Another patient dies while waiting for ED care
Posted by WhiteCoat on October 31, 2007
An article in the LA Times this morning titled “Untreated ER patient dies at Olive View” described another person with a potentially emergent medical condition (this patient had chest pain) who went to the ED seeking care, waited for a long period of time, and then died before being seen.
Edith Isabel Rodriguez died of abdominal pain while laying on the floor of a California ED waiting room. See nursing commentary about the incident here.
Beatrice Vance died in an Illinois ED waiting room after waiting more than two hours with “classic” symptoms of a heart attack. Her death was ruled a homocide by the coroner.
Obviously patients shouldn’t die waiting for care. So why does it keep happening?
- Uncaring attitude? I find it difficult to believe that any healthcare provider could be heartless enough to intentionally let someone sit in the waiting room knowing that the person has a life-threatening condition.
- Patients not accurately describing their symptoms?
- Poorly educated ED triage personnel? My kid knows that chest pain is a potential emergency. The patient’s friend said that chest pain radiating to the left arm was a “sign of a heart attack.” This patient was 33 years old though - a less likely cardiac patient (if you didn’t know about his smoking history).
- Are the EDs so overcrowded that they cannot handle the influx? At the ACEP Scientific Assembly this year, some physicians reported that their EDs are holding 30+ patients per day waiting for beds to open up on the floor. How can patients receive proper care if they are strewn throughout ED hallways?
- Understaffed EDs? If the ED is staffed with sufficient nurses to handle the patients in rooms and those nurses are also required to care for patients “boarding” in the hallways, it is a recipe for disaster. ED nurses are some of the best in the business, but we can’t expect them to care for multiple critical patients at the same time. In the ICU, the staffing ratio is usually one nurse to one critically ill patient, or one nurse to two ICU patients. Is it good policy to have one nurse caring for 8 or more ED patients that could all be critically ill?
Not sure if there is one or a combination of the above at play. Whatever the problem is, it needs fixing and it needs fixing NOW.
So now for a political comment:
Fixing the problem is going to cost money, and this nation has to determine where our priorities lie. Right now, we are spending billions of dollars to fund a war with no discernible end point. Couldn’t that money be better spent keeping our loved ones from dying these tragic deaths in ED waiting rooms?
By the way, ER Nursey had a neat idea to help support our troops. Send them all of those DVDs and CDs you aren’t using. Don’t forget about the people fighting for us.
October 31, 2007 at 10:46 am
A lot of the congestion could be cured by just filling the chronic pain/phantom pain/junkies full of feel good and sending them promptly out the door instead of wasting time titrating how little you can get away with giving them.
October 31, 2007 at 10:46 am
A lot of the congestion could be cured by just filling the chronic pain/phantom pain/junkies full of feel good and sending them promptly out the door instead of wasting time titrating how little you can get away with giving them.
October 31, 2007 at 11:03 am
I think that soon it will be the standard to have a 64 detector CT scan in ER’s which will assess any chest pain complaints for coronary artery disease, dissections, and pulmonary embolus. Yes, it will cost $250k dollars per hospital ER. This will likely prevent most, but not all, of these events.
Alternatively, we could have a political decision that legislates that use of current triage protocols protects the ER from being sued and accepts that a couple of times a year a young person will be underdiagnosed and drop dead in this country.
My guess is that spending say 5 billion bucks would save 10 lives a year. You can’t have both. I’d be interested in seeing a honest debate on such issues.
October 31, 2007 at 1:57 pm
The thing is … no one wants to be one of those 10 people whose lives wouldn’t be saved if you don’t spend the money. Unfortunately, many people still view medicine as an exact science when medicine is far from an exact science.
October 31, 2007 at 3:30 pm
Dear WhiteCoat:
I think that you are right. But it means that we’ll have to accept the current system and learn to be happy in it.
October 31, 2007 at 3:49 pm
We had a healthy 30 year old with an STEMI in the lobby for 1.5 hours with chest pain down the right arm starting while weightlifting. He didn’t collapse or anything and didn’t look to be in that much pain. Triage thought it was musculoskeletal. We all about died when we saw his EKG, rushing in there with the drips and everything else and had him to the cath lab in under 10 minutes, however….
I have to say that it’s going to happen sometimes, given the number of people his age that come in with chest wall and arm pain and the lack of beds. In our hospital, the problem MIGHT be fixed by, perhaps, having a closed-door room where we could do EKGs at least from the lobby (on patients where the likelihood of cardiac cause would be low) and overall willingness for the aids to do them from the lobby and doctors who will read them on lobby patients.
Currently, we are supposed to “bring them back at least for an EKG and put them back in the lobby if it’s okay” on a questionable patient, but nobody does that because (a) where do we do it on females? In the bathroom? Expose their chest in the hall? (b) general unwillingness to do an EKG and kick someone out of the bed, especially when it might be angina, especially from the physicians, which I can understand.
