Respiratory Therapy 101: Just Keep Breathing

Wow! According to some amazing new research, government programs for the needy place an undue burden on emergency services. Who would have possibly guessed it?

Now, before I get a thousand snippy comments from people who are angry that I am suggesting that the poor should be denied emergency services, let me clarify this. The reason that so many of these destitute bums* wind up coming to the ER is that they lack any other options. As I understand it, Medicare and Medicaid don’t typically pay well enough for private physicians to be willing to accept patients whose only means of payment is through those programs. This means that an enormous percentage of these people have no primary care physicians to do things like monitor chronic illness or manage minor ailments, and as such these people wind up presenting to the emergency room with bullshit complaints. People who aren’t in the field don’t seem to get this: our Fearless President recently stated that he thought it would be okay for people to just go to the ER rather than see a private doctor.

Now, even if we reformed Medicare/Medicaid and made it possible for the destitute* to go and see primary docs, we’d still have a fair number of problems in the ER. We’d still get the dumb-asses who come in pretending to hurt just to get drugs, the people for whom the question “what number from one to ten is your pain” is an invitation to suddenly drop their 200-dollar cell phone and pretend to writhe about in agony, screaming “it must be a twelve!” The only ways to get rid of these people are to either shoot them (generally considered unethical) provide them with terrible service so they don’t come back (frowned on by paper-pushers) or to perform large numbers of punitive diagnostics such as spinal taps and blood gases with 14g needles (also unethical.) I’m a believer that enough documented abuses of the ER should be grounds for refusal to treat; plenty of people get snotty and whiny about this, but they’re not the ones dealing with whiny liars all day.

But even if we got rid of the financial burdens and the lying whiners, we’d still be stuck with a big problem in the ER: overdiagnosis. By this I mean the overuse of expensive diagnostic exams for no real reason other than the ER doc feels like it or the ER doc fears a lawsuit if he doesn’t get this diagnostic. I was the victim of many useless diagnostics in a recent ER shift in which I performed 16 blood gases and four arterial lab draws with BGs in twelve hours. Of the 20 blood-gases I ran that day, maybe three of them were indicated: one on an unresponsive intubated patient, one on a decreased LOC, and one on a diabetic in DKA. The other 17 blood gases were drawn and analyzed mainly because one of our ER doctors orders them on everybody who comes in for no relevant reason. Now, a blood gas analysis costs somewhere around 200 dollars, so if you add it up I billed for 3,400 dollars in useless diagnostics over twelve hours. This is a problem in other departments, too: an enormous percentage of our patients get things like CT scans simply because people are out of ideas and want to feel like they are doing something. After all, even an unindicated useless exam is more something than nothing. Incidentally this is a clear violation of Rule 13, which I will be essaying about at a later date.

Anyway, the point I am driving at is this: the emergency medicine system is badly broken. No longer is it a system in which people having genuine emergencies are seen and treated by physicians who only use evidence-based medicine to solve simple and complex medical cases. It has become a catchall, a safety net in which the dregs of society are caught and given treatment based on either (a) the preferences of aging physicians who don’t believe in evidence or (b) the fear of lawsuits from irate patients. Genuine emergencies still come in frequently, but they are sadly overlooked and forced to queue with the patients who are in the ER just because they have nowhere else to go. Only if we can solve the problems of government healthcare, whiny liars, and overzealous physicians will the emergency room be returned to its proper place in the hospital: a place for patients in crisis to go and be treated.

Any ideas?