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Tuesday, October 21, 2008
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Wednesday, October 15, 2008
Fixing Our Broken Health Care System
Not too long ago Medblog Addict asked me this question in an interview:
"One of the presidential candidates has asked you for some advice on how to improve the nation's health care system. What do you tell them?"
I thought my answer was pretty decent so I'm reposting it here:
The health care crisis facing our country is akin to a festering butt pus in dire need of incision and drainage. Like butt pus, it’s well covered up so no one else can see, but it sure hell is a huge pain in the ass! My long rant on the subject can be seen here:
Slippery Slope to Socialized Health Care
To summarize, we have a real national crisis at hand and it seems that none of our politicians know how or even care to solve. When over 47 million Americans do not have health insurance, we have a big problem. Albeit that over half of these folks can afford it but choose to go without it, opting for tattoos, fancy cell phones, iPods, body piercings, drugs and alcohol, etc... rather than the basic necessities. Still, over 20 million is a very significant number, as for these Americans health care is completely out of reach. When a person in America has to make a decision between food on the table or pills in a bottle to take for his/her medical problems, it is a national disgrace. When a man have to resort to committing a petty crime to land him in jail just so he can get the medical care that he couldn't otherwise afford, it is disturbing. When hospitals pass on the costs of healthcare to the public by marking everything up by 1000%, we all have to pay painfully. When doctors, who all took the Hippocratic Oath, are too fearful of litigation to take care of patients, order more unnecessary tests (shotgun CYA medicine), spread the liability by consulting other doctors and specialists to get everyone under the umbrella, or worse yet, abandon clinical privilege at a hospital so he wouldn’t have to take care of unattached, nonpaying patients...the situation sucks all around. When hospital and HMO administrators without any clinical experience or medical background can dictate what tests and studies physicians can or cannot order, the ship is being run by idiots and is doom to sink. We're headed toward disaster, there's no doubt about it. This isn't all new. Everyone knows that this health care crisis exist but our nation choose to turn a blind eye. It is analogous to knowing that the levees in New Orleans cannot withold a hurricane for decades but we choose to ignore it all the same. The sad reality of all is that for most Americans, despite having health insurance, we are all one medical disaster (heart attacks, bad car accidents, etc...) away from bankruptcy. It is without question that we have the most technologically advanced health care system that is the envy of the world. But what good is it when we cannot afford it?
So how do we go about solving our health care crisis? Well, let’s go back to the butt pus analogy. Taking care of butt pus ain’t as easy as you think, but it ain’t impossible. A clinician must first be able to see the bigger picture and look beyond the patient’s ass. For instance, is this patient immunocompromised, is he a diabetic, etc…? Otherwise, just cuttin’ on and draining the abscess won’t address the underlying disease. How did this butt pus come about? Is it an infected pilonidal cyst? MRSA? Will antibiotics be required? And before cutting on this butt pus, one must ask, is this a peri-anal or peri-rectal abscess? Is there a fistula? You get the point, there’s more to butt pus than just the ass, or meets the eye. The problem with our politicians is that they cannot look beyond the ass and thus are oblivious to solving the problem.
From the patient’s perspective, health care should be affordable, easily accessible, and without compromise to quality. From the provider’s point of view, liability is the biggest issue, as well as autonomy, reimbursement fairness, and quality of family life. The buzzword that we often hear regarding health care reforms from our politicians lately is UNIVERSAL HEALTH CARE. Yes, indeed universal health care is a noble endeavor that we all should strive for in this country. But our politicians are approaching it all wrong, sliding into the direction of socializing health care. There is a HUGE difference between universal health care and socialized health care, but too many people mistake them for one and the same. They are not! It has been shown time and time again throughout history that whenever the government has absolute control, all things go to hell quickly in a handbasket. Our government cannot even keep its promise to provide health care to our veterans, what makes you think that Obama can provide health care for every American in this country? With that said, however, we can achieve universal health care without socializing it. In fact, you might argue that we already have universal health care right now. The Federal EMTALA law (Emergency Medical Treatment and Active Labor Act) requires that every patient who shows up to an ER of a hospital must receive medical screening and stabilization if that hospital participates in Medicare. Without Medicare funding, a hospital is certain to go belly up bankrupt and thus EMTALA is pretty much inclusive of all hospitals in the USA. Private clinics, however, are not bound by EMTALA to do the same. So in a way, we already have, sort of, universal health care here. The word is long out. If you have no health insurance and can't pay for health care, go to the nearest ER. You don't have to pay up front and we are too scare of lawsuits not to take care of you. You can make up phoney personal information about yourself, fake who you are, give 'em aliases, fake phone numbers and addresses, phoney social security numbers and you'll never have to see that hospital bill. Heck, all the homeless folks show up every night looking for a warm bed and free meal anyhow, in addition to free health care, of course. Three hots and a cot, as we call it. Now there's a novel idea! If you have a real medical problem that needs true emergent care, like an acute appendicitis or a hot gallbladder that needs to be operated on or something...pretend you're a homeless drunk, mess yourself up a little bit, wear dirty old clothes, not shave or shower, sprinkle a little beer on yourself for the smell...and if you want to really get into the role...piss in your pants for the stale urine effect...show up to the ER of a hospital they'll have to take care of you. You'll never see the hospital bill, guarantee it!!! The beauty is, they will never come after you, not for collections, not even with a 20ft pole, not ever! So there, you see, we already have universal health care in this country. Albeit inefficient, twisted and somewhat sordid, but free/charity healthcare nonetheless. The hoards of non-paying illegal immigrants have been showing up to our ER's in droves over the years to receive free care. EMTALA is a well-intentioned law meant to prevent patient dumping and abandonment. Too many people, however, take advantage of it and abuse the system. In honesty though, we're not all heartless, money-grubbing bastards. We're here to help everyone who truly needs our expertise. But it is very upsetting to see the ER being used for non-emergent problems like simple toothaches, sorethroats, runny noses, pregnancy tests, silly hang nails, etc...
We can achieve universal health care coverage for everyone in this country without socializing it through government mandates. And we don’t have to do it by forcing everyone to buy health insurance policies that they can’t afford either. And we don’t have to require all employers to provide health insurance coverage for their workers as well, because small businesses would certainly go belly up if such a mandate is handed down. How can we achieve such a gargantuan task? Too good to be true? Not really. Our health care crisis is multi-faceted and complex, and addressing only one aspect of it alone will not solve the problem. Putting a band-aid on a butt pus doesn’t make it go away! Over the years, many have blamed the increasing costs of health care on the enormous jackpot awards from frivrolous lawsuits brought forth by greedy trial lawyers, like John Edwards. Many states have tried to solve that problem by capping non-punitive damages on malpractice suits, but guess what, the plaintiff attorneys just worked harder, bringing up more lawsuits in order to make up for loss revenues they once enjoyed. Did health care cost go down? Not really. Did it make health care more accessible? Nope. More Americans are uninsured than ever and ER census across the country continue to rise in reflection to those numbers. Are doctors still practicing defensive medicine and ordering unecessary tests? You betcha, even in Texas and Florida. So do groundless lawsuits drive up the cost of health care? It may have contributed some but isn’t the only factor that has made things spiral out of control. Mitt Romney, to his credit, tried to solve the problem by a different approach while he was the governor of Massachusetts. His plan, mandating health insurance coverage across the board for every citizens, has proven to be too expensive, even for the rich state of Massachusetts to stomach. Government mandates have never worked, and never will. I can’t imagine poor Mississippi or Louisiana being able to do the same when the wealthy folks of Massachusetts have failed so miserably. The benevolent aspirations of Mitt Romney were there, but the execution, was all wrong, and it wasn’t just the mandates alone. Though the plan addressed the accessibility of health care, it failed to address the other problems. For true health care reform to work, every aspects of the problem need to be addressed:
Patient’s perspective:
Accessibility
Affordability
Preservation of quality
Provider’s perspective:
Liability
Autonomy
Reimbursement fairness
Let’s break it all down.
A) Accesibility. Health care has to be easily accessible to all. For over 47 million Americans without insurance (and that number is projected to reach 50 million by the end of the decade), it ain’t so accessible. In many cities, aside for the safety net of the ER, there is little to nowhere else for these folks to turn to. But it need not be that way. We already have the infrastructures at the local and state levels to increase health care access. I say expand our local Health Department system. Give the health departments a more clinical role rather than just being there to provide routine vaccinations and monitoring of infectious diseases. Doing so would, in essence, establish a national health care system to where people who cannot afford insurance or a private clinic can go to for routine primary care. This would serve the poorest and most impoverished segments of our society, in addition to providing care for those lazy asses who choose not to pay for themselves, the so called leeches. How do we fund this expansion? The states are already funded through Medicaid. Right now, the states are allowed considerable flexibility on how to execute the Medicaid program that costs over $370 Billions/yr. Anyone who has ever done a shift in the ER’s knows full well how rampant Medicaid fraud and abuses are. Let’s eliminate some of that flexibility and force the states to beef up their local health departments to a more clinical/primary care role. Give sovereign immunity to health care providers who are willing to take a pay cut to work in our health departments (more on liability issues later). You want free care? You can’t eat your cake and have it too. Eliminate Medicaid and establish a national health care system through expansion of the health departments. Let the states run them, if they don’t want to relinquish control. But Eliminate Medicaid! The reimbursement for Medicaid, as it exists, is paltry anyhow. Most private clinics refuse to accept Medicaid anyway. They shun it like butt pus.
