Hospital Diversion

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.

This creates a tough challenge for me. As the newspapers and ACEP present it, this policy clashes with my reasons for choosing a career in emergency medicine. But I've also held that innovative solutions for improving access to medical care should be able to 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 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. And as Ben points out below, it is important to see both sides of this story. But the impression of the program will suffer. Is that a risk I want to take in assembling my rank list?

If you're in my ethics class, we'll be focusing on this issue in two weeks.

Pet Therapy

A few months ago, we had a different sort of patient show up to the psychiatric emergency department. It had brown hair, floppy ears and four legs.

Read about it at my article on the Medscape blog. You'll need a free Medscape account if you don't already have one.

Residency Interviews

Finished with interviews for 3 weeks and I'm still brimming over with thoughts about the process. This time, I'm concerned about my horrible carbon footprint secondary to traveling to so many cities. Read about it at The Differential.
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NTSB vs Flight Medicine

There are a few emergency medicine programs that require residents to fly on helicopters. I will not be ranking those programs at the top of my list. MedEvac is an important part about emergency response and I respect the folks who fly a great deal, but I'm not sure it is a necessary part of my hospital training. Especially when more that 35 people have died in the last year on medical helicopter flights. The National Transportation Safety Board is hearing testimony about this issue this week.

Privacy

I'm finishing up preparations for a lecture on confidentiality and privacy for my Ethics in the ER course Wednesday, and came up with what I think is a great hook for discussion about a topic that is usually greeted as dry by many in the medical field. Here goes:

Who remembers their online HIPAA training course? If your experience is like mine, the topics of privacy and confidentiality seem like boring topics. This week on the blog, several of you posted very interesting accounts of dilemmas concerning confidentiality. If you didn't get a chance to read them yet, I'd encourage you to do so. So perhaps privacy isn't as dry as I first thought? Let's say you're not convinced by your classmates' challenges.

I'll step back a bit. Our medico-legal system may reinforce privacy as a topic learned by rote and repetition, but it gets a lot more interesting when you consider that this issue is at the core of the arguably most controversial Supreme Court ruling in the last half century. Can anyone guess what I'm talking about?

Roe v Wade was decided not based on statutes governing assault, or autonomy, or even Aquinas' principle of double effect. You couldn't guess that from the expressions, “right to choose” or "right to life."The case was decided on matters of privacy. Roe v Wade held that a woman's decision of an abortion falls well within privacy afforded by the 14th Amendment and the Bill of Rights. And since abortions these days are almost always in a medical setting, it's easy to see how the privacy from the state bleeds into the confidentiality afforded by patient-physician relationship.

If you are in the course and happened to find this post early, consider yourself a planted answer if no one responds to my question!

Straight from the Medical Record

Sometimes information in medical records cracks me up. Take for example these excerpts from a note for a patient I helped care for:

Interval History:
Had a good day, with an especially lucid morning. Enjoyed throwing rubber chicken into sink. Family pleased with progress.

Exam:
NEURO: Continues tremulousness, is mostly non-verbal (per family, is exhausted and getting cranky after busy morning). Throws rubber chicken onto attending physician and into sink.

ATTENDING STATEMENT:
I personally saw and evaluated the patient. She did seem to enjoy throwing a rubber chicken at me and into the sink. I discussed the patient with Dr. XXX. I agree with the findings and plan as documented in his note.

The moral? Rubber chickens never fail to amuse.

Critical and identifying information has been changed to protect this patient's privacy.