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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.
Published in General
Agreed, more or less. We once drove across the desert in the middle of the night at 90 miles per to get out of a town that only had a hospital to reach a larger town that had a walk-in clinic by morning.
Or, what’s the likelihood it’ll get better on its own before it gets much worse? ;-)
I remember coming down with something whose external symptoms perfectly mimicked DVT. It probably wasn’t DVT, but if it was…
We went.
No wonder the urgent-care clinician who thought I had meningitis was mystified that I refused an ambulance: she wanted me seen immediately, and since my husband drove me, I wasn’t. No harm done in the end, though :-)
My Dad had a massive heart attack when he was 51. As he lay on the ground waiting for an ambulance, he motioned to the friend with him and said weakly “Tell my wife….”
“What? Tell her what?”
“I have on clean underwear.”
Well, of course I didn’t. What writer would?
In my position I get to view a lot of claims data, and am reponsible for summarizing it at a high level. Last week I ran across an individual that had incurred 41 unique ER visits within a 12 month period, only 2 of which had resulted in inpatient admissions.
Or google it. Seriously. I mean, if you’re in a position to do so.
Sometimes googling works great. Like ruling out appendicitis because the pain is in the wrong quadrant. Saves you a trip to the ER. Yay!
Other times, it works less well. Turns out I, at least, cannot do an accurate ACL exam on myself, no matter how hard I try. Still, in my experience, it’s not worth going to the ER for a torn ACL anyhow, because even when it’s completely snapped, ER staff can easily overlook it. Waiting a while, then seeing an orthopedist if it isn’t getting better, seems the wiser choice.
And for some fraction of visitors, I imagine the fact that urgent care centers and pharmacy walk-in clinics generally close at night could have something to do with it.
I’m just old enough that our family doctor was still permitted by his group to make house-calls in my toddlerhood. This meant I got to avoid the ER for middle-of-the-night asthma attacks until I was old enough to care for my asthma myself.
My last trip to the ER was for me…on our anniversary. We went out to dinner…just at the end of the meal I started to feel uncomfortable, then I couldn’t stop throwing up, then I was hit with waves of pain. It turned out to be a kidney stone, my second of consequence. The first happened when I was at a global meeting in Germany. Didn’t leave my hotel room for 36 hours.
The EMT and ER staff did great work to get me comfortable and “flowing.” My primary figured out it was almost certainly the topiramate I started taking for migraine prevention. No topiramate, no stones…and just a few more migraines.
I was transported at prime time on Saturday: 9 PM. I believe one of the reasons I was treated well is because I was able to tell the docs everything Kozak noted. In addition, my wife and I were polite, but not passive (e.g., asked pertinent questions).
I’ve spent a lot of time googling stuff in the ER. It’s very helpful to evaluate what the doctor is telling you.
And since my opinion of good medicine varies widely from most docs’ view of good medicine, it’s essential for demonstrating that the doctor is not prescribing in accordance with the medical literature. You’d be amazed how often that happens.
My doctor would sometimes interrupt and ask if I’d like him to confirm my diagnosis. And he wasn’t even snarky about it.
Believe it or not, my self-diagnosis wasn’t always correct.
This is golden information! As the nurse that gets you ready for surgery, most of this applies to us, too. Your anesthesiologist needs to know all this information to safely put you to sleep for whatever procedure you are having no matter how “simple” you think it is. Great synopsis, Kozak!
I’ve got four kids: one rowdy girl and three boys who played football and rugby. Many, many trips to the ER and Urgent Care. Some visits okay, some outstanding, some bad and some just plain weird.
Weird: My then 12 year old feinted in church during a school mass. Other attendants called 911 before I got to him. A drive literally across the street to the ER with a couple of EMTS in an ambulance. They put him through a battery of tests; a Marine vet in our acquaintance came up with the correct diagnosis: he had been standing with his knees locked.
Weird part: after awhile in the ER the EMT was leaving and he asked why I was still there. “I’m his mother,” says I.
EMT: Really? You’re so calm I assumed you were just a bystander.
I found out later he pulled a nurse aside to voice his concern. Turns out the nurse was a friend from church/school. She simply replied: This ain’t her first rodeo.
Since then, I’ve been self-conscience about my own behavior during EVERY visit to any hospital/doctor/Urgent Care. But my kids have still never seen me panic.
‘Course it’s not, as my self-diagnosis that I hadn’t torn my ACL turned out to be. But as long as we know ourselves well enough to not be overconfident (and aren’t hysterical hypochondriacs by nature), self-diagnosis is still useful. It doesn’t replace doctors, but it can waste less of their time.
