I’m sure many of you bristle at the above paragraphs. “We have always taken all comers, and we shouldn’t be turning anyone away,” would be the argument. I am sensitive to this part of our mission; however, we have enormous issues before us, and collectively and as individual departments, we need to examine our problems with an open mind.

In situations such as we find ourselves in now, I believe that it helps to look back at our original mission. The reason the “emergency room” existed originally was to identify, stabilize, and begin treatment for serious and life-threatening conditions. To say that our mission has evolved over the years is like saying that Congress went on a small spending spree this year. Some of this has been for the better, and some has been decidedly for the worse.

On the upside, our collective talents have exploded, and we have become a vibrant specialty that attracts some of the brightest medical students. Our specialty is so advanced now that it is difficult to imagine our humble beginnings of 40 years ago.

While we have evolved, we also have taken on tasks that, while necessary, ideally would be done best elsewhere. How many of you enjoy being the drunk tank for the police, the dentist, the scut-boy (or girl) for the doctors who use the ED as their admitting service, the psychiatric clearinghouse, the homeless shelter, the temporary ICU, the writer of admitting orders, the social worker, the detox clearance station, and the chronic pain doctor?

Individually and in small amounts, these tasks, which are outside our area of expertise and mission, are just a nuisance. Throw them all together into a busy, overcrowded, underfunded department, and they are more than just a nuisance. These things distract us from our true mission, contribute to the dissatisfaction and burnout levels in our ranks, and, most importantly, put patients at risk.

I feel fortunate at my place because, while at times we become overwhelmed, for the most part we get through the day without a major crisis. For many departments, however, crisis mode is the norm, and they desperately need to create a safety valve.

One problem in creating a safety valve is maintaining compliance with the Federal Indentured Servitude Treatise, better known as EMTALA. The University of Chicago quickly learned that EMTALA compliance will be used as a weapon to try to maintain the status quo.