Woman's Bleeding Breast Not Emergency, Says Blue Shield

[RandySF]

http://sfist.com/2009/09/25/womans_bleeding_breast_not_emergenc.php

Sorry for the depressing way to start your Friday morning, but CBS 5's Anna Werner has a pretty damn harrowing tale of an insurance company, Blue Shield of California, twice denying a claim to a patient's breast tumor. It seems Rosalinda Miran-Ramirez woke up one morning back in April to find her breast bleeding from her nipple. Rightfully concerned, she darted to the emergency room where doctors told her she had a tumor in her breast.

"Doctors found a tumor and initially told her she had breast cancer. A biopsy later proved that assumption false; the tumor was benign.

But Miran-Ramirez said the real shock came when her insurance company, Blue Shield of California HMO, which had initially approved the claim for the emergency room visit, reversed course and sent her a new bill three months later requiring her to pay the total charges for that visit: $2,791.00."

But wait, it gets worse. After appealing the reversal, she was denied again by the health insurance mammoth. Blue Shield, it seems, told her she wasn't in "any acute distress" and "reasonably should have known that an emergency did not exist."

[MNDemNY]

1. I bet a bleeding penis would have allowed for an air-ambulance.

[Brickbat]

2. EXACTLY.

[demwing]

160. not exactly

According to Diversity INC, the Health Insurance Industry offers the greatest career opportunities for women and minorities. While it may still be dominated by men, it is by no means a hotbed for sexism and racism.

http://diversityinc.com/content/1757/article/5629/

[Mari333]

99. +1!!

[demwing]

156. -1

:eyes:

[Fire_Medic_Dave]

122. I'm guessing the insurance company would deny that $6,000 bill also.

[lumberjack_jeff]

129. No, insurance companies are unlike DU in this regard...

... they hate both genders equally.

[Gormy Cuss]

187. Coverage for birth control vs. Viagra.

Not at all equal.

[lumberjack_jeff]

201. I'm sure that money has nothing to do with that.

It's all a big misogynistic conspiracy.

[Gormy Cuss]

207. If money was the primary determinant, Viagra wouldn't be covered. n/t

[demwing]

155. That's not fare, and you know it

This has nothing to do with men and women, it has everything to do with greed vs compassion. You have no idea if that horrible decision was made by a man or a woman, or do you just assume that only a man would be allowed to sit in positions requiring financial decisions?

[progressivebydesign]

171. Umm.. how many insurance companies pay for viagra vs. birth control? n/t

[demwing]

177. LOL. Do you really think that only men get benefit from Viagra?

thats a riot!!!

There are so many jokes that coud spawn from this subthread...

[ThomCat]

186. I am getting very sick of men constantly denying that sexism and

gender discrimination exist. And I say that as a guy. Over and over again it's sexist guys insisting that sexism doesn't isn't real.

So, on what grounds do you deny that gender discrimination plays any role here? What is your supposed insider knowledge or expertise to deny the obvious? :eyes:

[demwing]

192. Is sexism real? Of course it is. Does it exist in this case? Who can say?

But if a claim of sexism is brought, let the person making the claim prove the claim. It's not enough to say that a women was involved, so she must be the victim of sexism. We don't even know that the person who denied her claim was a man! It could have been another woman.

And, as I pointed out in post #160, the health insurance field has been called out positively as a good example of an industry that promotes females and minorities.

http://diversityinc.com/content/1757/article/5629/

[ThomCat]

196. Whether a man or woman denied the claim is irrelevant.

Geez! Do you think that if women are treated differently than men by an industry that only the men in the industry participate in this?

You really are clueless.

And, just because the industry hires women and promotes them to some degree, while still remaining a male dominated industry, means nothing about the treatment of male versus female customers. Two entirely separate issues. Whether or not their HR departments are making progress in hiring and promotion doesn't mean squat regarding the history of women getting treated differently than men in medical judgments by the customer service departments.

What kind of proof do you really expect to show that sexism is a factor? In my experience, people who are incapable of seeing sexism, and therefore expect everyone else to provide the proof of sexism usually won't accept any evidence as proof anyway.

[Gormy Cuss]

188. If that were the basis for coverage, birth control would be a slam dunk. n/t

[ThomCat]

191. You are trying to be reasonable

with someone unreasonable. :(

[demwing]

195. Attacking me personally only shows

that you have a lack of facts to support your post

[ThomCat]

197. No. It shows that you're predictable, and unlikely to be swayed

by even the reasonable example just provided. :eyes:

How often we go through this, on thread after thread, with you denying that sexism exist, demanding proof, denying everything anyone posts, yada yada. It is getting old.

We should just accept at this point that you believe sexism exists in theory but you've never really seen an example of it in practice. You have never seen a situation where you couldn't defend male privilege and deny that any prejudice actually existed. you're incapable of seeing sexism. We've been through this before. Let's move on.

:eyes:

[demwing]

200. Another baseless claim when facts are at a loss

Thread after thread? Denying everything everyone posts?

You mean those who responded to the SINGLE post here, that made the completely rash remark that "a bleeding penis would have allowed for an air ambulance"?

Yeah, I challenge that, and everyone who makes a claim of sexism or racism or any other ism, then turns it back on the person or group being accused and demands they prove otherwise.

Last I remember there was a presumption of innocence built into the Constitution. Tell me is it more progressive to jump on the bandwagon of accusation, or to defend the rights of EVERYONE against such accusations which, though politically correct, are devoid of proof?

[ThomCat]

202. Thankfully

you're not part of any movement to advance feminism or women's rights. We'd never get anywhere with you as an ally. And just as thankfully, we've advanced plenty despite people like you as constant obstacles.

Good day. :P

[Gormy Cuss]

199. Just trying to show the limitation of that LOL remark. n/t

[Lorien]

204. Wow, you're quite a prize, aren't you?

I have no time in my life for knuckle dragging misogynists like you.

[demwing]

208. Ok byebye.

[ThomCat]

185. Are you kidding? Sexism is rampant in the healthcare industry.

It is so rampant in the insurance industry that stuff like this has had to go to the Supreme Court, and Congress has had to pass laws telling the Insurance industry, for example, that Pregnancy is a gender specific condition. They actually tried to deny pregnancy related conditions at one point, claiming it wasn't sexist because men wouldn't be covered if they got pregnant either. So faced with real history, and the real sexism of the real health care and insurance industries, what the hell are you talking about?

[demwing]

194. Read this article

http://diversityinc.com/content/1757/article/5629/

[ThomCat]

198. As I stated before,

And as anyone with even a basic understanding of logic should understand, they are two different and unrelated issues.

Just because an industry is making an effort to hire more women doesn't mean that it isn't still a male dominated industry.

Just because they are promoting women doesn't mean they are making it up to the executive suites, or making even making it up into middle management in large enough numbers to really influence behavior.

While the industries are still male dominated at the executive level men are still making the vast majority of the policies.

And the decisions of the HR departments has absolutely NO BEARING on what the Customer Service Departments do to customers, so this article has nothing at all to do with how male or female clients are treated.

So, basically, you just wasted my time and demonstrated gain that you really have no idea what the hell you are talking about. Your knowledge of gender issues is incredibly shallow, and it shows.

[demwing]

206. More personal attacks

thats all you fall back on. You call me unreasonable, but I haven't attacked anyone--you have. You say I'm ignorant of gender issues, but you've quoted no source or citation to support your statements - I have. You claim I've wasted your time, but your statements about the content of the article indicate you never really read it to any great depth.

So go ahead and accuse without fact, make claims without support, and read without reading.

[ThomCat]

209. I did read it.

And expecting other people to do your research for you to prove that sexism really exists is one of the classic warning signs people who defend sexism, or any form of prejudice. The next step is nit-picking any research I present, claiming that no research is ever enough so that I exhaust myself supposedly trying to educate you about sexism when you have no intent in learning. Sorry, I'm not wasting my time.

You're claiming that you're being attacked, but you're trolling, and you're being obvious about it.

[Lorien]

203. Indeed. nt

[TwilightGardener]

3. OK, at the risk of sounding mean here, unless it was lots and lots of

blood, it wasn't an emergency-room situation. It was a situation in which you immediately call up your doctor and make an urgent appointment. If everyone who found something suspicious or unusual on their persons went to the ER first (a funny mole, a little blood in the sputum), the emergency system would be overrun. That said, I can understand it probably felt like an emergency to her.

[MNDemNY]

4. Do you work for UHC or BC/BS?

[TwilightGardener]

8. No. I'm a registered nurse. I know what emergencies are, and

what emergency rooms are for. They're not for people who aren't in acute physical distress. They're for heart attacks, strokes, broken bones, hemorrhaging, gaping wounds, difficulty breathing, allergic reactions, etc.--things that can't wait for an appointment. I can understand that she felt it was an emergency, I'd be scared too. But I can also understand why it's not covered as an emergency.

