Sunday, December 28, 2008

Why Emergency Medicine Can Add to Health Care Costs....

In America, everyone expects perfection...people want to live forever (or as long as they possibly can). Hence my candid feelings about prolonging the inevitable. Frequently, patients are transferred from Nursing Homes sick...very sick. They arrive with limited information (hopefully a copy of the medical list and a short one page synopsis of their medical history). Unfortunately, many cannot speak secondary to their condition.

Many times treatment decision need to be made rather swiftly, sometimes in seconds, sometimes in minutes and more frequently in an hour or two. The decisions will ultimately add to the costs of medical care and perhaps to their suffering or perceived discomfort. What is frustrating to providers in the ED, is the lack of communication for advanced directives, documents that would help health care professionals determine "how far, and at what costs" patients and next of kin want for care.

All too often in these extreme cases, the patient is too sick or comatose to make such a decision and family members are guilt ridden with making a decision that may ultimately lead to a loved one's death. Unfortunately, families do not always make decisions in the best interest of the patient but rather for the best interest of the psychiatric care of the family - like placing octogenarians on ventilators when there is absolutely no hope of recovery let alone a decent quality of life.

In America, we spend a considerable amount of money near the end of people's life's but, even with health care reform, I can't see the government changing this. Do you really expect Presdient Obama and the rest of Congress to say, "Grandma's lived long enough, time to pull the plug?..." NOT!

Friday, December 26, 2008

The Economy's Impact on ED Visits...

As the year's end approaches, I wonder what the ED will be like. During a recession, people loose jobs and for the most part, their health insurance, which is tied to their employment. Very seldom will people still have the ability to pay their health insurance premiums without employment.

That said, it is a vicious cycle. People loose their jobs, they loose their health insurance and still need health care. But most often, without insurance they do not get routine health care, (except perhaps for their children). Parents tend not to be selfish, and will still provide for their kids at the expense of their own health and needs. People are less likely to take care of themselves and end up looking for episodic care - care when they need it. They forgo elective hernia repairs or perhaps put off having their gallbladder removed because of the loss of insurance.

People also tend to suffer not only financial but also emotional distress. Depression, drug and alcohol dependence, anxiety, etc. increases. The bottom line, society suffers in more than one way. And the impact on the ED - perhaps more visits for sicker and more desperate people who can't afford to pay their bills. They come to an even more expensive health care environment (the ED) to have their needs met.

Whether this will ultimate happen, is yet to be seen. But if the economy continues in a downward spiral with more people loosing their health insurance along with their jobs, the results are inevitable. With the new Obama administration, perhaps more will be insured, but the jury is still out. Financing for health insurance has to come from somewhere, and if that means from public funds either additional taxes, or cuts in other programs will have to pay for a hefty and expensive plan regardless of what the final product looks like...

Wednesday, December 24, 2008

It's Not Always the Obvious...

We clearly see different injuries and illnesses in the ED based on the time of the year. Frequently, during the winter months, we see many viruses that are responsible for gastroenteritis (nausea, vomiting, diarrhea, abdominal cramping and often times fever). Well, it's that time of year and out of 25 patients per shift ,we are seeing at least 5 patients with acute viral gastroenteritis.

Most of these patients need a few hours of intravenous (IV) fluids and some medication given in the IV for nausea. Infrequently, I will give some IV narcotics to help with the pain as long as I am convinced that I am right about the diagnosis with ample warning given to the patient in case symptoms do not improve or worsen. The last thing I want is to think the patient has gastroenteritis and is sent home with appendicitis (it does occasionally happen but you can't CT scan everyone who has vomiting and diarrhea).

Anyway, on my last shift I picked up a chart that read, "Nausea, vomiting, diarrhea for two days." The patient was in her early seventies and allegedly had no medical issues. She fit the picture of every other patient I had seen with similar symptoms that week - low grade fever, blood pressure (BP) was normal and her heart rate was slightly increased which could be a reflection of her temperature. Her examination was benign, she had no tenderness on examination of her abdomen. She appeared slightly pale (but frequently I have seen older patients look pale and yet the have no signs of anemia on blood testing).

I did the usual - IV hydration, and IV medication for nausea, no pain medication (as she had no pain) and re-assessed her. She felt better, had no temperature, her BP was fine and the faster heart rate had improved. I could see many physicians sending her home without performing labs. But I learned a long time ago to at least check people's electrolytes and kidney function with a simple blood test under these circumstances especially with patients in the upper or lower age limits. Her kidney's were not working as well (although that could be normal as people get older) and I had performed a cell count (CBC) to check her white cells (to check for infection), her hemoglobin (a sign of anemia) and her platelet count (needed for clotting). I had noticed a bruise on her thumb and she told be she had been lightheaded and fell a few days ago.

