Sunday, May 2, 2010

A Better Trip to the ED, Part III

(Author’s Note: Yesterday I began to serialize and admittedly VERY long piece in response to an article by Eric Wahlgren entitled, “Emergency Room Docs Offer Inside Scoop: How to Get Treated Faster, Better.” (, November 29, 2009). It lists tips and techniques for improving the quality and outcome of your ED visit. This is Part III. His tips in italics; my thoughts in “stand-up” letters.)

Try to be understanding: The reality of the ER is that unless you're dying, you're going to be treated after someone who is in much worse shape. "Going up to the nursing station and yelling and raising your voice about a relatively minor complaint is often counterproductive," says the ER blogger. That said, ER staff will be responsive if you have a reasonable request, he says. If your grandmother is in pain, for instance, let the staff know and ask if someone can assess her.

In an era of increasing ED numbers and decreasing resources, especially in hospitals that serve large populations of the underfunded and the uninsured, the focus in many hospitals has turned from high-quality, individualized patient care to moving patient volumes. This means that physicians and nurses are often understaffed and overloaded. Most patients don’t see that, and isolated from each other in private exam rooms there’s probably no reason they should. To me, it’s a shame they don’t know more about patient volumes and severity of illness. They’d have a better understanding of the intricate dance of chaos we do. There’s an old ED dictum that states an ED doc should be able to process through the system an average of two patients per hour. Even if true (and I suspect these numbers are dated, and the real number now is lower), this means that if a physician is expected to handle 12 different patients at a time, a total ED time of 6 hours is not unreasonable. Most of the time we can have your case resolved long before then, but it’s important that you understand the math.

It’s also important to have some reasonable expectations from your ED visit. Emergency Departments are set up to provide emergency care. The definition of emergency is an immediate threat to life or limb, and that generally works for me. My job is to find and stabilize those emergent conditions, and make an appropriate decision for admission or discharge based on this evaluation. Anything else I can do for you beyond this is really just icing on the cake.

Here are some reasonable expectations for your ED visit:

A clean room.

Polite caregivers.

Clinically appropriate evaluation, care, and disposition. (Clinically appropriate is the key word here. What's best may not be what you want. When those two things conflict, you deserve an explanation...see below. But that's why we went to medical school.)

An explanation of what we can or cannot, are or are not, will or will not do for you in the ED and why.

Navigation of the health care system in a way to give you the best possible outcome given the limits of the ED setting.

An option to participate in health care decisions where it’s reasonable to do so.

(True story on this last one. About three weeks ago I was in the Fast Track, or minor care, area of the ED. A young woman came in for the fourth visit in three weeks for what she said was the same unrelenting headache. I checked her old records to see that she’d never had a CT of the head done before. So I asked her if she would like that done today to make sure nothing was being missed. She replied that she wanted her headache to just away. I said I understood, but was asking if she wanted me to order a scan for her. She said she did, and I went to the desk to push the magic buttons on the computer to make it happen. As I did, the patient flew out the ED in a rage. She later filed a complaint with administration, saying, “I’ve been in the medical field, and I’ve never had a professional offer me a choice. It was rude and insulting.” The sad thing, of course, is that I had to defend that complaint. Go figure.)

Here are some unreasonable expectations for your ED visit:

Making sure your care is completed at a certain hour because you have a date/party/business meeting/need to pick up the kids/clandestine affair in three hours time. (That’s what appointments at the doctor’s office are for.)

A meal. A bus token. A taxi pass.

A cigarette. Permission to go outside to smoke a cigarette.

Consideraiton of your case as a life-threaenting emergency if I have to wait until you finish your cellphone call to talk to you.

A dentist to rush to your side for a toothache.

Immediate surgery because “I’ve had this for years, and it’s time to get something done.”

Refill of any chronic narcotic prescription, unless you are in a metal cervical halo, an external fixation device with steel pins coming out of your limbs, or have cancer. (For the record, in any of these cases, I’ll give you just about anything you want.)

Resolution of your homeless/jobless/friendless status, especially when you’ve come in with a wallet full of cash, a cellphone, a carton of cigarettes, and cocaine in your system. (Even I know they don’t give that stuff away for free.)

Automatic admission because you “need a rest.”

Considering your boorish behavior as a sign that we’re not caring enough or failing to cater appropriately to your wishes and should work harder to satisfy you (as opposed to meeting your actual needs which, after all, is our job.)

Nobody quite understands the make-up of ED folks, and even after two decades of work I’m not sure I do, either. But one thing I know is that by and large we are a patient people, and our tolerance increases with the civility of the patient and family, acuity of clinical condition, and the extremes of age (allowances are always made for small children and the confused elderly). However, our tolerance falls with inappropriate moaning, screaming, or yelling; making staff wait to do their job while you finish you cellphone call and your bag of Cheetos, and then say you’re in severe abdominal pain; casting our parentage into question or accusing us of carnal relations with our mothers or same-gender partners; calling administration to complain on your iPhone from the bedside; stuffing three or more family members into the exam room with the patient unless you’re here to sit with someone on a ventilator who’s FTD (Fixin’ to Die); and walking out to the nurse’s desk to tell us that you can’t walk. (There’s a local patient who comes down three flights of steps to meet the ambulance at the curb and is then taken to the hospital because she says she can’t walk.)