[MNDemNY]

21. She was not a nurse, and for you to defend this company's actions are indefensible.

I hope you are more compassionate in regards to your "nursing".sheesh.

[TwilightGardener]

30. I'm not defending the company, but it's a fact that if it's not a true emergency,

then it might not get covered--this is something people need to consider before they go in.

[Truth2Tell]

63. Bleeding from the nipple is not an emergency?

Really? That may the nuttiest thing I've ever heard. Please tell me where you work as a nurse so I can avoid that place at all costs.

[DireStrike]

101. That's a bad angle of attack

There are lots and lots of ways to declare that bleeding from the nipple is not an emergency.


What you should argue with is the thought that the general population ARE NOT DOCTORS OR NURSES and are incapable of identifying what qualifies as an emergency, and should never be held responsible for being frightened when their body rebels on them.

[TxRider]

107. A broken collar bone is not even an emergency

What I tend to see as an emergency falls along the lines that have been determined for emergency care.

If it's not life threatening, it's not an emergency.

It has legal basis. Emergency rooms do not have to treat uninsured unless it is an emergency.

I even took a friend with a freshly snapped collar bone to an ER once, and was sent away to the county hospital because it was not "an emergency".

I've used ER's 3 times in my life, none were emergencies really but insurance paid for all three anyway.

Scalding my chest, broken ankle, and getting my hand diced in a car radiator fan.

[TwilightGardener]

108. Actually, you're describing: an extensive burn, a broken limb, and

a severe hand injury. All three would be emergencies to most medical people.

[TxRider]

110. But I could have waited until the next day and seen my doctor

None would have killed me.

Though infection from the scalding (280 degree radiator) and the cut up hand would have risked infection.

I did find it fascinating though that I felt no pain for quite some time as I looked at all the skin from my chest that came off stuck to the inside of my shirt..

That situation unfortunately changed in a few minutes. I truly thank science from the bottom of my soul for injected opiate pain killers...

[TwilightGardener]

111. Oh my God...well, you're one tough SOB, I'll give you that!

And yeah, those injuries could very well have crippled you, disabled you, or caused massive infection if not treated right away--loss of function is an emergency, even if it doesn't kill you.

[TxRider]

166. ROFL Not that tough, you just do what ya gotta do

I didn't have a lot of choice, I had to cool the radiator down, fill it back up and drive to the ER..

Gotta admit they hopped up from behind the desk right as I walked through the door, I didn't even get a chance to slow down and say ouch before I was on my back in a room getting treated. I had insurance, but they didn't ask until I was starting to zonk out on the pain shots and was all wrapped up. I guess they would have treated it even without insurance.

The worst part was a couple days later, when my doctor insisted on scrubbing my chest down with a brush with no pain killers so he could put some plastic skin looking stuff on me.

The hand was sewn up by a young ER doc right out of med school, he did a fine job. It'll never be quite like it was, but it's 90% of normal. Couple tendons are little shorter than they once were, really tight to make a fist, and the side of one finger is permanently numb. I don't remember if they asked for insurance up front or not though. I kinda passed out as I walked in the door from shock.

The ankle I did just go home, 7hrs later at 2am I woke up and decided I wanted pain meds right now, not later.. And drove to the ER. I didn't know it was broken I thought it was just a bad sprain, my motorcycle fell on it. They definitely asked for insurance, and I believe would have turned me away without it.

The one time I really needed insurance I didn't have it, calcified gall bladder and it got infected, almost did kill me before I went to the doc. Had to pay $10,000 out of pocket for surgery after a lot of antibiotics. Luckily I'm a single scrooge and had the money.

[nadinbrzezinski]

130. No, you are describing a serious burn

that is an actual bona fide emergency.

The finger injury you describe could have meant nerve damage.

I've used ERs four times in my life, or is it three?

1.- I opened my lip on the job as a medic... Though I was at the real back of the buss. All dressed and ready to go, trauma code came in... I waited, and had numbing meds again... after that patient was on his way to the OR.

2.- I had a really bad ear infection at night, on a Friday night. Yes, I could have waited, except the pain was bad enough and even my hearing and balance were getting affected. Again, we waited patiently for hours. Sadly, since we do have insurance I was seen before a few people I'd think should have seen the doctor before me,

3.- It was one that could have been very serious, or the joke it was... no middle ground. My ear started bleeding. There was no other symptom... again it happened on a Saturday afternoon. We went to the non critical ER... not the actual trauma center. They were all but busy, so I was in and out in half and hour and the doctor said, he wished most people were able to realize an ear bleed can be VERY serious... thankfully this was stupid... Though we are still wondering how that happened since I never put anything in there.

4.- When I was three my mom took me to the ER after I stepped on a shard of broken glass. One of my earliest memories actually. I still have that scar.

[nadinbrzezinski]

124. +1 as a paramedic I got many a calls that made me go

THIS IS NOT an emergency... never told a patient that.

Took care of them, at times even calmly transported to the hospital....

Ok, we only went ONCE on a restaurant owner. His chef cut himself. He needed stitches... not an ambulance... and he INSISTED that we were not moving fast enough and his taxes were paying for this (They were not, private charity, Red Cross, we get no support). For the record, the cook said, before his boss INSISTED on the ambulance, that he could take a taxi to the ER... In fact, after we bandaged it and stopped the bleeding he insisted on that, but no... his boss started berating us for not doing our jobs.

Understand this was right after a call that involved declaring a six year old dead and calling the coroner, so we were a little short.

Oh we drove him to the ER... and on the way explained to the boss in dreadful detail why this might not be a good idea, in case there was a heart attack that needed an ALS rig...

[Berry Cool]

140. The restaurant owner could have been nicer to you, but his cook did need the ER

if not necessarily an ambulance to drive him there. I walked to an ER once with a cut finger that needed stitches. No other open medical facility in the area for me to use at the time. At first my insurance didn't want to pay, but I challenged and they paid. My argument was that because I needed a tetanus shot and I was warned of the life-risking dangers of infection and to watch for the signs even after treatment (and to seek treatment again immediately if they appeared), the cut was life-endangering without immediate treatment and hence the ER visit was a must.

This woman...well, the insurance company is technically right in that, while a bleeding nipple is one possible indication of breast cancer, no one is going to die of breast cancer (even if that's what it is) from not being rushed to the ER for treatment the second a symptom is found. And good thing, too--otherwise an ambulance would be screaming down the street every time a woman found a lump.

No doubt the woman fell prey to panic, though, as most of us do when we think we might have cancer. We've been so inculcated with the myth that "early detection = cure" (not true; it just provides more treatment options and possibly a better chance of success) that we get the notion that at the slightest suspicion that we may have cancer, we must race posthaste to seek medical attention. But really. It doesn't make any sense, any more than it does to call 911 if you feel a lump.

But blood scares people. It just does.

[nadinbrzezinski]

144. The problem was the restaurant owner,

we recommended ER due to the need for stitches. The cook said, just cover it up with a nice pressure bandage, I'll take a taxi. No need for you guys to take me there.

It went down from there.

The cook used to be an EMT years ago. So he understood it, and he just could not do the bandaging himself, since they didn't have a first aid kit. He used a towel before we got there. That is a whole different story.

The owner didn't get it and was very nasty to us, after all we were just ambulance drivers with no education....

So we drove him to the ER, and crossed our fingers that we would not have an emergency that needed an ALS rig, that was all. It was one of those days... one of those shifts.

[sohndrsmith]

175. but as a paramedic, I'm sure you know that people panic - and may

act inappropriately (call 911/request an ambulance) becauseof their panicked thinking more often than not, no? Those of us who aren't EMTs/paramedics or medically/professionally trained - can get pretty scared when bad things happen unexpectedly.

Last year, I suffered severe chest pains and ended up driving myself to the ED at 2:00am (I think - I know I waited too long and the pain was so bad there was NO way I could sleep). Finally, I just got too scared when it didn't go away and, nitwit that I am, got in the car and started out for the ED. BAD idea. I was in no shape to drive and shouldn't have. When I showed up, they yelled at me (kindly) - and admitted me.

My mother has driven herself 3 times to the hospital while suffering from a heart attack (she's had - per her cardiologist - "more than five, I've stopped counting"), and has subsequently called the ambulance after getting seriously chewed out. They get to her in under 3 minutes, and this is a seriously rural area. The last time, three ambulances arrived (one got stuck in the mud) which accounts for 2, not sure why the third one arrived...

So don't you think that as many instances there are of people calling when they shouldn't, there are a significant number of instances where people *should* be calling you (but don't), yet you might never know about these situations, or get the call when it turns really bad - or worse - when it's too late..

