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ER a profit center?

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sisoon posted 5/7/2013 18:23 PM

Friday, 9 PM, my W notices her vision is impaired - big blockage in the center of her vision with some flashes, maybe left eye, maybe both. She calls our telephone nurse who directs W to ER.

Resident does his diagnostic protocol, uses an ophthalmoscope and it doesn't look like a detached retina. W starts to feel a headache.

Res diagnoses migraine, based on history of migraines when W was young. Attending comes in, does her thing, goes away, comes back, says she's 99% sure it's an atypical migraine, but she recommends cat scan.

It's late; I'm tired. I ask if this is a CYA recommendation. Doc says it isn't. W agrees to the test, Attending goes away. We discuss.

Res comes back. We ask if it might be wise to wait on the cat scan. Would it be reasonable for W to see her GP on Monday? I actually asked the res if he would recommend the test be done in the ER if it was his mother and she was paying for it. He never answered, though he said it was a great question. (Of course, we'd come back immediately if symptoms get worse. We live about 1.5 miles from the hospital, so we can get there pretty quick.)

Res says we could wait on the cat scan. He goes out and asks the attending, who agrees.

We then have to wait 50-55 minutes before W gets discharged! The ER wasn't busy - ate least 4 people were sitting at desks reading.

Was that wait because I pissed off the attending with my CYA comment? Or is it normal? Or is it that the ER has to generate bills for their diagnostic equipment? I expected the discharge papers to include a statement that W was rejecting the doc's counsel, but there was nothing like that at all - just a eco to call her GP and a sheet on handling migraines.

The care seemed great, BTW, with very little wait for the care.

Our insurance is very good, though not as good as it was a few years ago, but I think overusing the benefits is wasteful....

Thanks in advance.

[This message edited by sisoon at 6:25 PM, May 7th (Tuesday)]

Mama_of_3_Kids posted 5/7/2013 20:16 PM

The problem is that if they would not have offered to do the CT and it would have been a stroke, they would have been liable, even if they were pretty sure it was just a migraine. A 50-55 minute wait, even if they didn't *appear* to be busy is actually pretty common for discharge. As far as any statements declining the CT, it wouldn't be on the DC paperwork, but it is probably charted somewhere, because again, they have to cover their butt.

Imo, it was not at all wasteful, just protocol. There are too many people that use the ER as a primary care physician and others who see everything as an opportunity to sue, so they have to have certain protocols set in place. While 50-55 minutes for DC seems like a wait, really, it's not that bad; we go to one of the biggest ER's in the state and there have been times where it has taken up to two hours for DC paperwork (after we've been seen) and to the non-medical person it would appear that they aren't necessarily busy (I'm an RN, so I know they probably *are* but it's a controlled chaos) and while *some* of the people may not be busy *some* are (example, there may not be anyone checking in at a set time, but the nurses and Docs may be running their tails off with patients).

metamorphisis posted 5/7/2013 20:23 PM

sisoon, those are some troubling symptoms and could have been indicative of a stroke. If they had sent you home and your wife had in fact had a stroke I doubt you would be asking these questions. What are they to do? If they miss something.. they are to blame. If they do the tests necessary to rule out something serious, they come under suspicion. I just don't think there is an easy answer here and I'd far prefer to hear she was thoroughly examined and taken care of than inadequately treated and harmed as a result.

sisoon posted 5/7/2013 22:21 PM

Thanks for the info, Mama. It helps.

I don't have a problem with the CT scan reco - I absolutely understand they have to suggest it and offer us the option, and no one tried to pressure us.

The res said the scan wouldn't show a stroke unless the stroke hit 6 hours earlier, and we were still under 3 hours from the first symptom.

purplejacket4 posted 5/7/2013 22:55 PM

Complex migraines and early strokes often look exactly the same. In my ER they would have gotten the CT, browbeat you into an admission and done an MRI in the morning. I know this because I admit patients like this All The Time.

The hole in the vision is called a scotoma. Feel free to look it up. And a discharge finished in less than an hour?!? Wow you must be living life right!

StrongerOne posted 5/8/2013 00:09 AM

55 minutes is pretty fast.

People sitting around reading may not be the people who are in charge of processing the discharge paperwork. Also, it may not look like many people are there, but it's quite possible that there are folks already being seen. We typically spend 4 - 5 hours for my son's ER visits, so plenty of patients may come and go and never know we are there.

Pentup posted 5/8/2013 06:26 AM

Myself, I would not have left that ER until that cleared up or I had a CT.
Hope your wife is doing well this morning.

[This message edited by Pentup at 6:29 AM, May 8th (Wednesday)]

StillGoing posted 5/8/2013 06:48 AM

I doubt the doc even thought the CYA comment was offensive at all. An ER is generally inefficient because by its nature it puts everything non-emergency on a low priority and there tend to be constant high priority interruptions. The inefficiency of 4 folks sitting around isn't related to your part in the process really. As my wife pointed out it's also hard to tell what's going on behind the scenes. Unless someone is screaming hysterically the ER staff in hospitals are usually calm and orderly and it looks nothing like the hasty commotion in a TV show, so someone being rushed into a room because he sawed his leg off with a lawnmower is probably going to be just as routine as your wife's visit in many ways because you're both in the ER.

