“What’s their problem?”
The nurse was both upset and frustrated.
The patient was a 16 year old young man. He had a fever for a few days and was vomiting … like half the other patients in the emergency department this week. Unfortunately, his mother was a hospital lab tech, so she knew a little bit about a lot of things.
Her requests started about 20 minutes after they were placed in a room. “Can’t you just line and lab him before the doctor sees him?”
He didn’t look that bad. Membranes moist. Vital signs were acceptable except that his heart rate was in the 140 range. OK. Fine. Here’s some IV fluid and we’ll do a couple of labs.
The nurse missed the first IV. The mom refused to let her try a second stick. “Nope. You get one chance only. Call someone with more experience.”
So they had to call the IV team. Which took more than an hour to arrive because they were so busy. In that time, the mom requested two pillows, blankets, grape Gatorade, and some IV Zofran.
When the IV team showed up, the mom wanted the patient to have D5 .45NS instead of normal saline. After all, he hadn’t eaten in a few days and could use the extra sugar.
Then the patient’s father arrived. He was reportedly a physician from another country who hadn’t been licensed in the US yet.
Why hadn’t we tested the patient for sinusitis? At least we needed an x-ray of the sinuses. After trying to reason with the doctor that sinus xrays are a poor method of determining sinus inflammation, that the patient had no symptoms or sinus infection, and that the treatment wouldn’t change anyway, we just ordered the x-rays. Press Ganey scores, you know. Oh, and in case you were wondering, the x-rays were normal.
All the labs were also normal … except a WBC count of 14. Great.
Doctor says “obviously that means he has a bacterial infection, what are you going to do to work it up?” So we went further down the rabbit hole. More fluids. Add urinalysis and a chest x-ray.
“How do you know he’s not septic?”
The fact that he’s sitting there smiling and texting people on his iPhone 5 was probably a pretty good indicator. I wonder if they’ve ever done a study about iPhone use in the emergency department and severity of illness.
“He doesn’t really appear septic to me.”
“But what about his elevated pulse and his fever?”
Flashbacks of a certain New York Times article and wayward journalist came to mind. OK, we’ll add blood cultures and a lactic acid.
The nurse mentioned that it almost seemed like they wanted the patient to have all this testing done.
The rest of the tests came back normal. Finally the patient’s pulse was in the 110 range. I broached the subject of discharge.
“Did you do a flu test?”
“He doesn’t have symptoms of the flu. And even if he did, he is outside the treatment window, anyway. Recall that his symptoms started a few days ago.”
“Maybe you could prescribe him Tamiflu just in case.”
“I’m sorry, but Tamiflu isn’t indicated for your son, the medication is expensive, and it has side effects.”
“Oh, and can you at give him some Claritin D before he leaves?”
“No. We don’t have Claritin D in the emergency department.”
“So can you at least give us a prescription for Motrin and Tylenol?”
“A prescription? You can pick that up at the dollar store over the counter, you know.”
“But our insurance will pay for it if we have a prescription.”
So despite the large amount of care and excellent service that they received, the parents were still unhappy because they would have to pay out of their pocket for ibuprofen.
So what was the family’s problem?
One word: “Insurance”
By having an insurance policy that provides everything at no cost to the consumer, there is no incentive to limit consumption.
If anyone was offered a “free meal” at a restaurant, most people would order a six course meal and then stuff their pockets with dinner rolls to eat at home later. How many people would have a peanut butter and jelly sandwich and then leave?
As the father was leaving, he looked at the nurse and said “You don’t look well. Maybe you have a sinus infection.”
She smiled back at him and said “Thanks. I’ll go pick up some Claritin-D at the pharmacy after work tonight.”