My take: Diagnosis, Big Dig, ED waits

1) Outrage that the VA would pressure counselors not to diagnose PTSD to save money.

No surprise. People revolt against private insurers who deny care to control costs. They’ll soon find out that the government will be no different.

2) The WSJ called Massachusetts’ health care plan the “new Big Dig“.

Having lived in Boston for 10 or so years, I felt the brunt of the real Big Dig. Calling something a new Big Dig are damning words indeed.

This is precisely when happens when universal coverage is promised without considering cost controls. Furthermore, their plan of cutting payments to hospitals and physicians is tremendously short-sighted, as this will further worsen already bad physician access.

Thankfully, I’m in New Hampshire now. The taxpayers of Massachusetts are not so lucky.

3) A letter to the editor, complaining about an ED wait.

Pain can certainly be distressing, but not all causes of severe pain are life threatening. What patients need to understand is the limited resources emergency rooms have. It is not feasible to treat everyone instantly. There will be some cases where patients, after being appropriately triaged, will have to wait long periods in significant discomfort.

Comments

IVF-MD
Sure it’s a lot to ask of the patient who is suffering the pain himself or of his family, but could they stop and reflect to ask themselves what they thought was the reason that they weren’t seen sooner? Did they think the nurses were just having a cigarette break? Did they think everybody was just dragging their feet deliberately? Or could they entertain that remote possibility that there were other patients with even more concerning symptoms who needed to be stabilized first?
Anonymous
I can certainly imagine that folks with dangling limbs and bloody excretions would take first priority.
The woman with the migraine who had a history of migraines I wonder why she didn’t have some meds she could have taken. I mean if you’re prone to them wouldn’t you have some around?
But the kidney stone does seem like something you’d legitimately go to the ER for. I was under the impression that pain from a kidney stone was pretty intense.
Cathy
I don’t know if trying to make patients “understand” that there are limited ED resources is the correct thing to do.
I used to work in a software company where I frequently had to explain to the public that we had “limited resources” and thus could not fix all the bugs in our software at once. Okay. That’s fair. Nobody can wave a wand and make all problems go away. But the huge secret was that our company was so grossly understaffed that the software was in a horrible state, the workers had no morale, and the entire project was circling the drain. So in addition to being rightfully angry that the software was junk, the customers were now additionally angry that they had to wait and be “patient” and “understand” that we couldn’t address everyone’s problems in a timely manner.
Of course we, the demoralized workers, only saw the immediate problem. The immediate problem was the customers riding our behinds all the time to hurry up and fix stuff. This made us feel even more demoralized about the staffing shortages and other things we could do nothing about. However, the real problem was the lack of resources, not the customers complaining (quite rightly) about the time it takes to get something done.
The answer to ED wait times is not more tolerance, patience, and understanding on the part of the customer who rightly expects humane treatment (and possibly a little help with their pain while they wait). I don’t think an hour is too long to wait. I’ve certainly waited that long to be seen when I had a migraine that didn’t respond to my normal medication. I brought a face mask and some earplugs and asked for a cold pack.
When I was coming down with a case of acute abdomen, I was sent to sit interminably in one of those uncomfortable waiting room chairs as waves of pain and nausea ran through me. At one point I began to sweat profusely and fell forward out of the chair. I had blacked out. Even if I had to wait to see a doctor, I think a lot more could have been done for my comfort during the period of waiting, namely a chair that didn’t force me to sit bolt upright like I was in church. Sick people in hospital waiting rooms often want to lay down or recline a bit.
I think we’re past the point where we can ask patients to keep being understanding and tolerant as service gets worse. We need to do what it takes to get the EDs staffed appropriately and make sure those who have a long wait are at least somewhat comfortable while they do.
Carol
The thing that really strikes me about all of this is the word service. When I think of an ER I think “Did I get good care?” not “Did I get good service?”
They’re most definitely two different things.
IVF-MD
Cathy said… We need to do what it takes to get the EDs staffed appropriately
I agree that you have stated the problem. But what are some solutions?
Cathy
