Suck it up, America - ER Doc hits nail on head

[Foxbat]

EMS should be able to refuse patients. Based on our assessment, your condition is not an emergency and does not require ambulance transport. If you are that concerned, feel free to make an appointment with a private doctor or go to the "Doc'n'the box.

But it's not our place to decide what is an emergency and what is not! We can't judge our patients! They can become dehydrated and die if they have diarrhea after eating too much chili, or their diarrhea may be caused by Vibrio Cholerae! Their toothache may be referred pain from MI and we are not educated to decide if it is so! Their paper cut can become infected and their hand will have to be amputated!
</sarcasm>

 

[firetender]

Now That You Got Me Started; Thanks!

Even in an intensive care unit, with our most advanced techniques applied, all we're really doing is optimizing the conditions under which natural healing can occur.

"Our best medicines are Tincture of Time and Elixir of Neglect." Taking drugs for things that go away on their own is rarely helpful and often harmful. We've become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.

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Although I agree with the good Dr.'s points, I want to chime in with a broader perspective. The root of everything he's talking about goes back to the demise in our world (talking USA) of COMMUNITY and the ascendancy of the Medical-legal INDUSTRY; essentially. the shifting of medical empowerment from the individual to the institution.

This has been a provocative subject for me. I started to reply, as above, but then spent the rest of the day (Literally!) exploring it.

The results can be found on my blog: (http://firetender.wordpress.com/2009/10/26/healthcare-reform-the-paradigm/)

I think it's important to see how important are the economic forces of which we're a part.

I look forward to your comments, and Mahalo!

 

[Melclin]

While I agree for the most part with the basic sentiment in the article, I think this doc and a lot of us forget how much we actually know about medicine. We say you should only come in/call an ambulance if it's an emergency. We expect the public to know what an emergency is, but how are they supposed to know? We forget, I think, how little the public actually knows about medicine. And why would they? How much do we know about computer programing, or plumbing, or accountancy?

One of my lecturers did her PhD on why people call the ambulance. She found that there was almost NO correlation between actual medical emergencies and EMS activation. The real reason people called was because they lost the ability to cope with the situation. They, in essence, defined a medical emergency as a medical situation that they didn't feel they could handle. This means if they don't know how to handle a blood nose, then that is a medical emergency in their eyes.

I think better public education is required to fix problems like this. There is an entire division of our ambulance service devoted to educating school age kids and adolescents about appropriate emergency management, including when to call and ambulance. This is a nice step, but in the future we should, and will, be doing more in the way of public education.

Before we complain that the public doesn't know when to call an ambulance, we should try actually teaching them. Its not as easy for a lay person to know these things.

That said, we've all seen people who are just idiots and, education or not, will still call 000/911 when they stub their toe. I noted that he said in his article that many were brought in by ambulance, which makes me wonder why EMS is bringing in calls they know are BS. I'm glad we don't have to worry about litigation here and that we have the education to back our decisions when we say, "No you can't come to hospital for a broken fingernail". There's a lot to be said for field triage of BS cases/legitimate cases that don't specifically need care in the ED. Mycrofft mentioned triage to other facilities. We can call local doctors, make appointments and drop people off if needs be. The 000/911 system also has a triage system where they can decide to refer the caller to a GP. But we can do this because our basics have more education than your paramedics and we are not running around suing each other for coffee that is too hot

 

[zaboomafoozarg]

Turning patients away wont help, I don't think. You need to get them to man up in the first place

 

[46Young]

Making the effort long before something becomes an emergency would cut down on ER over usage. There are minimal to no cost services for mental, pharmacy and health care in all 50 states whether a person is legally here or not. I've actually had quite a few people tell me they are advised to call an ambulance by "friends" so they don't have to wait in the waiting room. It isn't a coincidence they were all welfare or freebie cases. Diagnosis? Good ole entitlement syndrome.

As far as entitlement syndrome, I don't see that changing anytime soon. I've witnessed my fair share of medicaid and welfare abuse. When asking my pts who their PCP's are, I've been told on more than a few occasions "The ER doctor". A taxi ride costs money. EMS txp with a medicaid card does not (at least in NY). A trip to the PCP costs money. Tx at the ER after presenting a medicaid card does not. An individual with commercial insurance pays a co-pay with their meds, the medicaid pt does not. The individual with commercial insurance is deeply concerned with staying current with medical bills, lest their credit be tarnished, or their home be in jeopardy. The medicaid pt usually has no such concern.