Part of the problem is probably just a matter of logistics - when things happen after hours (nights/weekends). When people phone their doctor and get a callback by the on-call MD knows (or should know) that he/she will never diagnose or advise over the phone, unless it is clear that there is no cause for concern and advise to call next day. They tell the patient/person that, if they are that concerned, to get to a clinic/hospital. When after hours, the only option is (most likely) the ED.

I honor and respect the job you do - I'm alive today because of the rapid response and skill of the paramedics who answered the call.

The restaurant owner was clearly a jerk. Were you legally obligated to follow through on his demands? If you're RC/non-profit - does that alter the requirements you may/may not have to follow? Or your responsibility in assessing and advising whether or not transport is necessary or not? Sounds like you don't always transport after responding/providing treatment... who's choice is that? If the patient wants transport, are you obligated to provide it?

Anyway, I'm guessing a significant number of calls you respond to are unnecessary, and I'm sure that only makes a very difficult, honorable, exceedingly stressful job that much more frustrating.

I know you don't get to choose who you treat, and there is no guarantee they will be coherent, sober, sane or cooperative. My guess is the large majority fit one or more of such categorizations. As someone's who's life has been saved by the prompt response of paramedics, I apologize in for all of us. We all need you - or think we do - or think we do but aren't sure guess we should call you - precisely because we DON'T know. And there are those of us who *are* sober, coherent, and eager to be cooperative (but are so bloody scared out of our wits) who just panic and lose it. It's hard when one is in shock and/or panic.

Unfortunately (or perhaps fortunately), you know better than anyone: people are human. : ).

Thank you for what you do.

[11 Bravo]

151. Your ignorance is now on full display. ERs are for EMERGENCIES.

The woman was in no imminent danger. The medical professional on this thread tried to explain that to you.

[Truth2Tell]

152. I have no reason to believe

that the person in this thread claiming to be a "medical professional" is any such thing.

And I'll continue to use the age-old standard of common sense and simple reason to determine what is or is not an emergency. Feel free to use the Insurance Industry definition for yourself. Next time you start bleeding from an unexpected orifice, I suggest you just sit at home and bleed it out. After all, that's what the "professionals" suggest.

[progressivebydesign]

173. I wouldn't have gone to ER. That's the stuff of an urgent care center....

..not the emergency room. Having said that, the insurance industry has a helluva lot of nerve turning it around on her like that! If the doctors at the ER did not turn her away, then the insurance company should have paid. If the doctors didn't feel it was acute enough, they would have sent her to her doctor or clinic.

[Chemisse]

153. She is right of course.

As upset as we are about the health care situation, we still should not exaggerate to make a point.

Unless she was gushing blood, it is not an immediate medical emergency.

[Enthusiast]

115. Lay people would assume a

bleeding breast is a true emergency. This is only reasonable. Lay people don't have the benefit of your training. If the insurance company was not involved there would be no problem.

[RayOfHope]

135. And if she doesn't have a regular physician, its damn near impossible to get in

as a new patient. I live in the 3rd largest city in my state. When we moved and I was trying to find a doc for myself and a ped for my kids, I called EVERY doctor listed for the 2 major health systems in my city. I made over 40 phone calls, and not one, not ONE doc was taking new patients or it was a wait of several months. Last fall I tried to find a derm. for a spot on my leg. I called 5, and either non was taking new patients or they wouldn't see anyone without a referral for a specific issue from a regular doc. Tis spring I tried to get into a doc for strep and the soonest appt they had was 6 weeks away. That doesn't do much good when you have strep.

[roseBudd]

149. I had the same experience until I called the doctor whose name began with Z....

He is no longer my doc, I now have another doc with the same group whose name begins with W

[etherealtruth]

184. From a nursing and medical perspective it was not an emergency

From a patient's perspective it most assuredly was. Patients are not required to have professional insight into their conditions.

[skygazer]

54. May I get your testimony when I appeal my insurance company's decision to deny my husband's claim?

He did have a "gaping wound" that required 11 stitches, was bleeding profusely and it was a weekend when his doctor was not available. I took him to the ER where he was treated. The claim was denied on the same basis - not an emergency. :eyes:

It makes absolutely no sense to define an emergency by professional medical standards when the people making those calls are not professional medical personnel. It should be a "reasonable person" standard and I think most reasonable people would feel that bleeding from one's breast constituted an emergency.

[TwilightGardener]

56. Well, a gaping wound that requires stitches is obviously an acute situation--

I have no idea why they wouldn't cover that. That's ridiculous.

[Gormy Cuss]

190. They didn't cover it for the same reason they don't cover many claims -- greed.

The executives who set policy recognize that only a percentage of these denied claims are even questioned and therefore the company is paying out less on claims of that type. It's a business decision. It's also why we need to choke them out of this business with single payer.

[Berry Cool]

142. Good Lord, you should have challenged that!

Know how many stitches MY wound needed? Two. TWO. And I got my insurance to pay.

It is insane that your husband could not get insurance to pay for an ER visit for a gaping wound requiring 11 stitches! On a weekend! (Mine was on a weekend too!)

[REP]

85. I'm not a nurse and I know that's not a life-threatening emergency

When it happened to me, I waited a few DAYS. Then again, I knew the mass was likely cyst and people don't die from sudden onset boob mass.

[elleng]

136. Thanks for the info.

[kestrel91316]

Sadly, most people panic over little thiings that don't matter, and ignore

really impostant stuff that does.

I see lots of panicky, weeping pet owners because Fluffy has been sneezing a little for three hours and has a runny nose (while playing and eating just fine), but people don't seem to give a damn when Fluffy loses weight over a period of months until she is skin and bones (but THEN they come in and want her fixed on the cheap).

The average American has ZERO common sense when it comes to anything medical.

[KittyWampus]

11. so you think blood coming out of your nipple is a little thing that doesn't matter.

Huh, she actually did have a tumor. She was lucky it was benign.

I can't believe your attitude here.

[kestrel91316]

73. I guess I am an awful person for thinking she needed an office visit

and not a full-on hysterical visit to the emergency room.

Your reading skills are lacking. I was bemoaning the general lack of medical common sense in the US, and yes, I consider her failure to simply make an urgent doctor appointment to be an example of it.

I know what a genuine emergency is, and that probably ain't it, at least compared to, say, a gunshot wound to the chest, or a serious car accident head injury, or difficulty breathing, or an irregular heartbeat causing near-fainting like I myself had some years ago.

Going to the ER for every little thing that gets a person's panties in a twist is why our medical system is going broke.

[Statistical]

95. Even if it WAS a tumor it isn't an emegency.

Nobody died from a tumor in a matter of minutes, hours, or even days.

It wasn't an Emergency. Even Medicare administered by the govt will charge you if you use Emergency Room services for non Emergency.

Emergency Room costs are insane. That $2800 in Emergency Room likely would have been $400-$500 at an acute care center, or Hospital non-emergency visit.

The Healthcare system can't not afford everyone getting care that costs 5x, 6x, 7x what is required.

[Fire_Medic_Dave]

117. I believe they are just saying it wasn't an emergency.

[Beaverhausen]

12. well, would you consider bleeding from one's nipple a little thing?

I wouldn't. I too would get myself to the emergency room pronto if such a thing was happening.

[Statistical]

97. Well then expect a $2800 bill for using emergency services for non emergency

[Beaverhausen]

113. I went to the emergency room many times with food poisoning

I was throwing up and had diarrea. That's not necessarily an emergency, but it was covered by my insurance.

So, if I'm bleeding from a body part that is not EVER supposed to bleed, you can bet my insurance would cover the emergency room visit.

[TwilightGardener]

116. That could be considered an emergency--if you are vomiting or

have diarrhea to the point of severe dehydration and electrolyte imbalance, that is serious and can be life threatening--you might need IV fluids and monitoring, at the very least. I'd expect them to cover severe prolonged vomiting and diarrhea. But let's say you pass a small amount of blood in your stool one day. You are not supposed to bleed from the rectum. With no other symptoms (severe pain, sudden weakness) or relevant history (car accident, blood thinners, etc.), that's not necessarily an emergency room visit, but it IS an immediate call to your doctor to see what you should do next. They may not cover that, no matter how scary you find it.

[Fire_Medic_Dave]

123. I think you are wrong. Food posioning can easily be fatal.

I haven't heard of a case of exsangiunation from bleeding through a nipple. I'm guessing it is almost impossible without severe trauma or a clotting disorder.

[nadinbrzezinski]

134. Food poisoning IS an emergency

now I know where you are coming from... exactly. And it is not limited to Americans

But it is not this "misuse" of the ER that is the source of the problem. All medical systems have this misuse. It is the fact that people have no insurance so the provider of last resort is the ER. And I mean for everything, from a little food poisoning, which is an emergency and can kill, all the way to slight owies that should be handled ideally in an office setting.

