英國醫療人球事件？英國媒體如是說

既然如此，我們來看看英國媒體怎樣報導這樣的醫療事件。google找了太陽報和每日鏡報；據說這兩家報紙是所謂八卦小報－引用自wiki－且看人家八卦小報和台灣的八卦大報有何不同。

先來看鏡報；這個大標題和小標題如下，台灣媒體說的人球兩個字在哪裡？

A write pain: Schoolboy with pencil stuck in hand sent home from hospital twice

He was left in agony after he got the pencil jammed in the back of his hand while playing with school pals

A schoolboy was sent home from hospital twice – even though he had a pencil embedded in his hand.

Robbie Appleby-Socket, 13, was left in agony after he got the pencil jammed in the back of his hand while playing with school pals.

He was taken to A&E in Doncaster, South Yorkshire, but was told he would need an operation the next day.

When he returned with mum Emma they were sent home again and told to wait for a phone call to reschedule the surgery.

She took Robbie 20 miles to Pinderfields Hospital in Wakefield where they operated immediately.

He was then put on an antibiotic drip for two days in case the wound had become infected.

Emma said: “The staff at Pinderfields were amazing. They couldn’t believe the pencil had just been left in his hand and neither could I.

“Staff at Doncaster just left the pencil in and put a bandage over it and told him he would have to come back.

"I was worried he would knock it and the pencil would go even further into his hand.

“I was disgusted. He could have lost his hand if it got infected.

“It was only when I asked about infection that they gave us the antibiotics.”

A Doncaster Royal Infirmary spokesman said: “Robbie was listed for surgery the next morning and sent home with painkillers to rest and fast overnight in preparation.

“Unfortunately due to a number of very urgent cases requiring immediate trauma surgery Robbie’s operation was postponed.

"We apologised and gave him further painkillers and antibiotics.” 

接下來看看太陽報的報導，太陽報的用詞就比較強烈了，雖然圖片和內文有說＂without proper treatment TWICE＂＂Disgrace＂等字眼，還是有提到醫師too busy。同樣的，台霉說的人球這兩個字在哪邊？

Boy, 13, is left with a pencil in his hand for two days - after docs turn him away twice

A BOY was left with a pencil stuck in his hand for TWO days - after a hospital sent him home without proper treatment TWICE.

Robbie Appleby-Socket, 13, was in agony when turned away and told to take mild painkillers at home by docs too busy to end his ordeal. His livid mum Emma Appleby fears the teen could have lost his hand if she had not taken him to another hospital 20 miles away.

The pencil became stuck in the 13-year-old's hand during a playfight at his school in Doncaster, South Yorkshire, on Wednesday afternoon last week. Staff at Doncaster Royal Infirmary's (DRI's) A&E saw Robbie but told him he would have to return the following morning for an op.He was sent away with the pencil still embedded in his hand - with just a bandage for protection.

When Robbie and his mum returned last Thursday, they were told he would have to go home again and wait for a phone call over the weekend. Robbie's horrendous 48-hour ordeal finally came to an end when he was treated in Pinderfields Hospital, Wakefield, West Yorkshire last Friday afternoon.

Emma, 33, said: "The staff at Doncaster Royal Infirmary (DRI) just left the pencil in and put a bandage over it and told him he would have to come back.

"I couldn't believe it. I was disgusted. He could've lost his hand. I was worried he would knock the pencil and it would go in even further.

"They asked me if I had paracetamol at home, which I did, so they sent us away.

"I was so shocked they didn't even think about the idea that Robbie could have rolled onto his hand while he slept and injured it even more.

"I didn't sleep a wink, I kept getting up to check on Robbie in case he was in pain."

Emma was even more staggered when she returned the following day.She said: "I was absolutely outraged. Robbie was there with that pencil still in his hand, and it was starting to look sore around the point of the pencil.