To my surprise her CBC revealed her to have a low white count, dangerous low hemoglobin and dangerously low platelets count. It all made sense retrospectively, but I was surprised at the findings. She subsequently received IV antibiotics, along with blood products and more IV fluids and was admitted to the Intensive Care Unit. I updated her son, who felt uncomfortable with hospitals.

I wasn't certain which came first - her blood work, which suggested bone marrow suppression perhaps form a viral or bacterial infection, or perhaps even early leukemia (her mother had died of leukemia). I thought three days before Christmas...was she going to die, did she have leukemia? I told him, "Your mom is very sick and needs to be cared for in the ICU. I have contacted her doctor and she will also be seen by an infectious disease doctor and a hematologist and will require further treatment and testing." He had no further questions but I wondered if he really understood the potential of her dying in the next few days. If this was leukemia, she would live for a while even without chemo but if it was an overwhelming bacterial infection, she had a high likelihood of dying in the next 2-3 days...and Christmas was in three days. Life is so cruel, but perhaps she only had MDS (myelodysplastic syndrome - a chronic disease that affects most often elderly patients with bone marrow suppression)...time would tell. I'll follow-up to see what happens to her and pray that her family gets through the holiday season.

By the way, this is where mediocrity begins in medicine, especially emergency medicine. For physicians who don't have any interest in follow-up, business ends that day with this patient. You can choose never to do follow-up either in the form of speaking with her doctor to see what happens or checking her medical record to see how she does while in the hospital. I guess for many, you just forget it and go on with your own life, it's easier that way. Go home, enjoy the time with your family and forget about her.

I could never bring myself to practicing this way, but many would disagree. I'll keep her name on a list with others to follow-up and see how she does. Without following up patients after you admit them or discharge them you can never be certain as to whether or not you made the correct diagnosis, and if you were wrong (even though a consultant finds the right answer and the patient does OK), you have not learned from the patient and will continue to make the same wrong decisions...something that happens more often then physicians will admit or will even recognize...there is no room for mediocrity!

Friday, December 19, 2008

The Woes of Emergency Medicine...

First, I find it a huge challenge to write weekly, let alone daily and I apologize - not that anyone has read anything on here. I give people credit who can find the time to write a daily blog. I guess that's why I never could keep a daily diary when I was a kid. The demands of work are great, and when I'm done with a shift, the last thing I desire is to re-hash the last 12 hours.

Years ago, people went into the field of emergency medicine because of a great lifestyle. No call, days off when you wanted them, no pager, you left work and had no other responsibilities. I suspect that for some places, this may still be the case but for me, my work doesn't end at the end of the shift. At the end of my shift, I am still stuck trying to get dispositions on the patients I have seen. The work-up is not complete, consultants have not called me back, I'm waiting for the radiologist to read a CT scan on a patient with belly pain, etc.

Once I stop seeing patients I still need to figure out what to do with the ones I've seen. And even if I know what I'm going to do with them - admit them to the hospital or discharge them home, I still have to complete the paperwork. Since I mainly work in the area of the ED that sees most of the acute injuries and medical complaints, most of these patients are complicated. I'm not talking about a kid with a sore throat, an infant with a fever (although that can be very complicated), or a twisted ankle, I'm talking about patients with headaches, dizziness, shortness of breath (SOB), chest pain, falls, motor vehicle collisions, strokes, loss of consciousness, etc.

In the end, the headache may be nothing but a tension headache or related to stress or anxiety or it may be a brain tumor, a ruptured blood vessel in the brain, or meningitis (infection of the outer lining of the brain). And, the emergency medicine physician's job is to figure that out. Unfortunately, if you are wrong and you send the patient home and the patient dies or suffers ill consequences you more than likely will be faced with a major law suit and end up in court settling a case for a few million dollars (that is of course if your malpractice insurance has greater than one million dollars as it limits). You see, physicians are right if the patient suffers no harm, but once a patient suffers harm, everyone (especially lawyers) puts on the "retro scope" and looks for something that could have been done differently.

Recently, someone asked me what the "standard of care" was in a certain situation. My reply was there may not be a standard of care with every issue since many patients present in so many different ways. There is generally an accepted way to treat patients. You only potentially breech the standard of care if something goes wrong. "Standard of care" is a legal term and can differ in different parts of the country based on resources, hospitals, specialties, etc.