[Chemisse]

154. I would never go to an ER for blood coming out of my nipple

That would be silly. I would be very concerned and I would get a doctor appointment as soon as I could, and go from there.

[Deja Q]

Depending on what the issue is, we all have our areas of specialty regarding "zero common sense"

:shrug:

[hedgehog]

7. I'd like to know if she did have a primary care physician and if so,

did she contact that physician and what was she instructed to do?

[robinlynne]

9. If it were me, I might go to the emergency room too.

[Tempest]

25. She woke up with the bleeding breast

It's highly unlikely her primary physician's office would have been open at the time.

She did the right thing and Blue Cross should be forced to pay for the ER visit.

[Ruby the Liberal]

10. Sorry, but if my body is producing blood for no known reason in an area

that doesn't ever produce blood as a normal function and I am not "injured", I am going straight to the ER.

I hope the media pressure can help this woman.

[TwilightGardener]

13. Go ahead. That's your right. But don't expect it to be covered, is all.

[MNDemNY]

24. Gotta be UHC.

You aren't much of a "nurse".

[One_Life_To_Give]

70. As triage goes

This doesn't really take precedence over Heart Attacks, strokes, anything needing to be in the OR within 60 minutes, e.g. True emergencies. Not unless we are talking about serious loss of blood which should rate an Ambulance and Transfusion.

It's distressing and deserves an immediate call with the Doctors office. Hopefully actually being able to see your Primary Care Dr. the same day. But this isn't going to kill you within the hour or two.

[MNDemNY]

77. How "saturated" did her T-shirt have to be?

A broken arm is not likely to kill you in an hour either.

[TwilightGardener]

80. Bleeding aside, anything that threatens life, limb, vision is an emergency.

A broken arm threatens the limb--it may be causing irreversible neurovascular compromise if not stabilized, may be causing internal tissue damage and bleeding, and if not set quickly and properly may result in deformity and loss of limb function.

[MNDemNY]

81. Oh . give it up.

Fuck sakes, you are wrong.So wrong.

[DireStrike]

103. Whether it is a true emergency is neither relevant nor productive to consider

All I will say on that is, I will let the hospital staff decide what qualifies as an emergency.

The real point is, no person should ever be at fault for not being able to identify whether something is an emergency or not, according to whoever. It is unreasonable to expect the general public to be able to do this.

If we are going to hold people liable, we need to teach every citizen medical care....

I'm sure the insurance companies have a solution. They will include a page on emergencies in their packets, with a tiny disclaimer saying "you have now been informed of the nature of emergencies and can be held legally responsible for any costs incurred due to your failure to correctly self-diagnose."

[Fire_Medic_Dave]

125. What in her comment is incorrect? I can't find anything.

[Chemisse]

157. Why is she so wrong?

Because it contradicts the point you are trying to make?

[Gormy Cuss]

193. Again, people who aren't medically trained do not have enough knowledge to make that determination.

It's irresponsible for medical insurers to treat people as if they did.

[One_Life_To_Give]

89. More a rate than anything

You can tolerate up to 4 units of blood loss IIRC. Which is the amount you would also loose to a non-compound broken Femur.

So you would want to know both the total quantity lost so far and the rate of continued loss. As I said elsewhere 8oz to me would signify a concern for emergency. More importantly would have been the ability to bring such a bleed under control.

Perhaps more importatnly what this discussion points out is the need to have a place to call for medical advice when the average person is confronted with such a thing. Be it a bleeding brest or a feverish child. We should be focusing on matching the right level of treatment and urgency to the injury/illness present. Not the Maximum Level of response to every uncertain individual.

[mrs_p]

131. i agree totally!

why wasn't there someone at the hospital that told her that she really needed to see a specialist within the next day or two. emergency medical staff would know they couldn't really do any treatment for her that night.

[mrs_p]

126. are personal attacks really necessary?

[Raineyb]

74. There's absolutely no reason why it should not be covered

Unless you consider the profits of the insurance companies to be more important than the care of actual humans. And very few doctors will see you right away without an appointment. So the common sense thing would be to go where one can be treated aka the emergency room.

I hope to God I NEVER have to step foot in any place you work.

[hedgehog]

18. My first call would be to my family doctor, but I've known him for over 20 years.

If I didn't have a doctor or if it was day the office is closed, I might go to the ER if there was a lot of blood. If someone doesn't have good, quick access to a doctor they trust, I'd expect them to go to the ER.

[Fire_Medic_Dave]

118. Why not call an ambulance, if it's that much of an emergency?

[RandySF]

15. "Saturated with blood"

http://cbs5.com/local/insurance.claim.denied.2.1207332.html

When Daly City resident Rosalinda Miran-Ramirez woke up one morning in April to find her left breast bleeding from the nipple, she panicked. The shirt she had been sleeping in was saturated with blood. So her husband took her to the emergency room at Seton Medical Center.

[TwilightGardener]

17. Well, as I said, if it's lots of blood, then it's an emergency, and should be covered.

[MNDemNY]

26. Oh, don't flip-flop now!

Keep defending UHC ,etal.

[TwilightGardener]

32. You're weird.

[MNDemNY]

66. Your a bad,bad nurse.

[Shell Beau]

148. You don't know that.

And that is an ugly attack. She is simply stating that it isn't considered an emergency among professionals who know. I would also get my ass to the ER as quickly as my car will take me if I am bleeding out of my breast, but I don't see where this makes her a bad nurse. She is telling what constitutes as an emergency, not that the woman was crazy for going in.

[Chemisse]

158. You're a mean mean person.

[ieoeja]

36. No flip-flop. Twilight's 1st post: "unless it was lots and lots of blood" (nt)

[noiretextatique]

41. maybe Twilight should have read the article before commenting eom

[redqueen]

What a novel concept! (nt)

[noiretextatique]

47. indeed

:rofl:

[tammywammy]

46. I gotta say, I think approximately 3/4 of DUers don't read the articles. n/t

[noiretextatique]

49. hence the endless flaming and arguments

that wouldn't happen if people actually read before they type.

[tammywammy]

52. LOL! Yes indeed. n/t

[TwilightGardener]

50. No, I'm bad with only reading the excerpts, I admit that freely.

[tammywammy]

55. Hey, don't worry

I usually only read the excerpts unless it's a really interesting story that I'm going to comment on.

But at the same point, I think you highlight an important topic in this discussion. While she should have obviously been covered (a shirt soaked with blood), there are things that people go to the emergency room for that AREN'T emergencies and could ultimately be denied as such. Not that I think that's right, but it is how it is right now, and something I had never given much thought to, as I've only been to the ER twice in my life and they were both emergencies.

[TwilightGardener]

59. I went to the ER once, as a young woman, for a bee sting that made

my hand swell up so much I couldn't close my fingers at all--I looked like I had a Mickey Mouse hand. To me, this was an emergency, although I still had sensation, my fingers weren't blue, I wasn't having trouble breathing, etc. Well, they just about laughed me out of the ER--the doctor who saw me said, "Yup, bee stings swell, that's what they do." I felt like such an ass! I didn't have to pay for it, because it was military health care, but it made me think about what constitutes a medical emergency even before I went to nursing school.

[hedgehog]

67. And if you'd lost circulation in the hand with subsequent loss of a couple

of fingers? I'm not a doctor or a nurse, just an engineer,wife and mother with an active imagination!

[TwilightGardener]

72. Well, the first thing they did was assess my sensation and circulation--

that was fine. My fingers were in no danger, they weren't numb or anything. Which is why I should have just stayed home and elevated my hand and took some Benadryl and used an ice pack. Or at least called them for advice before I went in--I didn't even do that.

[hedgehog]

82. It takes four years of college to get a BS Nursing. A doctor might train for

12 years or more before entering practice. Yet somehow you are expected to make an evaluation on your own.

Years ago, my daughter had an odd wound on her thigh. She'd been wearing shorts and playing on a tire swing. Her brother wound the swing up and let go so she could spin. Somehow the skin on her leg got caught and torn by the rope. It looked nasty, but I didn't think anything could be done. When a doctor saw her lovely scar and heard how she'd gotten it, he told me I should have brought her in for stitches.

[TwilightGardener]

90. I know, I've not taken my kids to the ER right when I should have--

my older son had a gash up his leg, but it stopped bleeding and didn't seem too "gaping" or deep, so I cleaned it and bandaged it and kept an eye out for infection, and now it's a huge scar, much bigger than I would have expected. Probably should have had it evaluated. My younger son complained for a couple days about pain in his collarbone before I realized it was fractured! He'd landed on it wrong. Other times, I've overreacted, especially when they were babies. Judgment calls, judgment calls...

