I had a tough week recently. You wouldn’t believe how tiring it is to use your brain at a high level, with lives in the balance, for 12 hours straight. It’s a high stakes, high stress endeavor. When I work and the day is especially stressful, I am in bed asleep within an hour of getting home, and I sleep until it’s time to go back to work. Let’s look at one of the patients I had on one of those days:
A woman decided that she was going to kill herself by taking every pill she could find in her house. Three hours later, she changed her mind and called 911. She was a frequent visitor to the emergency room and had been placed on involuntary psych holds (called a Baker Act) a few times before, due to suicide threats that turned out to be cries for attention.
She was my patient.
EMS handed me a bag of empty pill bottles, all of which the woman claimed to have taken. A final count of the pills revealed that she had taken most of a 90 day supply of Digoxin, Wellbutrin, Sotalol, Xarelto, and a few other drugs. I think we finally estimated 50-60 pills of each were unaccounted for.
I asked the doctor if he wanted to do a gastric lavage. He said he didn’t want to, because it had already been 3 hours and any pills she had taken were likely digested by now. He also pointed out that her vital signs were unchanged, and this was a good sign that she was again acting out, but hadn’t actually taken anything.
I told him that, since the drugs she had claimed to have taken were mostly extended release, we would be looking at some real trouble in about another hour. He told me to watch her and call him if anything changed.
I had three other patients, including another Baker Act. Those involuntary admissions require a lot of paperwork, so I was busy.
About an hour later, I got a call from the telemetry operator that the woman’s heart rate had suddenly dropped from 62 to less than 35. I ran into the room and found her in a junctional escape rhythm at 32 beats per minute. I called the ED doc, who was on the other side of the department, and told him what I had. I recommended Atropine and Glucagon and asked for the order. He concurred and said he was on his way.
By the time he got to me, I had called a Resuscitative Medical Alert. That gets me the ED rapid response team, including a charge nurse, three other nurses, two techs, a respiratory therapist, and Xray tech with a portable Xray machine, and the ED doctor. I gave her two doses of Atropine and two of Glucagon. It didn’t do a bit of good.
I suggested that we start pacing immediately. He agreed, and we started external pacing. Her blood pressure was shit, so as the Dr prepared to intubate, we got orders for and hung an Epinephrine drip. Then it was Ketamine, Rocuronium, intubation, and a Ketamine infusion. By then the ICU doctor and a dose of Digifab had arrived. We got the Digifab running and took her to ICU.
She lived for 5 days in the ICU. That was 1 of the 22 patients that I had that day. She was also 1 of the 7 suicide patients I had that week, and the only one that didn’t survive. In fact, I had 81 patients that week and only 3 of them didn’t survive.
While she was there, she received over $300,000 in medication. The Digifab alone was almost $100,000 of it. They tried dialysis, it didn’t work because the Digitalis molecules were too large to dialyze out. Her total bill was well over a million bucks.
Some of the drugs she got were specialized and aren’t given to many people, so they are costly.
She isn’t going to pay that bill, because she is dead. So who pays it? We all do. The hospital spreads those costs out across every patient. It’s like going to a restaurant where everyone gets to eat whatever they want, they can order one of everything on the menu, and about a quarter of them don’t pay, so everyone else has to pony up the difference.
It’s an ethical conundrum. Who decides what treatments will be offered? If we leave it up to the hospital, does the patient get a choice? Does the insurance company? There are pitfalls to each answer, and trust me, it’s one that healthcare workers debate frequently.
Someone has to pay for all of the education and experience of the providers. Not only while they are actually providing care, but also for UHU reasons. Now UHU is a concept that originated with EMS, but applies to the ED as well. UHU stands for “Unit Hour Utilization” and symbolizes the amount of time in each hour, on average, that an asset is busy treating a patient.
If the UHU is too low, you are spending money to have expensive assets sitting around. If your UHU is too high, there is a chance that someone will need their help and it won’t be available because it’s being used elsewhere.
All of that must be paid for, and that’s the issue.
Americans demand the best of everything. They want to have top notch care, they want it available at a whim, they won’t tolerate errors, and that is expensive. Every one of the actions taken in that woman’s case were areas where mistakes could have been made. They have to be done every time, without error, and it must be the right thing at the right time, no exceptions.
Now multiply that by the 200-500 patients a day in that ED. That isn’t cheap.
That’s the issue- Americans want it perfect and they want it on demand. The best of everything. Cost is no object. Sure, Americans complain that healthcare is expensive, but mention a system where an official controls cost by denying your claim, or as in the case of Canada, recommending euthanasia, and see people howl.