"They didn't even check the wound. It was only when I asked about infection that they gave us some antibiotics.
"We've still not heard from them so as far as they know Robbie still has the pencil in his hand.
"The staff at Pinderfields Hospital in Wakefield were amazing. They couldn't believe that the pencil had just been left in his hand."

Robbie was kept awake during his 90-minute op in Wakefield, watching docs remove the pencil on a TV monitor. He has been left with a five-inch scar and has not yet returned to school. Emma said of the freak accident which led to the injury: "From what he's told me, he was play-fighting with a friend at home time.

"Robbie punched out at him and unfortunately the friend had a pencil in his hand so Robbie had punched the pencil - which then got stuck in his hand.

"He was in a lot of pain obviously. He was very pale and looked like he was going to faint."
A DRI spokesman yesterday apologised to Robbie for his ordeal.

He added: "Robbie was seen by the A&E team, who were concerned and asked an orthopaedic surgeon to assess him.

"Robbie was then listed for surgery the next morning. Unfortunately, due to a number of very urgent cases requiring immediate trauma surgery, Robbie's operation was postponed."

英國醫療人球事件？台灣媒體如是說

先來看看台灣媒體的報導；Nownews和蘋果兩家媒體都說是被醫院當人球，甚至Nownews還用踢這個動詞。

蘋果日報表示：

6吋鉛筆插入手　男童被醫院當人球

2012年11月16日16:20    

英國13歲男童索克特(Robbie Appleby-Socket)，日前在學校跟同學嬉鬧時，被六吋長(約16公分)的尖鉛筆插入手背，痛入心扉，媽媽立即送他到醫院求醫，心想只是取出鉛筆的小手術，應該不是太難，但院方卻告訴他們明天再回來做手術。

離譜的是，母子倆隔天再到醫院時，院方又說沒有相關就診紀錄，又再安排他隔天做手術。手背插着鉛筆等2天，媽媽無法忍受兒子還要再受苦，也怕傷口感染產生其他問題，飛車帶他到較遠的醫院求助，醫生立即替他取出鉛筆。

Nownews 表示：

英男童手遭16公分鉛筆刺入　醫院踢人球：明天再來！

 林依伶 2012年11月16日 17:59  國際中心／綜合報導

英國一名13歲男童索克特(Robbie Appleby-Socket)在學校和同學打鬧，不料手背竟遭一支6吋長（約16公分）的木鉛筆狠狠插入手背，痛到受不了。索克特的媽媽連忙將兒子送醫急救，但沒想到院方卻要他們「明天再來」，母子倆傻眼無助。

據外媒報導，索克特的右手背被一支筆頭削得尖銳的木鉛筆刺入，母親心疼送兒子到醫院，心想只是要取出鉛筆，非動什麼大手術應該很快就能處理，沒想到院方給了止痛藥後，要求手仍插著鉛筆的索克特先回家，明天再來動手術。

更誇張的是，隔天索克特挨痛護著受傷的手到醫院看診，院方竟回答：「無相關就診紀錄」，要男童另預約時間才能動手術。索克特的母親再也無法忍受兒子深受皮肉之苦，更擔心傷口感染引發其他症狀，開車到32公里外的另一間醫院就診，當地醫生二話不說動刀替索克特取出鉛筆。 

英國布里斯托爾皇家兒童醫院Bristol Children's Hospital接連兩起醫療事件

復活節放假病房沒醫護人員　7歲病童慘死

2012年09月09日19:48

三月下旬，7歲大的詹金(Luke Jenkins)在英國布里斯托兒童醫院(Bristol Children's Hospital)進行了一次矯正手術，術後恢復看來一切正常，轉進小兒專科病房休養，爸媽只要有空都會在病房陪他。

約一星期後的4月6日，是「耶穌受難日」(Good Friday)，也是復活節假期的開始，晚上詹金的爸媽都在病床旁陪他，爸爸先發現不對，詹金的臉色發白，似乎有點沒力，他想找個醫護人員看一下，卻發現找不到人，沒多久，詹金失去了意識，倒在媽媽的懷中，他們發現小孩心跳都停了，急著找人救命，但找不到半個人幫忙，第一個醫謢人員出現時，詹金的心跳已經停了43分鐘，醫生再也沒辦法救醒他。

