Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, April 22, 2008

So Just Do It

From the mouth of the Panda:
"If we just got aggressive with triage..."
I've never quite understood why EMTALA, the legislation referred to as an "unfunded mandate" by all the ER docs who bitch and moan about having to see everyone who walks through the door whether or not they can pay, is such a big deal. Here's the text:
In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists.
Here's how they define "Emergency medical condition," by the way:

(i) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in-

(A) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(B) Serious impairment to bodily functions; or

(C) Serious dysfunction of any bodily organ or part.

I've gone on to read all the rest of the regulations and amendments and commentary and so on. At no point is there any mention of the obligation of a facility or provider to an individual WITHOUT AN EMERGENCY MEDICAL CONDITION. In fact, they say so over and over again in the 44 page document containing the 2003 EMTALA amendments:
The statute plainly states that the objective of the appropriate medical screening examination is to determine whether or not an emergency medical condition exists. Therefore, hospitals are not obligated to provide screening services beyond those needed to determine that there is no emergency medical condition.
There is no way a rash for three months constitutes an "emergency medical condition", yet somehow Scalpel still interprets EMTALA as a mandate to treat. What's to stop you from booting someone once you've ascertained that no "emergency medical condition" exists?

I know what you're going to say, all you ER folks: there's no way to be 100% certain that no emergency condition exists, so not going ahead and treating everyone would put you at unreasonable risk of liability. Yeah; right. In theory; perhaps. But still! Just reading your blogs, it sure seems like plenty of folks come around offering pretty clear histories in triage (stubbed toes, for crying out loud!) that they aren't dealing with an emergency. Grow some testicles and street them.

Oh, wait: do some of them have insurance? Might they be a source of easy revenue? Is it your hospital's policy to treat all comers (as opposed to the dreaded "EMTALA")? Then quitcherbellyachin'. Or, as Panda says: "If we just got aggressive with triage..."


At Mon Apr 21, 10:15:00 PM, Anonymous Anonymous said...

Whoa. We do send the minor complaints home. And quickly, too. But they still have to be seen and that does tie up resources. I happen to have no control of triage and I have noted many times in my blog that many EDs are money-makers for their hospitals.

I don't believe I mentioned EMTALA in my article. It's not really relevant anyways as in no way do we even make a pretense of only treating emergency conditions. We're actually more of an expensive urgent care/acute care hospital with an occasional full-blown emergency.

At my department, we could send home a third of the patients without being seen at all by anyone and still be insanely busy. I generally don't mind the minor complaints at all except lately they have been interfering with actual emergency patients (if you can believe it).

At Mon Apr 21, 10:26:00 PM, Anonymous Anonymous said...

We do, by the way, send patients with rashes home with no workup. Same with other minor complaints, the stupidest of which I have ever heard being, "My ass is sweating."

But what about mild to moderate pelvic or abdominal pain in a young woman? I have picked up three ectopic pregnancies in the last month because we don't send people home with vague complaints that don't appear life-threatening. And I don't have a single attending who's going to play Russian Roulette with his license and livelihood every night despite how easy you make it sound.

If you are so sure that we are over-reacting, why do primary care doctors automatically send everybody (it seems) who calls with a harmless sounding complaint (diarrhea for example) to the ED? Kind of works both ways. Many doctors punt their liability to us knowing full well that just by telling a patient to go to the Emergency Department they have covered themselves and exercised a cheap standard of care.

At Tue Apr 22, 12:53:00 AM, Blogger scalpel said...

I don't mind evaluating anyone in the ER for any condition they are concerned about, whether it turns out to be an emergency or not. I'm legally obligated to evaluate them anyway, so I might as well be nice to them and offer what limited treatment or advice that I can for their condition.

If I'm going to evaluate them, I'm going to send them a bill whether I discharge them without any treatment or whether I write them a quick prescription. So I might as well treat them well and remain on good terms. It actually takes more time and energy to be a jerk, believe it or not.

Frequent flyers will get the quick medical screening exam and shown the door occasionally. But the average medically-naive healthcare consumer deserves the benefit of the doubt at least once or twice.

These sorts of folks aren't the EMTALA abusers we occasionally bemoan.

At Wed Apr 23, 05:07:00 PM, Blogger Unknown said...

Your scenario is playing out in some states, including Colorado. Screening exam in triage, then "show me the money" or "here's a list of free clinics you can go to."
The failure of a hospital to provide an exam in the ED can also cause a hit in public perception. Hospitals that get a reputation of "turning patients away" would be viewed as heartless, just as would a family practice that had the same policy.
Besides, if these patients can't get in to see primary docs, who is going to treat them?
I don't mind providing gratis care to someone when no one else will step up to the plate - provided that they don't abuse the privilege.

At Tue May 06, 10:47:00 AM, Blogger Tyro said...

I don't think you have to over-read EMTALA to see how timely and consuming a work-up would be, as noted above, for all the intermediate complaints including, for example, cough and abdominal pain. Or chest pain, even if non-cardiac.

That's a big work-up, and we're required to do it to SEE if an emergency exists. That's what ties up resources, not yahoos with minor complaints.

The biggest increase in ER visits is in insured patients according to the IOM, not the driftless uninsured, and a recent Annals of EM article pointed out that there is a crowding-dependent decrease in quality of care for ALL patients as volume rises. The crisis in Emergency Care comes from overloading down a variety of vectors, and a lot of it stems from inadequate primary care--something that I'm sure you are very aware of.

It's not the stubbed toe, it's the thirty-year old with a cough. We can't turf abdominal pain or chest pain to the street without an eval. Geez.

At Wed May 28, 10:01:00 AM, Anonymous Anonymous said...

ER's actually make money?!?! Is the media lying to us?! (please note sarcasm)


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