A little bit of a meltdown

[thegenius]

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Defined by who? I would consider 1-2 times per month but now that’s just semantics. We may have one patient in the entire system that averages out to >1 visit/week and she’s neither Medicaid or self pay. Nonetheless, it sounds like you don’t have the data to back up your 90% claim.

Edit: It's tough to find good data but slide 7 of this presentation () gives some info. I can't find the original paper (Hunt 2006) but this quotes that 86% of what they define as frequent flyers have insuranace and "more commonly have Medicaid (53% vs 39%) or Medicare. So, my numbers are likely a little off and your 90% number is likely incorrect as well.

Defined by me. I made the definition of ED Abuse frequency.

But if you want to define it as 2x/month...it's still people who don't see the bill nor make a copay.

My copay is $250 to go to the ER. If there are others who have similar copays they are NO WAY COMING TO THE ER 2-4x/month. You can't get realistically rich in this country being chronically ill, unless you are born into wealth or inherit it.

 

[thegenius]

I think it’s impossible to practice EM without eventually getting this way, once in a while. I’ve been there.

It's like this in every field. I had one bad fuucking day. A single bad day. All the other 364 days I'm fine and these patients I have a very neutral interaction with them because they are easy dispos.

Cardiologists have bad days.
Anesthesiologists have bad days
Oncologists have bad days.
ENTs have bad days.

I'll say this:

- it was 100% not right for that mom to bring in her daughter, after having a fever for 2 hours, to the most expensive place on this earth for an evaluation. If she is going to live in America then she has to learn how stuff works here. It's not "her fault", she wasn't malicious, she wasn't malingering, she isn't trying to game the system. But I contend that there are better trained doctors for a 2 hr fever in a well child. I would also contend that she has pretty poor general knowledge about health and it's embarrassing but she is a product of whatever educational system she grew up in and her culture. It's NOT HER FAULT.

- ER's in hispanic countries like Mexico and central america cost money for all patients. Mothers who have a daughter with a fever for 2 hours don't go to the ER's in Mexico because it COSTS MONEY. They usually go to the pharmacy and the pharmacists recommends tylenol or an antibiotic or whatever

- FREE SHIIIT IN SOCIETY IS ABUSED! 100% why is that so hard to believe

- it is 100% our job to educate people on the appropriate use of the ER. It's 100% our job to tell them what we are capable of doing. I think it should be done non-condescendingly, and I admit that on that day I was kind of a jerk to both those patients. But I ALWAYS EDUCATE people on what we do in the ER. All the fuucking time. Because I don't work up a lot of their nonsense even if the PCP's send them in.

- There are people who abuse the ER and they need to be called out

- There are people who don't know any better and come in for dumb stuff and we should politely teach them what the ER can and can't do. There is no shame in that.

- We TEACH AND WE EDUCATE PEOPLE ALL THE TIME.

- It used to bother me to write tylenol Rxs...but as I've matured now I don't care. it takes 5 second for me to write one. If a mother or father wants to wait 4 hours in an ER to save $5, then fine.

- I philosophically am at odds with others who think the ER is the safety net for all the uninsured, forlorned, homeless, etc. It is my job to render EMERGENCY CARE and not HEALTH CARE to the uninsured. It's not my job to figure out how homeless is going to afford, acquire, or dose their insulin. If the government wants ERs to do primary care for the uninsured...then the US government can talk to the ER RRC to change how we are trained, or pay us to do it, or they can eek! pass a law that ERs are supposed to deliver primary care to anyone who comes into the ER.

- THERE ARE FREE CLINICS for MEDICAID patients IN THE SAME CITY THAT I WORK. Free!



Lastly...

---- all of you people out there...have you ever had a teacher growing up who just once got really frustrated with you? Just once? Like in 4th grade math, 8th grade social studies, or 11th grade history? JUST ONCE?