事後，醫院表示，心跳停止這麼久，腦部已經受損，其實在醫護人員趕到時，詹金早已死亡。但讓這對父母不能理解的是，當天是星期五，晚上時段整個病房沒有半個醫療人員，等於是把病患放著等死，院方事後在接受調查時也坦承，當天因為是復活節假期，人手真的短缺，「但醫院其他單位還有人值班，只是他們並不知道搶救儀器放在哪裡，幫不上忙」。詹金的父親認為，這樣的調查報告根本就是個「侮辱」(insult)，決定要和醫院周旋到底。

英國BBC報導

最近又報導了同一家醫院的另一個事件，是在八月發生的

 全天量營養液1小時輸入　1周大女嬰心臟病夭折

2012年11月15日22:34 

英國布里斯托爾皇家兒童醫院，一名1周大女嬰梅茜野沃特斯（Maisie Waters），有先天性心漏症，等候做手術時，護士錯誤調校了靜脈注射營養液儀器，將本應是全日的份量，在1小時內全部輸送給女嬰，結果導致女嬰心臟病發，醫生搶救了45分鐘，都未能將她救活。

沃特斯的母親向法庭作證時指出，在女兒出事前，她已發現負責的護士邊工作邊跟同事嬉笑，顯示沒有專心工作。

英國BBC報導 

1. 九月的事件有可能是人力短缺。
2. 上班時間，最好還是不要聊天嘻笑被看到。

  

Tranexamic Acid Could Save Lives in All Traumatic Bleeding (from medscape)

以下為簡略翻譯

根據BMJ 上 9/11 發表的paper， Tranexamic Acid (TXA) 不只有用在嚴重創傷，對於所有的外傷出血都有可能有幫助。

在randomized, multicenter Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2 (CRASH-2) trial的研究發表之後，針對Transamin (TXA) 在創傷出血的角色有許多爭論；BMJ 這篇研究企圖彌平這個爭論。

這篇研究是從CRASH-2的data裡面篩選出來然後分析。根據死亡風險分為四組：less than 6%, from 6% to 20%, from 21% to 50%, and more than 50%.

研究者發現TXA 降低整體出血死亡率約 30%；同時也會降低血栓事件(編按：肺栓塞心肌梗塞腦中風等？)。如果TXA的好處在不同死亡風險組是相同的，作者推論在 < 6% 死亡風險組有 17% 的死亡可以避免；在6%~20% 風險組有36%的死亡可以避免；在21%~50% 風險組有30%的死亡可以避免；>50%風險組有17%的死亡可以避免。

(以下討論統計過程…實在是很困難啊!!)

結論就是如標題所說TXA在所有大小trauma都有幫助，應該在3小時內給予。

http://www.bmj.com/content/345/bmj.e5839

http://www.thelancet.com/crash-2-2010

流感季節又來了!!!

新竹縣政府衛生局SARS專區

「流感病毒抗原快速篩檢試劑」及「流感抗病毒藥劑」之費用申報及核付作業請於99年3月31日後停止辦理 回新聞列表

公告字號 99年3月3日新縣衛疾字第0990003900號函 公告依據 內　　容 主旨：因應H1N1新型流感疫情趨緩，「流感病毒抗原快速篩檢試劑」及「流感抗病毒藥劑」之費用申報及核付作業請於99年3月31日後停止辦理，請 查照。 說明： 一、依據H1N1新型流感中央流行疫情指揮中心99年2月26日新流中指字第0990100054號函及行政院衛生署99年3月3日署授疾字第0990000260號函辦理。 二、由於國內H1N1新型流感第二波疫情已確定結束，且世界衛生組織已於日前建議將H1N1新型流感視為季節性流感，而我國流感抗病毒藥劑之儲備量亦已擴增，是以，有關防疫所需之藥物使用，將回歸以公費儲備藥劑支應，透過與各縣市衛生局合約之醫療機構，提供治療性藥物予流感併發重症通報病例及H5N1流感調查病例。 三、行政院衛生署疾病管制局透過健保代辦之「流感病毒抗原快速篩檢試劑」及「流感抗病毒藥劑」費用申報及核付作業將於99年3月31日後停止辦理。

