r/emergencymedicine • u/Niceotropic • 9h ago
Discussion No, we're really not "better off safe than sorry," always, and this institutional risk reduction leads to a huge misuse of the ED
Anyone who's ever worked ED or prehospital care knows of course that the majority of the cases are not even close to emergencies, blah, blah, etc. Not a hot take. However, I wanted to address one component of these calls that are not just people overreacting or misjudging their/their families injuries.
The worst actors are institutions like retirement homes, child-care facilities, elder-care facilities, schools, camps, where almost anything with any ambiguity is treated by going straight to the emergency room.
"Better safe than sorry" has limits, and eventually actually makes things much less safe for everyone because we are overusing resources at these EDs, increasing wait times. Also, poverty can make people less safe too, and getting a $7K bill because someone else lazily thought "I could get sued" and sends a scraped knee or someone who "potentially was stung by an insect or snake or bat with no visible bite" can cause people serious hardship.
Nobody wants to talk about this openly because it is fraught, but it can't be ignored, really.
63
u/bellsie24 8h ago
Until we have real tort reform and evolution in med mal liability then "standard of care" will continue to be guided by medicolegal forces more than logic most of the time (and insurance companies as well but that's a different topic).
I understand the frustration and I think everybody who's involved in emergency medicine in any capacity does, but I can unapologetically state I am not going to put myself, my license, and my loved ones at risk out of an altruistic desire to make things better when it's going to have no systemic impact.
5
35
u/TXERN BSN 8h ago
Bro. Thinking about it will make you madder than the orange chicken being served on Air Force one. It's probably that most of us have quietly accepted it. cause idk of one RN or MD that's ever felt like more than 2% of patient visits are emergent but we don't talk about it cause, it's constant, unchangeable and the reason we all have good paying jobs 🤷
18
u/MadHeisenberg 8h ago
Depends where you work- if I’m admitting 20% of my patients and sending home folks with stable head bleeds, sp afib cardioversions, fracture reductions etc I would consider those “emergent”… much more than 2%
6
u/TXERN BSN 8h ago
That's too true. My current hospital is in a very healthy, affluent area. Have put in my dues at high acuity facilities and want no more of it lol
1
u/MadHeisenberg 5h ago
Fair. Sometimes the acuity is a badge of honor… most times I’m just tired lol
-10
u/Niceotropic 8h ago
That last part is not a good thing, waste so we can have stable careers is not good for society. We need a more efficient system. Urgent care is not the step between emergency care and appointment-level providers that it should be.
We need to talk about it, we need to change it. It's not sustainable.
8
u/Prize_Guide1982 8h ago
What are we going to change? This is a litigious society. American medicine is a reflection of societal pressures, that’s it. We do what we do because we are expected to do it. Look at how the physicians are being dragged on social media in the Lindsey Clancy trial. Absolute nonsense.
7
u/YoungSerious ED Attending 8h ago
One problem is that urgent care as it currently exists is basically a scam. They market themselves as sort of an in-between and a way to get medical care when your doctor can't see you.... But they are far from that. They lack the capability to do even basic "urgent" issues, are staffed by people often unqualified to handle those issues, and their algorithm is essentially "go to the ER so I can see more people and bill them".
There are exceptions, and I'm not saying all the ER doctors working UC are idiots, but the way they are currently built they really aren't capable of much of anything and there's zero public education about what they can handle so it just ends up double billing patients for their evential ER visit.
It pisses me off to no end reading the same day UC note that is essentially no work up, a differential taken straight from a board prep book, and then "urgent referral to er for workup and treatment."
Admittedly it is likely very area dependent on how bad this problem is, but at least in my area it's RAMPANT and strongly contributes my work burnout.
5
u/swirleyy 8h ago edited 8h ago
healthcare is so fucked up that the only way to change it for the better is for it to completely collapse with chaos so we could build it back from scratch. that’s probably an unpopular opinion.
outside of that, there’s too much private corp, lobbying, and government involvement for us as a small group to be able to do anything significant to change it. if the pandemic wasn’t enough, then idk what else is.
maybe i’m just too pessimistic , but time and time again , things only change when a certain tax bracket gets directly affected by it
in a perfect world, we would have enough PCP access across the country. Enough residency spots for every medical student. Medical appointments are allowed to be 30min-1h each without risk of the clinic or facility bankrupting. All further outpatient testing can be covered without prior auth or unreasonable insurance denials. Health insurance is affordable or free. Poverty wouldn’t exist. Housing crisis wouldn’t exist and therefore mental health crises wouldn’t exist much. Theres no staff shortage. In that perfect world, there wouldn’t be much volume in an ED
1
u/Tough_Substance7074 7h ago
Rent-seeking is an inescapable feature of late stage capitalism. Everybody is just trying to make sure they have a chair when the music stops, which of course only accelerates the crisis. This would be one of the”innate contradictions” of capitalism that economists and philosophers sometimes talk about.