While we’re at it, get rid of the federally funded State Children’s Health Insurance Program (SCHIP), too. Here’s the truth to the notion of providing umbrella health insurance coverage to every child in America, it’s wasteful and fattens the wallets of the insurance carriers and HMO’s more than it benefits us tax payers. While it’s a noble endeavor, it’s not cost effective. At first blush, it would seem to be a grandly benovelent idea to require health insurance across the board for all children. You can hear the outcries, can’t ya? “But, but, but...it’s for our babies! We are the wealthiest nation in the world...and we can’t provide healthcare for our children?...” Problem is, SCHIP is a gargantuanly expensive endeavour that does not provide the biggest bang for the bucks and makes no economical sense. Fact is, the overwhelming majority of kids do not get severely sick and have no need for expansive health insurance coverage. Sure they’ll get the routine common colds, snotty nose, cough, sore throat and the sniffles. But for the most part, the majority of kids are healthy and are not afflicted with serious illnesses. Therefore, mandating health insurance coverage across the board for every kid in America is wasteful and serves the health insurance industry more than it does the kids. As a physician, I would love nothing more than seeing a well insured kid for a routine viral snot nose and sniffle in my ER. Quick 5 minute exam...Easy Chaching! But as a responsible taxpayer I see it as nothing but wasteful drain on our collective wallets. Day after day on duty I see hoards of Medicaid covered kids rushed to my ER, sometimes even by ambulance, for routine snot noses and sore throats. Sadly less than 10% of all the kids I see in my ER have a true medical emergency. Medicaid abuse is sickeningly rampant. Fiscal discipline and responsibility is called for here and “it’s for the kids” can no longer cut it as an excuse.
Instead, for kids and healthy young adults, a catastrophic insurance policy makes more sense and is more cost effective, because these policies are much cheaper and are applicable in instances of unexpected calamity such as injuries after a motor vehicle accident, sudden illnesses requiring extensive/prolonged healthcare (meningitis, appendicitis, new onset diabetes, broken bones, ect...).
Abolish Medicaid and SCHIP! Use that $300+ Billions to establish a national health care system through expansion of the existing health departments. To get the manpower for the national health care system, give student loans breaks to physicians, PA’s, ARNP’s, RN’s, LPN’s, etc…who are willing to work for the health departments. Recruit students through scholarship offers to work in the health departments once they’re done. 4 yrs of med school for 4 yrs of indentured servitude in the national health care system is a very fair deal, much like the military’s GI Bill.
B) Affordability. Unless your portfolio rivals that of Bill Gates, Warren Buffet and the likes, for most Americans, myself included, we are all just one medical disaster away from bankruptcy, insured or not. Imagine a serious car accident, or heaven forbids, a diagnosis of some malignant cancer or leukemia. If you’re uninsured and play by the rule, you’re screwed. If you are insured and think that your HMO will be there for you, you’re naïve. ~$7,000 per day in the ICU ain’t no chump change! The spiraling costs of health care just boggles the mind. By 2012, health care expenditures are expected to be about 17-20% of the GDP. A routine visit for an ankle sprain with a simple ankle series xrays used to cost $40 bucks when I first started medical school, now it costs $240 bucks! That’s just the charges for the xrays alone, not for the visit, not for the splints and crutches, nor is radiologist’s charges for reading the films included.
Here's the truth....There is a 1000% mark up for every thing as soon as you step through the door of the hospital. That’s right, ONE THOUSAND PERCENT mark up, not including physician fees, just hospital charges alone. One could argue that the $10 Tylenol pill is also paying for the heating and air conditioning, lights, utilities, house keeping, grounds maintenance, etc… But c’mon 1000%? Ain’t that a little too obscene?
We’ve already established that socializing health care through gov’t mandates does not work. It never has, but creating a national health care system as discussed above is absolutely necessary and would certainly increase primary care access for the extremely impoverished segments of our society who could not otherwise afford it. And for children and young healthy adults, a catastrophic insurance plan makes more economic sense as such policies are much cheaper. But what about the rest of us who plays by the rules and see government handouts as un-American and an insult to the very foundation of our democracy, capitalism, self-reliance and individualism? How can we make health insurance more affordable for people who wants to take care of themselves and not rely on the gub’mint?
One of the main problem of our health care system is that there is no true competition. By that, I mean that there is an absolute lack of capitalism in health care. The spirit of capitalism is what made this country great, yet it is completely absent and devoid in the health care industry. From DRG fixed pricing through ICD codings established by Medicare, to the limitting and confining of insurance purchases within certain regions and state lines, capitalism does not exist in health care at all! And as a direct result, prices soar out of control to no end. It is completely senseless that there are over 1300 companies across the country offering health insurance policies yet we are confined to less that a handful of "Blue this Blue that" and the ilks regionally. To fix this problem we need to inject true capitalism into health care and let the basic principles of supply and demand economics take care of itself. Laissez-faire and let the market forces work! Let all of the hospitals and clinics compete. Let them set their own prices to drive down market costs. If at hospital A, I can get a hip replacement cheaper than at hospital B, transfer me to hospital A…If at the neighborhood clinic a routine visit is cheaper than at uptown clinic….you get the point. In the same vein, let all of the insurance companies compete across state lines. Allow small business, citizens of cities, towns, municipalities, etc…to band together for purchasing power to leverage for a cheaper price with insurance companies, much like the deals that large corporations can cut with these insurance companies.
The answer to our health care crisis is not to socialize it but to inject capitalism into it. Free enterprise! Let the market work!
C) Preservation of Quality. It is without question that we have the most technologically advance health care system that is the envy of the word. As it should be, because Americans demand and deserve no less. Any discussion in the overhauling of health care must include the preservation of quality that we currently have and must always strive to improve. Our health care providers must pass stringent criterias including appropriate trainings and board certifications. That cannot change as public confidence, not to mention safety, in our profession is of utmost importance.
D) Liability, Autonomy, Reimbursement fairness, and Quality of family life (The physician side of the story). I would like to lump all of this into one discussion from a physician perspective, as these issues are all dynamically related and intertwined. As a physician who has been frivolously sued numerous times, I can personally attest that each case was equally gut wrenching and ripped me to the core. It was one of the major factor that weighed heavily and contributed to my decision to leave Emergency Medicine. Yes, every single one of those cases were completely meritless but they still haunted my psyche all the same. I hated to practice defensive, CYA medicine. I hated myself for seeing every patient encounter as a potential lawsuit. Do groundless junk lawsuits drive up the cost of health care? Not entirely as recent studies dispute such arguments that frivolous claims are the largest contributor to our health care problem. But one thing is clear, these junk suits certainly do contribute to the pie of discontentment making all physicians miserable. On top of that liability insurance costs are insanely astronomical. In my group of physicians covering an ED of 78,000 patients/yr. census, it costs us $1.2 Million/yr in liability coverage. And that’s cheap compared to other groups of comparable census in other states. Patients and their families bring suit, for the most part, due to bad outcomes. However, recent studies have shown that nearly 80% of all claims did not involve errors and did not receive compensation. So why the hell are the rest of us paying so much for liability insurance to the point that it cripples our business?
Escalating matters in our current health care environment is that more and more Americans are uninsured and the numbers are expected to continue to rise. And where do they go for their health care? They show up to the ER's across the country, of course, bogging down the system causing a serious overcrowding. Why do they not show up to the local clinics for routine nonemergent stuff? Well, that's because the clinics will first do a wallet biopsy as soon as patients show up at their reception windows as clinics are not bound by EMTALA. Thus, uninsured patients show up in hoards to the ERs because we don't and cannot make them pay first to be seen. That’s the problem, EMTALA IS AN UNFUNDED MANDATE! I talk about the ER mainly because it is my field of expertise. But more importantly, I bring up this issue because unattached ER coverage is the single greatest cause of malcontent among the hospital staff of all specialties and subspecialties. As the growing numbers of uninsured patients continue to rise, compounded by the flood of illegal aliens, the safety net of the ER is the only place that these patients can turn to. At the hospital where I had been, our census doubled over a short period of 3 years. However, our ER reimbursement rate dropped to 27%. That means only 3 out of every 10 bills we send out get paid. About 3 out of every 10 patients we see actually pay us! Can you imagine any other business being able to survive on such piss poor returns? Just how do we survive and maintain our practice? The hospital has to kick in a subsidy, of course. But it's no where near enough for us to hire adequate staffing to be able to efficiently handle the patient load. The hospital in turn gets funding from the federal and state and local levels. What's more, the current nation wide nursing shortage bottlenecks our situation to a grinding halt on many nights. Not only are there not enough ER nurses, there aren't enough floor and ICU nurses as well. The facility actually has plenty of beds, just not enough nurses upstairs to take care of patients so they get boarded in the ER until one becomes available. Meanwhile, patients keep on showing up with no rooms to put them into. We triage and care for the sickest ones first, of course, and do the best we can. An average of 4-5 hours waiting time for nonemergent cases such as sore throats, runny noses, toothaches etc..is not uncommon at all....which all equate to crappy Press-Ganey patient satisfaction scores and lower incentive driven reimbursements and bonuses for grunts like me. Damn vicious cycle and ploy isn't it?
