money well spent?

NB: I wrote this in a hurry a few weeks back, it’s been sitting in the drafts folder since then. I’ve been reluctant to post something as it’s been so long since I have posted anything, well need to start somewhere.

It’s been a while since I bothered with the blog; a lot has happened in the interim, however perhaps not quite as much as I had wished and it’s just possible that this fact has contributed to my silence. But I felt compelled to share this and it wouldn’t fit in a tweet.

This past week was ACEP13, or the American College of Emergency Physicians 2013 annual scientific conference, here in Seattle. I enjoyed interacting via twitter and on the web with some of the dedicated and intelligent attendees, hopefully I did not antagonize anyone too badly.

The ACEP conference for those outside of emergency medicine, is generally billed as the future of the specialty, and I believe as do many involved in EM that it has a large influence on the delivery of all forms of healthcare. Now…

The other day while leaving the building I ran into my neighbor. He told me he spent five hours in the ER over the weekend as he rolled up his sleeve to demonstrate a bulky bandage encompassing his left forearm. He is a craftsman and works in wood as well as other materials. Apparently a few days earlier he had a piece of furniture grade plywood kick back at him while using a table saw, and slice open his left arm. The wood fragment lacerated the dorsum of his distal forearm. I had a pretty clear picture in my mind of my friend there in his workshop managing to call his wife while simultaneously bleeding through the rag with which he held pressure.

Naturally, they drove to the emergency department. I myself had been out of town at the time and in any case during the confusion they forgot about what I do for a living and I could see by the look on my neighbor’s face that that fact only registered when I said that I wished I had been around for you. I told him oh well, chatted a bit more and told him I’d be happy to take a look at his arm take the sutures out after ten days.

This whole story would be completely unremarkable except for the post that was forwarded to me from Facebook, it was written by my friend’s wife.

Redacted post appears here:

“Just opened the bills from {Xxxx}’s ER visit when he cut his arm using the table saw. I almost fell over. $97.76 for pharmacy (2 advil and 1 tylenol) $639.17 for an xray, $1904.03 for ER visit and $57.50 for preventative care service – are you Fricking kidding me!!! and another bill from {X medical group} for $556.20 not sure what for – the doctors maybe. Total $3254.66 so convenient with our $3500 deductible. SHIT!!!! I’m thinking we should just ditch the insurance altogether. Why are we paying $600 a month?”

*Brackets are my own.

This is my take:

I removed my neighbor’s sutures, to be specific (as if it were a medical record) I removed four simple interrupted sutures of 4-0 Prolene in their entirety and without complication, the pt tolerated the procedure well and three steri-strips were applied.

The wound had been well cared for, the wound edges were satisfactorily approximated, the sutures were taut, the knots were left over the laceration, there were adequate tails.
There was mild erythema as one would expect in a healing laceration of this acuity. There was no purulence, dehiscence or signs of an infection. In short, this was an uncomplicated laceration affecting an otherwise healthy male the trauma occurred by a minor MOI.

There would be no medical indication whatsoever to perform a radiographic study, even if there was a suspected foreign body it would be radiolucent, it’s wood! Perhaps you could argue for the use of bedside ultrasound if you really suspected retained FB, wait a minute, with US you could assess for fracture too all in less time then it would take to transport the pt to radiology never mind perform the study, return the pt to the exam room and wait for the PACS to load.

I fully respect pharmacists, they have saved my ass before and I understand we all need to get paid but please nearly $100 for OTC medication. Because of what, redundant allergy and dosing checks? Can’t we just assume that is covered in the hospital and provider fees? Don’t we always check: right med, right dose, right patient, right route?
I don’t even want to tear into charging for “preventative health maintenance” because the provider mentioned smoking.

Look, I’m a reasonable guy if I go into a particular kinda restaurant and order the Omakase or the Chef’s tasting menu where over in the price column it says MP, I know what I’m signing up for. But a) at least there is a menu, b) I chose this restaurant, I know, roughly, what the tab is going to be c) I know it is completely hedonistic to eat like that (I love it) but it’s a choice!

Now compare this to our healthcare (ahem) sickcare delivery system. a) there are no menu’s the public has no idea what these services cost or what they are being billed for, most providers don’t know the costs! b) a person who feels that they are having a medical emergency probably does not realize they have a choice or what those choices are.

Before this gets too expansive, I will say: could they have gone to an urgent care and not be subject to the costs related to running an ED 24/7 365? Of course. But for any providers reading this, ask yourself have you ever, ever, seen a patient in the ED or at triage and said: “You know, It’s gonna be really expensive for you to be seen here, you don’t look like you’re having an emergency that requires our services, you might wanna go to an urgent care”. Of course not.

We can do better than this, we have to do better then this.

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