[Hekate]

109. Twilight -- that is exactly the point most here are trying to make. My sis's finger is crooked...

... from being slammed in a door when she was three. Mom and dad were broke, mom was harassed with taking care of 4 kids, and mom did a lot of "home nursing" when we should have gone to see the doc. I look back on the year we had a ping-pong staph infection in the family -- a YEAR -- during which mom practically boiled and bleached everything in sight trying to clean it out of the house, and I wonder now if a visit to the doc and penicillin shots all around might not have cut this short. So it's not an ER example, but it is an example of how a layperson, especially one with no money, can misjudge a medical situation. Then there was the time I had some sort of walking pneumonia for 3 months when I was in high school...

Frankly, if I were to notice a drip of any color from my nipple I would make an appointment with my doc straight away. However, upon awakening with a bloody, saturated T-shirt, the normal human reaction would be to just about panic. I would cut this woman some slack, and in a humane health care system, she wouldn't be punished.

Hekate

[TwilightGardener]

114. I don't expect people to always know when it's an emergency--

I sure don't, myself. The point is, though, that the insurance co. can decide not to cover it, and they're not automatically wrong (although it sounds like they were in this woman's case). You just can't expect payment because you were really scared, didn't know, etc.--imagine how crowded the ER might be if there were no limits on coverage, no matter the level of urgency. If we had a different health insurance/health care system, or more urgent care centers, or clearer guidelines, etc., it wouldn't be such a dilemma for people when they're sick or have weird symptoms--but this is our reality for now. And for anyone who's ever sat hours in an ER waiting to be seen, you have to wonder if either the people ahead of you don't belong there, or if YOU don't. It really is best to call the MD, insurance company, or even the ER first if there's any uncertainty.

[barbtries]

179. they didn't give you a shot?

that happened to my son and i took him to the ER. they did not laugh at me, they gave him a shot of eppie.

i've been stung twice by bees. no way did i swell up like you and my son did. in my opinion you had an allergic reaction. hence the ER. i think your doctor was an asshole.

[Chemisse]

159. Maybe the insurance company did not know it was lots of blood either

I have had that happen to me, back when I was lactating, and it was just a little blood. That's all I could picture when I read about this woman.

[TorchTheWitch]

170. I think most don't even read full posts

and just read the titles.

[KittyWampus]

100. LOL! "lots and lots of blood" Is that a medical term understood only by nurses and physicians?

You think maybe that's a subjective term?

[TwilightGardener]

106. In fact, if you were to call a doctor or a triage nurse, they would try

to get you to quantify the amount of blood. For example, for heavy menstrual bleeding, they'd ask you if you were soaking an entire pad more often than once per hour. Amount really does matter, in situations like this. Location of bleeding matters, circumstances leading to the bleeding, prior medical history, all matter when considering if it's an emergency. For example, nosebleeds--usually not an emergency, depending on the circumstances and amount of blood. Bleeding or fluid from ears after an accident--definitely an emergency. No one is saying the woman was a fool for going in to the ER, clearly she was frightened. But all the same, I doubt very many women ever fatally bled out from the nipple. This is how insurers see it, right or wrong.

[nadinbrzezinski]

We used to try to ascertain blood loss at scenes

I used to ask patients silly things like... how many pads have you used?

And trust me, blood is really easy to look far more than what it really is. Even trained medics and doctors have trouble with how much at times.

[KittyWampus]

98. if you are bleeding from the nipple, first thing you do is measure the amount of blood

that's come out.

-SARCASM-

[Cessna Invesco Palin]

33. How much blood from the nipple is enough to qualify as an emergency?

And is the person who is bleeding from the nipple in any way qualified to determine how much blood is enough for it to be an emergency?

[TwilightGardener]

43. Well, having been to the ER for severe gynecological bleeding, myself, if you're

soaking through clothing and protection, without stopping, then it would be an emergency--your hemoglobin and hematocrit are dropping. If you have a small amount/spotting of unusual bleeding or discharge, then it's a cause for concern and a trip to the doctor. Again, I'm not blaming this lady for being scared and wanting to go to the ER, but people need to be aware that hospitals and insurance companies don't see things the same way as we do. We get understandably scared and emotional, but they aren't going to pay up for scared and emotional.

[noiretextatique]

there was lots of blood in her case

as there was in your jusitified emergency room visit.

[Cessna Invesco Palin]

138. So I must ask again - how much blood should there be before you fo to the ER?

[Cessna Invesco Palin]

139. So I must ask again - how much blood should there be before you fo to the ER?

[One_Life_To_Give]

83. 8 0z?

A full cup of coffee, enough to soak not just the night shirt but down into the mattress itself.

Granted most people may panic at far, far less. Was she qualified?? Don't know. Are we as a society perhaps too quick to expect an entire trauma team be at out beck and call? Probably.

[Chulanowa]

19. That's not the issue

The issue is, she was covered, then suddenly she wasn't. Three months later!

The issue wasn't whether she was bleeding "enough," the issue is that her coverage was yanked away a quarter of a year after she was told it was covered.

A secondary issue is that a trip to the emergency room cost her nearly three thousand dollars. Which, presumably, is partially due to insurance companies doing this shit to other people - "oh, it wasn't enough of an emergency!" resulting in people who thought htye were covered suddenly being unable to pay, meaning hospitals have to jack up the price (which apparently gives insurance companies a reason to increase their primiums...)

[TwilightGardener]

20. I'm guessing they did a case review and decided to be dicks about it.

[Chulanowa]

35. You think?

This sort of shit should be illegal.

Can you imagine going to the store, buying a bunch of stuff on sale, and then having the store bill you for the savings after their sale is over? It's like a Blackbeard version of bait and switch.

[Cessna Invesco Palin]

29. She was BLEEDING FROM HER NIPPLE you ridiculous twit.

Only in the US is this something where you just say, "Oh, I'll wait for the next available appointment."

[TwilightGardener]

37. Yeah. Bleeding from the nipple can be a sign of a tumor or injury. But that's

not necessarily an emergency, unless it's a lot of blood--if that was her case, then it should be covered as an emergency. It's a reason to get your ass to the doctor, pronto, but not immediately life or limb threatening. I wonder if people don't know what emergency rooms are for, anymore?

[noiretextatique]

44. her shirt was soaked with blood

is that enough blood to qualify as an emergency?

[TwilightGardener]

48. Sure. I've already said so.

[noiretextatique]

57. i understand what you are saying

i know people do abuse emergency rooms with minor injuries that don't require immediate care, but i don't think that happened in this case. i had breast cancer, so if i had blood coming from my nipples, i'd probably considered it an emergency.

[One_Life_To_Give]

84. Your generous

I would of suspected an 8in circle of "soaked" cotton. Which is less than a Tablespoon. I would of questioned the rate at which it was continuing to bleed. Can it be stopped with a simple dressing/pressure?

[hedgehog]

86. If you're not used to seeing blood, a tablespoon can look like a hell of a lot.

We heard some kids screaming in panic on a playground. One of them had a head wound and it was bleeding like crazy. I sent some of the kids to go get a parent, and sat the bleeding kid down and calmed him down by telling him that it was only a small cut, that he might need some stitches, but that he'd be OK. If you've never seen how much blood can come out of a small cut on your head, it's scary as hell.

[One_Life_To_Give]

92. I agree

I just think that as a society we need to find better ways to deal with such.

Did I ever tell you about the Paramedic/Coronary Care Unit taking care of a child with a broken are. While the Fire Department Engine COmpany had to deal with the Heart Attack patient?

[Fire_Medic_Dave]

119. Absolutely.

[nadinbrzezinski]

141. Even if you've seen it, it can still be scary as hell

:-)

[Cessna Invesco Palin]

132. Your attitude represents everything that is wrong with health care in this country.

People should go to the ER if they feel the need to do so. Especially if they are bleeding profusely for no discernible reason.

[Chemisse]

163. Really, people should go to the ER whenever they feel like it

A little cut to the finger, a twisted ankle, a bloodsucker stuck to you from swimming, a headache, really just anything. Hey, if you are scared, you deserve immediate reassurance.

Don't let those wheeled-in accident victims make you feel bad. You have a right to be seen at the ER any time you want.

And people who pay health insurance premiums are more than happy to cover these costs. You have every right to be pampered and coddled and have the fears soothed away at an instant's notice. Cost is simply no object.

If anybody contests this, just insult them personally until they stop.

:sarcasm:

[hedgehog]

168. Accident victims don't wait while the spained ankles get taken care of,

it's the other way around. While some big city ERs get swamped, I imagine a lot have some down time. What does the ER staff do in between bus crashes?

[Chemisse]

183. That's when they get to the sprained ankles, lol

I am in a rural area so don't know about big-city hospitals, but whenever I go to the ER for myself or a family member, there is a long wait. I have never seen the place empty.

