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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
MBF
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.
We refer to those patients as “frequent flyers”.
Umm, most of the time. The appendix can be located in the Left side (situs inversus). But we usually miss that too. Or it can point in funny directions. Particularly in pregnant women it can point up to the R upper quadrant. Or be drapped across the bladder and cause urinary symptoms. Missed Appy is one of those things we lose sleep over.
Yeah it’s the new normal, and it sucks. Continuity of care is a huge positive in medicine. I can’t stress it enough, and it’s the area where we in the ER are the worst, because you are almost guaranteed not to see the same doc 2 times in a row. I can’t tell you how badly it affects care when someone goes from doctor to doctor and hospital to hospital. Everything is fragmented and confused, needless tests are ordered and things get missed. If possible find a primary care doctor you like and trust, and use him as your primary resource to care for you and coordinate all your care. I really miss the good old days when I could call a doc and he would know his patient, it was an invaluable resource to me in the ER.
Yeah. I will try to find the picture I have of the Marine who accidentally swallowed his fiance’s engagement ring BEFORE he gave it to her. It’s sitting in his pelvis…
It’s almost as bad as the doctor saying you are an “interesting case”….
About that. I seethe when I see those signs driving in Florida. First off, it’s really dynamic. One minute there’s no wait, the next a critical patient has rolled in and everything in the ER has come to a screeching halt. Second, it’s usually a con. The ad’s say ” a doctor will see you within 20 minutes”. Stick a doc in triage and the condition is met.
The hospital I worked at was having a problem with “left without being seen” catagory patients. These are the patients who register, then get tired of the wait and leave. Because of our crushing volume we were up to 7 or 8 percent, and administration was freaking out, this is now tracked by the Feds and insurance companies and can result in loss of revenue.
So the solution, was to take a doc out of the back and stick him in triage. He would quickly screen and order preliminary tests. Then the patient went back to the waiting room. May have speeded things up a little, in some case slowed things down. We did lose that docs production in the ER. In any case we got our “LWBS” number down to 1-2%. Yea! Except, many were still leaving before completing treatment ( now with lab xrays etc done) but they were “eloped” patients, a category that isn’t tracked (Yet). Lies, damn lies and statistics at it’s finest.
I ran into one of the most socially inept doctors ever on one of those. Working at a Naval Hospital a kid about 8 came in with a FB in his nose. I couldn’t get it, too far back. I called the on call ENT, who was angry to be disturbed at dinner Sunday night. So she yelled at me, basically called me inept and told me she should would get there eventually. I had to placate the family during what turned into a 2 hour wait. When she got there, she proceeded to berate the parents and essentially accused the kid of being “special needs” if you catch my drift, for doing this at his age. I wanted to run and hide. I now had a furious Marine Colonel and even worse, a furious Marine Mom. They told me they weren’t angry with us, but oh, man, I think the ENT (who was a Navy Lt Commander) had a major reality check. She unded up having to take the kid to the OR to remove the FB.
Not that I ever understand the thinking in the hospital administration and insurance companies, but it makes no sense to me that LWBS cases would not be welcomed by everybody. Isn’t that saving money somewhere?
We know the ER resources were being fully utilized since people left because they didn’t want to wait any longer.
Administration feels it’s money walking out the door ( assuming the people leaving are insured, something that wasn’t true for about 40% of our patients). The feds and insurers use the number as “quality indicators” to compare hospitals. Also, in patient satisfaction surveys, that kind of thing will drive your numbers way down, and those are also used in hospital ranking and reimbursement. So it’s a race to keep the number down as far as possible.
Kozak,
Thanks for the info! A few years ago, I took my husband to Mercy San Juan when he started having very rapid heart beats. Turned out his blood pressure was sky high. Everything turned out well, he got great care, but waiting in the general reception area from 11 pm to 5 am allowed me to see a lot of “humanity” walking through the hospital doors — including a young lady trying to fake an illness to get drugs, a family who’s little girl may have ingested some cleaning product and all they could do was wait until the potential danger period had passed, folks with flu and bad colds, and others who looked fine, so made me wonder why the hell they were there.
I only wish they had “urgent care” facilities open during those hours (even if there were fewer of them available than during the day). It might help alleviate some of the more routine issues that come through Emergency Rooms. The one experience I had at such a facility seemed to indicate that the doctors who staff Urgent Care offices are former emergency room doctors who wanted a little less stress in their lives. So sprains, broken legs, gashes, flu, etc. could be taken care of without waiting hours for needed care. They might also act as a quasi triage unit that can assess if emergency room care is definitely in order, and call 911 to take them there. I suppose there could be security issues associated with that, but perhaps the ones that are open after hours could be located close to a fire station or police precinct. Anyway, just a thought.
Oh Claire, that must have been terrifying. I’ve seen some horrendous dog bites. I’m a dog lover but I cringe when I see people let their small kids get in a dogs face, any dog, even their beloved pet. You are lucky the dog gave it back.
The article was fascinating. There is already a pretty sizable “medical tourism” business in India. One of the things we are also seeing is the outsourcing of things like Radiology readings to India. Night time xrays, CT’s etc from the US are sent over the net to India where they get read since the time zone difference shifts it to daytime. These “Nighthawk” services are the first chink in the armor for US medicine in a global marketplace.
