(Today’s post is a continuation of yesterday’s.)
It’s so frustrating to be on the frontlines and see the reality as it really is, as opposed to the fantasy envisioned by others. There is an expression: The opposite of the good is the best. What that means is that in striving for the best outcome, we keep bypassing good enough outcomes. You know it from your own life. If you can’t get to the gym for an hour workout (“the best”), you won’t even go for a 20-minute walk (“the good.”) The problem with this, of course, is that usually we don’t do anything because we are then paralyzed in our striving for the best.
How does this relate to drunks in the ER? Well policy makers went for the “best” policy in their mandate to care for every single human being to our maximum ability. That is surely the intent behind the drive toward “medicalizing” so many human conditions and behaviors. But this “best” outcome can’t be achieved universally within a system that will always only have finite resources.
Our finite resources are: the number of hospital beds, the number of ED beds, the numbers of nurses and doctors. In striving to care equally for all comers, including persons who as a group are in very marginal need of medical help, we are excluding other people. I would have less problem with this result if people honestly discussed it and said it like it is, instead of pretending it is otherwise. Like if people said: sure, let us take care of every person, every time, even if their likely need for medical attention hovers around the 1% mark. His or her 1% need should be equal to everyone else’s. If that was the will of the American people, so be it. But really, no one phrases it truthfully.
No one comes right out and says: really is it worth it to “observe” a drunken person for endless hours and make everyone else wait? Such that the waiting contributes indirectly and directly to worse outcomes for those waiting folks? Saying such a thing would be completely heretical. But let us be completely honest: A drunk person will occupy one ED bed for 4-10 hours. A mom with a cut that needs stitches or a teenager with a broken ankle or a child with a fever, about 30-60 minutes. So that’s 10-20 people/families waiting … and waiting … and waiting … for a drunk person to get sober.
The other unwanted effect of medicalizing these common human conditions is that, over time, regular people start to medicalize these conditions too. Conditions people used to just treat at home, such as being drunk, having a cold, spraining an ankle, toddler falling off the bed etc. are now genuinely perceived to be medical conditions in need of emergency help. So, for example, it is common now to have patients who are merely at home, drunk, but brought in by friends or family. These relatives have internalized the message that being drunk needs a doctor. I have at least one patient like that every single shift.
Of course, if someone actually had to PAY for these services, things would come very close to righting themselves. Suddenly, concerned relatives would think it was just fine for Uncle Bill to sober up on the couch!
I did not working this New Year’s Eve or Day. Which means I got to miss a lot of particularly stupid things. Holidays are kind of like Dave Letterman’s Stupid Pet Tricks, but not as cute, and tons more work. I call it “Stupid Human Behavior.”
Different holidays bring different emergencies. For instance, most emergency physicians have seen at least a few patients in their career, come in on July 4th, with a partial amputation of a finger or two, from setting off firecrackers. But New Year’s specialty is, of course, drunkenness. Unfortunately, all the public drunks now to come to the ER, whereas in the past, they used to just go to a holding room in the local jail.
Every day, in every ER across the country, 1-5 beds are being occupied right now by a “patient” who is drunk. Yes America, all you sweetly concerned innocent bystanders who call 911 because “there’s someone lying on the ground outside the (fill-in-the-blank): liquor store/in the park/on the bench/on the sidewalk.” Did you know they all come to the ER? That is because to us over pampered Americans, clearly drunk people MUST need hospital services! In fact, isn’t it an excellent use of resources is to assign a drunk person their very own 25% RN? See, each RN is responsible for up to four patients. So her skills, talents, time, are needed to serve, I mean treat, a drunk, I mean patient, 25% of her time.
Where did this useful policy come from? You know, the one that has resulted in let’s say, $1,000 expenditure per drunk (with no medical problems) interaction? Well the policy up to about 20-25 years ago was to hold public drunks in a cell in the local jail, until they sobered up and left. Inevitably a person or two died. The numbers were tiny compared to the numbers being held. But still. We decided, as a country that tiny was unacceptable. What made much more sense to policy-makers and politicians was that every single publicly intoxicated person should have a nice, warm cozy, welcoming ER bed to sleep it off. I suppose that would make sense to anyone who DIDN’T work in the ER. Because to those of us on the frontlines, the outcome was super predictable … a lot of beds assigned to drunks, a lot of nurses assigned to drunks, and a huge amount of money utterly wasted on “observing” drunks with no useful medical purpose being served. Oh, and you over there reading this, you who cut your finger slicing cake for the party? Get comfortable in the waiting room; there’s not going to be any beds in the ER for a while. Here’s why:
A drunk will occupy one ER bed for 4-10 hours. A cut that needs stitches or a broken ankle or a child with a fever, about 30-60 minutes. You do the math. So that’s 10-20 people waiting … and waiting … and waiting.
