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4 pressing things to know about emergency room care in Texas

Not all ERs are the same, and every patient should know these 4 things

Emergency rooms exist to expect the unexpected, providing 24/7 care to patients with life-threatening or emergency medical conditions. Yet, not all emergency rooms are the same. Here are 4 pressing things that you should know about emergency room care in Texas:

• Some emergency rooms aren’t affiliated with a hospital and, thus, aren’t equipped to handle all emergencies.

• Hospital emergency rooms have varying levels of capabilities to handle challenging conditions such as trauma and stroke care.

• If you don’t pay careful attention, a fully trained physician may not see you during an emergency room visit.

• Most hospital emergency rooms can’t turn away a patient in an emergency medical condition or in active labor.

Some emergency rooms aren’t affiliated with a hospital and, thus, aren’t equipped to handle all emergencies.

Sometimes it seems that Texas has about as many freestanding emergency rooms (ERs) as bluebonnets. This is because of a change in laws that allowed independent ERs to open without being affiliated with a hospital. Many companies sprouted up seeking lucrative fees from expensive emergency medical care.

On the good side of things, freestanding ERs are convenient. They’re often located near large neighborhoods and have short wait times. 

On the other hand, there’s a bad side to freestanding ERs.

• Many freestanding ERs aren’t in-network and treatment can result in jaw-dropping fees that the patient gets stuck with paying.

• More critically, most freestanding ERs are more akin to an urgent care clinic rather than a true emergency room. They have scanners and radiology services that will allow diagnosis of a broken bone, for example. Yet, they lack the staff or equipment to handle a major emergency such as a stroke. In those circumstances, the best they can do is make a diagnosis and send the patient on the way to a real hospital ER.

The take-home message about freestanding ERs is think twice before choosing convenience. Don’t get me wrong—my family has used them for relatively small situations. But if it’s a true emergency that may require the involvement of medical specialists for life-saving or other complex treatments, the better course is likely to go straight to the hospital without wasting precious time.

Hospital emergency rooms have varying levels of capabilities to handle challenging conditions such as trauma and stroke care.

Even in hospital settings, not all emergency rooms are created equally. The spectrum ranges from basic emergency care to cutting-edge medicine. Two serious medical conditions demonstrate the difference.

Texas recognizes four levels of trauma facilities. 

• There are 20 Level I, or comprehensive, trauma facilities, which are equipped to handle any type of trauma. 

• There are 26 Level II, or major, trauma facilities. 

• There are 61 Level III, or advanced, trauma facilities. 

• And, finally, there are 196 Level IV, or basic, trauma facilities. 

If a Texas hospital ER isn’t on that list, it has no designation to handle traumas at all. In case you’re interested, you can read more about trauma facility criteria and designations here, including which Texas hospitals hold trauma certification.

Similarly, hospitals and their emergency departments may be recognized with different levels of  stroke certification by an accrediting body such as The Joint Commission.

• Comprehensive stroke centers have the around-the-clock staffing and equipment to handle any type of stroke emergency.

• Thrombectomy-capable stroke centers don’t meet all the comprehensive stroke center requirements, but still offer surgical intervention to remove clots causing ischemic stroke.

• Primary stroke centers provide intermediate stroke care.

• Acute stroke-ready hospitals provide basic stroke care.

Additionally, sometimes stroke centers are referred to by levels, similar to the trauma system. Level 1 stroke centers provide comprehensive care. Level 2 stroke centers are more like primary stroke centers, providing emergency stroke care when a Level 1 stroke center is more than two hours away from the patient’s location. Level 3 stroke centers provide emergency stroke care when a patient is located more than two hours away from a Level 1 or 2 stroke center.

The value of the stroke and trauma system is that emergency medical services (EMS) are kept in the loop of which hospitals hold certification and to what degree. Thus, ambulance crews transport patients to a hospital emergency room with the appropriate capabilities to treat the relevant medical condition.

If you don’t pay careful attention, a fully trained physician may not see you during an emergency room visit.

Even if you go to an emergency room at an excellent hospital, it doesn’t necessarily mean that you’ll be seen by a fully trained physician. 

Part of the mission of major academic hospitals is to train new physicians.

• Resident physicians have completed medical school, but have not finished their clinical training. Some residencies, such as internal medicine, last three years after medical schools. Other residencies are much longer. Residents usually start their clinical training in the July following their medical school graduation.

• Fellow physicians have completed medical school in residency training, but are completing additional advanced clinical training in a specialized field. For example, doctors who finish anesthesiology residency training may choose to complete a fellowship in pediatric anesthesiology. Or physicians who complete a radiology residency may do a fellowship in neuroradiology (brain and spinal cord imaging).

The standard of care requires fully-trained faculty and attending physicians to educate, train, and supervise resident and fellow physicians. Residents are notoriously sleep-deprived and overworked. Sometimes, they don’t receive adequate supervision. In these situations, patients can basically be guinea pigs.

That’s what happened to a client of mine who had clear symptoms of ischemic stroke and quickly sought emergency medical care at a well-known comprehensive stroke center hospital in Houston’s famous Texas Medical Center. The emergency room physician consulted the stroke team. A first-year neurology resident responded and saw the patient. 

Without any evaluation or supervision by a faculty member, the resident determined that it was all in her mind, and discharged the patient with the catch-all diagnosis of exclusion, neurogenic disorder. Unfortunately, she wasn’t seen by a fully-trained physician before she left. If she had been, I have no doubt that she would have been appropriately diagnosed with ischemic stroke. Instead, she went home and suffered a permanent brain injury because of the untreated stroke.

I can’t leave out another emerging issue in hospitals of all types, which some describe as scope creep. In some hospital emergency room, patients can be evaluated and discharged without ever even being seen by a physician. I’m not talking about the difference between a resident and fellow versus a fully-trained attending physician. I’m talking about non-physicians, traditionally called mid-level providers, handling all aspects of care. 

• Nurse practitioners (NPs) are advanced practice nurses. Sometimes they hold doctorate level degrees, such as the designation “DNP,” and may be called “Doctor.” That doesn’t mean they are a physician, though.

• Physician assistants (PAs) are college-educated health care professionals with some graduate level training. They, too may or may not hold a doctorate level degree, and may go by “Doctor.” That doesn’t mean they are a physician, though.

When receiving care at a hospital emergency room, as a husband was patient, or even in a clinic, it’s always a good idea to understand who’s treating you, including educational background and licensure. You just have to ask.

Most hospital emergency room can’t turn away a patient in an emergency medical condition or in active labor.

If a hospital has an emergency department and receives Medicare funds, federal law prohibits patient dumping when someone shows up at the ER in an emergency medical condition or in active labor. This law is called the Emergency Medical Treatment and Active Labor Act (EMTALA), which was signed into law by President Ronald Reagan in the 1980s.

Under EMTALA, the hospital hospitals must provide patients with a medical screening. If they are determined to be in an emergency medical condition or in active labor, hospitals must ensure that they receive stabilizing treatment before discharge or transfer.

Under Texas law, tort reform measures make emergency room cases more challenging. In some situations, it’s simply impossible to pursue a case. With that said, Painter Law Firm has successfully resolved numerous of cases that other law firms turned away because of the tort reform ER standard called willful and wanton negligence.

If you’ve been seriously injured because of poor emergency room care in Texas, then contact a top-rated, experienced Texas medical malpractice attorney for free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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