Medicare was originally intended to help the struggling individual along until they were self supporting, not as a lifetime source of income. You know, the single mother who may or may not be living with the baby daddy, who is paying money into the household, but shows no record of living there, or any ties to the children otherwise. The mother may be working off the books as well as the father. The city sees the mother as having no income, and gives welfare, medicaid, WIC card, subsidized housing. Meanwhile, the couple is pulling in plenty of cash off the books. Many times I've gone to a residence that has expensive cars, and/or a hooked up apartment with plenty of toys, and then I'm handed a medicaid card. "You my taxi ride". I can't tell you how many times I've heard that. It's also comical because I'm paying for the ride through taxes.

For every legitimate recipient of welfare and medicaid, there are many who abuse the system in some way shape or form, typically by misrepresenting income, by working off the books and receiving additional income from other family members not showing as contributing to the household as a matter of official record.

Politicians will naturally cater to the populations, socially or economically speaking, that will maximize their chances of re-election. Just look at NYC. Everyone knows that if you say and do the right things, are from the right places, play the game, you'll get a free ride. You'll re-elect those politicians who enable/safeguard those programs. I suspect it's the same on the national level.

 

[mycrofft]

Here is a novel thought.

1. Weigh basic, clinical, objective signs and symptoms more highly than patient complaints.
2. Say "no" to complaints unsupported by objective evidence and utilizing ill-affordable money and other resources.
3. If there is a credible likelihood of needing that special test, or the pt has the money and there is no critical limitation to access to the technology, then do the test.
4. Quit worrying someone's going to put one over on you or waste your money, when the key is to act like a parent/adult and just say NO, or YES, based on the truth.
5. The very first time your employer forces you to treat someone based on politics or favoritism, offer to turn the case over to them. Demand a written order if needed. Do not let them start ordering who you see based on fiat and whim.
6. If they persist, quit. They'll sell you downriver anyway with that set of "principles".

7. Oh yeah. Trial judges, quit allowing frivolous suits.

There is a reason professionals and professions are licensed, and that entails saying NO. If you cannot say NO, you are not in a profession.

 

[Summit]

While I agree for the most part with the basic sentiment in the article, I think this doc and a lot of us forget how much we actually know about medicine. We say you should only come in/call an ambulance if it's an emergency. We expect the public to know what an emergency is, but how are they supposed to know? We forget, I think, how little the public actually knows about medicine. And why would they? How much do we know about computer programing, or plumbing, or accountancy?

One of my lecturers did her PhD on why people call the ambulance. She found that there was almost NO correlation between actual medical emergencies and EMS activation. The real reason people called was because they lost the ability to cope with the situation. They, in essence, defined a medical emergency as a medical situation that they didn't feel they could handle. This means if they don't know how to handle a blood nose, then that is a medical emergency in their eyes.

I think better public education is required to fix problems like this. There is an entire division of our ambulance service devoted to educating school age kids and adolescents about appropriate emergency management, including when to call and ambulance. This is a nice step, but in the future we should, and will, be doing more in the way of public education.

Before we complain that the public doesn't know when to call an ambulance, we should try actually teaching them. Its not as easy for a lay person to know these things.

That said, we've all seen people who are just idiots and, education or not, will still call 000/911 when they stub their toe. I noted that he said in his article that many were brought in by ambulance, which makes me wonder why EMS is bringing in calls they know are BS. I'm glad we don't have to worry about litigation here and that we have the education to back our decisions when we say, "No you can't come to hospital for a broken fingernail". There's a lot to be said for field triage of BS cases/legitimate cases that don't specifically need care in the ED. Mycrofft mentioned triage to other facilities. We can call local doctors, make appointments and drop people off if needs be. The 000/911 system also has a triage system where they can decide to refer the caller to a GP. But we can do this because our basics have more education than your paramedics and we are not running around suing each other for coffee that is too hot

Great post

 

[mycrofft]

Second that.

Thanks Melclin.

 

[Seaglass]

1. Weigh basic, clinical, objective signs and symptoms more highly than patient complaints.

Finding the right balance on this one seems pretty tough, though. Sometimes a patient will complain that something doesn't feel right before the real problem becomes apparent, and sometimes basic vitals won't pinpoint that problem. And some providers really don't take any patient seriously to begin with.