Patient Rights?

[HCINEPT]

This morning, we had a patient come in complaining of a severe, itching, all over rash (ongoing for 4-5 months), with level 3 pain. She had indicated that she had seen 2 dermatologists, 3 allergists and her family phsyician on numerous occassions, to no avail. She had been prescribed many different anithistamines, antibiotics and prednisone, also to no avail. PT was visibly upset, crying and continually clawing at her skin. PT was well dressed, had excellent insurance coverage, paid her co-pay and explained that her quality of life had been greatly impacted in the past 4 days as the rash and itching had dramatically increased over that time period. Patient had gone to diagnostic center one week prior and no results had been released back to her and she explained that coming to the ER was a measure of last resort and she had already called her doc for an am appointment tomorrow. Triage simply indicated a slight elevated BP and no fever. No other work up was initiated.

ER phsyician entered PT's room, refused to examine her and lectured her about misusing the ER and released her. I felt badly for her and am not sure what to do. She left the ER in tears. As she left, I asked her what happened and she explained that he had been so harsh, that she felt stupid for coming to the ER with what to her was a serious situation. As she left, she indicated that she had a family history of diabetes, non-hodgkins lymphoma (her mother died as a result) and masses on her sisters thyroid and because previous doctor and labs hadn't been able to diagnose her, she had hoped that we could help by admitting her and running a battery of tests to eliminate any of those conditions, since no prior doctor could eliminate them as possibilities. Attending didn't ask her for medical history or personal history, he only repeated to her that she was in the wrong place, because ER's were for trauma, heart attacks and strokes, not "itchy skin". He told her he wasn't an "itching skin" specialist and she should wait until tomorrow to see one.

Based on the patients demeanor, history and lifestyle, I honestly do not believe that she was misusing the ER and that the attending was entirely too harsh on her. I think he should have at least examined her, ran some labs and/or given her a shot to help ease the intense itching until she could make it to her dr. tomorrow.

Am I being too sympathetic towards this patient because I feel I can relate to her (same basic backgrounds and lifestyle) or was the doctor out of line?

[HCINEPT]

Thanks for the responses.

I am new to the ER and wasn't sure what to think. True, I didn't hear the entire conversation. The attending does have a rep for being a hard azz though, so I may have judged the situation prematurely.

Again, your responses are greatly appreciated!!

[classicdame, MSN, EdD]

if he refused to assess me I would refuse to pay for the visit. I would also let the CEO know about it. Wrong attitude, IMHO.

[BrnEyedGirl, BSN, MSN, RN, APRN]

This kind of shocked me!!!!! How can an MD dismiss this without examining the patient. many many diseases have a change in a patients skin condition as a presenting symptom or a symptom. A lot of the autoimmunue disorders have a skin s/sx. The Md should have at least drawn a CBC to look at the WBC ct and perhaps could have run some other labs (ie.sed rate,ANA titer). If he or she could not come up with the cause the least they could do would to treat the symptoms and offer a referral. Do I think that is sub standard care YES..I think it is no care and I would not pay one cent of that bill and would instruct my insurance to do the same. I would also write a letter to the CEO of that hospital.

I am not familiar with this pt or the hospital system involved, but if this pt had been seen at my ER, and she had been using our hospital system for all of her workups, I would have been able to see her previous visits, including all lab results in our computer. If she has been worked up multiple times, and I can see that she had a normal CBC, CMP, ANA etc within the last few weeks, why repeat all this just to make the pt feel better?

I think it's a huge public misconception that the ER is the expert medical care for everything. That just isn't true. The ER staff has specialized training, and yes we are experts in EMERGENCY medicine. We are trained to keep you alive until you can see a specialists in whatever your EMERGENCY is! If you have a major traumatic injury, we can stabilize you until you can get to the OR. We are trained to keep you alive until you can see a surgeon, go to OR, then ICU, then maybe rehab..etc. If you are having an MI we can keep you alive until you can get to cath lab, see a cardiologist, and have a specialist actually fix what is wrong. If you break a bone we can stabilize it until you can see an orthopedic specialist.

The ER is not the place to manage your chronic illnesses. Pt's often get angry at our docs for not wanting to re fill BP meds, or not prescribing antidepressants, or not starting someone on meds for DM. The ER is not trained to do long term management of chronic illnesses! We are not designed to have long term follow up with these pts and from the pts stand point it would be foolish to rely on an ER to manage such things! If you need prenatal care, see an OB, if you're a diabetic, see an endocrinologist. If it's 2am and grandma is unresponsive and has a blood sugar of 20, we can fix that, but she needs to see her own specialists to manage from then on.

ER care is very expensive, because we are there 24/7. We are trained, staffed, and keep the resources on hand to intervene in life threatening/altering situations that can not wait. Seeking out the ER for a second opinion, or med RF's or help with chronic illnesses is a huge waste of resources and honestly isn't the best care for the pt.

[BabyLady, BSN, RN]

This is going to sound like the most, off the wall question, but see if someone can find out if she has been using a tanning bed during those months.

There are some tanning bed salons that use a solution for cleaning (I have never been able to figure out what it is), that when I laid down in them, after a couple of days, I started having a horrible, painful itching that had NO visible rash...my skin wasn't even red, other than where I itched...yet it felt like ants were crawling on me and biting me and it was maddening. Nothing oral or topical relieved it...it was a very strange reaction.

It continued as long as I visited a tanning bed. Later in life (I only go to tan for special occasions) I take my own solution of alcohol and water and respray the bed to get off that residue.

[Creamsoda, ASN, RN]

Its interesting. I worked with a nurse who was diagnosed with I beleive non-hodgekins lymphoma recently. she said that in retrospect, severe generalized itching was a symptom, but wasnt recognized untill after the diagnosis when she noticed a lump. She said she was horibly itchy all the time for the past few years. Your patient had of family history of that, so it makes me wonder. The girl I worked with said that once she had chemo/radiation the itchiness pretty much was gone. I feel bad for your patient. What else can you do when your so desperate?? I would have gone in too if it was me

[Footballnut]

I don't know who does your medical screening exams but our ED MDs do. If this patient did not have a medical screening exam by any designated personnel in your ED she needed one to satisfy EMTALA requirements. According to federal law a patient who presents to an ED has the right to a medical screening exam. Once a life or limb threatening condition was ruled out the MD (or designated personnel) would have satisfied the requirement.

She sounds like she was uncomfortable but I would not jump to any conclusions about her interaction with the MD unless you overheard it. Anything is possible. If this MD is a jerk I would be more likely to draw a conclusion and deal with it on an ongoing basis.

I explain to patients over and over that they will receive a screening exam and get what they need if this is a life threatening situation but I cannot promise that we will find what is wrong. They may need further tests with someone who will manage their overall care.

We see clinic patients all day. It helps pay the bills so we can keep saving lives. We plan for clinic-type patients and accommodate them as much as possible.