r/emergencymedicine • u/Silent_parsnip8 • 1d ago
Discussion The incoming small hospital apocalypse
I work at various sites that are mostly smaller facilities w/ about 20k-30k ER volume per year. I sit on a few committees within these hospitals and am familiar with their finances. Since covid every hospital I've worked at has been deeply in the red.
One of the hospitals I work at has been cutting services. We cut OB/GYN most recently which sucks. The state(s) I work in are red politically and added restrictions to Medicaid. We are seeing more and more uninsured/underinsured causing the hospital to lose more money. Lots of the younger med staff are talking about moving places more favorable to their politics. We've lost a couple docs to Canada recently. We can't recruit specialists and especially not OB. It's really a detriment to the local population. I'm worried at least one of my sites will completely shut down in the next couple years.
I'm really worried this is a phenomenon that is occurring across rural america. Curious if y'all are seeing similar issues in your neck of the woods.
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u/CozyBeagleRN 1d ago
Yep. Blue state facility cut OB/GYN recently. It’s rural enough compared to the surrounding, much richer counties. There’s little development and growth here.
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u/Dracula30000 23h ago
It was pretty bad after 2008, too. ACA kinda stemmed the bleeding. But the focus on surgical services payments has really hurt smaller hospitals that can’t provide the $pecialized $urgical $ervice$ that get high reimbursement.
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u/BUT_FREAL_DOE 1d ago
Yes rural America will continue to get the healthcare they have voted for over and over again.
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u/cdiddy19 23h ago
And then blame democrats for it sucking and being more expensive
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u/EM_Doc_18 ED Attending 10h ago
Our ED volumes have exploded and wait times are getting longer, hospital across town has cut most services so we are absorbing all of the patients. Local social media groups have tons of white boomers commenting, blaming "illegal immigrants taking up all of the space". Right wing media-sphere is a poison.
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u/paramedic236 Paramedic 23h ago
I’d gladly settle for a single payer solution over the abomination we have now.
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u/Genesis72 Other (Health Department) 4h ago
I work in public health. One of the things they hammer in to you over and over in school is that Americans pay 3x as much as other comparable countries and have worse outcomes.
Thats like saying "I wouldn't wish a Honda on my worst enemy" when your Ford has to be taken to the shop 3 times as often and will shit out on you way earlier.
But there isn't anything more American than paying for other people's healthcare AND a bunch of bloodsucking middlemen/administrators! Health insurance premiums totaled to $1.2 trillion in 2026. Thats a fuckin shitload of money that could just go straight into paying for healthcare, healthcare infrastructure, clinicians, etc
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u/Silent_parsnip8 23h ago
Why wouldn't you wish government run healthcare on your worst enemy. The president, Congress, military, and pretty much all modern countries utilize government healthcare.
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u/DODGE_WRENCH Paramedic 11h ago
I agree with you, but I’d rather be shitting shards of broken glass on a regular basis than deal with the VA ever again.
A lot of improvement needs to be made in more areas than just the payer system.
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u/avalonfaith 1h ago
I totally hear you. The issue here, like everywhere is there is a vast amount of difference between regions and locations. That shouldn't be. It should be standardized. I don't know if it's the quality of graduates willing to be in certain places (admin especially) or work culture or what the hell. Leadership is always going to be the issue in the end.
I'm sorry for yours and others experiences with poorly managed VAs. I live in a city with wonderful VA services and wrap around services and I for sure feel grateful for that.
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u/West-coast-life 19h ago
People like you are the problem. 🤣 every other 1st world country has single payer healthcare other than the USA.
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u/Redhawkrun2450 23h ago
Really? You wouldn’t wish say the Danish healthcare system on your worst enemy? Every other developed country has state sponsored healthcare. The alternative for lots of people isn’t some glorious private sector healthcare, it’s no insurance at all and healthcare deserts.
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u/pabrocjb 22h ago
My husband was asked to go to Denmark to testify in a medical case, as an expert witness. I got to go along. I had a minor problem, went to the ED. The doc was in traditional clogs, and was very cute. He solved the problem.
