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A Free Meal

Peanut Butter Sandwich

“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.
I agreed.

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.”
“Sorry, no.”
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.”



  1. “By having an insurance policy that provides everything at no cost to the consumer, there is no incentive to limit consumption.”

    Welcome to 2014: The Year Obamacare Destroys Healthcare.
    Coming to an ambulance bay near you, soon.

    But it’s the natural outgrowth (Stage IV, in fact) of EMTALA.
    If Congress had passed an unfunded mandate that McDonalds had to provide a free meal to everyone who came through the door claiming hunger, regardless of ability to pay, the entire chain would have gone bankrupt in about a month. The miracle here is that healthcare in general has cut as many corners as it can to keep providing an impossible level of care despite the nonpaying hordes seen every day.

    Last December, 25% of the physicians in my ED’s practice group turned in their retirement papers. Only two of them were ready to retire; the rest just didn’t think the game was worth the candle anymore.

  2. As a family that has “an insurance policy that provides everything at no cost to the consumer” I am quite pleased to see that my wife and I are in the minority of patients.

    I am not a fan of testing if it is not indicated. Perhaps it is because I work in a tech field and I get a bit of the “Have you checked for ….” syndrome.

    My opinion is, I (through my premiums) am paying a fair chunk of change for your expertise and insight, why second guess you? If I thought I could do better, I would not have come to see you.

  3. Ed, your insurance policy isn’t providing everything at “no cost” if you’re paying premiums. I’m in that boat, too.
    There was a bit of a discussion on Twitter about cost controls imposed on patients who have government insurance. In Medicare they exist to some degree, in Medicaid they do not.
    That lack of cost controls is a HUGE driver of excess spending.
    The only checks on spending in Medicaid are market-driven rationing. Payment to providers is low, so most providers do not see the patients. Waits to see doctors in offices is excessive, so patients go to the emergency department where the waits are less and the patients have to be evaluated.

  4. so my sons and i have medicaid. and for my son’s, the care is good. it is easy to get in to the doctor and if i can’t, there is an associated pediatric urgent care that we can go to- just walk in, no appointment necessary. for me– well, let’s just say i was having severe pain in my side one day, and i called the doctor to whom i was assigned, and they said the wait for a sick appointment was two months out. i hate the emergency room, so i waited it out, the pain went away and all was well. but if the pain had gotten worse, i would have probably gone to the emergency department. my fault? i don’t know. what i do know is i can’t wait until my husband has a job that offers insurance. that’s a huge problem, imo- companies use temp services to fill positions to avoid having to offer any benefits. and that leaves the family or, in the end, the government/taxpayers to foot the bill.

    • “what i do know is i can’t wait until my husband has a job that offers insurance. that’s a huge problem, imo- companies use temp services to fill positions to avoid having to offer any benefits. and that leaves the family or, in the end, the government/taxpayers to foot the bill.”

      Okay, not to be mean, but why should it be either your husband’s employer’s or the taxpayers’ job to provide you and your family with health insurance? And you make it sound like employers are being greedy and cruel by arranging things so that they’re not on the hook not just for wages, but for health insurance costs for the worker’s entire family (including “children” up to age 26). The whole idea that a boss is responsible for the healthcare needs of all of his workers and their families has always struck me as almost feudal &/or paternalistic.

      Seems to me it would be far better for each person/family to take control of their own health insurance needs, buying their own policies, with charities and to some extent the taxpayer stepping up to help those who are truly indigent.

      I have a good quality and fairly inexpensive individual high deductible catastrophic policy. Since I’m paying out of savings for routine care, making an appointment to see a doctor would not have been my first inclination upon having a pain in my side, unless there were other symptoms. As you learned, a lot of things go away on their own after a day or two, and when it’s your own money you’re spending you tend to be a little more conservative when seeking care.

      But on that note, if you could put aside just one dollar a day, then if something really urgent did come up and you couldn’t find a doctor who was willing to lose money to treat you (as they often do with Medicaid patients) you’d have a $365 kitty to take yourself off to an urgent care center and be seen immediately. In my experience that could easy cover 2 visits a year. And being on Medicaid, if they found something REALLY wrong, they could then send you off to hospital where the taxpayers would pick up your tab so you’d be no further out of pocket.

      Anyway, just some thoughts. And I’m sorry if my tone seems judgmental or harsh, I’m just becoming a little exasperated that more and more Americans are being led to believe that it’s their “right” to get free all-you-can-eat healthcare. When Obama bragged that he was going to add 17 million Americans to the Medicaid rolls, I just thought “this is going to control health costs HOW?”


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