Mom and dad with their two-year old child. He has a runny nose, mild cough, congestion, stuffy, cranky and intermittent fever. You know. A cold. I really try not to be impatient with parents. I figure they are doing the best they can and it’s hard taking responsibility for another human being, especially a tiny one. But this too falls into the category of “really?” Do you really think this needs to be seen in an emergency room at 10 pm?
I guess I was even more irritated because about two minutes after meeting this family, I discover they already went to their own doctor a day and a half earlier (almost exactly 36 hours.) Their doctor put the child on an antibiotic already. So they were seen, examined, evaluated and treated. But it has been a whopping 36 hours and omigod! The baby is not fully well and omigod! What should we do!
So let me tell you, from this small encounter, a few things that are wrong with our American health care system.
1. First off, medically speaking, this child did not need antibiotics. No way. No how. Wrong, wrong, wrong. This child had a cold, plain and simple. Colds are viruses. Viruses are not bacteria, so an antibiotic, which is another way of saying anti-bacterial, is utterly ineffective. Another time we will talk about the actual negative implications of taking antibiotics when not necessary. The implications are huge.
2. Their doctor undoubtedly put the patient on antibiotics for one of two reasons. Probably he was hurried, and it is so, so, so much quicker to write a ‘script than talk to the patient, especially if the entire family does not speak English. Or he took the path of least resistance. Many if not most patients do not believe a doctor who says that antibiotics (or x-rays, or CT, or MRI or blood tests etc) are not indicated. So we doctors learn it is less painful to not have our knowledge base continually trivialized by patients. (I have been asked at least a thousand times in my career: “How do you know it is a cold?” Or similar.) Not to mention keeping the customer happy, even if it is not good for the customer. We Americans have decided that customer satisfaction is an important variable in health care. And customers want tests and prescriptions.
3. The other reason the doctor may have prescribed antibiotics is that the doctor has already internalized such a risk-averse view of the American healthcare environment, that s/he cannot even think competently anymore in this regard. Many doctors now practice as if the 1% chance of something is the likeliest possibility. As in “there may be a 1% chance this is bacterial, so I should treat it as such.” That’s pretty much how it goes, and it is hard to tease out anymore what the doctor really thinks is going on clinically, from his perception and fears about malpractice and patient satisfaction. The doctor is pretty unaware that these factors have wormed their way into his clinical judgment. Because after all, most doctors know a cold when they see it. Except apparently when they are wearing their own white coat!
4. No ordinary, typical people who have to pay actual money to go see the doctor would normally wasted their own time and money like this. In the rest of their lives, normal people make “normal” decisions, taking into account the time and money factor. But these days the norm is to make abnormally ridiculous decisions, which is to run to the doctor. In fact, if people hesitate to run to the doctor, their friends and family are quick to criticize. “Have you gone to the doctor?” So the over-utilization of really expensive resources, which the ER is, is rampant and “normal.” Literally, only one generation ago people did not act like this. Up until the mid-1980’s people did not do this. But then the law changed, and people have internalized that as the new “normal.” More about that law in another post.
So a lady came in who had a C-Section ten days ago, to get her staples taken out. It is impossible for me to believe, despite seeing it every single day, the stupid things people believe or pretend to believe, to get their way. Like if you have just had a baby, that you honestly believe going to the ER to get your staples out is equal and equivalent to following up with your own doctor who delivered you? How is it possible that people believe that? Do you really have to have gone to medical school to know that that doesn’t make sense? So this is how it went.
Lady (with her husband and two young kids plus new-born baby in tow): “I am here to have my staples taken out.”
Me: “You have to go to your own doctor.”
Lady: “I missed my appointment yesterday, so I came here today.”
Me: “Why did you miss your appointment?”
Lady: (whining) “I had all my kids with me and it was the day before Christmas.”
Me: “Well, you brought all your kids here tonight, why didn’t you just bring them with you to the appointment?”
Lady: “I just couldn’t get there.”
Me: (to myself) Another stupid, self-involved person who should not be allowed to reproduce! Isn’t America great? Out loud: “You have to go to your own doctor because has to check you himself. You know. Because you had major surgery.”
