emergency care


Chest Pain Is Top Item On Nation’s $80 Billion ER Care Bill, Study Finds

(Courtesy Dr. J. Slutzman, presented to the American College of Emergency Physicians)

(Courtesy Dr. J. Slutzman, presented to the American College of Emergency Physicians)

If you’re feeling chest pain that you think might be a heart attack, there’s only one thing to do, medical experts say: Seek emergency care. Do not pass go, do not collect $200. Or rather, do not think about the roughly $1,000 your care will cost the hospital. Your life may be at stake.

But at a calmer moment less fraught with risk, you might want to contemplate the bigger picture of chest pain and emergency care, as sketched out by Dr. Jonathan Slutzman of UMass Medical School and colleagues at a recent national conference on emergency medicine. To wit: Your costs are part of a national Emergency Department care bill that totals nearly $80 billion, including nearly $5 billion for chest pain alone.

Every year, Americans log a total of about 130 million visits to emergency rooms, Dr. Slutzman said. Among those visits, according to his team’s analysis of millions of records, patients who come in for chest pain are the single biggest line item on the bill.

“Chest pain is one of the two most common reasons somebody comes into the Emergency Department,” he said. “It’s somewhere on the order of 5 percent of all visits,” which may not seem like very much until you realize it’s 5 percent of 130 million, and each chest-pain visit costs about $1,000.

The grand total: $4.7 billion. It’s so high because chest pain is both a high-volume diagnosis and the treatment is high-intensity, Slutzman said, usually including blood tests, X-rays, sometimes CT scans and sometimes stress tests. They add up.

So now that we see that prodigious price tag, what is to be done?

Emergency medical specialists are working on that problem, he said, in part by figuring out what the “best practices” are for evaluating chest pain. “This is on people’s radar screens,” he said, “to try and ‘rightsize’ our care,” meaning that “we can safely treat many patients while doing less.”

To which I naturally responded: “Yikes. I don’t really want the system to be trying to save money when I might be having a heart attack.”

Slutzman calmed me down. His No. 1 takeaway from the findings, he said, is that more patients should probably be evaluated as to whether they’re having a heart attack without having to stay overnight in a hospital. Chest pain patients tend to be almost reflexively kept in the hospital for at least one night of testing, he said, “and a big subset of those people don’t really need it. One big key is more rapid access to outpatient providers. If someone can see their doctor in one to two days and maybe get some additional testing then, they can be safely discharged.”

That calmed me down a bit. I do believe in staying out of the hospital whenever possible.

He calmed me still further with a story:

Historically, back in the late ’80s and early ’90s, if you walked into an Emergency Department with chest pain, you got admitted to a cardiac Intensive Care Unit, pretty much no matter what, because there was so much concern that they could be missing heart attack. There was a lot of fear of that.

And then, over time, we learned more and more. We could read our electrocardiograms — our EKGs — a little better, we could learn a little bit more about what the squiggles meant, and which ones were dangerous and which ones weren’t.

And then we got more blood tests that were a little bit more sensitive and a little bit more specific, and a little bit better at figuring out who was having a heart attack and who wasn’t. Continue reading

Elderly Man (Me) Found In Snow With Punctured Lung But Still, At 79, I Ski

Author Ralph Gilbert, who suffered a punctured lung in a ski accident, and his son, Keith, his rescuer (Courtesy)

Author Ralph Gilbert, who suffered a punctured lung in a ski accident, and his son, Keith, his rescuer (Courtesy)

By Ralph M. Gilbert
Guest Contributor

Traumatic pneumothorax: the presence of air or gas in the pleural cavity, which impairs ventilation and oxygenation, caused by a severe trauma to the chest or lung wall. Symptoms are often severe, and can contribute to fatal complications such as cardiac arrest, respiratory failure, and shock.

Every time I tried to lift my head the sky began to spin. Then I felt the nausea. I knew that I had to get up out of the snow but after a few attempts, I just lay back, exhausted. Suddenly, a spray of powder was kicked onto my face as a young ski patrolwoman executed a hurried skid stop. She bent down and put her cold face next to mine:

“Sir,” she said looking into my unfocused eyes. “Are you all right? Do you know where you are, sir? Where are you, sir?”


I realized that she wasn’t asking a particularly hard question, but I just couldn’t come up with an answer.

“I don’t know,” I replied.

She helped me to my feet.I looked around and saw the other skiers.

“I’m skiing…right?”

She radioed for help. The next thing I knew, I was being leaned back into a toboggan. Fighting the nausea and afraid that I would have to throw up, I asked to be tipped over momentarily before they restrained me to the sled for my ride down.

I regained consciousness in a strange hospital ER.