I tend to go to the ER if I know an x-ray will be needed, such as my recent bad ankle sprain. Otherwise, you go to the doctor and then he sends you to the hospital for an x-ray.

Luckily my insurance always pays.

[emilyg]

She could have seen her

doctor the next day.

[polmaven]

45. Twilight NEVER said

that anyone should "wait for the next available appointment". If the doctor was not able to see her THAT DAY, then he/she would refer her to the ER....making it covered.

I really don't think name calling was called for here.

[ieoeja]

31. But who is qualified to make that determination?

She made the decision to go to the ER. But she didn't tell them she had a tumor. She didn't tell them it needed removed immediately. The ER made all those determinations.

If BC/BS wants their money back from the hospital ... they should fucking ask for it back from the hospital. But, of course, the hospital is big enough to fight back. So they go after the person not responsible. Then she is stuck suing the hospital.

I can write the headline on that story:

Woman sues ER claiming they shouldn't have helped her!

When she will actually only be suing the ER for the money to pay back BC/BS.

[JerseygirlCT]

96. I would think that's where her

doctor would come in, wouldn't it?

I would have called my doctor upon waking... if the doctor thought it required an emergency room, she would have said so, and I would have gone.

[ieoeja]

102. Was it a Sunday morning? Did she have a doctor?

And in the victim's words:

"In my mind I know something serious is going on," said Miran-Ramirez. "I need to see a doctor."

"I am not a clinical person but if your breast is bleeding, for me that's an emergency."

[JerseygirlCT]

161. Many doctors do have someone on call

for weekends.

And again, as others have said, it depends on how much blood we're talking about - profuse bleeding... yes, if no doctor was available to consult first, I'd head for the ER. Some bleeding, I'd likely wait to see the dr. first thing.

It's definitely a scary thing, and definitely one of those "see a doctor" things. But it's not like a tumor is going to grow overnight. Serious, but maybe not urgent.

[emilyg]

34. This nurse agrees with you. The

woman was scared though.

[grantcart]

39. There was in fact a tumor, that it later turned out to be benign is fortunate

but for your argument to have any sense, it seems to me, a person would have to know that it was benign because a bleeding malignant tumor would have been considered an emergency.

It seems that they came to the conclusion based on information that no one had at the time of the examination.

[JerseygirlCT]

94. That's what I would have done

First, because that's where I think you start - but also because I'll avoid those ERs as long as I can! More often than not, emergencies we've experienced have resulted in really bad care there.

[dugaresa]

104. as somene who has unfortunately had way too many ER visits, I have to agree with you

the ER is for life threatening emergencies and a bleeding nipple is not one of them unless it was gushing blood and it could not be stopped.

I have visited the ER for asthma problems (life threatening situations where Q4 albuterol treatments were not working) and only getting worse with my kids.
I passed out cold at a neighbor's house and awoke to an ambulance ride.
I have suffered heart/blood pressure problems that put me in the ER.

Except for the passing out, I called my doctor first to get pre-approval and with the latter issue I called the insurance company directly because my doc was not responding and the nurse at the insurance company said, "you need to go to the ER now, do you want me to call the ambulance?"

People need to read over their insurance company's policies carefully because you can get burned by not doing your part to make sure they don't screw you over. In this woman's case I am betting that there were clauses about "pre-approval", etc. This is why she should have called the insurance carrier first and talked to a nurse on call. If the nurse from the carrier sent her to the ER she would have gotten an auth number and been somewhat safe from this mess.

Like you, I feel bad for her but even if it feels like an emergency to us, the carriers have different opinions.

[Obamanaut]

128. As a male, and having never had a bleeding nipple, I can assure

you that if Miz O had blood in any amount coming from anywhere it isn't supposed to - it is a freaking emergency.

When parts that don't bleed begin to bleed, it is lots and lots of blood, even it is doesn't seem to be so to those who see it every day.

I truly wish I could 'unrec' an individual post.

[dmr]

178. It could have been a week-end or holiday when she went to the ER

[ThomCat]

189. To hell with that. If you are bleeding, and can't stop the bleeding

then it is an emergency. Period. I've sure that if we polled people at random and asked them, "if your nipple starts bleeding and doesn't stop, what do you do?" 99% over people will say to go to the ER immediately.

It is easy to play armchair quarterback now, after the fact, and claim to be an expert when you were not her, and were not there. But if your breast was bleeding and you could not stop the bleeding you might have done exactly what she did.

At the very least, it is heartless to be judgmental of what she did. Get a life.

[hedgehog]

5. Somehow, a lot of hospitals have been able to set up free standing "urgent care'"

facilities which can handle cases like this at a fraction of the cost. Why can't they set up on-site facilities to triage people right there for appropriate care?

Of course, I'm starting to question whether a lot of hospital overhead costs get dumped into the emergency room because of the way hospitals are reimbursed.

[ChairmanAgnostic]

6. I HATE recommending this, if only because

I hate the topic and the insurance industry that acts like this. But, it is too important not to rec.

[jgraz]

14. Why aren't people in the streets over shit like this?

I can't figure out what it's gonna take to motivate people to action.

[femrap]

16. Un-fucking-believable.

I don't know why I carry Blue Cross...they'll just deny me if something happens.

[Shell Beau]

78. That is who I have. Fortunately for me, I have never been denied.

Even when I rushed my daughter (a week old at the time) to the ER on a Sunday morning because she developed these red dots all over her face. The doc said infants do that. I felt like a fool, but insurance still covered my cost. :shrug: I guess I am one the few lucky ones.

[hedgehog]

87. The younger they are, the scarier they are. I thought every one of my

kids had a cord infection. It can look pretty damn ugly as the stump dries up and falls off!

The one rule I always followed was that if I was worried about a kid, I called the doctor by 2PM. I had a good doctor who'd fit them in as needed at the end of the day or reassure me. It beat worrying half the night and hauling the kid to an ER at 2AM!

[Chemisse]

164. I have Blue Cross too and I have never had anything denied

I wonder if it is certain companies that do it a lot.

[aint_no_life_nowhere]

22. Who makes these kinds of decisions? Clerks with a Bachelor's degree?

How can clerks or claims personnel decide medical issues? Shouldn't they always defer to licensed medical opinion? If a clerk overrules a doctor's opinion, why isn't that considered the practice of medicine without a license? Isn't the decision to withhold treatment also the practice of medicine?

Even if they have a doctor working in an executive capacity at Blue Shield reviewing these decisions, they obviously are not observing the patient's condition first hand.

[MNDemNY]

27. Apparently ,bad nurses.

[Chemisse]

165. You really are an asshole aren't you?

You have been so rude to Twilight. Is that the way you always react when someone has an opposing opinion?

[closeupready]

53. It is illegal for anyone but a doctor to make these decisions.

n/t

[LeftyFingerPop]

23. Fuck insurance companies. Fuck 'em sideways.

Sounds like a fucking emergency to me.

I am male.

If I woke up with blood coming out of my nipple and a saturated shirt, I would reasonably say to myself..."yep...that's an emergency".

Bastards.

This shit has to change.

[Turbineguy]

28. "Hi....

I'm having a heart attack. I also believe that all of society's ills can be cured in the free market. So tell me, why is having a heart attack at your hospital a better value than your competitors can offer?"

(Died while waiting on hold).

[hedgehog]

38. Two or three times over the years, I've taken kids to the ER for something

in their eye or because they got hit in the eye. If you've ever had something caught in your cornea, you know it's agony every time you blink. I just don't feel it proper to attempt to remove something off an eyeball at home.

Now, life threatening? Hardly.

Dangerous to wait? It's possible that the risk of infection would rise the longer the dust particle or hair or whatever is stuck, but it's probably not that critical.


But, if you've ever had something caught in your cornea, you know it's agony every time you blink. I just don't feel it proper to attempt to remove something off an eyeball at home, or to wait until I can get in to see an eye doctor.

Other ER visits:

Asthma flares - nothing like sitting up all night in an ER with a wheezing kid waiting to be seen and/or get treatment. My favorite was the time I sat up all night only to see the kid clear up at dawn with absolutely no treatment.

Pneumonia in a 2 year old.

Kidney infection following chicken pox. The kid was up and running around on the grass outside when I left the house for 2 hours. When I got home, she was down with a high fever. I figured it was Reye's syndrome and took her in. It took 3 hours to get a urine sample, and another hour or so to confirm that she had a kidney infection. I figure she must have gotten one of the chicken pox lesions infected and that the infection traveled straight to the kidney. If it moved that fast, what would have been the outcome after waiting to call the doctor the next day?

Ruptured spleen: the kid flipped her bike over and was shaken up. She was lying down on the couch and seemed fine. I checked on her half an hour later and her stomach was hurting. I drove her straight to the ER, and she was admitted and treated with watchful waiting while the spleen healed. If I hadn't taken her in when I did, she might have lsoty the spleen, a kidney or worse.