The ED was spotless and beautiful.
When I was discharged, I went up to the desk and got out my wallet. The receptionist laughed and said, "There is no charge."
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u/pipesbeweezy 12h ago
Its apparently good enough for our senate, congress and executive whats wrong with giving everyone else the same quality?
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u/Pristine-Debate-8228 Med Student M4 20h ago
Rotated at a VA recently, and none of the patients complained about getting their healthcare paid for by the government. Sadly most of them were still against social healthcare for everyone else. It might not be the best system but it sure does alleviate a lot of problems.
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u/OttoOtter Flight Nurse 23h ago
Have you ever worked in a fully private system? Like the DRC or Uganda?
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u/justavivrantthing 23h ago
Are you trying to say that authoritarian governments do not support healthcare for all?
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u/OttoOtter Flight Nurse 23h ago
Saying that the DRC has a functional government at all is a hilarious stretch.
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u/justavivrantthing 22h ago
Lol no one said that. We all agree on that. It just seems like “healthcare for all” and “authoritarianism” don’t jive. It’s almost like those leaders want to milk the system till one of them dies …
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u/OttoOtter Flight Nurse 21h ago
Agreed. Authoritarians generally don’t want anything to cut into their cut.
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u/Pristine-Debate-8228 Med Student M4 20h ago
Yes, but I don’t understand how or why you would compare a resource pour system to the most expensive healthcare system in the universe! At least they are scrappy and doing their best to make it work.
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u/OttoOtter Flight Nurse 20h ago
The reality is that all the resource poor nations have essentially no healthcare system to speak of. The wealthy and healthy all have socialized care. The US is the only wealthy nation that doesn’t. And it’s killing us - literally - while goofs like the folks above yearn for the type of healthcare of the poor nations with the short lifespans.
Also they are *not* making it work. Any sort of systemic help they had came from USAID. Which we cut in order to promote “America First” - except that also isn’t happening.
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u/MedicJambi Paramedic 13h ago
Medicaid was the single best health insurance I've had when I had it.
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u/instasquid Paramedic - Australia 13h ago
The US government spends more on healthcare per capita than most nations with universal healthcare and has worse outcomes. How is that any better?
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u/Party-Count-4287 22h ago
*imaging here
We have seen longer wait times getting patients to appointments for primary and specialty care. It’s going to be more mid levels running things. Loss of ACA subsidies is hurting bottom line so admin will squeeze harder to maintain profits.
I’ve had patients often tell me it takes too long to get into outpatient appointments. So ER is their backup…
GI coverage is dwindling in our area. We not only see outpatients from long distances but now inpatients are being shipped far away because the city doesn’t have coverage.
I feel bad for this generation that’s going to need care. Hopefully it gets fixed for my kids and when I need it.
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u/valgerth 6h ago
I’ve had patients often tell me it takes too long to get into outpatient appointments. So ER is their backup…
I work on the prehospital side, and the amount of times I transport someone who really just needs to see a primary/specialist, and who understands that, but tells me the wait is weeks to a month is crazy.
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u/pooppaysthebills 23h ago
It's happening in blue states on the East Coast as well. Facilities with L&D in many regions are more than an hour's drive from each other and many miles apart. Even facilities in urban areas are closing L&D.
It's a money thing, not a red state thing.
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u/Silent_parsnip8 23h ago
Makes sense. L&D just doesn't pay much and is high risk. Really sucks that the solution is even riskier: precipitous ER delivery or drive an hour to a bigger hospital
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u/tablesplease Physician 23h ago edited 23h ago
I didn't do ten supervised delivery on ob service to not use my excellent delivery skills. I say let them come to the er. We can both learn how to deliver the baby together.
I'm also an antivaxer. Don't teach me about measles and polio unless you let me diagnose that stuff.
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u/ScarletCarsonRose 23h ago
But what about the ebil vitamin K shot?!
