A young woman came to the ER this past week with a number of vague complaints. She had lightheadedness when she stood up, occasional nausea and had done several home pregnancy tests which were all negative. She had had these complaints for weeks. She had state based health insurance. Unlike those of us with commercial insurance, she didn't have to make a copayment for using the ER as a walk-in clinic. In her defense, she had been unable to find a primary-care physician willing to accept her insurance.
The issue of why she was triaged as a priority 3, which put her on the physician side of the ER instead of the "fast track" for the PA's to evaluate, is a subject for another blog. Her vital signs were normal. She was fit, healthy looking and a cursory exam revealed no evidence of any disease process. A review of symptoms was unhelpful. This pleasant woman asked if I would do some blood tests. I was tempted to decline any testing as unnecessary and more appropriate for a primary care setting. The problem of a dearth of available options for this patient led me to acquiesce to her request. Her EKG, chem panel, thyroid screen and complete blood count were all normal. I referred her to the local health clinic knowing that they would accept her insurance but that she would be given an appointment several months in the future.
This is not an isolated occurrence in the ER. Every shift, I see many patients who could easily be assessed and treated in a physician's office or clinic. The ER staff tries to cope with these less than urgent cases along with the truly sick and injured patients that require emergent treatment.
Chronic pains, persistent skin conditions, medication refills, and management of long-term illnesses such as hypertension and diabetes make up some of the non-urgent problems arriving in the ER. Patients with a physician inexplicably show up in the ER within 24 hours of a scheduled appointment to deal with their problem. This pattern will be familiar to anyone who works in an ER.
Over scheduled primary care offices send patients to the ER as a convenient source of labs, x-rays and treatment. Call a pediatrician at 2:00 AM and tell him or her that little Johnny or Susie has a fever and more likely than not the concerned parent will be told to go to the ER. The reasoning is understandable. The doctor may have a full office the next day or it is the weekend and the office is closed. Fear of a malpractice suit based on advising the parent by phone and the child does poorly or dies, is also a valid reason to direct the parents and child to the ER.
Patients arrive in the ER by ambulance and through the front door. The ambulance patients are usually more seriously ill or injured. A significant percentage of ambulance patients simply use the ambulance as a free taxi ride. One's insurance determines who ultimately pays for inappropriate ambulance use. The non urgent patient who arrives by ambulance often expects the hospital to pay for a taxi to return them home. This cost is not recouped. The federally mandated requirement to provide translation services to all patients is also not compensated. The financial viability of community hospitals is tenuous. Free care, expensive "language lines", feeding and warehousing psychiatric patients for days, and taxi vouchers all adversely effect a hospital's bottom line.
Like all my readers, I am a tax paying citizen of this wonderful country. I vote in all elections. I make use of written and electronic sources of information to keep current. Local and national politician make laws that effect my own health care insurance and the way I practice my profession. No editorial comments will be offered by this writer. I am simply reporting the truths of the ER as I perceive them.
Saturday, February 19, 2011
Sunday, February 6, 2011
SUPER BOWL
One hour to kickoff for SB XLV. I worked the past 2 Sundays so that I can be home to watch the Big Game. The ER staff has lots of "rules" regarding events and holidays and even astronomical occurrences.
Let's start with tonight. No men between 16 and 60 will come to the ER until after the game. "When did your chest pains begin Mr Smith?" "After the first quarter, but I assumed that it was the buffalo wings." Women and children and the elderly will still arrive for real and trivial problems. After the game, the menfolk will come in for stomachs aches, chest pains and injuries sustained from heated debate during or after the game.
The full moon is allegedly associated with an increase in psychiatric complaints. The word lunacy is derived from the Latin word for the moon. The phases of the moon exert gravitational effects on the tides but have no biological effect on humans, except of course for werewolves.
The night before major holidays such as Christmas, Thanksgiving and Easter leads to a never ending stream of sick children who need to be cured before the night ends. After the holiday feast the overeating and suspension of dietary restrictions will produce patients with GI problems or congestive heart failure from excessive salt intake.
Saint Patrick's Day celebrants may drink a wee bit too much and suffer the direct deleterious side effects of alcohol poisoning. The disinhibition of alcohol increases the number of assault victims.