Clearly from time to time I will speak about law suits and other legal issues because in medicine, especially emergency medicine the stakes are high and I practice a high risk speciality. Society expects me to be right 100% of the time and there is no margin of error. That's no different that an airline. The plane has to take off and land safely 100% of the time but in health care, hospitals do not have the same resources and financial incentives as airlines. This is a concept that the public, elected officials, and policy makers don't recognize, or refuse to recognize!

Friday, November 14, 2008

We Don't Live in a Perfect World...

When I decided to go into the field of medicine, I was a young naive high school student who was idealistic. Some of my idealistic traits still persist (perhaps one of the reasons why I choose emergency medicine - so that I could treat all who come to the ED). But part of being realistic is accepting the fact that not all health care providers are idealists.

As an example is the heart attack patient I cared for on my last shift. Physicians (and patients) not only rely on the physician in the ED to care for them but also the nursing, ancillary, and secretarial staff. Unfortunately, the staff may have other agendas. Where we all would like to believe that when you arrive in the ED with a chief complaint of, "I have chest pain and the last time I had pain like this was when I had my heart attack in 1980!" patients do not always receive prompt care. Indeed, this patient presented at the triage desk saying just that and was brought back to a ready bed. We really were not busy and yet for some unknown reason it took the staff over 20 minutes to perform an EKG. Excuses like, "The ED tech is not available, there is only one tech or we can't find the tech," somehow just doesn't cut it in my book when I really need an EKG to diagnose a heart attack. Time is muscle (heart muscle) and if indeed a patient is having a heart attack that can be recognized on an EKG, I need to know as soon as possible to optimize the patient's management. One of the physicians actually said, "Give me the EKG machine," out of his frustration, "I'll do it myself" (knowing full well that he had not performed an EKG since he was a student.

The patient finally had an EKG performed and to no surprise, it revealed he was having a heart attack. The federal government, by way of the Center for Medicare and Medicaid (CMS) tracks outcomes and treatments for certain disease including heart attack for the hospitals nation wide. In this particular case, the evidence is very clear...the earlier someone who is having an a cute heart attack and receives either a medication known as a "clot buster" or is immediately taken to a cardiac cath lab for emergency angioplasty (using a balloon to open up the clogged artery) the better the outcome. In this case, the patient went directly to a cath lab after notifying the cardiologist.

It ceases to amaze me why other people just don't do their jobs. I suspect some of what I see is related to a lack of motivation (an individual issue), perhaps burn out, or a need to feel empowered over others. Regardless, when it comes to taking care of sick patients, I have zero tolerance for such behavior. I might add, I'm embarrassed when I'm faced with such a situation, but sometimes feel helpless.

Fortunately, the patient did well...despite the staffs efforts to be obtrusive!

Wednesday, November 5, 2008

Alcohol....The Good & the Bad....

Well, just finished up a string of night shifts and things just don't get better. It amazes me how many ED visits are linked to alcohol. One night shift (a Saturday), alcohol contributed to 25% of the visits. Take for example the 30-some-year-old who fell outside of his new house after loosing his footing. He didn't have any serious (as defined by life-threatening) injuries but required a plastic surgeon to repair the multiple complex and complicated lacerations to his face and ear (and that cost him a lot, especially if his insurance didn't cover some of the expenses).

Or how about the other 20-some-year-old who was at a party at a friend's house (and I suspected "mouthed off to someone else") and ended up getting punched in the head. He fell and suffered a brief period of unconsciousness. Fortunately, both patients were awake and pleasantly drunk as opposed to the many nasty drunks who present with possible injuries and needed to be sedated for their safety, the safety of the staff and my safety. The last thing I want is getting into a nasty altercation with a nasty drunk in the ED.

Alcohol obviously is not limited to older folks. The same evening I had two separate teenagers come in by way of ambulance. One 16 and the other 19 (both under the legal age of drinking). Both were drunk as hell, one vomiting. When the parents arrived, they were mortified. If you have any children, you can understand getting a call from the ED saying that your child was here and not knowing what to think.

The 16 year old female had a blood alcohol of around 350. To give you some perspective the legal driving limit in most states is 0.08 or 80%, and she was over 4 times the legal limit. Fortunately, she was not driving! As a parent, I pray that I never have to deal with a call from the ED, let alone for a drunk kid. Fortunately, both kids left after giving them some IV fluids, IV medication to avoid them from vomiting again, and a period of observation.

I've had staff members and parents say, "Let them suffer, why make them feel better, teach them a lesson!" That's part of emergency medicine, treating everyone the same, and maintaining an unbiased approach to all patients. Unfortunately many physicians in the field suffer from burnout and end up becoming very jaded in their approach and treatment of patients. The day I become jaded will be the day I leave emergency medicine.

