Del Meyer, MD, Pulmonary Medicine

MedInfo Health Line

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2005

Using Health Care Resources While Waiting in the Emergency Room

A forty-year-old lady with a tender breast bone that she called chest pain in the hospital emergency department, spent four hours in an exam cubicle from, 8 PM to 12 MN. The triage team had ordered a chest x-ray, electrocardiogram and a number of lab tests. She was told at midnight that it would be another six hours before a doctor would be able to see her. She then left with the pain did not changed. The next morning, she scheduled an urgent office visit, went by the emergency departments and brought the x-rays, ECG and lab work to the office with her.

Her tender chest pain was costochondritis, a benign painful cartilage between the sternum and the ribs, which took ten seconds to diagnose. I immediately gave her two extra strength acetaminophen tablets and continued to see other patients. On returning to her room twenty minutes later she felt much better and returned home. The chest x-ray, ECG and laboratory work were all unnecessary costs, as was the entire emergency visit.

How can this be avoided? As long as ER visits are relatively free to the patient ($15 to $50 ER copay are not market based and thus have no major effect on excessive utilization), there will continue to be overutilization and exorbitant costs. A percentage copayment returns the ER to the market-based controls. If the patient pays a percentage of every test and procedure, the patient will put a stop to excessive utilization and use normal channels of health care,like the doctor’s office visit, which is the most cost-effective health care expenditure.


A New Way to Commit Suicide

A patient with obstructive sleep apnea came in for his annual evaluation. He had been snoring for decades, but about six years ago, his wife noted that his snoring stopped abruptly in the middle of the night. She observed her husband and noted that his chest was still moving, as if he was breathing, but there was no snoring. She then put her hand over his mouth and nose and did not find any air movement. She woke her husband immediately and after a loud striker, he began breathing. She insisted he see his pulmonologist as soon as he could obtain an appointment. He was immediately place on a Continuous Positive Airway Pressure (C-PAP) device to wear at night and scheduled a Polysomnogram (sleep study). This confirmed the diagnosis of sleep apnea (no breath) and determined the optimal pressure to set the device to assure continuous breathing while asleep.

As I was finishing my exam and writing his prescriptions, he casually mentioned that a friend of the family, who had sleep apnea, also had severe respiratory failure requiring oxygen. His C-PAP was powered by oxygen pressure rather than compressed air. The friend was getting increasingly depressed over his disability and told my patient that sometimes he thought that he would just turn the machine off and end it all. Although my patient tried to joke him out of this approach, he apparently decided one night that he'd had enough. He apparently turned off the machine and the oxygen and quietly died during the night.

With all the emphasis on physician-assisted suicide, it is indeed unfortunate, if not absolutely heinous, that physicians should play the role of executioner. That such a proposition can be passed by public vote underscores the lack of basic medical knowledge we have been unable to provide to the public. They don't need an executioner to write a lethal dose of barbiturates. The patients have numerous lethal doses already in their possession. Most patients now get a 90-day supply of medications. If there are any cardiac, blood pressure, narcotic, hypnotic or psychiatric medications among them, it would not even take a full bottle to do the fateful tragic deed. Whether in The Netherlands, Oregon or Europe, we should never have to worry about whether our doctor is wearing the white coat of healing or the black cloak of an executioner.

A doctor in The Netherlands confided in me during a break in a medical meeting in Amsterdam that he once admitted an elderly lady to the hospital. She said she worried about being put to death while in the hospital. The doctor I was speaking with assured her that he would watch over her to make sure that didn't happen. The next weekend, he signed her out to a colleague. When he came back on Monday, he looked for her and couldn't find her. The nurse said she had "died." He quickly summoned his colleague as to what happened. He was told, "We needed the bed." He said he now felt it was a horrible tragedy for physicians to be involved in assisted suicide. It is more often an execution.

Statistics in Oregon, the first state in which physicians are allowed to kill patients who request it, indicate that perhaps as many as half of these patients have not signed a valid request that they wanted to be executed. These hospital mistakes are completely permanent. They are not simple medication errors that the Institute of Medicine feels are so tragic. Many of them are inconsequential and can be reversed. Physician execution of patients can never be reversed.