To the casual observer a busy Emergency Room can appear chaotic. If that observer is also a patient it might appear chaotic and frightening. Phones ringing, monitors beeping, children crying, someone bleeding, someone else making the sorts of noises you would expect to hear on the deck of a fishing boat in choppy water. The staff rushes from one bed to another, paramedics come and go through the back door, and the occasional police officer passes through either with someone in handcuffs needing an evaluation before going to jail or to take an accident report. You wonder how it’s possible for anyone to think straight in such an environment. There ought to be a law.
Well, there is. Or more accurately, there are. Lots of them. As I noted in a previous installment there are laws dictating staffing ratios, how many nurses are required for a certain number of beds. Other laws address the types of doctors that must be on call, the types of equipment the ER must have, the training required of the various staff members working there, and on and on. The ER, despite its appearance, is a heavily regulated place.
Most of the laws and regulations apply to the hospital and the professional staff, but there are two that apply directly to you, the patient, and you should know something about them. They are EMTALA, the Emergency Medical Treatment and Active Labor Act, and HIPAA, the Health Insurance Portability and Accountability Act. I know, boring. Keep going, it gets better.
Let’s start with EMTALA. In the not-so-good old days some people in some ER’s were not as hospitable to certain patients as they should have been. For instance, if you showed up in active labor and the hospital you chose didn’t have an OB department, but the one half a mile away did, the admitting clerk might have suggested you leave and go there. Or maybe you didn’t have any insurance and your problem looked like it could wait the twenty minutes or so it would take for you to get to the closest county-run facility. A brief discussion of the financial benefits might have been had convincing you the county would be best.
The problem with all this helpful redirection was that the patient in labor and uninsured guy with the innocuous sounding bellyache didn’t always get to the “other place” in time. People were having bad outcomes. The politicians called this “patient dumping” and went on to say it was being done strictly for financial purposes. In many cases they were right. Something needed to be done, and that something was EMTALA. It was passed in 1986 and was of such scope that after all these years, and hundreds of lawsuits, there is still some confusion about what, exactly, some of its verbiage means. But the basics are clear enough, and all you really need to understand. According to EMTALA, every patient presenting to an ER must have a Medical Screening Evaluation, regardless of one’s ability to pay for it. It’s free. We can’t even ask if you have insurance until the screening exam is complete.
The evaluation includes whatever testing and imaging is needed to rule out a serious problem. And, if a patient is found to have an Emergency Medical Condition, (there’s a list of what constitutes such a thing), that condition must be stabilized before any thought of transferring the patient can be entertained. Active labor is considered an emergency medical condition. Sorry, Ma’am, but we’ll be delivering your baby in the ER.
There are exceptions, of course. If you have a problem that requires a higher level of care than can be provided by the hospital you chose, you can be transferred, providing a call is placed to the other hospital and the transfer is arranged doctor to doctor. The ER doctor in the little hospital can’t just decide you need to go to the big place and call for an ambulance. That would be an EMTALA violation and could cost the doctor $50,000 that his insurance won’t cover, and could get the hospital suspended from the Medicare program.
So if you think you need to go to the ER, just go. Try to pick the one best suited to your problem, but no matter which ER you choose, you will be seen. You can worry about the money later. As I said in Surviving the ER, it’s negotiable.
HIPAA is the other law with which you should have some acquaintance. The name mentions health insurance and portability and accountability, but what it’s really about is Privacy. Your medical information, from your billing address to your medical history is yours and can only be shared with specific people, like the ones taking care of you, and others you specifically designate. The person working in the medical records department has no business snooping through your file and can go to prison if caught doing it.
This applies to you as well. It’s why we discourage cameras in the ER. Taking a picture of the hottie in room three, or the obnoxious drunk in the gurney next to yours is an extremely bad idea. In fact, taking a picture of yourself and the newly placed sutures in your forehead is almost as bad. If you catch the hottie or the drunk in the background you could be in some serious trouble.
That’s enough about the laws for now. Of course, the elephant in the room we haven’t mentioned is the Affordable Care Act. Suffice it to say that apart from making ER’s busier, at least for now, it has no impact on actual Emergency Medical practice.
Who are all these people acting like doctors?
Enjoy all the installments of the ER 101 Series in this handy index.