Not suprising

Saw this on Yahoo today:

http://news.yahoo.com/s/ap/20090401/ap_on_re_us/frequent_er_patients

I can tell you that for those of us who work in Emergency Rooms this is not surprising in the least.  This is a phenomena which is spoke of often amongst myself and my colleagues.  And while it is commonplace to us in the ER, it is something that comes as a complete shock to many lay people with whom I find myself discussing my job.

They find it astonishing that people use the ER for anything other than emergencies.  I in turn, find it astonishing that they think it is so astonishing.

What people might also find asonishing is that while the article attributes mental illness and homelessness as a major factor in these few patients with incredible numbers of ED visits, I dont find this to always the case.  Its easy to assume that people who "do this" must have "problems".  They cant have insurance or private Dr's or their own homes.   Unfortunately, this just isnt the case.

Here in Suburbia, right off the top of my head I can think of at least 5-6 patient who are seemingly "normal", productive members of society that I see in the ER at least once a month.  In my world, while just as prevalent, ED over usage is not as simple as mental illness, homelessness or uninsured.  As I have discussed in this blog before, it is multi factorial with no simple answer.

Just ask married, mother of two, kindergarten teacher that I see AT LEAST once a month for chronic back pain and frequent "sniffles".  Astonishing.

Head Injuries

Check this out:
http://www.cnn.com/2009/HEALTH/03/26/head.injury.emergency/index.html

I've worked a few shifts since the Natasha Richardson tragedy and I can tell you, pieces like this are FREAKING people out.

It speaks to a previous post I made that we are seeing a noticeable increase in patients with seemingly minor "head bumps" coming to the ER for "their Cat scan".  I've had at least 3 patients specifically mention Natasha Richardson in their histories as they describe their relatively minor injury.  They go on to speak of "dizziness" and "nausea" and "horrible headache" which are serendipitously the "warning signs" flashed on the screen with every report of this rare, horrible accident.  They all go on to ask for their "Cat Scan" because "they just want to make sure".

Sounds easy enough, right?  Just do the scan and be done with it.  Unfortunately though, its not that simple. (it never is)  But alas, I'm not going to use this post to berate patients for overreacting, nor am I going to rant about the resulting overuse of CT scans.

No, what I'm going to do is speak to the CONSTANT irresponsibility of the media while reporting on medical issues.  The Natasha Richardson case is a perfect example.  John Ritter is another.  The tone of the articles are always less informative and more sensational.  Aimed not at informing, but at shocking.  In the above article, for instance, why is there need to write of the little girl who was hit by the softball and the fact that "Dr. Cohen told us that if we hadn't brought her in Thursday night, she never would have woken up".

WHY?  Why report like that?  Why fill these pieces with this sort of sensational garbage and very little medical fact or valuable information.  Sure, on the video they manage to offer some legitimate advice on when to actually seek out the ER after a head injury, but only after showing this VERY RARE sensational case and then adding "If you're concerned just go to the ER,  IT NEVER HURTS!!"  It never hurts?  Yikes.  See this post and tell me "it never hurts".

I'm still waiting for the piece that doesn't include a horrible, rare, sensational anecdote.  I'm waiting for the piece that actually takes the calming angle of "this is very rare" and that Natasha Richardson was incredibly unfortunate and unlucky.  Or that she most likely DID have symptoms but ignored them.  Or how about a piece that emphasizes that NOT EVERYONE WHO BUMPS THEIR HEAD WILL NEED A CT SCAN?  All of these sorts of things would be beneficial to the public and to the health care system.

But you know what?  No one would watch them.  We don't want facts.  We want sensation.  We don't want to watch the news and be informed, we want to be shocked.  We want 700 stories on the Octomom.  We want Nancy Grace and the 400th story on Caylee.  We want Dancing with the Stars and Rock of Love.  We want Entertainment Tonite and TMZ.  And unfortunately, the media gives us what we want.  Why wouldn't they?

