The WalMart Greeter


Here is a story from Bryan Bledsoe, DO. Please send your stories to Tracy Napper at tnapper@acep.org.

Some call it Rapid Medical Assessment (RMA). Others call it physician triage. But, in essence, RMA is the medical equivalent of the Wal-Mart greeter—the intrepid individual who meets you at the door, gives you a smile, offers directions, and sometimes sage advice, and ultimately provides a shopping cart for your needs.
It’s nine o’clock on Monday morning and I log into the RMA computer. All of the busses are running and the crowd will soon be here. The doors to the emergency department open and the masses swarm in. In an abstract way, it looks like a casting party from the movie Doctor Zhivago. They storm the triage desk and then take their seats awaiting their on-demand health care. They are slowly brought back to one of two RMA rooms and await their first contact with a physician.
The first patient is an unemployed account manager who lost his job and his insurance. He has been off his blood pressure and diabetes medications for three months and family members pressured him to come “to the doctor.” He’s a nice enough guy and truly in a bad way. I refill his medications, trusting his recall is correct, and he’s off to the pharmacy.
The next is a non-English speaking patient with end-stage renal disease who shows up in the department every few days or so for on-demand hemodialysis. A quick look at the computer reveals that this is visit 83. I order the labs, get the EKG, and he moves to another waiting area where one of the other regular dialysis patients has brought breakfast tacos for all the “emergency” dialysis patients.
The next patient was seen in the emergency department 6 days ago for an ankle sprain and wants a work excuse for her week off work and a refill of her Percocet. She leaves with a work release and without a prescription.
The next patient is a trembling alcoholic who has decided that, on this Monday morning, he will make his seventh attempt to quit drinking. I arrange transport to the community detox facility. I give him enough Librium to keep his DT’s at bay and keep him from leaving before the detox center van arrives.
In the next room is a man in his 50s who missed his appointment at the hospital indigent clinic to follow-up on an abnormal PSA. He is certain his two-month old abdominal pain is cancer. I confirm a second clinic appointment for him.
Next, I go see a trembling, thin man who states that he needs his medications refilled. His pain doctor is reportedly out of town and he needs more of his methadone. A quick call to the pain clinic reveals that the patient was fired for noncompliance. He leaves RMA without a prescription and unhappy.
I move on to the next emergency and find a well-dressed woman with a pleasant smile. She just got her insurance and is here for a physical exam, pap smear, mammogram, and refill of her Xanax. She asks whether she can also get a colonoscopy today as well. She hands me her new insurance card. I take a quick look and note it is the local county welfare medical card. I refer her to the already overcrowded hospital clinic system—which certainly she will never get into.
The next patient is a young woman holding referral papers from a local chiropractor. It seems that she and her father were in an unfortunate motor-vehicle collision about a week prior. She says they are “trying to get some money” and the chiropractor her attorney referred her to sent her in for a “MRI of the spine.” After I completed a brief exam she left unhappy, without her imaging studies, warning me that I would be hearing from her attorney.
The next patient is a disheveled male who thinks that the people from Campbell’s soup are trying to kill him. I complete the paperwork and he’s committed to the mental health system and more sedate with some Haldol and Ativan.
As I’m completing his paper work an ambulance crew starts to unload a patient into an RMA chair. This person, later found to be a woman, wants to quit using her walker. I questioned her about the walker. She received it two days ago in the ED from one of the mid-level practitioners for an uncertain reason. I told her to quit using the walker if she didn’t like it. She seemed happy with my recommendation, then requested breakfast and a return ambulance ride to the homeless shelter. She left with juice and crackers and a bus pass.
If the emergency department is the safety net for society, RMA is the point of entry into the net. In less than 90 minutes on one Monday morning I experienced much of what is wrong with the American health care system. We don’t take responsibility for our own health. Poverty and unemployment are common. We don’t have access to primary care. Substance abuse and mental illness is rampant. On top of that, we have developed into a population whose defining trait is impatience. We want the best of everything and we want it now—be it health care, a new car, or that latest video game—and we often want somebody else to pay for it. Beyond that, we have a lottery mentality. An automobile collision or a mistake by a doctor can be a windfall for the whole family.
Has the emergency department become Wal-Mart? Are we to the point where we should offer on-demand health care to all? At what point does the health care system give up and just say come one, come all, we’ll take care of all of the injured and infirm in one place—just like Wal-Mart? Has the emergency physician transitioned to the role of the Wal-Mart greeter? Would you like a cart today?

  1. #1 by Andrew - November 2nd, 2011 at 10:08

    I have worked in two different Hospitals Emergency rooms, and those discriptions of ED are spot on! Unbeliveable Healtcare is broken.

