Field of Dreams
There is a lot of Medicaid money floating around out there, particulary in the pediatric population where a large portion of the patients are covered by the Children’s Health insurance Program (CHIP). To legally acquire as much of this bonanza as possible, my hospital built a dedicated Pediatric Emergency Department which opened two weeks ago. It has been aggressively advertised as a state-of-the-art facility with private rooms and limited wait times. It even has a separate waiting room from the adult Emergency Department and video games for the kids.
There has been both the usual adulation from the press and the self-congratulation from the advocates of everything and anything as long as it’s “for the children.” If we step back from the hyperbole however, in a city the size of ours there are not that many real pediatric emergencies…or at least not enough to justify building a Pediatric Emergency Department. The traumas and critically sick children still come to the adult side (also newly constructed) and as we usually get them up to the PICU extremely quickly, what’s left is mostly urgent care and general after hours pediatrics which is, of course, what the hospital is angling for. It looks to be a stunning success and the new department daily harvests a bumper crop of essentially well children eating up a couple or three hundred bucks apiece of scarce medical resources for mostly minor, self-limiting things that are thankfully mostly relegated to the Physician Assistants.
Build it and they will come and this is exactly what is happening. Why go to some crappy urgent care or the wait at the health department with the hookers and drug addicts if you can sit in a nice room with your children watching MTV on a brand-new flat-panel television while you wait for the doctor? Unfortunately, there are still long waiting times, you just wait in a private room instead of the waiting room, an improvement even if this is not what the hospital has disingenuously lead the patients to expect. Rooms are cheap. Doctors and Physician Assistants are not so real estate has never really been the bottleneck. The most common thing I hear when I am sent to the Third Level of Hell (the Pediatric Emergency Department I mean) to help clear out some of the backlog is the exasperated parent asking the nurse when the doctor will see them.
So the other night after my third twelve-hour shift in a row, I was riding the elevator to the parking deck with a disgruntled-looking tatooed couple and their mullet-bedecked toddler. The mother eyed my hospital identification badge, clearly identifying me as an Emergency Medicine Resident Physician, rolled her eyes and looked disgusted.
“How do you like our new Emergency Department?” I asked, somewhat taken aback by the hostility..
“They made us wait six hours just to tell us our kid has a cold,” snorted the mother, her nose stud gleaming in the soft recessed lighting as she and the putative father of her child stormed out of the elevator.
After the doors closed, another passenger looked at me and said, “Well I guess they shouldn’t bring the little motherfucker in if all he has is a cold.”
On The Other Hand….
I don’t have to tell you how much most doctors dislike patients who are google-based medical experts. Not that we don’t like well-informed patients because we certainly do, it’s just that the internet is so jam-packed with misinformation that without a background in science and critical thinking, two things which are not major selling points of our public schools, it is hard for many people to separate fact from fiction much less interpret their information in the appropriate context. The tendency is for people to view anything they see in a written form as the truth, or, as one of my patients put it about her stack of googled articles about the benefits of large doses of Vitamin C, “If it wasn’t true they wouldn’t write it.”
So it was with no small amount of trepidation that I knocked on the door to a patient’s room whose parents, the nurse warned me, had a whole binder of articles downloaded from the internet. The patient turned out to be a sick-looking, febrile nine-week-old baby who required a full septic workup including a lumbar puncture that was positive for a bacterial infection and who was rapidly admitted for IV antibiotics and supportive care. The mother initially apologized and said that although her parents said the baby didn’t need to come in, she had read some articles on the internet and decided to bring him in anyway.
I looked at her binder and the first article was the exact same one I had skimmed on the internet just before knocking on the door. I guess if you’re going to use the internet you may as well use it right.
During my history, I asked if the baby’s vaccinations were up to date. The mother looked embarrassed and said that her parents were against vaccinations and had told her not to get the baby his shots but that she had decided to do it anyway.
“My in-laws are retarded,” Explained the father.
Hope Springs Eternal
I have never seen a sicker patient who wasn’t actually dead or heading that way shortly (e.g. the typical 92-year-old cardiac arrest who looks like a cadaver but who we try to resuscitate anyways). About my age, emaciated, cachetic, profoundly pallorous, and acutely short of breath with any exertion more strenouos than talking. He had what felt like a large, sold mass in his abdomen that started under his left rib cage and seemed to extend into his pelvis. His teeth were rotted, his hair was dry and sparse, he had creepy-looking fungus-like lesions all over his body, and he was covered with a fine layer of what looked like powdered sugar but was actually uric acid salts, an indicator of end-stage renal disease. His chief complaint was hematuria (blood in his urine) but if there was any urine in his blood I would have been suprised. His serum hemoglobin, a surrogate marker for the amount of blood in the body, was 3.9 or about the blood content of a medium sized yorkshire terrier. And yet for all that he was alert, cheerful, and a fairly pleasant guy.