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u/tablesplease Physician 23h ago
I'm conflicted because it has the word vitamin which God made and is therefore good. But shots are bad. Being a physician is difficult.
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u/ScarletCarsonRose 22h ago
Obv solution. Aerosol diffuse at 1% strength. Follow up with lavender oil to restore body's natural humors.
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u/DagothUr_MD 18h ago
the most American thing I've ever seen is at work was a prison inmate delivering her baby handcuffed to the bed--which was adopted by a granola mom who refused the vitamin K shot once she had custody
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u/Silent_parsnip8 23h ago edited 23h ago
I know you're being tongue in cheek but that is my nightmare. Just so much that can go bad and wind up in an instant lawsuit all because the hospital doesn't want to pay for basic services the community needs.
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u/gym_rat_101 22h ago
Sorry you couldn't just blame it on trump like you wanted
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u/Silent_parsnip8 20h ago
Enjoy the downvotes
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u/gym_rat_101 19h ago
Yes the liberals of Reddit lol
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u/Silent_parsnip8 14h ago
Nah, just normal, everyday folks. Sorry you couldn't blame it on liberals like you wanted
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u/gym_rat_101 10h ago
lol says the person who made a whole post trying to blame republicans.
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u/Silent_parsnip8 9h ago
Re read the post snowflake. I didn't blame anyone just stated simple facts.
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u/slightlyhandiquacked RN - ER 🇨🇦 9h ago
Why do you assume the people downvoting you are liberal?
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u/gym_rat_101 8h ago
Oh bc this is Reddit :)
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u/slightlyhandiquacked RN - ER 🇨🇦 8h ago
Ah yes, the JordanPeterson and Conservative subs are notoriously full of liberals…
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u/AceAites ED Attending 22h ago
Red states voted for this though and you can bet a huge portion of those rural places voted for that, against their own state’s “color”.
Ironically, Trump healthcare disproportionately
hurts his own voters, who by majority live more rurally.1
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u/revanon ED Chaplain 23h ago
Yes. Context: politically red state that never expanded Medicaid under the ACA, with the cuts from the Big Beautiful Bill incoming. Several smaller hospitals across the state have closed or declared bankruptcy. My hospital (level III trauma center on the city outskirts, around 35-40K annual ER volume, about a 20-minute drive from the level I mothership downtown) also cut OBGYN before I was hired. Vast swaths of the state are now considered "maternity care deserts" including the next county over when the hospital there also closed their OBGYN service. I've certainly witnessed plenty of doc turnover, but I believe its cause to multifaceted, with a number of systematic issues at play.
However, I do think a lot of this is rooted in the history of racism in the US. The response to equality and integration is often to try to burn stuff down rather than improve it--ie, slowly dismantling public schools via private segregation academies, tax-funded vouchers, zoning and redlining shenanigans, and the like--and so burning down the healthcare system rather than improving it would be part of that pattern. That healthcare is unconditionally provided to even just some people seen as "less than" by the powers that be means that healthcare will always have a target on its back because we continue to elect people who fundamentally believe that certain other people don't deserve healthcare on spec.
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u/bubba1819 11h ago
Thank you for bringing up racism in this country as a cause! It is not talked about enough IMO.
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u/prefix_code_16309 Radiology Tech 23h ago
I'm astounded that any hospital has been able to continue operating under the current US system.
I was driving to work the other day pondering how amazing it is that any hospital can keep their doors open. If you ran a gas station, grocery store, or just about any business under an EMTALA style system, they'd be closed in a week. Anyone can fill their gas tank, and if they pay you, great, if not, sorry. Food? Take what you want, pay if you can. It would be utter chaos.
It's insanity, really. I am flabbergasted that anyone involved in how EMTALA was set up back in the day couldn't see that the structure of it would be impossible to sustain.
Obviously, E isn't the only factor dragging US healthcare into the vortex, we could talk about poor lifestyle / diet en masse, lack of education among the population on appropriate health care resource usage, etc etc. E just happened to be what I was specifically pondering on my commute that ties into your post.
