No emergency? No, thanks…

American ER Doc Gone Walkabout Episode 013

OK, so this isn’t directly about Oz: I’m here in the USofA for this case, but it offers quite a contrast between two systems.A 47 year old presents to an ER because of a couple months of constipation, bloody mucoid stools the diameter of a pencil, and a non-intentional 10 kg weight loss.

We know the diagnosis, confirmed by a CT – sigmoid carcinoma.
We know it’s in the US, and deduce that he has no health insurance – otherwise, why would he be in an ER for this chronic problem?So, now it gets pretty less-developed world-ish. He’s seen by surgery, and has no “emergency” – he isn’t actively exsanguinating, and he doesn’t have a high-grade obstruction. So, “no, thanks” says surgery.

He’s discharged from the ER with instructions to “find a PCP (GP in Anglo-Australasian) to refer you to a surgeon, or find a surgeon to do the surgery and an oncologist for treatment planning.” Several weeks later, having been “non-compliant” in med-speak, and not having found a surgeon to do the procedure for whatever the guy could pay, he completely obstructs and has a subtotal colectomy at another hospital. The surgeon who got to do the colectomy does not send a letter to the original hospital with the usual: “Thank you for referring this interesting patient”. The letter is more of the tone: “Are you guys f#@king nuts?”

The case was discussed at an M&M in the States: Some physicians (the “suits” – is that term used in Oz?) lauded the actions of the ER in protecting the hospital and the Department of Surgery from unreimbursable costs. Thankfully, others were appalled and distressed that our colleagues could send this man out the door. As ER Docs, we sometimes find fantasy problems requiring admission in far less egregious cases — I think a blood draw from a running IV line might have given us a Hemoglobin of about 55 and prompted an admit for transfusion. Reportedly, M&M discussion was vigorous (kinda like the Julia and Tony show at question time! – sorry, if you’re an American reader and have never watched Julia Gillard, the prime minister, and Tony Abbott, the opposition leader, go at it in Australian parliament, you’re missing a great show). I’m more discouraged that some would support this kind of case management, than I am by the failure of the young doctor to find a way, no matter how much lying was involved, to get him admitted and treated.

I can’t imagine something like this happening in Launceston, or any other part of Australia – correct me if I’m wrong.

About 44 million Americans have no health insurance and can face this sort of treatment. American law requires ER’s to examine all persons who come to the ER, but does not require treatment if no immediate life or limb threat is found: thus CT scan for diagnosis, but no treatment.

And, now we sit back and wait for a few months while the US Supreme Court rules on whether to undo all the political hard work done 2 years ago to try to establish a framework for universal (well, except for about 11 million) health care cover in the United States.So any of you thinking of trying American ER’s, prepare yourselves.

BTW – any jobs open for me in OZ? Every time I write one of these columns, I get the urge to book a flight back.

Honestly, I keep trying to come up with commentaries on the medical practice differences and they just aren’t that great: pacer vs isoprenaline drip for bradycardia, size of opioid prescriptions, aggressiveness of use of imaging technology, etc. But the health care system and financial stuff I find much more interesting for compare and contrast.

Later, Mates.

Next time:  Namaste! No overcrowding here…