Thursday, February 4, 2010

Emergency Room Abuse

You would not believe the number of patients we get that are under the age of 25 who are already chronic pain patients. This is a huge problem. It has created a need for a new kind of physician- pain specialists who dole out drugs to these patients with the agreement that they are only allowed to go to the emergency room 2, 3, 4, or 5 times a month. All through high school I had pretty severe dysmenorrhea and have probably dislocated my knee upwards of fifty times.... never once did I go to the ER for either issue. By the time I finally had my gallbladder taken out, the stone was the size of a golf ball and I had been dealing with it off and on for 15 years or more.... never went to the ER.

What makes it ok for some people to think that they need to go to the ER for everything? In this area the majority of the medical clinics have weekend hours. There are 2 urgent cares in addition to our three ER's. From our clientel, I can certainly see that a pattern has been created. Kids whose parents are ER abusers become abusers themselves. A lot of them aren't even med seekers. They are just so ingrained to come to the ER, that it seems they forget there are other options.

Don't get me wrong, there are some instances where I totally understand the situation. Back in the day, you could get your arm casted at your doctor's office. Not these days.. it makes sense to not have two bills to pay. I'll tell you a little secret though, we don't cast it either. We do an xray, reset the bones if needed, and splint it, then refer you to osteo for casting and follow-up. Not that we don't want your business, but you might as well go to the urgent care. They'll do the same thing we will. However, if you require surgery, they'll just send you to us. But really, for the average fracture, one out of every 20 or so might need surgery, and only maybe 50% of those are actually hospitalized... not counting geriatric hip fractures.

On this note, Ducky really pissed me off the other day. Our patients are sooooo fucking spoiled. He was up in arms because his brother-in-law came to our facility for a dislocated shoulder and his entire visit took 5 HOURS!!! 5 HOURS! Even for us this is maybe a little long, but really, come on. In a lot of cities it can take twice that long to even see a bed! Our average door to physician time is less than 30 minutes. Nationally, that is a phenomenal time. Triage is usually less than 15 minutes. I really have no idea how Brother-In-Law's visit went, but I do know that he came in during our busiest shift. First, he would be registered and triaged. Then the nurse would take him to a bed and get his medical history. (We are a 15 bed ER, on occasion, you have to wait for a bed to be available.) Then the doctor would see him. For a dislocated shoulder, they would do an xray to determine if it was anterior or posterior or if there was any fracture with it. They would do it as a portable at his bedside. That usually takes about 15 minutes -but definitely less than an hour- after being ordered as the tech has to be available and they do them in the order they came in, unless there is a critical patient that takes priority- and a dislocated shoulder isn't priority. Then they usually give Versed to temporarily put the patient to sleep while they relocate the shoulder. This is a fairly big thing, as the doctor and the nurse could be tied up for quite some time, so they would wrap up any other patients that are about ready for discharge. Also, this requires a Respiratory Therapist to be at the bedside to monitor breathing and O2 saturation. After the joint is relocated... which can take just a second- or can be difficult to get to go back in, they then do a post-reduction film to make sure that the shoulder is properly relocated. Then they wait for the patient to fully wake up from the anesthesia- this can take anywhere from 5 minutes to an hour. Usually the patient needs a tetanus shot. After injection, they are required to wait 20 minutes to observe for unwanted side effects. Then a registration clerk comes and gets the demographic and billing information*. Then the patient gets their discharge instructions. I would say that the average for this process takes us about 3 hours. Some times we get a tough guy who doesn't need the Versed. Some times we aren't busy and everything just falls right into place. Literally. hahaha.

But 5 hours, door to door, isn't unreasonable and certainly no reason to get your undies in a wad. And I can guarantee, that if they'd gone to The Other Hospital, it would have taken nearly that long for them to even see the doctor. Especially at the time of day they came in. That said, anything over 5 hours and that would be pushing it... but it's an ER. You never know what's going on. Cardiac and respiratory will take priority over everything. Suicidal patients take up a lot of everyone's time. An elderly person with a stomach bug being escorted back and forth to the restroom, is again, time consuming. Your nurse might be tied up running to Radiology to administer rectal contrast for CT, she might have to provide escort for a gynecological exam, or maybe her other patient needs a catheter that's difficult to place. Evening shift has 5 floor nurses, plus triage, plus a charge nurse, one paramedic, and 2 doctors and a physician's assistant. Each nurse has at least 3 patients and might be covering more for someone on break. Each of her patients could have a different doctor depending on when they came in and who was available when they arrived. ED often shares a respiratory therapist with another department. And there is one tech each for CT, Xray, and Ultrasound. A trauma, serious cardiac, or sexual assault patient is one on one with their nurse and she could be tied up with that patient for an hour or more. If there is a Code called anywhere in the hospital, we are required to send a physician and a nurse, possibly our paramedic as well. We don't see a lot of those, so we can't staff for the 'ifs and maybes'. We are a small hospital. Our Ed sees an average of 75 patients a day. Those who aren't critical might have to wait a few minutes. CHS owns A LOT of hospitals around the country, and we are one of the largest they have, but our times are in the top 90 percentages, for them and nationally, and we take pride in that. Those who have to wait a few minutes for something non-critical, might just have to suck it up and realize that they can't come first.

I saw a man in the lobby once throwing a fit because his daughter had a cough and they had been waiting for 45 minutes (this was back in the day when we were seeing 115 patients a day, before there were a total of 3 ER's and 2 urgent cares) It was explained that we had a very critical patient in the back that was tying everything up and he said he didn't care. He flat out said he wanted his daughter treated for her cough, and if someone else needed to hurry up and die for that to happen, then so be it. And that is what Emergency Medicine has come to.

*EMTALA law states that in emergency medicine you can not base the kind of care or speed of care on a patients ability to pay or their method of payment. To protect ourselves from such accusations, our policy is that we don't ask for demographic or billing information until the end of the visit. Prior to seeing the physician you are asked for name, SSN, DOB, phone number for follow up, and of course- a chief complaint.