Yer’ Stinking Tax Dollars at Work

(More questions from real readers. -PB)

What’s the Emergency Department Really Like?

The American College of Emergency Physicians and their bogus statistics notwithstanding, the majority of cases we see are not emergencies.   As I have mentioned before, most of the cases we see probably don’t need to be seen at all by anybody in the medical profession in any capacity.  I saw 34 patients last night and half of them were for nothing more than cold symptoms, symptoms that at one time in our nation’s history rational people just accepted without feeling the need to seek medical attention.  Today of course where everything is a friggin’ Emergency and medical care is absolutely free for the asking I walk into many patient’s rooms to find a tattooed, well-looking white chick and her less-tattooed mother waiting angrily to be seen by The Fucking Doctor Who Was Just Standing Around Typing On His Computer While They Waited Three Hours who then breathlessly spin a dire tale of a little bit of a sore throat and a little bit of a cough that is really interfering with the daughter’s two-pack-per day habit or whatever it is she does to lead a fulfilling life.  Either that or it’s a little bit of gas pain or some faint twinge or spasm in the back that has caused a slight discomfort that must be addressed immediately.

That’s a particular species of patient that knows no geographic boundaries, by the way.  Even here in the South where people are an order of magnitude more polite and well-behaved than in Yankeeland we still have the ubiquitous fire-plug of a mother escorting her wan daughter, both of them at various corpulent stages on the road to morbid obesity, who insists that not only is something wrong with the daughter but that every single test and study known to medicine must be ordered to ferret out the problem.  After taking a history, doing an appropriate exam, and telling the mother that her daughter has a chest cold and is going to do just fine, like clockwork comes that cold-as-fish look of disgust and the inevitable, “We want to see another doctor.”

Either that or, “My sister had the same thing and the doctor over at the Quickie Clinic gave her a shot.”

“Madame, the doctor at the Quickie Clinic works at the Quickie Clinic because he’s an idiot.  You’re in the big leagues here and I don’t just give shots.”

Of course I don’t say that. 

One patient opined that he could get served at MacDonald’s in five minutes so he didn’t understand why it took four hours to be seen, evaluated, and discharged.  He was an otherwise reasonable guy and really very pleasant but that sort of highlights the problem with Emergency Medicine and most Emergency Departments, namely that they are largely highly expensive, completely understaffed Quickie Clinics in which some real medicine is practiced from time to time; the twenty percent or so of patients who have real emergencies or legitimate complaints and are part of our core function in the community ironically causing so many delays for the other eighty percent who should have stayed home that, in our insane and upside down world, the various quality “metrics” used to rate how good a job we’re doing are entirely dependent on the satisfaction of irate people who didn’t need to be seen and did nothing but waste either their own money or the taxpayer’s.

There is, as you guessed, tremendous bureaucratic pressure to decrease waiting times and subsequently to increase patient satisfaction which is one of the most important contributing factors to the so-called crisis in Emergency Medicine, a crisis which wouldn’t exist except that there is money to be made in the high volume business of trafficking in minor complaints and very little incentive not to.  Most of our patients, after all, have some kind of insurance and taking money from the government to do what is essentially a well-child exam on a slightly febrile but otherwise healthy-looking toddler is like stealing candy from a baby which is sort of what we are doing (and why the Children’s Health Insurance Program is such a colossal waste of money and a harbinger of what is yet to come when the Sun-King, Ra-Obama, by one gesture of His Mighty Legislative Hand, turns us all into Medicaideurs).

So you can hardly blame the patients.  They come because they are encouraged to come-witness one billboard in town showing a comfortably sleeping baby proudly proclaiming that they are a “Pediatric All-NightER” never mind that it verges on child abuse to drag your healthy looking baby into the Emergency Department at two in the morning to share Cheetos with the crack whores-and they come because there is nothing to discourage them; no obstacle except a little bit of waiting and we have never chased anybody away who had a minor complaint for any reason so mundane as an unwillingness to budget some cigarette money for medical care.

