Car Accidents

Motor vehicle accidents can be a terrifying experience, and account for a large percentage of preventable injuries in the U.S. every year.

If you do a google search “When to go to the ER for a care accident” you will find dozens of web pages that tell you to go to the ER IMMEDIATELY following ANY/EVERY car accident.  You will also notice that none of these websites are medical, they are all lawyer sponsored sites.  That brings us to difference between legal necessity and medical emergency.

Think for a moment, what does a lawyer lose by telling you to go to the ER when you don’t need to?  Nothing.  If a lawyer sends 1000 people to the ER, and 999 of them go needlessly, what happens?  The 999 pay out of their own pocket for any co-pay, or for the entire visit if they are uninsured, while the one person who had an actual emergency  becomes a potential client of the lawyer and potentially sues someone else for their medical expenses.  This is a win-win situation for the lawyer, and a lose-lose situation for everyone else, the patient, the hospital, and the other driver.

The most important medical question you can ask yourself after an accident is, where do I hurt?  If you hurt somewhere, then you need to come and see me so I can evaluate you.  Nothing is more frustrating to me as a provider than when a patient comes to me after an MVC and tells me that they have no focal complaint or concern, and says “I just thought I better get checked out”.  I don’t have a test for that.  I cannot cat-scan every person from head to toe, it is wasteful and dangerous (radiation!).  The lawyer will say that you MUST get “checked out” right away in order to establish a relationship between  the accident and your injuries.  But, think for a moment, if you don’t have an injury, then I can’t diagnose one.

Here are some general guidelines, you should go to the ER following a car accident if:

The vehicle rolled over

The accident occurred at 35 miles per hour or greater

You were ejected from the vehicle

You were unrestrained and were hurt when you struck the inside of the vehicle

Airbags deployed in either vehicle

Anyone died in the accident

EMS had to extract you from the vehicle, or you were “pinned”

The vehicle is “totaled”

The car was damaged to the point that doors, dashboard, roof, etc. bent into the passenger compartment

Extensive glass breakage

You were knocked unconscious

You have extensive bruising, pain, an open wound, vomiting of blood, or any of the injuries I describe in my “Trauma” blog

You have fuel or glass in the eyes

If you have any FOCAL injury, especially neck pain, abdominal pain, difficulty breathing, or an obvious deformity

Generally speaking, you do not need to go to the ER if:

The accident is a minor “Fender-bender” with no airbag deployment and both vehicles are drivable

Police arrive and cancel the ambulance

You want to drive yourself to the ER, but first go home to shower or go out and get a pizza (this is only half joking)

Bottom line, I do not want you to suffer, and I want to identify and treat your injuries right away.  You are your own best doctor, so ask yourself if you feel you are hurt.  If in doubt, come see me so I can examine you and reassure you.

Remember, injuries aren’t like a fine pinot noir, they do not get better with age!


America’s REAL Healthcare Crisis

I had planned on the subject of my next blog being motor vehicle accidents, however; with the recent Supreme Court hearing on The Patient Protection and Affordable Care Act (Also known as Obamacare), I have decided to put that blog on hold and address some relevant national healthcare issues.

The purpose of this blog is not to take a political stance, nor is it to influence opinion on the health care legislation currently under review.  I do have an opinion on the matter, but shall reserve it for the time being.

What I hope to illustrate is what I feel are the real core issues of why Americans spend so much money on health care, and why access to that care is sometimes limited.  These are points that I believe most of my fellow health care providers will endorse, yet they are issues that politicians on both sides of the aisle have neglected to address.  And so, my dear readers, I shall endeavor to shine some light in a dark corner of the medical basement.

Americans like to feel good:

This is the greatest nation on earth.  Our forefathers endured a lot of suffering and hardships to get us where we are today, and for that we should be thankful.  Even the less fortunate among us enjoy a relative level of comfort to be envied by less developed nations.  We are generally well fed, well clothed, have a roof over our head, and go about our lives avoiding discomfort.  When we encounter pain or illness in our lives, whether it is physical or emotional, we want it to stop, and to stop right now!

Advertisements by pharmaceutical companies have only worsened this, as they portray their products as providing instant relief. One minute, the patient is in the throws of unimaginable physical and emotional turmoil, and the next they are smiling and laughing as they ride their unicorn over gumdrop rainbows, all courtesy of (Insert name of pill here).

What has happened is simple, we have become a nation that runs to a healthcare provider and the first sign of discomfort, rather than deal with it on our own or wait to see if it resolves without intervention.

Americans are well informed:

The information age has placed such a wealth of knowledge at our fingertips, via the internet, documentary television, and medical entertainment shows loosely based on fact.  As a result, the average American has a greater BREADTH of knowledge on medical subjects than they did a century ago.  However, the DEPTH of that knowledge has not grown at pace.  When an American has a stomach pain or a rash, they instantly go to the internet to research their malady.  The flood of information that ensues provides a long list of potential illnesses, some of which are quite serious.  The patient then becomes alarmed, and feels they must seek immediate medical care in order to prove or disprove the diagnosis.