http://khd.kcg.gov.tw/Main.aspx?sn=262&mt=18&qa=2454

流感快篩及克流感費用
問題	我從這個網站下載了-高雄市提供自費快篩克流感藥物醫療院所名冊，裡面我找到了一家診所，上面寫該診所有提供自費流感快篩，但不提供自費克流感，可是我才剛去該家診所做檢查回來，那時鼓吹我做快篩花了300元，檢查結果說是A型流感，所以又自費1200元買了一盒10粒裝的克流感，加上掛號費100元，花了我1600元，前兩天也是去了這家，打個點滴花700元和掛號費100元，看個感冒竟然前後要花費2400元？！按照該名冊上我找到附近另一家診所，名冊上寫這家兩者都有提供，索性打電話去問，恰巧這家快篩用完了，所以我就沒問快篩多少錢，但是克流感竟然只需要900元，為什麼會有這樣大的價格差異？一整個被坑錢的感覺！ 我不是很清楚現在健保是否有給付流感快篩及克流感的費用，如果都需要自費的話，那麼該診所是否屬於合法執業？明明寫不提供自費克流感但實際上是有提供，價格還貴300元，還不確定是真貨還是假貨？而且開立收據竟然只是手寫的，還是我自己問說怎麼沒收據？第一次看的根本完全沒有收據證明，我一整個感覺不對勁耶，懷疑根本就是家黑心診所，請問我可以透過什麼樣的管道去檢舉啊？因為擔心留言內容可能被對方發現是我，所以上述提及的診所名稱我暫時先保留，如果貴單位跟我聯繫，我再報上實際的診所名稱，也可以提供收據等等來佐證。 最後想問的是健保到底是保什麼？為什麼看個病好像都要帶個自費，加一加比以前沒健保的時候還要貴上許多，到底是怎麼回事啊？有沒有人注意到健保根本就是有問題啊！上次光只是拔個魚刺，醫生並未事先診斷，就直接要我去拍X光，拍完又說看不到魚刺，最後就直接從鼻腔探進去來拔，顯然這個X光拍的很冤枉，拔個魚刺竟花了我750元？看收據就更誇張了，除自費的掛號費300元及健保基本負擔450元，另外還有健保分項費用摘要的診察費618點，檢查費540點，處置或手術費1632點，總合計點數2790點數，外行人的我光看這些數據就覺得很誇張了，內行的你們有看出問題在哪裡嗎？ ps. 此留言如果沒有任何回覆的話，我要另外寫給陳菊市長及大話新聞的鄭弘儀來評斷看看，這個白色巨塔實在是太黑暗了！
答覆	敬愛陳先生您好： 一、有關您100年1月25日於本局留言版詢問「流感快篩及克流感費用」乙節，由於全民健保資源有限，目前依據中央健保局規定流感快篩及克流感並未納入健保常態給付項目，需請民眾自行負擔快篩檢驗費及藥費，本局為體恤民眾就醫之便利性，特調查本市提供自費快篩克流感之醫療院所，以便市民查詢。由於流感快篩及克流感係屬診所自行採購，其售價金額係依據診所消費買賣機制自行訂定。 二、有關掛號費部分，依據行政院衛生署99年6月21日公告醫療機構收取掛號費參考範圍：門診為0-150元，急診為0-300元。另有關診察費、處置費、手續費等收費情形，依據本市西醫醫療機構最高收費標準規定，以全民健康保險身份就診者，依全民健康保險規定辦理，健保未給付項目及非健保身分病人之醫療收費不得超過最高收費標準。建請陳先生提供本局醫政事務科就醫診所名稱及該次就診相關資料，俾利依法查察。 倘您對本案處理結果還有任何疑問，歡迎隨時與我們連絡（洽詢電話07-2513412郭小姐）。 敬祝您 順頌安好 高雄市政府衛生局局長何啟功 敬復
諮詢科室:疾病管制處 諮詢日期:2011/01/25 答覆日期:2011/02/01