The problem with uninsured patients is just not the financial aspect alone. Uninsured patients usually do not have a primary care physician. Because of such, many of them have not had any routine maintenance or preventive health care, and have neglected themselves for years. They tend to be noncompliant with medical management when they do show up. It's pretty hard to be compliant, though, when you can't afford things such as medications. Thus, it is of no surprise that the uninsured patient will usually have more complex medical problems and more comorbidities. From the consultants’ side of the story, the longstanding rule is that for a physician to have practicing privilege at a hospital, he/she must agree to take unattached inpatient and ER calls. Now if you are a specialist or surgeon, why would you want to take call at a busy county hospital that requires you to see more patients, who are sicker, who don't pay, have more medical problems that are more complex with higher comorbidity and thus, higher liability? Yes, these are precisely the patient demographics that sue most often. Taking call at such a hospital means that you'll have to work longer hours, see your family less, take care of more patients, with higher acuity, more complex comorbidities, who are likely to sue you more...and finally the kicker...not get paid for it. Furthermore, having to care for these unattached, nonpaying patients disrupts the physicians’ private practice and detracts time away from their own paying clinic patients. As a result of this, outpatient surgical centers are popping up everywhere across the country. These centers allows a surgeon/specialist to maintain his/her clinic and paying customer base while not having to take on unattached ER and hospital calls. Likewise for this reason, many internists, family practicioners, and pediatricians have given up their hospital privilege and just maintain a clinic. I can't say that I blame them. Many factors play into why physicians abandon hospital privileges, but bottom line, higher census, lower reimbursement, higher liability are all major factors. And quality of life kinda sucks when you're spending more time at the hospital than with your own family.
To answer for fewer doctors wanting to take unattached calls, many hospitals have started IMS (inpatient medicine service) programs and are paying physicians to work as Hospitalists. Once the hospitals started paying the internists to take unattached calls, they opened a can of worms, as all of the surgeons and all the subspecialists soon started demanding compensation for taking unattached calls as well. With low reimbursement, limitted fundings, and all the specialties wanting a piece of the small pie, hospital administrators are faced with tough decisions as they cannot afford to pay everyone.
Such are the realities of modern medicine. So how can we fix this mess? What incentives can we offer to health care providers, physicians, esp. the subspecialists, to retain them at the hospitals and take care of patients? It is my personal faith in the altruism of my colleagues that I say I doubt there are that many physicians so cold-hearted to the point of refusing emergent care of a patient based on inability to pay. I personally believe the ones who do are very few and far in between. Admittedly however, this broken health care system does grind us all down and has undeniably made cynics out of us all, unfortunately. But I refuse to believe that those of us in medicine, entrusted to care for our fellow man, someone’s father, someone's mother, brothers, sisters, sons & daughters… have abandoned humanity altogether. The root cause for such discontent in the medical community regarding unattached calls is the fact that EMTALA IS AN UNFUNDED MANDATE. But as I said earlier, I don’t think that any physician would deny emergent care to a patient based on inability to pay. What’s frustating about EMTALA, though, is that it’s a one way street that does not provide the physician any liability protection after being forced by federal laws to care for a patient with whom he/she does not have any established relationship with. Not getting pay for it is just adding salt into the wound. And the final thrust of the knife is the disruption of the physician’s office practice by taking away the time the physician could have spent with his/her paying private patients. It’s a triple whammy that leaves little to zero incentive for the doctor to want to take call at such a hospital. There will always be indigent patients, that’s a given. But let’s level the playing field. If physicians are forced to emergently care for patients with whom they have no prior established relationship with, then let’s make it a little fairer by allowing sovereign immunity for EMTALA care. Let the physician practice medicine the way that it ought to be without the fear of litigation. Let the physician use his/her clinical skills and intuition instead of ordering unecessary tests out of fear of a lawsuit. That certainly would help cut the costs health care. Or at the very least, let’s establish a medical court to where physicians will be judged by a jury of their true peers rather than by an easily persuaded sympathetic jury. Let’s face it, expert witnesses are a dime a dozen and both sides can pay a so claimed “expert” to say whatever each wants. I’m too familiar with this game after being embroiled in numerous groundless, frivolous lawsuits. Sovereign immunity for EMTALA care would be ideal, but let’s be truthful, there are plenty of incompetent quacks out there who should have never been given a license to practice in the first place. Let’s restore justice and establish a medical court system. You have patent courts, why can’t you have medical courts? Surely you cannot expect Joe Six-packs to be a fully knowledgeable and informed peer of a physician who've spent well over 12+ grueling years of higher education and intensive training to hone his/her craft? It’s only fair that we establish a medical court wherein a physician may be judged by an impartial and qualified jury comprised of not only respected physicians in the specialty pertinent to the case but also patient advocates who actually have a clinical background. If you think that physicians would be reluctant to punish another physician then you haven’t obviously been to any hospital Morbidity and Mortality Conferences, esp. the ones held by the Dept. of Surgery. Those folks are brutal to each other and character assassination is the norm. But to be expected, achieving a medical court will probably be an impossible uphill battle against the greedy trial lawyers and their lobbying associations. If a medical court is unattainable, why not have the state medical licensing boards perform peer reviews on all malpractice cases, since it's already their duty to police health care within their respected states, and make recommendations to the courts as to whether or not the standard of care was followed? Currently, no state board of medicine participates in the malpractice litigation process at all.
Lastly, the lack of reimbursement for EMTALA care must be offset for the time spent. As has been displayed by the State of Massachusetts, mandating health insurance coverage for every citizen is unfeasible as it is too costly. But for physicians willing to take on unattached calls, not getting paid for the work and on top of that, a double whammy to the books from time detracted away from paying clinic patients, hurt deeply to the operation of a business. This is essentially charity work, and so for fairness sakes, allow physicians to deduct non-reimbursed EMTALA care from their taxes. If you donate money or items to charity, you can deduct it from your taxes. This is no different. If you want us to provide charity/free care to the public, at least allow us to deduct a percentage of it off our taxes so it wouldn’t cripple the operation of our clinics, because when we’re spending time to take care of uninsured patients, it is time taken away from our paying patients.
There you have it, those are my suggestions for overhauling our health care system. Make it accessible, esp. to those who can’t afford it, by eliminating the inefficient and wasteful Medicaid and SCHIP programs to establish a national health care system through the expansion of the existing health department system. Make it more affordable by injecting capitalism into health care to allow hospitals, clinics and insurance companies to compete among each other. Ensure quality and patient safety. And lastly for health care providers, establish a medical court and level the playing field for EMTALA care.
"One of the presidential candidates has asked you for some advice on how to improve the nation's health care system. What do you tell them?"
I thought my answer was pretty decent so I'm reposting it here:
The health care crisis facing our country is akin to a festering butt pus in dire need of incision and drainage. Like butt pus, it’s well covered up so no one else can see, but it sure hell is a huge pain in the ass! My long rant on the subject can be seen here:
Slippery Slope to Socialized Health Care
To summarize, we have a real national crisis at hand and it seems that none of our politicians know how or even care to solve. When over 47 million Americans do not have health insurance, we have a big problem. Albeit that over half of these folks can afford it but choose to go without it, opting for tattoos, fancy cell phones, iPods, body piercings, drugs and alcohol, etc... rather than the basic necessities. Still, over 20 million is a very significant number, as for these Americans health care is completely out of reach. When a person in America has to make a decision between food on the table or pills in a bottle to take for his/her medical problems, it is a national disgrace. When a man have to resort to committing a petty crime to land him in jail just so he can get the medical care that he couldn't otherwise afford, it is disturbing. When hospitals pass on the costs of healthcare to the public by marking everything up by 1000%, we all have to pay painfully. When doctors, who all took the Hippocratic Oath, are too fearful of litigation to take care of patients, order more unnecessary tests (shotgun CYA medicine), spread the liability by consulting other doctors and specialists to get everyone under the umbrella, or worse yet, abandon clinical privilege at a hospital so he wouldn’t have to take care of unattached, nonpaying patients...the situation sucks all around. When hospital and HMO administrators without any clinical experience or medical background can dictate what tests and studies physicians can or cannot order, the ship is being run by idiots and is doom to sink. We're headed toward disaster, there's no doubt about it. This isn't all new. Everyone knows that this health care crisis exist but our nation choose to turn a blind eye. It is analogous to knowing that the levees in New Orleans cannot withold a hurricane for decades but we choose to ignore it all the same. The sad reality of all is that for most Americans, despite having health insurance, we are all one medical disaster (heart attacks, bad car accidents, etc...) away from bankruptcy. It is without question that we have the most technologically advanced health care system that is the envy of the world. But what good is it when we cannot afford it?
So how do we go about solving our health care crisis? Well, let’s go back to the butt pus analogy. Taking care of butt pus ain’t as easy as you think, but it ain’t impossible. A clinician must first be able to see the bigger picture and look beyond the patient’s ass. For instance, is this patient immunocompromised, is he a diabetic, etc…? Otherwise, just cuttin’ on and draining the abscess won’t address the underlying disease. How did this butt pus come about? Is it an infected pilonidal cyst? MRSA? Will antibiotics be required? And before cutting on this butt pus, one must ask, is this a peri-anal or peri-rectal abscess? Is there a fistula? You get the point, there’s more to butt pus than just the ass, or meets the eye. The problem with our politicians is that they cannot look beyond the ass and thus are oblivious to solving the problem.
