Sunday, August 21, 2016
Just When You Thought American Healthcare Could Not Get Any Worse.....
I was on a vacation/family reunion last weekend about 150 miles north of the Twin Cities and 120 miles west of the only large northern metro area. We were in the heart of lake country and about an hour from the closest emergency department (ED). About 20 people of all ages there for a few days to get reacquainted after a number of years, enjoy some good traditional foods, and outdoor activities. Things were going very well until the last day. Everyone was exiting the lake home to go to a local pizza establishment. One of the family members missed the last step and fell hard to the pavement, knocking the lens out of his eyeglasses and sustaining a contusion/abrasion over the left supraorbital ridge. No loss of consciousness. He did sustain an abrasion on the left hand with some residual wrist pain. He has some chronic medical problems but is not on anticoagulants. Another family member is a nurse and applied an ice bag and cleaned a small laceration in the area of the abrasion. It did not appear to need sutures and it was steri-stripped.
The only other bit of information that is necessary about the injured man is that he is 80 years old. As a geriatric psychiatrist I ran down the usual considerations of the old approaching the old old - especially anatomic traction on bridging veins and subdurals from that injury. I did not want to miss any needed brain imaging protocol based on these factors. I decided to call the local hospital emergency department and run it by the triage nurse. The call went like this (this is not a transcript).
Hospital: "Can I help you?"
Me: "Yes - I am currently out at a lake cabin and a family member took a fall and struck his frontal area. No loss of consciousnesses, headache, visual change, or neurological findings. I would like to talk to your ED triage person to see whether imaging is indicated."
Hospital: "Is he from Minnesota?"
Me: "No he is not."
Hospital: "We cannot allow you to talk with the ED if he is not from Minnesota.
Me: "Are you sure about that?"
Hospital: "Yes very sure."
Me: "I am a physician - is there any way that I can talk directly physician-to-physician with an ED physician."
Hospital: "No you can't. You have to call the number on the back of the insurance card."
That was a precedent setting call for me. I did not identify myself as a psychiatrist, but I have really never encountered this kind of administrative obstacle to medical care. I viewed my question as an important one and one that an ED physician would probably know more about than me. In that context there was something about an out of state resident not getting equal access to medical care. I am sure it would be easier to get access in France or Germany than it was in Minnesota. I collected the medical card and made a second call to the nurse triage line listed on the back of the call. My experience with nurse triage lines is that they at least call the physicians on call and get some semblance of an answer to your question - even on the weekends.
Me: Explaining the situation again in its entirety and giving all of the relevant insurance information both on and off the card. The off card data included date of birth and three repeats of a call back number. It was at that point the triage nurse said:
Triage RN: "Well I am afraid I can't help you because you have to talk with a nurse who is licensed in the state where your relative resides. But I will transfer you."
Cricket sounds and bad muzak for about 5 minutes.
Triage RN (back on the line): "The wait times are too long. Let me just tell you that as long as he has no headaches, nausea, vomiting, visual changes or neurological symptoms - you can just watch him. Bring him to the ED if any of those symptoms occur."
Me: "OK - there is no imaging study given his age?"
Triage RN: "No".
As multiple posts on this blog can attest - I am openly critical of how business and government interests have rationed access to health care. I had really never imagined obstacles to standard health care based on your state of residence. I had never encountered a system that refused physician contact with another physician in their system. I can see the gears turning on how to turn these calls into billable fees, even if it means a steep out-of-pocket payment by the patient. But even in that case giving me the correct medical information is money in their pocket if it results in a CT scan. Medical imaging generally covers about one-quarter of the operating budgets of hospitals these days.
For now it appears that after hours physician consultation may be rare and a sequence of calls based on legitimate concern needs to be answerable by a triage nurse's database or a visit to the emergency department.
And you better hope that you are in the right state.
George Dawson, MD, DFAPA
Supplementary (posted on August 23):
Getting back home and doing a little more research shows that both the Emergency Medicine (2) and Internal Medicine (1) literature say that age alone is an indication for a CT scan following a minor TBI. UpToDate says that age 65 years of age or older is an indication. The emergency medicine literature uses New Orleans Criteria suggesting an age of > 60 and the Canadian CT Rule suggesting an age of > 65 under CT if any criteria present. According to these criteria - age alone is an indication for a CT scan.
1: Randolf W. Evans. Concussion and mild traumatic brain injury. In: UpToDate, Aminoff MJ, Moreira ME (Eds), UpToDate, Waltham, MA (Accessed on August 22, 2016). - see graphic 50743.
2: Haydel M. Management of mild traumatic brain injury in the emergency department. Emerg Med Pract. 2012 Sep;14(9):1-24. Epub 2012 Jul 20. Review. PubMed PMID: 23101569. (full text online).
That's me walking on a dock in Lake Country.