[閒聊] 以醫院員工觀點出發的禁忌／吉利食物(和行為)列表

勞方(員工)／資方(老闆)看法常常是對立的；老闆希望生意好，錢賺的多，員工希望工作少，薪水還是一樣多。

在醫院這個場合，幾乎所有的醫護人員都希望能夠安安穩穩的工作然後下班，但是來客數(病人數目)常常隨著季節／日夜／節慶假日平日，而有很大的起伏變化；有時候在非預期情況下突然的病人數目減少或是增加－比如普通的平日卻像假日一樣忙碌－這時候就會有各種穿鑿附會的想像出現，來解釋這樣不合乎以往慣例的病人數目增減。比如：某某人都很旺，只要他上班，病人就會很多。

除了個人的＂運氣＂，＂吉利的事物＂也是東方文化上的傳統；因此很多食物在醫院這個場合也都會被列為禁忌或是祈禱好運的吉祥物。在此列出一份清單，歡迎大家提供意見、實際臨床經驗，共襄盛舉~~

• 吉利食物 

1. 涼爽茶－名稱就很涼很爽的樣子 
2. 乖乖－工程師也愛的吉祥物 
3. 水果布丁－睡個不停！保證值班時候一覺睡到天亮，不過要小心是不是手機沒電忘記開… 

• 禁忌食物 

1. 鳳梨－台語諧音＂旺來＂。
   衍伸用法－人形鳳梨。
   例句：他就像是人形鳳梨，只要有他上班，病人就一直掛。 
2. 芒果－諧音＂忙＂。
3. 芒果布丁(進階版)－忙個不停!! 
4. 有C字的飲料－和CPR的C有相關，有時候醫療上溝通也會把CPR簡稱為＂C＂；好比＂今天C回來了一個＂＝＂今天CPR救回一個＂。
   這方面的飲料，每日C(每天都會CPR)、85度C、愛C櫻桃(很愛CPR)。
5. 養樂多－事情會很多。
6. 旺旺仙貝－名稱就很旺。 
7. 鴨胸－和CPR時候的＂壓胸＂諧音 。
8. 烤布丁－call不停，值班大忌!! 

• 效果不明 

1. 龜苓膏－雖然諧音＂歸零＂，可是不知道會作用在＂病人數目歸零＂，還是病人心跳血壓歸零… 
2. 可口可樂Zero－同上 
3. 零卡飲料－零卡寫作0卡，看起來就很像O卡 → OHCA!! 

• 行為 

1. 印章加水－這也是大忌之一；相傳在急診室把印章加水，病人就會如潮水般湧來。
   醫生護士幾乎都要隨身帶著印章，寫病歷藥單等等各種事情都要蓋章，代表自己負責任。如果印章可以用到＂貧血(紅色幾乎看不見)＂，可想見是有很多工作了。 

美國華盛頓州的急診醫師們對州政府提出控告!! Washington Docs Sue State over ED Visit Limits

美國的老人和窮人醫療保險制度


前篇文章簡介了一下美國的老窮殘醫療保險；Medicaid主要是由州政府承辦，對於窮人的醫療補助。


接下來是最近的新聞Washington Docs Sue State over ED Visit Limits

ref: http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/28826

主要是說州政府面臨預算赤字危機，決議要從州政府主辦的醫療補助Medicaid著手，減少支出。官方發現有部分民眾濫用了急診，造成整體支出上升；於是限制使用Medicaid的窮人們每年以＂非緊急病情＂到急診看診的給付次數為三次。