“Do you have any medical problems” I asked.
“No,” he said.
And he was technically correct because a search of our records and those of the other major hospital in town showed that this gentleman, a lifelong resident of our city, had never so much as visted the Emergency Department. Apparently he had been getting sicker and sicker and, like most guys, initially decided to ignore his symptoms but then got so used to being tired and worn out that he forgot he had ever lived any other way.
“I’ve got a good one for you,” I said to the tired medicine resident who was down in the department admitting his sixth vague abdominal pain of the night.
“Ooh, let me guess, another bogus chest pain,” he said wearily, “I can barely contain my excitement.”
“Naw,” I said, “This guy is the real deal.”
I explained the particulars of the case and the resident perked up a little.
“And get this, he has never seen a doctor. He’s terra incognito, man! Virgin territory. You’ll be the first guy to plant the flag, kind of like Neil Armstrong.”
“What studies have you ordered?” the resident asked.
“Not a whole lot,” I said, “We’re going to transfuse him but other than that…well…knock yourself out.”
“I love you, man.”
22 thoughts on “Chicken Soup For the Emergency Medicine Resident’s Soul: Inspiring Stories From the Emergency Room”
What would you think about an educated patient getting into an argument with the PCP on whether 75mg Effexor XR daily raises blood pressure?
Phama reps, say no. Many psychiatrists say yes.
(I have no opinion.Â The only psych med I use on my patients is Haldol.Â -PB)
I really enjoy wit, “but if there was any urine in his blood I would have been surprised”, as for the Ped”s ER, how would the hospital be able to fund it even with Medicaid if patient volume is low?
(The point is that they don’t really need it for the stated purpose, Emergency Care, but only as a money-maker for the hospital.Â Nothing wrong with this but there it is.-PB)
even though patient misinformation from the internet drives me crazy, i would probably rather have that than have a patient completely uninvolved in their health, which seems to be the greater majority of patients, unfortunately.
Haha I’m on my medicine rotation right now… the dreaded CHEST PAIN is 70% of what we get from the ED. I can imagine the excitement on that resident’s face 🙂
wow, I didn’t know someone would be able to make it into the ER on their own with a Hb of 3.9. Wow.
(He came in by ambulance, called by his mother, with a chief complaint of hematuria.Â A normal HGB is around 13 for those of you who don’t know. -PB)
Misinformation on the Internet? There’s a whole lot of misinformation going on in tech schools right now. I had a respiratory therapist bring her daughter into the pediatric emergency department last week, stating that the child was in pain because she was not breathing deeply enough, and therefore not getting enough oxygen to the aching areas of her body. Now I know—according to the Physicianship Training classes that I’ve been taking—that I’m supposed to be a professional and empathetic listener. But when someone who works in the hospital says something as asinine as, “She needs to take deeper breaths so that more oxygen can get to the painful areas upper body,” all I could do was just shake my head.
Wow, so what happened to the last guy? Did he live?
Well maybe we should have let the Dem’s push the SCHIP definition of “Children” to age 25. You’d now be able to offload a bunch of adult patients onto the “peds ER.”
Effexor XR 75 mg can raise blood pressure, although usually a bp increase isn’t seen until 150-225 mg/day.
We opened one of those money-making pediatric EDs-in-the-sky last year. Trauma came about 9 months later. (Just you wait – it’s a fantastic circus.) Ours came complete with billboards all over town (including on a city bus) and a 30-minute door-to-doctor goal. And way too many rooms for all the urgent care crap we see with too few providers. (As I keep telling the man-in-charge, it’s fine for me to carry 10 adult patients undergoing big workups. I can’t carry 10 kids with runny noses and ear infections who only need the attending to sign their paperwork. or at least I shouldn’t – they should go home.) This is a place that trains residents – and we see so much crap that the good (as in helps-me learn) stuff gets really diluted. (I’ve had shifts with NO admissions.) And mostly, what we’ve managed to do is collect people who’ve heard how fast and pretty the new children’s ED is and would rather come there than go to their pediatrician for their cold AND people who bring their already-evaluated and likely unsolvable-in-the-near-future and you-need-to-see-the-specialist-you-were-referred-to problem to the big children’s hospital for the speedy miracle cures they’re sure we stock. Nobody’s fooling us, this isn’t about the children, it’s about the money.
I love this – “if it wasn’t true they wouldn’t write it.” Good grief. At least this patient was actively engaging…
Saw this piece today in the Bmore Sun and thought of you Panda – welcome back!
The good Dr. Jenner is spinning fast enough to turn table legs.
This is why, when discussing any condition with an MD where I have looked symptoms up on the Internet, I open with an apology.