The public's thirst for the sensational has become just one more variable in our medical decision making.   And in her untimely death, Natasha Richardson has become one more hurdle to clear along with Dr. House, Greys Anatomy, and ER as we desperately try to stay objective and provide proper care.

The Tough Ones

WARNING: The following is a touchy-feely, slightly self indulgent post. Read at your own risk. WARNING

For whatever reason I've had a tough run of cases lately. In the last month I've had two patients in their 30's with MI's. I've made new diagnosis of cancer on a 45 year old and I've intubated two kids under the age of two.

Its not talked about often, but I think if you asked a lot EM physicians, most would tell you that the "young ones are the toughest". While its never "easy" to take care of a really sick patient, it becomes especially difficult when that patient is "young". Somewhere deep in our sub-conscious mind it effects us a little bit more. Now, this in no ways suggests that "older" patients get different care. It simply means that as physicians, when a young patient is sick, it effects us more.

I've found over the last few months that while taking care of these patients has been difficult, it has also reminded me why I do this. It has made me reflect on my interactions with patients. Most importantly, it has made me reflect on the role I play in their lives. Each of these cases has led to an interaction with a loved one where I have realized the magnitude of what we do on a daily basis.

In one case, I had been managing a VERY sick child and had finally gotten the patients stabilized. After it was all said and done and we were transporting the patient to the PICU, I had a moment to speak with the parents. I had been speaking to them throughout the case and they had been present so there wasn't much more to explain. I simply told them I thought their child was going to be fine. (which was true) The scary part was over. What struck me was the immediate change this brought about in the parents. The look of relief and change in body language was something I cannot explain.

Realize, I've given bad news. I've saved lives. I've taken care of TONS of sick patients. I've had patients cry, yell, scream, throw things, hug me, kiss me and proclaim everything from "You SUMOFABITCH" to "You SAVED MY LIFE". For whatever reason though, this simple change in body language and look of relief effected me more than any patient interaction I've ever had. EVER. It may have been the subtleness of the change. It may have been the age of the patient. I'm not sure. All I can say is it was noticeable and it effected me.

I realize that to most people who dont do this every day, it might be unfathomable that we would take our duties for granted. That we could possibly forget how much of an impact we have. That we could even for a second lose track of the role we play. Unfortunately though, many of us do forget this. Like anything else, the more often you do something, the less of an impact it has. The more routine it becomes. We are human and we have the same self defense mechanisms as everyone else. We rationalize why someone is sick. We avoid thinking about poor outcomes. We downplay our role. We forget the enormity of what we do.

Whether it for a second, a minute, a week or a career, we all can lose track of why we do this. We show up for shifts and simply start "movin the meat". We diagnose, treat, discharge and admit. We look forward to the end of our shift, our string of days off and our bi-weekly paychecks. We forget about our interactions. We forget about our role. We forget about our impact.

Sometimes it takes a string of "Tough Ones" to remind us.

A little bit of Obama and a little bit of Rush

I saw this on Yahoo today:

Overexposed: Imaging tests boost U.S. radiation dose

I have no issue with the study nor with the implication that physicians are ordering "too many" tests. There is a MOUNTAIN of data which implies increasing use of CT scans. Also, while the data isn't quite as clear, there is an increasing concern amongst the health care community regarding the associated increasing radiation and risks it carries with it.

It also seems there is good reason to be alarmed at physicians ordering tests and profiting off them directly.

Unfortunately, the article doesn't mention two things:

1.) Physicians are not only paid for imaging they order, but also the history they take, the exam they do, the surgeries they perform and the labs they send. When we have a medical system like ours, in a free market society, it is impossible to avoid this sort of conflict of interest. On one hand we are paid for "what we do" and on the other we are expected to at all times make decisions based on the Hippocratic Oath and do only whats medically necessary. And while from the sounds of the article, we as physicians need to do a better job at it, I wish it would have taken the tone that this is quite possibly a necessary evil in our "Free Market Health care System". It would have made for a much more interesting article.