My last trip (for me) to the ER was while I was in the Navy almost a decade ago. Part of the reason the ER was so full was the shortage of available PC appointments had reached a point that the PC clinic was telling people to just go to the ER if they wanted to see a doctor before the illness played itself out. Some time in the last couple of years the Navy hospital here turned their ER into an urgent care. Now any real emergencies are shunted to the civilian hospital.
I wonder if this is the new normal in medicine. I have a doctor, and if I’m willing to wait for a week or two I can see him. This means he’s pretty much just there to tell me annually to quit smoking and lose weight. Otherwise, I go for a walk in at the office with whichever doctor is stuck with urgent care that day. For my annual bronchitis and a Z-Pack it works great. I’ll only go to the ER if I fear for my life. Even the appendicitis pain was manageable enough to wait until the urgent care opened in the morning.
RE: 3. You are going to wait.
Everything Kozak writes rings true to me based on my years as an ER doc.
Whenever I accompany my children into the ER (e.g., the time my son needed his badly broken nose reduced and I did not want him remembering me in the role of Nose Straightener), I always emphasize that if there’s any wait you want to be at the end of the line. Surrounded by staff, being whisked ahead of a crowded ER waiting list is what we call a poor prognostic indicator.
::sniffle::
You don’t get to be favorite without writing about losing your nose in India.
Are you willing to do what it takes?
I love it when I am watching a movie with an alien possession or a demon or zombie attack. Invariably, someone with say “we gotta get him to a hospital!”. Is that an ER kind of thing? How would you diagnose and treat an alien possession, etc?
As a radiologist, I love a good foreign body case. I always call the doc to find out the alleged story. I have seen the cucumber in the rectum on CT. And weird foreign body ingestions from prisons and psych places, like ballpoint pens, batteries, paperclips, etc.
My sister is a nurse in the critical care unit of a level one trauma center in Florida. I love hearing her talk about work and the interesting cases she gets. She prefers her unit to the ER she says because she only has to deal with the really sick people. Sometimes heartbreaking, occasionally funny, always interesting stories from her.
Yep.
A doctor this backed up who’s willing to do e-mail or phone consults can work, at least if the sudden problem is related to one he’s already seeing you for.
Yep.
Might I add that not all hospitals are equal. If you have a trauma case, try to go to a trauma ranked hospital in your area.
We learned the hard way when my husband lost part of his finger in an accident at work. Not the right type of surgeons on site (or on-call for that matter).
If I had a car that day, I would have packed him up and driven to another hospital. We went from “we will be able to save the whole finger” to eight hours later telling us that “you’ll just have to get a little closer to wag your finger at someone from now on.”
Yeah, I had a finger that I wanted to wag at that nurse.
My favorite was a kid who had the game “Operation”, got bored with doing fake surgery on the little doll with the light-up nose, and so invented a new game: sticking the little plastic organs up her nose, then blowing real hard to see how far her nose could shoot them. She ended up with a miniature plastic spleen stuck up there.
How about #8 – Check online for ER wait times before dropping by.
I assume y’all put your ER wait times online in the Great Green South…
I would occasionally get called down on psych cases…which were relatively straight forward, other than the psychotic woman who came at me threatening to ‘cut my baby out because I had stolen it from her”–on the other hand, no ER duty for me the rest of my pregnancy ; )
but the ones with objects up their backsides always made everyone laugh…not so much the “initial crime” but the “cover up” tale, which was definitely worse.
July 4th – gentleman had a statue of liberty statuette in a place where the above cited cucumbers might go. He had woven an elaborate tale of 4th of July celebrations and showers. Of course, he couldn’t tell it the same way twice. He was generally referred to as our most patriotic patient.
I may be the victim of a micro aggression here because I’m pretty sure my concrete post was well over 100 comments before it got promoted to the main feed. (Sniff) I am just unsure who to resent, the editors or Kozak for writing much better than me! :)
Don’t complain. Last time I got a post promoted to Main Feed it was a book review in which a chapter had been written by Rob Long. First time one of my reviews hit the main feed, and I think maybe the second time anything written by me made the main feed ever.
So, if you want your posts promoted to the main feed, make sure you prominently mention Rob Long.
Seawriter
Well Seawriter, for what it’s worth most of the books you review end up in my Goodreads “to read” index. I really appreciate you sharing them here.
When I fell off a roof last year, I made sure that I didn’t start making up creative answers to the ‘name and date of birth’ questions the nurses kept asking. They flew me up to Sioux Falls anyway for observation. The flight crew bonked my head when they loaded me into the plane. They then bonked it again when they unloaded me.
Annefy @#41: Honestly, I now believe in reincarnation. You are EB. :)
That’s why it’s critical you keep it in your wallet or phone. Most people have one of those with them all the time.
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