Tuesday, May 13, 2008

Consults Circa EMTALA


Dr. A: Hey Bill, I've got a patient down here that has a lung mass. She has no insurance and no job and is quite distressed. She needs a biopsy and maybe surgery and chemo. Can you help?

Dr. B: Well jeez doc, my schedule is full for the next few days, but maybe I can work her in between appointments on Friday. Tell her not to worry, I'll see her in my office. I'm sure we can get her plugged in.

Dr. A: Thanks Bill, she really feels badly about not being able to pay you much and her husband says they can pay some over time... They are really nice folks and will try their best.

Dr. B: Yeah, okay, probably won't see a dime but let's get her in. I'll ask the oncology folks to get involved too. Jim will jump on this. Maybe we can fix her.

Dr. A: Thanks so much. See you at dinner on Saturday, got a few days off coming up.

Dr. B: See you then.


Dr. A: Hey Bill, I've got a patient down here that has a lung mass. She has no insurance and no job and is quite angry. Had to wait three hours to be seen and all. She needs a biopsy and maybe surgery and chemo. Can you help?

Dr. B: What, am I on call for the ER?

Dr. A: That's what it says on the schedule.

Dr. B: You guys are killing me. That's four patients over the weekend that will cancel my clinics on Tuesday. You guys just cost me over five grand from paying patients.

Dr. A: Yeah, us too. Thirty people waiting to be seen. Twenty walk-outs today. Eighteen ambulances and four of them reasonable calls. This woman was actually diagnosed with a lung mass last year but never followed up. Still smokes. Came in tonight because she's been coughing up blood. Says she 'can't afford to see a doctor so she came here.

Dr. B: Fucking incredible! What does she think that the ER is free?

Dr. A: It is free to her. She will never pay for any of this, says she's disabled. Drove herself in, has a cell phone that she's been talking on half the time I've been in the room. Seems quite unconcerned except for the wait. Says her lawyer said to come here and that we have to treat her.

Dr. B: Do we?

Dr. A: Yes.

Dr. B: Lawyer?

Dr. A: Yeah, she's suing the poor sap who took her chest film a year ago. Says he didn't explain the consequences of the XRAY findings to her adequately... says she didn't understand this was dangerous. Went to the lawyer before coming here.

Dr. B: Holy shit, now I really don't want to take care of her! Hey can't you transfer her to the General?

Dr. A: No, EMTALA prohibits it.

Dr. B: But she can't sue the city hospital but she can sue the hell out of me! Can't you get Dr. C to take this one?

Dr. A: No, his privileges are suspended for not signing his charts on time.

Dr. B: Suspended for not signing charts?

Dr. A: Yes.

Dr. B: Well, come to think of it, I haven't signed my charts in a while. Maybe I can get suspended too?

Dr. A: Worked for him.

Dr. B: Can we get oncology to consult?

Dr. A: They aren't on call tonight?

Dr. B: Well will they help out after the biopsy?

Dr. A: Don't know, you will have to ask them, we only heave oncology ten days out of the month.

Dr. B: Fuck this! I knew I should have gone to business school. I can't wait till I retire. Just so you know, I'm seriously considering dropping my privileges and doing all outpatient stuff, surgery center, the whole bit.

Dr. A: Join the club. Sorry.


  1. That's it.

    I'm going to business school.

  2. no ee,

    now's the perfect time to start med school. by the time you finish residency the battles will be over. you will either have a nine to five job and make a decent living doing rationed care, OR, doctors will push back and medicine in the US will undergo a renaissance. either way, you're set for life.

  3. 911doc...

    thats just wrong.. on so many levels..

    hello military operational medicine!!!

    HM2(FMF) "Doc" H

  4. 911doc, I always knew you were an optimist!

  5. Gah! I'm sorry you guys and gals have to go through this. How long do you think it's going to be before things colapse, and real reform begins?

  6. That exact scenerio happened to a friend of mine. Sued for a chest xray 1 year earlier that wasn't followed up on by the patient or her primary doctor. WOW! Did you just make that up 911? That post EMTALA conversation goes on 10,000 times every day in EDs all across the country. Horay for us.


  7. The way this feeds on itself is via the fucked up incentives set up by these mandates. Docs realize that being involved with a hospital that falls under these moronic rules is not worth it. They then pull all lucrative business out of the hospital (day surgery, endoscopy etc...), leaving the hospital with the non-payers and crap cases that lose money. Stressed hospitals then cut "non-essentials" like paying for reasonable coverage, making more docs want to leave the hospital.

    It's like a bad Escher print.

  8. Ah, the academic world. Salaried, can't be sued. Awesome. You know, I knew an ENT at my old community hospital, who, when told he had to talk ER call every other night (forced to see ALL patients at least once in follow-up in his office, regardless of insurance coverage) responded by email to the entire medical staff and hospital administration. It went something like this...

    "I appreciate your request, but politely decline your offer to see more patients for less money. My surgical center will open in a few weeks, so I hereby resign my position from X Medical Center. Thanks and good luck."

  9. Exactly how many times does this EXACT scenerio play out? I doubt there are REALLY many non-insured people wanting to get cancer treatment who actually consults with an attorney before even seeing a doc. and then makes it known they have done so.

    If your going to spin a yarn, at least make it a believable one. The majority of the public do not act in this way and you make it sound as though every person you see sues you..BS

  10. well, anonymous, in terms of this EXACT scenario, one.

    in terms of people riding the ambulance in for 'free care' beacause they don't want to pay a 'real doctor', for me personally about 4 or 5 patients a shift.

    you are sadly misinformed. and no, i have never been named in a malpractice suit, though i have been told by about 1 patient a week that they are going to sue me.

    collections in the ER for bills run 30 cents on the dollar. people do see us as 'free care'. you are an ill informed doucehbag.