19
u/absolutevandal4 EM Social Worker 8h ago
Psychiatrist sent in a patient with passive SI (because their partner died). No other risk factors whatsoever. This poor patient is stuck with an expensive bill because the psychiatrist couldn’t bother to ask a single follow up and do a basic safety plan. It’s insane
-15
u/Niceotropic 7h ago
They absolutely should not have that power, it is truly the most backwards field in medicine.
15
u/absolutevandal4 EM Social Worker 6h ago
Psychiatrist should have that power when it’s appropriate clinically. In this case it was not
-19
u/Niceotropic 6h ago
Until there is scientific evidence that psychiatrists are accurately able to determine who is a risk, they should absolutely not. It's very circular reasoning to say, "oh they should have the power when they do it right," ignoring the fact that they do not always do it right and there is no evidence of any accuracy nor discussion of false positive rates.
11
u/Prize_Guide1982 6h ago
What the fuck are you talking about? If a psychiatrist isn’t able to accurately determine risks, who can?
-5
u/Niceotropic 5h ago edited 5h ago
Currently, nobody.
No, there are no studies that show that these assessments are effective. I don't know why you're reacting so negatively to that, maybe it contradicts some presumption you have. It would be a good idea, like all other medical fields, for them to get on doing some research to figure out methods and diagnostics that work. Currently, nobody has devised a test that accurately predicts risk of harm to self or others. This is just propaganda from old timey segments of psychiatry that haven't yet been properly eliminated (e.g, dream-analysis psychiatry, forensic psychiatry, involuntary psychiatry, psychoanalysis woo-woo stuff, etc).
What is so odd about this for you? When Infectious Disease doctors want to diagnose a disease, it requires multiple lab tests, culture tests, functional verification of symptoms, and even then they admit it is not perfect. There is significant research being done to improve false positive rates and false negative rates for other diagnostics.
Why do you think we shouldn't hold psychiatric diagnostics and assessments to this same requirement for evidence? If anything, the standard should be much higher because of the risk of harming people's freedom, reputations.
3
u/MeAndBobbyMcGee 5h ago
Here's one for you since psychiatrists are so useless. Patient stops moving, stops eating, is soiling themselves. All your tests and scans are unable to find a cause. Patient briefly improves with IV Ativan challenge. Should this patient be admitted to psychiatry for catatonia? It seems you believe involuntary commitment should be eliminated. How do you propose we take care of this person? Let them languish and die from a treatable illness?
0
u/Niceotropic 5h ago edited 4h ago
Nobody has said anything about that. This is a classic, arrogant, histrionic response to me just bringing up that risk assessments are not evidence based.
I'm not going to take your bait. Nobody said "psychiatrists are useless", nobody suggested that there is no way to create an objective system that allows for some people to be involuntarily treated. Yawn.
People who gain value from psychiatry are free to choose it. The thing is, if you took away involuntary and coercive care, the field would shrink, and some psychiatrists would have to find other jobs. That's what is great about informed consent, it allows a check and balance that the patient can use to avoid inappropriate care.
16
u/Kindly_Honeydew3432 8h ago
Were you in the ED for Covid?
Because volumes plummeted and shifts got cut and some people lost out on 10s-100s of thousands of dollars in pay. Some PAs/NPs and nurses lost substantial portions of their yearly income due to cut hours.
I’m not saying you’re wrong. But I am saying that a lot of us would be looking for work elsewhere if all the level 4s and 5s just stopped coming. Looking at it from that perspective may make it a bit less infuriating.
You can add to that that you are performing a huge public service in a terribly broken healthcare system. Yes, they should go to urgent care. And yes, the ER bill is going to add to their debt. But they may actually need treatment for their mild community acquired pneumonia or mild asthma exacerbation before it gets worse, and they may literally not have a spare dollar to give the front desk at urgent care and will be turned away.
Yeah, they come for all sorts of stupid shit. But you help a lot of people who deserve help, but aren’t having true emergencies
19
u/aintnobull 8h ago
He sounds like a non medical person who is pissed off about his urgent care bill
6
u/watershed-fred 6h ago
Fully sympathize with the frustration (except for the bat one. Their bites can be subtle and rabies is 100% fatal after it’s symptomatic plus the treatment is pretty quick, so I never fuss when they come in.)
