Life in the ER: Questions for Dr. Valerie Norton

Life in the ER: Questions for Dr. Valerie Norton

Valerie Norton is former medical director of emergency services at Scripps Mercy Hospital. Photo: Sam Hodgson

Saturday, July 26, 2008 | At Scripps Mercy Hospital’s emergency room in Hillcrest, doctors see an average of 2.2 patients an hour with everything from gunshot wounds and drug overdoses to urinary tract infections and sore throats.

Dr. Valerie Norton knows that life well. She served as medical director of emergency services at Scripps Mercy for three years until this month, when another doctor rotated into the position. A 17-year veteran of emergency medicine, she remains on duty and spoke with voiceofsandiego.org about the changing world of the E.R., the effects of the health-care crisis and the waiting room.

How is the crisis in the health-care system being reflected in the E.R?

We have fewer hospitals, fewer hospital beds, fewer emergency departments and a severe nursing shortage.

In San Diego County alone, five hospitals have closed in the last 10-15 years, and this is reflected across the country. But the population is increasing. You have a smaller number of emergency-room beds and upstairs hospital beds to serve an increasing population of people.

This means you can’t get people into the EDs (emergency departments), so they sit in the waiting room for hours and hours. Where 15 years ago you maybe had an average one-hour wait to get seen in this ER, on a busy day now it might be 4-5 hours or even longer.

In some places in California, it’s truly astonishing, the waiting times they have. At the L.A. County hospitals, you might wait 12, 16, 24 hours to get seen.

What are other ways you see the effects of the health-care crisis?

Many more patients than when I started do not have access to primary care follow-up, do not have insurance and can’t afford prescriptions that we write for them.

When I started practicing, I almost never heard a patient say, ‘I can’t fill this prescription for Amoxicillin.’ (Now), routinely, once or twice a shift, someone says, ‘I really appreciate you taking care of me, but I can’t fill this prescription.’

Amoxicillin isn’t that expensive, right?

We’re talking about $10 or $20 prescriptions that are really hardships for people. I had an elderly woman the other day start to cry because she had to take a $10 cab ride back home from the ED. For old people on a fixed income, that could be the difference between having a meal or filling (a prescription).

Besides frustration, what does it mean to patients when they have to wait? (If you have) something like abdominal pain, you might be in terrible pain, but your vital signs look good, you look good, you don’t have a fever, you’re not passed out on the floor. You might have to wait 3 or 4 hours.

And that’s horrible to be in terrible pain and have to wait 3-4 hours to be seen. That happens all the time. …

We try to treat that pain, give you something while you’re in the waiting room, but there’s sort of a limit to what can be done. … You might be stuck with a couple Vicodins. We can’t give you anything really heavy duty.

The concern is that we’ll occasionally miss something really serious and think it’s OK for that person to wait 3 or 4 hours, but it’s not and they end up dying in the waiting room.

Fortunately, that has happened extremely seldom in our waiting room and other U.S. waiting rooms that I know about. But I think it’s only a matter of time before anecdotal cases like that make the headlines (as happened in New York recently). …

And even here in our own waiting room, we’ve had a case where an elderly person was brought in in a wheelchair, and the family said she just wasn’t acting right. There was a line of 10 people waiting to be triaged, and she was at the back of the line. By the time she got to the front of the line, she was dead.

It’s not anybody’s fault, just inadequate resources. I don’t think the family realized how sick she was, that she wasn’t breathing.

Do patients get angry about the wait?It used to be when I first started working here that people would be really angry at the amount of time they waited, even if it was only an hour or two. Now I see people waiting for 4-5 hours, and I apologize for the wait, and they say “It’s OK, we understand.”

I wonder if that’s a nationwide phenomenon, if people are getting so used to the idea that this is a finite resource that they just expect these long waits. … Have we gotten to the point where this is the new norm?

What are you seeing more of that you didn’t see as much in the past?

We’re seeing more MRSA. It’s mostly skin abscesses. We have definitely started to see a real epidemic of that in the last five to six years,

We’re seeing more STDs because people have gotten more complacent about condoms since AIDS became a manageable disease instead of a death sentence. We’ve been seeing more syphilis.

Are there things you’re seeing less of?

It used to be we saw a lot more horrible blunt trauma from car accidents. There’s less of that because of airbags. A lot of people’s lives are being saved by airbags.

And then because the population is aging, we are seeing more elderly who have trauma, mostly from falls — falls at home, in the bathroom, over curbs or steps. Often they have very severe injuries because they’re frail, or they’re on blood thinners.

We’re also seeing fewer horrible complications of AIDS. When I first went into practice, you would typically see several patients in a shift with pneumocystis pneumonia, Kaposi’s sarcoma, thrush, weird fungal infections — really ill.

Because of the fabulous new AIDS medications, and a better network for care of AIDS patients, they’re being managed more as outpatients.

We see them for other things, their ankle sprains and back pain, but it’s unusual to see people for other complications of AIDS until they really get to the end stage when the medications aren’t working anymore.

Are there certain kinds of conditions that ER doctors have gotten better at treating since when you started?

We get EKGs in the ambulance, which we didn’t used to have 10-15 years ago, so we often know when someone is having a heart attack when they hit the ER doors.

We’ve gotten better at treating bad pneumonia and what we call sepsis, septic shock. We are doing better in taking care of people with congestive heart failure and COPD (chronic obstructive pulmonary disease).

Even though patients have to wait longer, they’ll still get the same level of care they would have gotten in the past, right?

Maybe even better because of the advances in medicine. We have better technology and our lab is faster than it used to be. We have better imaging and monitoring equipment than we used to, and better medications.

(Also), people are much more highly trained than they were 20 years ago. In general, you’re going to get excellent care.

Do you ever watch “ER”?

When people ask if “ER” is like your practice, I say it’s like all the worst things that happen in a whole month crushed into one hour.

(In real life), it’s a lot more bread-and-butter medicine — people with a toothache, a sprained ankle, they’re having spotting in the first trimester of their pregnancy, they’re having chest pain but it’s not a heart attack.

That’s 90 percent of our job. The other 10 percent is the really exciting, lights-and-sirens TV-show stuff.

— Interview by RANDY DOTINGA

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