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Taking up the challenge from our favorite editor, Claire Berlinski, I herein wish to enlighten all of you about a few things that every Emergency Room physician would appreciate your knowing.
1. Please, when you come to the ER, have an up-to-date list of your medications with dosages and any medication allergies you have. Please don’t say, “It’s in the computer.” Maybe it is, maybe not. Or, “My doctor knows.” He’s not available, and even if he was, he probably doesn’t know exactly what every one of his patients is taking. Also, “medications” includes your birth control (a major omission that happens all the time), all the over-the-counter meds you’re taking, and can even include any supplements you are taking (some of them have significant interactions with medications). Having this information on you may save your life. I repeat, having this information on you may save your life.
If you really want to get fancy, include all your medical problems, and any surgeries you’ve had. You can really impress us if you have all this on a thumb drive with a recent EKG and an image of a chest X-ray. (I’ve seen that a couple of times — usually an engineer-type.) Maybe upload it to the Cloud. Whatever. It can really help, and there’s an App for that.
2. Please don’t lie to us about your smoking, drinking, and drug use. We’ve seen it all. You will neither shock nor impress us. But when someone comes in reeking of tobacco, with nicotine-stained fingers and teeth, and burn holes all over his clothes, “I smoke occasionally” is not a likely scenario. Ditto the guy who drinks on a daily basis, has all the stigmata of alcohol use, and liver enzymes through the roof. Not mentioning your cocaine use or your benzodiazepine use can be a needless ticket to the ICU. So please, be honest. That way I can know to watch out for things like the DTs, or avoid giving a drug like Flumazanil that can cause instant, almost irreversible seizures in patients who take lots of Benzos, or not use a drug that’s got narcotic-agonist activity on someone who’s doing 20 or 30 mg. of Oxycontin a day, causing acute withdrawal and instant misery. Honesty is the best policy. It’s also embarrassing when I get the tox screen back and Mr. “I don’t do any drugs” comes up positive for 8 out of 10 on the screen. A little bit more of my faith in humanity dies at that point …
3. You are going to wait. I’m sorry, but count on it. A recent hospital I worked at was so overwhelmed in the ER that wait times at night frequently were 8 to 10 hours. When I came in on morning shift, I felt like I needed a whip and a chair to see the patients, they were so hostile. And that’s typical of ERs all across the country: way too many Indians, not nearly enough Cowboys — or beds or nurses to deal with the loads we’re seeing. Now, if you have a serious problem like chest pain, 99-plus percent of the time we’ll get you in fast and get you taken care of. If you come in on a Saturday night shift with three weeks’ worth of back pain, want a second opinion on your umbilical hernia, or have cold symptoms? Pack a lunch and bring a good, long book. Oh yeah: Please don’t call an ambulance in an attempt to cut the line. Once upon a time, anyone who came by ambulance went right to a bed, and we ended up seeing them fast. I remember seeing this as a suggested strategy for being seen quickly in a magazine for executives. But while you were using the ambulance as an expensive cab, that stroke victim had to wait an extra 20 minutes to get to the hospital. Also, we now screen you as you come in. If the complaint is minor, we just send you out front to triage and join the waiting throng.
4. Don’t lie about your chief complaint to try to sneak in faster. Just don’t. Telling the triage nurse you have chest pain to move to the head of the line is going to result in a lot of needless testing, and will probably relegate whatever you came in for originally to a distant second place that might not even get addressed. If we find out you pulled this little stunt, expect major repercussions. Working in Sacramento, California, I picked up a chart that under “complaint” said “syncope,” or fainting. The triage nurse and the rooming nurse documented that the patient stated she’d fainted multiple times in the past week. When I went to see the patient, I grabbed a DMV form on the way and started to fill it out. The patient initially indicated she’d been fainting, then started to tell me about another problem. When I asked her about the fainting, she told me, “I just said that because I knew I would get seen faster.” I handed her her copy of the completed DMV form that suspended her driver’s license for six months owing to a medical condition that resulted in an altered level of consciousness. I told her that the chart documented in three separate places that she’d been fainting, and reporting this was mandated by the state. She would need a letter from a neurologist to reverse that. Losing your driver’s license in California is almost a death sentence.
5. Please think really hard before coming to the ER between about 3:00 a.m. and 7:00 a.m. If we aren’t completely swamped, we’re almost certainly tired and not at our sharpest. Obviously, if you have a real emergency, come on in. In that case, the adrenaline kick the staff get from a serious patient usually provides a little boost. But even people who work nights regularly are still operating subpar during those hours. Circadian rhythms and cortisol levels at work here.
If you can, wait for a fresh crew at 7:00 or 8:00 a.m. You’ll probably find a much more chipper, happier staff. And the slowest times in the ER are generally from about 8:00 a.m. to 12:00 p.m. Things pick up through the evening, and usually at around 9:00 p.m., a “bus unloads” in triage — and we’re off to the races.
6. Our hospitals are usually operating near capacity all the time now, so even if we admit you, you may spend a long time in the ER. It’s not a great place to spend a couple of days. We in the ER are sorry, but it’s out of our hands. Believe me, we would get every patient upstairs to a floor bed at the first possible minute. But there has to be a bed, and nursing staff for the bed. Also, some bean-counting geniuses in our hospitals squeeze pennies out of the budget by cutting cleaning staff. (I know, yuck.) That means you’ll be waiting for the housekeeping staff to get the room and the bed ready. They’ve also closed lots of beds as a cost-saving measure. The floors push back all the time when we try to move the patients: “We can’t take report now.” “The nurse is busy.” “The nurse is on break.” So you wait. That means the next patient in the waiting room also gets to wait a little longer.
7. If an object finds its way into a body cavity, please don’t tell us an elaborate story about how it got there. Again, you aren’t the first, and you won’t be the last. “I was walking through the garden and and I slipped?” And what, that cucumber went right through your blue jeans, or do you garden in the nude? “I fell in the shower?” Bullseye! A direct hit. Don’t worry, it will be our little secret.
Okay, in all seriousness. In my years in the ER, I’ve had the privilege to work with some of the best and most dedicated doctors, nurses, paramedics, techs, and orderlies in medicine. Day after day, they manage with too many patients, not enough resources, and a society that dumps every intractable problem on the ERs. It’s the only area of medicine where you can never, ever say, “No.” Through it all, they almost always manage to deal with whatever gets tossed their way — and they have a positive impact on countless lives.