March 1, 2009, 2:19 am


al-fenn-6551And the staff gathers ’round to watch the last episode of ER…..

I hear George Clooney will be back.

Doesn’t matter, I can’t stand that show.

It’s like being at work, only I’m not getting paid.  Clooney may be handsome, but he’s not that handsome. Now, if Will Smith or Jeff Goldblum had been in the show, that would have been compensation enough for me!

My husband could never understand why watching “Trauma: Life in the ER” was not high on my list.


(Photo credit: Al Fenn for Life Magazine. June, 1955. Omaha, Nebraska)


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It’s time for an intervention.

I have to admit it.

I am Facebook illiterate.

People poke me, send me goodies, invite me to groups, send me really cool memes on rock songs, buy me drinks, send me plants.

And I have no clue what to do with those.

Okay, I do know how the Pirate game works and I will steal your gold coins if I find them, but that’s it.

Oh, and I learned how to upload videos – found an old Boyce and Hart video. Totally cool.


I’m in a mood.

Luckily, I’m not at work because moods don’t really make one popular with one’s colleagues.


This patient came into the clinic the other day…

Oh, you thought I worked in an ER?  Well, that is what it says on the sign on the street and over the sliding doors, but trust me, I work in a clinic.

And, if you walk into your place of business and it says “Emergency” over the door, you probably work in a clinic, too.



I give the general public, health care consumer, client, guest (or whatever the current politically correct term-of-the-day might be), credit.

Yes, I give the vast majority of those people who walk into the ER credit.

Credit for knowing exactly what they are doing and why they are doing it.

  • Credit for knowing what a true emergency is: chest pain, stroke symptoms, broken limbs, eye injuries/pain, difficulty breathing, uncontrolled bleeding
  • Credit for being concerned that something dangerous might be happening.  You can have gastroenteritis from hell and think you are dying.  Pain so severe it cannot wait until the next day.  An ankle the size of a grapefruit and you aren’t sure if it’s broken.  Cut a wide berth of slack here – pain is frightening.
  • And most of all, I give most folks credit for knowing when an emergency department visit is not appropriate, but they use it anyway….because…

1.  They can’t be turned away.

2.  They don’t have to pay a penny up front.

3.  They don’t have to wait for an appointment with their doctor.


Are you surprised by #3 up there?

I know we are supposed to believe that the emergency department crisis in this country is tied to the 45 gazillion un-insured amongst us.

Not in my experience.

I would hazard an educated guess that at least 80% of the patients I see for non-urgent problems have primary doctors, and that is a low estimate.  I know, because I ask them at triage.  Which means they have insurance coverage of some type, even if it is through the state.

If they have Medi-Cal, they are supposed to use the county hospital and clinic system, but they don’t because our ER is (a) nicer, (b) faster, (c) convenient. So, these insurance companies and the State of California are paying through the teeth for emergency department visits that did not need to happen.

Or, they don’t pay at all, which drops the over $1000.00 bill right into the patient’s lap.

And often, the emergency department doctor is not paid for their services and the hospital takes a loss because, well, not everyone can handle a debt like that, and not everyone makes payment arrangements.

If you get my drift.

One. Thousand. Dollars.


For a cold, a stubbed toe, back strain, minor fever, cough x 5 weeks, headache x 8 months (I’m not kidding), STD testing, family of five children with runny noses (I’m serious),  family of five with no symptoms who were rear-ended and “just want to be seen”….


As long as it is convenient and there is no incentive to do otherwise, the ER will continue to be populated by people with clinic-type chief complaints that have no place in an emergency department – see #1, #2 and #3 above.

Meet the Emergency Medical Treatment and Active Labor Act (EMTALA), the King of Unfunded Mandates.

So, how do we provide the incentive to use a primary physician or clinic when the patient actually has one?

It’s called a medical-screening exam.  A provider evaluates the patient at triage and if it is determined that the patient is not having a life or limb-threatening emergency (see above), and the patient has a primary doctor or clinic, they are told to follow up with their provider and will not be seen in the emergency department.


What is the advantage of the Medical Screening Exam?

I know it can seem harsh to send a patient away from the ER.

But in the end, it is a patient-centered procedure.


  • Staff can focus on the patients who need care the most.
  • The ER is not tied up with non-urgent/emergent cases, decreasing wait times for the patients who need care the most.

Meaning, the patients who truly require the resources and procedures of an ER receive those services more efficiently.

And while they may be miffed at not getting an emergency department berth, by being triaged to their doctor or clinic for follow up, the  patient with the clinic complaint is (a) not saddled with an ungodly bill for unnecessary ER visit, a bill they may not be able to pay and (b) sitting in a waiting room, possibly for hours.


I know I’m a nurse and I should have unmitigated mercy and compassion for all those with whom I come into contact with in the course of my duties.

I ain’t feelin’ it.

Especially when I know that most people are not dumb and they know exactly what they are doing when they come to an ER for a non-urgent problem.

I give them credit.

Now give me time to work with the patients who really need me.