From the patient’s perspective, health care should be affordable, easily accessible, and without compromise to quality. From the provider’s point of view, liability is the biggest issue, as well as autonomy, reimbursement fairness, and quality of family life. The buzzword that we often hear regarding health care reforms from our politicians lately is UNIVERSAL HEALTH CARE. Yes, indeed universal health care is a noble endeavor that we all should strive for in this country. But our politicians are approaching it all wrong, sliding into the direction of socializing health care. There is a HUGE difference between universal health care and socialized health care, but too many people mistake them for one and the same. They are not! It has been shown time and time again throughout history that whenever the government has absolute control, all things go to hell quickly in a handbasket. Our government cannot even keep its promise to provide health care to our veterans, what makes you think that Obama can provide health care for every American in this country? With that said, however, we can achieve universal health care without socializing it. In fact, you might argue that we already have universal health care right now. The Federal EMTALA law (Emergency Medical Treatment and Active Labor Act) requires that every patient who shows up to an ER of a hospital must receive medical screening and stabilization if that hospital participates in Medicare. Without Medicare funding, a hospital is certain to go belly up bankrupt and thus EMTALA is pretty much inclusive of all hospitals in the USA. Private clinics, however, are not bound by EMTALA to do the same. So in a way, we already have, sort of, universal health care here. The word is long out. If you have no health insurance and can't pay for health care, go to the nearest ER. You don't have to pay up front and we are too scare of lawsuits not to take care of you. You can make up phoney personal information about yourself, fake who you are, give 'em aliases, fake phone numbers and addresses, phoney social security numbers and you'll never have to see that hospital bill. Heck, all the homeless folks show up every night looking for a warm bed and free meal anyhow, in addition to free health care, of course. Three hots and a cot, as we call it. Now there's a novel idea! If you have a real medical problem that needs true emergent care, like an acute appendicitis or a hot gallbladder that needs to be operated on or something...pretend you're a homeless drunk, mess yourself up a little bit, wear dirty old clothes, not shave or shower, sprinkle a little beer on yourself for the smell...and if you want to really get into the role...piss in your pants for the stale urine effect...show up to the ER of a hospital they'll have to take care of you. You'll never see the hospital bill, guarantee it!!! The beauty is, they will never come after you, not for collections, not even with a 20ft pole, not ever! So there, you see, we already have universal health care in this country. Albeit inefficient, twisted and somewhat sordid, but free/charity healthcare nonetheless. The hoards of non-paying illegal immigrants have been showing up to our ER's in droves over the years to receive free care. EMTALA is a well-intentioned law meant to prevent patient dumping and abandonment. Too many people, however, take advantage of it and abuse the system. In honesty though, we're not all heartless, money-grubbing bastards. We're here to help everyone who truly needs our expertise. But it is very upsetting to see the ER being used for non-emergent problems like simple toothaches, sorethroats, runny noses, pregnancy tests, silly hang nails, etc...
We can achieve universal health care coverage for everyone in this country without socializing it through government mandates. And we don’t have to do it by forcing everyone to buy health insurance policies that they can’t afford either. And we don’t have to require all employers to provide health insurance coverage for their workers as well, because small businesses would certainly go belly up if such a mandate is handed down. How can we achieve such a gargantuan task? Too good to be true? Not really. Our health care crisis is multi-faceted and complex, and addressing only one aspect of it alone will not solve the problem. Putting a band-aid on a butt pus doesn’t make it go away! Over the years, many have blamed the increasing costs of health care on the enormous jackpot awards from frivrolous lawsuits brought forth by greedy trial lawyers, like John Edwards. Many states have tried to solve that problem by capping non-punitive damages on malpractice suits, but guess what, the plaintiff attorneys just worked harder, bringing up more lawsuits in order to make up for loss revenues they once enjoyed. Did health care cost go down? Not really. Did it make health care more accessible? Nope. More Americans are uninsured than ever and ER census across the country continue to rise in reflection to those numbers. Are doctors still practicing defensive medicine and ordering unecessary tests? You betcha, even in Texas and Florida. So do groundless lawsuits drive up the cost of health care? It may have contributed some but isn’t the only factor that has made things spiral out of control. Mitt Romney, to his credit, tried to solve the problem by a different approach while he was the governor of Massachusetts. His plan, mandating health insurance coverage across the board for every citizens, has proven to be too expensive, even for the rich state of Massachusetts to stomach. Government mandates have never worked, and never will. I can’t imagine poor Mississippi or Louisiana being able to do the same when the wealthy folks of Massachusetts have failed so miserably. The benevolent aspirations of Mitt Romney were there, but the execution, was all wrong, and it wasn’t just the mandates alone. Though the plan addressed the accessibility of health care, it failed to address the other problems. For true health care reform to work, every aspects of the problem need to be addressed:
Patient’s perspective:
Accessibility
Affordability
Preservation of quality
Provider’s perspective:
Liability
Autonomy
Reimbursement fairness
Let’s break it all down.
A) Accesibility. Health care has to be easily accessible to all. For over 47 million Americans without insurance (and that number is projected to reach 50 million by the end of the decade), it ain’t so accessible. In many cities, aside for the safety net of the ER, there is little to nowhere else for these folks to turn to. But it need not be that way. We already have the infrastructures at the local and state levels to increase health care access. I say expand our local Health Department system. Give the health departments a more clinical role rather than just being there to provide routine vaccinations and monitoring of infectious diseases. Doing so would, in essence, establish a national health care system to where people who cannot afford insurance or a private clinic can go to for routine primary care. This would serve the poorest and most impoverished segments of our society, in addition to providing care for those lazy asses who choose not to pay for themselves, the so called leeches. How do we fund this expansion? The states are already funded through Medicaid. Right now, the states are allowed considerable flexibility on how to execute the Medicaid program that costs over $370 Billions/yr. Anyone who has ever done a shift in the ER’s knows full well how rampant Medicaid fraud and abuses are. Let’s eliminate some of that flexibility and force the states to beef up their local health departments to a more clinical/primary care role. Give sovereign immunity to health care providers who are willing to take a pay cut to work in our health departments (more on liability issues later). You want free care? You can’t eat your cake and have it too. Eliminate Medicaid and establish a national health care system through expansion of the health departments. Let the states run them, if they don’t want to relinquish control. But Eliminate Medicaid! The reimbursement for Medicaid, as it exists, is paltry anyhow. Most private clinics refuse to accept Medicaid anyway. They shun it like butt pus.
While we’re at it, get rid of the federally funded State Children’s Health Insurance Program (SCHIP), too. Here’s the truth to the notion of providing umbrella health insurance coverage to every child in America, it’s wasteful and fattens the wallets of the insurance carriers and HMO’s more than it benefits us tax payers. While it’s a noble endeavor, it’s not cost effective. At first blush, it would seem to be a grandly benovelent idea to require health insurance across the board for all children. You can hear the outcries, can’t ya? “But, but, but...it’s for our babies! We are the wealthiest nation in the world...and we can’t provide healthcare for our children?...” Problem is, SCHIP is a gargantuanly expensive endeavour that does not provide the biggest bang for the bucks and makes no economical sense. Fact is, the overwhelming majority of kids do not get severely sick and have no need for expansive health insurance coverage. Sure they’ll get the routine common colds, snotty nose, cough, sore throat and the sniffles. But for the most part, the majority of kids are healthy and are not afflicted with serious illnesses. Therefore, mandating health insurance coverage across the board for every kid in America is wasteful and serves the health insurance industry more than it does the kids. As a physician, I would love nothing more than seeing a well insured kid for a routine viral snot nose and sniffle in my ER. Quick 5 minute exam...Easy Chaching! But as a responsible taxpayer I see it as nothing but wasteful drain on our collective wallets. Day after day on duty I see hoards of Medicaid covered kids rushed to my ER, sometimes even by ambulance, for routine snot noses and sore throats. Sadly less than 10% of all the kids I see in my ER have a true medical emergency. Medicaid abuse is sickeningly rampant. Fiscal discipline and responsibility is called for here and “it’s for the kids” can no longer cut it as an excuse.
Instead, for kids and healthy young adults, a catastrophic insurance policy makes more sense and is more cost effective, because these policies are much cheaper and are applicable in instances of unexpected calamity such as injuries after a motor vehicle accident, sudden illnesses requiring extensive/prolonged healthcare (meningitis, appendicitis, new onset diabetes, broken bones, ect...).
Abolish Medicaid and SCHIP! Use that $300+ Billions to establish a national health care system through expansion of the existing health departments. To get the manpower for the national health care system, give student loans breaks to physicians, PA’s, ARNP’s, RN’s, LPN’s, etc…who are willing to work for the health departments. Recruit students through scholarship offers to work in the health departments once they’re done. 4 yrs of med school for 4 yrs of indentured servitude in the national health care system is a very fair deal, much like the military’s GI Bill.
B) Affordability. Unless your portfolio rivals that of Bill Gates, Warren Buffet and the likes, for most Americans, myself included, we are all just one medical disaster away from bankruptcy, insured or not. Imagine a serious car accident, or heaven forbids, a diagnosis of some malignant cancer or leukemia. If you’re uninsured and play by the rule, you’re screwed. If you are insured and think that your HMO will be there for you, you’re naïve. ~$7,000 per day in the ICU ain’t no chump change! The spiraling costs of health care just boggles the mind. By 2012, health care expenditures are expected to be about 17-20% of the GDP. A routine visit for an ankle sprain with a simple ankle series xrays used to cost $40 bucks when I first started medical school, now it costs $240 bucks! That’s just the charges for the xrays alone, not for the visit, not for the splints and crutches, nor is radiologist’s charges for reading the films included.