I don’t like this whole “stop the war to help people here” business. It’s a constitutional duty of the United States Federal Government to protect its citizens against its enemies, and since we have an elective government, that decision is delegated to them. We’re in healthcare, and our duty is to figure out how to make our current system work or do things to change the current system so it DOES work.
Trying to monkey around with wars is not the duty of doctors just like its not patients’ jobs to tell doctors what to order for tests or medications.
Focus, people, focus.
October 31, 2007 at 7:14 pm
Mark,
The problem is, the patients who have no possible way to understand why “the hospital just doesn’t spend the money” are the ones who aren’t paying a dime out of their pockets. The poor who qualify for Medicaid have the government pay for their care. The poor without insurance just don’t pay the bill, period. The working middle class who have insurance only see the bill if they have a deductable or co-pay.
They have no concept of the big picture nor are they interested in the economics of spending Billions more dollars that the United States can no longer afford and sinking it into such hardware just to save a few more lives.
It would be nice to just accept the current system and be happy in it. But the current system is broken but none of the players desire nor have the heart to fix it. Would you like to be the first to be told you only have the basic level of insurance so you only get the 10 year old CT scanner and not the 64 slice?
There is only so much money that the population can possibly spend on healthcare. We have gone beyond that limit but no one wants to face that.
When Medicare was started, there were something like 10 or 15 working people for every 1 retiree. So, the retiree only needed to pay their $10 or $15 a month to pay for Medicare, with the rest paid by the working folks.
Now, there are only TWO and soon to be 1 and 1/2 working people for every retiree in Medicare. Given that it is roughly $1000/month (1995 statistics that I have heard) to provide medical coverage for a Medicare benificiary, wonder why Medicare (thats FICA and the Medicare deduction out of your paycheck) has gone up so much? The Medicare beneficiary pays $40-60/month (I think).
November 1, 2007 at 5:15 am
Most webusers are familiar with Godwin’s law, relating to the likelihood that a web conversation will involve Nazi comparisons- it approaches unity as the thread goes on.
I now propose jb’s corollary: As any societal problem is discussed (in this case ER overcrowding), the likelihood that George Bush will be blamed approaches unity.
There is no question that urban ERs are overcrowded and understaffed for the tasks that we assign to them. There is not enough money in the world to provide all the medical care that people demand when the cost is free for most of them, as it is in urban ERs. Is there any doubt that ERs would operate much more efficiently if administrators and bureaucrats would let the docs and nurses alone and let them run ERs? How about putting some reality into the tort system? (Not to mention headline seeking politicians who label an error in clinical judgment a “homicide”). Don’t you think that these common sense and nearly cost free steps would greatly improve the responsiveness and efficiency of ERs all across the country, decreasing the possibility that folks would die in the waiting room? No, a cheap shot at the Iraq war, even when you agree that the troops are “fighting for us,” is much more self satisfying.
The government has the responsibility to protect us from foreign attack. You can argue about the means, or whether the financial and human cost is worth it, but there have been no further attacks on US soil since the USA went on the offensive against the Islamofascists. Whether the government has the responsibility to evaluate and treat chest pain is open to argument. It certainly has evolved that way in our society, but rather than questioning the war, why not question whether government financed health care is the best way to go? Your two examples are excellent arguments for getting government out of healthcare entirely.
November 1, 2007 at 6:04 am
[...] variety of comments at Kevin, MD and WhiteCoat Rants are puzzling over what can be at the root of this recurring [...]
November 1, 2007 at 10:01 am
And despite the seemingly endless nature of our recent intervention in the Middle East, eventually that expenditure will be greatly reduced, unlike the establishment of yet another Socialist Ponzi program which would only increase ad infinitum.
November 1, 2007 at 11:17 am
My initial thinking on this subject was that we need an explicit national discussion on these issues without rancor. I agree with the idea that the current system is in trouble and that we do not appear to have the will to fix it. Of course, the alternative to fixing it is to learn to like the current system.
I don’t think that we can devise a system where no 33 year olds drop dead of an unexpected problem somewhere in the country a couple of times a year. No matter how much we spend. And certainly, every dollar spent on preventing chest-pain associated death in 33 year olds is a dollar taken from some other equally desirable outcome.
November 1, 2007 at 11:37 am
I think you ALL have it ALL wrong! If the hospitals would STOP advertising to the public how wonderful they are and put their dollars where they are most needed, we might be able to ease the problem in the ER’s. Also, every hospital should open up an urgent clinic adjacent to the ER’s so that critically ill patients ONLY are seen in the ER and all others are seen in the clinic. That ought to straighten things up.