  • Medic999

    March 1, 2009 at 7:18 am

    Medical screening exams sound good to me. We have been doing similar to that in my ambulance service for the last 4 years. If a patient dials 999 and I attend and they obviously aren’t an emergent problem and there isn’t another genuine reason that they need to travel to a&e by ambulance (e.g a patient who has a chronic problem and they are at their wits end and have no transport), then I will either refer them onto thier GP (primary physician), one of the multitude of community nurse led services or ultimately tell them they do not need to go. This took some paramedics some getting used to and some were afraid of the complaints coming in but ultimately it has been a great success and long may it continue

  • Nurse K

    March 1, 2009 at 10:04 am

    The MSE will be back en vogue once the newly “insured” with Obama’s feel-good but tried-and-failed-all-over-the-world-already spending program get their medical cards and flood the ERs since no one else will take the card but those who are forced to.

    In my state, BTW, Medicaideurs aren’t expected to use the county health system.

  • Candy

    March 1, 2009 at 1:01 pm

    Best yet, by far! WooHoo, girl!

  • Healthcare Today

    March 1, 2009 at 1:15 pm

    EEEEE-NOUGH!!!!!!!!!!!!!! // Emergiblog…

    What is the advantage of the Medical Screening Exam? I know it can seem harsh to send a patient away from the ER. But in the end, it is a patient-centered procedure.


  • Karin RN

    March 1, 2009 at 1:17 pm

    Thanks for the laugh about FB. I’m with you.

  • NPs Save Lives

    March 1, 2009 at 7:20 pm

    I have been hearing that some are being turned away from ERs and told that they must be seen by their primary providers. I hope it’s true and it’s about time!

  • geena

    March 1, 2009 at 7:51 pm

    How long until people start gaming THIS system though?? c/o chest pain, etc, to get seen??

  • emmy

    March 2, 2009 at 2:30 pm

    It really does sound like a good idea, and if you can get our Primary Care Doctors on board that would be wonderful. Last time I called mine hoping to see her and avoid a trip to the hospital, her surley receptionist told me that there were no appointments available until the following week and I should go to the ER because cellulitis can be serious.

  • […] in the gomers. A lot of patients who come to the ER should really go to the clinic instead, opines […]

  • Premed Journey

    March 3, 2009 at 1:53 am

    This article about the University of Chicago Medical Center is relevant to the conversation about people visiting the ER without emergent needs.,0,1975597.story

  • Jen

    March 3, 2009 at 8:25 am

    I lost part of a toe in an accident (horse fell on my foot) in 2006. You could see the one at the end of my big toe and blood was oozing out of the sandals I had put on to get my boot off. Despite this, the ladies at the front desk wouldn’t let me back or give me pain relief until I had provided my insurance information. Another front desk lady was dabbing at my toe with gauze trying to keep blood from getting on the floor, and it hurt like an SOB. While I can understand wanting it, I was hardly able to talk as I was vomiting from the pain and the sight of my bone.

    I don’t understand why they didn’t get me into a room, out of the public eye, and think about pain relief or getting my foot somewhere where the blood wasn’t as big of a concern before getting the insurance information.

    Once they had it, and had verified that I had insurance (excellent coverage, BCBS), I was immediately taken back to a room and given a nerve block (lasted over 12 hours).

    I can understand how hospitals are losing money due to large numbers of non-paying patients and/or medicare patients, but at what point is patient comfort substituted for the bottom line?

    I wonder what would have happened if I had not had insurance? Would I have been given the same painkiller? Would I have been taken back as quickly? Would the attitudes have differed?

  • kris

    March 3, 2009 at 6:25 pm

    i went to the er for 1. falling down a flight of stairs hitting my back on each step on the way down and couldn’t move and 2. spilt boiling chicken soup on me and got 2nd degree burns on my thighs arms and abdomen..based on your criteria I’m wondering if I should just waited and gone to the doc. the first ended up being a sprained back and the second were pretty painful blisters….nothing super serious. btw I’m a klutz

  • holly

    March 6, 2009 at 9:40 pm

    I think ERs need an urgent care physically adjacent to take patients who fail the ER screening exam. They can choose to wait for their MD or be seen by an NP for colds, UTI’s etc. Of course their insurance may not cover the urgent care charge, but it may be the only time they can get a ride, or they can’t get off work without losing a job. These are common real life concerns that cause at least some inappropriate ER visits. Kaiser often has a system like this so it could be economically feasible. The physical proximity is important for those few patients who turn out to be really sick on further eval. I work in an urgent care several blocks away from the hospital and we have had a few patients who refused ambulance but didn’t make it to the ER fast enough…

  • […] in the gomers. A lot of patients who come to the ER should really go to the clinic instead, opines […]

  • Old Lady Nurse

    May 15, 2009 at 9:30 pm

    In 2007 I went to the ER with a severe asthma attack – I was made to wait in the waiting room for 45 minutes. I finally passed out and awoke intubated. Needless to say I never went to that ER again. LOL, one elderly visitor in the waiting room even recognized my distress as she offered to call 911 to have me taken to another hospital.

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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