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!
Friday, November 14, 2008
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...
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 pay...do 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...
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 pay...do 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!
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...
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...
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