Oh Doctor…

My niece was sick.

Lethargic, vomiting, more like Sick instead of just sick.

My sister sent me messages and called with some questions about what was normal and what wasn’t, asking what else she could do, which to her credit wasn’t much more than I would do.  A pediatrician friend of hers suggested slowly re-introducing fluids and calling their own pediatrician if nothing improved.

I told my sister that the only thing more I could do was give her some IV fluid to help her rehydrate and kick whatever was bothering her quicker.

One morning found them in the pediatrician’s office.  With my sister at  her wit’s end and her daughter asleep half in the chair in the waiting room from exhaustion and dehydration, the pediatrician did exactly what I would have done.

Well, not exactly.

He admitted them to the hospital for IV fluids.

You didn’t misread that.  The same intervention you and I do on a daily basis, sometimes with small children, isn’t being done in the office, but clogging up the hospital.

It got me wondering about private practices and just how much the MDs and PAs are doing on their own.  They send us out of the office for labs, for screenings, for X-rays and now not even a simple 22g catheter, a bag of fluid and a quiet room to help a sick child under their care.

And why not?

I understand not being able to do the blood work, and the X-rays and screenings, but a simple intervention that could have an almost immediate effect on the patient?  Had I arrived at this office and encountered this child on duty, my protocol would REQUIRE IV access PRIOR to hospital arrival.  But here is an MD, a pediatrician, someone who I am constantly reminded knows loads more than me, unable or unwilling to intervene in the health of a child under their care.

These MDs today are busy folks.  Insurance companies demand they join groups and take on more patients than they can manage to maintain reimbursements.  They must see all patients prior to recommending a specialist so they can act as a gate keeper to the system, keeping the useless requests for resources from moving past what can be done in office.

Right?

So my sister and niece are heading for a calm, relaxing day in the pediatric wing of the local hospital, exposing her to God only knows what illness in her weakened state, all to get the intervention I have been doing for all these years.

But what about all those nurses at the office who admit us, take our vital signs, administer vaccines and take my payments?

They’re not nurses?  But they wear scrubs and give shots, what gives?  Oh, they’re “Medical Assistants.”  I’ve seen those ads on daytime TV.  8 weeks to a great job working in a doctor’s office.

It is clear that not all offices are staffed with 8 week trainees, I’ve seen those with seasoned professionals, but I still wonder if they would act in the best interest of the patient or ship her off and get that room turned over to get another paying customer through the tills.

Would it really be so bad to set one room aside for a few hours to run in a 20-40cc/kg bolus?

Or is it something more bothersome than that?

If the room is not the problem, and the staff really do care about the patient and her quality of life, what is stopping them from administering this intermediate level skill?

Could it be that last word, “skill?”

Is it possible that the Pediatrician and their staff of scrub wearing billing assistants and medical assistants can’t assist when it comes to patient care?  Are there any persons in that office trained or experienced in starting IVs?  If not, then why not?

If all they can do is innoculate, why not just hit me up on skype and tell me where to go to actually get care?

I know I am a different kind of parent and not everyone can discern the difference between an exacerbation of bronchitis and another run of croup.  I still have to drag my miserable child into the office and wait 45 minutes for a 2 minute “Yup, that’s croup again, here’s a script for what worked last time.”

If the Doctor demands I come in then I think it’s time we demand they start treating us on site.  If not, then just let me through to the rest of the system that can help me.  Stop fooling us by having your billing staff in scrubs, and leave those to the folks actually doing the patient contact.  And name tags would be nice, and right under their name, their level of training.  You proudly display “Board Certified Pediatrician” on your coat, let me know who’s who on your staff so I know who can help us and who is just there to take my co-pay.

Respectfully,

Justin Schorr

Licensed Paramedic, Concerned Uncle

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18 thoughts on “Oh Doctor…”

  1. Amen! Locally we have several fast response clinics that can treat better in mild cases like this, where the ER is a mess and the Doctor can’t or won’t treat… and if an ER is needed, you’re already pre-screened for early admission when you get there!

  2. Amen! Locally we have several fast response clinics that can treat better in mild cases like this, where the ER is a mess and the Doctor can’t or won’t treat… and if an ER is needed, you’re already pre-screened for early admission when you get there!

  3. Working for a private ambulance service, I once responded from two cities away to a physician’s office for chest pain. We hit a few miles worth of traffic on the highway, and as we were coming up the offramp, we got word from our dispatcher the the office had called back, asking us to “expedite.” As we hit the door, here’s the concerned doctor (nowhere near his patient) demanding to know “what took us so long” (apparently this patient was in such extremis that calling 911 for the local ALS transporting FD was simply out of the question).

