Take a Number

A Milwaukee woman died earlier this month because her local ER wait times were purportedly too long.  She Facebook’d:  “’Idk what they can do about the emergency system at freodert (sic)but they damn sure need to do something,’ she wrote around 7:35 p.m., according to the Milwaukee Journal Sentinel. ‘I have been here since 4:30 for shortness of breath, and chest pains for them to say it’s a two to SIX hour wait to see a dr.’”

A family member picked her up from the ER to take her to an urgent care center, where she subsequently collapsed, and was later pronounced dead when returned to the original hospital.  “Ward did have a history of an enlarged heart, which was detected in March after she gave birth to a baby who died when the umbilical cord wrapped around its neck. The report did note that a chest X-ray revealed cardiomegaly, but triage staff said her heartbeat appeared normal.”

The article doesn’t give to many particulars regarding the hospital, which is understandably tight-lipped.  So taking the patient at her word, let’s speculate about the delays at the local ED in Anywhere, USA.  Every ED has policies about rushing back anyone with chest pain or shortness of breath ahead of lesser complaints, and in every one I’ve ever worked, the staff tries their best to do just that.  But what if the beds are all full?  Which reminds me of…

… a couple weeks ago.  We had a patient who had been on a booze-and-meth bender, and arrived septic, in acute renal failure, and with the highest CK value any of us had ever seen.  Arriving by ambulance, this very sick patient truly needed immediate attention.  This particular hospital has neither dialysis nor even nephrology, and so we hopped around for the next eight hours doing what we could while trying to find a bed in a facility that could more definitively help this guy.  Our entire local area was on critical-care diversion, and ultimately, we had to ambulance him to a hospital over four hours away (weather had the local air service grounded).  So on a very busy afternoon, one bed and one nurse were permanently occupied while the waiting room filled up.  And like pretty much every other ED everywhere, we stayed backed up.  

So why are ED ‘s nationwide usually so backed up?  In my ED, the backup is due to my instinct for preserving my own sorry hide, ordering numerous tests that I don’t actually think are necessary.  Of course I do that because I just might be wrong, and in the event of a bad outcome, the first thing the compassionate lawyer will check is whether I CT-scanned this or ultra-sounded that, or gave antibiotics for an obvious viral ailment.  We are also backed up due to numerous minor complaints that no competent clinician would send to the ED, filling up beds with sniffly noses and stubbed toes.  Once they are in rooms, the abdominal pains and altered mental status cases in the lobby will have to wait, unless they pass out or raise enough hell that security gets involved.  “Just send the minor stuff back to the lobby!”, I hear you suggest.  Sure.  I’ll interrupt the harried RN rushing from the triage room to take a bedpan to the failure-to-thrive geriatric’s impatient family to answer a call light wanting more pain meds to remembering to document the last med she gave lest she be fired; I’ll interrupt that nurse to tell him to stop everything, move the (now angry) sore throat back to the lobby, strip and change the bed, and then go put the higher acuity patient in.  Hint:  when the sore throat sufferer stomps out, incident reports have to be generated, making the RN’s day even long, and inviting even more criticism from administrator and efficiency experts.  Sure, we could just hire more nurses, but budgets are too tight when so many critical assistant billers, chart reviewers, HR managers, and JCHAO pre-inspections have to be paid for first, being so much more critical to good patient care. 

True, so many minor things fill up ED beds because the hospitals need to charge where and when they can, to stay afloat in small communities, or buttress tight budgets handed down by huge interstate corporations that are still making bazillions while strangling their employees a little more every year.  And in any case, we have – taaaah daahhh!!! – the Emergency Medical Treatment and Active Labor Act.  EMTALA – which requires that EVERY patient no matter how silly the complaint be medically screened – combined with slobbering, red-eyed predatory lawyers to effectively remove the ability of hospitals to send BS piddly non-emergencies away.  A patient can demand to be seen because he is angry that his Xbox One is on the fritz and it made him sad.  If the staff runs that turkey out into the street as he deserves, BOOM!, instant federal fines and a chance of a frivolous malpractice suit.  Add to that the encouragements of Medicare and Medicaid to their beneficiaries to go to the ED for …anything… and you take up a few more beds.  And the glorious achievements of the Affordable Care Act, sadly, did not include the creation of any new hospital beds, nurses, or physicians.

