This week I worked 3 12's, I only had 2 patients who were actually sick, even out of the dozens who were admitted, basically because we have to watch them even though we know nothing is wrong for fear of being sued by the one who really does have something wrong.
It seems like half of my patients this week said they called thier PCP and they told them to come to the ED (with BS complaints).
It seems like the vast majority of my patients are seeking drugs or attention or a combination, or they can't see a doctor because they don't have insurance, so our taxes will pay for a $14,000 work up for the WORST HEADACHE OF THEIR LIVES, when they just drank too much last night and ate too many tacos for breakfast (not that I have anything against tacos).
If there has to be a place for these people to go, why does it have to be the emergency room, and why do we have to be so afraid of a law suit that we do a $14,000 work up on everyone when we all know that there is nothing wrong with them. How is that the greedy have taken away all of the power that Doctors have to make a financially intelligent decision. How many tests do we do on a daily basis based purely off of fear of being sued, really think about it. Is there a way to fix it? We have these great facilities in place in order to save lives, but we rarely ever actually do that, all or our resources are spent on the "others." Sometimes it feels like a fruitless waste of effort, and like I am contributing to the further degradation of society as people become more helpless and pathetic every day. It's not that I don't love being a part of the times when we really do help someone that is sick, I just don't understand why we have to spend so much time, energy, effort, and money on people who are NOT SICK.
The Institute of Medicine's Committee on the Future of Emergency Care
in the United States Health System was convened in 2003 to examine the state of emergency care in the U.S., to create a vision for the future of emergency care, including trauma care, and to make recommendations to help the nation achieve that vision. Their findings and recommendations are presented in three reports:
1. Hospital-Based Emergency Care: At the Breaking Point explores
the changing role of the hospital emergency department and
describes the national epidemic of overcrowded emergency
departments and trauma centers.
2. Emergency Medical Services at the Crossroads describes the
development of Emergency Medical Services (EMS) systems over
the last forty years and the fragmented system that exists today.
I have to agree that there is a certain level of disrespect of the ER. I am sure that most can agree the ignorance, although irritating, is not near as maddening as the following:
Being in the ER waiting room with DH having SEVERE pain r/t Crohn's disease and having to stand while another family takes up 14 chairs, grandma in ER, and spending two hours showing off the newest member of the family. Very little was talked about grandma, but boy did they love passing that baby around and making trips to the food court every hour. Poor DH was in such pain and not once was he offered a chair. (and he was admitted and on TPN for a week)
Sheesh. I'm sure that some VERY sick people get missed in the ER because the facilities make their nurses take as many as 15 patients at a time instead of 'closing' beds if they are understaffed. There has got to be a better way to do the ER thing. It is NOT the staff's fault. They do the best they can under some sh**** circumstances. The ER is the place where the poor get social services (beds, food, shelter) because there are not enough services for them to access in our society, and politicians in their infinite wisdom have decreed that everyone and their dog should have access to the ER regardless of whether or not they really ARE sick.....Ugh. I love emergent nursing care, but I sure wouldn't work in a large ER because it has got to be like working in a war zone.
I agree that something needs to be done about the people who abuse the ER. It is these people that make it difficult for those who are really sick to get the benefit of the doubt. I say this because 12 years ago my husband was really sick. I had taken him to the ER and they said it was the stomach flu, gave him 100mg of demerol and promethazine for N/V and abd pain. I took him home and he continued to have severe stomach pain. Took him back 2 days later, saw the same doctor, he said it could be kidney stones and sent us home with a strainer and said to walk to get the stone moving. 3 days later husband still not better, stomach distended, uncontrolable diarrhea and still in pain. Called a friend of mine who is an RN, she called the physician on call, he said to bring him back in. So, went in a third time and the same doctor was working, asked us what we wanted this time, I said "Nothing from you and you can leave now because the doctor on call is coming to see my husband". Husbands appendix ruptured 48 hours prior and walled off in his bowels. Bowels had shut down and he was taken to surgery opened from stem to stern and on antiobiotic therapy for 11 days. So you see I believe that no lab work was ever done because we did not have insurance at the time, we were not trying to milk the system and we were not drug seekers, we just needed the care afforded to those who had insurance.
Now I am not saying that this is what routinely happens in the ER, but those who abuse the system make it hard for those who really need their care.
ND MOM, I think your story indicates the need to take all ER patients seriously. Had your husband died, it would not be the girl-in-the-waiting-room-with-the-hangover's fault, it would be the doctor's fault. The doctor who has decided people who come to the emergency room aren't really sick.
I think the best solution for this problem is to have free, or income-based, clinics. If a non-emergent person comes to the ER for treatment they would be sent to the clinic. Of course, then you'd have the ones nobody thought were emergent who died on the way to the clinic. Perhaps it's just best to make sure everybody stays alive and worry about the money later. Considering potential lawsuits, it seems the most practical way to go. However, the clinics for routine care would definitely take a load off the ER and the budget.