A young woman was standing over me. She asked: “Do you really think, sir, that a man of your age should be skiing alone in the glades?”

I hated that question. I found it particularly humiliating. As an intrepid, former U.S. Army trooper, I didn’t want to be talked to that way, especially by a woman who asked me the same questions my wife often asked.

Tests indicated a concussion. Upon release, I was told to buy a new helmet (each helmet can absorb only one crash), and not to ski for a week. I took only one day off, which I thought was plenty. I then purchased a new helmet and two days later I was back up on my skis again.

My next accident a few years later was to be worse, much worse.

Age denial? Not So Much

Before I tell you that story, I’d like to note that I’m not in total age denial. Now 79, I spend less and less of my après-ski time trading embellished ski stories with my buddies in smoky bars. These days, when we go on our annual ski trip, I can be found at night alone in my little room, carefully applying ice packs and winding compression bandages around my ill-treated joints.

I reject the idea, however, that I am suffering from any age-related diminution of muscle tone, balance or endurance. My ski dreams are still intact even if my body is not. I do realize that I should avoid the super steep double black diamond trails that I once traversed. But I just can’t resist.

Why? By story’s end, I’ll try to explain.

Male Bonding

Each year, twelve of us, former army buddies at Fort Bliss, Texas go on a ski trip together. We had trained as Nike Missile crewmen back in 1958 during the Cold War. Our job was to join with others to protect the City of New York.Stationed in a darkened radar van, we were to monitor our radar screens for Russian bombers. Our Nike Missiles were buried in concrete shafts near us. Our vantage point was Spring Valley, New York, which otherwise is known for kosher chickens and Hassids. If we saw any Russians in the air we were to electronically challenge them, then shoot them down. Continue reading

What If Our Health Care System Kept Us Healthy?

Rebecca Onie is the cofounder of Health Leads, the Boston nonprofit that helps doctors “prescribe” basic necessities (housing, food, heat in winter) to low-income patients, in addition to just medications.

In her recent TEDMed talk, she asks some radical question: What if our health care system actually kept us healthy? What if doctors could truly prescribe solutions, not just drugs? What if ER waiting rooms around the country weren’t just places to watch the clock and read old copies of Good Housekeeping, but rather, were transformed into service-oriented, patient-centered hubs where, in a brutal New England winter, a family could go and a volunteer could help that family get the heat turned back on? Listen to Rebecca’s talk and get inspired:

Why An Emergency Medic Might Ask About Your Race

In his column yesterday, The Boston Herald’s Howie Carr makes it sound like Massachusetts medics are so busy these days filling out forms about their patients’ race that they may ignore the medical emergency at hand.

Howie’s rants are often enjoyable to read for their inflamed wrath, but this one struck me as so oddly lopsided that I asked the Department of Public Health what was up. Howie included just this from the Department of Public Health statement: “Patient health and safety must always be an EMT’s highest priority. Collecting this information must not delay nor prevent patient assessment or the provision of care.”

Here’s the whole statement, which makes clear that this sort of collection of patient data is a national norm, not a PC liberal plot:

Patient health and safety must always be an EMT’s highest priority. Collecting this information must not delay nor prevent patient assessment or the provision of care. State regulations (105 CMR 170.347) require EMTs to collect a variety of background information from patients, including their name, address, age, race and ethnicity, past health history, and medications that they are currently taking. Of course, if a person objects to responding, they have the option not to respond.

For years, more than 25 states — representing every region of the country — have been collecting this data and submitting it to the National EMS Information System (NEMSIS), and the other 25 states have committed to doing so.

NEMSIS is funded by the U.S. National Highway Transportation Safety Administration (NHTSA) in order to standardize collection of EMS data by creating a uniform data set that is used to compare and assess the quality of provision of EMS across the country. Similar data is collected in other areas of the health care system, such as hospitals and nursing homes. The NEMSIS system will catch the EMS sector up to the rest of health care in terms of having data-driven assessment available, and provide a valid way for looking at what EMS is doing, what are patient outcomes, and how EMS can be improved. Massachusetts is in the early stages of data collection and has not yet begun submitting data to NEMSIS.

Clearly, collecting data on race is a way of detecting disparities in how patients of different races are treated. Howie writes: “This is about a sick obsession by the liberals with somehow proving “disparities,” which there certainly are in this country, only they’re exactly the reverse of what the moonbats would have you believe they are.”

In actual fact, the data on disparities suggest that they’re not only real, they’re deeper than many of us might suspect. Here’s a post of ours on a national Massachusetts General Hospital study that found black and Hispanic patients were treated differently for chest pain. And here’s an overview of racial disparities in health from the CDC, an institution not generally considered a bastion of political correctness.