Things I learned from working in the ER, Part 1

I just finished my month of Emergency Medicine. It was a learning experience in many ways. I learned a bit of emergency medicine, in general, and I learned to think broadly, practice my differential diagnosis recall, and try to think of every test and lab that I could possibly need (quite opposite from Internal medicine where you often have to work hard to justify every lab you order). I learned that - despite earlier beliefs - I really don't like the ER that much (more on that later). I learned to appreciate the skills - and limitations - of ER physicians, and I got a more complete picture of how our (not very well) patched together system of health care works in this country.

So where to start? How about the frustrations of working in the ER in country without universal health care?

On Thursday's Daily Show episode, Jon Stewart showed a clip of Bush criticizing universal healthcare as the government's way of trying to get involved in the decisions between a patient and their doctor. Stewart pointed out that the people who don't have insurance, don't have doctors. It was a funny and accurate response to Bush's paranoid and idiotic argument, but -after a month of working in the emergency room - it was also stingingly accurate in its implications.

If you ever want to see what it means to have no universal healthcare coverage in this country, you should spend a month in the ER. It is overwhelming, frustrating and depressing. Probably 1/3 of the people I saw had no insurance coverage (that does not include the majority of the people I saw who were covered by some sort of government insurance: Medicare, Medical or County). They came in with vague abdominal pains, abnormal bleeding, the end stages of whatever untreated diseases they had, or as victims of car accidents.

There were in general, two separate groups: the very poor, homeless, and often addicted, who are usually not only incapable of helping themselves but also unable to show us how to help them; and there were the working lower and middle class, for whom the hospital visit was a last ditch necessity that would likely bankrupt them and often not provide a solution to their problems.

These latter cases were most frustrating and sad on a personal level. These patients were unlucky enough to be born into the middle class, working the average hourly wage, in the average job that does not provide healthcare, and found themselves with the average medical conditions that can stricken every American. A few examples:

A few weeks ago, I had a healthy 20-something year old with sudden onset of scrotal pain. He was a good kid, worked at a retail store, didn't do drugs, couldn't afford insurance - "I tried but then I couldn't afford my rent." His presentation was concerning for a medical condition - testicular torsion- that, if not diagnosed and treated surgically within 4-6 hours, could cause him to lose his testicle. We rushed him to ultrasound for the diagnosis, and once that was negative, began the work up for the other conditions he could have. He left with the final diagnosis of epidimytis, mostly by exclusion since he really didn't have the risk factors, a bill for thousands of dollars, medication he may not need, and instructions to follow up with a physician he didn't have if his pain didn't going away. I felt horrible sending him out. It was the right decision for him to come to the ER; had he had torsion, we could have helped him. But he didn't and we hadn't, and now he was left with pain and a whole lot of debt.

Another patient I had was a woman in her 60s who didn't qualify for Medicare as she was a recent legal immigrant. She had been in a work-related accident a few weeks ago and her employer - she was a caregiver - didn't have worker's comp. Since her accident, she's had nausea, anorexia, headaches, and occasional vomiting of blood, and now couldn't work. We scanned her head and abdomen, ran a bunch of other tests and couldn't find anything wrong with her. She was sent home feeling the same way she did when she came in, with the reassurance that we couldn't find anything that would kill her anytime soon, and with a bill that probably exceeded $10K.

I have to say that often in the ER, I felt like I wasn't helping anyone. In the cases above, which were depressingly numerous, I actually started to feel like I was hurting my patients more than anything - simply by participating in the cranking of the wheels of a failing and destructive health care system. Part of the problem was that while I was so disturbed by what was happening around me, the ER continued to move forward without pause. My attendings' mantra was "If everything is negative, send them home." My ER residents would unemotionally reply "I don't know" and walk away when patients asked how much their visits would cost and if there were any resources to help them pay for it. It wasn't that they didn't care; it was that it was so common, that they couldn't get involved.

And because everyone was so busy, we were actively making the system worse. For instance, when a patient who didn't speak English came in with abdominal pain as a chief complaint, my resident automatically ordered the complete abdominal pain work-up on her -around $1-2K, I would guess. I lifted up her shirt, and noted she had shingles, but by then, the tests had already been sent. This wouldn't cost her anything, because she had Medicare, but it would contribute to the skyrocketing cost of health care. However, this is the way the EM system has become: ERs are so overwhelmed by patients who don't have primary care physicians to go to, they are run in the most efficient - often least economic- ways to get patients in and out as fast as possible.