Guest Editorial: A tale of two ERs

Dr. Massoglia is a second-year Resident in the Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD.

While recently vacationing with my family in the Dominican Republic (DR), I had the opportunity to experience medical care outside the United States. My 2-year-old son slipped in the "kiddie" pool and struck his chin on the side, which opened up an impressive bleeding laceration. After kicking myself for dereliction of my paternal duties, we went to the resort nurse for help. The laceration was too big to close with a butterfly strip, so she suggested we go to the ER in the local village. She thought it was likely that he would require sutures and would probably need sedation.

Visions of an ER in a Third World country came to my mind. I just knew that we would wait for at least a day and a half in some shack with dirt floors while chickens ran around loose before the "specialista" would come. Then he would have some pseudo-sterile stitches placed with some crazy sedative cocktail. Afterward, I would be buried in mounds of paperwork as they rummaged through our passports over and over again. Finally, all my cash and valuables would be gone in exchange for my son's release. I was sure that we would be lucky to get out alive. Despite all my anxiety, I threw caution to the wind, packed up a weekend supply of juice boxes, diapers, a blankie, a couple stuffed animals, passports, money, camera, sandwiches, some more diapers, and a change of clothes.

The resort called a cab for us and said there would be no charge. Something was amiss. We got to the ER, and the cabbie asked if he should stay for 10 minutes until we were done. I almost fell over laughing. "Mañana," I told him. We walked into the ER, and a medical student met us and escorted us to a room. The clinic was immaculate and brand new. After a cursory examination by the student with his broken English, the attending surgeon walked in and took a look at my son. "No problemo," he said. We went into another room, and within 5 minutes he had cleaned the cut and had masterfully applied some sterile strips while the medical student helped. He got on his cell phone and motioned for us to wait. I turned around, and he gave me some antibiotics and told me how to take care of the wound; I then realized that he had called us a cab. I thanked him, and we walked out.

Just then the insurance guy arrived. I was sure that this was when the torture would begin and that I would be filling out forms until dawn. We sat down and he asked for my name, address, and social security number. He photocopied my passport and walked us to the cab. He gave the cabbie a voucher and waived adios. No fuss, no muss. Total elapsed time in the ER-45 minutes.

Contrast this with my experience back home in the good old USA a few months earlier. While visiting family, my son (the same one) poked me in the eye with a toy. I could not see a thing or keep my eye open. The pain was excruciating. It was less painful, however, than the thought of going to the ER. I spent an hour trying to minimize the symptoms, but my wife convinced me to go to the ER. I really didn't want to go. I had a career-threatening injury and terrible pain, but the thought of going to my hometown ER somehow seemed worse. I knew this hospital well. Now, I was to be a patient there. We dropped our son off at his grandmother's house and braced for a long night ahead.

We entered the ER, went to a secretary, had our insurance card copied, and filled out a couple sheets of paperwork, including insurance forms. Forms are amazingly difficult to complete when you can't see.

Then we waited until we were called to see the triage nurse. I said, "My son poked my eye." She said, "Looks like you have a corneal abrasion." "Yes," I said. Great, we had an instant and correct diagnosis. Maybe, I thought, this won't take so long. After taking my blood pressure, temperature, respiratory rate, heart rate, weight, and height, I was sent to another room to wait . . . and wait . . . and wait. Then we were called back to the secretary for more insurance forms and card copying. Then we waited again. We were then called by a second triage nurse for repeat vital signs. No, they hadn't changed. Then we went to an exam room to wait for an hour. Something was amiss. The intern finally arrived, took a history, and did a physical exam including vitals again. Then we did some more waiting. "I'm looking for the Woods lamp," the intern explained. We waited some more. Finally, I got ocular tetracaine drops. Finally, sweet relief. "Now, I have to see my attending," the intern remarked. We waited some more. My wife and I found new depths of boredom as we counted ceiling tiles and rifled through drawers. We read the only magazine article and then quizzed each other on random trivia. "How many words are there in the second paragraph?" Another hour passed. Finally, the intern came back and gave me some other drops for my eye, and we did more paperwork. Finally, we left, or so we thought. One more stop at the secretary to fill out more paperwork and copy the insurance card again. Total elapsed time-6 hours.

I am not sure what to take from this. My wife mentioned that in the DR they never took my son's vital signs or asked if he had any rare bleeding disorders or if he was ataxic or felt light-headed before he fell, or maybe had a headache and needed a cranial CT. Maybe they did miss something. Maybe they were nice because we were tourists. I still have not paid a dime for that trip to the ER in the DR. In contrast, within a week, I got the bills from my home ER trip. Since they couldn't find my insurance information, the bill was $1,816.23. We are currently on our second round of discussions to try to fix the problem.

There is something wrong when a doctor with a career-threatening injury doesn't want to go to an ER because of the expected frustration, boredom, inconvenience, and unrelieved symptoms. Maybe less is more. Maybe it is what the insurance guy at the ER in the DR said when I commented on how fast everything happened. "First we take care of the patient, then we get the insurance card."

Next time my son pokes me in the eye, I will fly to the DR, go back to that clinic, and fly back in the same time it took me to negotiate my own local ER. It seems that American medicine is real broke and, for the moment, so am I.