Final Online Challenge

Your last challenge is to complete this course survey. It should take between 10 and 15 minutes to answer all of the questions, but I'd ask you to consider taking a little extra time to write more lengthy comments. My only compensation for teaching the course is the privilege of the experience. Think of your honest responses as the currency of my payment. We're looking for candid feedback so that future incarnations of the course will improve. The names of the participants will be kept separate from the answers, and your grade will not depend on your responses, except that we are asking that you complete the survey before we file your grades.

THANKS!

Harry and Louise

In our final class, the focus will be on how issues related to access to health care impact emergency medicine. While we will not be able to go too deep into the political forces involved in this issue (they are many and strong), we DO need to keep in mind that they are out there and that we have the opportunity, if not the obligation, to speak out on behalf of our patients and for the sake of medicine itself. That's why I posted this week's challenge.

Back when the first Clinton administration was trying to reform health care, there was a series of commercials aimed at blocking the first lady's efforts. The commercials starred Harry and Louise. They were touchstones for the movement against "socialized" health care. View these ads and you will understand why vignettes (even poorly acted ones) hit home better than numbers.



What would you tell Harry and Louise? Fast-forward several election cycles, and it seems they are singing a new tune.



Is health care at the top of this president's agenda? Is everyone at the table?

Week Nine Online Challenge

57 million Americans had trouble paying medical bills in 2007. This is up 33% from 2003. In four years, more than 14 million more people went into debt or were contacted by a collection agency about healthcare costs. Hundreds of hospitals nationwide are in the red. These seem like frightening statistics, but historically, numbers like these fail to make meaningful inroads in public policy. My opinion is that unless we link human stories to crises, our minds tend to neglect the seriousness of the problem. And unless concerned citizens (who are nurses, doctors and EMTs) contribute to the local and national conversations, health care reform will remain theoretical.

This week's challenge requires you to put on your activist hat. With emergency care in mind, post a comment that furthers the discussion of health care system reform. Your response could take a couple of forms.

• Write a case vignette that tugs at the heartstrings of a concerned populace.
• Respond to last week's news story from the University of Chicago. (A boy was reportedly sent home to follow up at another hospital after he was attacked by a pit bull.)
• Teach us about a part of the local health care safety net that we can plug patients into.
• Hypothesize about how the worsening economy may change emergency medicine.
• How has pre-hospital care been affected by the current health care crisis?
  

Keep in mind that you don't have to be a Democrat or Republican to be concerned about the health care system. There are plenty of ideas from both sides. In case you are wondering how this fits into a medical ethics class, try to think about your responses using the rights and justice terminology.

EMTALA

The important law that will come to bear on our discussions this week is the Emergency Medical Treatment and Active Labor Act (EMTALA). This is a Federal law that places restrictions on medical care from hospitals that receive Medicare money. As with all legislation of this type, a majority of the written law addresses how it is to be enforced. This is definitely not breakfast table reading. If you are up to the task, visit the Health and Human Services web page to read the whole thing. (I did, and I still don't understand some of it.) I've included some choice snippets from the law that should help you understand the EMTALA basics. If you are not in the mood to be an EMTALA gunner, the American College of Emergency Physicians (ACEP) has some good resources, including an EMTALA Q&A, guidelines for appropriate interhospital patient transfer, and practice guidelines regarding taking blood alcohol levels in the ED.

I. General Information. EMTALA requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition. The term “hospital” includes critical access hospitals. The provisions of EMTALA apply to all individuals (not just Medicare beneficiaries) who attempt to gain access to a hospital for emergency care. The regulations define “hospital with an emergency department” to mean a hospital with a dedicated emergency department. In turn, the regulation defines “dedicated emergency department” as any department or facility of the hospital that either (1) is licensed by the state as an emergency department; (2) held out to the public as providing treatment for emergency medical conditions; or (3) on one-third of the visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis.