ED nurses have to take ridiculous amounts of time triaging patients, asking mandated garbage like whether patients feel safe in their home, even if the chief complaint is “I ran out of my blood pressure medicine a month ago.”  Doctors grin and (often) fake it, because they can’t afford to get fired and only invite complaints when explaining to someone that taking an ambulance because I can’t sleep and don’t have a car is perhaps, y’know, not the most intelligent or considerate move.  

It is very sad that this poor woman in Milwaukee died.  If her assessment that wait times were too long are correct, who’s fault is it?  It is the fault of the malpractice lawyers and cowering doctors; it is the fault of corporate industrial medicine that grinds up their staff like so many disposable syringes, with no push-back against our D.C. masters; it is the fault of massive bureaucracies, and arbitrary federal interventions which remove the clinical and operation judgement from those who actually know how to deliver care.  And let’s be honest, it is the fault of patients who have empowered their lawyers, insurance companies, health systems, and politicians to hold authority over their physicians and nurses.  This includes the great majority of physicians and nurses themselves, who as professions support the continuation of these sclerotic influences, and will not demand and force radical change.  Our society continues to attempt to validate an impossibility, the delusional combination of finite abilities and unlimited resources.  Physician groups seeking to square this circle, not by making hard choices but by ducking them, are contemptible.

So if you need to go to the local emergency room, sign in and take a number.  We’ll get to you when we can.  

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Pat Conrad MD

Pat Conrad is a full-time rural ER doc on the Florida Gulf Coast. After serving as a carrier naval flight officer, he graduated from the University of Florida College of Medicine, and the Tallahassee Family Medicine residency program. His commentary has appeared in Medical Economics and at AuthenticMedicine.com . Conrad’s work stresses individual freedom and autonomy as the crucial foundation for medical excellence, is wary of all collective solutions, and recognizes that the vast majority of poisonous snakebites are concurrent with alcohol consumption. 

  5 comments for “Take a Number

  1. Bridget Reidy
    February 3, 2020 at 4:34 pm

    Anyone else think of the problem of chief complaints changing all the time? And often the CC for any sx is “high blood pressure”, because they were worried about the sx and decided to check their BP and then blamed their symptom on it. That’s a common one but similar situations occur any time a patient thinks we already know or don’t even need to know what their symptoms are.

    Sometimes with EMR it’s just too hard to know what someone else got for their CC. They could tell the receptionist CP and SOB and assume the triage nurse knows that and tell him “I’m worried because my brother just got diagnosed with a widowmaker” or whatever else they think might be the second most important thing to say. This happens in ER and office. In office we have to tell receptionists not to let them go on and on about their symptoms and what disease they think it is and such because when they do see us they’ll just assume we already know all that.

    In my office it’s often hard to tell even after attending to every problem they want attended to. Was the CC what they told the receptionist when they called last week, what they wrote on my form in the waiting room (which asks for one main concern and also anything else they’d like to address if time), what they first tell me when I come in and greetings are completed, what unwritten issue they interrupted me with when I was concentrating on or explaining something else, or the thing they brought up after I concluded and summarized and headed for the door?

  2. NN
    January 31, 2020 at 11:45 pm

    Bingo. Well said.

  3. Douglas Farrago MD
    January 31, 2020 at 1:29 pm

    Just a brilliant post!!

  4. R Stuart
    January 31, 2020 at 1:24 pm

    Great post!

  5. Dave
    January 31, 2020 at 11:57 am

    God Damn you are so dead on!!!

    I have to say though, that “Xbox One is on the fritz and it made me sad” is so strangely specific, that I have to believe someone actually saw that patient!!! Enter EMTALA: CBC, CMP, UDS, ETOH, UA (and maybe even APAP and ASA levels), plus a psych/social work consult later….patient goes home with a stack of paperwork and resource information…and his Xbox One is still on the fritz!

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