而華盛頓的急診醫師們提出抗議，根據聯邦法律EMTALA－據說這法案另外暱稱是反拋棄病人法－急診醫師們必須不論病人有沒有錢都要提供醫療照顧。如今州政府決定限縮給付，可是急診醫師又不能把病人趕走，那錢要找誰去要？


有沒有覺得跟台灣情形很像~~


其實有幾點可以觀察討論
1.州政府有提出配套措施和事前／事後排除條款
2.美國的EMTALA法案對急診室的影響
3.關於急診室是否被濫用，政府vs.急診醫師的態度，美國和台灣的看法是否不同？

Washington Docs Sue State over ED Visit Limits

Emergency physicians in Washington are suing that state's health department over a new law that limits the number of "nonemergency" emergency department visits that Medicaid will cover.

華盛頓的急診醫師們對於州政府的衛生主管單位提出控告；因為一項新的法律，限縮了使用窮人醫療補助 (Medicaid) 的民眾，在＂非緊急病況＂卻跑去急診看病的就醫給付次數。

The Washington State Health Care Authority recently notified Medicaid beneficiaries that starting Oct. 1, Medicaid will pay for no more than three nonemergency visits to emergency departments annually per beneficiary.

華盛頓州保健管理署最近通知了窮人醫療補助 (Medicaid) 的保戶，表示從10月1日開始，沒有＂緊急病情`"卻跑去急診看病，每年將只給付三次這樣的就醫費用。

Limiting emergency room visits is illegal, according to the lawsuit, which was filed by the Washington branch of the American College of Emergency Physicians (ACEP).

美國急診醫學會的華盛頓分部提出異議，表示根據相關的訴訟判決結果，限縮人民的急診就醫是違法的。

Washington's new law also would reclassify 700 diagnoses as "nonemergent" conditions,including chest pain, abdominal pain,miscarriage, and breathing problems, but ACEP is arguing that many of the codes represent true medical emergencies and should be covered by Medicaid, no matter how many times the patient has visited an ED during the year.

華盛頓州新的法律同時對於700項疾病診斷碼重新歸類為＂非緊急病況＂，包括了：胸痛、腹痛、流產、呼吸問題。但是美國急診醫學會反駁說很多疾病診斷碼事實上是代表了＂真正緊急的病況＂，應該包含在窮人醫療補助 (Medicaid) 的給付範圍，不應該限制病人每年的急診就醫次數。

"This list of nonemergent diagnoses puts patients in danger and unfairly targets the poor and those in most need of care," said Stephen Anderson, MD, president of the Washington Chapter of the ACEP, in a press release.

美國急診醫學會華盛頓分部的主席Stephen Anderson發布新聞稿表示：這份＂非緊急病況＂清單針對了那些最需要醫療補助的貧困民眾，不但不公平，甚至是導致他們處在危險之下。

The Health Care Authority spent nearly $98 million last year on 327,965 emergency department (ED) visits for Medicaid patients, according to a Sept. 22 press release.

根據9月22號發布的新聞，去年使用窮人醫療補助 (Medicaid)的民眾，總共有32萬7千9百6十5人次的急診就醫，同時花費了保健管理署將近98萬美元(編按：將近3億台幣)。

The three-visit plan is estimated to save the state $35 million a year.
The plan stems from a directive in the state's 2011-2013 budget that directed the Health Care Authority to find ways to cut unnecessary ED visits to save money.

這項＂三次就診限制計畫＂預估每年替州政府省下35萬美元(編按：約1億台幣)。這項計劃是根據2011-2013年的州政府預算要求，命令保健管理署找出辦法減少不必要的急診就醫來節省支出。

"This is a realistic strategy to change clients' behavior and improve patient care as well as assure taxpayers that we are addressing the state's continuing financial crisis," Doug Porter, director of the Washington Health Care Authority, said in the press release."Nonemergency issues and chronic conditions should be treated by a primary care provider, not by an expensive visit to hospital emergency rooms."

