Medical Tuesday Blog

I Want To Know What’s Wrong With Me: NOW

Jul 22

Written by: Del Meyer
07/22/2016 3:14 AM 

The vast majority of medical emergencies are really not emergency conditions. I first learned this when I entered private practice at age 35 having completed all my post-doctoral work, residency, fellowship, and two years in the Air Force, all of which had very structured responsibilities. In private practice, patients call me instead of just showing up in the Emergency Rooms. The call was normally from a family—perhaps a daughter or wife reporting that the father or husband passed out and they were on the way to the emergency room. In my early years, I would get in my car and head for the hospital. After all, they said they were on the way to the Emergency Room.

When I got there, they had not arrived. After waiting for half an hour or more, I frequently called the patient to find that they had not left the house. Well, how is father or husband doing? He’s resting comfortably and the ambulance is on its way. After another 30 minutes and no patient, I would normally make another call after which I learned the ambulance had just left.  When the patient arrived finally in the ER, he was alert, oriented, with normal vital signs—blood pressure and pulse. His neurologic exam was unremarkable with no evidence of a stroke. Electrocardiogram was normal and the tests for a myocardial infarction were negative.  He stated he had not had any chest pain and didn’t understand why his daughter or wife was so concerned. He wanted to go home to which I agreed. Stopping the cardiac evaluation after the basics saved considerable health care costs. The costs were approximately $6,000 in hospital charges for the basic screen I did.  To have proceeded to the Chest x-ray, ECHO cardiogram, etc. would normally have been $9,000, the standard ER charge in my hospital for a complete cardiac evaluation. The insurance company declined to pay me for my 4 hour ordeal stating it was not really an emergency. I couldn’t disagree. I could have accomplished the same evaluation in 30 minutes in the office for a $125 office call, which is what they eventually paid me for my four hours of night work they felt was unnecessary on retrospective review of the hospital chart.

Over the 45 years in practice, I’ve found that the majority of emergency room visits are the result of an anxious family member. They wanted the answers NOW. They didn’t want their father or husband to die, especially at home. The skill is being able to allay the families concerns and not add any medical risks.

But father or husband in this case was not in danger of death. As soon as they had him rest on the couch, he was awake, talking, and felt fine. The best care would have been to let him rest, take his blood pressure and pulse, sit with him for an hour or so and then put him to bed.

So it didn’t take me long to understand that when an emergency call came in, I would wait 10 minutes before calling back.  By that time the family agreed there was no emergency, that the father felt well, and decided to simply let him sleep.

The other variable was when we had guests and when the phone call arrived from the answering service. All eyes were upon me. They wouldn’t let go. The eyes told me, “Why are you not running to answer the exchange? Why aren’t you getting into your car?”

I tried to settle my guests explaining that I needed to let the family settle down. Responding after 5 or 10 minutes, there was a more informative discussion in which I could access if an emergency did indeed exist. By then the family realized there was no impending death. Then if the decision was to take him to the ER, I would wait until I got the call from the ER which immediately evaluates all arrivals. Then I would get an informative message of the medical status, whether my patient could be sent home, or needed admission. If he needed admission, I could be there within 10 minutes and proceed with the complete physical evaluation, order the appropriate tests for the next morning, and rest assured that all basis are covered.

This allows the practice of medicine to flow skillfully and smoothly with minimal stress on physicians—and at the highest quality of care.

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