July 4th is sure to bring in hand injuries from exploding fireworks. One fourth of July I treated 2 geniuses who filled inflatable pool floats with acetylene gas. When the toys exploded, their eye and ear trauma was severe.
An increase in suicide ideation and attempts occurs with most major holidays. The upcoming Valentine's Day may be a very lonely day if one doesn't have a valentine.
The beer is chilled. The chili and chocolate cookies are prepared. The Chinese take-out and the guests will be arriving soon. Kick off in 20 minutes. GO ______!
Let's start with tonight. No men between 16 and 60 will come to the ER until after the game. "When did your chest pains begin Mr Smith?" "After the first quarter, but I assumed that it was the buffalo wings." Women and children and the elderly will still arrive for real and trivial problems. After the game, the menfolk will come in for stomachs aches, chest pains and injuries sustained from heated debate during or after the game.
The full moon is allegedly associated with an increase in psychiatric complaints. The word lunacy is derived from the Latin word for the moon. The phases of the moon exert gravitational effects on the tides but have no biological effect on humans, except of course for werewolves.
The night before major holidays such as Christmas, Thanksgiving and Easter leads to a never ending stream of sick children who need to be cured before the night ends. After the holiday feast the overeating and suspension of dietary restrictions will produce patients with GI problems or congestive heart failure from excessive salt intake.
Saint Patrick's Day celebrants may drink a wee bit too much and suffer the direct deleterious side effects of alcohol poisoning. The disinhibition of alcohol increases the number of assault victims.
July 4th is sure to bring in hand injuries from exploding fireworks. One fourth of July I treated 2 geniuses who filled inflatable pool floats with acetylene gas. When the toys exploded, their eye and ear trauma was severe.
An increase in suicide ideation and attempts occurs with most major holidays. The upcoming Valentine's Day may be a very lonely day if one doesn't have a valentine.
The beer is chilled. The chili and chocolate cookies are prepared. The Chinese take-out and the guests will be arriving soon. Kick off in 20 minutes. GO ______!
Saturday, February 5, 2011
Writer's Block
As I stare at my laptop and pray to St Francis de Sales (patron saint of writers) for inspiration, I realize that I have writer's block. The fact that I am not Catholic, highlights my dilemma. Hermes, Thoth, Kuan Yu or Ganesha are all deities that might heed the desperation of a blocked writer.Then I remember that I am an ER doctor who enjoys writing and my block was relieved.
A not uncommon presenting complaint in Emergency Medicine is constipation . Bowel complaints may be either the main problem, a symptom of a disease process or an issue revealed during the ROS (review of symptoms).
First it is necessary to define our terminology. Constipation is very patient sensitive. Missing part of the GI tract due to congenital or surgical reasons leads to "dumping syndrome". Normal number of bowel movements per day for these people may be 1-20. Many people have a single BMPD. Other perfectly healthy individuals may only have 2-3 BM's per week. Therefore the question I ask is "has there been a change in your bowel habits".
A brief aside is needed to deal with euphemisms. Bowel movement is a somewhat stilted term for a universal bodily function. Dumps, poops, cacas, number 2's, craps, and sh_ts are all acceptable ways of addressing the concept of fecal elimination. Similarly diarrhea may be referred to as the trots, runs, or squirts. My brother-in-law likes to say he is peeing out of his ass.
The extremes of age constitute most patients with a main complaint of constipation. The elderly have less vigorous contractions of the muscles of the large intestine. This problem is aggravated by many of the medications that the older patients may be taking. Medications for asthma, emphysema, COPD, Parkinson's disease, glaucoma, hypertension, insomnia, anemia, depression, psychosis, pain and nonprescription meds for colds and the flu may all lead to constipation. Decreased thirst and lack of access to water in the nursing home patient may also contribute to constipation.
Mothers frequently bring in their babies with a chief complaint of no stools in (_) number of days. A quick examination of the abdomen and possibly the taking of a rectal temperature may cure the problem. Changes in formula or powdered formula that is not diluted with the recommended amount of water may make the stools hard and difficult to pass. In the newborn, congenital problems with the coordination of the nervous and muscular components of the intestines must be considered.
Diseases of the spinal cord may present with constipation. Spinal stenosis, multiple sclerosis, arthritis of the vertebrae, infections near the cord and intervertebral disc disease may all cause constipation. A careful history and physical exam should help in diagnosing these serious conditions. Imaging studies, especially MRI of the spine will confirm the ER doc's suspicions.