ERs are never profit generating as far as I can tell. They have to deal with so many brands of insanity and obnoxiousness that they're destined to lose money. If there's anyone with a profit motivation for an ER visit it's the insurance company in the middle making everyone miserable.

Mama_of_3_Kids posted 5/8/2013 06:58 AM

Unless someone is screaming hysterically the ER staff in hospitals are usually calm and orderly and it looks nothing like the hasty commotion in a TV show, so someone being rushed into a room because he sawed his leg off with a lawnmower is probably going to be just as routine as your wife's visit in many ways because you're both in the ER.

Yep, controlled chaos. It takes a special kind of person to be able to work in an ER...there's no way I could do it. They know how to make the situation look and feel calm, even if it's chaos.

ERs are never profit generating as far as I can tell. They have to deal with so many brands of insanity and obnoxiousness that they're destined to lose money. If there's anyone with a profit motivation for an ER visit it's the insurance company in the middle making everyone miserable.

Word!

Skye posted 5/8/2013 07:06 AM

I do believe ER's are not a profit center--at least 20 years ago when I worked in hospitals they weren't!

I don't know how old your wife is but a few years ago I had something similar and was admitted for a few days. Fortunately, what they were looking for wasn't the issue. I asked my own doctor about all the tests, etc., and she explained that at MY age, the treatment I got was standard. If I had been 25 years younger, they wouldn't have done the same type of tests. Did she have to remind me how old I am??

trumanshow posted 5/8/2013 07:31 AM

I always tell a patient with a discharge order that it will be at least an hour

[This message edited by trumanshow at 2:55 PM, May 8th (Wednesday)]

jo2love posted 5/8/2013 11:45 AM

How is your W feeling? Has she seen her GP?

sisoon posted 5/8/2013 19:26 PM

Thanks for your concern and feedback. W saw her GP and has an apt to see an ophthalmologist and will have a cat scan.

She slept decently Friday nite and felt much better Sat AM. We had a good weekend - Shabbat services and lunch with friends on Saturday, a concert on Sunday.

A little clarification...the visual symptoms resolved into a headache while we were in the ER. The headache actually started as we were on our way to the ER.

One of the reasons we rejected the scan in the ER is that the exam was pretty thorough, and everything checked out normally (eye, limb strength, neurological stuff, etc.). Everyone who talked to my W was caring, helpful, and confident. They seemed competent, and I'm confident they were. I have every confidence that if they thought my W was in immediate danger, they would have been more assertive when we when negative on the scan.

I'm sort of sorry if asking about CYA wasn't offensive. Among others things, it's a really stupid question - there's only one answer you can give to it.

I always thought ERs have to be inefficient in a business sense; otherwise they can't respond when a whole bunch of emergencies occur at once. So I didn't really think hospitals look to ERs for profits but I had to ask.

jo2love posted 5/8/2013 20:01 PM

I'm glad she is doing ok. Please keep us updated.

JanetS posted 5/8/2013 20:09 PM

I'm very concerned about the "potential" of a detached retina, and here is why.

My best friend had headaches, and flashes and spots. She made an appt. with her opthomologist, and was given an appt. for a Friday. Got a call Friday delaying it till early the following week. Then they called again and made it even later.

By the time she went to the opthomologist, he said "go to the hospital immediately...don't even go home...I will call ahead".

Well, her detached retina became More detached over the delayed appt. God Awful painful appointments. Months of "face down" therapy (in a special chair and could only look up for eye drops...even had to sleep face down in a special pillow. Watched tv via a mirror on the floor.

Now almost 2 years later her eye still looks bad. Her vision is still limited (esp. her peripheral vision). She did not drive for over a year...and even now is terrified on the highway.

The delay cost her a lot. She feels dependent on her husband and others. So, if there is any doubt if a detached retina is involved, then get her to her opthomologist immediately.

sisoon posted 5/9/2013 18:40 PM

Thanks, JanetS.

W is watching this closely, and I'm keeping track, too. The ophthalmologists around here respond very quickly to emergencies, so if she has more flashing or vision obstructions, she'll be in pretty good shape for getting care quickly.

Especially at our age, we don't mess around with head or eye issues. At the same time, some things that appear to be emergencies turn out not to be very serious, and that's how this seems to be turning out (for which we are both very grateful).

Our son gets migraines, and it also turns out that her symptoms are how our son experiences migraines.

roughroadahead posted 5/9/2013 19:27 PM

WH was an er manager. I can assure you they're not profit centers! Nothing can throw an entire hospital into the red faster than opening or upgrading a trauma center.

A few years ago, WH worked in a hospital attached to a university, but located in a pretty bad neighborhood. Cars would occasionally pull up near the ambulance doors, kick out someone likely bleeding and unconscious then speed away. EMTALA demands that they are treated and stabilized, regardless of ability to pay. Large hospitals end up eating a lot of that cost.

Glad your W is feeling better!

roughroadahead posted 5/9/2013 19:27 PM

Phone posting strikes again

[This message edited by roughroadahead at 7:29 PM, May 9th (Thursday)]

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