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Seven Things Your ER Doc Wants You to Know
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.
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So awesome! Thanks for posting this, lots of laughs and some good tips.
Yikes! I’d always thought the whole “I Slipped” thing was an over-exaggeration on TV shows.
This is great. There’s one question you didn’t cover, though, and I wonder if maybe you’d consider adding it. My question is, “When should you go to the emergency room?” I mean, obviously, if you’ve amputated a limb with your chain saw, that’s a pretty clear call. But what symptoms are “more worthy of a trip to the ER than most people think?” And which ones regularly send people to the ER in a panic, even though 99.99 times out of 100, they should have taken two aspirin and called you in the morning?
Ugh. This is why I should continue to take no medications. I’m well past 66 years of age and like being able to tell the opthamologist, orthopedic surgeon, or dermatologist staff, in answer to the question: None. They always seem to be surprised. And it leaves us time to talk about other things.
I can’t say none ever, and I won’t promise to keep things this way forever, but for now it makes life so much simpler.
Thanks to ObamaCare, I don’t even have a primary physician now. It has been a year and a half since I last saw my old one, whom I did like. I didn’t mind that his first name meant Mohammed, and that while the Twin Towers were on fire but not yet fallen he threw the word “cancer” at me. (He was right.) He is a good guy, young enough by far to still have a practice. I suppose you could say it’s my fault for not picking up the phone to try to find a new one. I have pretty decent insurance, after all. But for the past several years ObamaCare has been making the whole experience of seeing a doctor less pleasant and less efficient for both patient and physician.
Good article, btw.
Nothing about clean underwear? I guess Mom was wrong… ;)
We are lied to constantly about drug use by new hires. I love it when someone has a very convincing (not really anymore) sob story about kids/wife and how they need this job so bad and God bless you for giving them a chance, then fail the pre employment drug screen that THEY KNOW AHEAD OF TIME they need to take. Then we cross into the “creative reasons why they failed” the test phase. Sometimes the levels are so high they apparently did coke in the parking lot of the lab but swear some was spilled on them at a party. Of course the majority test positive for marijuana which they invariably were exposed to by a “friend” or we get the diluted negative from one of the available masking agents. Good times….
Oh yeah, we notice, mom was right.
I’m not a doc, but I’ve spent enough time going to ERs between myself and my kids to have arrived at a protocol.
If you think whether you should go, you don’t “need” to go.
So now that you’ve decided you don’t need to go, you can do a little triage: can you wait to see your regular doctor? Will it likely get better on its own? Do you know enough first aid to fix it yourself?
If the answer to that last question is no, then you should go take a first aid class, which will likely teach you enough to handle most situations, and make those where you do need to go more orderly. This can also be the difference between getting a couple of stiches and being able to use krazy glue (that’s right) and a Band-Aid. More training is better.
If you’ve decided you need to go, you need to decide how to get there. If you come in on an ambulance, you will bypass the emergency room waiting room, which might be my least favorite place on Earth. That is monumentally expensive however, so should not be abused.
And they will triage you. If you find yourself in the waiting room for a long time, you’ve may well have miscalculated the severity of your injury. Chalk it up to experience. ;)
Okay, I’m going to punt this to the NIH….
When to use the Emergency Room
As you can see some of these are a little tough like “pain in the arm or jaw”. If you are a 70 year old with coronary heart disease, hypertension and diabetes it could well be a heart attack. If you are a healthy 25 year old it’s unlikely to be anything serious.
Great tip in there about urgent care clinics. They’re great for things like suspected breaks or non-life-threating stitches, where you know you need attention, but you’re obviously not going to die.
I’d like to add that such decisions seem clear cut when making them for yourself.
They are anything but when making them for others.
I do wish that ER people would realize that as a caregiver–parent, for example–the decision has to be made differently. I wouldn’t take a chance of guessing wrong with someone I was caring for.
Just a quick little story: My poor husband nearly sawed his finger tip off with his table saw one day two summers ago.
The ER doctor was amazing. What was astounding was how familiar he was with this type of injury, how matter-of-fact he was.
He looked at it and sewed it up as if he saw this every day of the week.
It is amazing to consider how many specialty medical areas the ER docs practice in. They work at a dizzying pace and get into every medical area imaginable.
They are really the top docs in medicine. They have a special kind of genius.
LOL.
So my daughter hurt her wrist at a party we were attending. Off to the ER on Saturday night. No worse place to be.
Just a sprain, a “wasted” visit.
Next time, she wanted some cherries out of our cherry tree, so I told her to get a ladder and get some herself. “You’re the kid…”
A few moments later, shrieks. Again, injured wrist. By this point I’d adopted my four-day rule for suspect breaks: if you’re not sure if it’s really broken, wait four days. If it still hurts, then go.
But I got one of our roller-blading wrist protectors out and had her wear that, figuring it would take care of what I suspected was a sprain.
Two weeks later she informs me that her wrist still hurts, and she points to the bone. Oh, no.
Wife takes her to the orthopedist—whom I’ve been seeing since I was 11. Sure enough, busted growth plate.
