ars heroica

by Paladin Knight RUSM

I must begin by warning potential readers that this topic involves medicine. I have tried to remove any gory details. I have also removed the names of people and institutions. I apologize in advance for any jargon that remains. I tried to remove most of it!

During my undergraduate studies, I worked as an emergency medical technician. Every Thursday, Friday, Saturday, and Sunday nights the Emergency Department was mine to roam.

I could use this article to discuss the gunshot victims, the myocardial infarcts, the dead infants, but I have little regrets in my choices in all of those cases. I know that the ED staff and I did everything possible to save those lives. I guess it is just an axiom that you cannot save everybody and some people are just beyond our ability to save them. You can usually call the outcome of a case the moment the medics come rolling in with the gurney.

What I do regret is the problem I call the rotating door. It is the primary reason why most people must wait hours in the ED waiting room. It is the reason why patients get so upset and frustrated. It is also part of the reason why those hospital bills cost so much.

The rotating door refers to the “troll” patients as they are so affectionately called. They tend to be afflicted with alcohol dependence. Most of these patients are not homeless as you might expect. They have jobs, they have money, and some have pretty nice homes. What they do not have is the ability to pay the exorbitant hospital bills because of the frequency in which they visit.

A usual visit begins with the paramedic radio going off. “Male approximately forty years of age found unconscious – possible ETOH.” There it is. ETOH. Around five minutes later the patient arrives not unconscious, but just wanting to sleep. This patient is breathing, usually able to ambulate (walk on their own), and aware of their surroundings. Yet, the ambulance ride gives them a first-class ticket back to the ED, which means that the little girl with the high grade fever and abdominal pain will have to wait a little longer for a room.

What happens next disturbs some people. I will tell you that it disturbs me too, however, after experiencing it hundreds of times I have no regrets about what usually happens. The first step is we check in the patient and get a set of entrance vital signs, including a PBT breathalyzer. The patient is usually well over the legal limit and sometimes over the lethal limit. It is not uncommon to see a reading of .6 or higher. The amazing thing is that these patients can walk without assistance. If they can walk, they are usually discharged on the spot either to police custody or their own (depending on whether the police were on scene when the ambulance picked them up). The problem in either situation is that the patient will be back in an hour or two.

These patients cost the hospital money, so the idea is to get rid of them before they become sick. The problem with severe alcohol dependence is the need of alcohol. An alcohol dependence patient that is allowed to sober up in the ED will become a very sick and possibly a dead patient – seizures, delirium tremens, etc (they can even become violent. I have personally been punched, bitten, spat on by these patients). The hope is that we can get them into police custody where they can be allowed to sober up in the drunk tank under the supervision of a nurse; and sent back to us if things do go poorly. The problem is that the patients cost the police department money and the CPC truck (constable protective custody) will drop them off a couple blocks down the road, so the cycle repeats. The system falls even more apart when a social worker gets involved. The social worker can only suggest a treatment program, but unfortunately, the wait list for such programs is six months to a year.

I have stood back and watched these patients enter and leave and enter into the ED again and again. I stood back when I know there is something that must be done to break the vicious, expensive cycle. I know longer work in the ED, but when my clinical rotations begin next year, I will be faced with the situation again. What will I do differently? I do not know, but I am open to suggestions.

Regardless, the next time you are in an ED waiting room and must wait for hours; do not get mad at the nurses and doctors who are there to help you. Realize that something, like this might have occurred. The fact is that alcohol dependence cost us all millions of dollars every year.