So you could control costs by making it easier to be a medical professional, but that would mean lowering standards, more medical errors, worsened medication quality controls, and more frequent things like hospital acquired infections.
Or make it cheaper through rationing. You could wait 2 years for an MRI.
I’m not saying that there aren’t examples of waste and fraud. I know there are. I also have a problem with hospitals not disclosing their rates up front. You should know that it’s going to cost $20,000 for a CT scan, another $1500 for the radiologist to read it, etc. Trump tried to do that, and the hospital lobby shut it down through Congress.
However, how do you control that in a nation as large as ours? Anyone who says there is an easy answer is being childishly naive or doesn’t really understand what’s going on.
If you passed a law mandating that anyone could have dinner at any restaurant they wish, could order whatever they want, and the restaurant couldn’t demand payment up front, and people could buy “dinner insurance” to pay for it, what would people eat, where would they eat, and how much would dinner cost?
37 Comments
Outwest · September 4, 2025 at 5:08 am
One of your best ever posts.
Charles · September 4, 2025 at 5:40 am
Just wanted to give you a hello.
Brian · September 4, 2025 at 6:59 pm
If a ct machine on the high end cost say 2 million and the hospital charges $20 000 I’d have to say that highway robbery. What do you think?
JimmyPx · September 5, 2025 at 6:42 pm
Brian radiology is the cash cow of every hospital. A new MRI or CT scan will be paid off within a year and then after that except for maintenance and paying the tech and radiologist it’s a money machine.
Many of the departments in a hospital at best break even and many LOSE money but radiology balances it out. For that reason at budget time, what radiology wants they usually get.
oldvet50 · September 4, 2025 at 6:04 am
You refer to the ethical conundrum but never refer to the principal of personal responsibility which is the most ethical point. You should be allowed to reap the rewards of your own decisions, not only for your own edification, but as a lesson to others. As an example, I believe drug overdoses are becoming more prevalent, not only from the increased drug supply, but from the widespread use of Narcan (free to the recipient) – people learn that drugs won’t always kill you. As you pointed out, the restaurant business would certainly fail if allowed to operate as medical care, so why should we be surprised if our medical system fails from the financial abuse inflicted by a small portion of society? As you described in your earlier ‘Healthcare’ article, socialized medicine has a waiting period for procedures – perhaps that would have eliminated the $1M final bill that the woman incurred. The outcome would have been the same. We cannot save everyone and trying to do so is harmful to everyone else.
Divemedic · September 4, 2025 at 2:08 pm
So when your doctor decides that the pizza or steak you ate are what disqualifies you for treatment?
oldvet50 · September 4, 2025 at 3:16 pm
??? I would not have such a doctor. No doctor would be better than the one you described. I try to avoid all medical care and if I could procure the necessary drugs for infections, etc. without seeing a legalized drug agent, I definitely would. Florida used to have a law (the 1985, I think) that allowed you to go to the pharmacy and get Rx without a Dr’s OK, but it was very short lived. Seems the pharmacies did not want the legal liability. Perhaps our medical care would be better if we eliminated the legal profession.
Divemedic · September 6, 2025 at 8:01 am
That’s the ethical conundrum- If we can deny care to someone because they are using drugs, and drugs are harmful, then what is the difference between that and denying care for fatty or salty diets, skydiving, alcohol use, anything that is bad, then next thing you know, all restaurants are Taco Bell and we have to use the three seashells in the toilet.
Birdog357 · September 4, 2025 at 6:49 am
You probably don’t know the answer to this, but I’m going to ask it anyway, what’s the cost of those drugs in the US, vs foreign countries? Make the rest of the world pay a fair price and our costs will go down.
Cederq · September 4, 2025 at 5:37 pm
Actually, Europe and Asia pays a much lower price for the same medication we use, but the US subsidizes the rest of the world and pays for our litigiousness culture of malpractice and fraudulent lawsuits here.
Steve · September 5, 2025 at 7:20 am
True. And Congress could fix it by simply repealing the drug reimportation law. Trump would sign it. Get three years of US paying the same prices as overseas and it’s permanent.
Birdog357 · September 6, 2025 at 7:17 am
I’m aware of that. I was curious what these specific drugs cost and how much of that cost was us subsidizing the Euro’s “free” healthcare.
Tom235 · September 4, 2025 at 7:27 am
Good, fast, cheap. Pick two.
its just Boris · September 4, 2025 at 6:29 pm
Pick two, at most. From what I can tell, socialized medicine often comes down to one, or none of the above.