    We were told the patient had chest pain and “EKG changes.” I was a Basic at the time, so I couldn’t tell you what they might have been. “He needs an IV, start him on oxygen, and monitoring, and he’s going to Non-PCI Hospital” (2-3 miles away, if that).

    What’s sitting in the (calm, in no obvious distress or pain) patient’s lap? A nasal cannula, still rolled up. What’s all over the room? Oxygen cylinders. He needed that life-saving oxygen so badly that he had to wait 20 minutes for us to bring it to him.

    Later, when we got our times, we realized what the problem was. Our onscene time was 17:05, or thereabouts. We were told to expedite not because of the patient’s condition, but because was Doctor Oxygen was going to be late for dinner.

    They’re not nurses? But they wear scrubs and give shots, what gives? Oh, they’re “Medical Assistants.” I’ve seen those ads on daytime TV. 8 weeks to a great job working in a doctor’s office.

    Hmm. Maybe in California. Out here the schools that don’t offer Medical Assisting as a 2-year Associates Degree take 9 months to get it done. You and I both know that there’s many Paramedic schools that don’t take that long.

    It is clear that not all offices are staffed with 8 week trainees, I’ve seen those with seasoned professionals, but I still wonder if they would act in the best interest of the patient or ship her off and get that room turned over to get another paying customer through the tills.

    Trust me, the patient could stay in that room till tomorrow for all the MAs care. Flipping the room might mean another day in Florida for the doctor this winter, but it means more work for the MA.

  4. Working for a private ambulance service, I once responded from two cities away to a physician’s office for chest pain. We hit a few miles worth of traffic on the highway, and as we were coming up the offramp, we got word from our dispatcher the the office had called back, asking us to “expedite.” As we hit the door, here’s the concerned doctor (nowhere near his patient) demanding to know “what took us so long” (apparently this patient was in such extremis that calling 911 for the local ALS transporting FD was simply out of the question).

    We were told the patient had chest pain and “EKG changes.” I was a Basic at the time, so I couldn’t tell you what they might have been. “He needs an IV, start him on oxygen, and monitoring, and he’s going to Non-PCI Hospital” (2-3 miles away, if that).

    What’s sitting in the (calm, in no obvious distress or pain) patient’s lap? A nasal cannula, still rolled up. What’s all over the room? Oxygen cylinders. He needed that life-saving oxygen so badly that he had to wait 20 minutes for us to bring it to him.

    Later, when we got our times, we realized what the problem was. Our onscene time was 17:05, or thereabouts. We were told to expedite not because of the patient’s condition, but because was Doctor Oxygen was going to be late for dinner.

    They’re not nurses? But they wear scrubs and give shots, what gives? Oh, they’re “Medical Assistants.” I’ve seen those ads on daytime TV. 8 weeks to a great job working in a doctor’s office.

    Hmm. Maybe in California. Out here the schools that don’t offer Medical Assisting as a 2-year Associates Degree take 9 months to get it done. You and I both know that there’s many Paramedic schools that don’t take that long.

    It is clear that not all offices are staffed with 8 week trainees, I’ve seen those with seasoned professionals, but I still wonder if they would act in the best interest of the patient or ship her off and get that room turned over to get another paying customer through the tills.

    Trust me, the patient could stay in that room till tomorrow for all the MAs care. Flipping the room might mean another day in Florida for the doctor this winter, but it means more work for the MA.

  5. Here, here. I have been saying this same thing since my days as a mom. We went thru bladder infections, URI’s, sinus infections, earaches, sore throats…. Meh!! Always a hassle even when it was just a reinfection of last month’s germ.

  6. Here, here. I have been saying this same thing since my days as a mom. We went thru bladder infections, URI’s, sinus infections, earaches, sore throats…. Meh!! Always a hassle even when it was just a reinfection of last month’s germ.

  7. I can give you 2 good reasons why this is not done in a clinic.

    1. A quiet room does not exist in any primary clinic. To make ends meet, every exam room needs to be maximized for turn over. Some clinics/offices has only 2 or 3 exam rooms. Can you imagine the impact of losing 30-50% of your capacity? How would that affect the waiting time for the other pts?

    2. Stocking costs. As you know, IV fluids expire. The turn over is high on an RA. But not in a primary clinic. I’m doing clinicals at a busy pediatric office. I have not seen a single pt who needed IV fluids in the past 2.5 months. I would imagine they might see 2-3 such pts in a year. How many bags do they need to stock? How many would they end up throwing out because of expiry dates?

    1. Helen,

      1. Reinforces his point about money vs. patient care. I would be willing to bet the majority of doctor’s offices have a room to spare. Plus, if you only see a handful of these patients, how much of an impact on your turn-around is this really having?

      2. Stocking costs are minimal actually. 1000 cc fluid bags are around $1 apiece, and usually last for at least a year…not really breaking the bank. If you know you’ll realistically see 2-3 such pt.s, I would assume you’d stock IV supplies accordingly.

