CYA and Healthcare Reform

Ok, so I know that I haven’t written a post for some time now and you are about to understand why. About one month ago, my dad called me to tell me that his primary care doctor had instructed him to go to the ER immediately because his routine EKG showed a change from last year. She had in fact stressed him out to the point of probably giving him a heart attack with her behavior which included wanting to call 911 to take him directly to the ER from the clinic.

Was he having symptoms (chest pain, shortness of breath, diaphoresis, decreased exercise tolerance)? No. In fact, he felt totally normal. Was he having ST elevation or depression on his EKG (findings typical of heart attack or diminished blood flow to the heart respectively)? No. He had “nonspecific t-wave changes”. Were his vital signs concerning? No. His blood pressure was 128/72, heart rate was 88. So why call 911? Because the primary care physician wanted to practice CYA (cover your arse) medicine.

For some reading this post, the term CYA medicine might be something of a novelty. Certainly one never sees Dr. House, MD or Dr. Cox from “Scrubs”, or even Dr. Green and Carter from “ER” practicing this type of medicine. What exactly is this type of medical practice?

It basically involves the most limited degree of mental commitment possible in a medical encounter, where you are asking yourself only one question, “How can this patient hurt me later?”.  Based on the medical provider’s answer to that question, they then proceed accordingly. It doesn’t matter how much this will cost the patient – insured or not. It doesn’t matter how many needless tests you have to order at the patients physical, financial and emotional expense. It also doesn’t really matter if the patient agrees with you or not, especially if they are insured – because you can always threaten them with an AMA (against medical advice) discharge where their visit will not be covered by their insurance. They are your prisoner so you can strategize your defense from a medical malpractice lawsuit.

As an ER physician myself, I cannot always blame providers who practice medicine this way. I don’t believe that anyone graduates residency intending to practice medicine this way. Its after someone comes after you for something only God could have forseen that you get gun-shy. At the end, it becomes a vicious cycle of abuse from both ends.

This is the biggest problem with Healthcare reform – the hidden nooks that politicians can’t see the way we, as healthcare providers, see them from within. There are too many groups mining in the medical gold mine – malpractice lawyers, insurance companies, drug companies, etc. – and they each have powerful lobbies to back their interests. The purity and simplicity of the doctor-patient relationship with all that it used to contain of trust, friendship, understanding and forgiveness has been plundered and I personally am not sure we can return to that after having let in the greedy pirates mentioned above.

So, back to my dad. He asked me to come with him to the ER – in my car and not the ambulance – to make sure they didn’t rape him there with unnecessary tests and procedures. He had me stand behind the ER provider who was practicing CYA and give him thumbs up or down depending on whether I agreed with the management or not. They of course told him that he could die if he wasn’t admitted for “further testing”, but he did just fine at home until his next follow-up appointment.

Top Three ER Patients that Make You Go Hmmm

Anything but the needle doc

I have had this post on my mind for quite some time but it has come to the forefront due to some of my recent patient encounters. There are certain things in Emergency Medicine which are so strange and become even stranger because of the fact that it seems they are found in all other emergency rooms. Its kind of like someone getting a 1500 calorie fastfood meal and then ordering a diet coke – it doesn’t make sense and yet people everywhere seem to do it.

The first type of patient that causes many of us to just wonder – sometimes out loud – people with multiple tattoos, usually very large ones at that and often with the added variety of body piercings, who refuse to get a shot. Why you might wonder? Because they say they don’t like needles. It makes us wonder if their tattoos were painted on with a brush or maybe the kind you get out of a bubble gum machine. Piercings though – that’s like having a 10 guage needle stuck in you repeatedly – and often in some very sensitive areas as well. For the non-medical out there, we use needles that are at least half that size and sometimes only one third.

The second patient group that leaves us scratching are heads are those that come in with “vomiting”. This group is often divided into two categories: the truly sick and those who aren’t. Those who aren’t sick baffle us because they routinely insist on vomiting on the floor even though typically the waste basket or vomit-bin/bag/etc is literally within easy reach. I used to think that such people would never do such a thing at home, but after doing some EMS ride alongs and seeing some of the conditions that some people live in, I understand that they probably just vomit on their own floors/couches/chairs/etc as well.

As for those who aren’t so sick, its amazing how often they come in complaining of nausea while they munch on Doritos and drink some nasty grape soda or other carbonated sugar poison. One day I’m just going to lose it and tell them that maybe if they weren’t treating their stomachs like toxic waste dumps that they wouldn’t be nauseated. But usually, I just take the polite road and encourage them to do a bland diet for a few days and that they will likely feel better.