Grumpy51 · September 4, 2025 at 7:55 am
Well stated. There are NO easy answers and EVERYONE one of them has ethical issues. NO blanket statement will work. But there are a few (low-hanging fruit)
1. IF your there for chest pain, and your UDS (urine drug screen) is positive for stimulants, the workup stops and you’re discharged (I know of NO cardiologist who’ll put a cocaine/amphetamine positive patient on a cath table and I’ve worked with several LARGE groups in DFW)
2. IF you come from a nursing home, over 80, and your baseline is not responsive, you will be made a DNR/AND (Do Not Resuscitate/Allow Natural Death).
3. IF you have COPD, over 80, oxygen-dependent, STILL smoking, you’ll receive breathing treatments/steroids and be discharged home.
4. IF this is your 2nd-attempt at suicide, you’ll be discharged home.
5. IF this is your 2nd drug-deal to be involved in and shot, you’ll be discharged home.
6. IF you have a G-tube (feeding tube), over 80, baseline of unresponsive, and you come in with aspiration pneumonia…… the country phrase “pneumonia is an old man’s best friend” comes to mind.
I could go on and on. For those who think above is calloused, I would posit – “death isn’t the enemy, inhumanity to each other is.” In almost 45 years in the trenches, I’ve seen routine things FAR WORSE than death. Notice that NONE of my examples above are because of money – each example above, I see routinely and are the result of poor choices.
For those who believe in evolution, above should be easy, for IF evolution is true, who are we to alter it???
Woody · September 4, 2025 at 9:04 am
“Cost is no object” when a loved one is in the Emergency Room. That changes when the bill come due.
JimmyPx · September 4, 2025 at 9:15 am
I love these people who want a “do over” after trying to kill themselves.
They don’t realize (like the woman you treated who died), that they may have done too good a job in their attempt and you couldn’t save her. It’s the same as people who slash their wrists, you can really kill yourself doing that.
Regarding health care, people in this country have to get real about the subject of death. EVERYONE is going to die, it’s just a matter of how and when. Our country spends HALF of our healthcare money on terminal patients that have NO chance.
Why do we give chemo and radiation to stage 4 cancer patients who are terminal and it does no damn good but costs a fortune ? Sure once in a great while you’ll have a unicorn where it works but 99% of the time it doesn’t. Instead people need to be told the truth and have hospice take over.
Bear in Indy · September 4, 2025 at 11:08 pm
I was diagnose with stage 4 cancer in early 2016. Did radiation (a total bitch) 30 sessions, and chemotherapy seven treatments, also hard. Nine years have passed.
The doctors were amazing, the staff was even better. Got a sever infection the last two radiation treatments, in the hospital at the time because of the 103 degree fever.
Hurt so bad I didn’t want the last two doses. The team did it anyway, I recovered, got better, and now 9 years, cancer free.
I can only say, to you all that do this amazing work of saving lives. Thank you.
Bear in Indy
JimmyPx · September 5, 2025 at 9:18 am
Bear, I’m happy things worked out for you but you are a unicorn in this. Very few people survive stage 4 cancer and in the perfect World where costs don’t matter, it wouldn’t be an issue. But as Divemedic pointed out, all of that care has to be paid for somehow and by someone. The question that needs to be asked is “Is it worth it to spend a fortune on treatments that will only help 1% or 2% of the people and the rest are terminal” ?
WHY do you all think that health care costs a fortune today ? A large chunk of the federal deficit and debt was caused by massive health care spending on Medicare, Medicaid, VA etc.
The day is coming when the US dollar will no longer be the reserve currency of the World. When that happens we can no longer “print money” and hard choices will have to be made on what we spend money on. Health care IS going to change because it has to. The current system is NOT sustainable.
Divemedic · September 5, 2025 at 11:21 am
That’s what I am driving at- people love to say that “cost is no object” when they are not the ones bearing the cost.
That is, in my opinion, the biggest problem with US healthcare- Americans demand flawless care and don’t care what it costs, because they don’t ever see the bill.
JimmyPx · September 5, 2025 at 2:34 pm
DM, I do find it interesting that those of us who work in Healthcare all have a different perspective on things versus people who do not.
We all see it day after day “He’s a fighter, he’s gonna beat this thing” or “it’s THEIR choice to do chemo and radiation even though they’ve been told they are terminal”.
Then people I know who say that crap, I see their obituary within 6 months EVERY TIME. Meanwhile the working class who work and aren’t on the dole can’t afford health insurance and let things that can be treated when caught early wait and wait to get care because they can’t afford it. Then they come in and it is often too late but it also bankrupts them getting treated.