 

[miacomet]

<vent>

I had two small meltdowns in front of patients the other day:

1) mom brought in her 2 yo daughter because of fever for 2 hours. That's it. She felt hot at home. Temp was 100.9 in ED. Everything is normal. After I looked at the daughter for 5 seconds, listened to lungs for 5 seconds, pushed twice on the belly, I spent the next 7-8 minutes using the Google Translate app from English to Spanish explaining how this isn't the right use of the ER, nobody in their right mind is going to workup a fever for 2 hours, she is fine, and loads of other stuff. I remember saying "no child in the history of mankind has died after having a fever for 2 hours". then i said "Seriously! Maybe once like 200 years ago. 1 child died right after having a fever for 2 hours." Then I said "There is no doctor that is going to workup a fever for 2 hours." "There is nothing to do." Then I said "I will only consider trying to figure this out if she has a fever for 5 days." then I quipped "Do you understand what I'm saying?"

She said "yes".

I left the room. I think Mom was upset with me.

2) 45 yo woman comes in with epigastric pain for 45 minutes. It resolved prior to coming to the ER. Every vital sign was normal, and her exam was normal. The description was such that it was either hepatobiliary or gastric, not cardiac. Nonetheless the EKG was normal. I wouldn't have even ordered labs but they were ordered by triage. Normal. I again spoke to her (and her son translated from English to Spanish) that she must have made an immediate decision to go to the ER the moment she had this pain because it takes time to drive and come to the ER. Did she bother taking any meds? Did she bother to say "maybe I should just wait and see what happens?" 98% of all doctors are out in the world, not in the hospital, and you need to see them. They are there for a reason. The hospital and ER are only here if you are dying. Literally dying like you are in a car accident and there are bones sticking out of your body. Or if you are unconscious. If you are unconscious then I hope you get yourself to an ER and get treated for that. There are 100 things that can cause her transient upper abdominal pain and I'm not going to do anything about it because it went away. I can't test for all of these 100 things. Honestly next time this happens take some tylenol and motrin and lay down in bed. Just wait a little bit. then I said "I'm not trying to be dismissive here...but no doctor is going to do anything about having pain for 45 minutes that just goes away."

</vent>

1. This is a violation of CMS rules- get a certified translator, it's the law. Maybe something really serious was lost in translation. Poor translation can kill people. That's why there is a law. So follow it.

2. Clearly you don't work anywhere that cares about patient satisfaction, which is awesome!

3. Do you have an issue with Spanish speakers? Because if you do, please leave EM or work somewhere without Spanish speakers. Anyone who needs a translator is higher risk, and plenty of patients have serious medical conditions missed due to poor communication.

4. People are allowed to use the ER for any reason. You may not like it. But they are. You can do whatever work up you want and send them away, but these folks aren't torturing you, they are seeking care. You are punching down, and it's not OK.

If you did any of these things at my job, you would be shown the door, especially not using a translator.

 

[Arcan57]

This guy will make a great Team Health site director one day.

If you're not in it, it's kinda hard to believe how much being able to fire "problem" docs at will is a selling point to the hospital.

 

[Arcan57]

I think it’s impossible to practice EM without eventually getting this way, once in a while. I’ve been there.

Trauma makes us act in ways we wouldn't have acted before being traumatized. Moral injury is traumatizing and there are parallels to CTE. There's a lot of research on big dramatic events and how they change people (PTSD, etc). These are the identifiable TBIs of moral injury. Pt's dying because we weren't good enough, being physically assaulted by a patient, children dying, etc. Even if we're still crap at supporting people dealing with these injuries, at least we mostly recognize that an injury has occurred.

I think "burnout" is going to end up being identified as something akin to the repetitive subconcussive trauma that underlies a lot of CTE. We often don't recognize the trauma because it stops feeling traumatic and just becomes "this is what working a shift is like". The patient that you hear moaning in pain for 45 minutes after the first time you reminded the nurse you ordered pain meds, being pulled away from critical tasks to deal with nonsense that someone else decided to throw kerosene on before getting you involved, the patient that you send out into a dangerous night because there's nothing else you can offer them. All that trauma adds up, and the more it accumulates the more things become traumatic. Kinda a central sensitization thing. And all the sudden you're on the Internet ranting about something that is absolutely f$%#ing up your life and people are staring at you like you're the [email protected]

I wonder if someday we're going to have baseline emotional testing the way we have baseline cognitive testing. It might be nice to have a way of identifying that you're on a downhill slide that's not your partner leaving you, getting fired or sued, picking up a DUI, or figuring out the best way to suicide.

