrote off $12.5 million in emergency care in 2002. "People with private insurance ultimately make up the difference" by paying higher insurance premiums, says Chuck Wright, chief executive for the Providence Health System in Southern Oregon. "That’s why our health-insurance premiums are so high. As Medicare and Medicaid (Oregon Health Plan) pay less and less of the bill, the hospital’s only alternative is to raise its charges." As the afternoon passes, more than a dozen patients wander in. There’s a teenager who fell while climbing into an attic, a child with a mild allergic reaction to insect bites, an older woman with persistent diarrhea, to name just a few. The dramatic life-and-death situations that fill TV medical shows are still relatively rare in Southern Oregon. "Patients with life-threatening conditions show up four or five times a week, at most," Tice says. "It’s not even one a day." "It’s a nice place to live," says Brad Branam, a nurse who serves as Providence’s trauma coordinator. "People aren’t shooting and stabbing each other." "We see the kind of stuff that happens to all of us," says Paul Sage, a physician assistant also assigned to the swing shift. Many hospitals have added physician assistants to their emergency staff to treat the relatively minor, routine injuries that find their way to the ER. Doctors are then free to concentrate on more serious cases. "We see everybody here," Sage says. "The first person I sutured on my own was a retired Supreme Court justice from Hawaii." Most patients are treated and sent home within a few hours. Some aren’t so lucky. 6 p.m. A fall victim comes in — a 92-year-old man who went down hard and is complaining of pain. He goes to X-ray, and the films confirm that he’s broken his hip. While nurses comfort him, the ER contacts an orthopedic surgeon, who arrives a few minutes later and starts preparing for surgery. Southern Oregon’s growing senior population means local ERs see more older people than big-city hospitals portrayed on TV. "Patients are just getting older and older," says Polyniak, the nurse. "We see people 80 and older all day long. There are days when the average age of patients is 75." "When I started here we had a few patients over 80," Tice says. "Someone over 90 was rare and we never saw anybody who was 100. Now the 80- and 90-year-olds are common and we see people over 100. On any given day, we’ll probably see five patients between 80 and 100." Older patients are more difficult to treat because they often have multiple medical problems, says Dr. Chris Garrard, Tice’s partner on the swing shift. "It’s a fairly detailed thing to figure out what’s wrong with them." 6:30 p.m. A mother arrives with her 2½ -year-old son. The boy found some medicines while the family was moving, and nobody knows how many pills he may have swallowed. "He’ll have to have his blood drawn," says nurse Betty Martinez. "We don’t know how much he took. Toddlers put everything in their mouth. They’ll give him activated charcoal (to absorb the medicines)." Martinez says many ER patients don’t know how to get access to health care other than through the emergency room. "There’s a guy in 11 with chronic anxiety disorder," she says. "He lost his Oregon Health Plan (insurance) because he didn’t make his payments. "Every time he comes in he tells us a different story. He said somebody stole his car today. We don’t know." He’s a "frequent flyer" — ER slang for patients who come in often enough for the nurses to know them. He’s shaking in his hospital bed, and some of the nurses wonder whether he’s in the middle of drug withdrawal. He is given some drugs. They’re not the drugs he wants, but he takes them and leaves. "We have to make decisions that are good for him and good for the system," Martinez says. "We can’t make him see a psychiatrist." Cases start to merge in a visitor’s mind as patients are evaluated, treated and released or moved to the hospital. Some stand out — like the 80-year-old fall victim who comes in around 7 p.m. He looks shaken but OK, except for the crusted blood where his arm scraped against something as he fell. "His skin is like paper," says a thirty-something woman, a friend who brought him to the hospital. "It tears really easily." Nurses clean his arm and wrap it with a gauze dressing. It’s his second trip to the ER in three weeks, the friend says, and his second fall. "I bring him here for everything," she says brightly. Then there are the two young men, admitted within a half hour of each other, both with one badly cut finger. "I was washing dishes with a sponge and a glass broke in my hand and cut my finger," says a lean, shirtless 21-year-old. He gets three stitches and a seamless tubular bandage that pads the finger and immobilizes it at the same time. A 19-year-old with a shaved head caught his index finger in his bicycle wheel while he was doing a repair project. The first joint is open to the bone. "I just stopped paying attention," he says. "I went to pull my hand away and it was in the chain tensioner." He gets a seamless bandage, too, on top of six stitches. The last 90 minutes of the shift are relatively quiet, except for a woman with a bad migraine and a 50-year-old heavy smoker with SOB — shortness of breath. "He’s 50, and he won’t see 55 if he keeps this up," nurse Deb Strauss says. Tice and Garrard, the doctors, talk about whether they should admit him to the hospital for more treatment. People who come to the emergency room account for about 40 percent of hospital admissions at Providence Medford Medical Center, and about 41 percent at RVMC. They represent a large percentage of the hospital’s income. "The emergency room is the door to your hospital," says Wright, Providence’s chief. "If we closed that door, we couldn’t survive." 10:45 p.m. Just two beds are occupied and the nurses have time to relax and chat. Tice leaves a few minutes early, after working a double shift. Garrard stays around to brief Dr. Kenneth Brown, the night-shift doctor. "Unpredictability of patient flow makes it hard to staff," says Garrard, a veteran of 26 years at the Providence ER. "Generally our volume right now is right at the stage where it’s not enough for two doctors but it’s really too much for one." Brown takes up where Garrard left off, waiting for the next patients. Reach reporter Bill Kettler at 776-4492, or e-mail [email protected] Local emergency rooms draw more than their share of regulars A relatively small number of heavy users helped push Jackson County emergency room use to record heights in 2002. Preliminary data collected by Dr. Jon Gell indicates that 481 people made at least six visits to the ER at Rogue Valley Medical Center in 2002. One person visited the ER 35 times. Gell, the medical staff director for Medford’s two hospitals, is studying emergency room admission data as part of a project to connect frequent ER users with a doctor or a clinic that could provide less expensive care. Gell has not yet analyzed admission data for Providence Medford Medical Center or Ashland Community Hospital. Gell is also analyzing the medical complaints that drove people to seek emergency care. Migraine headache was the most frequent complaint among the six-time ER users at RVMC, followed by non- migraine headache, dental disorder, general abdominal pain, acute upper respiratory infection (common cold), back pain, sore throat, ear ache, bronchitis and depression. 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