Friday, April 30, 2010

A Better Trip to the Emergency Department, Part I

(Author’s Note: Several months ago I found this great article about tips to improve your ED experience, and decided it would be fun to comment on it. Problem is, once I got rolling, I kept on commenting…and commenting…and commenting. Every other day there would be a new thought, a new idea to work into the effort. But finally it’s time to stop. So in a first-ever Writing With Scissors exclusive, the next post will be serialized over the next several days. Be there. Aloha.)

Trolling on America Online (yes, I’m the Philistine who keeps them in business; and yes, I know I should change to another browser but I’m simply too stuck in my ways to do so. The tech-savvy Bride also tells me I’ll have to learn to Tweet someday just like John McCain), I ran across an article of interest. Entitled, “Emergency Room Docs Offer Inside Scoop: How to Get Treated Faster, Better” by Eric Wahlgren (, November 29, 2009), the article offered several tips for those who use the Emergency Department (ED) that might expedite their visit.

In general, I have very little use for these kinds of articles, as they rarely reflect the reality of ED care. However, the tips in this piece were actually pretty good, and showed signs of being reviewed by real live doctors working in real live ED’s rather than consultants, “thought leaders,” and other experts who get paid lots of money to cover their ignorance with polysyllabism and sesquipedantism (not bad, huh?), and whose ranks I someday strive to join. However, I’ve felt compelled to offer the following amendments to Mr. Wahlgren’s most commendable effort.

“First, let's debunk a persistent ER "shortcut" myth. If you or a loved one has a life-threatening emergency, by all means call an ambulance, as paramedics can immediately begin care as you're being rushed to a medical facility. But don't expect to get treated any faster for sunburn or a stubbed toe just because you arrive in an ambulance, emergency physicians say. You'll be triaged based on the severity of your condition, just like everyone else. "We have people who've called an ambulance for earwax or prescription refills," says one ER physician…"When they come in by ambulance, they go right into the waiting room."

This is absolutely true. An ambulance ride in and of itself does very little to promote your movement through the system. Paramedics are very good at figuring out quickly who’s sick and who’s not, and when they tell us it’s serious we listen and triage accordingly. But even if your condition is non-emergent, there are other modifiers which impact your ED stay. It does not help your chances of receiving expedited care when you ask the paramedic to avoid certain hospitals or doctors because you have “had problems” with them before, or because they are (choose one or more) racist, sexist, homophobic, incompetent, don’t understand your pain, don’t like the homeless, or hate people without money. Believe it or not, most people whose chose emergency care as a career are pretty proud of the fact that unlike many of our colleagues, we care for anyone who shows up at the door, no questions asked. So don’t even try to to hit us there.

Nor are you seen faster if you phone 911 from the waiting room of the ED because you’re tired of cooling your heels. You will not be seen faster if you call 911 from the treatment area to take you elsewhere because the service is not to your liking; as long as you are capable of making that decision, your desire to go does not mandate my begging you to stay. Possession of a Florida Medicaid Gold Card does not mean the ambulance is your personal taxi. Finally, be aware that “Why did you call an ambulance to bring you to the Level II Trauma Center at 3 AM on a Sunday morning?” is always a legitimate question, as is “Why did you tell the ambulance to bypass three closer hospitals to come here today?” These questions will be asked, and an answer will be expected, even though we both know what the answer really is. (If you’re here for a life-threatening condition, we won’t ask because we’ll already know why and be doing something about it.)

Now, to the tips themselves:

Avoid nights, weekends and holidays: Face it folks, doctors take time off, too, and you'll be seen more quickly if you show up at 10 a.m. on a weekday rather than 10 p.m. on Saturday night -- after there's been a series of car wrecks. "Even if it happens to be less busy on a night or weekend, the staffing is lower," the ER doc in the northeast says. "There may only be five people ahead of you, but it will take a while to get seen." Holidays are also a bad time to go, as is the day right after, as hospital staff may extend their vacations. True emergencies, of course, give little advance warning. But if you have an inkling your bandaged finger, say, may need stitches, best head to the ER as soon as possible, rather than waiting until after work when you'll have plenty of company.”

An ED is generally not somewhere you go on a planned basis. While I would by all means encourage you to go to the ED for an actual emergency, the very nature of a medical emergency precludes preplanning and scheduling. However, should you decide to use the ED for your non-emergency complaint, we would encourage you to contact our maitre d’ and reserve your table for somewhere between three and seven AM. You may indeed be seen faster at that time, but with a somewhat larger dose of skepticism as to the true urgency of your problem. Please also note that our level of concern will decrease with the longer duration of the problem (for good clinical reason…if you’ve lived with it for months, the chances of it being a life-threatening emergency at the moment are very small), and that your pain tolerance is also expected to rise the more time has elapsed since your illness, injury or surgery. And as regards stitches, the advice is exactly right. Wounds left open more than 12 hours (up to 24 on the face) are usually not closed due to an increased risk of infection. So if you think you need stitches, go to the ED now. Do not pass GO. Do not collect $200. (We have staff that will do that for us.)

