Healthcare

Well, it happened. For better or for worse our leaders passed a landmark healthcare bill last week. I'm not going to sit here and rant about whether or not I think this is a good or bad thing for our country, but I will provide my two cents about what I believe the impact on emergency medicine will be.

I believe the impact will be two fold: initially positive, yet progressively negative as time progresses. Currently, federal law (i.e., EMTALA) requires the emergency department to provide care to everyone, regardless of insurance. So it only begs to reason that if this bill is going to provide insurance coverage to 35 million additional Americans, less patients will present as self pay ( aka: good luck getting reimbursed). Using elementary math, more patients in the ED with insurance equates to more payouts.

One could argue that there are numerous negatives to this plan. I'm going to argue that this bill does nothing to address the shortage of primary care physicians which I believe is one of the largest problems with our current healthcare system. As an ED doc, why do I care you ask? As the shortage of primary care docs in this country grows, so does the amount of primary care I have to put up with in the emergency department.

The common cold.
Lost medications.
Poor glycemic control.
Depression.




Those are just a handful of daily complaints I have in the emergency department. None of which are emergencies. I predict that as more and more people receive insurance, intuitively there will be an increase in people seeking care. Instead of waiting three, four or even five weeks to see a primary care physician, they'll just jump in the car and come to the ED. "Why not, I have insurance now," they'll say.

Technically according to my first paragraph this wouldn't necessarily be a bad thing; however it would inevitably worsen ED overcrowding. About once every couple of years I here about a patient dying in the lobby of an emergency department as he or she was waiting to be seen. Incidences like that, albeit rare, do represent consequences to ED overcrowding, and the prevalance of these negative consequences under this new system I believe are destined to rise.

Then again, I'm just an intern, and this is a very simplistic view of a very complicated matter. Time will tell how it all plays out.

Ultrasound

I'm fortunate in my residency program to have a handful of attendings that are extremely proficient in using the ultraound for various procedures in the ED. The ultrasound has recently gained a lot of popularity in the department for its practicality. Most seasoned physicians have at least taken a CME course or two to learn how to do a pretty accurate F.A.S.T. exam in trauma bays, but now there are entire fellowship programs devoted to its use.

We had this huge woman present today in DKA. She had ketones in her blood and urine and her blood glucose was around 800. Initially, none of the nurses were able to get a line on her so I strolled in the room with the ultrasound machine. I took one look and popped in an IV. The peripheral line was a temporizing measure as I got everything I would need for a central line. Using the ultrasound I took one look at her neck, found her IJ, and with one stick, got the line. If you look at the new data floating around that shows the decrease in complication rates with ultrasounds guided central lines, some would say it is malpractice to attempt CVLs without it.

The lesson of the day: the ultrasound machine is your friend. It takes practice, especially in using it for peripheral IVs, but it is absolutely worth it. I've used the machine for the following: scanning for aneurysms, gall stones, comparing kidneys for hydronephrosis, looking for pericardial effusions, and evaluating for ectopic pregnancy.

It is a great tool for the ED doc to have in his arsenal.

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The night train

I haven't posted as mush recently. I've been working a lot of nights and its tough to keep something like this up. Briefly, one of our regulars came in last night. Only this time she was coding. Found down by EMS, she arrived intubated and actively receiving chest compressions.

She was young (in her 40s). Always came in with pancreatitis because she couldn't stay away from the alcohol. She was actually one of our more pleasant regulars. I felt sorry for her in some way. She wasn't addicted to narcotics, just alcohol. She only came to the ED because her habit caused her pancreas to flare up.

She died last night. It was her thirteenth visit this year. How unlucky.

I'll be back on days soon. Better blogs will return...

Crying Wolf

A guy came in to the ED last week. He also came in three days ago and again last night. I've only been doing this for about 10 months now, but I'm already starting to recognize some of our regular customers. He uses different chief complaints every time only to mask the real reason for his routine visits: he is homeless and has nothing better to do. Last night's chief complaint was back pain. He says it started four days ago which, oddly enough, was before his last visit three days prior in which back pain was not mentioned.

There was nothing special about the circumstances of his pain: no falls, no recent trauma, and his vitals were stable. I rely on vitals often when someone is complaining of pain. If they are in the room saying this is the worst pain of there life with a heart rate of 68, I'm always a little suspicious about their "pain". As was the case with this guy tonight: severe pain with normal vitals. I gave him a shot of dilaudid IM and was going to reevaluate. Twenty minutes later he was asleep.

I went back in to reevaluate about an hour later and told him I was going to be sending him home soon. He said I had done nothing for his pain. I didn't buy it, but feeling generous I gave him a script for some percocets and told him to follow up with the free clinic in the coming days. He reluctantly agreed.

I got a page from one of my friends who was working the day shift today. The patient came back in with bilateral pulmonary embolisms.

Shit.




Sure I feel bad for sending this guy out with blood clots in his lungs. Could I have done more of a work-up on him? Sure. Should I have? I don't think so. Some people will argue a D-dimer maybe, but I've seen too many false negative even in low risk patients for me to put any credibility in that test (my apologies to Wells and his criteria). Also, you can't Ct scan everyone. Especially those who have spend years abusing the system.

So the guy ended up being put on anti-coagulants and he'll be fine. At least until he comes back tomorrow...

Can't save everyone

Last night I signed up for a back pain. I had about five other active patients at the time so I figured a back pain wouldn't hinder me too much. I walked in to the room just as EMS was leaving. I heard them mention to the nurses that they had given him 75 mics of fentanyl, 4 mg of morhpine and 4 mg of zofran. I could tell this guy was really uncomfortable. He was diaphoretic and his blood pressure was 225/115. I ordered 1 mg of dilaudid and 10 mg of hydralazine (his pulse was 65). We waited a few minutes, cycled the pressure and saw no change. This guy was in his 30s so I looked at his wife and asked if he did any drugs. She looked at her husband and then looked at me with remorse. She didn't say anything, but her eyes had YES written all over them.

The patient then began to say he felt the pain tearing up his back. I looked at the monitor and saw a once normal heart rate now beating at 150 bmp. The patient grabbed his chest, and then he took his last breath.




I couldn't believe it. This guy's presentation was so classic it was surreal. I blogged a few weeks ago about how useless pneumonics and "classic presentations" were in real-world medicine, and then this guy classically dissects his aorta right in front of me. Of course we started ACLS on the guy, but it was useless. While chest compressions were being performed, one of the other residents grabbed the ultrasound machine and placed the probe on his abdomen. We all saw the dissection clearly.

I went to talk to his wife as she had been escorted out of the room while all this was going on. She looked at my face, and with tears in her eyes I knew that she knew there was no good news coming. I was blunt but compassionate when I explained the circumstances of her husband's death. I concluded with saying "despite out bests efforts, your husband died today." I find there is no substitute for the "D" word. If you say "he passed away" or "he didn't make it" a patient will, for one reason or another, maintain the faintest bit of hope that there is chance for their loved one. Death is death, clear, and unmistakable.