Saturday, February 19, 2005

 

Sometimes they don't need it;sometimes they do.

Everyone's familiar with patients who arrived at the ER in an ambulance, but didn't really need to be brought in that way. All they suceeded in doing was generating a $350.00 useless charge, because they spent hours sitting in the same waiting room as the folks who drove themselves in. The ones I do wonder about, though, are the ones who really did need an ambulance, but made it in somehow on their own. It seems like the ER was full of those kind tonight.

The first one was a young lady, two days post-op, who was totally unresponsive when I ran outside to see what all the commotion was about. She was spralled across the passenger seat, wearing nothing but an adult diaper (which was overflowing) and her husband said, "I think she's a little dehydrated." Fortunately, her father had gone to check on her an hour earlier and insisted that she be taken to the ER. Unfortunately, even that wasn't fast enough. Can you say sepsis? Hours later, the husband was still insisting that she "shoulda had some more water."

Number two was brought in (begrudgingly) by her son-in-law. "She says she's having an asthma attack," he says, "but she has them ALL the time." A little later, I overheard her grandson (Little Johnny) on his cellphone. "We'll probably be here a while...Dad says she's really putting on an act this time," he related. I could have approached it as a learning experience: "Hey Johnny!" I could have said, "can you spell V-E-N-T-I-L-A-T-O-R ? Why? Because that's what grandma's using to breathe right now. Instead, all I said was, "I don't really think she's faking it Johnny."

Third was a lady who drove herself to the hospital. Even though she had wrecked her other car a little earlier, she didn't appear to have a whole lot wrong with her at first. Five hours later, though, she looked awfully pale when someone finally noticed her. Now on a normal day things might have gone a little differently. Patients in the triage waiting area are supposed to have their vitals rechecked every two hours. But today, eight people called in sick, and that just didn't get done. It was kind of chilly today and she was all wrapped up in a sheet-- she could have been any other patient who waits for hours with big toe pain. Fortunately, someone did happen to notice her, and one transfusion due to a huge GI bleed later, she might just be OK. I wish I could say that for the other two, but I can't. We only batted .333 today. That's good for baseball...but bad for ER.

Saturday, January 29, 2005

 

I don't know...

"I don't know" must be the stock answer of teenagers these days. Last night an eighteen year-old walsks in the ER:

"What's going on?" I asked.
"Well," she replied, "I'm from out of state but I go to college here. Is it OK if I'm seen here?"
"Sure it is," I said, "we take anybody, any time. What's the problem?"
"I'm pregnant and I was spotting last night, so I thought I'd come in today"
"How far along are you?"
"I don't know."
"Do you have any idea?"
"Well, I guess maybe...oh...three months or so."
"Did you doctor tell you when you are due?"
"Oh...well..I haven't actually been to the doctor yet...but I'm here now."

Thinking back on the past 20 years I realized that things haven't really changed that much after all.

"Will I have to wait long before I see the doctor?" She asked, meeky waiting for my reply.
"I don't know."


 

The Preacher Man

When he was rolled into the ER, he was wearing the preacher's robe...and that's all. That's exactly the way the policemen found him when they arrived at the scene of the church break-in last night. Patient X had been told by "the Lord" that he needed to spread the Word. So, he broke into the church, undressed, stole and donned the robe and preceded to the pulpit. According to the arresting officers, he was preaching "one helluva sermon" up there, prancing around like he was on fire. Did I mention that "the Lord" had also told him that he had no need for the cast we had applied to his broken leg a few days earlier, so he had removed it himself. When I left for the night, he was still in the acute adult pod and had been rather heavily sedated. I'll bet he's in a different pod today-- no doubt he's still spreading the Word.

Sunday, January 09, 2005

 

Who's to Blame for Healthcare Costs?

Who do we blame for the cost of healthcare? I've got a few ideas.

You could probably say the government started it back in the 1940's if you wanted to. At a time when wages were frozen by the government, someone came up with the idea of paying for health insurance to lure in prospective employees. They couldn't give them more money, but they could give them benefits. Suddenly, any job worth having offered health insurance. People simply got used to this benefit and began demanding it, because they were somehow entitled to it. To this day, one of the first questions asked of prospective employers is, "What kind of health plan do you have?" Can you imagine what would have happened if they had decided to pay for your car insurance or house insurance back then as well. You can bet that people would still be demanding those benefits today. I wonder how much they would cost now.

Of course, the health insurance benefit wasn't a big problem at first, because people still had to pay a fair sized deductible and probably 20% of the charges after that. But, it covered catastrophic damages that they never could have covered on their own. You could blame the government again for their interference in the 1960's if you really wanted to. The decade of Medicaid is surely one that changed healthcare forever. Do you remember when the government said, "Why should you doctor's worry. We don't want to change the way you practice; we only want to pay the bills for the elderly. Why should you care where the money comes from?" Of course, we all know what happened next. People really decided to take advantage of this free healthcare and in no time the government couldn't afford to pay for it anymore; not without controlling what services took place and how much physicians would be paid. You couldn't tell the people to stop having those elective surgeries that the government volunteered to pay for, because, by then, the older people had a right to free health care, didn't they?

