March 10, 2006, 4:15 pm

Your ER Bill: A Bitter Pill (Or Why You Pay Through the Nose For Injuries to Toes)

Oh great.

This never even occured to me until I saw this ad.

All those times I ran into the back to grab a bite of the Super Garlic large pizza with extra garlic-flavored cheese on a garlic filled crust…..

Could I?

Do I?

Must I add Tic Tacs to my pocket arsenal of patient tools?

I suppose I could always say that it’s an olfactory hallucination that always happens with chest pain or dyspnea or abdominal pain or stubbed toes.

You know, blame the patient.

Knowing me, I will now become fanatical about this and brush my teeth four times a shift and lose twenty pounds eating nothing but Certs for breakfast, Tic Tacs for lunch and Ice Breakers for dinner with a snack of Altoids in between.

But I will not give up my coffee or my diet Pepsi. A nurse has to take care of herself somehow!


It’s a holiday weekend. The doctor’s office is closed

Besides, your doctor is on vacation anyway for two more weeks.

Your left big toe is three times its normal size secondary to an ingrown toenail you hoped would go away by itself but you dropped a desk on it and now you are in agony and really would like to walk without a scream escaping from your throat with each step.

You decide to go to the ER.


Have a seat in the triage room. If it isn’t a crazy night, the nurse will take a look at your toe, commiserate with your suffering, grab you a wheelchair, elevate your foot, take some vitals, get a history and send you to registration.

Okay, your registration is complete and your nurse has your chart in hand and she calls your name. You are wheeled to your room, where you hop on the gurney.


You have just spent a few hundred dollars.

The ER doc will see you, commiserate with your suffering but she knows what to do! After an x-ray to make sure you did not fracture your toe, your toe is numbed, your rather severely infected abcess is drained and the offending nail is cut out.

Your nurse places a gauze bandage on your toe. You may need a cast shoe for comfort for a few days.

It’s sort of late by now and your doctor wants to save you the trouble of going to the pharmacy so she asks the nurse to give you your first dose of antibiotic before you leave.


You just spent a considerably few hundred dollars more.

You are given your discharge instructions, prescription and told to follow up with the doctor on call for yours in two days to recheck the wound and make sure it’s healing well.

Thanks for using our Most Excellent ER! Take care!


Six weeks later you get the bill from the Most Excellent ER and it is well over one-thousand dollars.

After you pick yourself up off the floor, you look at the bill to see where it says they gave you a heart transplant, because surely an ingrown toenail can’t have cost that much!

But it does.

That charge includes:

  • the triage, the registration, the “room charge” which is based on your initial complaint
  • the medications used to numb you and the antibiotic used to treat you which were obtained from the drug dispenser maintained by pharmacy
  • the disposable instrument tray used to cut you, the gauze used to bandage you and the cast shoe used to help you obtained from the equipment dispenser maintained by central supply
  • the nurse who went over your discharge instructions (and was assigned to your care)
  • the fact that you had a procedure (the incision and drainage of your infected foot).

But still, you say, over one-thousand dollars?


Because you took advantage of a service that is available to everyone who needs it, twenty-four hours and a day, seven days a week. The ER. Your bill pays for the salaries of those four RNs and one tech who are there whether there is one patient in the department or twenty patients every hour or none at all during a night shift. Your bill covers the services of those who have no insurance but never pay their bill, those who are indigent, or homeless and post-cardiac arrest.

You are paying for the advantage of having, and using a 24/7 emergency health care operation.

Oh, and by the way, the ER doctor and the x-ray department radiologist (the specialist who will ultimately read your x-ray officially) bill separately. They are not employees of the hospital.


Now I gave an example of someone who really had no other choice. This infection could have turned serious very fast and they were in excruciating pain. I added the element of the x-ray to make a point.

It doesn’t make economic sense to use an emergency department for a non-emergent problem. If you aren’t sure what constitutes an emergency, or if your pain is umbearable, we are there for you. Don’t take a chance.

But…if you are not in any danger of losing your life, limb or eyesight

  • Call your doctor, even after hours. Speak to whomever is on call. See if they have some advice they can give you over the phone. They may say, go to the ER! If so, come on down!
  • Wait until office hours the next day, if you can. That sore throat you’ve had for a week will not go away just because you visit an ER that night. Trust me. Even if we start treatment, you won’t be immediately cured. You may have to go through a possibly lengthy ER wait/visit when your doc may have been able to fit you in.
  • If you feel you are not having an emergency but must be seen, and if you have access to an Urgent Care Center (often called a “Doc-In-The-Box” as a joke), use it. It will be cheaper and hopefully faster than most ERs.

An Emergency Department is there to care for anyone and everyone who needs their services.

No one can be turned away.

It can be a lifesaver or it can be one very expensive band-aid.

If you need the ER, use it! If you have another option, you’ll save time and money.


  • Moof

    March 11, 2006 at 6:06 am

    Kim! Great post! You should consider making the advice on when to visit the ER a page with its own link so that it won’t get lost as it vanishes into the archives with passing time.

    You’ve laid it all out very well!


  • Robin

    March 11, 2006 at 6:18 am

    Oof. One of the things that makes me happy to be Canadian.

    Interesting to hear about the differences firsthand. This part really does seem foreign to me.

  • Jodi

    March 11, 2006 at 7:24 am

    I had all those thoughts going through my head when I had that last final gallbladder attack.