  2. #2 by Justin - November 3rd, 2011 at 08:48

    Federally mandated, but not federally funded.

  3. #3 by Efrain Rodriguez Jr. - November 5th, 2011 at 15:45

    As a Pre-hospital Provider We were met with many of the types of patients described here. WE used to routinely not transport them, declaring after an assessment that their issues weren’t “sufficient to require an ambulance”. WE got into trouble many times for this, especially when one time we threw a female in lablr out of the ambulance because we wouldn’t let the 6 members of her family ride in the ambulance with us, so they decided to follow us in their car. Today’s EMS system is nothing more than a “cover your ass”: for the municipalities not to get sued for malfeseance. Medic’s should have the authority to refuse transport to “frequent flyers”; abusers of the system whose sole purpose is to get to the hospital for whatever free service they can get, and to those “the sky is falling” calls that portent to be of an urgent nature only to be seen sitting outside their homes with the $10 in their hand for the cab ride home. It might make for a long quiet tour but that crew will surely be able to respond where they are truly needed.

  4. #4 by Savage Henry - December 17th, 2011 at 13:08

    I know this is old, but maybe somebody will see it:

    Efrain, I feel your pain.

    There’s nothing like rolling up to an address you’ve been to 15 times this year for the frequent flyer who’s going to walk right out of the ED and stroll to his buddy’s house near the hospital. It’s even worse when you hear dispatch sending two other rigs to a rollover MVC right by your station – while you’re transporting the dingdong who thinks you’re a free taxi.

    I hate that – we all do.

    Still, the longer I do this, the less and less I want the RESPONSIBILITY to deny transport.

    I used to be an xray tech before finding a home in EMS. I work a zillion hours in a busy system because I love it, and I read medical stuff for fun. I’m pretty good at my job. I know a lot more than most medics – and I still get surprised from time to time:

    “Hey Doc! Sorry about the last one….Oh? He had what!!?!?? Dang….I thought he had another flare of end-stage hypovicodinemia! Glad we brought him in, then….”

    Doesn’t happen often, but it still happens.

    We just don’t have the gear on the bus to rule out all possible Badness. Mix in how much of what we see is URgent, but not EMERgent, and the responsibility for us to refuse transport is a recipe for disaster. Imagine this conversation:

    “Granny can’t move her left side now! We were sitting here chatting and she went all weird on me! Call an ambulance!”

    “Naw….don’t bother. Billy wanted a ride last week and they told him no. They ain’t gonna take Granny, neither. We can take my car when Freddy gets back with it. We’ll get some gas on the way, and I gotta run by the post office, too.”

    That’s a bit of hyperbole, but I’d hate to be (even indirectly) responsible for something like that.

    Also, think of what will happen once the pencil-pushers figure out we can refuse transport. Do you want to be evaluated in part on how much money you save the system by refusing rides to people? Here’s another conversation I don’t want:

    “Gee, Henry – you’re a pretty good medic. Patients seem to like you, and you haven’t screwed up big-time yet. Hell, even Dr. Bledsoe grumbled that you’re marginally competent once.

    Only thing is….the guys on ALS 123 have a way better refusal rate than you. They’re saving us tons of money because they’re back in service five minutes after they get on-scene. So….we’re giving them a raise/promotion/Disney vacation instead of you, because they earned it…”

    That kind of pressure will be inevitable. It’ll distort the thinking of even the most dedicated prehospital provider. That guy with the Star of Life tattooed on his forearm who wants to be a supervisor someday and has a new baby at home – he’s gonna have to make some crappy choices if you hand him this two-edged sword.

    Look at how much crap the Emergency Medicine docs get for “questionable” admissions to the floor. Those EM docs have access to stat bloodwork, hallway/phone consults with specialists, enough diagnostic ionizing radiation to keep a platoon of oncologists happy for years. They’ve also got AT LEAST five times as much training as you or I…and they still admit people that turn out not to need it.

    Do you really want the same responsibility that doc has? Even at some ghetto bus stop in the rain at 0230, and all you’ve got is your monitor, your stethoscope, and a 22 year old EMT-B to “consult”? Remember, your career and livelihood are going to tell you one thing, but your license and conscience will tell you the exact opposite.

    I don’t. Not until I’ve got a CT machine and a med tech running bloodwork in the back of my rig. I don’t get paid enough, and I don’t KNOW enough to risk those kind of decisions.

    We do a lot in EMS. We can do a lot more. We’re actually a pretty badass group of people when it comes down to it. We’re gonna get hung out to dry if the powers-that-be make us “responsible” for people who abuse the system, though.

  5. #5 by Darcy - September 22nd, 2012 at 04:10

    What a stuff of un-ambiguity and preserveness of valuable experience regarding
    unexpected emotions.

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