  11. here's another MD on his blog (multiply published) who, wow, says kinda that same thing as i'm saying here. go figure you anonymous troll.

  12. come on up to Canada where patient fly into the airport with their CT's in hand having a seizure. Everything is covered for them (in a way -- they're not included under the provincial coverage but you have to treat). At least we kknow that if they're a resident we'll get money for them (albeit less than private). Probably works out to the same pay-out to the docs though.

  13. Anonymous: I'm an attorney, and 911 is on base. You have no fucking idea what goes on. I'm not even in active practice anymore and people I know contact me constantly about exactly these issues.

  14. Well, since you ask, anonymous, here's one from just down the road, just last week. Wonder if she's paying for her EMS transport? Her ER bill? Wonder if her attorney is on contingency? Wonder how many times she's gone to their ER for free? I wonder?

  15. She looks Russian. She's that ugly.

  16. I work in EMS and see these degenerate fuckers every day. Same bullshit lies. I'm a paramedic making $17 an hour and some flea bag bitch threatens to sue me? Me? What the fuck are you going to get from me? A lot of debt and some old baby clothes?

    I have been threatened with law suits like you wouldn't believe. People get kicked out of an ER for being abusive, they walk off hospital property (mere inches off. They know the drill) and call for an ambulance demanding transport to some far flung motherfucking hospital way out of our city. Oh, they get a choice. Then some asshole cunt of a supervisor calls me when I refuse to take this lying prick to anything but the closest appropriate hospital and backs the patient.

    Meanwhile, we're down to 3-4 ambulances covering 400 square miles and 1.1 million people because fuckers like this opiate addict sickle cell malignering motherfucker wants his fix in the suburbs. So the truly sick and truly fucked up people, the cardiac arrests, the peanut allergy toddler with a face swelling like a balloon have to wait 10 minutes or more to get an ambulance.

    And do this shitbags pay their bills? Hell no. I ran one patient today who has been run up to 4 times in a day. Kicked out of hospital after hospital after hospital. 40 times in the last 12 weeks. At A base charge of $1000 plus $14 per loaded mile, it's thousands for each transport.

    So who is getting the no lube assrape? You. This city. Your insurance. Who we charge a shitload for precisely because these pricks don't pay.

    Next time you see some homeless shitbag holding a sign that says, "homeless. pleeze help. hungry" just tell them to suck a cock because you already gave at the office, and at home, and at tax time when you paid for their ambulance bills with your taxes.

    You know how I would love to say to people, "Fuck you. You don't get a choice. You go to the closest open hospital or you fuck off." More "customer service" in this world of health care.

  17. Before EMTALA? That's from some era I've only heard of, where people got theophylline and skull films.

  18. I just got back from a seminar that taught me "What to do" during a deposition. All of my Doctors who are ove 4o years old have been named in Lawsuits and some of the younger ones too.

    We actually have a group at the hospital called "Mal-anon" started by one of our Doctors to chat about being named in a lawsuit.

  19. I can vouch for 911doc's insight and truth! Happens daily! I've been spat on, threatened with being followed home after work and be shot, and, of course, the daily law suit (get in line, pal!!) and the "going to administration" and "gonna get your ass fired" routine! Always from some ER abuser scumbag!

    I even had one idiot with crushing chest pain come in from the high country to the ER via Code-3 EMS on a lousy, half rain/half snow night... and immediately sign out AMA! I sat him down and basically tried to reason with him to at least let us evaluate his chest pain--- but he refused... in parting he admitted that he didnt have a ride into town and figured the "free" ambulance ride was a safer than asking a drunken buddy... and besides- he didn't have any gas money!!

    Ambulance company got paid by MediCal (Cal state Medicaid) and we got stiffed again. Never even stayed around to get fully registered! I was pissed and tried to report it to the state MediCal people (we even got their fraud dept business card hanging on the bulletin board) but was told their fraud investigators are focused on investigating PROVIDER fraud, not PATIENT fraud, and it won't be investigated due to low manpower, but "thanks anyways!"

    Then I was REALLY pissed and was gonna pursue it further just on principal, but I was distracted by the fact that there were still another 18 patients in the waiting room to see... (...most of whom did not need to be there either!)

    As for the EMTALA scenario described: Right on, spot accurate!! Happens every day! ...Things sure have changed in 25 years!

  20. Dear anonymous paramedic:

    If you want to blog sometime send me a message. You're more than welcome to post on my blog.

    I think you're fucking hilarious.

    911: Alright, alright, I'll think about it... ;)

  21. OK OK, this "ill informed douche bag troll," who has "no fucking clue" concedes that obviously I don't have. Certainly you are the one's who work this everyday. you know better than I, how people act when they come to see you.

    but, my remarks were basefd on the idea I find it unreal that people act in this way. certainly I must be of the minority as I have never spit on, called any physicians any names whatsoever, taken a shot at any of you, cursed at any nurses, nor have I ever sued any of you. but, since I now know what your opinion of me is, and that this is what you expect from us, maybe I should change my actions toward you to match your expectations?

  22. sorry for the hard slap anonymous but when you post anonymously we assume you are the same anonymous that just pissed us off five minutes ago. kinda like walking into the wrong kinda bar and saying the wrong thing right as the music stops.

    and to your credit you admit that my story might actually be a common occurence in one of its many permutations (every single day).

    please come back any time.