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OK, I had about the most stupid question asked of me tonight:

I was climbing over a baby gate, slipped, and mashed my bare foot sideways against the wall. One of my toes hurt beyond hurt, tingled, and became swollen. Time for a trip to the friendly E.R.

Since I absolutely can't walk on that foot, or even put a shoe on it, my wife goes inside and asks for and gets me a wheelchair to get me from the parking lot to the inside. When we go through Triage, the lady at the desk asks me a number of questions while a nurse takes my vitals.

#1. Why are you here?
A reasonable question.
I explain about the injury. I tell her I think my toe may be broken.
#2. On a scale of 1-10, how much does it hurt?
Another reasonable question.
I tell her about an 8 to 9. (I would almost never say 10, to me 10 is saved for the guy in Alien who gives birth via his chest.)
By now, she has realized I am sitting in a wheelchair in front of her desk. She gives me a dirty look and scowls:
#3. WHY are you in a wheelchair?
I explain about the injury. I tell her I think my toe may be broken.

Good news: after X-rays and an intellegent exam, the doctor determined the toe was not actually broken but badly contused. I should only have to immobilize it for 3-5 days compared to 6 weeks. Now I get to wear one of those cool cast-shoe thingies on it and get a 3 day pass from work. Not to mention the perscription pain meds

Some people are under the impression that to be in a wheelchair you need to be in a special elite class or have some sort of license or something... otherwise you are taking a valuable resource (the wheelchair) away from someone who might actually (in their minds) need it.

Marty, the folks in the ER have seen all manners of grisly things, so a stubbed toe scarcely ranks high on their lists of priorities. So, they're just trying to keep you entertained!

If you want service next time, come in with labored breathing, grasping at your chest with an anguished look on your face. That's worth at least a 10 minute boost in priority...

The last time I broke a toe and went to the local clinic's urgent care section (not even the ER), the intern said "Yup, looks broken to me. What are you doing here and what do you expect us to do?" When I said it might be nice to X-ray the toe and maybe tape it up, his response was "Okay, it's your money; but you could have saved us all the trouble by just taping it up yourself". Maybe he'd had a bad night, I don't know. I told him I'd take the "do it yourself" approach to heart if I ever broke a leg or felt a tightness in my chest and had trouble breathing. He wasn't amused.

Chuck(G) wrote:The last time I broke a toe and went to the local clinic's urgent care section (not even the ER), the intern said "Yup, looks broken to me. What are you doing here and what do you expect us to do?" When I said it might be nice to X-ray the toe and maybe tape it up, his response was "Okay, it's your money; but you could have saved us all the trouble by just taping it up yourself"...

The last time I broke a toe was in high school. I caught a hurdle at track practice. I went to my family physician and he told me the same thing: "Next time, save us all some trouble and tape it up yourself".

I am SO glad that I pay $800 per month in health insurance so I can get this kind of service when I need it (which I have also experienced but won't belabor the point with). My car get treated better than I do, heck I even repair instruments with better customer service. Though, I have to admit, I actuall DO want my customers to come back, unlike ER staff

In the last three weeks, my wife and I have each had serious problems with our right little toe... probably broken. We both agreed that "HOLY SH*T THAT HURT"!... but it's happened before and we know that if it is broken and we make a trip to the clinic.... there is no treatment, anyway... other that maybe a cold pack for a few hours.

Well, the reason I went in the first place was I couldn't walk on it. A day later, I still really can't.
But it is interesting to see how much I posted last night after taking the narcotics they gave me!

One of the things I don't like around here is the medical service. There is only one full-service hospital in our county, and it is run by the local doctor cabal. Competition is good, and they have managed to shield themselves from it.

My mother-in-law, dying from lung cancer, had a spell that needed immediate attention. We had already learned that just showing up to the (one) ER in the area in a private car would result in a waiting time of 6-12 hours. We knew this because it had happened on at least half a dozen occasions in the previous six months. Time and time again, my wife's stoical-but-terminal mother would suffer patiently while those arriving in ambulances got service only to be released again (while we were still waiting) with stitches and a bandage.

So, this time, we dialed 911. The ambulance driver refused to take her to the (one) hospital in the area, stating that his orders were to take all emergency calls to the emergency clinic that was on our end of the county. My wife told him to unload her, she'd drive her in the car. The ambulance driver refused, and my wife threatened to call the police. After a lengthy and heated discussion with the dispatcher, where the question was asked who at the bedless cut-finger clinic was capable of dealing with a neutropenic Stage IV cancer patient, they finally agreed to take her to the hospital. That whole sorry episode cost nearly an hour.