The current system is crazy and needs a reform badly both on how it is paid for as well as how it is dispensed. The days of “price is no object” and “give me the magic pill that fixes 30 years of abuse” need to be over.
Divemedic · September 5, 2025 at 2:49 pm
There are more posts coming on this, simply because the response to these posts has been so large.
Noway2 · September 4, 2025 at 10:07 am
“ I’m not saying that there aren’t examples of waste and fraud. I know there are. I also have a problem with hospitals not disclosing their rates up front. You should know that it’s going to cost $20,000 for a CT scan, another $1500 for the radiologist to read it, etc. Trump tried to do that, and the hospital lobby shut it down through Congress.”
Here in NC, there is the healthcare plan for state employees. It’s not insurance per se, but it is administered by an insurer. That used to be Bug Blue, but is now Aetna. The state auditor demanded from big blue a list of the cost for every procedure, etc. He got hundreds of pages saying, “the cost for X is .. redacted”.
The system is a racket, as in racketeering.
I keep coming back to the idea that the overall lowest cost option is to put everybody in one pool and try to focus on preventative measures to keep things from getting to the critical and expensive stage. Also, some countries do seem to get it right. The alternatives shouldn’t be just the US system and Canada.
Steve · September 5, 2025 at 7:31 am
I keep coming back to the idea that the overall lowest cost option is to put everybody in one pool
Since this is tagged “Economics”, not “Morals”, that’s going to be among the highest cost. “First come, first served” and “Everyone gets the same” are moral claims. Triage is saving the most savable. Economically speaking, anyone who is of age and is not working (for whatever reason) needs to be at the tail end of the triage.
But let the more wealthy buy their way up in priority. If they are willing to pay more, it means the rest of us can pay less.
Gerry · September 4, 2025 at 10:32 am
The pricing of drugs is mysterious. I had to close down my business because my wife’s ABC drug cost $1000 a month in addition to my already outrageous insurance premium. I took a job 1000 miles away with the same BC/BS health insurance and now the drugs were covered with a $20 co-pay.
My wife’s PT goes home to Brazil for her private healthcare once a year. Same drugs are 10% of the cost here because the US consumers fronts the development cost. Brazilian can’t pay $20K for a CT scan so they don’t get charged the same amount. The $1,000,000 MRI gets depreciated at the same 20% per year there as it does here.
My sister and sister law were ER nurses so I understand your experience, but the numbers just don’t add up on drug cost. Pharma can tell me a drug cost $100K a dose or treatment, but can they account for it. And yes I have worked on FDA approvals so I know they are costly.
Anon · September 4, 2025 at 1:13 pm
From out here is the cheap seats, it seems like if we have a suicide we let them go and we just saved $1,000,000. It is what they wanted after all.
EN2 SS · September 5, 2025 at 6:37 am
I’ve long advocated for druggies to be given a five gallon bucket of the drug of their choice, put in a private room and let nature take its course. Find an OD? Call the coroner.
SoCoRuss · September 4, 2025 at 2:05 pm
My sister in law was a ER nurse also in NYC, she is retired now. We have had multiple conversations about this lately especially the number of chronic health care users like your case. I have been of the mind that if they really want to go and never respond to the help they claim to need then either allow their decisions to kill them or help them go. Its the same for someone who has some incurable disease and doesn’t want to suffer and chooses to go out on their volition, I respect and understand that choice.. I understand Canada has taken that to ridiculous reaches. But I had 2 cousins who were dedicated drug users and lived thru this crap and since i was the only family in area, I got the calls. They cost the medical system millions saving their useless asses over years until finally no one could save them the last time. .My sister talks to her friend still working and sees a system and staff on the edge of collapse now and now leans to my view let them go don’t waste resources or Euthanasia the only real way out anymore. You save who you can and let the others go. You can’t help anyone who wont take the help. Spend the money on the ones you can.
I understand folks will have religious view problems on the topic that’s their choice but things have to change, do we allow the system to go down over folks that wont agree to be “saved’?
Honk Honk · September 4, 2025 at 6:46 pm
The neurologist said you do this thing called no damage to the cortex after stroke two.
I don’t but God does and I say thank you daily.
The lawsuit against AI creator is because it gave instructions to a 14 year old in how to self-murder and told him it was brave.
Texas Dan · September 4, 2025 at 7:32 pm
Ivan Drago had it right, ‘if he dies, he dies’. A million bucks on a suicide? Madness.
Brad · September 5, 2025 at 2:51 am
The costs you quote are just insane. Just as an example: reading a CT scan – takes maybe 30 minutes by a trained radiologist – $1500? Nuts.
