19 December 2006

Just go to the ER

Surgeon in my dreams commented:

I have migraine headaches and asked my doctor just last month during a visit what should I do if I have another like the one I had just gotten over. I mean I was hurting so bad I just knew I was about to die and welcomed it. I was throwing up with barely any time to come up for air in between.

I asked him if I come to his office would he give me something or just what should I do. He TOLD me to to go the ER. He said he did not keep anything strong in his office so it would do me no good to go there.
[sigh] This is so emblematic of much that is wrong with health care (especially primary care) in this country. No criticism to you, SIMD, you and many many other patients do what they are told and "just go to the ER." And we are there to see you, because we have to be. But the point is that people like you shouldn't come to the ER. I should be clear on this point -- there are times when, say, a headache or abdominal pain do warrant an ER visit. New onset symptoms which are not well understood do require an emergent evaluation. But for chronic conditions which have been appropriately diagnosed, we are all better off if you are treated by your personal doctor. And let's be honest: doctor's offices do have IVs, medicines, fluids, etc., and if they do not it is a matter of choice on the part of the office practitioner.

I am not trying to criticize my office-based colleagues. I suspect many of them would love to provide comprehensive care, from routine and preventative visits to more urgent, acute problem-based care. Flea gets insanely pissed off anytime someone is diverted away from his care. He may be an outlier, but I suspect he is representative of many clinic docs' desires. Most clinic docs will not or cannot manage to provide these services because primary care compensation is so low that their financial viability is dependent on through-put, and the reimbursement given under ambulatory care codes is woefully inadequate compared to disruption to the office flow and the time investment required to provide the care. Change the site, though, to the ER and I can collect three or four times the amount (far more including facility fees) for the exact same service. Even with the recent RVU updates, the system remains broken, and one of the consequence is the shuffling off of much primary care to the ER.

Symtym covered this pretty well last month. A couple of key points that bear emphasizing:
  • Emergency Medicine has been a willing victim of its own success.
  • Emergency Medicine has been all too willing to cover for the deficiencies in the availability of primary care (in terms of numbers and time).
  • Emergency Medicine is not an essential service, but a convenient service.
  • "Just go to the ER" is not a national health policy.
I particularly like the last point.

To respond more usefully to you , SIMD, we must acknowledge that we go to war with the health system we have, not the one we would wish (to paraphrase the departed but not lamented Sec Rumsfeld). Let's also acknowledge that the ER is expensive, overcrowded, inconvenient, and the care there is in many cases suboptimal. So what else can you do? If I had migraine headaches, and on an occasional basis they became uncontrollable, and if I had a PCP who knew and trusted me, I would ask for the following "Emergency Kit":
  • Two tablets of orally-disintegrating Zofran
  • Five tablets of 10 mg Toradol
  • Four tablets of 2mg Dilaudid
This is in addition to any other migraine headache medications which had proved useful in the past (Imitrex, Zomig, etc). As long as the crises which require the above meds are relatively infrequent, I suspect that most clinic docs would not balk at the above, especially when presented in the context of "I want to stay out of the ER." I do not know you, SIMD, and I am not giving you medical advice, because this plan would not be appropriate for everybody. But I suspect that for many people, such advanced planning (or even prescribed acutely) would manage their illnesses better than the ER does.


  1. I barely know you, but I think I love you.

  2. This whole post sounds alien to me. Let me explain. Ia m 56 years old and in my entire life, I have never once had a PCP whose office one could just show up at and get treatment for a migraine headache (or anything else).

    Migraine headaches don't allow for a week or 10 days or even two week Dr. appointment. When you get a migraine you need treatment for it pretty quickly. When I call my PCPs we are schedlued atleast 7 days out. If it is something that has caused you to be acutely ill then yes, we are told to go to the ER.

    Hell, I was recently informed by a nurse, in my PCPs office that "All we really do here is prescribe your meds for you." This was in response to my asking about test results from a specialist that HE had sent me to. So, it is no wonder that patients are confused about just what it is that PCPs do anymore? I mean, I can just call to get refills on my prescriptions is that is all it is about.

