A Pitibull Situation in Chicago
Shadowfax has been following the case of the child in Chicago who was attacked by a Pit Bull and discharged from the ER without his apparently severe facial lacerations being closed. This post started as a reply but got too long, so here it is.
Delayed wound closure, even of a dog bite to the face, is not necessarily unethical and in some cases (heavy contamination, lack of specialist availability, delayed presentation) is itself the standard of care. Referral of uninsured or Medicaid patients to county facilities is not unethical either, and in many situations is the only reasonable option available. More and more physicians are refusing Medicare, Medicaid, and the uninsured, so there is no guarantee these patients will be seen when they follow up as an outpatient unless they go to a county facility.
It's the combination of these two issues that is controversial. Activists are using the drama of an "untreated" disfiguring attack (on a child!) to advance their socialized medicine agenda, much like their ideologues use the "unfairness" of foreclosure to advance their Socialist goals.
While it's tempting to blame Michelle Obama and the hospital policies she reportedly helped design, this particular disposition was made in the trenches by an ER doc, not in the upstairs offices by a committee. Not having seen the wounds, it's hard to comment on the propriety of the decision, but I will say that it's becoming increasingly difficult to have Plastic Surgeons come to the ER to repair wounds, much less to have them admit these patients. The days of "if a patient requests Plastics, then they get Plastics" are becoming but a fond memory.
I've personally had to suture several uncomfortably complex wounds I would have much rather had a specialist fix because the specialist just wasn't going to come in. "Just do the best you can to get it together, and I'll see them in my office," they say. We wield the "last resort" of requiring their presence via EMTALA with caution, because if we use that weapon injudiciously we might find ourselves out of a job. So we do the best we can and move on to the next patient.
There are few wounds that *have* to be fixed right away and even some gaping disfiguring wounds with flaps hanging about can technically be approximated, bandaged, and cosmetically fixed later. Is this the type of care that I'd want for my own son? No, but I pay for my own son's medical care. This controversy isn't about wound care though, it's about indigent care. Everything is politics.
Delayed wound closure, even of a dog bite to the face, is not necessarily unethical and in some cases (heavy contamination, lack of specialist availability, delayed presentation) is itself the standard of care. Referral of uninsured or Medicaid patients to county facilities is not unethical either, and in many situations is the only reasonable option available. More and more physicians are refusing Medicare, Medicaid, and the uninsured, so there is no guarantee these patients will be seen when they follow up as an outpatient unless they go to a county facility.
It's the combination of these two issues that is controversial. Activists are using the drama of an "untreated" disfiguring attack (on a child!) to advance their socialized medicine agenda, much like their ideologues use the "unfairness" of foreclosure to advance their Socialist goals.
While it's tempting to blame Michelle Obama and the hospital policies she reportedly helped design, this particular disposition was made in the trenches by an ER doc, not in the upstairs offices by a committee. Not having seen the wounds, it's hard to comment on the propriety of the decision, but I will say that it's becoming increasingly difficult to have Plastic Surgeons come to the ER to repair wounds, much less to have them admit these patients. The days of "if a patient requests Plastics, then they get Plastics" are becoming but a fond memory.
I've personally had to suture several uncomfortably complex wounds I would have much rather had a specialist fix because the specialist just wasn't going to come in. "Just do the best you can to get it together, and I'll see them in my office," they say. We wield the "last resort" of requiring their presence via EMTALA with caution, because if we use that weapon injudiciously we might find ourselves out of a job. So we do the best we can and move on to the next patient.
There are few wounds that *have* to be fixed right away and even some gaping disfiguring wounds with flaps hanging about can technically be approximated, bandaged, and cosmetically fixed later. Is this the type of care that I'd want for my own son? No, but I pay for my own son's medical care. This controversy isn't about wound care though, it's about indigent care. Everything is politics.
Labels: health care crisis, links to greatness
posted by scalpel at 9:36 AM
19 Comments:
You're always kind of an asshole to the poor. No, really. In the same way that you accuse proponents of socialized medicine sifting through the evidence to see what they want to see, you see patients on public assistance the same way to justify your beliefs.
Life itself is kind of an asshole to the poor, I'm just pointing it out. I don't see poor people any differently than I see anyone else. Even well-insured and wealthy people aren't always able to get immediate specialty consultations in the ER, but they are more likely to get more lavish and timely followup.
I don't think that is unfair or unethical, as long as everyone eventually gets the care they need.
I have insurance, and I still sometimes recieve rotten care !! Stacy.
oh and I don't let that get by you know!!