On the other hand: I probably have about a 75% batting average for times I took the kids in to check something out. Sometimes it was nothing, sometimes it needed treatment. If I didn't have a family doctor, those might have been ER visits.

[RandySF]

40. I bitch and moan about Kaiser

But with the few ER visits we've made, they took care of my wife and son without springing unwelcome surprises later on.

[hedgehog]

42. I think the key is "few ER visits". I'm assuming you have good access to

a primary care physician? That can be critical with a little kid. They can be scary as shit, dying one minute, running around the next!

[TwilightGardener]

58. Eye injuries are emergencies--you're right not to mess around with those.

[hedgehog]

51. Lots of times you go to an emergencyroom for something that

looks bad only to find out it looks worse than it is. For example - one of my kids got hit in the eye with a matchbox car thrown by his 2 year old sister. Emergency or not? Until someone checks things out, how can anyone tell if the cornea was scratched or if the retina was damaged?

Lots of insurance companies have nurses on call to offer advice over the phone. That's a job I'd like to have : talk to scared people who are total strangers and try to make a diagnosis (which isn't your job in any case) and hope to hell you're right. Gee, did that guy really have reflux or was he having a coronary?

[tammywammy]

60. Hit in the eye with something hard? Emergency

And I say that as someone that's managed to scratch my eye 3 times in the past year or so. One time I got to wear an eye patch for a day, arrgh matey. ;) Thankfully they've always happened during the week, so I could either go to my doctor during the day, or their night clinic in the evening. But like the time it was bad enough I had an eye patch, if it had been on a Sunday, and I could get to the doctor, my butt would have been in the ER, it hurt!

[Shell Beau]

150. That happened to me with the emergency call nurse.

I was pregnant, and it had been determined that it was likely an ectopic pregnancy. Further testing was needed. I was to go back to the doctor in 2 days. Well in the mean time I started bleeding like crazy. The doctor told me to watch for bright red blood. Well wouldn't you know it happened after doctor hours, so I called the nurse thinking I was surely hemorrhaging. She told me to take a warm bath and try to calm down. If my tube had ruptured, I would surely know. Well, I did just that. But I was so freaked out that I was possibly bleeding to death that there was no calming down. Off to the ER I went. I was admitted, and I stayed 2 nights, but no rupture had taken place. I was bleeding because of the swelling. But again, I didn't want to take her word that I would know. I wasn't supposed to be bleeding like that. It was scary. But I went with my gut. That is all you can do. I would rather go and be wrong, then stay home and be right.

[Stargazer09]

169. I don't envy those on-call nurses

My five year old had surgery on a Friday morning to remove impacted ear wax. He had signs of infection in his left ear, so the doctor prescribed antibiotics. Well, the next day, Matthew was screaming in pain, and pus was draining out of his ear. Now, Matthew has something wrong with him, and he doesn't feel pain like normal kids do (what we'd consider a 10 on the 1-10 pain scale would probably be closer to a 5 or 6 for him). The fact that he was obviously in agony worried me.

I called our insurance company's on-call nurse and explained everything to her, including Matthew's quirkiness with pain in general, and she told me to keep giving him the antibiotics and take him in on Monday.

By Sunday, he was in even worse shape, so I took him to the base's urgent care clinic. The doctor there sent us to the ER, because we couldn't determine what was causing Matthew's pain (the ear, the diarrhea from the antibiotics, or something else). He just couldn't verbalize what was wrong with him. His ear obviously hurt, but so did his tummy. The local children's hospital ER was able to determine that it was his ear that was causing the pain, and they gave us a different antibiotic. It made a world of difference, and when I took Matthew to the ENT specialist a few days later, we learned that the infection had basically ruptured Matthew's ear drum.

Staying on that antibiotic, as prescribed by that on-call nurse, would have prevented Matthew from getting the proper medication to cure the infection in his ear. I agree with you that it would be a tough job to have, since you have to make judgement calls based on verbal information that may not be entirely accurate or complete.

Threats to vision are always considered an emergency, and I know that scratched corneas hurt like crazy.

[Warren DeMontague]

61. But... But... George Will sez that AMERICANS LOVE THEIR INSURANCE COMPANIES!

Don't you dare interfere with the right of Americans to grovel for coverage from their corporate overlords, Socialist!

[tammywammy]

62. I have a friend that had a baby three months ago

She just got a bill from a doctor because her insurance company hasn't paid it still! I told her she should be thankful they didn't deny the labor and birth as a pre-existing condition due to conception. :eyes:

[Warren DeMontague]

65. I think the SOP w. insurance companies is to deny all claims, initially.

They know a certain % of people will give up and just pay. I can't even count the # of "covered" things that we've had to fight over in the past 5 years.

[tammywammy]

68. I've been very lucky

I have "good" insurance, in that it's always covered what they've said they'd cover, and they've always paid as well. My friend just said "You'd think they'd never dealt with a woman that gave birth before."

[hedgehog]

71. I swear to God I heard a report about Medicare claims clerks that said

they were all handed a certain number of claims every day. If a complicated claim took up too much time, then the remaining claims on that day's pile would all be denied. No link, and this was a few years back, but it sure sounds plausible to me!

[dflprincess]

64. Years & years ago Blue Cross of Minnesota had to be sued to

treat miscarriage as an emergency. This was before the "reasonable person" rule was created for ER coverage, back then if you weren't bleeding out or were still breathing you'd have a hell of a time getting your trip to the ER covered.

You know the mandates health insurers yell about - the ones that the federal or state governments have passed requiring them to pay for certain conditions? Should we be surprised that most of those mandates are for conditions more common in or exclusive to women or children?

[hedgehog]

88. Beautiful example - among other things after a miscarriage there should be an exam

to ensure that the uterus is empty and that there are no further issues like excess bleeding. Any leftover tissue can cause real problems down the road. It's also nice to get an exam to see if there is any way to determine what caused the miscarriage.

[Contrary1]

69. If this should happen to anyone reading...

The emergency room is not the best place to go. Any breast abnormalities should be seen by a breast specialist, if possible.

And, unless the woman was bleeding profusely, this would not be considered a medical emergency. Emotional, yes.

No need to argue with me, as my reconstruction failed. The implant could be seen protruding from my chest wall, and I still had to wait five days before I could get in for the surgery.

[hedgehog]

76. It is true that the emergency room is the last place to go when you might need

special care. The problem is that for a lot of people, it's the only place they can go.

One of my kids had a friend who did a face plant off her bike and knocked out all of her front teeth. Her mother took her to an ER where they dinked around for hours while her mouth was swelling and all those teeth were dying. The poor kid eventually lost every tooth after endless visits to dentists trying to save them. That ER should have sent her straight to an oral surgeon who might have had a shot at saving the teeth if he'd seen the girl within the first few hours.

[haele]

75. We ran into that once before - if you aren't sent to the emergency room by medical personnel

- A doctor, nurse, or paramedic/EMT, insurance doesn't like to cover it. I took Laz and the kidlet to Urgent Care after a fender-bender they were in and was informed that we were lucky I took them there (Urgent Care) first, or it wouldn't have been covered by our PPO, because it wasn't "life threatening" and an ambulance hadn't brought them in. Urgent Care did the initial work-up, then shuttled them over to the hospital Emergancy Room across the street for the MRI, and brought them back to process them out. $15 co-pay (they billed both as one visit), $45 for lab and x-ray, and $115 ea. for a CAT workup was about what it cost us - and that was three years ago.
After that experiance, unless it's between 10pm and 7am, we go to Urgent Care first - it's the difference between a $15 co-pay and 90% of procedures covered, and a $200 co-pay and 60% of procedures covered - or nothing covered if the doctor doesn't indicate it's an actual emergency or if we weren't "referred" there. We'll suffer through the night, if that's what it takes. Some emergency rooms (Kaiser comes to mind) won't even see you unless it was one of their doctors that referred you or if it was an ambulance that brought you there.
Some insurance companies might be a bit more lenient about the referral requirement, but I haven't heard of one.
The county-associated hospitals and clinics are about the only ones that take walk-ins nowdays, anyway.

Haele

[hedgehog]

79. One of the reasons I consider Urgent Care centers a scam is that hospitals love them

because everyone who shows up at an ER must be seen regardless of ability to pay while Urgent Care centers are allowed to turn people away.

Isn't it amazing that urgent care centers can get you in and out quickly while you wait forever in an ER and os often they're run by the same corporations? Why does the urgent care center bill at a fraction of the cost of an ER when they provide the same care?

Health Care Reform doesn't end with the insurance companies, that's only the beginning!

[MineralMan]

93. Urgent care clinics are perfect for most things.

The cost is less, you get seen reasonably quickly, and you're done. If you have insurance, it's going to be covered, as long as you make sure to pick one that accepts your insurance.