Several times a month, I have patient’s tell me that the reason they are seeking care is that they have either read something on the internet, or have a family member with some level of basic medical training, which spurns them to come to the hospital to be “checked out” for a feared condition.  The subsequent costs of these visits, as well as the cost of the tests to prove that the patient’s fears are unfounded, add up to a staggering amount of needless medical expenditures.

Fast food nation:

Aside from the actual fact that fast food and our diet of excess in general has caused a litany of health problems, one should also take note of the fast food MENTALITY, and how it affects our health care.  Unlike decades ago, when Americans today decide they want something, then they want it RIGHT NOW.  In the process of wanting it NOW, we also want it our way, and with as little effort as possible.  Ever notice that there will be 15 cars in the McDonald’s drive-thru but no customers inside?  Americans want to sit in their climate controlled vehicles and listen to music while awaiting their rapidly prepared foods.  This mentality carries over to how Americans view their health care.  We want to feel better NOW, right away, and we want to do so in a manner that we dictate, preferably without leaving the comfort of our vehicle. The bottom line, we want drive through cures.  Just as you can suddenly decide you want fries and a shake, and pull off the highway for both, Americans want the freedom to suddenly decide they want their shoulder pain to stop and want the services at their disposal to have it completed in time to get home to watch Jersey Shore.

This is the real cause of Emergency Room overcrowding.  Several studies have shown that access to care and insurance have little to do with who goes to the ER.  Most non-emergent ER visits are a matter of convenience.  We are the drive thru, and are viewed as being easier and faster, even when our wait time exceeds six hours.  People FEEL like they saved time and effort when they come to the ER, even if their primary doctor could see them in a day or two, with minimal time in the waiting room.

Americans are special:

This factor has a two pronged effect.  On the patient side it is obvious; everyone wants to feel as if THEIR case is unique, and that they deserve a special level of care and attention from their physician.  As a result, most patients feel that, although every other patient should get the alloted twenty minutes of the physician’s time, THEY are special, and deserve more.  Since every patient feels this way, the result is that everyone wants a bigger piece of the pie.

The other side of the coin pertains to my colleagues and I, and how we perceive our role as care providers.

A study conducted in the 1980’s evaluating why Detroit automakers lagged behind their Japanese counterparts in efficiency and production showed that the percentage of American auto workers who were “managers” or “supervisors” greatly exceed those in Japan.  Americans like to have special titles, and to be recognized as subject matter experts.

American doctors want to be experts and sub-specialists.  The prestige, monetary reward, and limits of liability are all heavy factors in this.  A recent study of graduating medical students showed that only half as many new doctors are choosing to enter primary care specialties as a decade ago.  What this means, is that fewer doctors are choosing to be clinicians who patients go to repeatedly for their day-to-day healthcare needs.  Instead, doctors are overwhelmingly choosing the path of the “Expert consultant”.

The percentage of sub-specialists to primary care physicians has a huge impact on access to care.  In Great Britain, where the number of primary care physicians is still high, a patient can consistently rely on being seen within 48 hours of calling to make an appointment, but may wait up to eight months to see an endocrinologist if they are diagnosed with a thyroid problem.  In America, primary care visits are often booked weeks in advance, but a patient can be seen by a sub-specialist within 3 weeks of the referral.

Americans like to be in control:

If you visit a major city anywhere in the world, you will see streets filled with cars loaded to capacity.  In America, everyone rides alone, and the carpool lane is empty even while the expressway is at a standstill.  Americans like to drive themselves, to choose their own radio station, to be in CONTROL.  When it comes to health care, Americans want to choose.  They want to choose their doctor, the tests they receive, and play an active role in their own treatment.

This desire for control is a great thing, it is what makes us leaders of the free world, but it also makes treating us a bit more challenging, and time consuming.

The American Spirit is an amazing and unbridled phenomenon.  We are different from every other nation on Earth.  It is for that reason that we should remember that our health care system is unlike every other.  For a moment, let’s forget about the argument of where America’s health care “Ranks” in the world (FYI, those VERY flawed studies had more to do with patient’s PERCEPTIONS of health care, and less to do with patient’s actual OUTCOMES), and let’s remember all we have done as leaders in healthcare.  From control of infectious diseases such as malaria, to vaccinations, to cancer screening, our system has lead the way, and the world has reaped the benefits.  Do not be too quick to condemn our system based on cost, and consider for a moment the rewards it has returned.

The next time you wonder who is responsible for the state of our current healthcare system, ask yourself if perhaps you may have been one small part of the problem.

(Author’s note:  I did not discuss frivolous lawsuits and tort reform, that would take an entire blog by itself)


Trauma

When most people think about an Emergency Room, they think about trauma, even though that is only a small fraction of what we do.  The question is, when is trauma significant enough to warrant a trip to the ER?

