If Swine flu becomes a problem, here's why.....

So, last night, I was working in the EC when I got an up front introduction to the way that medicine will fail if we do get a serious pandemic. My patient was a five year old girl who came in with headache and fever for two days. Her flu swab was positive for type A. SO, the question then was how does further testing for swine flu occur? Well, here is what the byzantine process involves:

Any positive swab is sent for probe testing. This testing tests for all kinds of common flu, but not for H1N1. So, if the probe comes back positive, then it is Type A non-H1N1, and you are done.

If, OTOH, it comes back negative then it is possibly swine flu. At this point, the system starts to break down. Then, if it is suspect, it is the ordering physicians responsibility to call an epidemiologist. Then, the epidemilologist reviews the case, and if they agree, then they petition the state board of public health to send the sample on for definitive testing at the CDC in Atlanta. 

Now, anybody who looks at systems should immediately see the problem with this.

It starts with asking the question "Why would one be suspicious of swine flu?"

Well, presumably, you would gather a history which would include interrogating about exposure to either known cases of swine flu (For instance: somebody at this child's school was  positive for swine flu), or travel to endemic areas (if they had been in Mexico during the outbreak, for instance). The problem is that what if there had been an exposure, but it was not tested? Say that one of the cases of swine flu had gone home to Detroit after a trip to Mexico. Let's then say that while they got sick, they kind of "toughed it out" and kept going to work because they were in denial, or maybe they did not want to deal with the stigma of being infected with swine flu while everyone was getting ready to panic. So, they hide their symptoms, but it get's passed on to someone at home. They take the flu to school. Their school teacher gets infected, and then it gets passed onto another child, and then they pass it to my patient at a birthday party (which this child had attended the day prior to coming to the EC).  Now, the only reason that this child was brought to a doctor was because their mother has no intention of paying for her health care, so they inflict themselves upon the EC with no intention of paying their bill.

So, here sits a senior resident who has an influenza positive case with no *KNOWN* exposures to swine flu. Considering the hoops required to jump through, I look at this case and decide not to pursue further testing because I do not think it is warranted. Now, repeat this throughout Emergency Centers throughout the country, and you get to see how a pandemic can boil along under the surface until we only figure out the problem when we see skyrocketing numbers of influenza cases.

I think that if we are worried about swine flu, we should be automatically testing cases, or we should decide not to worry about it, and just follow trends in positive cases of influenza. This beureacracy driven modality is cumbersome and inefficient, IMHO. Then again, I am just a lowly resident, and there are a whole bunch of "really smart people" whose job is to design these systems.

I hope that they are right.

btw, the parent of this same patient kept calling the ER after she had left asking me to change the dose to a subtherapeutic level because that was all that her insurance would pay for. When I told her that I would not do that in order to save her the $60 copay, she basically threatended to come back to the EC and demand that we give her the meds. I was livid that someone would incur a $600 expenditure of resources by the taxpayer because they did not want to spend $60 for their own child. 

Because of this, I have changed my mind on always treating patients whether they can pay or not. I am now of the opinion that to walk in the door and get triaged, you should have to pay $20. Not to get seen, not to get a bed, but to walk in the door, up front.  I realize that people will not come to the EC asmuch, and that there will be patients who delay being seen until they are really sick, costing more money for *that* visit, but I think that as a whole, it will be cheaper, and will encourage people to either get insurance or to see their primary physician, or at least an urgent care clinic for the sniffles, which, frankly, is what they are there for.I think that if we were to also start a policy of having the family of terminally ill patients on life support indefinitely that refuse to withdraw support pay $20 a day in cash, every day, we will come up with a net savings. I have had one too many experiences with families refusing to withdraw support on a patient in a persistent vegatative state, racking up over a thousand dollars a day in healthcare costs in order that they might collect on that patients $600 a month welfare check.

I just read this morning that the AMA is pledging to cut costs by 1.5% annually by some vague increase in efficiency. I would submit that it will not include my suggestions, and that their ideas, whatever they are,  WILL. NOT. WORK.

Respectfully Submitted,
-doc Russia