Friday, April 03, 2009


So here's a cherry example of what happens when the government sees a problem in the private sector and tries to fix it by passing a law. I witnessed this in action in my military days. One summer, when the medical students on a military scholarship were rotating through various hospitals in the military system, a student was killed in a traffic accident en route to their clerkship. The military then decided that no medical students would be allowed to drive to their summer clerkships. Good solution, wouldn't want anything dangerous to happen to someone in the military. Cars are dangerous.

So did the kid need his lip fixed? Maybe. That's really not the point. I don't have pictures and I wasn't there so I can't comment, but choosing NOT to close a dog bit to the lip or to opt for delayed closure is at least reasonable. The teaching changes every few years and I will close most dog bites, but not all.

Both our national colleges fell for this hook, line, and sinker. What a bunch of pussies. How can you say that this boy didn't need treatment immediately? Here's how... This kind of repair, evidently done by a plastic surgeon, would be impossible outside a large city as large cities are the only places where you can get one 'on call'. You might get lucky and be at a hospital with OMFS (oral-maxillofacial surgery) or a game ENT, but right from the get go this is a hot potato of liability for any doc that chooses to close this wound. Do you want to suture his lip with an angry mom watching your every move knowing that the wound, by definition, has a high likelihood of infection? I don't. So not everyone in the country would have this procedure available at the drop of a hat and that's not fair. What to do... What to do?? I got it! Let's pass a law guaranteeing access to a plastic surgeon 24/7 anywhere in the US. Awesome! Problem solved. Next? This governing thing is so easy.

I can see it now. An angry mom, justifiably so (but angry at the wrong person), not getting what she wants that very instant for her child. An angry mom convinced she and her son are the victim of the 'wallet biopsy'. In fact, I would wager a lot of money that had the mom NOT been a person of color that she would not have succeeded at the second hospital. If the lip was torn to shreds it would be beyond an ER doc to fix it properly and if it was torn to shreds there is no 'emergency' here... the child was referred for definitive closure at a later date. So what's the problem? The appearance of an EMTALA violation.

EMTALA, the law that killed American medicine. The law which, if it were applied to say, grocers, would read, "Thou shalt give food away to anyone in your store who claims to be hungry or you will be fined and may lose your license to sell groceries and if we are really mad we'll throw in a lawsuit too."

The law which the average Joe on the street has finally figured out. The law that gave us this bit of ridiculousness. The law that killed my profession by making it an endless parade of entitled (mostly) faux-misery. The law that makes otherwise apparently very bright people say something like the following...

...ACEP's Dr. Gardner said emergency physicians must consider not only legal obligations but also moral and ethical responsibilities to the patient. "Every action we take as emergency physicians should pass the 'Aunt Betsy' test: 'Is it good enough for your Aunt Betsy?' " she said. "If not, I don't think it's something emergency physicians should be doing."

Or this from a physician whose other job is to outlaw guns in every home and who oversees the chaos and failure at Atlanta's Grady hospital...

The danger is that patients without private insurance often do not have access to care elsewhere.

"If we don't see them in the emergency room, they will not get the care they need, and some of them will come back much sicker," said Dr. Kellermann, professor and associate dean for health policy at Emory University School of Medicine in Atlanta, Georgia. "Most of my colleagues are unwilling to not treat [low-acuity] ED patients if they do not have reasonable assurance that the patients have someplace appropriate to go."

Okay, I'll play with your hypotheticals Drs Gardner and Kellerman. My Aunt Betsy is a non-compliant diabetic, alcoholic, child abuser who films and distributes child pornography and just took 8 hits on the crack pipe. She was bitten by one of her thirty attack dogs which she does not properly keep, and her lip is 'tore up'. The family can't wait for her to die. She has cost us all countless hours of misery and countless dollars hiring lawyers to keep her sorry ass out of jail. So yes, it is "good enough for Aunt Betsy".

As to Dr. Kellerman, well, I sure would like to save the world but right now I'm just trying to make it through another year in a high acuity ER with 30% payors, 30% admissions, and 50% 'shoulda gone somewhere else and didn't need the ambulance and wont pay a dime.'

But back to Aunt Betsy... Fifty Al Qaeda fighters, wounded in battle with the USMC, somehow manage to get to your ER. All require surgery. What do you do? Ten escaped convicts who just murdered your security guards? Charles Manson with a heart attack? Hitler? Satan? I am comforted that I now have an answer and will simply think of "Aunt Betsy." There's a fine line between clever and stupid.

Practicing Emergency Medicine as Dr. Gardner would have us practice also would lead to the following (as long as we are throwing out hypotheticals). People will get the message that there's no downside to walking around uninsured. There's no need to budget for it. All you have to do is call 911 or go to the ER. If you don't get what you want then threaten or scream and ultimately you might just need to go down the street to the next ER. "The government" is paying for it so it's free. Also, if you feel you are were treated poorly (with the wealth of medical knowledge that you have acquired by studying in your off-hours) then you can call one of those lawyers on those billboards and sue. You might just hit the jackpot. Then, ER physicians, castrated, will quit mid-career and leave a gaping hole in coverage across the United States, and hospitals will close or 'reorganize' so as to avoid the money pit. Oh wait, that's what's happening now.


  1. 911...I can't read the just takes me to some sign in page for Web MD.

    But you are right on about everything else....even though you made me some bad flashbacks....I used to work at Grady LOL! I think I should qualify for disability for PTSD!

  2. As usual, everyone misses the REAL victim, the poor DOG!!! What about HIS treatment??? With your typical ER patients normal flora Fido's lucky to be alive...where's PETA when you really need em???

  3. "ACEP also questioned whether the south side medical center's treatment of a young dog-bite victim nearly violated the requirements of the Emergency Medical Treatment and Labor Act."
    So now you're supposed to be worried if you NEARLY violate a law?

  4. I vomited and shit my pants while reading this. A complete evacuatation of my GI tract. Every shift at my new clinic makes every shift in the ED incredibly difficult. You see, people are glad to see me and PAY for my service, training, sacrifice and risk-taking in this business environment. And our volume is picking up. Soon, God let it be soon, I will be out of the ED for good. The ED patients seem to be more demanding, more litigious, and downright shitier. Oh, there are bright spots and those who are thankful you are awake when your cortisol levels are near zero, but they are few and far between.

  5. Wow! I feel for your future. Better to left aside than behind.
    I have been seen twice in 19 years in an ER that I'm also a paying HMO member. Once a casuality of workmans comp.; the other a victum of stupid self induldigence (hunting, ankle injury).
    I can't imagine how ER docs deal with the rabid populations I experianced then as you have now.
    Get out.. That way the problem will fix itself!
    My Doc was so pissed that an X-ray took 3hrs, he told me to look for a sports medicine Doc for further treatment.
    Good Luck in all you do. I know you'll need it.