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u/Forward-Razzmatazz33 23h ago
It's really not EMTALA though. The masses that use the current system could probably be discharged with follow up. Most people are not having an emergency medical condition needing stabilization.
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u/Silent_parsnip8 23h ago
Agree, I don't think EMTALA is necessarily causing hospitals to go broke but rather it is contributing significantly to burn out, workload and is overall cumbersome.
If I could just tell the stable patient with a possible surgical conplication to drive 30 min down the road to the hospital where they had the surgery instead of getting stuck in our ER for hours to days at a time while trying to transfer would be a good start.
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u/fayette_villian Physician Assistant 21h ago
It would have to come with tort reform, and having a medmal jury be made only medical professionals, as well a removing satisfaction as a metric and repeal of the starka act.
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u/Nishbot11 ED Resident 9h ago
100%. I’d go a step further and say EM providers should be immune from simple negligence med mal. Instead of having to scan everyone in case of that 1% miss, you can rely on clinical acumen more. The cost savings and wait time reductions would be tremendous.
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u/robotanatomy 21h ago
Right. EMTALA was set up but the structures needed to support its success were not.
EMTALA is only sustainable when most people have better options than going to the ED for non-emergent care. Unfortunately, we don’t have that for a number of reasons.
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u/prefix_code_16309 Radiology Tech 23h ago
Yeah, ran out of time in that post, it's obviously not only EMTALA, but I think it's a significant part of the problem. I tried to acknowledge that it's a larger problem in my last paragraph before I had to get to work.
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u/Ok_Student_740 18h ago
We learned that first week or two of the Covid lockdown, with people too scared to go get their turkey sandwiches and ginger ale. My ambulance call volume dropped 90 percent.
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u/Rose76Tyler 5h ago
You forgot to add...that rubber hotdog spinning on the grill? $10,000. And we'll tack on the mustard for another $2000.
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u/bananastand512 23h ago
I'll say it again (as someone who works rural) ... voting has consequences and this is what red areas voted for (cuts to waste, fraud, and abuse).
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u/Forward-Razzmatazz33 23h ago
Don't worry, they'll be told that this is the natural progression of Obamacare and they need more red representation or else it will get worse. And they will buy into it because the alternative is 3 high school trans athletes in the junior varsity high jump.
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u/bananastand512 23h ago
Oh I'm well aware how this will play out. Difference is they just won't have healthcare and will still have trans athletes in schools. I will gladly go back to big blue city ER nursing and continue to have access to healthcare while happily hanging out with my trans friends.
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u/Sunnygirl66 RN 20h ago
Only problem is, we’re gonna be inundated by all those rural folks, driving or catching ambulances to our EDs, just like during COVID.
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u/organikmatter 22h ago
There’s truth to that. But there are also many supporters of expanded health care in rural areas. It’s not a monolith. Since the whole US is technically red right now (having won the last election), we’d all deserve the consequences by similar reasoning.
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u/bananastand512 22h ago
I voted for a chance at Medicare for All so, no, I don't think I asked for these consequences.
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u/organikmatter 22h ago
That’s what I mean though. Rural counties have sizable populations that voted like you did. 30-40% in the areas I work. Those people don’t deserve to lose their healthcare.
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u/bananastand512 22h ago
They don't, but they also more or less choose to live in these areas. I understand some can't leave due to family, work, or various personal obligations, but it's not super hard to find a job in a big city and move an hour away. It might be more expensive to live in the bigger city, but wages and opportunity tend to be higher.
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u/aplayonturds Physician 21h ago
By the same logic, we choose to live in the US so we all deserve what’s happening with the federal government, even if we didn’t vote for this administration. I understand your sentiment but as someone that lives in a rural area and worked in critical access rural hospitals for many years, rural people don’t just leave where they live. My sense is that it’s fundamental aspect of who they are.