Here's the truth....There is a 1000% mark up for every thing as soon as you step through the door of the hospital. That’s right, ONE THOUSAND PERCENT mark up, not including physician fees, just hospital charges alone. One could argue that the $10 Tylenol pill is also paying for the heating and air conditioning, lights, utilities, house keeping, grounds maintenance, etc… But c’mon 1000%? Ain’t that a little too obscene?
We’ve already established that socializing health care through gov’t mandates does not work. It never has, but creating a national health care system as discussed above is absolutely necessary and would certainly increase primary care access for the extremely impoverished segments of our society who could not otherwise afford it. And for children and young healthy adults, a catastrophic insurance plan makes more economic sense as such policies are much cheaper. But what about the rest of us who plays by the rules and see government handouts as un-American and an insult to the very foundation of our democracy, capitalism, self-reliance and individualism? How can we make health insurance more affordable for people who wants to take care of themselves and not rely on the gub’mint?
One of the main problem of our health care system is that there is no true competition. By that, I mean that there is an absolute lack of capitalism in health care. The spirit of capitalism is what made this country great, yet it is completely absent and devoid in the health care industry. From DRG fixed pricing through ICD codings established by Medicare, to the limitting and confining of insurance purchases within certain regions and state lines, capitalism does not exist in health care at all! And as a direct result, prices soar out of control to no end. It is completely senseless that there are over 1300 companies across the country offering health insurance policies yet we are confined to less that a handful of "Blue this Blue that" and the ilks regionally. To fix this problem we need to inject true capitalism into health care and let the basic principles of supply and demand economics take care of itself. Laissez-faire and let the market forces work! Let all of the hospitals and clinics compete. Let them set their own prices to drive down market costs. If at hospital A, I can get a hip replacement cheaper than at hospital B, transfer me to hospital A…If at the neighborhood clinic a routine visit is cheaper than at uptown clinic….you get the point. In the same vein, let all of the insurance companies compete across state lines. Allow small business, citizens of cities, towns, municipalities, etc…to band together for purchasing power to leverage for a cheaper price with insurance companies, much like the deals that large corporations can cut with these insurance companies.
The answer to our health care crisis is not to socialize it but to inject capitalism into it. Free enterprise! Let the market work!
C) Preservation of Quality. It is without question that we have the most technologically advance health care system that is the envy of the word. As it should be, because Americans demand and deserve no less. Any discussion in the overhauling of health care must include the preservation of quality that we currently have and must always strive to improve. Our health care providers must pass stringent criterias including appropriate trainings and board certifications. That cannot change as public confidence, not to mention safety, in our profession is of utmost importance.
D) Liability, Autonomy, Reimbursement fairness, and Quality of family life (The physician side of the story). I would like to lump all of this into one discussion from a physician perspective, as these issues are all dynamically related and intertwined. As a physician who has been frivolously sued numerous times, I can personally attest that each case was equally gut wrenching and ripped me to the core. It was one of the major factor that weighed heavily and contributed to my decision to leave Emergency Medicine. Yes, every single one of those cases were completely meritless but they still haunted my psyche all the same. I hated to practice defensive, CYA medicine. I hated myself for seeing every patient encounter as a potential lawsuit. Do groundless junk lawsuits drive up the cost of health care? Not entirely as recent studies dispute such arguments that frivolous claims are the largest contributor to our health care problem. But one thing is clear, these junk suits certainly do contribute to the pie of discontentment making all physicians miserable. On top of that liability insurance costs are insanely astronomical. In my group of physicians covering an ED of 78,000 patients/yr. census, it costs us $1.2 Million/yr in liability coverage. And that’s cheap compared to other groups of comparable census in other states. Patients and their families bring suit, for the most part, due to bad outcomes. However, recent studies have shown that nearly 80% of all claims did not involve errors and did not receive compensation. So why the hell are the rest of us paying so much for liability insurance to the point that it cripples our business?
Escalating matters in our current health care environment is that more and more Americans are uninsured and the numbers are expected to continue to rise. And where do they go for their health care? They show up to the ER's across the country, of course, bogging down the system causing a serious overcrowding. Why do they not show up to the local clinics for routine nonemergent stuff? Well, that's because the clinics will first do a wallet biopsy as soon as patients show up at their reception windows as clinics are not bound by EMTALA. Thus, uninsured patients show up in hoards to the ERs because we don't and cannot make them pay first to be seen. That’s the problem, EMTALA IS AN UNFUNDED MANDATE! I talk about the ER mainly because it is my field of expertise. But more importantly, I bring up this issue because unattached ER coverage is the single greatest cause of malcontent among the hospital staff of all specialties and subspecialties. As the growing numbers of uninsured patients continue to rise, compounded by the flood of illegal aliens, the safety net of the ER is the only place that these patients can turn to. At the hospital where I had been, our census doubled over a short period of 3 years. However, our ER reimbursement rate dropped to 27%. That means only 3 out of every 10 bills we send out get paid. About 3 out of every 10 patients we see actually pay us! Can you imagine any other business being able to survive on such piss poor returns? Just how do we survive and maintain our practice? The hospital has to kick in a subsidy, of course. But it's no where near enough for us to hire adequate staffing to be able to efficiently handle the patient load. The hospital in turn gets funding from the federal and state and local levels. What's more, the current nation wide nursing shortage bottlenecks our situation to a grinding halt on many nights. Not only are there not enough ER nurses, there aren't enough floor and ICU nurses as well. The facility actually has plenty of beds, just not enough nurses upstairs to take care of patients so they get boarded in the ER until one becomes available. Meanwhile, patients keep on showing up with no rooms to put them into. We triage and care for the sickest ones first, of course, and do the best we can. An average of 4-5 hours waiting time for nonemergent cases such as sore throats, runny noses, toothaches etc..is not uncommon at all....which all equate to crappy Press-Ganey patient satisfaction scores and lower incentive driven reimbursements and bonuses for grunts like me. Damn vicious cycle and ploy isn't it?
The problem with uninsured patients is just not the financial aspect alone. Uninsured patients usually do not have a primary care physician. Because of such, many of them have not had any routine maintenance or preventive health care, and have neglected themselves for years. They tend to be noncompliant with medical management when they do show up. It's pretty hard to be compliant, though, when you can't afford things such as medications. Thus, it is of no surprise that the uninsured patient will usually have more complex medical problems and more comorbidities. From the consultants’ side of the story, the longstanding rule is that for a physician to have practicing privilege at a hospital, he/she must agree to take unattached inpatient and ER calls. Now if you are a specialist or surgeon, why would you want to take call at a busy county hospital that requires you to see more patients, who are sicker, who don't pay, have more medical problems that are more complex with higher comorbidity and thus, higher liability? Yes, these are precisely the patient demographics that sue most often. Taking call at such a hospital means that you'll have to work longer hours, see your family less, take care of more patients, with higher acuity, more complex comorbidities, who are likely to sue you more...and finally the kicker...not get paid for it. Furthermore, having to care for these unattached, nonpaying patients disrupts the physicians’ private practice and detracts time away from their own paying clinic patients. As a result of this, outpatient surgical centers are popping up everywhere across the country. These centers allows a surgeon/specialist to maintain his/her clinic and paying customer base while not having to take on unattached ER and hospital calls. Likewise for this reason, many internists, family practicioners, and pediatricians have given up their hospital privilege and just maintain a clinic. I can't say that I blame them. Many factors play into why physicians abandon hospital privileges, but bottom line, higher census, lower reimbursement, higher liability are all major factors. And quality of life kinda sucks when you're spending more time at the hospital than with your own family.
To answer for fewer doctors wanting to take unattached calls, many hospitals have started IMS (inpatient medicine service) programs and are paying physicians to work as Hospitalists. Once the hospitals started paying the internists to take unattached calls, they opened a can of worms, as all of the surgeons and all the subspecialists soon started demanding compensation for taking unattached calls as well. With low reimbursement, limitted fundings, and all the specialties wanting a piece of the small pie, hospital administrators are faced with tough decisions as they cannot afford to pay everyone.
Such are the realities of modern medicine. So how can we fix this mess? What incentives can we offer to health care providers, physicians, esp. the subspecialists, to retain them at the hospitals and take care of patients? It is my personal faith in the altruism of my colleagues that I say I doubt there are that many physicians so cold-hearted to the point of refusing emergent care of a patient based on inability to pay. I personally believe the ones who do are very few and far in between. Admittedly however, this broken health care system does grind us all down and has undeniably made cynics out of us all, unfortunately. But I refuse to believe that those of us in medicine, entrusted to care for our fellow man, someone’s father, someone's mother, brothers, sisters, sons & daughters… have abandoned humanity altogether. The root cause for such discontent in the medical community regarding unattached calls is the fact that EMTALA IS AN UNFUNDED MANDATE. But as I said earlier, I don’t think that any physician would deny emergent care to a patient based on inability to pay. What’s frustating about EMTALA, though, is that it’s a one way street that does not provide the physician any liability protection after being forced by federal laws to care for a patient with whom he/she does not have any established relationship with. Not getting pay for it is just adding salt into the wound. And the final thrust of the knife is the disruption of the physician’s office practice by taking away the time the physician could have spent with his/her paying private patients. It’s a triple whammy that leaves little to zero incentive for the doctor to want to take call at such a hospital. There will always be indigent patients, that’s a given. But let’s level the playing field. If physicians are forced to emergently care for patients with whom they have no prior established relationship with, then let’s make it a little fairer by allowing sovereign immunity for EMTALA care. Let the physician practice medicine the way that it ought to be without the fear of litigation. Let the physician use his/her clinical skills and intuition instead of ordering unecessary tests out of fear of a lawsuit. That certainly would help cut the costs health care. Or at the very least, let’s establish a medical court to where physicians will be judged by a jury of their true peers rather than by an easily persuaded sympathetic jury. Let’s face it, expert witnesses are a dime a dozen and both sides can pay a so claimed “expert” to say whatever each wants. I’m too familiar with this game after being embroiled in numerous groundless, frivolous lawsuits. Sovereign immunity for EMTALA care would be ideal, but let’s be truthful, there are plenty of incompetent quacks out there who should have never been given a license to practice in the first place. Let’s restore justice and establish a medical court system. You have patent courts, why can’t you have medical courts? Surely you cannot expect Joe Six-packs to be a fully knowledgeable and informed peer of a physician who've spent well over 12+ grueling years of higher education and intensive training to hone his/her craft? It’s only fair that we establish a medical court wherein a physician may be judged by an impartial and qualified jury comprised of not only respected physicians in the specialty pertinent to the case but also patient advocates who actually have a clinical background. If you think that physicians would be reluctant to punish another physician then you haven’t obviously been to any hospital Morbidity and Mortality Conferences, esp. the ones held by the Dept. of Surgery. Those folks are brutal to each other and character assassination is the norm. But to be expected, achieving a medical court will probably be an impossible uphill battle against the greedy trial lawyers and their lobbying associations. If a medical court is unattainable, why not have the state medical licensing boards perform peer reviews on all malpractice cases, since it's already their duty to police health care within their respected states, and make recommendations to the courts as to whether or not the standard of care was followed? Currently, no state board of medicine participates in the malpractice litigation process at all.