“the virgin territory”
I love that. Coming from a medicine doc, virgin medical patients with actual medical problems are ALWAYS the most enjoyable to evaluate and work up.
Panda – Romney or McCain?
Good man! I’m a Democrat (as if you couldn’t tell from my past posts) but I’d certainly vote for McCain in the general election over anyone else. It’ll feel weird since the last time I voted for a republican at any level was in 2000 or 20002 when I voted for an incumbent mayor of my town.
You (and the passenger in the elevator that said they shouldn’t have been bringin’ the kid to the er) ROCK!
Tch, tch. So doctors dislike their patients getting information off the Internet? Well maybe patients turn to the Internet because they are not getting answers from their doctors. Or in self defense to find out what those powerful drugs can really do to them.
Doctors are ignorant of anything they did not study completely and thoroughly in Med school. Do you want to guess how many years it took them to diagnose my chronic condition as Sarcoidosis? Years and years. But Sarcoid isn’t a popular illness and big Pharma can’t make money off it so why bother?
As an aside, I found a very successful way to treat my BP by taking a herbal substance made in India. It was suggested by a Natropath who happened to be on a message board I belonged to. When I show an MD the results I get a bland look and no questions. At least they don’t try to argue because one can’t argue with success. The BP meds the doctor prescribed made me ill; the herbal supplement doesn’t and it does the job.
The arrogance of the medical profession never ceases to amaze me.
As far as the ER for people of a certain age, health care should be for all. All life is precious. The way we are going we will have a nation of healthy kids and sick adults.
(Please.Â When a patient comes to me and asks me to buy into the latest medical conspiracy theory about, let’s say, vaccines it only proves that a little knowledge is a dangerous thing.Â In your case, I can assure you that you don’t know much, especially how much you don’t know.Â Generally speaking, your doctors, whatever their other faults, are keenly aware of the limits of their knowledge, something that cannot be said for the typical expert patient who has it all figured out and doesn’t have the humility of those who are truly knowledgable.Â I have relatives who know about as much about medicine as I know about quilting (nothing) but act as if they are infallible and will never, ever, say to me, “You know, Panda, seeing that you have the advantage of four years of medical school and three years of residency training maybe you’re right about this homeopathy stuff being a load of crap.”
So you see, it’s not the educated patient, it’s the uneducated patient armed with bogus information that is a chore.
As for all life being precious, this means exactly nothing.Â Is all life so precious that we should spend hundreds of thousands of dollars (literally) keeping a somebody alive on a ventilator and other artificial support for an extra precious month or two?Â You can’t believe this and at the same time complain about the high cost of medical care because precious as all life is, this kind of thing ain’t cheap. -PB)
Well you certainly proved my point about doctors not listening. Half of what you addressed as my post was not in it. Not even implied. And you do not know my background and the extent of my medical knowledge because I did not give it to you.
Exactly what I was talking about.
(Again, whoa.Â I make general comments about things in my articles and my comments.Â You implied that Doctors don’t like internet-expert patients because they have some knowledge that the doctor doesn’t possess and I commented that it’s more often because swimming throughÂ the morass of half-truths and outright misinformation from the internet is tiring.Â There is, for example, nothing I could say to convince you that any number of well-researched, inexpensive, and quality controlled blood pressure medications are probably not only more effective but safer and cheaper than your Chinese herbs but you won’t listen.Â You know it all.Â It’s the nature of our egalitarian society where everyone, from the pool boy on up disdains the very notion that he might not know everything.Â The only people who I have ever met who openly profess the limits of their knowledge are physicians.
On the other hand, we know what we know and within the confines of our knowledge, to include an understanding of the methods and principles of science and reason, we know more about medicine than ninety-nine percent of our patients….and you ain’t in that one percent with yer’ Chinese herbs. -PB)
Another brilliant post.
As a doctor and a pathologist, the only internet printouts I’d ever bring with me to see my doctor would be off PubMed.
Kudos to that brave, brave woman who had the guts to vaccinate her kids against her loony parents’ advice, and who, in looking up things on the net, probably saved her child’s life. But they’re rare.
I have to say that working in a pharmacy, you’ll get the same amount of nuts who come in and preach that all these medications are worthless and only herbs can cure you because someone one some random site said so. I love the patients who come in and have read about some of the medications and have questions about them but not when they think that what they read is everything.
I also have to agree with the expanding the CHIP deal. Though my local hospital has decided to start advertising on TV that its a small town feel and the ER is so fast. What all it did was drag the druggies and chronic ER abusers out to our hospital. What use to take you a short time to see a doctor now takes a hour or two on good days. I think I’ve had to go to the ER twice in 23 years, a broken ankle at age 12 and a broken wrist at age 20. I really hate the people who go in there because their kids have a cold and are demanding the antibiotics or sometimes antivirals.
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