The etymology of the word impaction comes from Latin impingere, to impinge. In the ER impaction may refer to third molars (wisdom teeth) growing into the second molar. A fracture of a bone is said to be impacted if the two ends of the fractured bones are jambed together, i.e. impinged. The use of the word impaction that makes even the most seasoned ER doc cringe is fecal impaction.
When a patient with constipation has a mass of dense stool that is too large and/or too hard to pass, he or she has a fecal impaction. Sometimes a thin liquid stool may ooze past the impaction and the patient has both symptoms of constipation and diarrhea.
My PA, Robin and I try to take turns "curing" the dreaded fecal impaction. One prepares for disimpaction by donning a barrier gown, and double gloves. My armament includes a mask with a dab of Tiger Balm applied to the inside. This gingery scented ointment counteracts the inevitable odor emanating from the patient. Sedation is beneficial as disimpacting is a painful procedure.
Ah, I feel relieved. Treat your digestive system well. Eat lots of fruits and vegetables. Exercise daily. Whole grains are the bowel's friends. Don't abuse laxatives.
A not uncommon presenting complaint in Emergency Medicine is constipation . Bowel complaints may be either the main problem, a symptom of a disease process or an issue revealed during the ROS (review of symptoms).
First it is necessary to define our terminology. Constipation is very patient sensitive. Missing part of the GI tract due to congenital or surgical reasons leads to "dumping syndrome". Normal number of bowel movements per day for these people may be 1-20. Many people have a single BMPD. Other perfectly healthy individuals may only have 2-3 BM's per week. Therefore the question I ask is "has there been a change in your bowel habits".
A brief aside is needed to deal with euphemisms. Bowel movement is a somewhat stilted term for a universal bodily function. Dumps, poops, cacas, number 2's, craps, and sh_ts are all acceptable ways of addressing the concept of fecal elimination. Similarly diarrhea may be referred to as the trots, runs, or squirts. My brother-in-law likes to say he is peeing out of his ass.
The extremes of age constitute most patients with a main complaint of constipation. The elderly have less vigorous contractions of the muscles of the large intestine. This problem is aggravated by many of the medications that the older patients may be taking. Medications for asthma, emphysema, COPD, Parkinson's disease, glaucoma, hypertension, insomnia, anemia, depression, psychosis, pain and nonprescription meds for colds and the flu may all lead to constipation. Decreased thirst and lack of access to water in the nursing home patient may also contribute to constipation.
Mothers frequently bring in their babies with a chief complaint of no stools in (_) number of days. A quick examination of the abdomen and possibly the taking of a rectal temperature may cure the problem. Changes in formula or powdered formula that is not diluted with the recommended amount of water may make the stools hard and difficult to pass. In the newborn, congenital problems with the coordination of the nervous and muscular components of the intestines must be considered.
Diseases of the spinal cord may present with constipation. Spinal stenosis, multiple sclerosis, arthritis of the vertebrae, infections near the cord and intervertebral disc disease may all cause constipation. A careful history and physical exam should help in diagnosing these serious conditions. Imaging studies, especially MRI of the spine will confirm the ER doc's suspicions.
The etymology of the word impaction comes from Latin impingere, to impinge. In the ER impaction may refer to third molars (wisdom teeth) growing into the second molar. A fracture of a bone is said to be impacted if the two ends of the fractured bones are jambed together, i.e. impinged. The use of the word impaction that makes even the most seasoned ER doc cringe is fecal impaction.
When a patient with constipation has a mass of dense stool that is too large and/or too hard to pass, he or she has a fecal impaction. Sometimes a thin liquid stool may ooze past the impaction and the patient has both symptoms of constipation and diarrhea.
My PA, Robin and I try to take turns "curing" the dreaded fecal impaction. One prepares for disimpaction by donning a barrier gown, and double gloves. My armament includes a mask with a dab of Tiger Balm applied to the inside. This gingery scented ointment counteracts the inevitable odor emanating from the patient. Sedation is beneficial as disimpacting is a painful procedure.
Ah, I feel relieved. Treat your digestive system well. Eat lots of fruits and vegetables. Exercise daily. Whole grains are the bowel's friends. Don't abuse laxatives.
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