cc: "I think I'm pregnant again"
HPI: 22 y/o sexually active WF LMP "last month" c/o possible pregnancy. Denies pain. Denies vag. bleeding. Have not performed home pregnancy test.
ROS: 9 points ROS o/w neg.
PMHx: none
PSHx: none
POB/GynHx: G4P4Ao, all NSVD w/o complications, no STI's
PE: WDWN, AAOx4, NAD, ambulatory, drinking bottle of Sunkist soda.
HEENT: NCAT, EOMI, PERRLA, nonicteric
Neck: No LAD/mass/JVD/thyroidmegaly
CV: RRR, no m/r/g
Chest: CTAB no crackles/r/r/w
Abd: +BS, soft NT/ND, No HSM/masses. unable to palpate fundal ht.
GU/Pelvic: deferred since patient denies pain, VB or d/c
Back: No MT, no CVAT
Ext: 2+pulses throughout, no c/c/e
Skin: warm, dry, no obvious rashes
Neuro: grossly intact, no lateralizing signs, nonataxic gait.
Assessment: Young female requesting pregnancy test. LMP last month. Denies pain. Denies VB. PE benign. Abd. without pain on palp.
Plan/Dispo: Patient instructed to go to local pharmacy and get a home pregnancy test. If pregnant, f/u with her Gyn MD.
The above is the actual medical record documentation. The following is how things really transpired.
Me (after reading triage sheet and rolling my eyes): Hi, I'm Dr.____. I'm the doctor in charge of the EMERGENCY Department tonight. I see that you came by AMBULANCE. What was so bad that you had to call 9-1-1 at 3 AM to be rushed to the EMERGENCY ROOM by AMBULANCE? What is your MEDICAL EMERGENCY? What is your LIFE OR LIMB THREATENING problem??
Patient (clueless to the sarcasm): Oh, I think I'm pregnant again.
Me (thinking that this clueless girl still don't get it): You must be in a lot of pain or bleeding severely to come in by ambulance, huh?
Patient: No. I just didn't have a ride.
Me: So you're not having any pain or vaginal bleeding?
Patient: No, no pain. No bleeding.
Me: Did you take a home pregnancy test?
Patient: I didn't have one.
Me: You know they sell them at Walmart. They're open 24 hrs.
Patient: Well I couldn't go to Walmart in the middle of the night.
Me: So you took an ambulance?
Patient: Yeah, but my insurance will pay for it.
Me: Insurance? It says here that you've got Medicaid.
Patient: Yeah, that's my insurance.
Me: No, dear. Medicaid is not insurance.
Patient (quickly interupting me): Yes it is! That's my insurance!
Me: No, dear. Medicaid is not insurance. Medicaid is a government hand out! It's only called insurance if you're paying for it.
Patient: Well, what ever! Medicaid will pay for it.
Me: Good grief! You didn't have to take a $400 ambulance to the hospital for a simple pregnancy test.
Patient: But I didn't have a ride.
Me: You could have taken a cab. Surely you got $20 bucks for a cab. And those pregnancy tests are under $20 bucks at Walmart ya know. $400 bucks ambulance ride versus $20 bucks...You could have save us tax payers a lot of money, ya know.
Patient: My insurance will pay for the ambulance.
Me: Good grief! How many times do I have to tell you that Medicaid is not insurance? And it won't pay for nonemergent problems.
A quick 5 seconds physical exam. Push on the belly, no pain. Scribbled the discharge instructions and handed to patient to sign:
Go to local pharmacy and buy a home pregnancy test. Follow up with your medicaid assigned gynecologist if positive. If having pain or vaginal bleeding, return to ER.
Patient: So you're not gonna run a test to see if I'm pregnant?
Me: No, a possible pregnancy is not a medical EMERGENCY.
Patient: But my insurance will pay for it.
Me: Not if I don't order it. And even if I did order it, Medicaid...Oh never mind, just go to Walmart or any drug store and get yourself a home pregnancy test, alright. They're the same urine pregnancy test that we use in the hospital anyway, and it's much cheaper, too.
Patient (indignantly): So how am I gonna get home now? I got 4 kids at home.