You don't pay for your son's care any more than I do and I've always, probably like you, ENsured that my family is INsured. Insurance companies, hospitals, and our industry in general leverage the cost of treating the poor onto the insured so that it's never so simple as to imply that you pay and they don't. You don't pay the full bill, not a chance.
Speciality care is a huge issue but the ED in this case took the heat and made us ED docs look bad for what is essentially a lack of speciality coverage--we're made to look bad for being left in the lurch.
Scalpel—I have lived a privileged life. I was born privileged and secure with everything I needed to keep myself safe, nourished, educated and healthy. The fact that I was born to intelligent parents who always did the right thing for me guided me to make good choices as an adult. One thing I know for sure is that I could have dealt a different hand.
I am so glad that I haven’t lost touch with the fact that the majority of the world is not as fortunate as I. You state that you pay for your son’s medical care. Really? Are you sure? I know that I don’t pay the full bill for my family’s medical care and I’m guessing you don’t either. I also know for a fact that my ability to provide insurance for my family is a privilege.
Omnipotent Scalpel?
Whether I'm paying the "full price" (whatever that is) of medical care or not, if I'm paying $1000/month for insurance plus whatever copays and deductibles are required, then I believe I should expect to receive better service than someone who pays zilch, and in fact whose "lack of privilege" (or incentive, or intelligence, or ability, or whatever) a significant portion of my exorbitant taxes are already subsidizing so that his unprivileged life doesn't suffer in other ways.
You, apparently, do not. You are entitled to your opinion, comrade.
you expect better service than those who pay zilch? you do see poor people differently and as far as I can tell the medicare patient must be really be your shit list because what they paid in has long been used up and we're footing that bill too.
I pity the unfortunate among us who believed the lies told to them by our previous Socialist leaders regarding the ability of Medicare to meet their healthcare needs. When you rely on the government (or anyone else) to provide for you, you shouldn't complain when that which is provided is less satisfactory than you had hoped.
Them's the breaks.
On July 3 2007, I fell off a 40 foot cliff, ripping my face open on the way down, as well as shattering a hip.
The tear on my face went from above my nose, up into my hairline, and over to come down by my right ear. My face was half ripped off. Needless to say, this would leave a disfiguring scar.
Since I already have other scars on my face, my wife didn't want me to have the emotional impact of more, so she requested a Plastics consult in the ER I was airlifted to.
Didn't happen. I was fully insured, with very good coverage, but she was essentially told that the plastic surgeons weren't available at that time. Scar's still there, and I figure I got off lucky with it, although I wish it wasn't there.
Point is, an ER is for keeping you alive. Disfiguring problems requiring plastics are rarely so important as to get involved at the ER level.
Some wounds need to be left at least partially open. Not all of the facts are presented. Anons and trolls shouldn't make half brained assumptions about his care and to conclude his care was less than proper. There are many possibilities and none of you know what actually happened.
I posted anonymous 04:58:00 PM
I recognize that tax payers subsidize non-taxpayers. There is huge cross-subsidization in the medical field. In fact, I believe this is true of all essential services.
However Scalpel, an uncomplicated vag birth uses up more than a year in premiums. Well baby checks are costly as well. Heaven forbid a preemie or congenital issue. Gee.. if by chance I or my husband or worse yet..one of my children receive a horrific diagnosis which requires expensive testing and treatment it wouldn't take very long before my insurance premiums, collectively, fall far short of the coverage needed and I become the one being subsidized. Insurers are so cut-throat that in spite of having good coverage, assets, and income I could be left hurting. I would like to think that I would be worth more than that to an ER doc should the situation arise.
At that point you would be *worth* the same as anyone else. You just wouldn't be able to afford the same level of medical service (or home, or car, or entertainment) as you did previously.
Why the heck should anyone who suffers a catastrophic illness/event expect to remain financially secure and have society take care of them forever? I pay a bundle for disability, health, and life insurance, and I save as much as I can, but I still understand that if I have a catastrophic event that I'm pretty much screwed (just less severely than I would be otherwise). That's just the way life is, and no amount of nanny-state manipulation is going to change that.
Read this, if you haven't already. There are 4 parts.
i think how a nation takes care of its truly disadvantaged says a lot aout that nation's soul..the too bad too sad arguement is sad since we are all by the grace of god one step away from that. How do you feel about the first responders at 9/11 who are now suffering the consequences of breathing all that toxic substance..is that just another tough luck charley life ain't fair get over it mantra?
