The E.R. Needs An Anal Probe

I am a proud emergency physician. I am proudly an old emergency physician. I didn’t realize the distinction of new versus old 37 years ago when I first became the ringmaster in that circus of misery – the E.R. Then again, 37 years ago I don’t think my immature brain, made up of so much gray goo, would have registered the bullshit that is allowed into an Emergency Room today. Much like cortical blindness my senses were all normal, but that brain was like an infant’s – unable to cope with the data input.

My brain has finally matured and I now see like I never did before. I believe this physiological process is reportable to The New England Journal of Medicine, but most of the editorial staff suffers from being stuck in the gray goo phase of maturation, unable to register reality with their own senses.

Last night I was on shift seeing the “sick.” In fact, as is the case in most of my shifts, the number of sick I saw and treated was less than one out of five. Even most of the truly sick patients should have stayed in their respective hospices waiting for the inevitable end, as was their wish.

See the truth my people! We are a society that allows Emergency Departments to be over-run with the non-sick. Thank God the government understands what goes on in our country’s last line of medical defense, the Emergency Room. (Hopefully you note the sarcasm here). It makes no move to curb the waste and actually appears to encourage it, because (whisper this)… it keeps the electorate quiet.

Somewhere in the primeval past, patients that presented to E.R.’s were turned away if they had no money. I have been in hospitals since 1977 and have never seen this, but I’m sure it happened. A hospital is a business like any other, responsible for its bills. If it takes in no money it closes. On a “good” note, the government (through your kind and happily given tax dollars) helps support hospitals through Medicare and Medicaid programs; and now for that money demands all hospitals follow EMTALA. The Emergency Medical Treatment and Labor Act was created by Congress in 1986 and essentially states the hospital has to medically evaluate every patient that can walk, hail a cab, or grab an ambulance and find their way to an E.R. door. Bad idea? No, this is a very noble idea. The practice of a wallet biopsy on presenting patients when dinosaurs roamed; to be seen by a doctor, or that some asshole doctor refused to see a patient in need if they didn’t have cash was abhorrent, uncivilized. and barbarian. Receiving an M.D. commits you to taking care of the truly sick, period.

Here is the sticking point: I will defend my fellow doctors, physician assistants, and nurse practitioners… Not one of us that I have ever worked with refused to see a truly sick patient, especially one in distress or about to die. Let me repeat… Practitioners like to get dirty saving lives. Puts hair on a man’s chest. Makes his balls the size of grapefruits. We won’t talk penis size (I’m sure the women have some sort of equivalent).

As with all math, there are multiple parts to an equation. In treating patients under emergency conditions, the second part of the equation is the patient should have a REAL EMERGENCY that needs EMERGENCY CARE. Now let’s be fair. Most patients are not medically trained and so sometimes they have scary symptoms like chest pain, vomiting, high fever (no 99 is NOT a high fever), or bleeding. They believe their death is imminent and emergency evaluation is needed. I agree, sometimes the chest pain is a muscle strain or gas, but sometimes it is a heart ready to stop beating. The government once again steps in and says if the patient truly thought they had an emergency, the insurance companies have to pay for it and the hospitals/doctors have to evaluate it, money or no money. I say fair enough. Don’t take a chance. Minimally educated people realize that the number of 18-year-olds having chest pain is almost zero, but if the 18-year-old is at home snorting the white powder and suffers severe chest pain, my colleagues and I are there for you.

These really aren’t the patients I’m ranting about. I will offer two cases that have presented to the Emergency Room in the last 24 hours. Given the above, do you think society should pay the bill for these two cases?

Case #1
A 20-year-old female presents to the Emergency Room complaining of headache. She has no past medical history, has had the headache for months, has normal vital signs (blood pressure, pulse, temperature, and respiratory rate), and is eating and drinking well (no signs of weight loss or dehydration). She states she is not pregnant. She has come into to the E.R. at 1 a.m. with two friends. When I go in to see her, she is joking around with her friends in a well-lit room, taking pictures with her new iPhone (of them, and selfies). By the way, she says her pain ‘is horrendous’ with a smile, and sitting up. Let’s see if you can diagnose a real emergency.

Question #1: Do you think this is a sick patient?
Question #2: Do you think society should pay for this abuse of the system created to help THE SICK AND POOR?
Question #3: (Since she is a Medicaid patient, meaning our taxes are paying for her demands) do you think the hospital/doctor should demand $200 from her in cash to be seen? Or can she actually make an appointment to see her doctor (yes, she actually has one in a clinic that doesn’t need an appointment to be seen)?

If you didn’t answer #1, NO, #2, NO and #3, YES – you are part of the problem and not part of the solution.

Case #2
An 11-year-old boy wakes up due to a bowel movement, and trembles for less than 30 seconds. He is fine now. Vital signs are normal, no vomiting or diarrhea and… wait for it… he isn’t sick. Brought in by his mother at 2 a.m., in 9-degree weather, laughing, and carrying on. It’s a school night… Oh, by the way, he is hungry and mother wants to know if we have food for him.

I’d continue on with the case, but I’m too depressed. I would go to the E.R., but unlike all the patients I see, I’d have to shell out a $150 co-pay. Screwed again.