There are also times when our patience disappears altogether. Our patience is gone when you verbally cast our parentage into question or accuse us of having an Oedipal relationship with our mothers. It went away weeks ago the moment you take a swing at someone. There is a reason we employ big people as Security and as ED Techs, and a reason they loiter around the cubicle of the intoxicated and violent patient with a gleam in their eye and a set of half-inch thick locking leather straps in their hands.

One final paradox: The “busiest” ED in town is often the “best,” and the high level of quality in and of itself produces long waits and “turnaround” times. While “best” is a relative term, it’s true that the ED’s with the longest lines tend to be larger hospitals with the full complement of specialists on call 24 hours for anything truly grave. I believe that pretty much any ED can competently care for a minor illness or injury, but there is no clinical question that serious events such as heart attacks, strokes, and major trauma cases need to be seen at a specialty center. Physicians refer their patients to more advanced centers and patients are being transferred in at all hours. People in the community recognize this as well. In addition, these hospitals tend to be the ones located in central urban areas with a greater commitment to serving the poor, resulting in further congestion. It’s kind of like the paradox where the best surgeon in town has the worst outcomes. It’s because he takes on the difficult, high-risk cases that other doctors refer to him.

Bring somebody with you: It's likely that when you go to the ER, you won't exactly be feeling your best. It's always a good idea to bring somebody with you -- a spouse, perhaps, or a trusted friend -- who can help answer questions about your condition and recall any information the medical team gives. "If you're the patient in the ER, there might be situation where they're talking about certain problems and you'll want to have someone else there," says Turk. But if at all possible, don't bring along kids or others who could distract both you and the medical team.

There are two main reasons it’s important to bring someone with you to the ED. The first is well described above, and is especially important if you will be unable to provide any history yourself due to changes in your mental state due to illness or injury. (Okay, you can’t predict that in advance, but you get the idea). It’s also critical to come to the ED if you’re helping to care for someone with dementia, cerebral palsy, stroke, or other problems which impair communication. One of the biggest questions that help us as ED staff is to know if the patient’s confusion, behavior, and activity level is something new or simply represents the baseline status. The answer can significantly change evaluation and care.

The other reason is because you’ll often need someone to take you home. If you come to the ED with a painful condition, chances are that you’re going to get some pain medication. Once that’s in your system, I can’t let you drive, walk home, or take a taxi until its effect has fully worn off, which may be hours. Having someone with you to take you home also allows someone to watch you overnight if needed (for example, to observe for signs of delayed head injury), someone to pick up a prescription for you on the way home, and someone to help you navigate daily tasks while getting used to using crutches, a walker, a cast, or a wound dressing.

If you’re the other person who came to the ED with a patient who needs care, thank you for being here. But at least let the patient try to speak for themselves when I ask them questions. Few things annoy me more than trying to ask a patient something and having someone else answer for them. Not only do I not get an answer from the “horses’ mouth” that gives me a better sense of the actual concern, but the way patients answer questions can also provide important clinical information. Having you talk for the patient, or the patient deferring all talking to you, tells me a lot about family dynamics, but very little about what’s going on with the patient. And while it’s true that the patient not be able to talk to me due to medical conditions or age, I’m still going to talk to them first before talking to you. I’ll do that because I’m never quite sure how much is really going on inside their heads or what kind of response I’ll get, and therefore I’m going to address them as individuals. They may well not respond, but doesn’t common decency demand that I at least show enough respect to try?

(One quick story, which I may have told before. Almost twenty years ago, a man and his wife showed up in a Gainesville ED with a referral note from a doctor in Miami on a hotel cocktail napkin. I went into the room and introduced myself, and asked what was wrong. The man made some kind of noise that started like the start of a word…and was immediately interrupted by his wife who shouted, “SHUDDUP MORTY! I’M TAWKIN TA DA DOCTAH!” She then proceeded to tell me all about his condition, omitting nary a corpuscle, pausing just long enough to ask my name again, inquire if I was Jewish, learn if I was seeing anyone, and note that that she had a lovely granddaughter who was single. Poor Morty’s eyes pleaded with me to find a bang stick.

Which, in turn, reminds me of a joke:

“Knock, knock.”

“Who’s there?”

“Interrupting Cow.”

“Interrupting Co….”


Avoid the ER altogether: If you're suffering from an urgent -- but minor -- problem like a cut, ear infection, flu or animal bite, you may be able to go to an urgent care center instead of a hospital ER. Typically, patients are seen more quickly at urgent care centers. "From my perspective, if you have minor problem for which you are not going to need, say, a CAT Scan, go to an urgent care center as opposed a large hospital emergency room," Turk says. For more serious emergencies such as chest pain, poisoning, or head or spinal injuries, go to the ER after dialing 911, of course.

Please make sure you have an emergency before going to the emergency room. I know that sounds like a trick question. But I’d wager real money that if you asked 100 patients in ED’s across the land at this very moment what was the emergency that brought them to the ED today, right now, what was changed or different that made them decide this is THE DAY to be seen, well over half would be unable to answer the question. So please have an answer. It’ll make life easier for all of us. And also note that while we are often forced into the role of primary care, it’s not what we do and not what we’re good at. So we’ll push you identify a specific problem you want us to help with. It’s unreasonable to expect exploration of more than a single focused medical issue during your ED visit. True emergencies come one at a time. If you have multiple problems and you don’t know what’s worse, by definition none of them are emergencies.

Well, that’s it. Hope that it helps. As Granny says, “Y’all come back now, y’hear?” Just not too often. That gets on our nerves, too.

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