 

[turkeyjerky]

1. This is a violation of CMS rules- get a certified translator, it's the law. Maybe something really serious was lost in translation. Poor translation can kill people. That's why there is a law. So follow it.

I fully agree with you. However, I just wanted to mention a recent experience of mine. I needed a spanish translator at 2-3 am a few weeks ago. The patient was there for some utter BS, like a runny nose and a covid test or something. We a use a video interpreter ipad--pulled it into the room and while it was dialing examined her and got enough history using my broken splanglish to tell she was fine. Wait 15 min in the room awkwardly (by this time had switched to the phone version for faster response). Then I walk the thing back to my desk, still on hold, write my note and dc instructions up so I can do it all in one go. Still on hold, I drop the thing off at the charge nurse's desk, ask her to overhead me when they pick up and go see another patient or two. I think it was a 45-50 min wait, all in. For like a 30 sec conversation.

 

[thegenius]

I fully agree with you. However, I just wanted to mention a recent experience of mine. I needed a spanish translator at 2-3 am a few weeks ago. The patient was there for some utter BS, like a runny nose and a covid test or something. We a use a video interpreter ipad--pulled it into the room and while it was dialing examined her and got enough history using my broken splanglish to tell she was fine. Wait 15 min in the room awkwardly (by this time had switched to the phone version for faster response). Then I walk the thing back to my desk, still on hold, write my note and dc instructions up so I can do it all in one go. Still on hold, I drop the thing off at the charge nurse's desk, ask her to overhead me when they pick up and go see another patient or two. I think it was a 45-50 min wait, all in. For like a 30 sec conversation.

I get intrepertors for any language if the conversation is important or the patient is very sick. ALWAYS. And i spend 20 minutes in the room with the patients. I'm in the top 25% of patient satisfaction in our group. Nurses LOVE me becuase I talk to patients more than most other docs.

But I happen to know enough spanish to get by on some medical stuff like chest pain, abd pain, some infectious symptoms. and sometimes I supplement with google translate. And yes..I'm aware that Google Translate may not be sufficient if it were brought up in court. but what would happen to patient satisfaction if i had to get a translator every single time? it would tank because the waiting time would be 4-8 hours.

This isn't directed to you @turkeyjerky, and guess what? I am hispanic. Patients get frustrated and surprised at me all the time for not knowing enough spanish. They've been in this country for 20 years and don't want to speak english, and get mad at me becuase my last nane his hispanic and my spanish isn't that good. I have nothing "against" hispanic people and some of them are very hard working. like they will cut their finger off at work and want to go right back to work! I love that! I do everything i can to help them. But the hispanic panic is real, it really is real.

 

[miacomet]

I get intrepertors for any language if the conversation is important or the patient is very sick. ALWAYS. And i spend 20 minutes in the room with the patients. I'm in the top 25% of patient satisfaction in our group. Nurses LOVE me becuase I talk to patients more than most other docs.

But I happen to know enough spanish to get by on some medical stuff like chest pain, abd pain, some infectious symptoms. and sometimes I supplement with google translate. And yes..I'm aware that Google Translate may not be sufficient if it were brought up in court. but what would happen to patient satisfaction if i had to get a translator every single time? it would tank because the waiting time would be 4-8 hours.

This isn't directed to you @turkeyjerky, and guess what? I am hispanic. Patients get frustrated and surprised at me all the time for not knowing enough spanish. They've been in this country for 20 years and don't want to speak english, and get mad at me becuase my last nane his hispanic and my spanish isn't that good. I have nothing "against" hispanic people and some of them are very hard working. like they will cut their finger off at work and want to go right back to work! I love that! I do everything i can to help them. But the hispanic panic is real, it really is real.If

If you are not a certified translator, you are in violation of CMS rules, and frankly, unless you are fluent, you have no way of knowing if you miss something important.
I-pad translators are ubiquitous in most hospitals. I've never had to wait more than a couple of minutes. Unless all your nurses are fluent, they should be triaging with your translator system. Administration knows this, they need a better translator service if it's that cumbersome.
You honestly have some issues here- Hispanic panic is a discriminatory term. Plenty of people panic, including white people, we just give them a pass.