2.) There are MANY factors which have led to the increase in imaging over the last few years and I actually think "Physicians making money off the scans" is the least of them. In addition to our decreasing knowledge of the physical exam and crammed schedules and overcrowding which limits our patient contact (both major contributors), I believe one of the most important factors in our increasing imaging is the medical legal climate. Many physicians unfortunately view sophisticated medical imaging as the ultimate "rule out" and feel like they are leaving themselves far to open to lawsuits if they choose to rely on a good history and physical exam to diagnose patients. They fall back on these scans to protect themselves from the one in a million patient which may threaten their livelihood.

So how do you fix the problem? Bipartisanship, my friends. First, shout to the mountain tops "YES WE CAN", socialize medicine and pay all physicians a salary. You'd effectively eliminate the free market and any temptation to fatten our bottom line by ordering frivolous tests. Second, grab your cigar and oxycontin, give a shout out to Ronny Reagan and pass a law outlawing the John Edwards' of the world. No more plaintiffs whores. Then take away any rights of patients to sue their doctors and give physicians complete medical legal impunity except in cases of gross negligence.

VIOLA! No fear of lawsuits. No greedy test ordering. Less cancer. Everyone wins..........

Thank You

If you had asked me how long it had been since I blogged, I would have said "about a week". YIKES! Its been 5 months. I dont have an excuse, I just havent been motivated to write. Hopefully that will change. Just in case anyone still reads, here's a great story. Its stuff like this that keeps us going.....

I was halfway into my shift when the triage nurse called me to come up front. "Someone wanted to speak with me".

Now, in the city, it might not be a good idea to go up front and explore who it might be. In the suburbs, I was pretty confident I would be ok. I didnt want to make too big of a deal, so without inquiring who it was, I started for the front.

I was greeted by a middle aged gentleman. He had a smile on his face.

"There he is!" he exclaimed when he saw me.

"Hi, I'm Dr. Suburban" I said extending my hand.

"I know! You dont remember me, but you saved my life." he said "I wanted to come shake your hand."

He went on to tell me about his experience. We really hadn't done anything extraordinairy, just followed protocol. What had seemed like a routine patient to most of us in the ER, was anything but to him. We had "saved his life". In his eyes, if not for our intervention, he would have died. We saved his life.

We forget that each and every day we have the potential to give someone more time with their loved ones. We forget just how powerful that can be for people.

On his way out he gave me a hug. A perfect stranger. And I dont mean one of those uncomfortable "man hugs", this was an embrace. It seemed like it lasted forever and when he pulled back he had a tear in his eye.

Needless to say, the rest of the shift was pretty easy.

So when DO I go to the ER????

My last post about the article which articulates the complex and multi-factorial nature of ED overcrowding elicited the following  question from "Anonymous" in the comment section:

"OK, so when should I go to the ER as opposed to my primary care Dr? what symptoms justify or warrant a trip to the er? Thanks."

--Anonymous

Well, the answer to that is very easy.  You go to the ER when it is an EMERGENCY.  Now, the more difficult question to answer is "when is it an emergency?".  That answer is very individual and I cannot define it for you or for society.  In fact, I would bet that if you forced 10 ER Docs to define an "emergency" you may get 10 different answers.  And those are ER docs!  For the general public it becomes much more difficult.

Each person has a completely different idea of what an emergency truly is.  That idea is based on ones lifeview, access to care, education level, health status, financial status and many other facts.  I have posted about our attempts in the ER of empathizing with patients who show up with minor complaints. When viewed from the perspective of patients it becomes easier to see how they could have been perceived as "emergent".

What becomes difficult is when people use the ER and in no way could their issue be construed as an emergency.  I think if you ask most people who work in ER's they would echo this.  It is the reason my post about "Cathy" evoked such response.  There is nothing worse than having to deal with people who are obviously "abusing" the system when you know there are sick people who need your care.

How common is this? I would guess that 3 out of 10 patients I see are simply in the ER out of convenience.  While 30% might seem low, think about it on a larger scale and you may start to understand the frustration.