Head Injuries:

Any trauma that involves a head injury resulting in being unconscious or confused is potentially serious.  Continued vomiting after the head injury, or a severe headache is also cause for concern.  Vision changes, loss of balance, or ringing in the ears are all potential signs of a moderate to significant head injury.  If a head injury occurs with no immediate symptoms, and twenty-four hours has passed without any of the symptoms mentioned, then you probably don’t need to go to the ER.  Bottom line, if you strike your head and the next thing you remember you are waking up and EMS is hovering over you, take the ambulance ride to the ER, do not refuse transport.

Broken Bones:

Broken bones can be both painful and debilitating.  If you have injured your legs/ankles/feet, and can walk five steps, then you probably can wait to be seen by your own doctor for x-rays in a day or so.  If you cannot bear your own weight, or have an obvious deformity, then go to the ER right away (Don’t eat on the way, in case I have to sedate you to set the bone).  In the case of injuries involving the arms, if it is deformed, numb, discolored, or you cannot move it, then you need to go to the ER for evaluation as soon as possible.  A good rule of thumb for fractures was taught to me by my high school football coach thirty years ago:  If you THINK it’s broken then it probably isn’t, and you can wait till tomorrow, if you KNOW it’s broken then go to the ER right now. (This worked for me when I broke my hand in a game, played four quarters, and then went out drinking after the game.  Although, my dad was less than thrilled taking me to be seen the next morning).

Falls:

Any time you suffer a fall from a height greater than 6 feet, and have any pain, especially in the neck or in an extremity, then you need to come to the ER for evaluation.  This is especially true for the elderly, and is the reason granddad should not  be hanging his own christmas lights.

Cuts:

If you have a cut, apply direct pressure.  If bleeding cannot be controlled in about 10 minutes, come to the ER.  Cuts to the face that are deeper than just a scratch should be seen to prevent disfiguring scars.  If cuts occur on the hands and fingers, there is a chance of loss of function due to injury of tendons, nerves, or blood vessels.  Also, scarring on the hand can cause difficulty in the future.  If a hand wound becomes infected, it can be very serious.  Bottom line, if you have a deep cut, come to the ER within 12 hours of the time the wound occurred.  After 12 hours, naturally healing has already begun, and we may not be able to stitch the wound.  Also, come to the ER for any cut that may be contaminated by bacteria, or if your tetanus shot is out of date (greater than 5 years), tetanus is deadly.

Assaults:

It should go without saying, but I will say it anyway, if you’re shot or stabbed, come to the ER.  In addition to caring for your wound, we will help you with the legal aspect of your safety.  This includes assaults without weapons as well. Any trauma to the eyes warrants a trip to the ER (you only have two, let’s protect them).  Also, any blunt trauma to the abdomen or chest which causes significant pain or bruising.  These could be indications of internal injuries, so let us take a look.

Summary:

A general rule of trauma is than if you feel fine then you probably are.  If you have any focal area of pain or disability, I want you to come let me evaluate you.  A pitfall to avoid is coming to the ED with no focal complaint asking to get “Checked out”.  Please remember, I am not Dr McCoy, I don’t have a tricorder, and I can’t do a whole-body MRI looking for a needle in a haystack.  Seek care if you need to, but if you aren’t sure why you are going to the ER, then I am probably not going to be sure what to look for.

This isn’t all encompassing, but I think you get the idea.  In future blogs I will address some specific mechanisms of trauma such as animal bites and burns.

Next time:  Motor vehicle accidents.


When should YOU Go to The Emergency Room?

Over the course of my career I have seen a wide spectrum of “Emergencies”.  When I say Emergency, I refer to that specific condition or malady which brings someone into my ER seeking my help.  The spectrum has ranged from the ridiculous to the truly terrifying.

An example of ridiculous would be a young man coming to the ER stating “For about four years now, my right shoulder sometimes makes a ‘pop’.  But it hasn’t done it in a few months.  I thought I should have you check it out”, as opposed to the terrifying, an elderly woman feeling “A little under the weather for a few days” which progressed to septicemia (a blood infection), and who was literally on the brink of death when she arrived.

The common thread here, and one that many of my colleagues and I recognize, is that many people do not know the WHEN and the WHY as it pertains to going to the ER.

In a recent BlueCross BlueShield study, it was found that between 43% and 46% of ER visits in New York State were non-emergent conditions that could have been handled by a primary care physician (PCP), or required no medical intervention whatsoever.  What I hope to illustrate for you is when to go to the ER for a condition, and when to stay home and possibly seek care elsewhere.  This will provide two benefits:

  1. You, the patient, will receive optimal care, without unnecessary waiting and testing.
  2. Your local ER will have a lower number of non-emergent patients, therefore having shorter wait times, and will be better able to provide the level of care that all patients deserve.

Beginning in my next installment, I will outline when you should and should not go to the ER for specific conditions/complaints.

Next blog: Trauma


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