Some people have also heard that July 1 is a day to avoid. That’s because the new crop of interns and residents (new graduates from medical school and those in specialty training) start their new year. Flushed with shiny new degrees and promotions, many of them actually believe that they know something, which poses a danger to you. (The smart ones learn within about three weeks that they really know nothing. The dumb ones never do.) This myth is simply not true. While the young doctors on call that day might be total screw-ups on that day, the nurses will save your…donkey.

Here’s how this wisdom was beaten into me. I was on call for the internal medicine service during my first month of graduation from medical school, and was called to the ICU to see a patient with a falling BP. I entered the room and promptly did what I thought all good doctors would do. I approached from the right side of the bed as I was taught, and put my stethoscope on the chest. One of the things they never tell you in medical school is that you can’t hear low blood pressure by listening to the heart.

The ICU nurse that night was a guy named Bill, an old Air Force RN who had been doing intensive care since General Pershing’s Punitive Expedition into Mexico. He started laughing. I looked up and him from my auscultatory musings with an annoyed look that can only be generated by an annoyed 24-year-old who doesn’t yet know that he’s in waaaaay over his head.

“What?” I growled.

“You might want to listen to the heart.” He let loose with a hearty guffaw.

What? He was questioning me? OF COURSE I was listening to the heart. At least, I thought I was. Thirty seconds later I realized I actually couldn’t hear any heartbeats, but the “beep-beep-beep of the monitor continued on. This was because I had not fully taken into account the actual dimensions of this very large patient, and I had spent the last two minutes listening to the patient’s right breast. Turns out that breast tissue does not exhibit cardiac activity.

I tried very hard not to let on, though, and repositioned the stethoscope so it looked like I was searching carefully to determine the site of a heart murmur in it’s loudest dimension (a trick which can help to isolate the site of a murmur…honest, it really does.) So I kept listening, and repositioning, and listening, and repositioning, and trying to think if I heard anything and what I would do about it if I did, when the low blood pressure alarm began to wail.

“So, Doc, what do you want to do about this?” The tone had changed. No more laughing, but instead the voice of the career non-com who’s had just about enough of this newbie from OCS.

I mustered up my confident voice, the one I keep in reserve for occasions like scolding the dog (not like it does any good) and instructing patients with STD’s to use protection at all times while having sex (ditto).“Well, I suppose we ought to treat it.”

Sensing that the trap was about to be sprung, Bill raised an eyebrow and the corner of his mouth turned up in a mongrel hybrid of a sneer and a smile. “Well, DOCTOR, what should we use?”

I’m sure you, the rest of the medical world, and even the radio audience at home understands by now that Bill knew exactly what to do and how to do it. He just wasn’t going to share that with me.

“DOC-TAH?” Bill’s voice went up an octave for comic effect. Twitters of giggles were now heard from Vicki, the hot night nurse from Arkansas, who had been in the next room and came to join in on the fun.

It was over. Game, set, and match. Sparkling new stethoscope, pressed lab coat, diploma in hand, and I was nothing more than a good-looking book with a lot of blank pages. I was the walking epitome of the concept that medical school teaches you where to look things up, but residency teaches you what to do. It was time to do justice, love mercy, and walk humbly before your nurse.

Meekly, I whined. “Ummm…what do we usually use?”

“Dopamine is nice,” came the reply. “How much?”


“How about we use the protocol, then, doc?” With my abject failure, Bill’s task was done. The intern had been humbled, and the right care given to the patient. “And let me give you a copy of our dosing sheets to stick it in your pocket. Never know when you might need something like this.”

So from that time until now, I put a lot of stake in what the older, experienced nurses want to suggest, and pretty much give them a wide leeway to do what’s best for the patient. When I’m faced with a critical patient and I’m out of ideas, I always ask around if there are any other thoughts; and if nurses I trust say that they want to start some treatment before I can get to the patient, they have carte blanche to do so. I also follow their advice as to what’s best for the nurses. For example, I was told many years ago that disimpaction of stool in the rectum is not an ED nursing procedure. You can give these patients a laxative for home or they can be admitted. Those are the only choices. I have followed this advice religiously, and I’d like to think it has earned me friends on the nursing planet.

One other time to avoid are nights of the full moon, especially when these coincide with a weekend. Despite studies which argue to the contrary, I am firmly convinced that there is something about it…tides, gravitational pull, illumination, reading The Twilight Saga, whatever…that increases the volume of patients seen and the inherent craziness of each. (The Bride has recently earned three billion spouse points for not making me go see it, although I have reconciled myself to the fact that every now and then she’ll cry out the name Edward in the middle of the night.) On the other hand, if you’re not looking for care but an experience, I highly recommend a visit on the Friday or Saturday night of a full moon, especially if it’s Bike Week or Spring Break down here on the Fun Coast.

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