Krev wrote: Wed Apr 02, 2025 2:34 pm
After reading FM ErickC's excellent rebuttal to Billy Corgan's homunculus, I can understand why these underserved people could be taken by a conman bullshitter. The medical system is irrevocably fucked.
To clarify, I wasn't necessarily speaking about the Texas situation in particular; rather, I was using gallows humour to lament the dismal state of hospital closures in rural America in general while also pointing out that the rural EDs that remain tend to send pretty much anything they can get away with to the next level-of-care (whether it's appropriate or not) to keep their capacity up because their resources are so strained already.
I don't think most people truly understand the depths of how messed up emergency medicine is right now.
Up here in Rochester you can add these (often unnecessary) transfers to the running tally of daily EMS transfers to the ED from local skilled nursing facilities and assisted living facilities for minor issues, some patient-initiated and some facility-initiated, where the patient did not need to come to the ED, but the patient or facility insisted (you can speculate on the reasons, but I'll tell you right now that a lot of patients
really enjoy the one-on-one care they get in the ED and a lot of facilities
really like the idea of decreasing their census a bit for the night or having someone else deal with a medical issue now instead of waiting for their following physician to see the patient tomorrow or utilizing teleconsult services).
Needless to say, with the larger EDs being level I trauma centers and actual emergencies (like, you know, cardiac arrests, strokes, severed limbs) taking precedence, the waiting rooms get very full very quickly, as do the patient rooms and the pressure to get people discharged is enormous. This is part of what's driving serious ethical issues with hospital discharge policies, because the hospital targets vulnerable populations (the poor, the homeless, people with substance use disorders or mental health, pediatric boarders who aren't safe to return home for a variety of reasons, typically behavioural dysregulation or who have no real disposition options, undocumented immigrants, people withdrawing from substances "who seem sober enough to me," et c.) for immediate discharge, safety be damned.
And when hospital leadership talks about the problem of repeat ED admissions, they always ask us to target these patients for discussions because one or two patients with chronic mental health or substance use had visited the ED many times in the past year, and maybe needed a $10 cab ride, but they're happy to turn a blind eye to the multitudes of relatively affluent and privileged white seniors living in facilities who made fewer visits each, but collectively number a large number of visits, and who never had any medical reason to come to the ED in the first place, who now need a $150 wheelchair ride or $250 stretcher ride back to the facility on each visit and refuse to use their own resources (until the charity coffers run out, at which point they magically discover they had the ability to figure it out all along and the poor can just deal with it, too bad for them). I'll give you two guesses as to whether this particular group of seniors, who insists that they have earned the right to be helpless and that the hospital staff need to solve everything for them, tends to blame "immigrants" or "billionaires" for their problems. Welcome to a world where health care is overrun by the "me" generation.
Mind you, transporting the patient back to the facility is all predicated on nursing being able to call report to the facility. Conveniently, often nobody answers the phone at night... guess the patient will have to stay until the morning when staffing at the facility improves. Probably coincidence.
Why would we have serious discussions with area facilities on when it's truly medically necessary to send someone to the ED versus using the teleconsult services we spend so much money to offer them or have tough discussions with patients who prefer EMS to Pepto Bismol when we can just drop the hammer on the most vulnerable patients instead? We can board a patient overnight if it's not safe for them to return to their facility without an available stretcher van, but if it's not safe for a committed patient who is an imminent risk to themselves to be discharged to the streets and there's a CBHH bed tomorrow if we can hold them for a night? Fuck 'em. That's the county's problem. The needs of the profitable patients come first.
So the waiting rooms get busier and busier and the resources get slimmer and slimmer and the pressure to discharge gets higher and higher and the conduct gets shadier and shadier and somehow this isn't a problem to anybody. Leadership doesn't care about anything but discharging people who aren't going to admit to an ortho or other surgical service. The ED doesn't make them money. If they had their way, we wouldn't offer psychiatric care at all and EMTALA wouldn't exist.
