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Commentary: A tale of two emergency rooms, one in St. Louis and one in Ireland

This article first appeared in the St. Louis Beacon, Sept. 5, 2010 - Most of us will be fortunate to visit the local emergency room only on a handful of occasions during our lives. I had occasion to visit emergency rooms in two countries in a seven-month period: one visit to a St. Louis ER while home visiting my parents; the second to an ER in Ireland, where my husband and I live with our two young sons.

My experiences with emergency medicine in these two different locales may be interesting in light of this year's passage of federal health-care reform. You can compare costs, treatment options and outcomes all you want, but none of us can really get a grip on how we feel about a particular approach until we suffer an illness or an injury and seek care.

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In August 2009 while in St. Louis, I had a bad spill on a bike in a local park that resulted in a trip to the ER at St. John's Mercy Medical Center in west St. Louis county. Seven months later, I lacerated my right index finger with a kitchen knife and ended up in the ER of my own "local" hospital, in Sligo, a town of about 17,000 in northwest Ireland.

When I arrived at St. John's, I immediately noticed that it was sleek and pristine, with hardwood floors and large treatment rooms. I had the sense that the ER had been renovated recently. No piece of equipment appeared to be more than a year or two old (although I am no expert in the maintenance or provenance of any such equipment).

Access to the best technology is a staple of the U.S. health-care system, as borne out by statistics compiled by the Organisation for Economic Co-operation and Development on the number of MRI and CT scanners. Not only does the U.S. have greater access than Ireland to such equipment, it has the highest proportion of such equipment in the world. All the staff I encountered -- the ER doctor, the nurses and X-ray technicians -- were professional and kind. The visit hummed along smoothly; I was never left waiting for longer than 15 or 20 minutes and was sent home, cleaned up and stitched up after about three hours.

The differences in my two emergency visits were immediately apparent once I stepped into Sligo General Hospital's Accident and Emergency Department after I had badly cut my right index finger while cutting butter. The hospital's A&E was run-down, worn, tired and looked as if it had been built on a budget in the early 1970s. Chairs in the waiting area for the triage nurse had an obvious "public sector" look about them -- vinyl covering on cheap aluminum frames. Ireland spends a much lower percentage of its GDP on health care than the U.S. (7.6 percent in 2008 compared to 16 percent for the U.S.), and the most obvious manifestation of this was the waiting room. Everything about it looked government-run -- exactly what many Americans fear will happen if the U.S. government "takes over" American health care.

When I arrived, I visited the receptionist with a letter from my general practitioner. The general practitioner is similar to a family practice doctor in the U.S. and is the first point of contact with patients. I had rushed to this doctor after cutting my finger in the vain hope that he could fix it (which he couldn't). He had wrapped the finger up enough to get the bleeding to almost stop and sent me off to the hospital, a 40-minute drive from my house. After visiting the receptionist, my wait in A&E began.

First, I waited 90 minutes to be seen by the triage nurse, whose responsibility was to assess priority to be seen by the doctor. The triage nurse determined that there was no point trying to re-attach the skin that I had completely lacerated, but that the wound would have to be dressed. This 90-minute wait was a ridiculous amount of time simply to determine priority to be seen by the doctor. Because I was a walk-in case, I was automatically a low priority.

The triage nurse then sent me back to the waiting area.

While waiting, I noticed that most of the people in the waiting area (about 15 to 20 people at any time) were over 75. According to Ireland's Department of Health and Children, in 2008 people over 65 years made up 48 percent of stays in hospital. None in the waiting area appeared to be seriously ill. They were in the emergency room because in Ireland it is the quickest route to gaining a temporary bed in the hospital. What these elderly people really required was a short-term stay in a nursing home as they recovered from illness or injury. Instead, many of them will wait several hours - even days - in the emergency room to be admitted into the hospital to recuperate.

But back to my wait. After seeing the triage nurse, I passed four more hours in the waiting area before being summoned to see the doctor. The doctor was actually a resident doctor, more than likely studying to be a general practitioner in the community. In Ireland, all residents studying to be general practitioners spend one year of their three-year residency working in an accident & emergency department. In addition to the experience they gain from dealing with emergency patients, they also ameliorate a shortage of ER doctors. Of course, a resident doctor's pay is less than that of a fully qualified specialist ER doctor, thereby also keeping costs down.

After almost seven hours (my waiting time plus treatment), I left Sligo's emergency department. Over the course of the next week, I visited the nurse in my general practitioner's office three times, where she changed my dressing and checked for signs of infection. In all, these three visits cost me 75 euro -- about $100. And that was the only charge for all the care I received. No charge for the initial evaluation by my GP. No charge for the visit to the emergency room.

My bill for the ER visit in St. Louis, before my health insurance began its battle with the hospital, was over $3,000.

Despite huge differences in cost, with the U.S. experience costing 30-fold more than the Irish, and treatment time (about seven hours in Sligo compared to three hours in St. Louis), the outcomes of the two ordeals were very similar. In both cases, I encountered capable doctors and nurses who left me feeling confident that I was receiving good care. In both cases, I healed well (although there were some later complications in the healing of my arm in St. Louis). The OECD's statistics on life expectancy and infant mortality paint a similar picture: On average, the Irish health system is keeping people alive longer and doing it more cheaply than in the U.S.

So, does government-run health care necessarily imply that quality is sacrificed? In my experience, the quality and capability of the health-care professionals in both places were equivalent. At no point during either ordeal did I question the abilities of either hospital staff. Rather, what has been sacrificed in Ireland is quick access to health-care professionals. Cost containment has dictated that access to professionals is by urgency: The most severe injuries receive treatment first and every other case follows, even if this means several hours or days waiting (as is sometimes the case for elderly patients).

These delays are, of course, frustrating and exhausting. My experience as a patient in the Irish government-run health system is one of quality care at an affordable price. But I had to sacrifice time and access to more comfortable and modern surroundings.

Originally from St. Louis, Siobhan McGarry currently lives in County Leitrim, Ireland. She has worked in economic development and policy in Washington, D.C.; Glasgow, Scotland; and Ireland. 

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