I had a recent emergency room visit for a kidney stone. CT scan, emergency surgery, overnight hospital stay. Cost billed to insurance: low 4-digits, and my country’s prices are high for Europe.
As a follow-up, I am currently taking a fairly common, generic medication. Cost here $0.50 per tablet. In the US, even going to Cuban’s discount online pharmacy, the price is $2 per tablet, so 4x what I pay. I assume normal prices are even higher.
The US health system is so broken. Where is the will to fix it?
SiG · September 5, 2025 at 9:09 am
As many have said, I think a fundamental problem with it is absolute lack of transparency of prices. It’s fashionable to blame the healthcare industry for that, but I think it’s more a problem of politicians and industry leaders trying to provide what people demand – or make the people believe they’ve provided it. I can’t tell you how many times I’ve heard things like investigative reporters saying they tried to find a master price list or book and never could.
If I take my car in for service or call contractors to work on my house or major appliances, I can shop. That’s essentially impossible with any medical provider or service. ER bills are going to be places that complicate this because you can’t shop because you might not be conscious or aware of anything and you’ve just been brought there.
Insurance is a real problem because people seem to expect that no matter what they’re charged, insurance will pay for it. I get these EOBs from Medicare and my supplemental insurance that are insane to read, like they’re been printed by a random number generator.
Something like this totally made-up example
amount billed: $3,000
amount excluded $2975
amount paid $00.
Your balance due: $25.
I gather that if I walked in off the street with no insurance I’d be paying $3000 but by having the glorious, wonderful, magnanimous gubmint negotiating for me, we find that’s a figure nobody pays except the uninsured.
Divemedic · September 5, 2025 at 11:19 am
That is, in part, due to Medicare (in other words, government) interference.
There are literal books of regulations on pricing. This massively distorts the market.
jimmyPx · September 5, 2025 at 2:52 pm
DING DING DING. It is ALL because of the government. Because of government (including Feds, State and Local), they have this game they play. I’ll give you a quick example. Say for example you need a new HP server for the data center and the real cost if you went to buy it is $10,000.
The State of Florida negotiates with all vendors and they DEMAND like a 60% discount because “hey we are the government”. So what does HP do ? They make the base price of the server $100,000 and give them a 70% discount. The government people say “see we got a 70% discount, we saved BIG money”. In reality the state paid $30,000 for a $20,000 server.
SAME exact thing with medical costs. Some insurance statements even show this, the base price of the procedure is $20,000 and the insurance company paid $2000. Insurance companies negotiate REAL prices with hospitals and medical companies every year on renewal. Ever wonder why one year they’ll say “we no longer accept Aetna” ?
It’s because they couldn’t come to a deal on prices.
The biggest rip off is that people who have NO insurance “called private pay” are charged the base rate and ripped off massively. That’s why they will “work with you” and drop the price down if you pay X. That crap should be illegal, private pay should pay what the insurance companies do.
Sorry about the extra posts but people not in healthcare don’t understand this stuff and they need to have it explained.
Divemedic · September 5, 2025 at 3:07 pm
I’ve thought about this, and although I am against a government solution, mostly because they usually screw it up worse, the government is who caused this in the first place. A two part rule:
1 Drug companies won’t be permitted to sell a drug in the US if the cost of the retail price of the drug in the US is more than double the retail price in any other country where the company sells that drug. If a company tries to skirt this rule by forming a second company to sell the drug, thereby saying “IT wasn’t us doing it” then the patent on that drug is void.
2 Insurance companies cannot receive a price discount of more than 75% off what a cash customer would pay. If a procedure’s cash price is $1,000, the insurance company can’t negotiate a price that is less than $250. Any patient who can prove through preponderance of evidence that this has been violated is entitled to an award of ten times the difference, plus $10,000 and reasonable attorney’s fees. Healthcare employees who blow the whistle on such a practice being committed by their employer get an award equal to 25% of the total amount that the employer wrongfully collected from ALL patients who were subjected to the wrongful charges, plus attorneys fees.
Vitaeus · September 5, 2025 at 1:31 pm
Lots of replies, if I missed this, did the after death review point out the cost of a stomach lavage versus the final results? Somewhere between a million dollars for a suicide and an involuntary DNR, there really needs to be a middle ground.
Divemedic · September 5, 2025 at 2:47 pm
There were still pills found caught in her esophagus when a lavage finally was done, but I don’t think it would have mattered with the amount of drugs she took.
The combination of anticoagulants, beta blockers, and Digitalis were just too lethal of a combination.
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