Now available in your friendly neighborhood ER: Norovirus

January 18, 2007

I’ve been ranting recently about physicians recommending visits to the ER partly/mainly/largely to mitigate the risk of being sued instead of basing recommendations entirely on medical grounds. That costs patients and caregivers time (often a lot) and money, slows treatment for real emergencies, and makes health insurance more expensive by driving up costs to the system.

Does this phenomenon also represent a threat to public health? From yesterday’s Boston Globe (Intestinal germ leaves trail of misery)

More than 3,700 patients stricken with nausea, vomiting, and diarrhea have visited Boston’s emergency rooms during the past six weeks in a wave of gastrointestinal illness… “We have seen a large number of cases of what appears to be a sudden onset and intense, short-lived diarrhea, nausea, and some abdominal pain,” said Dr. Jonathan Olshaker , Boston Medical’s emergency department chief.

The cause?

[N]orovirus, an intestinal germ that travels easily from person to person.

The article says public health officials can’t quite figure out why it is spreading.

My first concern (attention commenters, get ready to pounce!) is why so many norovirus patients are in the ER in the first place. Sure some are at risk of dehydration. But how many are sent there by on call docs “just in case of lawsuit” for an illness that passes in 24 hours?

My second concern is the number of other ER patients and caregivers –some at the ER for no good reason as described before– who may be getting infected while they wait around for hours.

SARS spread in a similar fashion in Canada, after all.

The outbreak surfaced in February 2003, when a woman from the Toronto area contracted the virus on a trip to Hong Kong and returned home, dying soon after. Her son went to a hospital with an unidentified condition that was later diagnosed as SARS. While waiting for 16 hours in a crowded emergency room, the man transmitted the virus to two other patients, and it continued to spread, the commission’s report says.

8 thoughts on “Now available in your friendly neighborhood ER: Norovirus”

  1. Amen.

    Having JUST got over this myself, I briefly considered going to the ER for IV fluids when a sip of water wouldn’t stay down. I waited it out though and guess what? I lived!

    The only lingering problem seems to be my breastmilk supply took a hit (I’m nursing twins).

  2. Agree completely.

    Docs are to blame for a couple reasons in addition to the one David mentioned (CYA). They fail to insist on being called first for non-life-threatening conditions. They fail to educate parents as to signs and symptoms of severe dehydration.

    Please remember this is a self-reinforcing phenomenon. When a patient goes to an ED and gets an IV, it’s natural for them to assume that vomiting and diarrhea = IV. This is a sure way for the patient and everyone they know to show up at the ED with gastro, thereby infecting everyone in the waiting room.

    The local radio station botched this story. The reader said that 3,000 patients “were sick enough to go to emergency rooms”. He should have said these patients BELIEVED they were sick enough to need emergency level of care. The distinction is crucial.

    best,

    Flea

  3. David,

    I think you mischaracterize the recent “rant” when you suggest that doctors are sending patients to the ER to mitigate their risk, and comparing them to “lawyer[s] or accountant[s] who always provided the most conservative advice with the most expensive consequences.”

    In your case, you were upset that doctors at a dinner party or on the phone were unable to prevent you from going to the ER on Christmas eve, just before you were leaving on a trip. Had you had time, any of them would have suggested that you seek further evaluation the next day or the next weekday, in an appropriate outpatient setting; but you were leaving the country. Surely waiting until the morning or the next weekday would not have resulted in a serious change in your son’s outcome, but YOU didn’t have the time, and you were counselled with this in mind.

    Your analogy suggests that you also get (or would even seek) serious, potentially life-altrering advice from your accountant or lawyer at a dinner party, or on the phone, without the benefit of the usual documents these professionals rely on.

    Please let’s be intellectually honest. If a patient describes a condition on the phone (or at a dinner party) that MAY be serious enough to warrant evaluation sooner than it can be had by waiting for the office to open (or because of impending travel) it is not only a risk mitigating act, it is good sound medicine.

    Rich

  4. But how many are sent there by on call docs “just in case of lawsuit” for an illness that passes in 24 hours?

    How does the on-call doc know that the illness is one that lasts 24 hours?