November 1, 2007 at 11:55 am
Sorry Phyllis, we don’t have it even a little bit wrong. Hospitals advertise their profit making services so that they can have some cash flow to cover the cost of all the free care they are required by federal law to offer in the ER. Most hospitals have urgent care clinics very close by; they compete with the hospitals for paying patients who have relatively minor problems. Unlike hospitals, they are not required to provide unlimited free care to anyone who shows up, so all the freeloaders will continue to go to the hospital ER. Many hospitals do have integrated urgent care centers, and all that does is make it more likely that the occasional person with a significant problem and will be triaged to the urgent care area, leading to delayed care and increasing the risk of lawsuits.
That ought to straighten things up.
November 1, 2007 at 12:18 pm
Our urgent care area (3 beds) oftentimes turns into a monitorless chest pain holding area for EKGS….
November 1, 2007 at 4:33 pm
My war comment wasn’t intended to blame everything on Dubya. I apologize if it appeared that way. I’m not a political person. I greatly respect the man, but I disagree with some of his decisions.
My intent was more to point out my belief that our country’s priorities are misguided. No one will ever know whether this 33 year old man would have died even if he got straight back to a room and the MI was diagnosed immediately.
When we cut services and cut payments because our priorities are focused somewhere else, all of a sudden our infrastructure ends up a shambles. I am very concerned that these people who have bad outcomes because they can’t get timely care are “canaries in the coal mine” representing the tip of a very large iceberg.
Funding for essential services is going to make or break us and it is drying up for medicine - especially emergency medicine.
November 2, 2007 at 4:18 am
Thanks for the clarifying remarks, WC.
According to Wikipedia, the USA spends 1.7% of GDP on military related affairs; the percentage devoted to healthcare is roughly 15%. The trend for the former, despite the current shooting war, has been downward in recent years, and upward for healthcare. As PJ O’Rourke has said, “if you think healthcare is expensive now, wait until you see what it costs when it’s free.” He may have been thinking of costs in dollars, but some people, including the 2 that you highlight in your post, pay with their lives. Why anyone would think that the US government would do a good job running the medical system is beyond me. It started innocently enough as a payment program, but it inevitably morphed into the people who make the rules. Now that everyone gets everything for nothing, there isn’t enough to go around in some cases. As the guy who runs the lab says, “When everything is stat, nothing is stat.”
November 2, 2007 at 10:08 am
When everyone is on driveby, nobody is on driveby.
November 2, 2007 at 11:10 am
I resent the statement that as a working stiff who has insurance I don’t understand how much medical care costs. I certainly DO know that the cost of the emergency appendectomy I finally managed to get after visiting not one but two ERs exceeded 20 grand, and I certainly DO grasp the concept that my insurance rates are sky-high because hospitals have to provide free treatment for the indigent and for people who work in jobs that provide no insurance.
When I went to the ER of one of the major hospitals in the sixth-largest city in the nation with acute lower right-quadrant pain and vomiting, I sat outdoors on a cold stone bench for four hours with exactly NO attention. Next to me was a young woman who had been there longer than that; she was miscarrying a baby. She also had received no medical care.
Finally along about two in the morning I called some friends and asked them to come pick me up. The floors were two filthy to lay down on, and because the pain was so intense I could no longer sit upright. I might die at home, but at least I would die in a bed.
At dawn I called my doctor’s office at the Mayo. The doctor on call told me to dial 911 and have them take me to the Mayo hospital. I said I did not think they would take me to the hospital of my choice. She said they had to. When the 911 crew showed up at my door, they proposed to take me right back to the place where I’d languished for hours with no attention. They flat refused to take me to the Mayo, which is no further from my house than the hospital in question and in fact, because it can be reached by a freeway rather than over the surface streets, is actually a shorter drive in terms of time.
I sent them away and had another friend drive me to the Mayo. Finally–after 23 hours of suffering acute appendicitis–I got some attention; at the Mayo I was promptly carted into surgery. I was 60 years old at the time…those of you who are medical doctors undoubtedly understand the implications of this set of conditions.
The message here is that if you have lots and lots of money and you can afford to go to the Mayo Clinic, which is serves a part of the city where middle-income earners cannot even think about living, you can get decent medical care. The rest of us slobs can go to places where doctors think we’re faking when we say we have acute belly pain, where the check-in staff gives you a dirty look when you can’t help throwing up, and where some doctors evidently think everyone is so stupid we don’t even know what medical care actually costs.
November 3, 2007 at 6:22 pm
Thanks for the plug, Thanksgiving and Christmas are coming up and the kids (that is right, no matter what you think about the war these are kids we are talking about) are a long way from home and loved ones. The appreciate knowing that we are thinking of them. They especially enjoy magazines, newspapers, DVD’s, CD’s, cards and letters. Everything you send is enjoyed by the whole base. Thanks again.