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Life in Emergistan

Life in Emergistan

The Convenience Workup and Other Tribulations Inflicted on Patients

Leap, Edwin MD

doi: 10.1097/01.EEM.0000697736.08620.e2
    convenience, bill, cost

    Sometimes we aren't very kind to our patients. Don't get me wrong, we practice incredible medicine. We snatch them from the jaws of death or the claws of meth. We (mostly) do the right thing scientifically. But sometimes those human beings can become data points or commodities. Worse, they can become annoyances and liabilities that we try to avoid. And we do things to them that may cause them distress or financial hardship.

    I transferred a patient from a small rural hospital a couple of weeks ago. While talking with the transfer line staff, hoping against hope for a direct admit, I was told, “Well, he'll need an ER evaluation anyway, so we'll just accept him there.” It made me angry, but it also made me wonder: How often do we transfer patients from one place to another only for them to have a second ED charge, mostly for the convenience of the admitting doctor on the other end?

    Send them to the ED even though they have already had tens of thousands of dollars in workup. Mindless of the many tubes of blood and multiple radiological studies, they need to go to a new department where it's entirely possible that someone will order everything again just for convenience. I know it's policy, but it seems a poor one, one that traps frightened patients in busy emergency departments for even longer and costs them far more money than it should.

    What else do we do? We fly patients. There are times when it's appropriate, but sometimes we fly them because it's sexy! “Send the bird,” I've been told by receiving physicians. “But it's only 30 minutes by ground,” I protested.

    Our colleagues still love the bird. It is exciting and validating. It plays into all of our deepest physician rescue fantasies. I've been there. I loved the bird when I was flying on it. Helicopters have their place, but few would disagree that they add little benefit, especially in urban areas, except to avoid heavy traffic or to speed transport from long scene times.

    But those birds fall from the sky now and then. Even when they don't, a ride costs a whole lot of money. And that money is expected from a person who is already having a bad time, medically and financially. When the bill comes, there will be sticker shock for the patient who may have already incurred six digits in medical expenses.

    Complex Tapestries

    Sometimes, sadly, we don't think about those things. All we can see is the dead-or-alive dichotomy, our own perception of success or failure, so we'll do anything to keep patients in the correct column, at least as long as they are ours.

    No doubt it's difficult for us to consider our patients' nonmedical concerns in the midst of stressful, chaotic shifts. We get angry, for instance, when they want to sign out or don't want to be admitted or transferred. We invoke the AMA form and warn them (falsely, by the way) that insurance won't pay if they leave. Sometimes, however, their reasons are valid.

    Maybe she has an elderly spouse at home who has no help. Or a new job he can't miss without being fired. Perhaps he can't drive well at night. It may be that she is just frightened, or has had so many medical problems that she just can't endure another night amid the endless sounds, sights, and other terrors of the hospital.

    Whatever their concerns, my answer is mostly the same. “You're an adult. I'd like you to stay, but if you have to leave, you are welcome to come back anytime, and we'll figure this out.” I give them discharge instructions. Leaving AMA shouldn't be uniformly perceived as an insult to us or a waste of our time. Sometimes people just have to leave.

    Real Human Needs

    Other times, they have to stay. The people we commit for suicidal behavior end up being treated worse than criminals. Already depressed, they're consigned to rooms with nothing except a cot, frequently without even a television to watch. They languish in paper gowns for days or weeks, eating hospital food, being constantly observed by a person sitting outside the door. If your depression was bad already, it would be worse by the time the transfer or discharge happens.

    Emergency departments are busy, and we're usually overwhelmed and exhausted. But in the midst of our need to move through patients quickly and do the right thing, it's important to remember that the people before us have real human needs that are just as important as their medical issues. In some cases, more so.

    While we ply science to save lives, we need to remember that people's lives are complex tapestries of physical and emotional health, human connections, financial stability, cultural and religious imperatives, and dozens of other factors.

    Kindness often involves much more than diagnosis and treatment, no matter how annoying or inconvenient that might be.

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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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