So the answer, "Anonymous" is very simple.  You go to the ER when you perceive your symptoms be an emergency.  If you're a reasonable person, and you think you're emergent, then by all means, come see me.  I'll do my best to take care of you.  Hopefully either I'll fix ya, admit ya, or tell ya nothing is wrong.  Either way, its my job and I'm happy to do it.  

Just dont show up because you didnt have time to make it to the Dr.'s office.  Dont show up because you think its free.  Dont show up because you've "gotta know now".  And fer crissakes, PLEASE dont show up because your earlobe hurts and you saw a patient on House who died of "earlobinitis".

Wow

If you enjoy ANYTHING about my blog over the last months, I encourage you to read this article published on Slate.com today.

It really is one of the best articles I have read which deals with ER overcrowding.  I wish I could say I wrote it.

I have blogged repeatedly about my attempts to understand and empathize with patients who come to the ER for "minor" complaints.  On the flipside, I have also written numerous blogs about the frustrations of people misusing the ER.  This is a conflict which arises within many ER Docs.  Amongst many great points made in the article is the fact that while it may be difficult to understand sometimes, and frustrating for those of us "in the trenches", it actually turns out that ED misuse is NOT the major contributing factor to ED overuse.

Anyway, its a great article and the authors do a great job of articulating many of the things I have touched on in my blog.  I thoroughly enjoyed it.

Never mind.....

I wrote a post a few weeks ago about House and Greys and ED overusage.  Here is a comment from that post:

cathy said...
Nice theory. I'd like to add on to it.

If you're pretty sure you've got a complicated problem, the LAST thing you want to do is go to your regular doctor.

Why? You call your regular doctor. Now you have an appointment tomorrow (if you're lucky). He decides you need a specialist. Now you have an appointment for a specialist next week (if you're lucky). The specialist decides you need some imaging/lab tests. Those tests get run within the next two weeks (if you're lucky). You don't get the results for a month, which is when you are scheduled to see the specialist again. Maybe you find an answer. Maybe it's more appointments, more specialists, and more tests.

All the waiting between appointments (presumably while feeling poorly) plus all the time off from work plus the travel time to/from plus the "doctor is inevitably running late" time plus all the fragmented care (just to MAYBE get to the bottom of your constant abdominal pain) equals frustration with the current system.

When I have a choice between waiting eight hours for an answer or waiting for nearly two months, I would rather wait eight hours, thanks. I'm tired of doing year-long dances with doctors ten minutes at a time until they finally stumble headfirst into an answer.

WHOA!!!!!

Now Cathy, I'm sure you're a wonderful person, and maybe this was all sarcastic and tongue-in-cheek, but for the sake of this rant, I'm assuming you are serious.  It is disheartening how many people truly believe exactly what you speak of and have no idea the consequences of their actions.

We have become a selfish, "right now" society.  I believe it is one of the main contributors to ED overcrowding.  We have decided that we must have everything from our hamburgers to our medical diagnosis' RIGHT NOW.  It doesn't matter the consequences it may have on ourselves, our neighbors, or our society.  We need to know RIGHT NOW.

People from all walks of life view the EMERGENCY room as one giant "right now" clinic. Simply show up at any time of the day, talk to the magical, all knowing Dr. and he/she will fix you.

Never mind that he/she was trained in EMERGENCIES and has very little knowledge as to the differential diagnosis of your vague symptoms.

Never mind that the EMERGENCY room is for EMERGENCIES.  People consistently show up at ER's all over the country expecting us to cram in 8 weeks worth of tests into 8 hours regardless of the acuity of the problem.  They "cant wait" for numerous doctors visits.  They HAVE to know now.  Their belly has been hurting for 3 weeks but TONITE they NEED to know.

Never mind the fact that the bed you take up could have been used for the septic cancer patient who's waiting in the waiting room.  Her vital signs not bad enough "yet" to bring her back to a room.  So she waits as you, Cathy, take up a bed in the EMERGENCY room because you couldn't stand the multiple Dr.'s visits.

