Here’s how to endanger and frustrate people going to a hospital emergency room for care. First, increase the number of ER patients and decrease the number of hospital emergency departments. Then cut the number of hospital inpatient beds—this will delay moving ER patients who need to be hospitalized into inpatient beds, which will create more ER crowding. To make things more chaotic, decrease the number of nurses and on-call specialists. Do all this, and you’ll have accomplished what our healthcare system has done—created uncertain, sometimes dangerous conditions in the ERs of even our best hospitals.

Just ask 36-year-old Marnie Abramson. For her, it began with an upset stomach around 8 on a Saturday night. She tried to sleep but awoke at midnight feeling very sick. She called her doctor, who told her to go to a hospital emergency room if she didn’t feel better in an hour. When she didn’t, she went to George Washington University Medical Center.

“When I got to GW at around 2 am, the ER waiting area was packed with 40 or more people,” she says. “There wasn’t a seat to be had. There was a young guy bleeding with a broken nose and a woman who said she thought she was having a heart attack who was filling out a form. I waited an hour and still hadn’t been seen by anyone. I felt a little better, so I thought, ‘This is ridiculous,’ and decided to go back home. Just as I was getting into my car, the pain and nausea hit me again and I started throwing up.”

Abramson, director of marketing for the Tower Companies, a large real-estate firm, returned to the ER, where she waited another three hours.

“Finally, at 6 am I was put into triage and brought to a bed in an ER bay. By this time, I was feeling very weak. I was given an IV and fell asleep. I woke up an hour and a half later at about 7:30 am, and still no one had done an assessment of me. A nurse came in and drew some blood. I passed out, and I woke up and felt sick again. By this time, I’d been vomiting off and on for more than seven hours.”

By 10 am, more than eight hours after she arrived, Abramson—feeling better and able to keep apple juice down—was released from the ER. “As I walked through the waiting area, the young guy with the broken nose was still there. I waved to him and told him I was sorry, and he just shook his head.”

Other than a burst blood vessel in her eye from vomiting and weakness that lasted for a few days, Abramson recovered. She wanted to know her blood-test results to see if they identified the cause of her illness, but in the turmoil of the ER her blood samples apparently had not been sent to the lab for analysis.

“The doctors and nurses were all pleasant to me,” she said, “but they were understaffed and totally overwhelmed.”

Recounting Abramson’s experience is not meant to single out GW’s emergency department, which has a tradition of delivering good care. Rather, it illustrates what’s happening in hospital emergency departments more often. Every ER in the area is overcrowded and understaffed at times, and patients suffer the consequences. As one emergency physician says, “At one time or another, every emergency department runs into serious problems.”

Emergency medicine today is caught in a tug of war. It has made dramatic strides in quality of care in the past 25 years. Emergency rooms once were the province of moonlighting doctors who worked in the ER to make extra money, but emergency medicine has evolved into a recognized medical specialty that requires physicians to undergo extensive training and pass a rigorous board-certification examination.

But as Abramson’s story and others illustrate, hospital emergency departments face increasing problems. The result is that the medical safety net that treats people from all walks of life—the ill and injured, the uninsured who by law can’t be turned away, people with psychiatric, alcohol, or drug problems—seems in danger of collapse.

In December, the American College of Emergency Physicians (ACEP) released its annual report card on the state of emergency medicine. It gave the nation’s emergency-medicine system a C-minus overall and termed it a “ticking time bomb.”

The normally understated Institute of Medicine (IOM) subtitled its 2006 report on hospital-based emergency care, “At the Breaking Point.” Both reports underscore the increasingly distressed state of hospital emergency departments.

The numbers tell part of the story.

Between 1993 and 2003, the IOM report said that the population of the United States grew by 12 percent, hospital admissions increased by 13 percent, and emergency-department visits rose from 90 to 114 million—a 26 percent increase.

Over the same period, the United States experienced a net loss of 703 hospitals, 198,000 hospital beds, and 425 hospital emergency departments. Moreover, patients coming to ERs today are older and sicker and require more complex and time-consuming workups and treatments.

The nation’s hospital emergency system, ACEP said in its 2008 report, is “under more stress than ever before.”

The Washington area is following national trends, but the ER situation is better here than in many other places.

Hospital emergency-department visits are up across the region. In the District they rose from 366,673 in 2000 to 407,719 in 2007, an 11-percent increase—despite the loss of two emergency departments. DC General Hospital, which had 51,491 ED visits in 2000, closed in 2001. Hadley Memorial Hospital—now called the Specialty Hospital of Washington—which had more than 9,000 emergency visits in 2000, quit operating its emergency department.

Fourteen hospitals in the Maryland suburbs had 619,878 emergency visits in 2000 and 767,708 in 2007, an increase of about 25 percent.