One of our friends is a nurse in that hospital, and she can't take it anymore and is moving to Phoenix. A doctor friend of ours moved from Houston to this area because of his wife's work and found that the local doctors prevented him from setting up a practice without kissing their backsides (financially). After three years of being unable to build a practice, in an area where the average wait time for an appointment for a specialist is three months, he moved back to Houston and is once again happy in a high-end hospital.

My parents have flatly refused to consider moving to our area because of the poor medical care. Bloke, we do not have the issue here that you described in Memphis. This is purely a case of a group of small-town doctors unwilling and unable to keep up with suburban growth, and unwilling to let anyone else try. They successfully prevented a new hospital in the neighboring area by politicking with the state hospital board.

And Jonathon, this is not a problem with our private medical system. The problems is that many areas have public hospitals, and in many areas even private hospitals are intensely regulated by politicians--not to ensure quality, but to limit supply. Our medical system needs more of that free market. The medical care in Houston is 1000% better than here, and largely because of a locus of private hospitals in the Texas Medical Center. I find it incomprehensible that as close as we are to Johns Hopkins, Bethesda, Georgetown, and other notable medical facilities that it has not brought up the expectation of medical care in the suburbs.

I'm persuaded more than ever that despite the cost cutting of corporations, strong competition between hospitals is a good thing.

And my friends wonder why I refused to go to the hospital when I tore the PCL in my right knee before Christmas. It still hurts, and sometimes badly. But I have zero confidence that the medical "attention" I would get locally would alter that in the slightest. There's no way I'd endure that hassle for a broken toe, unless it was a compound fracture and I was bleeding to death. I went to the emergency room to get treated for a severe allergic reaction to a particularly nasty case of poison ivy--my right arm was so swollen I could not bend it enough to play the tuba--and we drove to the next county's hospital. It still took six hours to get that five-minute exam, in a waiting room that never had more than two others in it.

Rick "finding that many failures of market economics are the result of too much manipulation of it" Denney

My dogs get pretty good medical service. There's an emergency 24x7 vet on call and it usually just takes a phone call to let them know you're coming. If my vet misses something, she puts it right on her own nickel, talks to me as if I actually could think for myself and is courteous and gentle with our animals--and takes whatever I say seriously.

I want to find out if she'll take human patients.

Heck, my uncle was trained as an MD and set up practice in the US as a very successful vet (McCarthy era politics wouldn't allow him to be certified to practice medicine in the US. With two kids and a wife and no hopes for employment, he made a very savvy decision. Eventually retired to the Florida Keys.)

DCottrell wrote:I am SO glad that I pay $800 per month in health insurance so I can get this kind of service when I need it (which I have also experienced but won't belabor the point with). My car get treated better than I do, heck I even repair instruments with better customer service. Though, I have to admit, I actuall DO want my customers to come back, unlike ER staff

$800 a month eh? Holy cow! You should move to Canada, free health care!

Chuck(G) wrote:My dogs get pretty good medical service. There's an emergency 24x7 vet on call and it usually just takes a phone call to let them know you're coming.

That says it in a nutshell - good health care has gone to the dogs. Just hope HMO's never get involved with Vets.

Chuck(G) wrote:The last time I broke a toe and went to the local clinic's urgent care section (not even the ER), the intern said "Yup, looks broken to me. What are you doing here and what do you expect us to do?" When I said it might be nice to X-ray the toe and maybe tape it up, his response was "Okay, it's your money; but you could have saved us all the trouble by just taping it up yourself".

Mark wrote:The last time I broke a toe was in high school. I caught a hurdle at track practice. I went to my family physician and he told me the same thing: "Next time, save us all some trouble and tape it up yourself".

A week ago my son injured himself while sparring. Jump kicked too high and landed on his side with his elbow between his ribs and the mat. Knocked the wind out of him, but nothing major. Wife wanted to take him to the ER. Talked he out of it, bu she insisted I take him to the doctor the next day.

So I get to spend an hour at the doctor's office, and then 2 hous at the hospital to get an X-ray. Just to learn what I already knew. The doctor want an Xray to see if it was cracked. Why? To know how long it'd take to heal. When I ask would the treatment be any different be it a brake, crack, or bruise, the (expected) answer was (of course), "No".

Still despite my best efforts, 2 extra hours were wasted for an unnecessary at her insistence. Wonder what the bill for the Xray would be, and would she have been less insistent had insurance not been expected to cover most/all of the cost? And then I missed 4 hours of work too. It would have been different if he had acted like it was broken and punctured the lung, but for something so common with no real treatment available?

So I have to agree with the doctors above (and wish his had backed me up on the Xray). Why waste the time and money to have a doctor/nurse tape a toe (or finger)? Perhaps is people were a little less quick to got to an ER, the doctors/nurses there would be able to treat people in need better. Those with free medical are the worst offenders. But those who have a decent plan with a low co-pay are almost as bad. My wife suffers the later. $10 for the office visit (instead of $100) make it all too easy to go for any/every little thing. And the ER fee is only $50, again rather cheap compared to the $300+ it would run otherwise.