  3. As one of those office-based docs, I do refer my procedures to the ED. Sorry, but it's not worth my time or money (oh, but they are the same, after all) to keep my pediatric office stocked with all the proper equipment, then take the 1/2 hour to find a vein on a dehydrated infant, and keep all my other patients waiting and just get too far behind. The reimbursement doesn't make it worthwhile. Same for sutures. If Medicaid wants to pay me what they pay you for the same procedure and visit, then I might change my tune.
    Also, not to dump/turf, but I do lean on the ED on the weekends or nights when I get the telephone call from a parent: "my child is having trouble breathing," etc. Yes, most of the time it's just nasal congestion, but I tell them: if I can't assess your child over the phone, I want someone else to do it in person. I don't send every little thing to the ED, but certainly the problems that cannot wait until my office opens. The ED for the most part has been cooperative, and better yet, they try to educate patients not to use them as just another clinic. Probably once every couple of days (!) the ED sends us a non-urgent patient who shows up on their doorstep even though we ARE open and available. Educate, educate, educate. The ED is best for some things, the office is best for others, and we can quibble about the middle ground, but as long as the patient is seen and helped, that's all that matters.

  4. I am also one of those office-based docs, and I agree with Dr. Scott. Most importantly, discussing symptoms on the phone is never the same as actually examining the patient, which, for us office-based docs, is often next to impossible after-hours.

    Anon 7:55 - I am sympathetic with you regarding your confusion about what a "PCP" does (I hate the term myself). I am an internist, and I go out of my way to diagnose and treat illnesses and conditions that fall within any number of subspecialty areas. It is when I feel that my skills or knowlege are inadequate that I refer to someone else (your so-called specialist).

    When I refer a patient to a specialist, I am referring them for consultation, interpretation of results, discussion of results with the patient, and coordination of care with me. I do not send them to specialsts so that they can order tests for ME to interpret and relay result to the patient. I am fully capable of ordering tests myself, but it is the interpretation that often requires "specialist" intervention. When a patient has been seen by a "specialist" and there are test results, but no other communication from the "specialist" I refer the patient to the specialist to learn about the results.

    I also choose a different "specialist" in the future.

    If your Doc admits that he is nothing but a prescription refill service, you should find another.

  5. Yeah, this used to annoy the hell out of me. But I know the shift is going to busy and the waiting room is going to be packed full of stupid stuff, and that those with the stupidist stuff will be the angriest with the wait. Since they are not actually dying they will be pissed at me and pissed at their primary for sending them. However the fact that they have a primary makes them much more likely to actually have health insurance versus the 30% I treat for free. Now I just say:

    Can I have another?

  6. Drs Scott & Rich -- I hope I was clear enough that we see that we are singing the same tune here. IF you were paid appropriately for your services, instead of inexplicably taking a 50% pay cut for the exact same service that happens to be provided in an office and not an ER, then it would make economic sense to do more of this in the office. Sadly, as things are, that is not likely to happen in the foreseeable future. Also, I was mostly directing my comments to those chronic/non-urgent complaints which "could" be addressed during office hours. No reasonable person would fault you for sending a complaint of "trouble breathing" to the ER.

    Anon 10:44 -- Good point. With the unfunded EMTALA mandate, these "worried well" are our profit margin, aren't they? Like you, I have adopted a zen-like serenity about it (or I'd have gone nuts by now). I'd love to 'educate' folks better about the appropriate use of the ED, but I get in enough pissing matches as it is and I only have so much piss in me.

    My, that was an odd metaphor. I'd best leave off now.

  7. Be careful what you wish for! Good urgent care centers are sprouting up all over the country that are owned and operated by ER trained physicians. They are perfectly happy to take the very business that you obviously see as a nuisance.

  8. I'm one of the lucky migraineurs (hah!) who doesn't get violent nausea. Many of my co-sufferers can't keep oral medication down, which is why they wind up in the ER-- tablets and orally-dissolving meds won't stay in the mouth long enough to do any good. Some sort of injection is called for.

