Defensive medicine in the ER

It doesn’t get more blatant than this. And you wonder why health care costs are so high:

18-year old comes in with malaise, mildly elevated fever and body aches. Her head hurt a bit, her belly was a little sore, and her legs were achy along with her back and other muscles. Nothing beyond a couple of days off of work and a little extra sleep.
Work up/treatments:
Head CT to rule out head bleed or tumor
Bilateral venous dopplers to rule out DVT due to sore legs in an 18 year old with no risk factors and no leg swelling
Abdominal CT with PO contrast to rule out…whatever because it was a little sore diffusely
2mg of dilaudid IV push, yes 2 mg (I gave 0.5 only, thanks)
Fluids
Zofran
Full panel of labs
Chest XR
Urine sample

Comments

Anonymous
If doctors didn’t practice “defensive medicine”, how much cheaper would healthcare be?
Elliott
It has nothing to do with “defensive medicine” and everything to do with incompetence, but noone is going to report nice guy Dr. Marvin to anyone for the necessary discipline.
Anonymous
a) What is there to report?
b) To whom would it be reported?
c) What is the necessary discipline?
d) If the patient were discharged with a dx of viral syndrome, and advised to return if symptoms failed to improve or worsened, and subsequently died from a ruptured appendix, would you not be singing a different tune? No, you’d likely suggest that this wouldn’t have happened if he had been properly disciplined (i.e. “police yourselves”) for underdiagnosing in the past.
RoseAG
Did she need a note for work from a Doctor that she’d been sick and that’s why she missed work?
If that were one of my kids we might have called the PCP but it doesn’t sound like nearly enough to go to the ER.
Sometimes a couple of Advil and a little time will fix those things right up!
Diora
So, I asked before and I ask again.
How this is different from stealing (if the patient pays out of pocket) or insurance fraud (if insurance pays)?
Does “I am trying to protect myself in case of lawsuits” is enough reason to take somebody’s money? Is this reason more compelling than “I have a hungry child to feed” from a maid who steals the lady of the house’ jewelry? In the latter case, it is a theft while in the former it is simply “defensive medicine”. Does it make it morally right?
What is the probability of any of these conditions in an 18-year old? 1/1000? 1/10,000? Did the ER doctor advise this 18-year old of the odds? What would the risk of a lawsuit be if the 18 year old refusees.
So you are making this 18 year old pay for “insuring” you in case of a tiny risk of lawsuit. Is he in this type of insurance business?
Again, how is it different from theft?
Anonymous
Elliot:
Since you know more than this incompetent doctor who should be disciplined please do tell us the differential diagnosis of hematuria and the corrsponding w/u. If you don’t know it then look it up, then you might see the possible utility of a CT.
Nurse K, Generic ER Nurse
The important part of the hematuria story is that it was the same as her chronic musculoskeletal back pain, just worse. It had no features of kidney stones (didn’t come on suddenly, wasn’t really flank pain, no difficulty urinating). She had no fever, she had no dysuria, and the rest of her UA was negative. Her CBC/chem panels were all negative.
The Ct was ordered solely on the basis of microscopic hematuria with the low back pain.
If the urgent care’d been open, she’d have been triaged there where the work up would have been far less extensive.
Anonymous
Nurse K:
I also think you need to look up the differential diagnosis of hematuria. I don’t argue that simply following this issue could be warrented by a PCP. But this isn’t a PCP. This is an ER doc’s whose job it is to r/o the worst possibility (which isn’t a nephrolithiasis). No comment on f/u or if she even had a primary. These are prime considerations in seeing pt’s with an abnormality that my or may not get followed up on in a timely basis.
Elliot: The simple fact is you know nothing about medicine. Your comments are those of an ignorant fool who wouldn’t know true medical malpractice if it bit you in the butt.
Anonymous
You don’t know that Dr. Marvin does it every single time, only that he seems to do it a lot.
Interesting things tend not to be noticed when they are absent.
There are a lot of people with these same symptoms who did not come to the ER. This one did. Experienced docs know there is value in that information.
Did Nurse K survery several weeks worth of Dr. Marvins patients and note that he does this every time? Or is it just obvious because he does it more than the other Doctors?
Elliott,
Please provide us with your criteria for competence. It seems that docs who over-order are incompetent and should be disciplined, and those that under-order are incomptent and should be disciplined. You have stated in other posts that if we docs reported our incompetent colleagues, we would have little to be concerned about regarding malpractice. So what are the criteria?
Kevin
Elliott,
No foul language please, censored or not.
Kevin
Anonymous
So I’m wondering why healthcare is so expensive, and Kevin says stop wondering, it’s defensive medicine.
So if we take the “defensive medicine” out, how much cheaper is it? And who keeps the extra cash?
Nurse K, Generic ER Nurse
You don’t know that Dr. Marvin does it every single time, only that he seems to do it a lot.
Yes, not every time, but often enough where we made up a word for his work-ups.
There are also little things like making sure every young person with gastroenteritis can tolerate crackers before discharge and medicate and wait until they can even if the patient says they’d like to go home. I mean, normally after N&V they recommend clears for 24-48hrs anyway…why insist that the pt can tolerate solids right away? It just takes a lot of unnecessary time, and I feel bad about giving them the crackers if they don’t want them.
Or the hours of repeated enemas until “everything is gone”. You get the picture.
My feeling on the hematuria was that since the patient was stable, she could get a repeat UA at her clinic when she followed up there for the back pain. If you don’t have a clinic, we give you a card for a clinic that offers low-cost primary care services. If we were treating in anticipation of the patient not following up, we should’ve given her a 6-week supply of Percocet and muscle relaxers too, no? Maybe called and set her up for PT in a couple of weeks? Maybe informed the neurosurgeon that she may be needing surgery for her back and she wouldn’t be getting a referral from a clinic?