Me: Well, you should have thought about that before you took an ambulance. Surely you didn't think that we would admit you to the hospital for a possible pregnancy, did you? Your kids are not at home by themselves are they?
Patient: You're a mean doctor!
Me: No I'm not! If I was, I wouldn't have ask about your kids. They're not home alone by themselves are they?
Patient: No, they're with a friend of mine.
Me: Alright. I'll see if the charge nurse can help you with a cab voucher home. There's also a cop here from your part of town. Maybe he can let you hitch a ride home in a while.
It's so frustrating trying to convince the local EMS folks to be not so fearful of litigation and have the balls to call their on line medical control and get a refusal to transport order for all these silly nonemergent problems.
Adden: I must issue an apology to all of my EMS brethens regarding the above statement. The problem is not with the heroic folks pounding the streets because they are only following orders and protocols established their chicken-shit administrators and medical directors who are the real ones fearful of lawsuits.
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- I once had aspirations to make a difference in the world, now I just work at it one guaiac card at a time. The lucky ones come back negative. Blue's a bad color!
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45 comments:
Good grief!
Please tell me why, again, the ambulance had to take her to the hospital?
Reason I ask is back in 1999, I had an allergic reaction in the middle of the night -- anaphylactic scary type with lips swelling and difficulty breathing.
I called the ambulance and they told me to drive myself to the hospital as that they could not pick me up.
I made it to the door, started vomiting, ran back inside and afterward and downed a half of a bottle of Children's Benadryl.
I never did make it to the ER, but I'm alive and carry an EpiPen with me at all times as a result (PCP wasn't able to diagnose what caused the allergic reaction, i.e. food, etc.).
As an aside - ACK! Who does your transcription? It's awful. I'm an MT and the mistakes are making me cringe.
PE: WDWN, AAOx4, NAD, ambulatory, drinking bottle of Sunkist soda.
HEENT: NCAT, EOMI, PERRLA, nonicteric (ANicteric).
Neck: No LAD/mass/JVD/thyroidmegally (THYROmegaLy)
CV: RRR, no m/r/g
Chest: CTAB (P!! - Percussion!) no crackles/r/r/w
Abd: +BS, soft NT/ND, No HSM/masses. unable to palpate fundal ht.
GU/Pelvic: deferred since patient denies pain, VB or d/c
Back: No MT, no CVAT
Ext: 2+pulses throughout, no c/c/e
Skin: warm, dry, no obvious rashes
Good one!
At least in the US medical services are not given gratis to everyone. Where i live everything is payed for by the government - for everyone - so you can imagine what its like at the A&E...instead of going to their GP people end up going to casualty because like that they dont have to fork out their money.
I would LOVE to see them start actually enforcing the EMS abuse laws....
Please tell me this woman is going to get a big fat bill from the hospital. Don't tell me that medicaid WILL actually cover this crap.
Perhaps it wasn't fear of litigation the motivated the ambulance company to bring her to the hospital, but the motivation of profit.
I'll never forget working overnight in the peds ER one night when a notorious repeat offender brought her kid in because he started screaming about his leg while he was in the tub. She brought him in (via ambulance, of course!) and it turns out he was screaming because he didn't want to take a bath.
When I presented to the attending, I prefaced my presentation with, "You're not going to believe this but..." He replied (dripping with sarcasm) that he truly had now seen it all and that he could die happy.
You'd think that Charity is making all this sh*t up but he truly isn't because I see the same damn ambulance abuse every day in my ED.
Yep, seen this one many, many times Makes ya just want to slap 'em!!
I used to volunteer out at the greet desk of the ER in a city hospital that had to take in most of the free-load. I at first found it amusing, and later annoying at having to explain to people why coming in an ambulance doesn't guarantee they'll be seen sooner, once they'd been sent out to the lobby to wait like everyone else. Hope they enjoyed the ride.
Also, assuming she had a $400 dollar ride and that the typical ER workup costs $700, can we assume her little jaunt ended up consuming over a $1,000 in public funds?
Isn't it bewildering that these folks never place any thoughts about how they're going to get home after taking an ambulance to the hospital for nonemergent problems? And what's worse, they go ape shit and become upset at the ED staff that they have no way to get home.
