We’ll Get to You When We Can…

The word is that more patients are tired of waiting in increasingly crowded ER lobbies, and are leaving Against Medical Advice (AMA) in greater numbers.  Kaiser Health News is reporting a 57% increase in patients leaving AMA in the past 7 years from California ER’s.  One physician observed, “Most patients are sick but not critically ill,” which is an important point.  The article later explained that, “Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.”  Which tells me they were less likely to be suffering an actual emergency, and were less likely to be concerned with the bill.   

Think that sounds harsh?  Wait-times in ER’s are increasing nationwide, with no stop in sight.  Per Kaiser, the waits are longest in the dense population states of California and the Atlantic Northeast.  In multiple, less populated small-town ER’s in Florida and Alabama, we have seen the same trends.  When a patient leaves AMA, the hospital corporations, administrators, and government auditors don’t care whether he was a frequent flier checking in for a sniffly nose or fishing for happy pills.  The general attitude is that the ED staff needs to prove that they were not negligent, while running between beds, dealing with demonstrative family members, or electronically charting inane mounds of pointless info mandated by those same corporations and government officials.  Quite a lot of patients who drive themselves to the ER are having serious, even life-threatening emergencies; and quite a lot how call EMS services also stretched thin, are having no emergency at all.  It is commonplace in ER’s everywhere for a mother and several children, all on Medicaid, to check themselves in for colds, simply because she didn’t feel like waiting an additional day to see their assigned PCP.  It takes a while for the triage nurse to fill out five different charts. When a family member wants a demented, chronically bedridden, elderly loved one “checked out” for weakness, they get the full workup because…among other reasons, lawyers.  I’m NOT saying they shouldn’t get evaluation or care, but the intensity and duration of that evaluation is often far greater than clinically necessary, which backs everyone else up.  And it is often the case that those who complain the loudest, and most often about waiting have the least emergent complaints, until they claim “shortness of breath” or “chest pain” to jump the line.  

Emergency department staffs are hamstrung by increasing numbers, tightening hospital budgets, punitive and stupid EMTALA requirements, unrealistic patient expectations, and the ever-present fear of malpractice lawsuits.  And throughout all of that, we actually want to do a great job and give the best care to those truly sick and hurt.  Beaten down as in other areas of medicine, ED physicians have a hard time standing up for themselves.  

“When someone requests to leave,” said one physician in the article, “it needs to be a priority that ranks just below a cardiac arrest.”

Wrong.  That patient is choosing to change their own status to non-emergent.  In a sane world that respected health care professionals, that choice would be respected, and no one else held accountable for the results.  But we don’t live in that world, and so will continue to get the blame for a situation over which we have no control.