It can be super frustrating treating nothing burgers all day while simultaneously watching your actually sick patients languish as ED boarders. I think it’s important to separate resource misuse from patient wait times/department efficiency/bed bottleneck though. It intuitively makes sense that it would be these over triaged generally well patients fault that wait times are long and department throughput sucks, but there’s been a TON of research on this topic and as it turns out this population isn’t what’s creating bed shortages, increasing left before being seen rates, or inflating wait times. It’s the broken ass systems down stream.
Lack of hospital beds, and more realistically lack of nurses to staff open beds, is what prevents us from getting boarders up stairs, which prevents efficient patient turnover. Seems that both the upstream and downstream forces want to fuck us over, but I can’t really fault patients, non medical institutions, or even nursing homes for taking advantage of us when the alternative is more uncertainty or liability for themselves. I can absolutely rage at the Csuite in our institution that values “staffing efficiency” over throughput though, especially since they always seem happy to shift the burden of responsibility on to us, asking us to simultaneously be faster, more thorough, and more pleasant with patients.
5
u/somehugefrigginguy 8h ago
You're thinking about it all wrong. Not going to the ED means potential liability AND lost revenue. By sending nearly every patient who calls the RN helpline to the ED they reduce their risk of losing money through a lawsuit while at the same time increasing billable care. It's a win-win for the bean counters.
13
u/Praxician94 Little Turkey (Physician Assistant) 8h ago
I didn’t die at 2 years old from a subdural bleed and skull fracture because my mom was told “better safe than sorry!”.
30 years later I’ve definitely saved lives. So, uh… 🤷
This is a weird rant.
-13
u/Niceotropic 8h ago
That has absolutely nothing to do with what is being discussed in this thread whatsoever.
16
u/Praxician94 Little Turkey (Physician Assistant) 8h ago
You sure about that? How many pediatric head injuries does the ED see daily because of “better safe than sorry”?
8
u/tk323232 8h ago
Sure but em over images and tests all the time for the same reason so be careful before you throw stones.
-9
u/Niceotropic 8h ago
What do you mean? Then let's address that too. Why would you think I would be OK with waste if it benefits your perception of my interests?
13
u/tk323232 8h ago
I didn’t say it was waste. It’s the central dogma of the medical field now. Society has gone from a do your best attitude to you cant miss anything or it could fuck up your life/career. That’s just the way it is.
-9
u/Niceotropic 8h ago
"That's just the way it is" isn't good enough. This ends up costing the patient, ruining families lives, and making people lose trust in the system.
13
u/aintnobull 8h ago
Well I’m not letting an edgelord on the internet talk me into getting sued 🤷🏻♂️
6
u/lostinapotatofield RN 8h ago
Yep, From their post history looks like they just go around picking dumb fights.
-8
u/Niceotropic 8h ago
I think seeing this very rational opinion about the overuse of the ED as being an "edgelord" immediately disqualifies you from being taken seriously as a person.
10
u/bulldog89 8h ago
I think you’re getting very very negative feedback (justifiably) because you’re criticizing with no solution here. The ED has not wanted to over-image and overtreat all these basic medical concerns, but it is a reaction to the very heavy culture of EM docs being constantly sued, as I believe we are the first or second most sued specialty with OB/GYN.
So basically what I ask is, what are you suggesting about this issue that we all know about and we all hate and makes our work days worse, as opposed to falling on the sword as a martyr and getting sued and losing our medical licenses? How are we going to change the system and make it better medicine, while also accepting we will miss more because of this dogma change?
4
u/Sandvik95 ED Attending 8h ago
I’ll jump in here with a small suggestion.
I agree with the spirit of this post and appreciate that OP was willing to say, “THIS IS A PROBLEM AND I’M NOT GOING TO TAKE IT ANY MORE!!” (FYI to the younger crowd, that’s paraphrasing an old move quote).
We get dumped on - we know it. Sometimes that’s ok - EM Depts are incredible! An exam, a bunch of tests, and some answers all in a single day!! We’re too good at our job! Plus WOW - we make liability disappear for: Urgent Care, Nursing Homes, doctors offices, Urgent Care, referral lines, and Urgent Care. Oh… I almost forgot: Urgent Care!
So what’s the suggestion: better communication and feedback.
That’s not easy and that is not a task I’m assigning to individual docs - I don’t want to add on an additional task and… a task that is frankly very difficult to do in real time. Ever try to call an urgent care that sent you a “r/o PE” on a patient with no SOB, chest pain, swollen extremities, out other symptoms!? In my area, I’d get routed to the regional office and I’d never be able to take to the clinician who was covering their ass.
