Confessions of an ER Doctor

July 5, 2006

One of the more popular venues during the National Cherry Festival is the emergency room at Munson Medical Center.
On that note, we talked to an emergency room doc who reported that Traverse City’s population triples and so do the number of ER patients. Of course, the wait lengthens, too, except for serious cases. The good news: it won’t be so bad next summer thanks to an expansion from 20 to 42 beds (in progress and due for completion in January 2007).
Munson’s Emergency Department isn’t the minute-by-minute life and death drama like the TV show ER, but there is no shortage of emotion. There’s the joy of a life saved or pain eased. Patients, the ER doctor said, sometimes stop her on the street and profusely thank her for the good work done.
But that’s not always the case; some people are disgruntled because their expectations aren’t met. ER is the place where the pressures of a dysfunctional health care system—and our society—are most painfully felt. The emergency room has become a place of last resort for those who lack health insurance or decent health insurance. Patient visits have rocketed to 42,000 a year. Federal law requires that anyone must receive a medical screening if they show up in ER.
Talking about the ER realities might get people to stop thinking of it as “fast-food” medicine, and exercise more patience and courtesy, said the ER doctor.
NE: Where did you work before coming to Traverse City?
ER Doc: I worked in Chicago, which was much different than here. It was a scary place to work. There was once this young guy, who had a gunshot wound -- a bullet to the chest -- and there was something like that every day. So his gang buddies show up at the ER and they’re very angry and they’re intimidating the nurses. One of them told the doctor, “You need to save our friend or you’re dead,” and these gang guys got on both sides of Ralph, the doctor, and picked him up off his feet. Thank goodness, the police came. Ralph continues to work in that ER. Very scary. The nurses ran, and some didn’t come back for months. Poor Ralph: he was a resident at that point, he only got two days off.

NE: We recently ran an article about Paul Oliver Memorial Hospital, and the vulnerability of its very small late evening staff. (Last spring, a man threatened to kill the ER staff and then himself after he was refused prescription drugs. Police were called.) Same problem at Munson?
ER Doc: Every day, there’s someone demanding drugs and getting nasty. Stomping out if we refuse them. But if they make a threat, I call the police. One threat is all I need to hear. Our top priority is the safety of other patients and the staff. Trying to deal with someone like this is trying to rationalize with someone with an alcohol problem. I tell them, “I don’t discuss it—this is the law. If you threaten me, I call the police.”
If they’re unruly, disruptive or threatening, they might get tied down. I’m not going to put anyone in harm’s way. I don’t try to reason with them if they’re intoxicated—it’s nearly impossible. You check on their vitals routinely to make sure they’re okay. Sometimes they become resentful and spit on us and then they get a mask for the protection of staff. You tell them, “Hey, we’re here to help you and you’re spitting on us. I know it’s the alcohol talking.” It happens every day.
Almost invariably they say, “I’m going to try to kill myself. I’m depressed, I can’t deal with the pain.” Sometimes I’ll call the police or the psychiatrist; sometimes you have to get both involved. We have a team that works with psychiatric or drug-crazed patients and they have an algorithm they follow—it’s usually a nurse, a social worker and a psychiatrist, and they develop a plan for each patient.
We see a lot of psychiatric patients in a 24-hour period. Sometimes six or more a day. Our job is made more difficult if they’re intoxicated or on drugs; a psychiatric worker won’t see them until their alcohol level is under the legal limit. A lot of people just want a quick fix for their drug problem—“I’ve run out of medicine and I want a refill.” That complaint is usually at night, so I’ll give them enough to last until the next day. If it’s daytime, I’ll call the family doctor. Most people ask specifically for the drug they want. I tell them, “You shouldn’t be in ER for a medicine refill.”
There is one man, he comes in 10 times a week. He has a terminal illness and the ER has become a second home for him. He says he’s depressed, he has a terrible headache, and he wants drugs to help with the pain. But we gave them to him once, and he overdosed on it the same day, so I tell him never, ever again. If he wants drugs, he has to see his family doctor.