 

[namethatsmell]

I'll prance into the thunderdome offer this: the ED is the great mixing bowl where healthcare

meets "public safety" meets politics meets the court of public opinion meets corporate greed.

What rational person thinks these various "stakeholders" would mix particularly well?

So the gaslighting begins by simply showing up for work in ~80% of ERs in the country, where there's around a 0% chance to fully meet the expectations of these various interests that have sunk their claws into the ED and try to assert their dominance on us. We all know we're not there to feed these birds and we can say we don't care...but when you're made the scapegoat or made to hold the bag for the utter failures of a clownshoes "system," it's totally natural to snap/lose one's cooler/emote at the irrationality of it all.

Be kind to yourselves. The job is hard. We need you. As a BCEM you do a job that literally nobody else can do, including the non-clinical muppets that try to tell you what to do and how to act. The patients aren't perfect, and none of us are perfect either. Well, except for those of us who struggle to decide if Arby's or Taco Bell is the superior widely-available fast food chain...for to struggle with that question is to dance with the gods. But everybody else isn't perfect.

 

[thegenius]

If you are not a certified translator, you are in violation of CMS rules, and frankly, unless you are fluent, you have no way of knowing if you miss something important.

Incorrect. Categorically.

 

[thegenius]

If you are an ER doctor and "know" a foreign language, are you certified to have a medical conversation in that language?

 

[Mount Asclepius]

I speak Spanish very well. Not fluently, or even almost fluently (high bar to that claim too in my opinion), but very well. I occasionally have to correct the video interpreter or have them clarify with the patient when I think they are wrong. All that being said, I try to use their service as close to 100% of the time that I can. I don’t know if there is much medico-legal risk, but I don’t want to take that chance. Not too infrequently, I also find them helpful. If all the iPad on wheels aren’t lost somewhere in the ED, then the most time I usually have to spend waiting for them is a few minutes for it to fire up and for them to collect identity information. It’s not that big of an inconvenience. Sometimes non-Spanish speaking staff will fire it up for me as they triage the patient, then come get me as soon as they’re done with it all ready to go. I’ll circle back with patients and not use the interpreter for every conversation, but I feel it’s worthwhile to at least put in the chart once that an interpreter was utilized.

 

[miacomet]

I speak Spanish very well. Not fluently, or even almost fluently (high bar to that claim too in my opinion), but very well. I occasionally have to correct the video interpreter or have them clarify with the patient when I think they are wrong. All that being said, I try to use their service as close to 100% of the time that I can. I don’t know if there is much medico-legal risk, but I don’t want to take that chance. Not too infrequently, I also find them helpful. If all the iPad on wheels aren’t lost somewhere in the ED, then the most time I usually have to spend waiting for them is a few minutes for it to fire up and for them to collect identity information. It’s not that big of an inconvenience. Sometimes non-Spanish speaking staff will fire it up for me as they triage the patient, then come get me as soon as they’re done with it all ready to go. I’ll circle back with patients and not use the interpreter for every conversation, but I feel it’s worthwhile to at least put in the chart once that an interpreter was utilized.

I speak Spanish reasonably well, and medical Spanish better. I find our interpreters to be excellent, both in person and Stratus, and I use them partially to make sure the nurses, who are not ever disciplined over this, at least give discharge instructions with an interpreter.

We are required to document it for CMS compliance, although as usual nursing can do as they like and physicians get in trouble.

My understanding is that there are no rules preventing bilingual caregivers from giving care in the patient's primary language, but that the Joint Commission and CMS etc encourage training programs to ensure standardization and language competence.

000002120

What are the key points organizations must consider when interpreter services are provided by staff and practitioners ?

www.jointcommission.org

 

[thegenius]

One of our nurses got in trouble with the nursing board because she was speaking in spanish to a patient and wasn't "certified" to do so, even though she was equally fluent in spanish and english.

She got in trouble because she ended up documenting something they said.

 

[WilcoWorld]

One of our nurses got in trouble with the nursing board because she was speaking in spanish to a patient and wasn't "certified" to do so, even though she was equally fluent in spanish and english.