IVF-MD said: “I agree that you have stated the problem. But what are some solutions?”
I’m not an insider, I’m afraid. Unlike in the software company, where I could see how management decisions and understaffing were ruining the product and annoying our customers, I really have no idea how a typical ED is staffed.
I can only see the problem as a symptom: long wait times in less-than-ideal conditions for people who are feeling bad enough to be there and doctors who are so pressured for time that they are a) demoralized and b) in a hurry.
Blue Cross Blue Shield referred me to an ED when I called their help line with symptoms indicating a likely kidney stone. (It was, indeed, a kidney stone.) I sat in a chair in the waiting room for over an hour when all I really wanted to do was curl up into a ball on the floor. Then I was sent to an ED “bed”, one of the temporary ones lined up against the walls where I waited a couple more hours before somebody noticed me and said “has your nurse come by yet?”. No, nobody had.
In the meantime, since I was parked near the ED’s central station, I got to hear interesting things while I was writhing in pain on my little bed. An older doctor was complaining within earshot that things could not go on like this. He rattled off a list of people who didn’t belong in an ED, who had been brought there by ambulance at great expense for practically nothing. He bemoaned the fact that the ED is now the de-facto “Urgent Care” for everyone after all the daytime doctors go home. They were ten patients above and beyond capacity, and still had a full waiting room. This couldn’t go on. I agree with him.
So if we can’t magically increase the supply of doctors, perhaps we can re-route people away from the ED? I sure would have gone to an Urgent Care if I could have found one available in my area at 9pm. Maybe it’s time for hospitals to offer both Emergency Departments and Urgent Care clinics? If EDs weren’t paranoid about drug seekers or malpractice suits, maybe it would be fruitful for triage to assist non-emergency patients with their pain such that some of them could be sent home to see their regular doctors in the morning (and the rest, presumably, would be less frantic about having to wait).
But I’m not an insider, so I can only muse. Maybe you have suggestions?
My only real point was that pain is important. When people are in pain, they can only focus on themselves. If we could make genuinely ill people more comfortable, they might not complain so much about the wait.
Shaheen Lakhan
Carol,
Yes, “care” and “service” are two distinct things. It really stems from: What do you want, expect, and deserve from your doctor? This is the very question we recently asked at Brain Blogger.
We would like to read your commentary on our article. Thank you.
Sincerely,
Shaheen
Anonymous
ED’s are likely to continue to be undersized and understaffed because my ED for instance the “customers”:
1. 10% illegal imigrants
2. 20 % self pay = no pay
3. 25% medicaid laughingstock rates.
4. 20% Medicare – just covers cost
5. The remaining are insured patients that have been able to coercively pay a reduced rate.
In any other business would there be good “customer service” if you had to give half of your goods away?????
Anonymous
I had a friend who sat in a chair in the ER for about 3 hours in pain – she had a ruptured appendix. I don’t know if they had more serious cases at the time, or if they triaged her wrong. She felt acute pain when she was driving to work, stopped for a bit on the shoulder hoping for it to pass, then drove straight to the ER instead of work. Maybe the fact that she came on her feet and alone gave the nurse impression that her case wasn’t that serious. Could there have been some mistake in the triage system that thought her case was less serious than it was?
ivf-md. I don’t think people who are in pain can stop and reflect. Wouldn’t the fact that you can actually stop and reflect and think of something other than your pain mean that your pain isn’t that bad to begin with?
I do understand that people who are brought up by an ambulance because they are having a heart attack have priority. I also realize that there are a lot of people who come to the ER who have no business coming there. I wonder if sometimes just because someone walks in, there is an assumption that the case is not as emergent.
Anonymous
Difficulty: in the linked article, the delay was in TRIAGE.
” … my ailing 83 year-old father was not seen or spoken to by anyone on the medical or administrative staff at the hospital. After about an hour of this unacceptable and potentially dangerous behavior, my sister was forced to choose between remaining in the ER waiting room at Lake City Community Hospital or drive my father another 25 minutes to the ER in Florence. “
The delay is serious and unconscionable.
And that’s not even getting in to whether it is good practice or ethical to leave patients in misery in a waiting room for extended periods after triage.

My take: Diagnosis, Big Dig, ED waits

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