Um, did you document a full exam when you just palpated her abdomen?
Not that I'm suggesting you should have done a full exam just that it's a little scary that you documented all that stuff if you did none of it.
i constantly question why some medics ask "do you want to go to the hospital" when the person is malingering. best advice i can give you, as a medic, is that if an attending took me aside and said to use my discretion and not bring BS patients, and to feel free to call for refusals, it would help greatly.
love the blog.
wealthandtaste
Such lazy, ignorant, entitled people make me crazy. Way to put her in her place!
Doc? Would you please drop me an e-mail through my blog? Question to ask.
Mark
This is crazy. The unnecessary stress it brings to the ED team and taxpayers!
"It's so frustrating trying to convince the local EMS folks to be not so fearful of litigation....."
About as frustrating as trying to convince ER docs fearful of litigation not to have unecessary admissions. We each pick our poison.
Hehhehe, anon. 5:27AM.
Touche, touche.
Good gogley mogley...a whole new breed of stupid walks the earth.
Similar story from the UK:
Patient had attended 2 days previously having stubbed toe and sustained small flake fracture of Right Big Toe, strapped in A&E, seen the following morning in Fracture clinic by Orthopods, lightweight walking shoecast applied. Pt returned home.
Patient brought in by 999 emergency ambulance at 5am. Patient had been out drinking and hit his cast on the door, so causing some pain. Pt had then removed cast and called 999 and was brought in.
Consultation went something like this (Me as Doctor doing See and Treat without triage)
"Hello, What is your emergency today?"
"My toe hurts"
History as above is relayed by the patient.
"So why the ambulance?"
"I needed a lift"
"So why the ambulance? They cost £395 and someone could die of a heart attack whilst they are dealing with you"
"Well I didn't have any money"
"How much did you spend on a night out last night?"
"£50" [Pt began swearing - is threatened with expulsion.]
"So why did you remove your cast? The written and verbal instructions you were given in clinic say "Do NOT remove it"
"Cos I can, and I want a ambulance home when I'm finished - is it going to be long?"
"So what do you want me as your EMERGENCY doctor- at 6am in the morning to do?"
"Fix it"
"Sir, you've already been seen by a specialist, been treated, you have then decided to go against their advice. That is your decision and one you are allowed to make. Your selfish attitude towards caring for other people is also your own problem. Your best bet is to wait for 9am, go to the fracture clinic, book in to be seen, and hope they will replace the shoe for you. I recommend that you buy some simple painkillers from the pharmacy to help with you pain. Next time think about your grandmother being seriously ill and in real pain whilst the nearest ambulance crew are dealing with someones poorly toe, and act accordingly. Oh and the bus stop is right outside the hospital"
So you see, different countries, different systems, same stupidity!
And THIS is why I am so pissed off that I HAVE real insurance that I pay an exhorbitant amount for each month and I still can not seem to get them to pay anything for my son's medications without going round and round and round. I guess they would prefer for me to be poor (which I might be soon if I keep having to pay the price of medications without the insurance helping out) and let him get sick enough that I end up in the emergency department with him. Because that would be cheaper for them than just helping with our prescription coverage like they are supposed to but apparently only on certain drugs (not the ones the doctor thinks he needs) and only when the moon is full or something. I can only imagine how frustrating it must all be for docors. I posted a rant about it on my blog if you want the details.
22 and this lowlife already has four kids? People like that should be forcibly sterilized.
saw her here last night too, but she spoke spanish to me.
forcible sterilization is not needed. all we need to do is have low level radiation emanate from the tv during all soap operas and oprah and jerry springer re-runs and professional wrestling shows. over the years, problem solved.
"Patient: You're a mean doctor!
Me: No I'm not! If I was, I wouldn't have ask about your kids. They're not home alone by themselves are they?"
Hilarious! I wish I could have conversations like this with some of my patients...I often ask this sort of patient so why exactly did you come in now (for this clearly non-emergent problem)...they often stare blankly back!
unbelievable! in the last week, i've had two patients come in requesting pregnancy tests. one because she couldn't afford the preg test (yet she was pregnant, so how she will afford the baby, i don't know) and another who just had to know! it is so frustrating. unfortunately, i don't have the balls to tell them to go home for fear of complaints.