Rick F wrote:

Chuck(G) wrote:My dogs get pretty good medical service. There's an emergency 24x7 vet on call and it usually just takes a phone call to let them know you're coming.

That says it in a nutshell - good health care has gone to the dogs. Just hope HMO's never get involved with Vets.

Well, there's another big difference--and I figure that I'm getting to the age where I can talk about it.

Things have changed a lot since my grandfather died back in the 1950's and my father in the 1980's and my father-in-law in the 1990's.

When my grandfather quiety expired at home at the ripe old age of 71, the explanation offered for his demise was "old age". My father spent 2 years in and out hospitals being carved at and eventually wound up in hospice care. in great pain. He basically died at age 71 from the effects of a lifetime of smoking, drinking and a bad diet. My father in law died at 86, after more than a decade of taking buckets of medication (I helped to clean out his room--I'm not joking) and seeing varioius "old people" doctors (some urologists have made a lucrative business out of taking medicare payments by old men with prostate cancers) twice a week--his life had degraded to the exclusive goal of seeing how long he could stay alive.

All lived a good and productive life. The big difference was those last few years of life and the heroic measures with no cost spared to get them as technology improved; quality of life be damned. The medical cost for my grandfather's demise was a home visit by the doctor. The cost for my father probably ran into the mid 5-digits; for my father-in-law, the mid 6 digits.

We've got a bunch of dog tags nailed to the trees around the house, so we've had our share of animals. My vet always has leveled with us about treatment and prognosis. On the average, I know a golden retriever will live about 13 years, more or less. Arthritis, deafness and blindness often accompany age and decrease the joy a dog gets in being a dog. So when my 9-year old female was diagnosed with a nerve sheath tumor, I had it removed because she's still able to enjoy life. But if it recurs a couple of years hence, I'll probably let it go.

At some point, we need to get realistic about extreme treatments for the elderly. No buckets of meds and weekly trips to the doctor for me when I get to that point. I want to die not of cancer, or Alzheimer's, or cardio-vascular failure, but of "old age", thank you.

Does anyone know the proportion of medicare dollars spent on the last year of life? I'll bet it's not a minor portion of the overall budget. And I'll have to agree with Joe--by subsidizing no-holds-barred care for the aged, we may have created a monster.

Okay, start throwing your bricks...

Chuck(G) wrote: When my grandfather quiety expired at home at the ripe old age of 71, the explanation offered for his demise was "old age".
All lived a good and productive life. The big difference was those last few years of life and the heroic measures with no cost spared to get them as technology improved; quality of life be damned. The medical cost for my grandfather's demise was a home visit by the doctor. The cost for my father probably ran into the mid 5-digits; for my father-in-law, the mid 6 digits.

I hope to live and die in a manner similar to your grandfather.

I do not wish to spend year and $x00,000 t $x,000,000 to eack out a few extra years of miserable existance.

Okay, start throwing your bricks...

No bricks from this direction. Guest I need to duck too.

My mom tells me that when she arrived at the hospital to give birth to my brother, the lady at the desk asked her what she was there for. Now I never saw any pictures of my mom when she was pregnant but if she looked even half my size at nine months along no one with eyes in their head would have questioned which area of the hospital to send her to.

I have to speak up in support of my pediatrician's office who gives some of the most competent medical care I have ever seen. It's a very busy office but my children have always been seen the day I've needed to get them in. Our doctor has been excellent about referring us on when the problem is beyond him--he doesn't dabble in things he isn't trained to do. And the one time we were in crisis and needed to find a specialist immediately he set his nurse on it and she stuck with it until she came up with some options for us. It would be cheaper for us if we had an HMO but having choices and getting quality care has been worth every penny.

Chuck(G) wrote:At some point, we need to get realistic about extreme treatments for the elderly. No buckets of meds and weekly trips to the doctor for me when I get to that point. I want to die not of cancer, or Alzheimer's, or cardio-vascular failure, but of "old age", thank you.

The question is, which "we" are we talking about?

The problem, it seems to me, is that we seek out that competition with death ourselves. It was not an expectation your grandfather had, but it clearly was for your father and father-in-law.

My grandmother died in the 80's at age 70, after having lived in a nursing home for ten years following a severe stroke. In the end, her kidneys failed and it was a choice (left to my mother--my grandmother was in a coma by that time) to let her go or to face daily dialysis and other organ failures for a few more months. My mother chose well, in my opinion, but the guilt of that choice still haunted her for many years.

