But America’s greatest public health vulnerability–the deteriorating condition of the country’s emergency healthcare system–is being ignored, says Arthur Kellermann ’80M, chair of emergency medicine for Emory’s School of Medicine.

“Despite all the money that is going to homeland security, emergency services has been elbowed out of the way. . . . This is where the most critically injured would be taken. If we can’t stay open, who’s going to provide the care?”

As a doctor on the front lines at Grady Memorial Hospital’s Emergency Care Center (ECC), Kellermann daily witnesses a system pushed beyond the breaking point: harried nurses, patients lined up in hallways, and overtaxed physicians who sometimes dread going to work.

In response, he has become a national spokesperson on the issue of emergency room gridlock, badgering congressional committees, government agencies, and medical associations alike.

“E.R.s are filled to the rafters with ill and injured patients because inpatient beds are full or aren’t adequately staffed,” Kellermann says, standing in the hallway of Grady’s ECC as patients on stretchers are wheeled past. “So the patients are trapped like soldiers on Omaha Beach: They can get in the E.R. door, but they can’t advance any farther into the hospital.”

Ninety percent of hospitals across the country report that they are operating at or above capacity, according to a survey by the American Hospital Association. On any given day in metro Atlanta, several major hospitals may be on ambulance “diversion” at one time, meaning that their emergency departments are so overcrowded that ambulances must go elsewhere.

“Right now, Atlanta area hospitals couldn’t handle an airplane crash, let alone thousands of casualties from a terrorism incident,” says Kellermann.Nationwide, emergency room visits increased by five million in 2001 and are still on the rise–due to aging, population increases, and a growing number of uninsured. One in six Americans now lacks health insurance. Medicare patients are being dropped by their primary-care physicians due to decreasing reimbursements.

Because E.R.s must accept patients, they have become providers of health care for millions who have nowhere else to go. “In emergency departments, we keep redefining the limits of what’s acceptable,” Kellermann says. “Every day it gets a little worse. Administrators think E.R.s are the only infinitely expansible space in the hospital. Somehow, we find a way to stagger through the shift no matter how bad it gets. But there are near misses in all the chaos and flurry that the public isn’t aware of. It’s like two commercial planes that fly less than a hundred yards from each other–only the air traffic controller knows how close it was. That happens all the time in America’s E.R.s.”

Grady, Atlanta’s public hospital and only level one trauma center–and a principal training ground for Emory physicians–has seen a 15 percent increase in uninsured patients since last year. This represents an additional burden of $15 million. “We cannot continue to do more with less,” says Karen Frashier, vice president of public affairs at Grady.

“This is a problem that is threatening access to lifesaving emergency care,” Kellermann says. “In the best of times, this should be deeply disturbing. Now that our nation is engaged in a war on terrorism, it is unconscionable.”

Emory has one of the country’s oldest and largest residency programs in the specialty of emergency medicine. Many of its graduates go on to staff hospital emergency departments throughout Georgia and the country.

“Emergency medicine specialists are highly regarded for their ability to think clearly and act quickly to save lives,” says Kellermann, who oversees the emergency departments at Emory, Crawford Long, and Grady. “We are also big believers in prevention, because we see what happens when prevention fails.”

Kellermann has long made it a practice to take on daunting problems that threaten the common good. A 1980 graduate of the Emory School of Medicine, he holds a master’s degree in public health from the University of Washington. He returned to Emory in 1993 to found and direct the Center for Injury Control, which combines the strategies of prevention, acute care, and rehabilitation to reduce the impact of accidents and injuries.

Two years ago, shortly after being elected to the Institute of Medicine of the National Academy of Sciences, Kellermann was selected to co-chair a committee analyzing the issues raised by the uninsured. He was shocked by the committee’s findings.

“More than 40 million Americans suffer the consequences of lacking health insurance, but the crisis is threatening access to care for 290 million Americans–all of us,” he says. “We share a common destiny.”

The current overcrowding crisis is not caused by uninsured patients using E.R.s inappropriately for minor problems, Kellermann says. “That is a widespread and cruel misconception. Overcrowding occurs when seriously ill and injured patients–victims of car crashes, strokes, heart attacks, stabbings, and other serious health problems–require hospitalization yet cannot be moved to an inpatient unit because no beds are available. And more patients are coming in every hour.”

Emergency room overcrowding is a life-or-death issue for everyone, no matter how rich or well insured, Kellermann warns. “The next time you have a crushing chest pain and are diverted because the E.R. is full, money won’t make a bit of difference because the system doesn’t have the capacity to care for you,” he says.

Kellermann has several ideas for improving the system: Place a few stretchers in the hallways of each inpatient unit to spread the E.R.’s burden. Put limits on the length of time admitted patients can be held in the E.R. before being transferred. Provide financial incentives to hospitals to keep E.R.s open and operating efficiently. And devote a fair share of federal and state dollars to emergency departments. “This is the biggest health threat facing the middle class,” he says, “but the middle class doesn’t know it.”