I have been a physician for approximately 20 years and despite much frustration for caring for patients in the ED, I have no intention of leaving quite yet...although the night shifts do take their toll and you often feel sorry for yourself and your life style since many in America have "9-5" jobs, weekends, and holidays off...

Friday, October 31, 2008

Why Do I Make a Big Deal about "EMTALA?"

OK so why make a big thing out of this EMTALA stuff? Well, what EMTALA means is that all comers to the ED must have a medical screening examination to assess the "stability" of the patient.

The "examination" consists of eliciting a history for the patient and an examination. The examination may be directed to an injured area (i.e. the patient's ankle if complaining of a sprain, or a comprehensive examination, in the case of a serious motor vehicle collision). What also is included in the evaluation is any diagnostic tests performed, blood tests, urine tests, throat cultures, x-rays, CT scans, ultrasounds, etc.

If someone presents complaining of "twisting' their ankle, further testing may not be needed or the patient may have an x-ray. However, if the patient is involved in a motor vehicle, he or she may have blood and urine tests, multiple x-rays, a bedside ultrasound, and multiple CT scans; and, all of these tests and the physician's time and services can be billed to the patient, but if the patient does not have any insurance or cannot afford the services, care for the patient (including the evaluation) cannot be denied. And, neither the physician nor the hospital may be paid! Oh did I forget the part about not getting paid but still have the threat of a law suit if I make a mistake...more of that much, much later...

The cost of EMTALA mandated care is substantial for the emergency physician. According to a May 2003 American Medical Association (AMA) study, emergency physicians annually incur, on average, $138,300 of EMTALA-related bad debt. Approximately 95.2% of emergency physicians provide some EMTALA mandated care in a typical week and more than one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week. Physicians in other specialties provide, on average, less than six hours per week of care mandated by EMTALA, and each incurred, on average, more than $25,000 of EMTALA-related bad debt in 2001. Information taken from the American College of Emergency Medicine (ACEP).

What's the big deal? Try going to McDonald's to buy a hamburger and see what happens when you don't have any money to you get a free one, or does McDonald's give out a free hamburger for every hamburger it gets paid for? Now I realize that this may be overly simplistic, but is an economic fact of emergency medicine and health care delivered in the US.

Of course, liberals will scream, how can you deny people emergency health care, it is a right! After all, it's not a right to eat at McDonald's. But I would counter argue that, it is a right for people to eat (perhaps not at McDonald's since the last time I checked most of what's served there has a high fat content) - that could be good for the emergency medicine business (heart attacks, strokes, gallbladder disease, obesity, diabetes, etc.) but only if those individuals can afford health care or are insured with decent coverage. Well, enough for now, as I have to get ready to rest up for an upcoming night shift...

Thursday, October 30, 2008

EMTALA - An Unfunded Federal Mandate...

Since I don't work everyday in the ED, I have decided that on my days off that I discuss some of the many issues in the practice of emergency medicine (EM). Perhaps one of the biggest challenges faced in this field, is a law known as EMTALA. EMTALA is a Federal statutory-regulatory complex, consisting of statutes (laws passed by Congress) and regulations (rules adopted by the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services, to enforce and further define the EMTALA statute).

EMTALA stands for the Emergency Medical Treatment and Active Labor Act (EMTALA) which was passed by the U.S. Congress in 1986.

In the case of a hospital that has a hospital ED, if any individual comes to the ED and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Not written into the law is who will pay for the services. In essence, all ED's and physicians must provide the services regardless of costs!

Wednesday, October 29, 2008

The Beginning...and the Purpose......

I am an emergency medicine physician who works in a busy suburban emergency department (ED) and for now, my identity does not matter. What does matter, is that people need to understand the issues related to emergency care in this country and it is for this reason, why I have decided to establish this site.

Perhaps, someone outside of medicine may eventually understand what it's like to practice in an ED, where care is rendered to all who enter, regardless of race, religion, sexual preference, ethnicity, financial standing, or insurance status 24 hours a day, 7 days a week, 365 days a year and be required to render such care often times free under the laws of our great land.

For now, I will try to blog as often as my busy schedule permits since the majority of ED physicians are shift workers. I anticipate that some of what I have to say will enlighten you about America's health care system - the good and the bad, the successes and the failures. The opinions expressed here are my own and in no way reflect the hospital or my employer's opinions - so much for my disclaimer. That said, I hope that anyone who stumbles upon this blog will at least understand what goes on in health care...