華盛頓州保健管理署主席Doug Porter在新聞稿中表示：＂這是個很實際的方案，一方面可以藉由改變受保民眾的就醫行為，同時增進病人照顧；甚至對廣大納稅人來說，這代表我們有努力在解決州政府越來越嚴重的財政危機＂。不緊急的問題和慢性疾病應該在基層醫療照護(Primary care provider)接受治療，不應該去花費昂貴的醫院急診就醫＂

The state is working with providers to develop alternatives, including opening up walk-in primary care clinics located near the hospitals and lining up case managers to work with EDs to find the right care for nonemergency patients, according to the press release

新聞稿同時表示，州政府目前與基層醫療照護單位合作發展替代方案，包括在醫院附近開設＂不需要預約可以直接看診＂的基層醫療診所；和招募個案管理師與急診醫師們合作研究出非緊急病患的正確照護方式。

The limit wouldn't apply to children who are in the foster system or living with relatives or other caregivers. Nor will it apply to patients brought in by ambulance,police, or emergency medical technicians; visits for mental health diagnoses or for clients seeking detoxification services; or for visits that result in inpatient admission, emergency surgery, or admission for observation.

這項限縮的政策，不會影響下列幾類病人：寄養系統、由親戚照顧、或是其他託育的兒童；經由救護車、警察、EMT送醫的病患；精神疾患或是戒毒酒癮戒斷患者；或是就醫診斷後需要住院、需要留院觀察、需要緊急手術的病患。

In addition to harming patients, the physicians argue in their suit, the limits will harm physicians. ED physicians must provide care under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) regardless of coverage rules, and will be penalized under the new law because they won't be paid for treating Medicaid beneficiaries who've exhausted their three-visit limit.

醫生們在提出的抗告中爭論，這項限縮政策除了對病患有害，也對醫生有害。根據聯邦法規《緊急醫療勞動法》(EMTALA)，不論病人是持有哪種保險、或是完全沒有保險，急診醫師都必須提供醫療服務；但是卻受到新的限縮政策懲罰，因為州政府對於超過三次就醫限制的窮人醫療補助 (Medicaid) 病患不支付醫療費用。

"Physicians also will suffer harm in that patients are likely to unnecessarily delay treatment, there by exacerbating the risks and costs of treatment and interfering with the patient-physician relationship," ACEP said in the lawsuit.

美國急診醫學會同時在訴訟中提到：＂這項政策讓病人容易遭受不必要的醫療延誤，因此增加治療上的風險和花費，影響了醫病關係，這樣的改變讓醫師受到危害＂

Washington Medicaid's chief medical officer, Jeffery Thompson, MD, said that 97% of Medicaid clients don't exceed emergency room visits in a given year, but that a "small number who exceed that limit are responsible for scores of visits," mostly for chronic conditions and pain complaints that result in a prescription for narcotic painkillers, he said in a prepared statement.

華盛頓窮人醫療補助 (Medicaid) 的首席醫療官Jeffery Thompson在準備好的聲明中表示：根據統計，97%的窮人醫療補助 (Medicaid) 保戶每年急診就醫次數不會過多；但是少部分的病患急診利用次數卻特別特別多，才造成整體就診人次上升。大部分都是慢性疾病和需要麻醉類管制止痛藥品處方的疼痛病況。

Washington's Medicaid office is working with a number of other states interested in developing similar policies, and if Washington state's policy goes into effect, other states may follow suit, Anderson said.

美國急診醫學會華盛頓分部主席Anderson表示，華盛頓窮人醫療補助 (Medicaid) 當局正在和其他有興趣的州合作發展類似政策；如果華盛頓州的政策開始生效，其他州可能也會跟進。