Why is it, by the way, that while I have had many people complain of being unable to afford low-cost antibiotics, inhalers, and blood pressure medications I have never, and I mean never, had anybody cry poverty when presented with a prescription for pain medication?  I could write a wino living under a bridge for three months worth of Lortabs and he’d accept the prescription without demur.   A prescription for Penicillin for his dental abscess?

“Come on, Doc, I ain’t got the money for that.”

So what’s an Emergency Department like?  In reality it’s a little like a miniature hospital onto which has been grafted an STD clinic, an Urgent Care, a psychiatric ward, and a small intensive care unit.  At any time and within ten feet of each other you can have a critically ill dialysis patient being kept alive by pumps and ventilators, a genteel dowager having The Big One, a teenage girl with some vague menstrual cramps, a smattering of varying kinds and degrees of abdominal pain, several people in “Just To Get Checked Out,” and lots of kids and adults with nothing, apparently just in for the novelty of watching a different television and having a nurse at their command.  The only thing we don’t have is an operating room but can the time be too far off when irate patients will opine, angrily, that it’s been three hours and they still haven’t got their appendectomy?

17 thoughts on “Yer’ Stinking Tax Dollars at Work

  1. I am an M1 at Texas A&M and I have read every single one of your posts (some of them multiple times). Believe it or not, I still want to be a doctor, and I am actually considering EM.

    I appreciate your prose because I am walking into this with my eyes open. I fully expect (though at this time I may not fully appreciate) the amount of sucktude that my career choice will have. I still want to do it though, does that make me nuts?

    With respect to EM, I know that EM docs are trained for true emergencies and that primary care is beyond their scope. I hear alot of EM docs complaining about the amount of PC they do. I wonder if the best attitude is to just accept the fact that 80% of my cases will be non-emergent. It may not help foster any change, but at least I will preserve my sanity. What do you think?

    (Just accept it. If I get two or three really sick or challenging patients a shift I declare victory and leave happy. Additionally, a lot of minor complaints do actually need to be seen urgently; things like lacerations, broken bones, and the like. I must reiterate that we do not do primary care. Primary care is a lot more difficult than many of you imagine and why we have (or used to have) Family Practice Physicians. What we actually do is a little bit of critical care, a little bit of trauma, a little bit of internal medicine, a lot of general medicine, and a fair amount of school nursing. In this respect ER doctors are the true General Practitioners of our era. -PB)

  2. Panda, I would really like to know how you think this ew bill will affect EM physician salaries and wages. Also, you ever think about moving to Texas to avoid the malpractice??

    (Louisiana has pretty good tort reform in place. Believe it or not. -PB)

  3. It’s heartwarming to know that 35 yrs. after I started working in this field, morons are still allowed to practice medicine. Not so much that they can have blogs.

    (Why would you say that? Have I said anything that is not true? -PB)

  4. Did you mean “gentile” dowager – or “genteel” dowager? I assume the latter .

    As someone who hates being dragged out of bed in the middle of the night – I cannot understand why anyone who isn’t *very* sick would want to go to an ER (or even a Waffle House) at 3am. Only times I have ever been in that position were – for example – FIL with double pneumothorax – middle aged husband with long-standing FUO (eventually diagnosed) when temp spiked over 106 – me with double over abdominal pain – had internal bleeding and needed immediate surgery – etc. I do recall being in at least one ER that had a sign to the effect – “if you’re not really really sick – you’re going to be waiting a long time to see someone”. Seemed to keep down the number of patients who needed “take 2 aspirin and call me in the morning care” (or less).

  5. Do you think deductibles would fix this sort of thing? Why not put all these people on medical insurance, and simply charge them something for which they’ll feel a little bit of sting when they have an emergency room visit? Even a $10 deductible forces them to chose between that visit and a pack of cigarettes, especially if it’s automatically added to their next month’s insurance premium (or taken out of next month’s welfare check).

    Just a thought….

  6. hhmmmmm…back in the saddle again Panda? Great to see you’re saying the things that we all think.