She got in trouble because she ended up documenting something they said.

Few things will "get you in trouble" in a hospital faster than doing the right thing.

Fortunately, I've learned to not worry much about getting in trouble. Though I doubt I can give any generalizable advice on that front.

 

[Brigade4Radiant]

I don’t mind people using the ER for random stuff easy dispo and it helps keep the doors open. Remember the Covid days?

 

[turkeyjerky]

I don’t mind people using the ER for random stuff easy dispo and it helps keep the doors open. Remember the Covid days?

Anyone else getting sick of this aphorism?

 

[calvnandhobbs68]

It's like this in every field. I had one bad fuucking day. A single bad day. All the other 364 days I'm fine and these patients I have a very neutral interaction with them because they are easy dispos.

Cardiologists have bad days.
Anesthesiologists have bad days
Oncologists have bad days.
ENTs have bad days.

I'll say this:

- it was 100% not right for that mom to bring in her daughter, after having a fever for 2 hours, to the most expensive place on this earth for an evaluation. If she is going to live in America then she has to learn how stuff works here. It's not "her fault", she wasn't malicious, she wasn't malingering, she isn't trying to game the system. But I contend that there are better trained doctors for a 2 hr fever in a well child. I would also contend that she has pretty poor general knowledge about health and it's embarrassing but she is a product of whatever educational system she grew up in and her culture. It's NOT HER FAULT.

- ER's in hispanic countries like Mexico and central america cost money for all patients. Mothers who have a daughter with a fever for 2 hours don't go to the ER's in Mexico because it COSTS MONEY. They usually go to the pharmacy and the pharmacists recommends tylenol or an antibiotic or whatever

- FREE SHIIIT IN SOCIETY IS ABUSED! 100% why is that so hard to believe

- it is 100% our job to educate people on the appropriate use of the ER. It's 100% our job to tell them what we are capable of doing. I think it should be done non-condescendingly, and I admit that on that day I was kind of a jerk to both those patients. But I ALWAYS EDUCATE people on what we do in the ER. All the fuucking time. Because I don't work up a lot of their nonsense even if the PCP's send them in.

- There are people who abuse the ER and they need to be called out

- There are people who don't know any better and come in for dumb stuff and we should politely teach them what the ER can and can't do. There is no shame in that.
- We TEACH AND WE EDUCATE PEOPLE ALL THE TIME.

- It used to bother me to write tylenol Rxs...but as I've matured now I don't care. it takes 5 second for me to write one. If a mother or father wants to wait 4 hours in an ER to save $5, then fine.

It used to bother you to write tylenol Rxs but now you don't care so you decided to start a thread about it and write gigantic replies? It seems like it might be bothering you.

I mean number 1 is annoying and maybe it was a sucky night for you but like at least 25% (probably lowballing it) of peds ED visits are for pretty ridiculous things (my kid has a headache/runny nose/cough/fever/"feels hot"/threw up once/ate a Crayola/whatever). Extra points for the language barrier but that's not even a semi-rare thing in any urban peds ER. I wouldn't venture to say it was a particularly hard situation and certainly one someone might reflect on blowing up about unless the mom was being a pain about it and refusing to leave until you pan-scanned her kid.

Seems like you might be using all these points to try to justify your interactions with these patients. It can just be a bad day and you can just feel bad you yelled at a mom who brought her kid with a fever for a few hours in because she was worried and didn't know any better. Rather than doubling down on all this stuff as justification for why that happened. Sounds like you might be having more than one bad day though.

 

[WilcoWorld]

What are "these types"?

@ER BlueBlood
I see that today you laughed at my question from Monday. I don't see that you've answered it. You forecast an infiltration of society by a certain group - I think asking you to define that group is a reasonable question. What am I missing?

 

[ER BlueBlood]

@ER BlueBlood
I see that today you laughed at my question from Monday. I don't see that you've answered it. You forecast an infiltration of society by a certain group - I think asking you to define that group is a reasonable question. What am I missing?

This thread has gone long enough bud. Not opening up that whole discussion. Just remember, some estimates have the fed gov buying 67% of all the baby formula in the country for the SNAP WIC program. You can see the future right there. Enjoy.