Help me understand...

[ERCougar]

There are plenty of things that I see at work that are educational issues--to someone in medicine, obvious ridiculous reasons to come to the ER, but if I stop and think a little, I can figure out where they were coming from.

Constipation is not one of those issues. It's such a common presenting complaint that it just doesn't phase me much any more, but really--what kind of definitional framework classifies constipation as an emergency? A doctors visit? Sure. But emergency?

Someone help quickly before I go choke this patient in triage.

[smokymountainrain]

There are plenty of things that I see at work that are educational issues--to someone in medicine, obvious ridiculous reasons to come to the ER, but if I stop and think a little, I can figure out where they were coming from.

Constipation is not one of those issues. It's such a common presenting complaint that it just doesn't phase me much any more, but really--what kind of definitional framework classifies constipation as an emergency? A doctors visit? Sure. But emergency?

Someone help quickly before I go choke this patient in triage.

What would be the harm in telling the guy you can't help him and sending him home? Is that simply against proper ER etiquette?

[ERCougar]

Yeah, technically, you COULD, but we don't for a few reasons. EMTALA requires that a physician at least evaluate every patient that comes. On an issue like this, the initial evaluation is your entire encounter, so you might as well complete the visit so you can get paid. Additionally, these types of complaints, as annoying as they are, are one of the more profitable things that comes out of the ER--they're fairly quick in and out, they dont tie up beds or nursing staff, etc. Even if only a third are insured, the hospital would make a killing if they just treated these all day (my pay doesn't change at all). Finally, these types of uberneedy patients are the most likely to complain when their needs aren't perfectly met. Complaining profitable patients don't make for happy administrators.

I know there are worse things to deal with in life, and actually, my job is pretty easy with these. It irritates me on a societal level, much like when I see people on disability for uncomplicated diabetes.

[SCcoug]

Maybe it is a case of the ER being their primary care.

[smokymountainrain]

Yeah, technically, you COULD, but we don't for a few reasons. EMTALA requires that a physician at least evaluate every patient that comes. On an issue like this, the initial evaluation is your entire encounter, so you might as well complete the visit so you can get paid. Additionally, these types of complaints, as annoying as they are, are one of the more profitable things that comes out of the ER--they're fairly quick in and out, they dont tie up beds or nursing staff, etc. Even if only a third are insured, the hospital would make a killing if they just treated these all day (my pay doesn't change at all). Finally, these types of uberneedy patients are the most likely to complain when their needs aren't perfectly met. Complaining profitable patients don't make for happy administrators.

I know there are worse things to deal with in life, and actually, my job is pretty easy with these. It irritates me on a societal level, much like when I see people on disability for uncomplicated diabetes.

Makes sense.

[ERCougar]

Maybe it is a case of the ER being their primary care.

Nope. That's a case that I can wrap my brain around and understand where theyre coming from. Yesterday's case was a guy who sees one of our CUFers; today's said that she 'couldnt get an appointment this morning' (i can sort of get this, but offices aren't open yet, so she hadn't tried and she has the day off--I always ask before I give them a clean out...)

[byu71]

It is probably TV's fault showing ER rooms where there is all sorts of chaos. It appears ER doctors see everything and therefor nothing would bother them.

Therefor, if I got something to ease a real serious constepation problem and I exploded all over the place, the ER staff would take it in stride where as I am not sure my regular doctors staff could handle it as well.

[WashingtonCoug]

It could be that people are not realizing the difference between an ER and an InstaCare. I don't know why they would do that, but I could definitely see that happening.

[ERCougar]

It could be that people are not realizing the difference between an ER and an InstaCare. I don't know why they would do that, but I could definitely see that happening.

Yeah, I think there's something to that. I guess I would think they would reflect on the term 'emergency' and that might lead them to a more appropriate response (we have an instacare in town), but practically speaking, I think emergency rooms have turned into quasi-instacares.

Doesn't that speak to something that needs to change on a societal level though? With healthcare costs out of control, this seems to make a pretty good case for cost-sharing. Constipation is far from the most ridiculous thing we treat.

[Art Vandelay]

I deal with two problems related to emergencies.