Lastly, the lack of reimbursement for EMTALA care must be offset for the time spent. As has been displayed by the State of Massachusetts, mandating health insurance coverage for every citizen is unfeasible as it is too costly. But for physicians willing to take on unattached calls, not getting paid for the work and on top of that, a double whammy to the books from time detracted away from paying clinic patients, hurt deeply to the operation of a business. This is essentially charity work, and so for fairness sakes, allow physicians to deduct non-reimbursed EMTALA care from their taxes. If you donate money or items to charity, you can deduct it from your taxes. This is no different. If you want us to provide charity/free care to the public, at least allow us to deduct a percentage of it off our taxes so it wouldn’t cripple the operation of our clinics, because when we’re spending time to take care of uninsured patients, it is time taken away from our paying patients.
There you have it, those are my suggestions for overhauling our health care system. Make it accessible, esp. to those who can’t afford it, by eliminating the inefficient and wasteful Medicaid and SCHIP programs to establish a national health care system through the expansion of the existing health department system. Make it more affordable by injecting capitalism into health care to allow hospitals, clinics and insurance companies to compete among each other. Ensure quality and patient safety. And lastly for health care providers, establish a medical court and level the playing field for EMTALA care.
Tuesday, June 12, 2007
Blissful Ignorance
Hey all! Blogging to ya from a remote tropical place where the sands are sugary white, the wind blows hard, and those little drinks with the colorful umbrellas never stop flowing. Being unemployed have never felt so relaxing. Truly this windsurfer's paradise. It's so awesome pulling off a duck jibe on a 65 liter board and a 4.0 sail. Rippin' it every day, man! The wind here is just unbelievable, steady and hard, while the water stay calm without the chops. But on the south side though, the waves breaks hard off the reefs. Oh man, perfect for wave sailing and surfing! Just visited the local ER, too, and they're hiring! Sweet! Tempting, but I haven't made a decision after the interview.
The internet connection here is slow and spotty.
I just checked Technorati and discovered that there's a healthy discussion here about one of my post. Unfortunately, many of these folks are non-medical and think that ambulance abuse is a rarity!
The internet connection here is slow and spotty.
I just checked Technorati and discovered that there's a healthy discussion here about one of my post. Unfortunately, many of these folks are non-medical and think that ambulance abuse is a rarity!
Wednesday, May 23, 2007
The Calling
My 8 y/o nephew interviewed me the other day as part of his homework assignment for school. He asked me the ultimate question, "Why did you become a doctor?" I didn't want to disappoint an impressionable child with the truth, so I gave him the usual inspirational answers about wanting to make a difference, helping people, saving lives, etc... But the truth is, I didn't know what else to do at the time so I went to med school.My application to med school was impeccable, I must brag. I was the total package, clawed my way out of the housing projects of Crack City to graduate at the top of my high school, graduated summa cum laude in engineering from a prestigious university with internship experience through several internationally recognized companies. Even won a couple of national collegiate engineering design competitions, too. I proudly enumerated all of my proud academic achievements and accolades on the application, of course. I also included 2 U.S. patents with my name on them, earned from my work as an engineer for 3 years with a very well known company recognized worldwide as the premier leader in its field. Heck the company pretty much has a monopoly in the area, and still does. Thank goodness I had the foresight to max out my employee stock options at the time. Oh, I also aced the MCAT to boot. But my career in medicine almost never happened, as my first med school interview was a complete flop. And I only applied to one school.
I walked up and down the corridors of the MOB (medical office building) looking for his office. Tucked far in the back hallway corner, I finally spot the sign on his door, Dr. Weinstein.
"Good morning, sir..." I introduced myself cordially.
"You're 15 minutes early, Mr. Charity," he grumbled in a deep baritone voice. "Why don't you just wait outside until I review your file and I'll call you back in."
I peered furtively into his office as he closed the door. There wasn't anyone else in there. It wasn't as if he was interviewing another candidate or something. Then why the hell was this man making me stand outside the hallway like a stooge, I wondered to myself. And since when is showing up early for an interview, or anything for that matter, a detriment? Oh this guy was a hard ass! I could tell from the very get go.
Exactly 15 minutes later, not a second more or less, the door re-opened and he instructed immediately, "Have a seat, Mr. Charity."
I didn't even have an opportunity to speak my mind. It was that quick and short.
"You have very impressive credentials, Mr. Charity," he tossed my files onto his desk, propped up his feet and opened the conversation. "Your essays are very moving. Powerful, I must admit," he complimented, "You're a very good writer. And the letters of recommendations, very persuasive in your favor."
My confidence was quickly shattered, though, when he sat up and dropped the hammer, "So, why the hell are you here?"
"Excuse me, sir?" I replied dumbfoundedly after being completely stunned by his informality.
"Why the hell are you here?" he repeated crudely. "It looks to me like you already have a successful career in engineering. You shouldn't be in medicine, Mr. Charity."
"Sir, I want to be in medicine...."
"Let's not waste each other's time anymore, heh," he interrupted. "You don't belong in medicine, Mr. Charity. You were born an engineer. Go back."
With that he stood up and showed me the door.
(To be continued)
Wednesday, May 16, 2007
Insurance?
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.
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.
Tuesday, May 15, 2007
Another Quote of the Night
From the same charge nurse to hysterical patient with a stuffy nose whose chief complaint was "I can't breathe" -
"Ma'am, if you can talk, you can breathe...Ma'am, just calm down...Ma'am that hole in your mouth is bigger than the two holes in your nose! If you can talk, you can breathe!"
Crushing logic, isn't it?!!
"Ma'am, if you can talk, you can breathe...Ma'am, just calm down...Ma'am that hole in your mouth is bigger than the two holes in your nose! If you can talk, you can breathe!"
Crushing logic, isn't it?!!
Sunday, May 13, 2007
Quote of the Night
Direct to you from last night's shift, wicked words of wisdom from Crack City ER's charge nurse to belligerent patient after polite attempts at diffusing a situation failed:
"Sir, as a nurse, I will clean your ass, I will wipe your ass, I will even stick my fingers up your ass. I will exhaust every effort to save your ass. BUT, I will NOT go so low as to kiss your ass. And rest assuredly, if you continue to piss me off, I will not hesitate to kick your ass! Now plant your ass down or I will take your temperature with my boot!"
"Sir, as a nurse, I will clean your ass, I will wipe your ass, I will even stick my fingers up your ass. I will exhaust every effort to save your ass. BUT, I will NOT go so low as to kiss your ass. And rest assuredly, if you continue to piss me off, I will not hesitate to kick your ass! Now plant your ass down or I will take your temperature with my boot!"
Saturday, May 05, 2007
Dereliction of Duty
It's May. My last month at Crack City so I'll try to blog as much as I can before figuring out my next move.
On some nights I'm just so sick and tired, so fed up with it all that I just wanna scream and ask, "AM I THE ONLY ONE WHO GIVES A SHIT AROUND HERE?"
Case in point, father of this 7 y/o little boy brings him into the ED last night reporting that his mother's boyfriend had beatened him black and blue with a belt, to which the mother did not deny. The couple had been divorced for a little over a year. On physical exam, the little boy had indeedly not been spared the rod at all. His buttocks and back were ecchymotic, black and blue with scattered scabbed marks from numerous whippings and beatings. It was unbelievable. Sort of reminded me of a scene right out of the TV mini-series Roots where LeVar Burton, portraying the main character Kunta Kinte, had been lashed repeatedly across the back. Yes, it was that gruesome.
The father had just picked up the little boy from his mother's house as he had court allotted time with the child on Fridays, Saturdays & Sundays. Upon giving the child a bath, he noticed the horrendous injuries and immediately called the mother, notifying her that he was bringing the child to our ED and will be filing charges. Poor kid was sleeping soundly when he arrived, whimpered a bit during the exam.
"It's OK, buddy. This is Annie, the nurse. And I'm Dr.____. We're just looking, alright. We want to help you get better."