NE: How many people go to ER with minor problems?
ER Doc: You just wouldn’t believe it. So many people don’t have insurance for an office visit, so they come here because their insurance will cover it or they don’t have to pay up front. That’s the biggest reason. I know how bad health insurance is because I have to buy my own. It’s only a little better than catastrophic insurance; costs $750 a month for my family, and we get minimal coverage. It’s crap.
The system is set up for abuse. We’re open seven days a week, 24 hours a day, and nobody has to pay any money up front. With this kind of abuse, the waits can get really long. The people who are really sick usually don’t bitch about the wait. It seems a small percentage that aren’t all that sick are the biggest whiners.
When we take a Medicaid patient, we are reimbursed about 10 cents on the $1. That’s why family practitioners take so few Medicaid patients or refuse to see them. If you take one, you lose money, and there are only so many patients you can afford. But ER has to take everybody.
In Chicago, there were so many people abusing the Medicaid system. The worst one I remember was a woman who drove up in her BMW. She had cut her hand on her huge sailboat, and she was on Medicaid. She was scamming the system, while I made $3 an hour.
I have no problem with Medicaid for the many people who need a hand. But I get a real bad taste in my mouth from the people who abuse it.
When it comes to migrants, 99% don’t have insurance, not even Medicaid. The hospital eats that. The hospitals eat a lot from the general population, and we’re seeing that everywhere. It’s not so much the poor; it’s the barely middle class people. There are a lot uninsured folks. Over the weekend, you get a lot of two-fers or three-fers. If one comes in, another will come along and say, “Since I’m here with her, I also have this big problem.” It pisses me off. This is total abuse of the system. You have to see the whole family and the paperwork is an inch thick for just one chart.
That is why our health care system needs a big fix. It’s a vicious cycle. Bad debts, bad insurance, no insurance, insurance providers who don’t pay. It hikes up the premiums even more.
NE: You hear a lot of terminology when it comes to ER; the most common word is triage. Explain that.
ER Doc: Those who are the sickest get taken care of first (instead of a first come, first serve basis). We triage if someone is bleeding, having a heart attack, dehydrated, needs an IV, loss of life or limb, belly pains, they go right back.
So that’s another problem. You’ll see someone with chronic pain come in and expect an expert diagnosis. They’ll have a back problem or neck problem for years: “My back’s been bothering me and I’ve seen five different doctors and not one of them can figure out why. So you tell me what’s wrong.” The problem is do they mean five different urgent care doctors or five different doctors who aren’t talking to each other? So I emphasize they use a primary care doctor who can orchestrate the sequence of testing to get to an accurate diagnosis. If they’ve been to the top five specialists in the country, there’s not much I can do. You just have the problem with people’s expectations. There are people who want drive-through medicine. They want everything fixed and they want it now. Some of them get upset. I empathize with them. I’ll say, “You appear angry or frustrated, but my job is to take care of life threatening crises and to take care of your pain.”

NE: I was once in a minor car accident
and I thought that the diagnostic tests in the ER were way over the top. Is the extensive testing because of liability? Do you feel you have to go beyond what’s necessary?
ER Doc: You try not to, but it happens. You might think it’s over the top, but there’s usually a good reason for the tests. People will ask for this or that test and we always listen. Munson administration is all about patient satisfaction, so we try to explain why we’ve decided on a particular test. Sometimes their expectations are not in line with what they really need.

NE: What have you learned as an ER doctor?
ER Doc: A lot of times, people land in the ER when their life has hit a wall—a milestone crisis and they have to make a major change. A 90-year-old who has been living at home and getting along fairly well, and has a gradual downward slope: loss of appetite, balance is off, loss of memory, what we call the major dwindles. Some of it’s reversible and they may go home, but not always. From the ER, they might go to the hospital and maybe to an assisted living or a nursing home. On the other hand, I just took care of a 94-year-old; he takes no med and is really mentally and physically with it. It was great to see.
You do get the cases like you see in the ER show—the life or death decisions you have to make in a split second. The bad car accident—the heart attack, the heart rate of 200. But it’s nothing like TV. For example, you’ve got loads of paperwork—you never see that on TV.

NE: Do you have a good relationship with the police?
ER Doc: Oh yes. They’re here all the time. They come in with a car accident or violent patients, and they’re very helpful. Camp Pugsley brings in a lot of folks, and the prisoners are actually very pleasant, “Thank you ma’am, no thank you ma’am.” I never ask them why they’re serving time; I don’t want to know. Of all of them I’ve seen, only one has sassed me back.
And I don’t tolerate a potty mouth. I tell anyone who starts to use foul language, “We don’t need to hear that. There are children around and other patients around.” If they talk like that, I’ll call them on it.

NE: What’s the ER like during the National Cherry Festival?
ER Doc: Fairly busy. It’s a pretty big holiday. You see the same things as you do year round, but it intensifies. We see a fair amount of car accidents, more lacerations and broken bones. More water-related injuries; we haven’t had a drowning for a year or so. Of course, it’s summer, people are on vacation and drinking alcohol, so that often plays a part.
We still have the same staff, but we’re limited with the room–that’s why we’re getting a new ER. Yes, the wait’s longer for the minor stuff because the major stuff has increased by 25 to 30 percent. Do we beef up? As much as possible, but you can only beef up so much with the amount of room we have. Radiology gets hit pretty hard during this time because you see more bone injuries.

NE: Speaking of radiology, I heard that Munson is faxing its X-rays to India.
ER Doc: At night, that’s true. If we need a basic read of an X-ray at night I’m not sure which country or state it is. Either the ER doctor reads it or it gets faxed via teleradiography to an expert radiologist and a report comes back usually within 20 minutes. For the more complex cases, we’ll call a radiologist to come in. It’s more cost effective than keeping a radiologist on the whole night. It works fairly well. Isn’t it interesting what part of the world is looking at your bones at 2 o’clock in the morning?