Kevin
Well, let’s say the head and abdominal CT’s were done “just in case” a one in a million diagnosis was there – i.e. defensive purposes.
A head and abdominal CT are in the ballpark of a thousand bucks.
Multiply that by the number of times this happens in the ER daily (I would guess in the tens of thousands). You can do the math.
Kevin
Anonymous
So assuming all those are done and are not medically necessary, and there is no other reason but fear they are ordered, and the numbers are what you say – who keeps the extra cash being spent now?
The health insurers?
Nurse K, Generic ER Nurse
Well, let’s say the head and abdominal CT’s were done “just in case” a one in a million diagnosis was there – i.e. defensive purposes.
And, even if they showed something, such as a brain tumor, the findings would have been “incidental”. It’s not like she was having chronic headaches or neuro changes.
Anonymous
What if she requested it be done? Still defensive medicine?
And again, who gets the benefits of all these savings? Do the 45 VPs at Kaiser all get a new Lexus?
Nurse K, Generic ER Nurse
If the test was never ordered in the first place, no one gets a “cash payment.” We are in a free market, and if defensive medicine was decreased, the cost of doing business for insurance companies would decrease, and, through competition, prices for insurance would decrease (or, at the very least, increase less). If she was a Medicaid patient, yours and my taxes would be reduced. As a chain reaction, more uninsured people who were previously priced out of the market would be able to afford insurance.
You appear to be a troll, but the goal of medicine isn’t to shatter the healthcare system as we know it by ordering so many tests that price of insurance makes it unattainable for most, if not all, people. Doctors’ goal isn’t to “stick it to The Man.”
What if she requested it be done?
So what? If there’s no indication, there’s no indication.
Anonymous
“My feeling on the hematuria was that since the patient was stable, she could get a repeat UA at her clinic when she followed up there for the back pain. If you don’t have a clinic, we give you a card for a clinic that offers low-cost primary care services”
I am sorry nurse K but everything you are telling me shows that you have not had to make primary medical decisions. I have seen FIRSTHAND docs go to court because their ER staff gave a “go to a low cost provider” card with address to a patient with an abnormality. Guess what, the person did not follow up and one year plus later showed up with metastatic cancer. Guess who went to court for that one. It wasn’t the ER staff, it was the ER doc. Your other analogy is stupid. PT visits are not emergent issues to be addressed in the ER (though important). I suspect if you bothered to ask the ER doc he would have given you a reasonable explanation (or maybe not). But the fact is hematuria needs to be followed/evaluated and not dismised because of what it COULD mean (remember that differential diagnosis of hematuria I was talking about). In the end it’s not you making the call and it’s not your butt on the line. If you feel you are right and the doc is an idiot there is an easy solution…go to med school.
Anonymous
Headline:
Eighteen year old patient dies of kidney failure from rhabdomyolysis. ER doctor implicated.
How many of you would be commenting with 20/20 hindsight that the idiot should’ve done more workup before letting the patient go home with some advil and a note?
Anonymous
agree with headline comment. although i doubt the kid was rapidly progressing. why not admit the kid and observe? if the kid isnt changing his loc why bother with an immediate CT. although we dont know the time frame and the actual experience.
yes its an expensive workup. but this was one case. im sure there are hundreds of kids sent home without a CT.
P O’ed
Bottom line: Nurse K and her/his ilk should quit spending long days in the ER and go to medical school.
That way, you can start practicing what you advocate with your own livelihood, professional liability, and liberty on the line. If you want to play, you gotta pay. PUT YOUR MONEY WHERE YOU KEEP PUTTING YOUR MOUTH IN, WITH YOUR IGNORANT CRITICISMS, COMMENTS AND BLOGGING!!!
POed 2
AND NURSE K AND YOUR ILK –
have you thought of spending your efforts and time on quality nursing, instead of 2nd guessing your docs in every turn? Wonder how much more efficient you could be getting the responsible steps done? And how many more patients your ER can provide primary care to…
NO, the doctors don’t make any more money for doing more tests; they actually get economically de-credentialed. [If you have no clue what this is, Elliot et al., go research it; it should keep you better informed than in your ignorant commentary]
ERMurse
Please spare us with the Doctor knows best and if your not a MD you cant comment on the care. The tests described for the patient is out of line and shows a lack of confidence and or assessment ability. It does not take a medical degree to figure that out.
yours truly
Nurse K and other pretentious fellas:
1. did you miss class when they taught what crackers and clear liquid diets are? or has your license changed this designation already?
2. were u also absent when ‘incidental findings’ was discussed? did your teacher really know what they are, or just pretended to, like you do now? well, my dear, its not too late…you can still educate yourself on this topic and others you like to pretend that you are knowledgeable or licensed for; your profile says you are age 27, and have lots of time to finish medical school, residency, get licensed…and finally [drumroll please] practice what you are itching-to-do-but-have-no-clue -about-to-question-at-this-point-
without-sounding-ignorant
3. or, you can go to law school and contribute your ‘expertise’ half-baked as such, to the licensed professionals who are truly the drivers of rising healthcare costs…
grey,md
“Please spare us with the Doctor knows best and if your not a MD you cant comment on the care.”
But why? So you can continue your ignorant critique of the docs who are licensed, ultimately responsible professionals for patient disposition and ASSESSMENT with liabilities to prove it…
ER[M]URSE go to med school, residency and BE TRULY RESPONSIBLE if you dare not to be professional at being a nuissance.
TAKE RESPONSIBILITY – you have discussed this in your blog intentionally or not, at one time or another. Look at yourself in the mirror, maybe you could see the ER “clients” you critiqued in your previous blog entries. TAKE RESPONSIBILITY AND STOP YOUR CONDESCENSION!!!