Rash Actions in the ER

Today I am going to grumble just a little.  Working in the ER is interesting.  I can't complain about the wages.  I have good folks to work with and considerable flexibility in my scheduling.  I don't have to wear a suit and tie.  Ever.

But there are some ongoing annoyances and one big one is people who use the ER for things that should be seen in a clinic setting.

I am not talking about that uncomfortable kid with an ear ache at 2am on a Saturday.  I am talking about people turning up, sometimes also at 2am on a Saturday, with a rash they have had for weeks. Or months.  Occasionally for years.

Hear me now, with a few exceptions you should not go to the ER for a rash.

Reasonable exceptions:  widespread poison ivy.  Shingles.  Possible acute allergic reactions.  Rashes that are one component of a potentially bigger disease process - rashes that pop up with a high fever for instance.

But when somebody turns up with some vague spots of uncertain duration and expects me to A) diagnose it B) treat it, and C) give them a note to be off of work, that is inappropriate.

First of all it is not the sort of thing an ER does at all well.  Some of the useful things that could be done elsewhere such as fungal cultures, skin biopsies etc are difficult to impossible to do in an acute setting.  More importantly it is the kind of problem where having the same person see it before and after treatment is key....and doing follow up on a minor problem in the ER is nonsense.  You seldom even see the same doctor twice in a row.

Also I have to function with a computer system that generates prescriptions for me.  It does not even have most of the dermatologic preparations in there.  I have to laboriously free text it all in.  And it hangs up when you try to figure out doses.  "Apply a thin coating" is not in there.  It wants to know how many grams, or ampules, or inhalations or something.

So what you say, Tacitus MD can get a little grumpy when he is sleep deprived.  So sad.

But the real issue is that taking time for this kind of stuff keeps me out of the other rooms down the hall where there often are serious problems developing.  Many people who lack the insight on this epic level are also extremely demanding.  They want that prescription...NOW.  They want that note keeping them off of work for a week....NOW.  I can't show them the sick grandma down the hall who may be developing sepsis.

Although the patients are the immediate source of this problem they are not the entire issue.  Our healthcare system now discourages clinics from dealing with minor acute to sub acute problems.  They are paid best for chronic disease management.  They have to generate numbers that prove they have improved the blood pressure control or the diabetes control of their patient panel by a few percentage points in order to get the bonus money that is supposed to motivate them.  They are not especially interested in whether a person with eczema gets seen in a timely fashion.  Truth be told most of the folks who come in the door of the ER for an extremely minor issue have no intent whatsoever of paying a dime for the service.

Healthcare as a Right.  It is an interesting notion, and one that appeals to the "free stuff" crowd in particular.  But like all rights it can be abused.