I don't want some Medicare bureaucrat, or even some doctor, making that choice. I want whoever makes that choice to be haunted by it--only then will they exercise the appropriate level of care.

My mother-in-law died three years ago of lung cancer. She was in her late 60's--not really old enough to die of old age. At first, there was the expectation that the cancer could be beaten, giving her some years more of relatively vigorous life. At some point, though, it becomes clear that the treatment to a cure has become treatment for symptoms to relieve pain and suffering while waiting for the inevitable. Thus, she decided to pursue the chemotherapy and radiation treatments the first time around, but passed on them the second time around. The point is important: It was her choice both times.

I hope I have the courage to let it go when the time comes. I think I will, but I'm no more ready to be done with life than I was 30 years ago, and 30 years from now I still might not be ready. I'll have to wait and see.

My discomfort when this subject comes up is the whole notion of this being a matter of government policy rather than individual choice. If the Medicare system were to set a policy of not providing additional coverage for those who are not expected to live, then surely those who might have been cured will be cut off and some will die anyway. There is no possibility of making that determination with any degree of precision, and thus there is no possibility of making it with any degree of humanity. Only the person can make that choice, or those loved ones who are entrusted with that person's care.

But we create the monster when we establish a government program to pay for it all. It is not all the government's fault, however. People these days have increasingly believed that they should be protected from all of life's mishaps and tragedies. That leads them to sue doctors for not doing everything, and that in turn prevents doctors from being open and honest about the prognosis.

During my mother-in-law's illness, I was continually amazed by how reluctant the doctors were to speak plainly. She would insist, and then the doctor would jump from reticence to brutality in one leap. I came away from that experience with even deeper disrespect for the medical profession than I had before, and that's saying a lot. But they obfuscate because the consequences of speaking plainly can often be grossly out of proportion, and the unrealistic expectations people have of doctors makes them aggressive in pursuing those consequences.

Doctor to patient: "Mr. Fryburger, we found a shadow on your lung X-ray, and we don't think it's anything but we'd like to do a biopsy just in case...Mr. Fryburger, the shadow seems to be a metastasizing tumor that is starting to block your trachea, and I would like you visit Dr. Oncologist to discuss your treatment...Mr. Fryburger, I'm prescribing a course of chemotherapy and radiation--both of which have made great strides in recent years both in terms of effectiveness and side effects...Mr. Fryburger, we the tumor has declines significantly, but we can't do more right now until we get that little issue of being neutropenic under control...Mr. Fryburger, as soon as we deal with that pneumonia, we'll consider our options...Well, Mr. Fryburger, if you insist on my frankest assessment, you are dying and it could be tomorrow or next month--whatever."

Consider the alternative: "Mr. Fryburger, I see a tumor on your X-ray, and the biopsy revealed it to be an advanced malignancy that is probably beyond our ability to treat. One round of chemotherapy and radiation will improve your prognosis and give you another year, though the treatment will cause you to be sick for much of it. It might give you some time to be with your loved ones and make any arrangements that are necessary. Things may go well and we might see the possibility of a cure, but I would not expect that much will be gained by anticipating anything beyond that single round of treatment..."

The second approach is no more brutal than the first, but it does give the person the tools needed to make a rational decision. I heard every one of the sentences in the first approach made to my mother-in-law. I never heard anything like the second approach, and my mother-in-law never really knew the possibilities when asked to make a decision about treatment. The doctor knew everything he needed to to follow the second approach, because he told it all to a nurse who is a friend of ours (though the doc didn't know it) and who passed it along to us after the funeral.

Rick "who hates the pusillanimity of the medical profession, and the greed of people and their lawyers who encourage it" Denney

Rick Denney wrote:But we create the monster when we establish a government program to pay for it all. It is not all the government's fault, however. People these days have increasingly believed that they should be protected from all of life's mishaps and tragedies. That leads them to sue doctors for not doing everything, and that in turn prevents doctors from being open and honest about the prognosis.

Rick "who hates the pusillanimity of the medical profession, and the greed of people and their lawyers who encourage it" Denney

Agreed. I think you fault the doctor a bit more than they deserve though. They don't have much of a choice. As far as treatment, they must do stuff they tyhink is a waste of time/money to protect themselves fior the lawsuits that are so prevelent to day.

As to being blunt and realistic in treatment option, your right on. But why is that? As you said, the doctor told the nurse exactly what he shoul;d have told the patient. Problme is, if he tell some patients that it another lawsuit. Too many people not only want, but expect to be coddled. And if they don't get it the they turn to the courts. All it takes here is one doctor to say"This alternate treatment will work and give many more, happy years." Now sutddeny the first doctor is sued for malpractuice, and inflicting mental anguish. The juries today are just as quick to stick it to the doctors, snd so the doctor/insurance company pay out millions (mostly to the lawyers).