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ERs are crowded for more reasons than just need. And ER visits are costly. They are also sometimes inefficient. Too much technology is being used instead of clinical skills at the bedside.
She had been in the ER since 10 PM the night before. I was consulted for her incarcerated ("stuck") belly button hernia at about 10AM the next day. Because of the risk of dead tissue in the hernia sac, I immediately took her to the operating room and reduced the hernia and repaired the defect. But I had not been consulted until she'd sat in the ER for 12 hours, got an uneccessry CT scan,and an ulrasound. The trainee (surgical resident) who saw her before me didn't feel the tender mass that assured the diagnosis, the clinical finding that made the CT and ultrasound unnecessary. Read: she got tests that cost the system a lot of money because neither the ER doc nor my resident knew how to examine the patient. This is a simple surgial problem.
Years ago the scenario would have gone like this: ER doc examines the patient and makes the diagnosis and calls me immediately at about 10:30PM. I book the case based on his expert track record and see the patient, do the surgery and send her to the recovery room by 1AM. She goes home that morning. Advantages? Less clogging of the ER, less expense, faster care for the patient, home sooner.
Why isn't this being done today? Because American doctors love expensive technology and because our medical schools have too few seasoned clinicians who know how to teach basic clinical medicine, or don't have the time to do so - instead they do research. Funding for medical education is in the proverbial toilet.
Health care reform? How about the same principle as for the similarly unthinking Wall Street financial fools: accountability. If a review panel of doctors deems a test to be unnecessary, the doc who ordered it pays for it.
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| Reviewed by Walt Hardester |
11/12/2009 |
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As a retired respiratory therapist and Viet-Nam medic, in my 25+ years in the field, I found myself the only person in some of the rural hospitals I worked in the only really qualified person to make critical decisions. Qualified by fire, and not nesesarily credentials to make a life and death decision. Most times there wasn't a Doc around and the nurses were calling, ringing their hands and waiting for a Doc. All the while the patient was crashing. In most cases I simply said screw protocal, I'm gonna do this or that.
The Docs were always happy I did what I did. And was generally given a free hand by the Docs to do what was nessesary. My bosses always said, "Walt, you do what you need to do and I will back you, but you had best not be wrong," I never was, because I used common sense. That is something that is lacking today and hands on is the best way to go. But try telling a newbie resident who can't move without tons of expensive test.
People survived for years and years without an MRI or CT based on the Doc's experience and intuition alone.
If you are afraid to make a decision based on S.O.A.P. you need to get back to the roots of medicine.
Thanks for pointing that out.
Walt
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