Hey, You Call, We Haul. That's All.
Some of us would rather that phrase be prefaced with "They Fall," but sadly when in the field we rarely get our way.
Reading your latest post made me remember all of the GOMERS we used to see at our local ED. I lived in a semi rural area with very poor public transport and the ambos would tell stories of regulars calling an ambulance and then asking to be dropped off at the local shops so they could pick up a few groceries. Must admit one of my guilty pleasures was to triage the latest frequent flyer and put them out into the waiting room. It didn't seem to matter how many times they were told, they still thought an ambulance guaranteed immediate medical attention.
How in the hell can they not afford a DOLLAR STORE test? They are a freaking dollar at the dollar store.
I was in the ER Friday night for severe abdominal pain (ruptured cyst). One woman came in for chest pains and vomiting. Ended up she took one too many painkillers. The family drug EVERYONE in. So much so that while I was in the waiting room I had to sit all the way by fast track and hope I could run to the bathroom in time to puke (in retrospect, I should have asked for a barf bag). Then a guy brought his wife and young daughter into the ER at midnight just to get his cast off???? Then three kids were brought in because they were stupid enough to be at a party and were drinking and fell and conked their heads. I mean come on, when you can eat out of the vending machine and drink soda, you are not ill enough to be in the ER. I was taken back before all the yahoos out in the ER but I heard them from my exam room when they were brought in.
Tell her next time go to the DOLLAR store and hand her a dollar. Much cheaper.
I've seen people come to the ER via ambulance for stupid things and yes they do get sent out to the waiting room.
They don't have rides home and in out rural area there really aren't any totally reliable taxis to call. The hospital doesn't give vouchers which doesn't matter because hard to get a taxi. The police don't drive them home either. Sometimes and I do mean sometimes as in rarely they can hitch a ride back with a rig if one comes in from their area and that depends on who's on and if they have another call.
So, inevitably they come to me(registration) for help - but if I am busy it is frustrating, especially because I know all the dead ends I will get trying to get them a ride. Sometimes in desperation (because they are looking at me pleadingly) I will pursue it with the ADN or ER staff. Basically, no one wants to be bothered. I do feel sorry for them and I know you are all rolling your eyes now. I don't agree with the choices they make but I hate seeing someone walk home in the dark or on a cold blustery nite, etc.
Years ago. I gave some people a ride home when my shift was over. I later told the ER supervisor and she was adamant that I should never do that again because of liability issues - so I never did.
When I said I feel sorry for the stranded people I actually did not mean the ones who abuse the system but we have had Patients come in that seemed to have a legitimate reason for being there (at least an understandable one) and they were poor and ended up being stranded, i.e., no car, family or friends to pick them up. Some people really have it hard in life.
I have to say that I have never seen anyone use an ambulance for a non emergent possible pregnancy. I wonder what her IQ was? Seriously!
Sometimes this stuff is generational too. Where it is all they know because their parents lived this way etc, etc. She totally didn't get you.
I agree with another comment where they are tying up the rigs from possibly rescuing someone in a 911 call.
We can count our blessings that we don't live that way.
It just makes me want to scream!!!
I LOVE YOU...! You are just so dead on with this...but I can't decide which trumps your patients blatent misuse of the "big red taxi": the "toofache" at 0300 or the sunburn at 0430-ish...
Great post. What really used to annoy me was when the patient said, "I called the ambulance because I couldn't get a ride," yet the exam room was full of concerned friends and relatives.
AAAARRRRGGGHHHHH!!!! This is so bringing back memories, and making me so very, very glad that I am no longer in the medical profession. Granted, I had to get injured and have my health ruined for it to happen, but it really is a god-send. I worked OB nursing in 2 different states for 5 1/2 years out of nursing school. This nonsense was a daily occurrence. Nevermind that the ones who "couldn't get a ride" and took an ambulance would have 1/2 dozen people show up at the hospital looking for said person before she even got to the hosptial by ambulance. BUT, she couldn't get a ride??? My foot!
One ant is pretty much like the next. Except for the queen they all look the same, and most do the same things, except for the drones who lounge about until needed. An argument can be made that the queen serves the colony as the colony serves her, and as C.S. Lewis says “presumably they have their reward”.
