(More questions from real readers. -PB)
What’s the Emergency Department Really Like?
The American College of Emergency Physicians and their bogus statistics notwithstanding, the majority of cases we see are not emergencies. As I have mentioned before, most of the cases we see probably don’t need to be seen at all by anybody in the medical profession in any capacity. I saw 34 patients last night and half of them were for nothing more than cold symptoms, symptoms that at one time in our nation’s history rational people just accepted without feeling the need to seek medical attention. Today of course where everything is a friggin’ Emergency and medical care is absolutely free for the asking I walk into many patient’s rooms to find a tattooed, well-looking white chick and her less-tattooed mother waiting angrily to be seen by The Fucking Doctor Who Was Just Standing Around Typing On His Computer While They Waited Three Hours who then breathlessly spin a dire tale of a little bit of a sore throat and a little bit of a cough that is really interfering with the daughter’s two-pack-per day habit or whatever it is she does to lead a fulfilling life. Either that or it’s a little bit of gas pain or some faint twinge or spasm in the back that has caused a slight discomfort that must be addressed immediately.
That’s a particular species of patient that knows no geographic boundaries, by the way. Even here in the South where people are an order of magnitude more polite and well-behaved than in Yankeeland we still have the ubiquitous fire-plug of a mother escorting her wan daughter, both of them at various corpulent stages on the road to morbid obesity, who insists that not only is something wrong with the daughter but that every single test and study known to medicine must be ordered to ferret out the problem. After taking a history, doing an appropriate exam, and telling the mother that her daughter has a chest cold and is going to do just fine, like clockwork comes that cold-as-fish look of disgust and the inevitable, “We want to see another doctor.”
Either that or, “My sister had the same thing and the doctor over at the Quickie Clinic gave her a shot.”
“Madame, the doctor at the Quickie Clinic works at the Quickie Clinic because he’s an idiot. You’re in the big leagues here and I don’t just give shots.”
Of course I don’t say that.
One patient opined that he could get served at MacDonald’s in five minutes so he didn’t understand why it took four hours to be seen, evaluated, and discharged. He was an otherwise reasonable guy and really very pleasant but that sort of highlights the problem with Emergency Medicine and most Emergency Departments, namely that they are largely highly expensive, completely understaffed Quickie Clinics in which some real medicine is practiced from time to time; the twenty percent or so of patients who have real emergencies or legitimate complaints and are part of our core function in the community ironically causing so many delays for the other eighty percent who should have stayed home that, in our insane and upside down world, the various quality “metrics” used to rate how good a job we’re doing are entirely dependent on the satisfaction of irate people who didn’t need to be seen and did nothing but waste either their own money or the taxpayer’s.
There is, as you guessed, tremendous bureaucratic pressure to decrease waiting times and subsequently to increase patient satisfaction which is one of the most important contributing factors to the so-called crisis in Emergency Medicine, a crisis which wouldn’t exist except that there is money to be made in the high volume business of trafficking in minor complaints and very little incentive not to. Most of our patients, after all, have some kind of insurance and taking money from the government to do what is essentially a well-child exam on a slightly febrile but otherwise healthy-looking toddler is like stealing candy from a baby which is sort of what we are doing (and why the Children’s Health Insurance Program is such a colossal waste of money and a harbinger of what is yet to come when the Sun-King, Ra-Obama, by one gesture of His Mighty Legislative Hand, turns us all into Medicaideurs).
So you can hardly blame the patients. They come because they are encouraged to come-witness one billboard in town showing a comfortably sleeping baby proudly proclaiming that they are a “Pediatric All-NightER” never mind that it verges on child abuse to drag your healthy looking baby into the Emergency Department at two in the morning to share Cheetos with the crack whores-and they come because there is nothing to discourage them; no obstacle except a little bit of waiting and we have never chased anybody away who had a minor complaint for any reason so mundane as an unwillingness to budget some cigarette money for medical care.
Why is it, by the way, that while I have had many people complain of being unable to afford low-cost antibiotics, inhalers, and blood pressure medications I have never, and I mean never, had anybody cry poverty when presented with a prescription for pain medication? I could write a wino living under a bridge for three months worth of Lortabs and he’d accept the prescription without demur. A prescription for Penicillin for his dental abscess?
“Come on, Doc, I ain’t got the money for that.”
So what’s an Emergency Department like? In reality it’s a little like a miniature hospital onto which has been grafted an STD clinic, an Urgent Care, a psychiatric ward, and a small intensive care unit. At any time and within ten feet of each other you can have a critically ill dialysis patient being kept alive by pumps and ventilators, a genteel dowager having The Big One, a teenage girl with some vague menstrual cramps, a smattering of varying kinds and degrees of abdominal pain, several people in “Just To Get Checked Out,” and lots of kids and adults with nothing, apparently just in for the novelty of watching a different television and having a nurse at their command. The only thing we don’t have is an operating room but can the time be too far off when irate patients will opine, angrily, that it’s been three hours and they still haven’t got their appendectomy?