I guess you could blame the HMO's for the next phase of problems, or maybe you could still blame the government again, because it was really the government's price freezes to combat runaway inflation that brought HMO's to prevalence in the 1970's. I'm even guilty of overusing them myself. The first job I ever had paid for my health insurance, but I still couldn't afford to go to the doctor, because I had to meet a $250.00 deductible first. When they finally got and HMO plan, with a $10.00 co-pay, I went to the doctor every time my nose ran and still didn't spend $250.00 in a year. It was a godsend. After that, no other kind of plan was any good. After all, I was entitled to the cheapest plan, where I could pay next-to-nothing and still get quality healthcare, wasn't I?

So, I sit here now and look at the escalating costs and wonder whose fault the current situation is. The truth, however unpleasant it may seem, is that it's me. I'm responsible for the problem, and so are you. Why? Because of our attitudes. We have somehow come to believe that free healthcare is a right in this country. We still have catastrophic insurance on our houses and cars, but we know that regular, routine maintenance is up to us. Yet, we demand free regular and routine maintenance of our healthcare plan. We got greedy with Medicare too. We were not willing to give up our newly acquired rights to any procedure we desired, even if the government couldn't afford it, but someone had to pay for it. Guess who that was. It was we...We the People of the United States of America who don't seem to care where they money comes from, as long as it's not from our own pockets. The only problem with that theory is that it's exactly where the money does come from...eventually.

Saturday, January 08, 2005

 

One Malpractice Solution is...

Maybe it will provoke a few nasty comments, but since the debate is already as nasty as it gets, I won't lose sleep worrying over it. What's the real problem with malpractice lawsuits? I think it's the incentive lawyer's have to file cases-- specifically the financial gain. Let's just say you were a lawyer. If four potential clients walked into your office one day, three of them obviously wronged by a horrible physician, but there is little chance of collecting a financial reward, and one of them with a so-so case, but a big opportunity for financial gain, which case(s) would you take? Most of you are going to pick the one where you might get the big bucks, right? It makes sense to do it that way. Face it, the "lawyering" business is just like any other business (physician included); if you can't make money at it, there's no reason to do it. Thus, there is a potential for a lot of legitimate cases never getting filed, but plenty of so-so cases being taken to court.

The lawyers have said a few things that make sense. They put up the money for these big cases, spending their own hard-earned dollars while taking a gamble that they will win. If they lose, they get nothing. So, shouldn't they expect to get a big part of the windfall? The problem as I see it, is the gambling thing. If they want to gamble their money, I'd much rather see them put it in the stock market. Then, they could take the cases that really do deserve to go before a judge. Unfortunately, the current system allows them the possibility that they might make millions. Take away that possibility and you take away the incentive for lawyers to choose cases based on possible large financial gains. The one thing that you don't take away, though, is the financial gain of a legitimate victim.

So, just how do you do that? Never let it be said that I didn't bitch and moan about something without proposing an alternative. Each possible case should be brought before a panel consisting of one judge and two medical professionals. Those that have merit will be assigned to a court-appointed attorney, and they will be reimbursed at a rate to be determined by the state. The courts must also approve expenses for each case (including expert witnesses, etc.). All lawyers will be required to serve in this capacity at some point in time, as will all physicians. It will be considered a part of their duty to their fellow man. Cases will still be tried, witnesses called, juries convened, and awards made. But, the financial incentive to pick cases based on money, rather than justice, will be eliminated.

Now for the last point-- before you get all huffy and start screaming about how silly this is, how it could never happen, and condemning it for its faults-- why not propose your own solution? It's easy to scream about how awful someone's proposal is; it's a lot harder to bring one of your own.

Saturday, December 18, 2004

 

No Good Way to Tell Her

It must have been troublesome, all that waiting and not knowing, while folks in the background tried to figure out a good way to tell her just what had happened. It was busy, you see. Lot's of trauma on Friday-- the trauma bays were fulls, the rooms were full, the waiting room was full...but she was only there because her husband needed some blood drawn. She would have been back on Monday, though, because her husband was scheduled for surgery then.

Unfortunately, his time ran out. Somewhere between "ball up your fist" and "you'll feel a little stick now" his heart decided to stop cooperating. It's a little unusual to hear a code called from that part of the building, and the response was fast, but by the time he got to the ED he was long gone. Meanwhile, his wife fluttered around, passed from one employee to another while folks behind the scenes scrambled to "set things up." You see, you just don't walk out into hallway with the "We did the best we could do" speech like you see on TV. We have to put the family in a nice little room, filled with councilors and shoulders to cry on, but...all of those rooms were already taken. So, it took a good forty-five minutes to find an unused space and set up some new place for the family to go. To top it all off, this woman was a hospital employee-- not from the medical side, but a "big whig" in the accounting department. So, the entire administration wanted to be on hand, offering their condolences. That means it had to be a a nice, big, and politically correct place as well. The whole thing started getting so big that I would not have been surprised if they had ordered in some food and waited till that got there to tell her. And all that time she sat lonely and afraid, tears streaming from her face, wondering why on Earth no one would tell her anything. I felt a little like the desk clerk at the hotel, because I wanted to say, "I'm sorry ma'am, but your room's not ready yet."

