Marion County ER

It's been long enough since the actual occurrence that I'm ready to tell a quick story from the McDowell Emergency Department that was particularly memorable. One of the reasons I am taking this year off is to study not only how we can make patient care better in this country, but how we can make it more efficient and less expensive. The average American racks up over $7,000 in health care costs each year, and for the majority, that is an insurmountable financial burden. With access to care issues and poor understanding of its use, the Emergency Department often turns into a primary care clinic. This causes long wait times, frustration, and increased costs. As a student in the ED, I often wonder how can this be fixed.

My preceptor had asked me to go see young lady (about 15 or 16), who was complaining of right wrist pain. It was a Sunday night in the ED, and there was a long list patients in the waiting room. I walk in the room and she is accompanied by her mother and little brother, who is bouncing off the walls after having waited more than a few hours. I start taking my history. The pain had been going on for about 2 weeks, not really getting worse, and perhaps getting a bit better; however, it was her dominant hand. There was no point tenderness, only a generalized soreness that was worse with use. She cannot think of anything that had caused the pain either. One morning she woke up with a bit of pain, so she saw her pediatrician who had splinted the wrist. She hadn't had fever or symptoms (weight loss, chills, cough, headache, etc.), and she was neurovascularly intact (she had a good pulse, with no numbness, tingling, weakness, or anything worrisome about the nerves in her wrist or hand). Overall her physical exam was rather benign. X-rays two weeks ago were normal.

One of the questions that I have learned to ask is, "So what brought you back in to clinic today? As opposed to yesterday or a week ago." There's usually a reason, especially for a prolonged issue. When I asked Mom, she stated that the pain had been going on for a couple weeks, and now was a "convenient" time to come in. The young lady had insurance and a pediatrician. Mom worked, and she actually was not working the next day (Monday). I left the room sure I was missing something.

During the actual report to my preceptor, I told him that I must be missing something crucial. I was running down the differential, thinking about the worst it could be. Fracture? Osteomyelitis? Osteosarcoma? I didn't know what I was forgetting. So we go back in the room together. In the meantime, the X-ray came back from triage (normal, of course). My preceptor probed a little bit more into what was going on. Apparently for the months prior, the patient had been doing a lot of typing on the computer (term papers, really? why are we still doing those), and sending thousands of text messages a month. She texts with her right hand. It had been getting more sore for a while, but then slept on it funny one night, causing her symptoms. The splint was for an overuse injury (originally, neither of them could remember the diagnosis she was given). We resplinted her, gave her some Motrin and advice, and sent them on their way.

I know this is a pretty mundane story, but that is kind of the point. The cost of an ED visit is sky-rocketing. Depending on your sources, median/average costs can range from $600 to over $1300 (and that's using 2009 numbers). Taking a ride in the back of an ambulance may cost you and equal amount (the flat rate at one of the companies I was working for was $600 for a drive to the hospital, plus the cost of care). So here we have a patient who does have insurance, does have a pediatrician, has a mother who is able to take her to her pediatric appointments, and doesn't have an acute injury. It just leaves me with such a disconnect. We are not educating our patients how much health care costs. We don't have enough transparency. And perhaps we aren't teaching enough common sense.

It is easy to blame patients; it's harder to ask ourselves where we can improve. But at times, I admit I'm frustrated.

Because wait times are long, we also aren't educating our patients when is an appropriate time to come to the Emergency Department, when they are in the Emergency Department. It seems like a perfect time. But that night we had several very sick patients taking up most of the ED physicians time and resources, and there just wasn't time to tell this patient, "This could have waited until tomorrow morning. Probably you would have only had to pay a copay, and that would be it. This is not an emergency." I think this requires a conversation, not a brusque remark.

I left the room that night wishing this was a part of every visit.