    I wholeheartedly agree that the ER isn't the right place for routine treatment for chronic pain, but a standing prescription for tablets won't solve the problem either.

  9. jonquil -- I do agree that given intractable vomiting, the ER is a reasonable venue, for IV fluids/anti-emetics. I would differ that the primary drawback of zofran ODT is not the efficacy (they dissolve pretty fast) but the cost -- which is unconscionable. However, one of my primary points was that doctor's offices are perfectly capable of providing that service; it just doesn't make economic sense to given the crappy reimbursement.

    Independent urologist -- there are lots of urgent care clinics, which are a business threat to me because they can siphon away the funded business. But they're likely not staffed by ER-trained docs, because they bill with ambulatory care codes which are a fraction the RVUs of ED codes and the hourly reimbursement is far less than can be made in an ER. But the point remains that ad hoc care by a doc-in-the-box (whether the box is an ER or walk-in clinic) is inferior to that provided by a known and trusted PCP.

  10. I don't mind taking care of migraine patients, except the ones who tells me that nothing works but Dilaudid or Demerol & Phenergan.

    My migraine cocktail consists of Toradol & Phergan (IM or IV depending on severity) and 1g or Tylenol. I set expectations early and tell the patients that the headache will probably not resolve but at least "will take off the edge." They will be discharge home no matter what after a routine 20 minutes observation for any adverse reactions or allergies.

    If I'm in a nice mood, maybe a li'l Nubain or Stadol. Gawd, bring back Inapsine!!


  11. There is a trend towards free-standing Minor Emergency Centers" like this group for example. They are staffed with real ER docs and bill with real ER codes (99281-99285) plus ER facility fees.

    Inapsine is still available, and I still use it occasionally. Now that Compazine is available again, I don't use Inapsine so much.

  12. The only thing I can say about Zofran ODT is that it tastes terrible - I find it adds to my level of nausea rather than reduces it.

    My wife (an ED RN) deals with chronic migraines. She finds the cocktail that works for her when she gets one that gets beyond her control is the following: 4mg of IV Zofran, 30mg of IV Toradol, 50mcg of IV Fentanyl, and sometimes 1mg of IV Ativan x 2. Usually this is accompanied by 2000ml of Normal Saline. Most of the time it works, but sometimes it still doesn't and she needs to be knocked down.

    About 4 months ago she got Botox therapy which consists of a series of injections into her hairline. She has had only 1 episode since, otherwise she is doing much better.

    Botox may not work for everyone, but it certainly worked for her.

  13. Neither compazine nor inapsine is in my hospital formulary, unfortunately.

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  15. Just a question to all you Docs from a migraine sufferer of 40 years ... I only go to the ER/ED outside of my doctor's biz hours or when I am on the road (alas, frequently). Would it help the ER/ED staff if I had a note from my Doc that described my situation and the drugs that work for me? I HATE the struggle for appropriate drugs.

  16. Having been in the ER a fair number of times, for migraines and other things, it's interesting to read things from a doctors perspective.
    I like to think I only go to the ER when I actually need to, and I sympathize with doctors who face a flood of 10/10 pain patients who can 'only' be treated with narcotics.

    I go to the ER with migraines for one of two reasons - Severe, persistent nausea that's left me dehydrated and unable to keep meds down (Although Zofran works most of the time, I find even if I can get it to dissolve fast enough, it does nothing against the worst migraine nausea) or a status migraine that's failed to respond to everything else (including a Zofran/narcotic/other cocktail prescribed by my nuro).

    I don't know what fiscal motivation might be involved, but my primary care and/or neurologist usually send me to the hospital at that point. My primary care isn't comfortable giving the medications required to knock a migraine of that level out. After a certain point even the local hospital will send me on (they won't do DHE 45). That may be because I'm still a peds patient.

  17. What if you are allergic to tordol? Any thing that would be comperable?


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