I'm defending the discharge from an ER without suturing of a kid whose face got mangled by a pit bull, how do you think I would respond to your scenario? Sheesh.
I'm sorry they're having problems and I hope they get the treatment they need, but that doesn't change my position.
your position is you get what you pay for, life sucks and isn't fair and that people just need to get used to it. btw manda not a troll and think that kid eventually got care.he needed I'm old enough to be pre emtla and real dumps are ugly.
Scalpel, your four part series is outstanding. I won't get into a point by point critique or compliment, but suffice it to say that any reader of average intelligence should be able to derive something useful from it.
Occam's Razor says that all other things being equal the simplest answer (that is, with the least accompanying assumptions) is the one that should be selected. So a short exercise in logic:
1) We live in a capitalistic society. We direct our behaviors toward the acquisition of capital or we fail to participate fully. This explanation unfortunately relegates many of those who are unsuccessful (through whatever reason either within or without their control) at the acquisition of capital or apathetic towards its acquisition to depths of poverty. Capital is not restricted to money.
2)If you want any event to happen in a capitalistic society, you have to create an incentive for said event that rewards those whose actions create the event. This incentive (or decreased disincentive) must be in excess of the combined value of incentive and disincentive that person can receive for acting to create another event. This explains why medical pro's leave the status quo in search of other opportunities that pay them better (increase the incentive) or provide less stress (decrease the disincentive) or a combination.
3)It is not outside of the governments scope of power (as assumed in contemporary times) to decide which behaviors are to be rewarded and which are to be punished. By paying EIC on a per child basis, the Treasury, as directed by Congress, is encouraging people to have at least 2 children on paper and furthermore to maximize the value of each child beyond that by incentivizing illegal actions to get that money by removing consequences through the restriction of punishments for said illegal action. On the other hand, the Treasury, as directed by Congress, also gives (as of now) refundable credits for paying for a college education. This encourages parents especially to send their children to college. I have no doubt that this will also encourage otherwise honest people to act in dishonest fashions because they are hedging their bets that they can maximize their money for a minimal risk of getting caught. The point of all this is to say that the GOVERNMENT CAN ONLY SPEAK TO PEOPLE AND ENCOURAGE THEIR ACTIONS THROUGH CAPITAL. THE ONLY CAPITAL AT THE DISPOSAL OF THE GOVERNMENT IS MONEY. MONEY IS THE ONLY THING THAT TRANSCENDS THE DISCONNECT BETWEEN THE HIGH PILLARS THAT GOVERNMENT SITS ON AND THE DAILY CHALLENGES THAT THE REST OF AMERICA FACES. THE GOVERNMENT CANNOT DEAL IN THE CURRENCY OF MORALITY OR ETHICS BECAUSE YOU CAN'T TRULY LEGISLATE EITHER IN A SOCIETY THAT WANTS LIBERTY OVER ORDER. If you are looking for morality or ethics and you are looking for the government or an elected leader as your source, the void you are undoubtedly staring into will only get deeper and darker with the passing hours.
4) This all fits into the medical problems (which aren't medical but rather financial) that our nation faces. The government must incentivize good health habits such as maintaining low blood pressure, staying w/i a reasonable BMI, etc. and good health/financial policy like allowing doctors to write off charity care and to protect our medical professionals as a whole from frivolous malpractice. Government at this time is unwilling to disincentivize personal health habits because the collective thought of the nation has not been changed to an idea that an individual's bad health habits cost EVERYONE and therefore the collective has a right seek justice for the injury committed by the negligent. This goes for the negligence of practitioners as well. Society's members need to be aware that there are such things as due diligence in relation to medicine. I hope that most doctors act with their patients best in mind, but when they chase the paycheck by acting outside of the standard of care as providers, they too should be punished.
First, it is entertaining reading you slugging it out with the Anonymous posters. Second, I agree that the discharge probably violated no laws. However, one would have to see how bad it was to really comment on it. It it was bad in my opinion, I would cajole a plastics guy to come in a do it - I have a pretty good relationship with a few of them and give them a lot of piece-of-cake insured lacs to do (and I am sure they rack in the dough for those) so they would help me out if I phrased it right, expressing my concern for disfigurement. However, the lac might have been totally nothing, in which care I might have fixed it myself (or my PA) or done just like the Chicago person did. Someone please post a pic of the lac!
We can't have a picture of the actual laceration...the bleeding heart liberals in our nation and in our hospitals HATE confusing an argument with factual data.. It really louses up the pity-party!
Pattie, RN
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