His eyes were scared, not knowing how to react nor whom to trust.
Now the mother openly acknowledged that the boy had been "whupped" by her boyfriend, but defended the SOB over and over by giving a sob story of how rotten and misbehaved this kid had been. Reportedly this kid has ADHD, violent impulsive behavior, had tried to burn down the house several times in the past, once lit a fire in the classroom at school, is on Adderal, zoloft, tegretol, risperdal, and a bunch of other psych meds to control his behavior. Hell, the list of mood altering prescription drugs that this kid is on just boggles the mind. It is absolutely unconscionable and irresponsible for any physician to prescribe that many controlled substances and drugs to a child. That list was as long as those we typically see in debilitating elderly patients or those with end-staged renal disease on chronic hemodialysis.
Oh, how the mother sobbed like a squeaky violin trying to explain that the kid wouldn't go to bed even though it was 2 AM, screaming at the top of his voice, throwing things in the house, kept on wanting to watch TV, yada yadda yadda. So the boyfriend, whom she lived with, spared not the rod. Damn son of a bitch. He beated the kid to a pulp. Yet the mother still defended and condoned his actions.
Armed with this latest injury to his son, the father remarked, "I'll be gettin' custody now!"
In response to the father's threats, the mother began telling a disturbing story of alleged sexual abuse against the child by the father, how the father has a large collection of child pornography, watches it in front of this kid, etc...and was somehow able to ditch evidence of all of it during the divorce proceedings and investigations. I suppose that's how she got custody of the child and he has visitation rights?
God, I was so nauseated and sickened by it all...He said, she said...the child was the unfortunate victim and I was sadly caught in the middle trying to figure out whom to believe. I had mother and father moved to separate consultation rooms at each end of the ED and placed a hospital security guard at the child's bedside.
"Where the f*k is that motherf'er!!!" I suddenly heard the profuse profanity from the hallway. "I'm gonna kill him! I'm gonna kill him! Nobody beat up my kid like that and gets away with it. I'm gonna kill that son of a bitch!"
The repugnant boyfriend apparently had showed up. Pandemonium erupted in the ED as you can imagine. We had to tackle down the father to keep him from pouncing the boyfriend.
CCPD naturally had been contacted earlier and as soon as the two officers showed up, the boyfriend took off like a hot rabbit and ran out of the ED through the ambulance entrance. Did this guy have a previous criminal record? I asked myself. Or was he just scared shitless about getting arrested for being a child beater? Hell, we should've let the father of the kid kicked his ass.
Here's where things become even more sickening and frustrating. Children Protective Services was of no help at all. I personally spoke to the guy over the phone but it took him over 3 hours to show up. The dude was a completely useless imbecile. He spent 2 hours interviewing the father, the mother and the child without offering any helpful solution to the problem. I had expected him to take the child into state custody until pending further investigation, but he didn't.
"So, what're we gonna do with the kid?" I asked when he was all done.
"Umm, we're very familiar with this family. We've taken several reports on them before. You can send the little boy home with his mom," the imbecile replied.
"What?!!! Send him home with his mom?!!! But the guy who has been beating this child lives with her! I ain't sending this kid home with the mom. No way! You need to come up with a better solution than that."
"Well, I talked it over with my supervisor, and..."
You can understand why I started tuning out whatever the imbecile had to say afterward.
"Listen, the guy who has been beating up this kid is still out there. The mother lives with guy in his house for goodness sakes! What makes you think that he won't beat up this kid again?"
"The father already pressed charges and the police is looking for him."
"That's good to hear, but they haven't gotten him yet, have they? Did you missed the part about the mother and this kid living with this guy in his house? They got nowhere else to go. And from my discussion with her, it doesn't look like she intends to move out anytime soon. What's gonna happen after the police release him or if he post bail?"
"What makes you think he's gonna beat this kid again?"
"Fk! Did you see the horrendous wounds on the back of the kid? Have you seen it?! Hell, it's a chance that I'm not gonna take!"
"Well, the mother has legal custody of the kid and we can't send him home with his father."
"Man, you're completely hopeless and useless. Thanks-for-nothing! When you're driving home later, think about what you just did and see if you can live with it. You make me sick, man! You should be ashamed of yourself! Child Protective Services my ASS!"
It gets even worse. I had the pediatrician on call paged. And he, too, balked.
"Hey, Phil I got this little kid down here..." I explained the situation.
"What do you want me to do about it?" came his totally unexpected response. "If CPS isn't going to take this kid into custody, what am I going to do? There's no medical criteria for admission here. Medicaid won't allow it. I can't do a social admit and be an indefinite baby sitter."
WTF!!! I argued back and forth at length with this pediatrician about doing the right thing, being a child advocate, protecting a kid from getting abused...but DAMN, all to no avail! He was a wall. When did this pediatrician lose his compassion for children? I sadly wondered. When did this pediatrician's decisions become solely business based? No medical criteria for admission? Medicaid won't allow it? Shit! I ended our phone conversation with much needed words of impugnity.
"You're peds, Phil, you're not suppose to be this jaded. We're not suppose to punish a child for the stupidity of the parents, aren't we? Where's your love, Phil? Where IS your love? Have you lost it, man? Have you lost it?" I hung up not giving him an opportunity to mouth back at me.
Oh, it gets worse. Desperate, I called the psychiatrist on call, who agreed that this child should be admitted for his safety but wouldn't do it himself.
"I'm sorry I can't admit him. He's not..."
I started tuning out his psycho babble...
"It's psychosocial, man. It's all related. I can't believe that you guys are so willing to load him up with a bunch of psychotropic meds but won't admit him when it becomes inconvenient for you."
So then, I called the hospitalist on call, who commiserated with my situation but quickly pointed out, "Look, I'm not peds. My liability policy does not cover 7 years old kids. I'm sorry, man." Oh, my God!
Desperate again, I called the surgeon on call and tried the trauma-related angle. "It's a horrible situation, but what am I gonna do but consult the pediatrician and social services like you already did. I'm sorry, man."
I didn't want to resort to having to wake up the hospital's Chief of Pediatrics nor the President of the Medical Staff. It would have been pointless and useless anyway. They weren't on call for the night and wouldn't have answered the page anyway. So, I placed another phone call to the police to see if they have anything to offer...NADA. "We can't take him to juvies..." I don't want you to! I was hoping that they would know of some social services or shelter that would take the child in until things were sorted out.
Child Protective Services - Strike one
Pediatrician - Strike two
Psychiatrist - Strike three
Hospitalist - Strike 4
Surgeon - Strike 5
Police - Strike 6
AM I THE ONLY ONE WHO GIVES A SHIT ABOUT DOING THE RIGHT THING ANYMORE?
I ended up admitting this kid last night to my hyperbaric service, because I can. It's the only inpatient admitting privilege I have. It's just easier for me this way, and with so much less aggravation of having to argue back and forth with a bunch of derelicts. Not to admit this kid and release him to his dysfunctional and degenerate parents would have been a true dereliction of duty. I was raised by a military father never to shirk duty and honor. And I was not about to disappoint him.
This morning, the HBOT team was completely surprised and concerned about why a 7 years old kid is on our census list. "It's another one of Charity's social admits again," they complained. The kid's wounds do not meet HBOT criterias of course. The morning doc in my group wasn't too happy about having to round on this kid so I told everyone that I would personally round on him myself and take care of his disposition come Monday. I'm not sure yet what I'm gonna do or how to even disposition the kid. For now, I'm just glad that he has a safe place to sleep for the weekend. So far the nurses have informed that the kid has been very well behaved, a complete angel and not a problem at all. Not surprising how a little love and TLC goes a long way, I suppose. The only medication that I wrote for him is Motrin and Tylenol as needed for pain. No psych meds. A hospital security guard is posted at his bedside, of course. Funny how the hospital security folks are the only ones who understand the situation and have not complained at all about having to post a sitter with the kid 24/7. I just added them to my Christmas list for the year.
On some nights I'm just so sick and tired, so fed up with it all that I just wanna scream and ask, "AM I THE ONLY ONE WHO GIVES A SHIT AROUND HERE?"
Case in point, father of this 7 y/o little boy brings him into the ED last night reporting that his mother's boyfriend had beatened him black and blue with a belt, to which the mother did not deny. The couple had been divorced for a little over a year. On physical exam, the little boy had indeedly not been spared the rod at all. His buttocks and back were ecchymotic, black and blue with scattered scabbed marks from numerous whippings and beatings. It was unbelievable. Sort of reminded me of a scene right out of the TV mini-series Roots where LeVar Burton, portraying the main character Kunta Kinte, had been lashed repeatedly across the back. Yes, it was that gruesome.
The father had just picked up the little boy from his mother's house as he had court allotted time with the child on Fridays, Saturdays & Sundays. Upon giving the child a bath, he noticed the horrendous injuries and immediately called the mother, notifying her that he was bringing the child to our ED and will be filing charges. Poor kid was sleeping soundly when he arrived, whimpered a bit during the exam.
"It's OK, buddy. This is Annie, the nurse. And I'm Dr.____. We're just looking, alright. We want to help you get better."
His eyes were scared, not knowing how to react nor whom to trust.