      As I’m sure Justin will tell you, there are many good MD offices out there with professional staffing, and will keep the pt.’s best interests in mind. It just seems in lately, premiums and copays are going up, while the level of service we get goes down. Stuff like this gets frustrating, especially when it involves a child.

      Next time, just bring ‘em by the station, and work it out with a still alarm and a transport refusal.

      1. Nate, great points all, but a trip to the Pediatrician was warranted in this case to rule out infection, sepsis, etc. It was the complete disregard for treatment that had me spinning, and I’m 400 miles away. But, alas, when I asked my pediatrician if she would start a line on my kids, she declined, but would offer to “take over your skills” for the time. . In the absence of other needed treatments, my kids would be resting at home with a fluid challenge, but I have that option, my sister did not.

  8. I can give you 2 good reasons why this is not done in a clinic.

    1. A quiet room does not exist in any primary clinic. To make ends meet, every exam room needs to be maximized for turn over. Some clinics/offices has only 2 or 3 exam rooms. Can you imagine the impact of losing 30-50% of your capacity? How would that affect the waiting time for the other pts?

    2. Stocking costs. As you know, IV fluids expire. The turn over is high on an RA. But not in a primary clinic. I’m doing clinicals at a busy pediatric office. I have not seen a single pt who needed IV fluids in the past 2.5 months. I would imagine they might see 2-3 such pts in a year. How many bags do they need to stock? How many would they end up throwing out because of expiry dates?

    1. Helen,

      1. Reinforces his point about money vs. patient care. I would be willing to bet the majority of doctor’s offices have a room to spare. Plus, if you only see a handful of these patients, how much of an impact on your turn-around is this really having?

      2. Stocking costs are minimal actually. 1000 cc fluid bags are around $1 apiece, and usually last for at least a year…not really breaking the bank. If you know you’ll realistically see 2-3 such pt.s, I would assume you’d stock IV supplies accordingly.

      As I’m sure Justin will tell you, there are many good MD offices out there with professional staffing, and will keep the pt.’s best interests in mind. It just seems in lately, premiums and copays are going up, while the level of service we get goes down. Stuff like this gets frustrating, especially when it involves a child.

      Next time, just bring ‘em by the station, and work it out with a still alarm and a transport refusal.

      1. Nate, great points all, but a trip to the Pediatrician was warranted in this case to rule out infection, sepsis, etc. It was the complete disregard for treatment that had me spinning, and I’m 400 miles away. But, alas, when I asked my pediatrician if she would start a line on my kids, she declined, but would offer to “take over your skills” for the time. . In the absence of other needed treatments, my kids would be resting at home with a fluid challenge, but I have that option, my sister did not.

  9. Awhile ago my Engine company was dispatched on a ‘Medic Response’, which gets the closest BLS unit & closest Medic Unit. The call was for an “elderly male, hypotensive, at the doctor’s office” (FYI- the doctor’s office was directly across the street from the ER entrance, and AMR was backed up on interfacility transport calls). The doctor’s office had called 911/the Fire Department to get a Medic Unit to transport the patient across the street.

    So we four EMTs arrive upstairs at the physician’s office and find the doctor and several staffers around the patient, who was on a TKO IV for some minor outpatient surgery. The report from the physician and RN (?) was hypotensive with decreased level of consciousness. After taking base vital sign readings and radioing a ‘short report’ to the incoming Medic Unit, one of my Firefighter/EMTs says, “He doc, how about if we open up the IV and get some additional fluid into the patient?” The doc thought that was a good idea after we mentioned it. Hmmmm.

    After the Medic Unit showed up, examined the patient, and conferred with the paramedic consultation physician, he was wheeled across the street on the gurney- into the ER.

  10. Awhile ago my Engine company was dispatched on a ‘Medic Response’, which gets the closest BLS unit & closest Medic Unit. The call was for an “elderly male, hypotensive, at the doctor’s office” (FYI- the doctor’s office was directly across the street from the ER entrance, and AMR was backed up on interfacility transport calls). The doctor’s office had called 911/the Fire Department to get a Medic Unit to transport the patient across the street.

    So we four EMTs arrive upstairs at the physician’s office and find the doctor and several staffers around the patient, who was on a TKO IV for some minor outpatient surgery. The report from the physician and RN (?) was hypotensive with decreased level of consciousness. After taking base vital sign readings and radioing a ‘short report’ to the incoming Medic Unit, one of my Firefighter/EMTs says, “He doc, how about if we open up the IV and get some additional fluid into the patient?” The doc thought that was a good idea after we mentioned it. Hmmmm.

    After the Medic Unit showed up, examined the patient, and conferred with the paramedic consultation physician, he was wheeled across the street on the gurney- into the ER.

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