I can't imagine going to an ER for anything but a life-threatening thing or a broken bone in a major extremity.

The one I visit is connected to the clinic where I get my primary care. It's open after hours, and is even open during normal clinic hours. If you're a patient of the clinic, you usually end up seeing your regular primary physician, if he's there. If not, your charts are available to whomever sees you.

Funny thing is that it costs less to drop into the Urgent Care than to make an appointment to see your regular primary care doc. Great deal.

I'd like to see these set up where folks without insurance can get care without the hassle and problems from going to the ER. That would free up the ER for major stuff, while helping those with no insurance get care for immediate stuff. I can't imagine why this doesn't exist everywhere.

[Lars39]

112. They really don't like to see you if you've had something serious like cancer.

They don't want to be liable for misdiagnosis,even if you're there for something minor like infected sinuses.

[MineralMan]

181. I suppose that's true, but for the stuff that typically shows up

in the ER in people with no insurance, they'd be better served in something like an urgent care clinic. Today, though, those clinics just refer people who can't afford to be seen to the ER. There should be a way to arrange for payment at the urgent clinic rather than the ER for such patients. It would save tons of money and free up ERs for their intended purpose.

We do have a sliding scale clinic in Saint Paul, MN, and it's on a bus route, but it's open during normal hours and is jammed with people all the time.

My wife and I visited a sick relative at a local hospital and passed by the Emergency Room at that hospital. It was a Friday evening, and the ER was just jammed. A car pulled up, someone got out, looked in the window, then got back in the car, saying "Too crowded. Let's go to another hospital." By the look of the car, which was an old beater, they fit into the can't pay category.

[One_Life_To_Give]

105. ER's going to have alot of overhead

To some extent the charge is probably punative if you don't need the full services. But an ER would need to have stuff such as Lab and personnel on duty, multiple surgical specialties either in house or on call. Pharmacists, etc.

OTOH we may be subsidizing the true cost of tghe person who gets into an accident and requires immediate attention by both a Nurosurgean and an Orthopedic Surgeon, plus meds, labs, etc.

[hunter]

91. Why do Emergency Rooms charge Emergency Room prices for everything?

That's the question.

If we can have 24 hour convenience stores for people who suddenly crave Oreo Ice Cream at two o'clock in the morning why can't we have 24 hour medical clinics? So maybe you show up in the Emergency Room by mistake, because dang it you are not a medical professional and some things are very alarming, why can't the ER kindly and without charge direct you next door or across the street to a 24 hour medical clinic equipped to deal with the small stuff at a much lower cost?

[mrs_p]

133. good idea!

[mrs_p]

120. i'm with the medical professionals on this one

it doesn't sound like it was an emergency unless she had acute blood loss leading to anemia and shock or high fever or was breast feeding and was worried about a mastitis - i'm surprised she was even seen that night instead of told to go to her regular physician. i've never been to an ER that would have given this a high priority.

that said, i think it is sad that her claim was denied. no one should have to pay anything to see a doctor IMHO.

[undeterred]

121. Maybe the insurance company should provide an "orifice" list

so the patient knows where bleeding is an emergency and it isn't. Bleeding from the breast is something I've never even heard of and I would be extremely alarmed if it happened to me- I'd want to see a doctor right away.

When I was in college I awoke one morning to find my pillow soaked with blood. It took me a few minutes to figure out that one of my ears had bled, for no apparent reason, during the night. The bleeding seemed to have stopped but I went to the student health emergency immediately anyway, because bleeding from the ear, in a copious amount, is alarming.

[mrs_p]

127. bleeding from the ear could be

a serious emergency b/c it actually could be cerebral spinal fluid - very bad and potentially life threatening.

[undeterred]

143. They didn't find a cause at student health

and I ended up going to a doctor in the community because I had no confidence in them. He said my eardrum had been broken- but he thought it was torn by the doctor in student health poking around. The bleeding just happened one night and never again. Extremely weird.

Anyway, even with no other symptoms bleeding from body parts that don't usually bleed is alarming.

[nadinbrzezinski]

145. Ok I feel good

I had some mystery bleeding last summer from my left ear

I went to the ER. I knew either this is very serious, or stoopid.

Somehow I managed to get a scratch in there... never put anything in my ear.

We are still wondering about that one.

:hi:

Good to know I was not the only one...

[undeterred]

146. The people in student health said maybe

I had a "pimple" in my ear (which I was unaware of and never touched). Didn't make sense then or now. But sometimes they're just saying "we don't know what caused the bleeding but you're ok now".

It was during finals week, so maybe I studied so hard my brain bled a little. :hi:

[nadinbrzezinski]

147. The ER doctor said the same thing

I went, go figure...

[nadinbrzezinski]

137. Well I hate to say this, but this is BLUE SHIELD of California

I am neither surprised nor shocked.

Hell, they denied a claim for one of their customers decades ago since we were NOT an approved facility.


Mind us, we didn't charge the family... but something like this coming from Blue Shield is all but surprising or shocking,

[demwing]

162. Advanced Medical Priority Dispatch System

http://en.wikipedia.org/wiki/Advanced_Medical_Priority_Dispatch_System

The Advanced Medical Priority Dispatch System (AMPDS), is a medically-approved, unified system used to dispatch appropriate aid to medical emergencies including systematized caller interrogation and pre-arrival instructions. AMPDS is developed and marketed by Priority Dispatch Corporation which also has similar products for police and fire.

The output gives a main response category - A (Immediately Life Threatening), B (Urgent Call), C (Routine Call). This may well be linked to a performance targeting system such as ORCON where calls must be responded to within a given time period. For example, in the United Kingdom, calls rated as 'A' on AMPDS are targeted with getting a responder on scene within 8 minutes.

Check out the spreadsheet that goes with the article, it answers many of the questions in this thread as to what constitutes an emergency, and what does not.

[Fire_Medic_Dave]

172. Of course AMPDS relies heavily on subjective information.

[demwing]

176. True, but it's a good base from which to judge

once accurate information is determined. Some of that is built into the spreadsheet.

[Fire_Medic_Dave]

210. If dispatchers are provided with accurate information it works quite well.

[TicketyBoo]

167. If this happened to me

and it was after office hours, I would freak out, but I would call the doctor who was on call for my doctor and ask what to do.

They would probably refer me to the E.R. if I was still bleeding, I would guess. I'd think they'd want to get the bleeding stopped.

My doctor was on call for her group one night when I became dizzy to the point of stumbling. I called and she had me go to the E.R. just in case it was the precursor to a stroke. All was fine. Insurance didn't question it.

I've had corneal abrasions. I call my eye doctor for that, even if it's after hours. Those are the most painful things, right up there with an impacted wisdom tooth. You can't mess around with eye injuries.

[progressivebydesign]

174. Here's the weird thing. We have a fancy new hospital in my town, and they ENCOURAGE people like that

they have ads running now touting their 15 minute wait times, and suggesting that people use it like an urgent care center, instead of an ER. Trying to figure out how the insurance company would feel if you went to the ER for a broken toe.

If that had happened to me, I would not have gone to the ER... but would have gone to urgent care if I was totally freaked out. She was quite lucky it was benign, because I thought it would be that duct cancer that also causes this.

[olegramps]

180. Why didn't the ER people tell her to contact her doctor.

Just what services did the ER provide other than tell her that it could be the result of a tumor? They didn't treat her if I understand the situation.

[GCP]

182. And now will they rescind her coverage as she now has a 'previous condition'

Fucking asshole system. SINGLE PAYER NOW.

[Fla Dem]

205. If it was a weekday she should have called her PCP office.

If after describing her condition they either would have had her come right in to the office or if they thought it was serious enough, told her to go to the ER. With that, insurance would have to pay because the PCP referred her to the ER. If it was a weekend, I guess I would have done the same thing as she did. I know when I call my PCP off hours or weekends, the recording says "if it's an emergency go to the ER." For each person what qualifies as an emergency can be markedly different.

Just as another twist I injured my eye working in my backyard. A palmetto frond snapped back and raked across my eyeball. It instantly was painful, and while there was no blood the eyeball turn red. It was 3:00 on a Friday afternoon and my PCP office does not have Friday afternoon office hours.....that's how I know what the recording says, because I called them first. I didn't want to go to the ER, but the pain in my eye was fierce. So I called my ophthalmologist. They were open and told me to come right in. Ends up I had a minor laceration to the eye. The Dr. put some antibiotic on it and something to numb the pain. He told me I did the right thing coming in, as the eye needed to be flushed and an antibiotic applied. If that hadn't been done it could have become infected.

Aetna would not cover the claim because they said I SHOULD HAVE gone to the ER instead of my ophthalmologist. Because my PCP did not refer me to the ophthalmologist, I was not covered. What a crock.