Now the mother openly acknowledged that the boy had been "whupped" by her boyfriend, but defended the SOB over and over by giving a sob story of how rotten and misbehaved this kid had been. Reportedly this kid has ADHD, violent impulsive behavior, had tried to burn down the house several times in the past, once lit a fire in the classroom at school, is on Adderal, zoloft, tegretol, risperdal, and a bunch of other psych meds to control his behavior. Hell, the list of mood altering prescription drugs that this kid is on just boggles the mind. It is absolutely unconscionable and irresponsible for any physician to prescribe that many controlled substances and drugs to a child. That list was as long as those we typically see in debilitating elderly patients or those with end-staged renal disease on chronic hemodialysis.
Oh, how the mother sobbed like a squeaky violin trying to explain that the kid wouldn't go to bed even though it was 2 AM, screaming at the top of his voice, throwing things in the house, kept on wanting to watch TV, yada yadda yadda. So the boyfriend, whom she lived with, spared not the rod. Damn son of a bitch. He beated the kid to a pulp. Yet the mother still defended and condoned his actions.
Armed with this latest injury to his son, the father remarked, "I'll be gettin' custody now!"
In response to the father's threats, the mother began telling a disturbing story of alleged sexual abuse against the child by the father, how the father has a large collection of child pornography, watches it in front of this kid, etc...and was somehow able to ditch evidence of all of it during the divorce proceedings and investigations. I suppose that's how she got custody of the child and he has visitation rights?
God, I was so nauseated and sickened by it all...He said, she said...the child was the unfortunate victim and I was sadly caught in the middle trying to figure out whom to believe. I had mother and father moved to separate consultation rooms at each end of the ED and placed a hospital security guard at the child's bedside.
"Where the f*k is that motherf'er!!!" I suddenly heard the profuse profanity from the hallway. "I'm gonna kill him! I'm gonna kill him! Nobody beat up my kid like that and gets away with it. I'm gonna kill that son of a bitch!"
The repugnant boyfriend apparently had showed up. Pandemonium erupted in the ED as you can imagine. We had to tackle down the father to keep him from pouncing the boyfriend.
CCPD naturally had been contacted earlier and as soon as the two officers showed up, the boyfriend took off like a hot rabbit and ran out of the ED through the ambulance entrance. Did this guy have a previous criminal record? I asked myself. Or was he just scared shitless about getting arrested for being a child beater? Hell, we should've let the father of the kid kicked his ass.
Here's where things become even more sickening and frustrating. Children Protective Services was of no help at all. I personally spoke to the guy over the phone but it took him over 3 hours to show up. The dude was a completely useless imbecile. He spent 2 hours interviewing the father, the mother and the child without offering any helpful solution to the problem. I had expected him to take the child into state custody until pending further investigation, but he didn't.
"So, what're we gonna do with the kid?" I asked when he was all done.
"Umm, we're very familiar with this family. We've taken several reports on them before. You can send the little boy home with his mom," the imbecile replied.
"What?!!! Send him home with his mom?!!! But the guy who has been beating this child lives with her! I ain't sending this kid home with the mom. No way! You need to come up with a better solution than that."
"Well, I talked it over with my supervisor, and..."
You can understand why I started tuning out whatever the imbecile had to say afterward.
"Listen, the guy who has been beating up this kid is still out there. The mother lives with guy in his house for goodness sakes! What makes you think that he won't beat up this kid again?"
"The father already pressed charges and the police is looking for him."
"That's good to hear, but they haven't gotten him yet, have they? Did you missed the part about the mother and this kid living with this guy in his house? They got nowhere else to go. And from my discussion with her, it doesn't look like she intends to move out anytime soon. What's gonna happen after the police release him or if he post bail?"
"What makes you think he's gonna beat this kid again?"
"Fk! Did you see the horrendous wounds on the back of the kid? Have you seen it?! Hell, it's a chance that I'm not gonna take!"
"Well, the mother has legal custody of the kid and we can't send him home with his father."
"Man, you're completely hopeless and useless. Thanks-for-nothing! When you're driving home later, think about what you just did and see if you can live with it. You make me sick, man! You should be ashamed of yourself! Child Protective Services my ASS!"
It gets even worse. I had the pediatrician on call paged. And he, too, balked.
"Hey, Phil I got this little kid down here..." I explained the situation.
"What do you want me to do about it?" came his totally unexpected response. "If CPS isn't going to take this kid into custody, what am I going to do? There's no medical criteria for admission here. Medicaid won't allow it. I can't do a social admit and be an indefinite baby sitter."
WTF!!! I argued back and forth at length with this pediatrician about doing the right thing, being a child advocate, protecting a kid from getting abused...but DAMN, all to no avail! He was a wall. When did this pediatrician lose his compassion for children? I sadly wondered. When did this pediatrician's decisions become solely business based? No medical criteria for admission? Medicaid won't allow it? Shit! I ended our phone conversation with much needed words of impugnity.
"You're peds, Phil, you're not suppose to be this jaded. We're not suppose to punish a child for the stupidity of the parents, aren't we? Where's your love, Phil? Where IS your love? Have you lost it, man? Have you lost it?" I hung up not giving him an opportunity to mouth back at me.
Oh, it gets worse. Desperate, I called the psychiatrist on call, who agreed that this child should be admitted for his safety but wouldn't do it himself.
"I'm sorry I can't admit him. He's not..."
I started tuning out his psycho babble...
"It's psychosocial, man. It's all related. I can't believe that you guys are so willing to load him up with a bunch of psychotropic meds but won't admit him when it becomes inconvenient for you."
So then, I called the hospitalist on call, who commiserated with my situation but quickly pointed out, "Look, I'm not peds. My liability policy does not cover 7 years old kids. I'm sorry, man." Oh, my God!
Desperate again, I called the surgeon on call and tried the trauma-related angle. "It's a horrible situation, but what am I gonna do but consult the pediatrician and social services like you already did. I'm sorry, man."
I didn't want to resort to having to wake up the hospital's Chief of Pediatrics nor the President of the Medical Staff. It would have been pointless and useless anyway. They weren't on call for the night and wouldn't have answered the page anyway. So, I placed another phone call to the police to see if they have anything to offer...NADA. "We can't take him to juvies..." I don't want you to! I was hoping that they would know of some social services or shelter that would take the child in until things were sorted out.
Child Protective Services - Strike one
Pediatrician - Strike two
Psychiatrist - Strike three
Hospitalist - Strike 4
Surgeon - Strike 5
Police - Strike 6
AM I THE ONLY ONE WHO GIVES A SHIT ABOUT DOING THE RIGHT THING ANYMORE?
I ended up admitting this kid last night to my hyperbaric service, because I can. It's the only inpatient admitting privilege I have. It's just easier for me this way, and with so much less aggravation of having to argue back and forth with a bunch of derelicts. Not to admit this kid and release him to his dysfunctional and degenerate parents would have been a true dereliction of duty. I was raised by a military father never to shirk duty and honor. And I was not about to disappoint him.
This morning, the HBOT team was completely surprised and concerned about why a 7 years old kid is on our census list. "It's another one of Charity's social admits again," they complained. The kid's wounds do not meet HBOT criterias of course. The morning doc in my group wasn't too happy about having to round on this kid so I told everyone that I would personally round on him myself and take care of his disposition come Monday. I'm not sure yet what I'm gonna do or how to even disposition the kid. For now, I'm just glad that he has a safe place to sleep for the weekend. So far the nurses have informed that the kid has been very well behaved, a complete angel and not a problem at all. Not surprising how a little love and TLC goes a long way, I suppose. The only medication that I wrote for him is Motrin and Tylenol as needed for pain. No psych meds. A hospital security guard is posted at his bedside, of course. Funny how the hospital security folks are the only ones who understand the situation and have not complained at all about having to post a sitter with the kid 24/7. I just added them to my Christmas list for the year.
Friday, May 04, 2007
Tricks of the Trade
Our friendly blogosphere urologist Dr. Keagirl over at Urostream had this nice thing to say about us ER folks when she got called in to help with a difficult foley on a trauma patient. Grunt Doc thanked her for coming in on behalf of all of us ER guys.One thing that has always puzzled me is...well here's the comment I left on her post with a little picture at the end:
Ditto, what Grunt Doc said.
I find that most urologists are very "ER friendly" and accomodating.
One of these days, I'm gonna have bribe one of them to show me some tricks of their trade in placing difficult foleys. Or at least get one drunk enough to reveal their secrets! Most of the time, the nurses have tried, at least over a dozen time with different size catheters. Then I get a crack at it with numerous attempts using different size catheters and coudets, from smallest to biggest as well... Firm grasp with the fist and pulling the penis straight up in the air toward the ceiling like we were taught during trauma rotation in med school, or angling it down toward the end of the bed, applying pressure at the prostate, pushing down against the bladder, some ativan, lots of KY and viscous lidocaine jelly, left handed, then right handed, then instructing the nurse, you grab I'll shove the catheter or, I grab you shove...and finally giving up myself after a few dozen exhaustive and frustrating tries. I then am forced to bow in humiliating defeat and have to place a consultation.
In comes happy-go-lucky, out-going urologist with the urology cart. One easy slip and it's in. Damn! Drives me nuts!!! Especially that smirk of triumph on their face afterwards every time. Oh yeah? We eased it up for ya!
I swear, it's a heavily guarded secret that they'll teach to no one else except one of their very own during some special secret session held only for urologists at some far and remote super secret locale where none of us mere non-urology mortals are allowed to know about or attend. I betcha anything that this is one of their esoteric board requirements for certification - How To Place Difficult Foleys And Make An ER Doc Look Like A Clown!
I knew it! I knew it! Look at the smirk on her face!Look at her... gloating! ;-p
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