It's 6:45 a.m. You're clicking frenetically to complete discharge papers for one patient while you wait for the hospitalist to call back so you can admit another. You've been too busy to check whether your other four patients' CTs and labs are back. There's no way you'll be done with your patient care before your shift ends in 15 minutes, let alone all your unfinished charts. The only new patient you would think of seeing before the morning doc arrives would be one who is critically unstable.
You look up and see EMS arrive with a cute little old lady—we'll call her Ms. Jones—who is having hip pain after a ground-level fall. You make eye contact; she appears comfortable. Neither leg is shortened or rotated, and no signs of trauma are visible. She rolls into a room, and a nurse goes right in to check her vitals and get her triaged. A minute later, Ms. Jones pops up on your screen. You inspect her vital signs from your desk, and they are stable.
Any seasoned emergency physician knows the reasonable thing to do, especially when you're single coverage, is to keep working on your other patients and let the day doc see Ms. Jones at 7 a.m. when he starts his shift. That's exactly what I did.
The problem was I was working in a newly minted trauma center at a for-profit hospital. Many for-profit hospitals seek trauma center status so they can cash in on lucrative trauma activation fees. If the hospital activated their trauma team for Ms. Jones, it could have charged more money for the same care.
A few days later, my boss—former boss, actually, because I no longer work in that system—asked me why I didn't see Ms. Jones. I explained that a ground-level fall generally does not meet the criteria to be a trauma alert unless there are extenuating circumstances. My clinical judgment after close to two decades told me she could wait 10 minutes. Unfortunately, the almighty dollar seemed to matter more than reason and clinical judgment. I was instructed never to let such a patient wait again because “trauma” patients must be seen immediately.
With the proliferation of trauma centers to capture reimbursement dollars, EPs may find themselves in an uncomfortable paradigm. A patient with stable vitals who had a ground-level fall and broke a hip can be cared for at any hospital with an admitting team, OR, and orthopedic surgeon. Our training has taught us that such cases don't require or warrant a trauma alert.
Yet we also understand that we are replaceable widgets in a system where insurance companies are reimbursing less and less and hospital systems are forced to grab any money they can. Consequently, when we are told to see any patient with a traumatic injury immediately, we tell ourselves, “Well, it's not bad medicine to check out Ms. Jones as soon as she gets to her room,” and then we dutifully try to please the bean counters, putting other patient care on the back burner, adding another chart to our stack, and creating more delay in the department.
We worry that involving a trauma team for cases like Ms. Jones' is helping the hospitals' bottom line more than it's helping her. Yet it's difficult for physicians to fight that battle one patient at a time. Making the argument that a patient needs less testing and fewer consultants, even if that's what all our years of experience tell us, can be medicolegal suicide if the patient should turn out to have a surprise injury. We do what we're told despite our concerns, rationalizing our multiple CT orders by telling ourselves that we have ordered CT scans for less.
Our colleagues in other specialties have concerns about the proliferation of trauma centers too. I remember talking to an orthopedic surgeon many years ago about the hospital where I worked converting itself to a trauma center. He had heard of hip fractures that could have been medical admissions with orthopedic consultation but were instead being billed—unnecessarily, in his opinion—by the new trauma center as trauma alerts.
He used the word fraud and said he was hesitant to have anything to do with those kinds of “trauma” patients. Yet it seems even surgeons, who generate more income for the hospital and therefore have more clout, are reluctant to point this out. We all know it doesn't end well for doctors who rock the boat.
The Ugly Truth
It took a patient to proclaim that emperor has no clothes. Ed Knight sought care at one of Richmond's new trauma centers; he needed 31 stitches for a gash on his arm, which should have cost around $3500. The bill he received was for $52,238. (KHN. June 14, 2021; https://bit.ly/3iklyFS.)
The article revealed that regional trauma cases and expensive trauma bills rose sharply after for-profit trauma centers opened, suggesting that many patients classified as trauma victims would have previously been treated less expensively in a regular emergency department. I applaud Mr. Knight for publicizing this phenomenon.
The ugly truth about the trauma emperor's clothes is that many trauma alerts at newly minted trauma centers are not beautiful cloaks woven from earnest threads of patient concern; they are pretenses for billing. Activating trauma teams earns money for hospitals, so we're seeing a proliferation of trauma centers and trauma alerts on patients who don't need trauma team care.
My hope is that more patients will see through the ruse and demand appropriate use of imaging and consults. The longer I do this and the more I witness how the business of medicine fleeces patients and doctors alike, the more I realize that patients and doctors are on the same team. I would love for patients like Ms. Jones and Mr. Knight who need just an x-ray but instead are subjected to full body scans to ask us, “Do I really need all this?”
Sometimes the best we can do in this uncomfortable new paradigm is to be honest with the patients about the emperor's nonexistent clothes. Injured people in our EDs are not sources of revenue; they are patients who are scared and in pain, and they deserve to be able to trust their physicians.
Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.