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ER Goddess: The Trauma Emperor Has No Clothes : Emergency Medicine News


trauma centers, for-profit hospitals, reimbursement


It’s 6:45 a.m. You click frantically to complete a patient’s discharge paperwork while you wait for the hospitalist to call you back so you can admit another. You’ve been too busy to check if your other four patients’ scans and labs are back. There’s no way you’ll be done with your patient care before your shift ends in 15 minutes, let alone all your unfinished business. The only new patient you would expect to see before the morning doctor arrives would be one who is severely unstable.

You look up and see the EMS arrive with a pretty little old lady – we’ll call her Mrs. Jones – who has a sore hip after falling to floor level. You make eye contact; she seems comfortable. No legs are shortened or rotated, and no signs of trauma are visible. She rolls into a room and a nurse comes straight in to check her vitals and get her sorted. A minute later, Mrs. Jones appears on your screen. You check his vitals from your office and they’re stable.

Any seasoned ER doctor knows that the sensible thing to do, especially when you’re single, is to continue working on your other patients and let the day doctor see Mrs Jones at 7am when he starts his shift. . That’s exactly what I did.

The problem was that I worked in a new trauma center at a for-profit hospital. Many for-profit hospitals apply for trauma center status so they can take advantage of lucrative trauma activation fees. If the hospital had activated its trauma team for Ms Jones, it could have charged more money for the same care.

A few days later, my boss—former boss, actually, because I don’t work in that system anymore—asked me why I hadn’t seen Mrs. Jones. I explained that a fall at ground level generally does not meet the criteria for trauma alert, unless there are extenuating circumstances. My clinical judgment after nearly two decades told me she could wait 10 minutes. Unfortunately, the almighty dollar seemed to matter more than reason and clinical judgment. I have been told never to let such a patient wait again because “traumatized” patients must be seen immediately.

‘Bad medicine’

With the proliferation of trauma centers to capture reimbursement dollars, EPs can find themselves in an uncomfortable paradigm. A patient with stable vital signs who has fallen to floor level and broken a hip can be cared for in any hospital with an admission team, an operating room and an orthopedic surgeon. Our training has taught us that such cases do not require or warrant a trauma alert.

Yet we also understand that we are replaceable gimmicks in a system where insurance companies pay less and less and hospital systems are forced to grab all the money they can. Therefore, when we are told to see a patient with a traumatic injury immediately, we say to ourselves, “Well, it’s not bad medicine to examine Mrs. Jones as soon as she arrives in her room.” , then we dutifully try to please. bean counters, putting other patient care on the back burner, adding another board to our pile, and creating more backlog in service.

We are concerned that involving a trauma team in cases like Ms Jones’s will help hospitals’ bottom lines more than it helps them. Yet it is difficult for physicians to fight this battle one patient at a time. Arguing that a patient needs fewer tests and fewer consultants, even though our years of experience tell us that, can be forensic suicide if the patient turns out to be has a surprise injury. We do what we are told despite our worries, rationalize our multiple CT orders by telling ourselves that we ordered CT scans for less.

Our colleagues in other specialties are also concerned about the proliferation of trauma centres. I remember talking to an orthopedic surgeon many years ago about converting the hospital where I worked into a trauma center. He had heard of hip fractures that might have been medical admissions with orthopedic consultation but were instead billed—unnecessarily, in his opinion—by the new trauma center as trauma alerts.

He used the word fraud and said he was hesitant to have anything to do with these kinds of “traumatized” patients. Yet it seems that even surgeons, who generate more revenue for the hospital and therefore have more clout, are reluctant to report it. We all know this doesn’t end well for doctors rocking the boat.

The sad truth

It took a patient to proclaim that the Emperor has no clothes. Ed Knight sought treatment at one of Richmond’s new trauma centers; he needed 31 stitches for a gash in his arm, which should have cost around $3,500. The invoice he received was for $52,238. (KHN. Jun 14, 2021;

The article found that regional trauma cases and expensive trauma bills rose sharply after for-profit trauma centers opened, suggesting that many patients classified as trauma victims would previously have been treated at a lower rate. cost in a regular emergency department. I commend Mr. Knight for making this phenomenon public.

The sad truth about the Emperor of Trauma’s garments is that many trauma alerts in newly created trauma centers are not pretty capes woven from serious threads of patient concern; these are pretexts to invoice. Activating trauma teams makes money for hospitals, so we are seeing a proliferation of trauma centers and trauma alerts for patients who do not need trauma team care.

I hope more patients will see through the trick and demand proper use of imaging and consultations. The more I do this and the more I see how the medical business is scamming patients and doctors, the more I realize that patients and doctors are part of the same team. I would like patients like Ms. Jones and Mr. Knight who only need an x-ray but are subjected to full body scans to ask us, “Do I really need all this?

Sometimes the best we can do in this uncomfortable new paradigm is be honest with patients about the Emperor’s non-existent clothes. People injured in our emergency services are not sources of income; they are patients who are scared and in pain, and they deserve to be able to trust their doctors.

Dr Simonsis a full-time nighttime emergency physician in Richmond, Va., and a mother of two. Follow her on Twitter@ERGoddessMD, and read its past columns at