Some humans have walked on the moon, another created an artificial human heart, still others conspired with dozens of skills, trades, disciplines and geniuses to create symphonies just because we enjoy the sound.
And then there’s your patient. I will not deny her humanity or call for her sterilization, but what the hell is she thinking? How does one foot fall in front of another for such a person?
Hey Doc!
I'm a staff RN somewhere in the Mid West.
I did graduate from the north east. During a preceptor ship round in the ER, we had the case of a patient who got so sick of waiting in triage for "my foot hurts", that the clown walked outside to the pay phone and called an ambulance.
NY ambulance crews can't refuse transport (I believe) - so they were forced to drive a block each way to bring this clown in.
The minute this dude hit triage, ER doc promptly eval'd him and turned him loose for "sprain. Advise rest". The minute clown stepped out of ER, city police arrested him for "abusing emergency services".
You could hear the whole ER staff cheer....
Hell fire, I'm not sure threat of litigation could have prevented me from marching her out the door 'poste haste'! It beggars belief.
I have to agree with EMSucker: "you call, we haul, that's all...." That sucks. And it's people like that which cause me (and other of my EMS brethren) to lose our minds. I can't tell you how many people I've lectured about abusing the system, but the vast majority of the time it's like talking to brick walls....
This may be a little over-the-top but only a little.
Anyone who thinks that inappropriate use of the ER is a rare occurence needs to get their head out of their !@#.
Just from personal experience I can give you two similar instances I witnessed. I was waiting for wound exploration and sutures for my finger. Ambulance brought in a kicking and screaming 2 year old who had fallen and cut his finger. One paper towel was enough to stop the bleeding. Doc put one stitch in the kids finger, only because she felt she had to do something. This was a largish urban university hospital. Fast forward to small rural community hospital with one MD in the ER at any given time. Sitting with my ds who needs some serious repair to his knee after a bicycle wreck. Family of 5, eating, smoking, getting soda out of the machine, loudly talking on their cell phones had come down to the ER at 8PM because they had colds and sore throats. They were there for freakin' strep tests in hopes to get out of work the next day (Friday). My son and I were waiting for over 4 hours for him to just to get looked at.
I have absolutely NO problem letting more emergent cases go in front of me, goodness knows when I was the one running into the ER with a barely responsive 3 yr old I wanted everyone to drop what they were doing (and they did) but when there are people who truly NEED the emergency room (but not critical) who have to wait and often wait in pain because some morons couldn't go to CVS and get a pregnancy test or some Chloraseptic or a Motrin? It's infuriating.
I do think that some of these people are post panic attack, suffering from anxiety and once they are in the hospital being 'taken care of' the perceived problem evaporates and/or the anxiety that drove them there is no longer evident.
You have just written the same thing the rest of us feel, but can't express in the P.C. midwest.
-HiltonLife
Midwestern P.C. E.R.
Dude,
I feel your pain. What is handed out for free has no "value". Our "value" to society will only be appreciated in our scarcity.
Keep the faith.
beat up surgeon in Oklahoma City
I certainly understand your frustration with this patient and patients like this. As a person who relies on Medicaid for some of health care needs I resent the implication that those of us who need help with health care expenses abuse the system. I used to work as an EMT, and while there are some who obviously abuse the system, the majority of people on public health assistance do not. It could almost be argued that some people who have "real insurance" abuse their insurance policies also, eventually raising health care costs and insurance rates for everyone.
I was injured on the job 12 years ago, but my private disability insurance ran out long ago. I currently rely on Social Security Disability, Medicare and Medicaid for my health care needs. Since I was injured at such a young age (26) I receive the minimum disability benefits ($630/month). With this money, I must pay rent, utilities, groceries, clothing and ALL other costs of daily living (poor people still need an occasional hair cut, must pay for auto insurance, and are smart to have renter's insurance). I don't qualify for food stamps or "help" with utilities or rent. To make ends meet, I share a house with 3 other people in a very small town...not exactly my dream come true!
With the new "Medicare Drug Plan" I often cannot afford some of my medications that are not covered. One example is Xopenex. None of the "plans" currently cover the drug that has been very effective in helping to keep me out of the ER for severe asthma attacks.