You're going to see a couple of potentially confusing abbreviations. Here's a key:

MSE: Medical Screening Examination
EMC: Emergency Medical Condition

Follow this link for the really juicy sections of the law. (Be sure to read them!) They are the sub-categories of 489.24. (Use the Table of Contents at the left of the .pdf when you link there, or just scroll down to the end of the document.) This section includes lay-person's language for how the law is to be interpreted. Here is the overview from the law.

489.24
Hospitals with an emergency department are required under EMTALA to do the following:

• To provide an appropriate MSE to any individual who comes to the emergency department;
• Provide necessary stabilizing treatment to an individual with an EMC or an individual in labor;
• Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC (or the capability or capacity to admit the individual);
• Not delay examination and/or treatment in order to inquire about the individual’s insurance or payment status;
• Accept appropriate transfers of individuals with emergency medical conditions if the hospital has the specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals;
• Obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer; and
• Not take adverse action against a physician or qualified medical personnel who refuses to transfer an individual with an emergency medical condition, or against an employee who reports a violation of these requirements.

The remainder of 489.24 includes details relevant to the exam the patient is asking for [489.24(a)] whether the patient's presentation is emergent [489.24(c)] or when is an appropriate time to transfer a patient to another hospital [489.24(e)]. The law even accounts for whether the patient needs to present anywhere on hospital property or in the ED [489.24(a)]. (It is anywhere on hospital property.)

Access to What?

Over the past decade, Americans are turning more and more to hospitals for care, continuing a trend seen over the last several years. For example, in 2003, hospitals saw more than 34.7 million inpatient admissions and nearly 111 million emergency visits - an increase in emergency visits of 11.6 percent in five years. This occurs in the context of reduced numbers of hospitals receiving emergency patients. Any ideas about why this is?

Diversion

This week, we're going to be wrestling with the difficult topic of access to care. There is a lot of attention on this issue that will only increase as the economy continues to sour. In emergency medicine, the conversation centers on diversion - or when it's appropriate to send patients to other hospitals. Please follow each of the links below to supplement your reading for next week.

Is it wrong for a university hospital to turn away a patient because he doesn't have insurance? What if it was a kid attacked by a pit bull? There's been a big splash in Chicago about a child with dog bites to the face being sent home to follow up at a different hospital. The situation has drawn criticism from the American College of Emergency Physicians, but the University of Chicago is defending its position to divert uninsured patients. This story's juiciness is enhanced by the direct connection between Michelle Obama and hospital’s Urban Health Initiative (UHI), which has as its goal to divert non-emergency patients away from EDs. It’s supposed to make the system more efficient by freeing up ED staff to treat the most urgent cases. But ACEP likens it to dumping unprofitable patients.

As the newspapers and ACEP present it, this policy clashes with one attraction for choosing a career in emergency medicine: being part of the urban health safety net. But shouldn't innovative solutions for improving access to medical care be implemented from within the ED? I didn't hear much about the UHI when I interviewed at the University of Chicago, but in a recent email to applicants, the U of C emergency medicine residency program director did say that resident training will actually not be very much different because of the University's policy. This makes a lot of sense, given that training occurs at four hospitals around the city and there are always patients in urban ED waiting rooms. As one of my friends (a student at U of C) points out, it is important to see both sides of this story. It sounds like the medical indications (not sewing up an animal bite wound because it had a high chance of infection) won out against the contextual features (it may look bad in the newspapers to send someone home with a loosely approximated animal bite wound).

Week Eight Online Challenge

"Nobody's Perfect!"

So goes the saying to console friends and colleagues when we fall short of goals or expectations. Personally, I have the feeling that in medicine, not being perfect isn't good enough. For this week's challenge, we're inviting you to do one of two things:

1. Write an account of a mistake you made or observed in a clinical setting. You may simply describe the mistake or reflect upon it by listing implications, detailing feelings or citing the ethical principles at stake.
2. Answer this question: What is different about mistakes made by health care providers that makes us uncomfortable to admit to them?

My contribution requires you to go to a different website. Last July, I made a mistake in the ED that was an amazing learning experience. Read it here then find your way back to post your own comment.