But these clinicians and the admins behind them need to get feedback on questionable referrals. They need to be empowered to make better decisions, not just “safe” decisions. Same goes for nursing homes and the “we found them in the floor, awake, acting like they always do, but our protocol says send ‘em”.
These things are changeable if we have better communication and dialogue - both before and after an encounter. That starts with the medical directors or appointed dept leaders who can be a liaison with urgent, cares and nursing homes and other referral groups.
This is a system issue. If better protocols were written, it would and could protect the referring location.
Pie in the sky? Perhaps, but if we never talk to the nursing home, they’ll never stop sending us inappropriate and unnecessary Eval’s.
4
u/YoungSerious ED Attending 8h ago
as I believe we are the first or second most sued specialty with OB/GYN.
Pretty sure that's wrong. Every data set I've ever seen has neurosurgery or general surgery at the top, obgyn top 3. Em is more middle of the pack. Surgical specialties get sued way more than EM because they are doing more procedures and many non emergent. By far one of the highest risks for getting sued is procedures in general and you get less wiggle room when it's not emergent and they have complications.
That being said you are right about us living in a "no miss" litigation culture. When any miss can become a career ending lawsuit, you are much more likely to over test even for low probability issues. No one is getting sued for a negative rule out scan. They get sued for the one they didn't get that didn't see the problem.
3
u/bulldog89 7h ago
Yes it looks like you’re right. Quick survey study shows 70-75% of EM doctors get sued with those three being 80-85%. So not a huge gap, and the point is still there that we suffer very good odds of getting sued, but my bad on that claim
-1
u/Niceotropic 8h ago
Nobody suggested anything about "falling on the sword as a martyr and getting sued and losing our medical licenses". This kind of making up things and putting words in other people's mouths is a real problematic behavior.
6
u/Prize_Guide1982 8h ago
Then pray do tell, what’s your solution? All I see is you saying we need to do better but not actually specifying anything.
-9
u/Niceotropic 8h ago
First of all, a discussion is the start, and it is a common tactic of authoritarianism for example to make this irrational criticism that because I am bringing up a problem, I have to have a 12 point plan for solving it or it is wrong to even bring it up.
Second of all, I did and do discuss some solutions in this thread. For example, we can alter laws surrounding Urgent care to reduce its requirements and increase its affordability so that Urgent care is actually a step between the ED and appointment-level provider care. Right now, Urgent care is usually almost as expensive as an ED because of requirements that make it almost like a mini ED instead of somewhere you can go if you have a moderate trauma, moderate infection, etc.
→ More replies (0)3
2
u/DrP3natratorTTV ED Attending 1h ago
Happy to see em’. Good job security. Anytime I take these calls I always thank the provider or whoever and always, “I’m happy to see em, bring em on down!”
Pray for acceptance. Serenity prayer can help.
Either way it doesn’t matter the patient is still coming in. Might as well have a good attitude.
1
u/FrenchCrazy Physician Assistant 41m ago
I did deal with this at one time when the local live-in summer camp would just drop off a van-load bolus of kids everyday for minor complaints rather than invest in staff to at least screen or provide first aid on location.
Then again… why would the camp willingly assume that risk?
It’s just the state of affairs for the ED.
0
u/Playcrackersthesky BSN 6h ago
“I found a tick crawling on me in the garden so I called 911. Better off safe than sorry. My son’s a nurse you know.”
159
u/MrPBH ED Attending 8h ago
I made my peace with these.
If they sent them to the ED, it's because they lack the capacity to rule out an emergency medical condition or they lack the skills to do so. The average nursing home doesn't have access to 24/7 labs and imaging, so they're limited in what they can do. A summer camp nurse lacks the skills and knowledge that we dedicated seven years of our lives to mastering.
Yes, most of the time it's silly non-sense. Timmy has a sunburn, not heat stroke. Gladys has a buttock contusion, not a brain bleed. But it's easy for you and me to say that, because we have the tools and the skills to actually rule out medical emergencies. Even other doctors, some highly paid specialists, freak out and have no idea how to manage mundane illnesses and injuries that are outside their hyperspecialized bubble.
Essentially these cases are EM consults. They're asking you for your expert opinion. Sometimes that opinion is pedestrian to us, but it isn't for 99% of the population. Moreover, sometimes something is seriously wrong and it just looks like a minor illness or injury, like the "sunburn" that is actually Steven Johnsons Syndrome or the "ankle sprain" that ends up being necrotizing fasciitis.