Sunday, December 12, 2004

 

How to make your life easier...

Four exams, three papers, a lab report and two Powerpoint presentations in one week...of course I avoided doing the laundry, because folding shirts just took much too long. I had even started putting everything on hangers, (yes, even the t-shirts) because it took less time. Unfortunately, my closet was getting way too full. What could I do?-- Then...I found this:

http://www.albinoblacksheep.com/flash/fold.php

Viola!!! All my concerns were over in a flash. Now, laundry time is my favorite time of the week. Unfortunately, it doesn't last long enough now and I sometimes have to wash clothes twice a week. Who'd have ever believed it!

Thursday, November 25, 2004

 

The "Regulars"

They're the "regulars". You know them by name. You know their illnesses. You even know what day of the week they are likely to arrive, and during the winter, they visit you more and more often.
Mary [not her real name] lives forty miles from the ER. She works weekends as a prostitute, but doesn't have transportation into the city, where the johns are, so she uses the next best thing...the EMS system. On Friday mornings, she inevitably has a sickle cell crisis, and calls EMS for transport to the city. After several hours of moaning and groaning, when it gets near dark, she heads out to the streets and hooks for the weekend. Then she gets a ride back home-- sometimes from her grandmother-- but if it's been a good weekend, she'll hail a cab. Did I mention that Mary is still a teenager?
Bobby [another fake name] comes in on Fridays as well. He tries his best to get admitted for the weekend, but he's more than happy to sit in the back hallway waiting area and watch TV for a day or two. IN fact, he has his own dedicated seat. He's used it so often that it is molded to shape of his butt, and no one else can sit in it comfortably. But, to Bobby, it's fine. And if he doesn't get admitted he still gets to eat, because someone is always jumping up when there name is called and forgetting the last few bites of his bacon double cheesburger. Nevermind...because Bobby will finish it up for you, and throw away the wrapper. You see, he doesn't like his room to be messy. I'll bet he's been like that since he was a kid.
BTW, what is it with food in the ER? All you have to do is make someone wait for fifteen minutes in the ER and they get incredibly hungry:

PATIENT
How long before I'll be seen? Do I have long enough to go get a taco salad, with sour cream and extra hot sauce?
ME
I think the doctor would probably prefer you didn't.
PATIENT
You know I've been throwing up for two days, and my stomach hurts really bad. Don't you think food would help that?
Now, I've been on the other end of the ER once or twice too, as a patient. Trust me, the last thing I ever wanted was food!


 

We're not a pharmacy...

So, it's Friday night in the ER and it's busy as usual. The Triage rooms are filled, the waiting room is filled, and there's a line of folks fighting to get through the revolving front door. In walks a 50-ish year-old man:

ME
In a formal voice: What is the nature of your complaint, sir?
PATIENT
I need to get my prescription filled.
ME
Ummm...did you go to the pharmacy? There's one right across the street.
PATIENT
I'm on out-of-state Medicaid. Greyhound lost my luggage and they won't fill it. They said you would.
ME
OK...Fill this form out for me and we'll start checking your vital signs in a few minutes.
PATIENT
I just need my prescription filled. That's all.
ME
I'm sorry, but it doesn't work that way in the ER; you have to see a doctor first.
PATIENT
How long will that take? Can't you just take my prescription back to him and have him give me some pills?
ME
No, sir, I can't do it that way. Like I said before, you have to see the doctor before you can get any medicine...and it might take a while.
PATIENT
Well, where is he? I can just go see him now. Is he in the back? [starts walking down the hallway, ignoring me] I'll bet I can find him and he probably just get me the pills, right?
---
10 minutes pass
---
PATIENT
Where'd you say that doctor was? I need to get my prescription filled.
ME
Do you remember any of the conversation we had earlier?
PATIENT
What?
ME
Do you remember when I told you that you have to fill out this form, see the triage nurse, then wait to see a doctor before you'll ever get any medicine? I'm sorry that Greyhound lost your luggage, but in the ER it works this way.
PATIENT
All I need is my prescription filled. If you''ll just quit giving me the attitude and give me my pills, I'll be out of here in five minutes...
...and for the next five hours this same conversation occurred-- every ten minutes. We finally got him through triage, but the wait at the level-one trauma center on Friday night is pretty long for folks who just need their prescription filled. I was never so glad to see midnight as I was then. There were a few times that I started to lose my cool. Such as when I told him, "What part of 'we're not a pharmacy' don't you understand?" and "No, Greyhound will probably find your luggage before you ever see a doctor here." Nights like those, I'd rather be in Pod7 (the pychiatric ward), because even in a crisis, most of those patients are reasonable.


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