Xopenex currently costs around $270 a month. Do the math... If I buy this drug, it doesn't leave much for regular monthly expenses. Occasionally, I end up in the ER because I can't get the meds I need to adequately control my asthma. There have been times I've gone to the ER, not because I'm in an emergency, but because I am very uncomfortable and wish to have some relief from a tight chest and moderate SOB when none of my other meds are working.
I've had snotty physicians who have no knowledge of my circumstance condemn me for coming to the ER, but after I explain the situation many of them feel like idiots for acting so self-righteous.
I know this sounds a bit strange, but perhaps some common compassion might have been in order for this young lady. Could she afford the $20 pregnancy test (some of us do not live near dollar stores)? Did she have the transportation to get to a store to purchase the test (taxi's cost money and are not available everywhere)? Would she understand how to administer the test and interpret the results (perhaps she cannot read)?
We can all agree that given the information available this was an inappropriate use of tax payer money, but it was also an inappropriate response by the physician. Being a self-righteous jerk isn't going to be helpful for the patient, the attending physician or the tax payer. If you had behaved like a caring human being, perhaps you could have actually helped her come up with a more appropriate solution for the current problem and appropriate use of the ER and ambulance service in the future.
It all comes down to one thing...treat others with the same respect, kindness and compassion you desire for yourself and your loved ones. Anything less is simply shameful and inhumane.
This makes me nauseous. I could write you an essay, but I think that the term "nausea" is much more concise.
I've been a paramedic field-trainer for about 13 years now, and this kind of story is beyond common-place. Probably 25% of my patients are similar abusers. Just the other night, I hauled a 21 year-old male, who cut his finger while screwing a coaxial cable into his TV. It wasn't even bleeding!
These kind of abusers are extremely common, and we don't have the luxury of refusing care. We're under a strict policy of hauling everyone. It's purely a liability issue. Definitely not a money issue as someone suggested, because the vast majority of these losers don't pay.
Opii writes,
I know this sounds a bit strange, but perhaps some common compassion might have been in order for this young lady. Could she afford the $20 pregnancy test (some of us do not live near dollar stores)? Did she have the transportation to get to a store to purchase the test (taxi's cost money and are not available everywhere)? Would she understand how to administer the test and interpret the results (perhaps she cannot read)?
Those questions are all irrelevant. She didn't have an emergency. She had no reason to be in the Emergency room to begin with. Should a person who is having trouble filing his income taxes also take an ambulance to the emergency room to get help from the ER doc? It makes as much sense as using the ER for a pregnancy test.
Charitydoc:
If pregnant, f/u with her Gyn MD.
Hasn't she already f/u'ed enough?
wondering if you're still out there....
I will never forget the first time I transported a "patient" like this. We're dispatched for a "baby not breathing", fly to the scene the wrong way up one-ways, rushing in to the Section 8 housing (which is nicer than any place I've ever lived, btw) with all of our equipment, asking "Where's the baby, ma'am?" while the woman who called proceeded to pack her phone, candy bars, etc. into her purse casually, get her coat on, etc. She sits herself down on the stretcher and admits "There's no baby, my friend just told me to say that so you guys get here quick." Me: "What?! You called 911 and told the dispatcher your ba--" Her, interrupting: "I have an appointment at the outpatient ortho clinic at [nearby hospital]." Me: "And you couldn't take the bus? I take the bus everyday." Her: "We're going now. Let's go."
We call our dispatcher to relate the story, noting that the woman HAS NO CHIEF COMPLAINT WHATSOEVER. We're almost ready to leave when she hears this and says that she has L foot pain, 10/10 (of course) and that we'd better take her to her appointment or she'd have us fired. Dispatch informs us that now that she has a C/C, we must take her to the ER, which we proceed to do. On the way there I repeatedly ask her "So you think this is a legitimate reason to call an ambulance? You are okay with the fact that you are wasting our time when someone may be having a real emergency and need our help?" etc. She refused an assessment/vitals, mostly giving me the silent treatment but periodically gazing at me to say "You look like 'da PO-lice."
Only "insurance"? You guessed it. Medicaid. This crap has to end!
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