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Life in Emergistan

Pile on the Fear, the ECGs, and the Debt

Leap, Edwin, MD

Emergency Medicine News: June 2019 - Volume 41 - Issue 6 - p 9
doi: 10.1097/01.EEM.0000559974.39534.29
Life in Emergistan



Most days I have a stack of ECGs on my desk. Sometimes, at the end of 12 hours, I've looked at 15 or 18 of the red devils, and I have noted that an overwhelming majority are pretty close to normal or at least close to baseline. Anyone who has done community emergency medicine long enough will relate to the sentiment that it would be nice to see something interesting on an electrocardiogram.

We have oodles of normal, though, because everyone is reasonably concerned about missing myocardial infarction, coming as it can in so many disguises. It seems we have convinced ourselves that the 15-year-old with chest pain is just as likely to have an MI as his 85-year-old great-grandmother, and that it must be cardiac when a young asthma patient has chest tightness.

In fact, it seems now that any patient presenting with a chest complaint must have an ECG and be assumed to have a coronary event. I sometimes shake my head at the reasons ECGs are done and struggle to understand the logic of it. Back when I was a larval physician, not everyone got a pulse ox because of course they weren't all short of breath. Now oximetry is a critical vital sign for everyone, like the pain scale!

An ECG is relatively cheap, but the untold number we do and the workups they trigger make me think about the amount of debt we put people in. I blame EMTALA for a lot of this madness. Sure, we can point the finger at lawyers for some of it, but it goes well beyond that. Fear of civil litigation doesn't seem as embedded in official policy as EMTALA.

We might have told a patient in the past that he didn't have an emergency after doing a medical screening exam, but few facilities do this now. Now people get IVs and fluids, protocol-driven labs, x-rays, and swabs just so we're sure they don't have a catastrophic illness. Some of this is done for the great dark gods of metrics and throughput, but much of it is for the fear that we'll get in trouble for not appropriately caring for or screening a patient with some horrible medical problem that is unlikely to be present.

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Squeeze Every Dime

We have caused financial devastation in the process. Hospitals and important trauma centers have closed. This is always treated like a mystery, but even my rudimentary comprehension of economics suggests that constantly giving expensive care to people who don't need it or can't pay for it will ultimately mean you run of out of things to give. This is not at all a judgment of the needs of the sick but that of the hard reality of the paradigm. Over time, every problem has been medicalized, and we have enabled this with our medical powers and tools.

What happens is that the squeezing pain of grief must have serial cardiac markers. The intractable nausea and pain of kidney stones lead to serial imaging. Simple numbness and tingling or even minor weakness can result in a costly stroke alert (and sometimes the administration of dangerous drugs). And sepsis? For goodness sake, you can't have a fever and tachycardia without getting an ocean of saline and enough lab work to pay for a semester of college.

I want all patients to have the care they need, but we suffer from a toxic mixture. Large hospital systems are trying desperately to squeeze every dime out of every visit, to the extent that a single ED visit could really financially harm some people. Case in point, I heard about an ED where patients were charged to use blankets! Physicians, nurses, and administrators, ever in fear of the local plaintiff's attorney or the federal EMTALA suit, order far too much for people who need reassurance as much as anything else.

We also like technology, and we like doing things. It's the rare physician who learns to order less—and to worry less. In fact, I talk to physicians around the country and hear that younger physicians have terrible anxiety about missing anything, are fearful of relying too much on the history and physical, and worry that they don't have enough data points of experience, so they test and test and test some more.

This sounds caring on the surface, but when that kind of compassion strikes our patients in the wallet, we might easily do more harm than good. And it hurts the system whether we are talking about private insurance or Medicare and Medicaid.

I'll keep reading all those ECGs and trying to keep everyone safe. I just hope that as I treat and reassure folks with legitimate fears about chest pain that my care doesn't end up producing more real anxiety about medical debt.

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Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter @edwinleap, and read his past columns at

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