A Modern Country Doc–The EMTALA end run and more

 –Tom Bibey

Over the ensuing decade, I did learn how to circumvent EMTALA (Emergency Medical Treatment and Active Labor Act). I call it “the EMTALA end run.” If by chance a doc has a patient who wound up in the wrong facility and can’t find anyone to accept a transfer, you do “the EMTALA end run”: tell the family to check the patient out AMA (Against Medical Advice—I try not to use abbreviations). Arrange for an ambulance to take the patient to a facility that has the specialist they need, such as neurology or cardiac surgery. Once there, the family can demand their loved one receive the specialized care not available at the first institution. This is an insider country doc trick, and it works every time. Oversight of medicines would be even more humorous, if not so sad.

One elderly patient came to see me and complained of being weak, nervous, and dizzy. Being the smart doc I was, I figured the three diuretics she was taking had something to do with it, so I changed her regimen to one that reflected current clinical rationale. In short order, she spun out of control, and became incoherent and combative. She was hospitalized for an intensive evaluation, only to find the resolution to the problem to be the urgent reinstitution of her old regimen. She returned to normal in a few days and again was weak, nervous, and dizzy. I knew the chart jockeys would come around in six weeks, and no one would understand, so I arranged a nephrology consult. (This guy was one of the smartest docs on our staff—the cats that get acid/base are always quick.) I’ll never forget the nephrologist’s thorough review of the entire medical record, and that poor woman doing her best to answer all those questions again. In the end, he told me it made no scientific sense, but he would continue her antiquated regimen. We all do our duty, I guess. I am still the patient’s doc; the patient is still weak, nervous, and dizzy; the nephrologist left town for a big-city practice where he can make some real money; and the chart jockeys still send letters. Some things never change, and all these government folks who believe they can morph these country people via legislation are naive as to medicine and human behavior.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

I love Dr. B’s cynicism and humor. What he says is often quite true. #1 Despite the high technology and money we spend on health care in the US, the system is broken. This is evidenced by the need for Dr. B’s EMTALA end run. It won’t take you much time on the wards or in the clinic to see what does not work about our health care system. This is one of the reasons we need energetic, young students interested in advocating for their patients and working for change.

#2 All the science doesn’t explain why some things work for certain patients and not for others. Sometimes they just do. Our scientific studies look for the average, but some patients are beyond the standard deviations of the norm. I don’t want to diss science, it helps me take better care of patients, but at times there is no rational explanation. This reality keeps one humble and also reminds me to see each patient as an individual.

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