1) Long term patients who go to the ER and/or urgent care for any type of red eye, especially those with a history of glaucoma. Not that docs like ER or JIC don't know what they are doing (both are a heck of a lot smarter than I am), it is just difficult to distinguish a low grade uveitis from a typical conjunctivitis if you don't see it every day. This really is a minor issue, but I try and inform patients, generally after the the topical antibiotic they are using, hasn't treated their problem, just call our office and they will 'page' me or one of the other doctors- saving them the ER wait on bill.

2) Bigger issue, and one I'm guilty of, not coming in soon enough. At least weekly, I see someone who has some sort of permanent vision loss (corneal ulcer, diabetic retinopathy, wet macular degen) that could have been prevented if they would have come in sooner. The worst is metal in the eye. Every sheet metal worker and welder, has tried to tough it out at least once. Unfortunately, they always leads to a rust ring under the metal and bigger corneal scar.

In about an hour I'm seeing a 21YO who likely is going to need his second corneal transplant, because he is having graft rejection of the first. His eye (which, obviously, has already had a transplant) was, red, sore, and blurry for 2 weeks but he thought it would get better. I saw him yesterday, when it now appears too far gone to stop the rejection. I feel bad for him.

[ERCougar]

Panicking about how much uveitis I'm likely missing...thanks, AV!

So seriously, I simply can't do a full workup on every red eye I see. I get concerned at recurrent episodes, or concerning historical features (joint pain and what not), but what else should I be missing. You guys don't want us calling you on every red eye in the middle of the night, I promise.

[Katy Lied]

I think employers who require doctor's notes are anachronistic and should be fined a public health fee for this company requirement.

Doctors notes are leftover from the days when doctor visits were cheap and sick leave was not permitted to minister to family members.

If someone calls in sick, why not have them go to a notary public and swear out a statement that they really were sick? Why bring the expensive health care industry into an employer-employee spat?

If I were an ER manager, I'd station a physician's assistant right outside the door to the ER to provide a doctor's note to anyone for any reason. Then the ERs would not fill up on Sunday nights.

[ERCougar]

I think employers who require doctor's notes are anachronistic and should be fined a public health fee for this company requirement.

Doctors notes are leftover from the days when doctor visits were cheap and sick leave was not permitted to minister to family members.

If someone calls in sick, why not have them go to a notary public and swear out a statement that they really were sick? Why bring the expensive health care industry into an employer-employee spat?

If I were an ER manager, I'd station a physician's assistant right outside the door to the ER to provide a doctor's note to anyone for any reason. Then the ERs would not fill up on Sunday nights.

These are annoying, but aren't numerous enough to account for overcrowding. Truthfully, we probably get more requests for notes stating they can go back to work, and I don't see an easy way out of that.

[Art Vandelay]

Panicking about how much uveitis I'm likely missing...thanks, AV!

So seriously, I simply can't do a full workup on every red eye I see. I get concerned at recurrent episodes, or concerning historical features (joint pain and what not), but what else should I be missing. You guys don't want us calling you on every red eye in the middle of the night, I promise.

That is exactly my point, you have to deal with so much stuff it blows my mind. I don't get that many after hour calls, so it usually isn't a big deal for me to come in and see someone. Heck most the time I can phone triage and see them in the morning. I honestly can't imagine seeing a screaming infant one second with a possible differential of cholic or obstructed bowel, then a non-communicative 90 YO the next (stroke or dementia?). Going from chest compressions to otoscopy. ER docs, much like military field docs, are my heros. It is one thing to know a lot about one area of the body, it is quite another to have to know (nearly) everything from head to toe.

Photophobia and pain are the two things most conjunctivitis don't have that uveitis do....unless it is herpetic then all rules go out the window

[BigPiney]

My turn to complain about ERs. Living in this small town, there are no other options after hours. When my son broke his arm 4 weeks ago, I called his primary care, and they said since the Orthos weren't open that day, to go to the ER. The ER doc looked at the x-ray, put a splint that went to mid forearm on a fracture of the radius and told us to see the pediatrician in one week for followup but that the severe bend in my son's arm should straighten itself out.
The ortho isn't in the office till 3 says later, so when we go in an see him and he sees the 26 degree angle in my sons arm he immediately schedules a closed reduction. $15000 later, my son's arm is straight and has a cast that goes beyond the elbow.
Am I within my rights to go kick the ER doc in the nuts?