    My insurence only pays 75% of the bill. So even 25% of a few thousand is a lot to this student. So I sat there, debating.

    I called my MD (It was morning) and they were booked.

    It occured to me that my MD might want to rule out an Appy anyway, so what was the point.

    I had a strong feeling it was my gallbladder but knew it could’ve been my appy….the thought of peritonitis with a perf directed me to the ER.

    I dreaded the long waits and the extra tests I would pay for, but had to be done.

    Great Post Kim! You should link this to your home page.

  • Susan

    March 11, 2006 at 4:18 pm

    Sometimes I feel we’re more like a Doc-in-the-Box than an ER. It can get the staff down, seeing nothing but urgent care patients the whole shift.

    What makes it worth it is the real emergencies that we handle and resolve like the professionals we are trained to be.

    Great guidelines, Kim!

  • Nurse Practitioners Save Lives

    March 11, 2006 at 6:44 pm

    This post may make the argument for the clinics run by nurse practitioners. I think the ER needs to be used for emergencies only. One of the hospitals in my area has a free standing clinic that does decompress the situation. Great Post!

  • may

    March 12, 2006 at 1:04 pm

    but you see, the definition of “emergency” totally depends on who is defining it. and for those who are “suffering”, anything related to it, IS emergency. i hope people get to read this blog before they go to ER.

  • Barbados Butterfly

    March 12, 2006 at 8:12 pm

    There was once a man who presented three times in a week when I worked in the ED. He called an ambulance to bring him in each time.

    The first time he came in because he’d fractured his pinky finger.

    The second and third times he came in via ambulance because his finger still hurt.

    The ambulance crew told us that they’d tried to get him to stay home on the 2nd and 3rd times but he was insistent about being transported to the ED and the ambos can’t refuse.

  • Flea

    March 13, 2006 at 7:49 am

    Call your doctor, even after hours. Speak to whomever is on call. See if they have some advice they can give you over the phone. They may say, go to the ER! If so, come on down!

    Kim, yes yes YES, and maybe.

    Absolutely you should call your doctor. I agree completely.

    But if he or she says you should go to the E.D., particularly if you are speaking to someone who does not know you, please ask whether the condition you describe requires emergency level of care and why.

    It couldn’t hurt to ask.



  • Stephen

    March 13, 2006 at 11:42 am

    I had a dentist who offered free coffee in the waiting room. It doesn’t matter if your breath smells like coffee if your patients also smell like coffee.

    These days, i don’t drink coffee.

  • mary

    March 13, 2006 at 3:58 pm

    Sometimes you get sent to the ER with an urgent problem by the urgent care center you waited up all night to go to in an effort to AVOID going to the ER.


    This happened to me when I sat around for 48 hours and let my appendix rupture, just so I could go to Urgent Care when it opened Monday morning (would not want to be thought of as over-reactive or anything!). At which, I was promptly seen and sent to the local ER. Luckily, the Urgent Care doc called the surgeon and he was waiting for me there (bless him).

    Yes, for you Canadians: I got bills for the Urgent Care Center, for the CT scan, for the radiologist, for the ER visit, for the ER doctor (what for??? the surgeon saw me and admitted me, still can’t figure that out, Kim?), the surgeon, the anesthesiologist, the patholigist who examined my icky ruptured piece of intestine and pronounced it an icky ruptured piece of intestine, and the hospital charge itself.

    It’s soooo….complicated. But still, Kim, very good advice.

  • Judy

    March 13, 2006 at 4:10 pm

    Luckily my local ER has a “fast-track” facility for minor, but emergent issues. I’ve been there twice in the last 6 months with my 10 year old. Kid has a tendency to injure himself after office hours, unlike his brothers who were more considerate and nearly always hurt themselves during office hours.

    Fast-track bills at the same rate as our local urgent-care facilities. I know the insurance company appreciates that.

    It’s worth asking about that sort of service as well.

  • Kim

    March 13, 2006 at 7:23 pm

    Mary, I think the way it goes is that while you are in the ER, the ER doc is responsible for you, even though you are being seen by a consultant.

    It’s a “Captain of the Ship” thing: suppose you come in on a rare, quiet night at 0400 and the ER doc is asleep in his room. We nurses start all the proceeding and get things rolling before we call him out.

    He is responsible for you from the moment you enter the department, even though he doesn’t even know you are there yet.

    Should, god forbid, you have needed resuscitation while in the ER, it would have been the ER doc doing the intubation, not the surgeon.

    So, essentially, you paid for the fact that the ER doctor had the ultimate responsibility for you while you were there and that is why they charge.

    If I’m wrong, somebody please correct me as that is my understanding.

  • unsinkablemb

    March 19, 2006 at 10:09 pm

    Great post! All that sounds so familiar since I volunteered at a Level I ED while I was in nursing school (for about 10 months) and also worked in my mom’s office (she’s family practice). I’ve seen more people in emergent situations wait for an appointment to see my mom rather than go to the ER. Frightening!

    FYI… In addition to the “Doc-In-The-Box,” clinics run by nursing schools are another option. My alma mater has a clinic that is funded by the city and university, open to the public, and is run by two NP’s (one of which is also faculty). Services are provided for a donation depending on the individual situation. The clinic also receives a discount from a local lab for services which are passed down to clients.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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