But the doc gets me off the hook: “Boy, whoever took care of this really knew what he was doing! This is a much better brace than I have!” He proceeded to show my wife why it was superior to the medical braces.
He sent her home in the same brace I gave her two weeks earlier.
The first few days of spring are “chainsaw injury season”. Lots of nasty cuts usually on legs, sometimes it will kick back to other body parts. The first good snowfall is “hand in snowblower day.” Why would anyone put their hand in a snowblower you ask. Well, what happens is they jam on ice or some object it ingests. The unsuspecting owner turns it off, thinking it’s safe, but it uses a very strong spring mechinism to propel the impeller. Once the impeller is free of the jam, it immediately spins and, there go a couple of fingers. One day I called the oncall hand surgeon and he had 3 patients already lined up for the operating room…
If I get hit by a big truck hauling hogs there’s a good chance I ain’t gonna have clean underwear on anyway. :)
These were the types of wonderfully funny stories the doctor told us as he stitched up my husband’s finger.
Unbelievable.
Far Side comic strip stuff. :) What a way to see your fellow human beings.
:)
That’s gonna be the least of your problems…
We want war stories, gang members taking over the ER at 3 am, worst industrial chopping accident ever, Lamest complaint brought to the ER, hangnail?
Yeah, I now find myself in the hypochondria grey area. At 25, it’s so unlikely that any symptom is a sign of anything worth seeing a doctor (no less going to the ER) that it makes perfect sense to ignore pretty much all of them, save for the kind that follows a massive accident and involves a major head injury or an amputation. Obviously, this isn’t true at 70, where a lot of symptoms are statistically more likely to suggest something is really wrong. But late 40s? There you get into the grey area.
If I went to the doctor every time I had “arm pain” — and if I paid for those visits out of pocket — I wouldn’t have money left for groceries. “Arm pain,” as I understand it, is a sign that you’ve had a proper workout or do a job involving a computer. Is there a particular kind of arm pain that says to you, “You might want to rule out the possibility that you’re having a coronary?”
Classically, it’s in the left arm, is an ache that isn’t affected by movement or positioning. Radiation of the pain into the jaw, or associated nausea, shortness of breath or sweating are other red flags.
The first thing your doctor is going to ask you is your risk factors.
Family History, Diabetes, Hypertension, elevated Cholesterol, smoking, being a male (I guess that one is getting pretty complicated…) If all of those are negative your risk is really slim. It’s never zero.
Partially torn fingernail that came to the ER by EMS. I swear to God.
Unfortunately for the young lady I was the City EMS Medical Director at the time and read her the riot act.
Dumb question but why do most patients come in late at night? Doesn’t anything bad happen during the day? Are we “too busy” to go to the ER?
This was amazing to me when I pitched up in an ER in Delhi with (literally) no nose. Clearly I wasn’t the first person they’d seen in this condition. And it made a huge difference that they were so entirely calm about things, I must say. I thought they must have shot me through with a ton of sedatives, because I was so blasé about a situation that was, obviously, a little alarming, inherently. But when I got home and looked at the bill, I saw clearly that they hadn’t given me any such thing: They just gave me antibiotics, rabies, tetanus, and novocaine (or something related to it — a local anesthetic in that class). My sense that it was no big deal and that I was just fine with having no nose was entirely owed to the ER staff being so calm about it. It was a pretty amazing experience of the placebo effect. (And the moment I figured out that I hadn’t been sedated or given any kind of narcotic, I realized that my nose hurt. A lot.)
Urgent care clinics were a good way to go for non-threatening injuries or symptoms that seem too urgent to wait for a normal doctors visit. They were generally as inexpensive as a regular doctor visit, much cheaper than ER. After Obamacare the prices at urgent care clinics have skyrocketed. Before Obamacare the urgent cares in my area used to charge ~$75 for a standard visit – i.e. sniffle, a couple stitches. Now they charge $250, the health insurance negotiates down to $175, and you are stuck with a $75 co-pay. The same price they charged for the entire visit 5 years ago.
Kodak, thanks for the tips. It is a shame how far health care has deteriorated. It is going to get much worse. Some day when your bank account hits a certain point you will chuck it in. There are three Doc’s on my street that retired in there fifties.
I’ve been overseas for 2 years, will be coming home in October and I hope to only work part time from then on.
We joke about the 9 or 10 pm rush “nothing good on tv”. Part of it is night. People get a little more scared at night, and worry, and end up in the only place open. Lots of people operate on reversed schedule, up all night, sleep all day. Many of these people are unfamiliar with the concept of “getting up in the morning to work”.
Although, let’s be honest. Not every emergency gives you time to swing home and pick one of these lists up.
In other words, type your own medical history form and save yourself, or your relative, the agony of trying to remember all these things while under great stress in a waiting room, filling out forms by hand that don’t give you nearly enough room to write out your answers unless your writing is microscopic :-)
OK, I admit carrying my written medical history around on a thumb drive, but so far, no doctor’s office has been impressed: if I don’t bring it printed out, it’s like it’s not even there. Glad to hear your hospital is more tech-savvy!
Awesome! I’m getting that app!
Okay, I have got to go here.
My dog has no nose Monty Python
Okay you cannot leave it at that. Uh uh.