Lady: “You mean you won’t just take my stitches out?”
Me: (broken-record me) “You have to go to your own doctor. He has to check you. That’s why he gave you an appointment.”
Lady: “I can’t believe you made me wait here this whole time to tell me that! Fuck you!”
Ah. The American public. So gracious about getting free care. The problem with socialized medicine, which is what the ER is, is that if people don’t pay for things, they don’t respect it. This is a completely obvious fact of life that every person has observed. Those of us who work in the ER, get treated disrespectfully every single day because a huge percentage of people that show up, in addition to being irritable anyway, have been trained to devalue the people and the experience. All day, every day, people expect the doctors and the nurses to be their servant. For free. The worst of them know they have us over the barrel. Wait until I tell you about EMTALA and “patient satisfaction scores.”
P.S. Words an emergency physician does not want to hear from an 85 year old patient (or anybody else) on Christmas Eve: “I just had my penile implant removed. But now it’s really swollen! You have to help me!”
I feel it is the nice thing to do, being Jewish, to work Christmas Eve and Christmas Day. I do it every year. So here I am, in the ER, wondering what will unfold.
This morning I saw a patient, brought in by the manager of the board and care where she lives. The manager is concerned that the patient can’t stay there any more because she is “suicidal.” The patient is an elderly Alzheimer’s patient, who appears to be well put-together and gracious. While I know that she is probably hard to handle at home, in terms of confusion and wandering, I am too experienced to not know that this is a Christmas Eve dump. I’m sure it’s a hassle for the board and care to constantly monitor this lady. And what a relief it would be to not have to do that for a couple of days, especially over the holidays. The quickest path to that outcome, for the burdened manager of the board and care, is to state the patient is suicidal and “can we just keep her here a couple of days.”
From my perspective, on the one hand I really hate the exaggerating that patients or relatives or others use to game the system. ER doctors as a group are much more likely to do what you want if you don’t scam us. We’re actually pretty smart and have a good amount of common sense and powers of observation given that we deal with the public day and night. On the other hand, our country does an absolutely terrible job at helping people in difficult situations. A generation ago, you could essentially drop grandma off at the hospital for a few days. I am not advocating for that for many reasons, including the fact that medicine is infinitely more complicated and expensive than it used to be, and costs shouldn’t be misappropriated. But the need to get a break still exists and hasn’t been factored into the system at all. So people try what they can to get what they need. So instead of the family saying to their family doctor, who they’ve known for years “wink-wink” grandma needs some rest, now the caregiver says “Mrs. Smith has had chest pain and I’m worried it may be another heart attack.” Or today’s caregiver “I am so worried this patient is suicidal.” Never mind today’s Alzheimer’s patient has forgotten what suicide is or how to plan out such a thing. It is completely obvious that is not what is going on, but it’s not like I can say directly to the caregiver, whom I’ve never met, a) either you are lying or b) I get it, you’re tired and you need a break. She knows and I know that wouldn’t get anywhere, plus the “paper trail” already has “suicidal” written on it, which escalates the perception of the severity to the point of having to document like crazy if I don’t pretend to take it seriously. This results in needless tests and hospitalization expenses. A smarter (and more compassionate) use of funds would be to have caregiver breaks built-in, paid as part of the cost of caring for a disease.
This is my first blog and my first entry. I am an emergency physician in the Southern California area. I am here to tell you the good, the bad and the ugly about what really happens in the emergency room. It is definitely not what you think, unless you happen to be an emergency room doctor or nurse.
People always ask me what I think about “health care reform.” It’s impossible not to sound flippant, but the truth is: many of us in medicine don’t care. Because no “reform” currently being discussed will make things better. That is because everyone in a position to change/improve things in our unbelievably dysfunctional health care system, misses the major point. Which is that we Americans spend crazy money on all the wrong things. We could literally do all the right things that people actually need, but somebody credible would have to stand up and explain it to the public and get people behind it. Seeing as the only somebody I could think whom the public might listen to would be President Obama, and seeing as he is kinda busy with lots of other stuff and has never worked in an emergency room, I would be pretty pessimistic if I were you. So you might as well stop following the news now! Nothing really significant is going to happen, except continuing to have higher premiums and more dissatisfied health care workers. The best and brightest no longer aspire to be physicians anyway; those days are long gone. Now we have the solidly somewhat above average. Soon they won’t want to be doctors either.