• How a phone call saved a trip to the ER

    We nearly brought our youngest child to the ER last night. Struck by an asthma attack in her sleep, she was gasping and vomiting at 9:40PM. This one came on frighteningly fast. By happenstance, I had been in her room checking her covers at 9:20PM and she was fine, resting comfortably and hugging the pillow in such a comical sprawl that I actually laughed out loud.

    I was not laughing 20 minutes later. Not only was her condition frightening, the thought of rushing her to the ER to treat it filled me with dread. We’d been there before with her for the same problem. Once it led to a three-day hospital stay. It was best for her health, but such health care use takes a toll. Though sometimes it’s the lesser of two evils (if she needs the the ER, she needs the ER), nobody is happy about an ER visit. Nobody takes it lightly. If she can be treated effectively at home, that’s far better.

    Two things saved us from an ER visit. One was a call to Aaron. It’s a long and unnecessary story why we called him and not the doctor on-call for our regular pediatrician. Suffice it to say we needed to talk to someone right away who would handle the problem appropriately, not pushing us into the ER if it wasn’t warranted, but also not ignoring the urgency of the problem. Aaron did a great job, advising us how to use the meds we had on hand. It took five minutes of his time and saved what might have otherwise been hundreds to thousands of dollars of, what turned out to be, unnecessary health care use.

    The other hero of the night was our daughter. She’s a fighter, especially in her sleep (she really never woke up, despite the circumstances, and she recalls nothing about the episode this morning). Her little, nearly four-year-old body is strong, even when depleted of oxygen. She kicked and punched making delivery of medication impossible. However, she calmed down enough to take her meds when we told her if she didn’t, she’d have to go to the hospital. Somehow she heard that and it was enough. I’m impressed with the maturity of her decision under the circumstances and at her age.

    The other things that made this successful home treatment possible were ample health literacy of her parents (we knew enough to know the options and knew enough to know when to reach out for more help) and ample supply of relevant medication and equipment. There are likely many people who have neither and, thus, would not have been able to steer such an event away from a trip to the hospital.

    In other words, there was a high- and low-cost treatment option presented to us last night. That we were able to avail ourselves the low-cost one relied on a fair amount of health infrastructure and information transfer. From our own education, preparation, and insurance-financed supplies to the ability to obtain a timely, accurate phone consultation (itself the product of years of education, training, and practice), a lot of health care was actually used, but not the most intensive sort that could have been brought to bear.

    At the time of “transaction” — last night between 9:40PM and 11:ooPM — no bills were generated. Nobody is getting paid. There was no thought of “skin in the game.” But it was the best care for the situation. Maybe Aaron should send me a bill. For avoiding the ER, I’d happily pay it.

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    • It’s great that everything worked out.

      For argument’s sake, would “skin” in the game have affected your choices? Would cost have affected your decision on the choice of ER treatment? Would you have shopped for the best price?

      • If we had a choice between a low-OOP-cost and a high-OOP-cost ER (and we knew this in advance), we’d be motivated to learn if there was any useful advantage to the high-cost one. We’d probably learn this by asking our ped and our friends. Then we’d make a cost/quality-based decision in advance, as in, “If we need to rush to an ER we go to this one and not that one.” So, yes, cost would figure, but not in the moment.

        How do I know this? We do have a low and high cost option. In our case, the cost is travel time (not trivial given other demands, in particular the care of our other child and that we have only one car). We decided based on experience and asking our ped where to go. We go to the one further away (high cost in travel time) because it is better. Our actual OOP cost (in cash) does not vary.

    • Nighttime pediatric asthma attacks are scary — glad your daughter is OK.

      The other thing that jumps out at me from your story was that you chose not to call the on-call doctor, but a doctor friend. My friends call me all the time for urgent advice, rather than call their doctors. Your circumstance may vary, but this is a common problem: on-call doctors are often not very helpful. I’m sure there are good reasons for this:

      — They don’t get paid for the call
      — They don’t know you and aren’t personally invested in the care
      — They may be worried about liability if the patient gets worse and they don’t go to the ER
      — They don’t want to be interrupted from what they’re doing and “go to the ER” is the easy and safe thing to say.

      Nurse advice lines are good to have, but it would be nice if there were systems in place with more resources to avert ER visits.

      • I am writing up a plan to integrate into a non-FFS plan for our department., including some hospital plans also. I think this kind of care offers some real potential savings once you get out of FFS care. At present, no one gets paid for it and they only incur potential liability.

        Steve

    • I don’t know what your current situation is with your doctor but you should have an “Asthma Action Plan” which lays out meds, measurements and what to do when things start to get worse.

      http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf

      I am glad this worked out well for you. Asthma is one chronic disease where informed patients (and parents) can make a real difference.

    • Again glad you and your wife had the education, supplies and experience to respond appropriately and your child is fine.

      However, Dr. Aaron deserves reimbursement for his professional services in the five minute phone consult, somehow and someway. If we prepaid our physicians for anticipated services then handling a phone call from a patient/parent would be provided for.

      Most patients/family with a chronic condition know basic management and first aid for their conditions. If not they can learn it. You’d be surprised what can be handled with a bag of frozen peas, super glue, ace bandage and a few steri-strip. (Benedryl syrup, antibiotic ointment, cortisone creme and hydrogen peroxide are also essential items.) This I learned from my vet and not my pediatrician though my child benefited from it a number of times and it saved many a ER visit. As a soccer Mom I carried the oddest array of items in my car’s first aid kit.

      • Agreed. The five minute consult saved so much that the physician should be paid at least double rate for the time. For the hassle saved, I’d even pay it out of pocket, but for many that would be a bad incentive.

    • This is a good story.

    • if one studied the actual services provided in emergency rooms it might be determined that a “telephonic triage” service would be productive if the service was covered by insurance

      what is the profitability of an ER hospital service line?