Defining Emergency

Defining emergency, as it pertains to the treatment of neck and back pain by the emergency department chiropractor, becomes complicated by the perspective of the interested person. The triage nurse will use a definition of an emergency to help determine who will be taken first. An individual who is considering our health care system as a whole will use a definition that concerns the ability of our institutions to provide care in a reasonable and efficient manner. They will want to consider how differing classification systems will affect the emergency department, its staff, the patients served and those who provide funding. The patients have their own definitions of emergency that vary from individual to individual and may differ greatly from that of the caregivers and insurance carriers.

Our legislators, in an effort to protect the public, instituted the EMTALA regulations. EMTALA prevents emergency departments from refusing to treat patients on the basis of their ability to pay. This regulation prevents discharge of unstable patients, as well as "dumping" difficult patients on other institutions or premature discharge from care.

Once a potential patient is on the hospital grounds, the staff has an obligation to evaluate them. If the hospital has the ability to treat the patient, they must. Under most circumstances, unstable patients cannot be transferred (i.e., discharged) to another institution or home. Interestingly, patients with severe pain are considered unstable even if their illness does not endanger life or limb.

Some patients erroneously believe that not having the ability to pay for private medical care makes every medical condition an emergency. In many instances, emergency departments are overwhelmed by uninsured patients with relatively minor complaints, such as nasal congestion or the desire to be evaluated following a minor trauma in spite of a lack of symptoms.

Many doctors and nurses would like to have their emergency-department patients limited to those with true life- or limb-threatening illness or injury. High volumes of minor complaints overtax the staff, limit valuable resources, and lead to significant patient dissatisfaction due to long waiting times and the appearance of inadequate attention by the staff. Unfortunately, what constitutes a life-threatening emergency is not always clear. One evening, as I stood behind the nurse's station, I observed a nurse walking a 45-year-old man to his room. The man complained, "I don't know why I'm here. I just feel a little anxiety in my chest." He then added almost as an apology for being a burden on the ER, "My wife made me come here." A few moments later, the nurse came running out of the patient's room announcing that the EKG revealed a myocardial infarction.

Pain as a criteria for emergency classification can be controversial. Some pain, such as the chest discomfort described above, is an obvious harbinger of a serious life-threatening disorder. It is reasonable to categorize a patient with chest pain as an emergency for deciding who to take first from the many people waiting in a typical hospital emergency department. If evaluation reveals that the chest pain is a result of a benign condition (e.g., gastric reflux), it would be reasonable to provide the appropriate treatment prior to discharge from care. If chest pain resolves following treatment for gastric reflux, it confirms the correct diagnosis.

While lower back pain sufferers do not typically warrant the same level of concern as a patient with chest pain, the lower back pain can also be symptomatic for a very serious and life-threatening disorder (e.g., an abdominal aortic aneurism). If evaluation reveals a more benign cause of pain, the appropriate treatment should be provided prior to discharge to confirm the diagnosis and to satisfy the EMTALA guidelines concerning the discharge of patients considered unstable due to pain. According to ERISA standards, only the attending ER physician with knowledge of the patient's condition can determine the most appropriate treatment for the patient. In many cases, this will be chiropractic treatment.

Like most things in life, defining an emergency, as well as defining appropriate care to be provided in an emergency setting, lacks distinct boundaries and falls into shades of gray. What may at first appear to be an emergency is frequently revealed to be a condition that could be more appropriately treated in an outpatient setting. An additional benefit of providing chiropractic care for these patients is for the purpose of education. Providing relief through conservative care for a patient who believed they were suffering from a true emergency is an education of action to help the back pain sufferer feel more comfortable in seeking conservative care first. The long-term benefit is an unburdening of the ER, the third-party payers and the health care system. The short-term benefit is relief for the patient, decreased workload for the ER staff, and an enhanced reputation of the hospital for providing comprehensive care.