I used to live in a poor Black city, where there was a constant stream of terrible violence coming from the segregated parts of the city that were pretty much 100% Black and bereft of many services, and I can’t tell you how many times I heard hospital staff say “I don’t understand why people don’t just move”. Whether it’s that they won’t or they can’t, it’s oftentimes not as simple as just deciding to up and leave your life.
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u/adoradear 16h ago
I’m sorry to tell you, but to the rest of the world, you’re just as responsible for those consequences as you view the rural population to be. The PP is right - you’re all considered red to us bc you voted them in, just like you consider all rural folk to be red bc they voted them in.
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u/Tony_The_Coach 1d ago
a lot were bought by bigger hospital chains in order to feed them patients. made sense even if the smaller hospital had a negative margin.
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u/Silent_parsnip8 23h ago
Just curious if you're familiar with this process. Do the bigger hospitals strip down the smaller ones to streamline them to make them transfer almost everything to the mothership?
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u/subtlelikeabrick0 23h ago
We have to have a 911 ALS truck come transfer every single patient who needs an ultrasound to the larger facility 20min away. Every time. That's what's available.
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u/justavivrantthing 23h ago
From my experience, I worked for a tertiary system. And it grossed me out. They purchased a local failing hospital, but when I would transport patients for them, you could see how they would transfer non-private insurance paying patients and ones requiring isolation to that facility from the “nicer” campus. Trust me, I was on the receiving end of getting yelled at from several patients who would specifically drive to the “nicer” campus knowing they needed to be admitted. It’s not bc the older hospital had better isolation rooms or different services.
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u/Tony_The_Coach 23h ago
they might “invest” in the first few years. But the smaller hospital ceo will eventually have to make budget. “ no margin no mission” usual BS
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u/avalonfaith 23h ago
And our maternal/fetal mortality/morbidity rates are already abysmal for developed countries. Can also add in the race/ethnicity disparities to take that down further.
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u/blowsraspberries 23h ago
That’s my suspicion. One of my hospitals loses about a service a year since being taken over by large health care system and the answer is always to just transfer.
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u/Comntnmama 22h ago
I last worked for a 20 bed med surg/ICU hospital about 30 miles out of a major city. We have cardiology and Gen surg. We flew out or transferred anyone needing a vent or other consults. I think I saw one vented pt in the ICU in over a year. Great place to work but so many transfers.
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u/Tsjr1704 EM Social Worker 5h ago
Yes, I worked at a rural trauma center before where I currently am at, and they started doing massive layoffs / restructuring right before I left. They were trimming back on travelers (though like an abusive relationship they tend to come crawling back when staffing gets bad) heavily! It's very interesting how many of my coworkers (even now in a dark blue state) are Republican, I don't think they realize how bad our ED is going to get when all the smaller regional hospitals and medical centers continue decreasing their beds. The problem of psych boarders in particular has blown my mind-people with nothing medically going on with them, sitting in a load hallway bed, often suicidal and homicidal, sometimes in deep psychosis, having to listen to a Lucas machine thump down on dying patients in a room next to them / family members wailing over a loss.
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u/MasochistNurse 11h ago
Our L&D closed right after Covid hit. We are a small independent community hospital in a swing state. But don’t you worry, they are evidently trying to make up some lost $ by doing tons of unnecessary testing on every patient who walks through the door.
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u/deliciouscurryboy69 1h ago
OB is being cut everywhere because its an easy way for uninsured and under insured patients to get into the hospital. EMTALA is essentially an unfunded mandate, and any bean counter on the hospital admin side is gonna shut down open doors like that. Follow the money in US healthcare and youll usually find your answer...
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u/edwa6040 RN & MLS (Lab Tech) 3h ago
20-30K per year is small? Man ive worked at a place that was like 3 to 400 er patients per year. Hell a hospital in the county near me has like 1 or 2 er visits per week is all.
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u/heyinternetman EM/CCM/EMS Attending 1d ago
They just need to pick themselves up by the bootstraps and get that hospital back to work