My own thoughts.....This has been debated and will continue to be for ever....When the govt became more involved with health care they pushed it over the edge and now its a runaway train headed down the mountain without brakes..There was a time when if u had a PMD you could call up in the am and usually get in sometime that afternoon...now that Uncle Sam had decided that the PMD's can only get paid a set amount for said treatment our local Family Practice MD's now have to increase their pt load to make up the difference thus eliminating those "open spots" for call ins. When you call hoping to get in you get a message..."if its an emergency go to your local ER"...So those that do have a PMD cant get in to see them for something unplanned...That doesnt include those that have repeatedly been given "DR's List" and encouraged for the 100th time to find a PMD for their chronic back pain..or a dentist for that single rotten tooth in their head...All of that is a BIG problem..another problem for us is the "DUMPING" of LTC pts for this reason or that reason...the most recent one..Pts running a fever.....reported by EMS that according to LTC staff said pts temp upon EMS arrival was 97.6F. So because LTC had reported it as a fever the ER work up had to be for fever...labs...u/a...cxr...dispositing diag...NOTHING Wrong with pt...Then to the other extreme..pt comes in from LTC uros septic because they have been sick for days with fever and no one pursued the obvious...
With the advent of the precious P/G survey everyone is affraid to say what they really need to in order to get some people's attention but something has to be done to restore some order and sense to Emergency Medicine. Dont know if I will see it but I hope it comes to pass...
BTW...10yrs ER exp..and counting...Burnout...lol my flame was blown out along time ago..and not planning on refiring anytime soon...
Maybe the problem is those of us who can see what the problems are and may even have solutions don't have the time or energy to be politically active, we are too worn out from working in the ED!
I think the issue goes even deeper, but I'm not sure that there's an easy solution. I know that on several occasions, I've called my PCP office, only to be directed to go to the ER because they they didn't have any available appointments that day (then of course they get frustrated with me when I disagree that the ER is the appropriate place to go- if I needed to be seen at the ER, I most likely wouldn't be having a phone conversation with the doctor's office nurse because I would already be at the ER). Also, most PCP's are reluctant to give any orders unless they have assessed a patient themselves, which I don't necessarily disagree with. So, you have a patient in the ER with a non-emergent issue that would have been better addressed with the PCP... it's a vicious circle. Also, the ER isn't designed to provide the continuity of care for chronic problems that is often necessary to really resolve a problem, or at least manage it. Then you have the opposite end of the spectrum, the patient's that don't seek medical treatment soon enough and it has dire consequences.
so our taxes will pay for a $14,000 work up for the WORST HEADACHE OF THEIR LIVES, when they just drank too much last night and ate too many tacos for breakfast (not that I have anything against tacos).
and why do we have to be so afraid of a law suit that we do a $14,000 work up on everyone when we all know that there is nothing wrong with them.
My own thoughts.....This has been debated and will continue to be for ever....When the govt became more involved with health care they pushed it over the edge and now its a runaway train headed down the mountain without brakes..There was a time when if u had a PMD you could call up in the am and usually get in sometime that afternoon...now that Uncle Sam had decided that the PMD's can only get paid a set amount for said treatment our local Family Practice MD's now have to increase their pt load to make up the difference thus eliminating those "open spots" for call ins. When you call hoping to get in you get a message..."if its an emergency go to your local ER"...So those that do have a PMD cant get in to see them for something unplanned...That doesnt include those that have repeatedly been given "DR's List" and encouraged for the 100th time to find a PMD for their chronic back pain..or a dentist for that single rotten tooth in their head...All of that is a BIG problem..another problem for us is the "DUMPING" of LTC pts for this reason or that reason...the most recent one..Pts running a fever.....reported by EMS that according to LTC staff said pts temp upon EMS arrival was 97.6F. So because LTC had reported it as a fever the ER work up had to be for fever...labs...u/a...cxr...dispositing diag...NOTHING Wrong with pt...Then to the other extreme..pt comes in from LTC uros septic because they have been sick for days with fever and no one pursued the obvious...
With the advent of the precious P/G survey everyone is affraid to say what they really need to in order to get some people's attention but something has to be done to restore some order and sense to Emergency Medicine. Dont know if I will see it but I hope it comes to pass...
BTW...10yrs ER exp..and counting...Burnout...lol my flame was blown out along time ago..and not planning on refiring anytime soon...
Thank you for this great post. I can't tell you how many times I've had to take a child screaming in pain to the ER for something "minor" because the PMD couldn't fit us in. Remember, you might call at 9 AM, but not get a call back from the office until noon, if not later. I'd try OTC meds while waiting for an appointment, but could not let my child stay that way until the PMD's nurse could call with an appointment time.
For instance, the above situation happened to me once when my son (around 2 y/o at the time) had a fever, was crying in pain and pulling at his ear. Called the doc's office, they can't fit him in until noon the next day. I called later in the day and asked if they could call something in for his ear infection. Nope. Wait til we see you tomorrow. NSAIDs were doing nothing for my child and I called again at about 9 PM begging for pain relief. The answer: "Just go to the ER." I sat in the ER until 2AM getting scoffed at "for coming to the ER d/t an ear infection." When the ER doc saw my son, he put a hook-like device into his ear and pulled out a large ball of pus and said it was one of the worst ear infections he'd ever seen. Thanks to the ER, my little guy got some pain relief and antibiotics.
I guess the point of my story is that, sometimes, the patient HAS tried other routes of care before finally resorting to the ER.
For worst headache of your life you might get--A CT of the head, IV, blood work, UA, blood cultures (very expensive), spinal tap--more cultures. I did this exact work up for someone who didn't even have a fever, was young and healthy did not have have health insurance, did not appear sick AT ALL, but insisted that she was dying and wanted everything checked out. Of course everything came back negative. Now I don't know if this cost $14,000 but I know the CT and cultures alone are several thousand dollars--I do tend to exaggerate though!:chuckle
Uptoherern, RN
337 Posts
It is not only the state that is paying........it is you & I, in the form of taxes.