The last group that comes to mind – although their are a few others out there deserving of mention – are those that come in with a complaint that just started. “I have a sore throat”. How long have you had it? “Oh, it just started about 30 minutes ago”. Or, “my child has a fever”. When did it start? “I just checked their forehead 20 minutes ago and it felt hot so I rushed him in”. Granted if the patient has some extreme history, like they had epiglottitis or febrile seizure, I would certainly understand and do my best to reassure them – but come on.

Creepy Love and Other Relationship Oddities of the Week: I

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From time to time in the ER, we have the unfortunate experience of seeing relationships so foul that they can only be called “creepy love” as a nurse so aptly put it one night. It is just the sheer volume of people that we interact with that necessitates, to some degree, that we see all sorts of oddities. To narrow it down to just a few is so hard that I decided this would only be one part in a mini-series. Prepare to be horrified.

Creepy Love #1  goes hands down to a mother and son team that came in last night. The son, a young man of 19 years, presents with mom because his testicles hurt. Ok, nothing weird so far. Before I go in the room, I see mom step out as he gets gowned, something totally expected. I figured she would stay in the waiting room till he got discharged. Wrong.

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As I start the exam, Mom returns. I tell her from behind the curtain that we are about to examine the private area and if she would be comfortable returning later. To my surprise, they both – almost simultaneously – say no. So, she comes back to watch me examine her boy’s family jewels.  Afterwards, we come to the a set of questions of what he was doing when his balls started to hurt.  I am totally amazed as he goes into a detailed description – again in front of Mom – of how he was making out with a girl for “a really long time” without hitting the pay-off at the end. So, I told him that most likely he was suffering from a case of  ”blue balls” – or testicular vasocongestion in medical speak. 

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Mom very creepily laughed at this point and told me that this is what she had suspected as well. I thought to myself, “If she starts talking about how this kid’s Dad used to get blue balls when they were still a fledgling couple – I am outta here!”  Usually young men cross the – Mom, “this is kinda private” – line around 15 years old. 16 wouldn’t be weird. 17 is pushing it. College age is already weird. But 19 going on 20 is just creepy (this guy is about to start junior year in college).

 

Creepy Love #2: Young woman – 25 years old – presents to the ER after having a fall the night before when she was plastered. There is a gentleman (used very loosely) in the room with her who appears to be in his 50′s. I’m thinking Dad, but I learned a long time ago to not assume anything in this area (We’ve all been there before – “So, this must be your Mother right?” Patient’s wife replies in a very insulted tone, “Mother? I’m his wife“. Ohhh - can the Earth please open up and swallow me now please).

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So, I casually wait for a moment to ask the man, “And you are?”. He replies that he is a “good friend“. Another lesson that I have learned is that “good friend” can also mean any one of many things. Apparently, Mr. Good Friend was with this young lady at the bar last night and drove her home. So, I’m thinking maybe he lives on the same street – saw his neighbor trading sober for hammered and kindly offered to take her home. No, that would be too normal. This was all about the creepy.

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So, since she had fallen in her less-than-sober state, I needed to check certain areas of her that were still clothed. I told her to get gowned and that’s when the creepy-meter hit red. I walked out of the room to let her get undressed – and he didn’t.  Now I know you’re thinking, it isn’t necessarily weird for an older man to date a younger woman less than half his age, and that in some ways it can be totally socially acceptable. Believe me, this wasn’t one of those cases.  

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The last couple for this post wasn’t a creepy one at all, just a sad one. 55 year old man comes in with chest pain. There is a woman with him who looks like she fell from the ugly tree and hit every branch on the way down as well as ate bark. But I really do believe that beauty is partly from within and not only skin deep – so I really didn’t think much of it. Until I started the interview.

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Everytime this guy would try to answer a question, this woman would literally scream at him and say he was lying. Then she would tell me something else. He didn’t seem to fight it, so I could only assume she was right. It was more typical of the way an angry mother would correct her delinquint son, but this was husband-wife dynamics.

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When we got down to the social history, the guy turned out to be a regular drinker. Imagine that. I mean, who wouldn’t want to be sober to deal with a delightful woman like her everyday? To understand this dynamic better, I researched the net and found this interesting article: Top 10 Signs She’s a Bitch. Oddly enough, the first comment to that article was written by a man who called himself F@&k Me who wrote: “what happens when you’ve been married to one for 17 years, and just can’t take it anymore?”. I guess my patient was asking himself the same question everyday as he cried into his drink.