    I am going to start a new research project at my local shop: i am going to collect all the excuses i get why people need pain meds. After cataloging all the responses i get for exactly 6 months, i will start the competition while will reward one dreg of society a 6-pack of vicodin when i hear an original excuse that is not in my 6month collection.

    i figure we need to reward individuals and encourage their creativity….at least that might make the hours get a little bit more tolerable on my end…what do you think?

    remember….nothing runs like a Deere

  7. Suggestion for the Pandictionary…

    Troll Factor: Survivability is inversely proportionate to social worth.

    Example…If you live under a bridge, have ESRD, Hepatic failure, COPD, maintain a BAL of >350, and are shot 6 times in the chest, you will survive. However, if you are a teacher, police officer, nurse, or physician, your stubbed toe will get infected, develop gas gangrene, and you will die.

  8. Any suggestions for fixing US healthcare? Because the basic facts are not pretty:

    – We spend nearly $7500/year per capita on total health care costs (state, federal & private)

    – That’s 1 1/2 the next most expensive health care system on the planet (Luxembourg), and 2x as expensive as a typical single-payer socialized health system (France, Netherlands, Sweden, Canada).

    – At the same time, by every metric that matters, those systems beat the US in terms of life expectancy, infant mortality, outcomes in a variety of treatable & chronic conditions. We have trouble breaking into the top 30 on any of those areas. In other words, “hosing patients down with money” isn’t working, and we spend metric buttloads of cash only to wind up less healthy than our pinko-commie neighbors to the north, over in Europe, in parts of Asia & Latin America, etc.

    – US Health Costs currently absorb 17-18% of GDP. In 1970, that number was about 10%, and the trend is only up from here.

    – “Administrative Costs” (also known on Wall Street as the Medical Loss Ratio) consume from 15-30% of every health dollar spent in private insurance, depending on the company and region. The Medical Loss Ratio of Medicare, Medicaid, the VA and smaller government programs is typically 4-8%.

    So from a purely pragmatic perspective, we spend a hell of a lot more while getting worse results than most other developed countries on the planet. Spending more only to get less makes most people feel like chumps.

    The Democrats think the federal government can fix things. I have my doubts, myself. But with medical costs predicted to break 20% of GDP by 2017 (and overall medical outcomes not improving one whit), the wheels are clearly coming off the train here. Will we be the first global power bankrupted not by mercenary armies & expensive colonial wars (Napoleon, Britain), but by over-medicating ourselves?

    If the Democrats have the wrong solution, what is the right solution?

  9. Panda, I recently enjoyed a visit to a wonderful emergency room due to immense abdominal pain, diarhea, and bloody stool. I spent five days in the hospital to find out that I had campylobacter. I am not so distressed about the bacteria infection as it was several months ago. However, since leaving the hospital I received bills in the amount of 30K. I certainly respect the fact that the people that gave me the care should be paid however I am a student with no health insurance. I don’t have 30K and frankly I think it is unfair that I should be charged that kind of money without it being disclosed to me first. If I would have known it was costing me $1800 a night, $250 an IV bag, and $200 a 2 mg morphine shot I would never have been admitted. I was in so much pain that I was not in a decision making mental state and my wife is slighty naive about this sort of thing. Is there anything that can be done or am I up a creek without a paddle?

  10. Taylor: I find it disgusting that you’re looking for someone to bail you out (or that at least it’s not *your* fault you racked up $30k worth of medical bills). You mention that you’re in college; I’m sure they offer a health insurance plan. One which you could probably take out student loans for. But rather than do that you would much rather save $3000-$4000 a year. But something happened, and now you expect the government to bail you out because you were an asshole who didn’t want to be covered?

    You save thousands a year on premium and stick others with the $30,000 bill. You got what you deserved.

  11. Xantho:
    First of all you do not know me from Adam, I gave a brief description of the problem. I was not in school at the time (I was in between schools and they do not offer health insurance while you are not enrolled). I was unemployed and looking for work when the incident happened. I only asked if anything can be done. If nothing then that is fine. I am not looking to “stick” taxpayers with anything. Interesting enough you jumped to conclusions and called me inappropriate names perhaps you need to learn some manners. I hope for your sake that you don’t treat people you know with that kind of contempt. If so what a sad little life you must lead.

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