Chronic

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.