    It is also a bit extreme to believe that anyone thinks about the potential for a lawsuit when recommending a dehydrated gastroenteritis patient go to the ER for IV fluids. The risk is not that high, even on the phone. Their probably thinking about the patient’s well-being, their inability to hydrate themselves, and that the ER is probably one of the few places where the patient can get IV hydration.

  5. Rich,

    You have some minor details wrong that are relevant for your points. I was leaving in two days, not the next day. Nobody told me to wait till the next day. If they had I would have waited a day and gone to the ER then if needed –although in this case the problem cleared up.

    (The resentment I’m reading in comments about the informal “backyard” or “dinner party” comments is an interesting topic, which I’ll take up in the future.)

    I stand by my main point: Many doctors send patients to ERs to mitigate their risk. Does anyone really deny that? When I asserted in a previous comment that my regular ped and internist don’t do so, it was met with incredulity. Kevin MD called such docs “naive.”

    David

  6. The broader, more important point is that the current medical-legal environment creates a very hostile environment for those of us who have to “phone-triage” patients with some frequency.

    “Intellectual honesty” –
    1. Physicians in this country either lower their threshold for recommending ER evaluation (based on legal concerns alone – NOT medical reasoning), or get to spend a lot of time in court.
    2. Most practices should have an electronic medical record system that does provide access to the “usual documents”.

    P.S. I am on call tonight and I am going to send the next male over the age of 40 who calls me with “I think it must be acid in my stomach” straight to the cath lab!

  7. David,

    Yes, docs do send patients to the ER to mitigate their (the doctor’s) risk. Often, however, the doctors and the patient’s interest are aligned, and so they are also mitigating the patient’s risk of a bad outcome. When the patient’s inconvenience in the ER exceeds the danger posed by a potentially serious missed diagnosis, then their interests are not aligned, and when the dangerous diagnosis is excluded, which is likely (but not guaranteed) the patient is upset that they “wasted” their time. Since the dangerous conditions are generally less common than their less serious mimics, it is usually the case that the final outcome is one that generally does not need ER intervention. Hindsight is 20/20.

    Similarly, patients often forego their physicians advice, and “stick it out” as your reader does above, then exclaim, “I was fine!” Most of them will be. Of course, those that aren’t are also not posting comments on blogs anymore, or sharing their harrowing experience with friends and acquaintances.

    I still assert, though, that your example of gastroenteritis is an unrealistic one, because the risk of a bad outcome is so very low.

    Another way to see it (which is not how I see it, but how I understand others do) is to consider the absolute risks, rather than the relative ones (which probably reflects your assertion):
    1. The absolute risk of a bad outcome for untreated disease/illness/complaint X is greater than zero.
    2. The absolute risk of a lawsuit after a bad outcome, having referred the patient to the ER by phone-triage, is zero (or very nearly zero, not counting claims about prior care).
    3. The absolute financial loss after a single lawsuit is much greater than the financial loss sufferred by losing one dissatisfied customer.

    By this analysis, it is in the doc’s best (financial) interest to refer the phone-triaged patient to the ER. Ideally, however, in the absence (or extreme unlikelihood) of a life threatening diagnosis in the differential, the patient should be deferred to the office during business hours, or some similar care.

    As for waiting a day, I meant to suggest not that you would go to the ER the next day, but to _your_son’s_ physician’s office the next business day, which in your son’s case, was probably the best advice, absent time and travel constraints. I did a search on foot and ankle injuries: in the absence of significant physical exam findings, and your son’s ability to bear weight for several steps, an x-ray would likely not be needed. The key, though, is the physical exam. I eagerly await your comments on the “cocktail party” examination.

    I agree with “an internist” on points 1 and 2. But lowering one’s threshold does not mean that the threshold is on the floor every time. It is simply more likely that the patient will be referred, not a certainty, contrary to your assertion that you are “always provided the most conservative advice with the most expensive consequences.”

    Secondly, I agree about EMRs; I use one, and it has prevented many a trip to the ER for my patients. But I was referring to accountants and lawyers – surely they do not answer their home phones at 1:00 am, grab their laptops, and answer your tax questions.

    Enjoying your blog,

    Rich

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