Never mind that by the time we do your 8 hour work up and discover nothing, convince you to utilize the system properly and see your Dr and get you out of the room, she's tachycardic and has a marginal blood pressure and was robbed of precious hours of fluids and antibiotics because you had to know "right now".

Never mind the time spent explaining to you that this is not an EMERGENCY and despite your desire to "know right now", we most likely cannot or will not come to a diagnosis in the ER.

Never mind the fact that those minutes could have been spent deliberating subtleties of an EKG that may or may not have led to a life threatening, EMERGENT diagnosis.

Never mind the time you spent on our CT Scanner getting your pseudo-emergent scan and the time it took to get you off the scanner so we could scan the head of a potential stroke.

Never mind that those precious seconds could be the difference between full recovery and life in a nursing home.

Never mind THOUSANDS of extra dollars it takes to do this work up in the ER instead of as an outpatient.  The insurance companies pay for it.

Never mind the fact that those dollars get spread back to you and eventually forces a single mom to drop her coverage, lose her PMD and leads to her bringing her 4 year old to the ER for an earache thus completing the cycle.

Never mind the fact that the EMERGENCY doctor was looking up the differential diagnosis of your vague symptoms instead of picking up the chart of the "chest pain". 

Never mind that it turned out to be a patient with an aortic dissection who  ended up coding and dying because his blood pressure wasn't controlled on time.

Never mind any of those things, Cathy, because you need to know right now...........

A shame

I've seen numerous versions around the internet recently of this article on Yahoo.  While I understand some parents skepticism in light of the "media blitz" over a few marginal studies done years ago and the occasional anecdotal story, I just cannot fathom making the decision to undoubtedly put your childs health at risk because of this skepticism.

Now, I'm not an immunologist, nor a pediatrician and I cannot claim to be up on the worlds literature regarding the risks of vaccinations.  What I can tell you as a physician, is that vaccinations save lives.  Ask any physician who has been practicing over the last 20  years or so, (before and after the Hib vaccine for instance) and they will tell you how much less often we see things such as meningitis, orbital cellulitis, or epiglottitis.  Again, I cant quote literature, but anecdotally, vaccines work.  We just dont see these entities NEARLY as often as we used to.

The reasoning behind skipping vaccinations obviously lies in parents fears that the vaccines "cause" autism and various other disorders.  I would bet most parents who refuse vaccines are not fully informed as to the "chances" of these vaccines causing those disorders versus the "chances" that the vaccine would prevent a deadly infection.

From my limited experience, it seems many of the decisions to not vaccinate stem from fears bred through either the mainstream media's sensationalizing of a few limited studies OR from parents anecdotal experiences with "a friends child who has autism because of a vaccine".  I always wonder if parents would feel the same if they also "had a friend"  who experienced the horror of watching their child respiratory arrest because their epiglottis was the size of a grape.......

The Phelps Effect

I'm a sucker for the Olympics.  I eat it up.   I love sports and I love "once in a lifetime sports moments".  I'm not a Tour de France guy, but when Lance was going for 7, I was GLUED to the internet.  I hate the Patriots but I was PISSED when Eli ruined "The Perfect Season".  So like a lot of the rest of the country I bought into the Michael Phelps hype, hook, line and sinker.

So a week ago he's racing in "The Relay" and I'm at work.  I had actually forgotten about the race as it was quite a busy night.  I came out of a patients room and noticed about 8 staff members in an open room looking up at the TV.  I arrived just in time to see Phelps finishing his leg.  For the next 2 minutes we stared up at the TV riveted.  Each of us saying stuff like "Cmon, CMON!!"  And "He's not going to do it!  He's too far behind!!"

When Lezak touched and they flashed that American flag we all ERUPTED in cheers.  It was cool, but not the cool part.  You see, in Suburbia we have TV's in each of our patients room AND in the lobby.  So simultaneously, every patient room AND the lobby EXPLODED in cheers.  It was one of the coolest things I've seen.

Gotta love it.