Your also dead right about the lack of clarity about costs. I literally have NO idea what the cost of care is. It’s an arcane mix of coding, billing, special rates negotiation that makes it impossible to say what the cost is. In the ER we are forbidden to ask about insurance status before we see a patient. In one way it’s a relief, I treat everyone the same. In another it can be a disaster for a patient who is paying out of pocket, and actually plans to pay their bill.
And in Rob’s words it would really help if more patients had “skin in the game” as to the costs. For many, “my insurance is paying” or no one is paying, so cost is no object.
Part of the reason I’m setting up record sharing for my VA records to be accessible by my PC. Sure, the shoulder is its own problem, but the VA has been more comprehensive in evaluation whole health than my PC. He only checks what I complain about.
WOW, [redacted]. Believe it or not you hotshots down in the ER aren’t the only one that are busy, we floor nurses are working just as hard as you are.
Here’s some actual solutions.
Why your CFO needs to fix ED holding
WOW, Kozak slimes hard working floor nurses, and I get redacted. I guess the Doc’s do walk on water and floor nurses should be grateful that they acknowledge our existence, even if it is to slime us.
I guess this CoC double standard only applies to just words, and not content.
It applies to ad hominem attacks. In other words, arguments of the form “You are X” are forbidden. You’re of course welcome and encouraged to challenge and debate any Ricochet member’s ideas. But not his or her character.
I’m saying Dr Kozac’s attack on floor nurses is ad hominem, not based in fact, and is completely inflammatory. I deal with this kind of behavior almost every day from ER doc’s, and because of my lowly position, I am not allowed to hold those in my hospital accountable. Dr Kozac is not in my hospital, and I feel it is about time to let him know horrible his attitude towards us lowly floor nurses is. It was in his post that he stated “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. You don’t understand how long we floor nurses have had to deal with kind of condescending put downs.
Well, the interesting thing is that it wasn’t. I was blithely calm about it. To the point that Nick and Meetu assumed (as I did) that they’d just shot me up with morphine, because I was laughing it off. My reaction wasn’t appropriate at all until I got back and realized that no, I wasn’t drugged — and that what had happened was in fact quite serious. After that I was depressed for days, but not because of the injury, per se. I was depressed because I’d really trusted that dog. I’d never been betrayed by an animal before. Humans, yes. A dog? Never.
I have a lot of notes about the care I received at that hospital that I couldn’t fit into that piece. Might even be worth a post of their own.
Sounds like you could write an interesting post about the things you wished people understood about floor nurses. I’d like to read that. Bet I’m not the only one.
Kozak’s comment that we on the floor “are too busy, or taking a break” to do our jobs just got on my last nerve. I find his inference to be that our sloth and/or laziness are what is keeping him from doing his job properly made me see red. That comment was uncalled for so completely disrespectful, I just couldn’t sit here and let it go unchallenged.
Have to agree with the “can you fix it with krazy glue”…
Cost me over a grand at the ER for them to just use the equivalent of krazy glue.
There are lots of reasons transfer to the floor gets delayed, among the others I mentioned were closed beds, and cut backs in housekeeping services. But whether you like it or not a big factor is delay is taking report from the floors on accepting patients. Trust me I have personally heard ” the nurse is in report, or on break ” as the delay hundreds of times over the years. Here’s the result of a study in the Journal of Emergency Nursing
Faxed report to the floors for admitted ED patients: A pilot project
And heres some example comments from a nursing site.
http://allnurses.com/emergency-nursing/now-ive-heard-49528.html#comments
The best situations are when a system is put in place and there’s someone to take report and the patient when they are ready to go if the individual floor nurse isn’t ready for whatever reason. But just expecting us to sit on them is not viable solution. We can’t turn off the flow of patients, they keep coming, We can’t say no to the ambulances, or the walk in’s. If the ICU can’t meet their 2-1 rule for staffing, we get to keep the patient in the ER with 1 nurse for every 4-5 patients, no matter how sick they are. For some reason it’s fine to stick patients in the ER hallways, but heaven forbid it happen on the floors. In addition every unseen patient in the waiting room is a potential time bomb.
“Trust me I have personally heard ” the nurse is in report, or on break ” as the delay hundreds of times over the years.”
I’m sorry, from now on I’ll just drop everything, because you know better than I how to do my job. I’m so sorry that I had the nerve to question the great Dr Kozak. Please forgive me, and please continue to teach me how to do my job properly, because in the presence your wisdom and knowledge, I am a mere floor nurse, unable to think and act for myself. Oh, by the way, what time my I use the restroom? Don’t worry, I’ll fetch you coffee first. Would you like cream or sugar with that?
Or, you know, flatter “your favorite editor.”
(“What signifies protesting so against flattery (would he cry)! when a person speaks well of one, it must either be true or false, you know; if true, let us rejoice in his good opinion; if he lies, it is a proof at least that he loves more to please me, than to sit silent when he need say nothing.” — Dr. Johnson.)
Dear Ricochet compatriots, I can tell you nothing infuriates a nurse more than doctor telling them how to do their jobs. We are professionals guided by our own standards of practice. Doctors do not know any more about how we do our jobs than the house keepers do. Doctors seem to think that because taking their medical orders is in our job description, they can tell us how to do our jobs. Dr Kozar is being insulting and condescending if he thinks he knows how to do my job. He posted links to surveys, but does not offer any explanation as to how nursing research is conducted, or how to interpret the results of our research. Until he graduates from nursing school, he needs to stick to medicine, and leave the nursing to the professionals.
This post is getting even more educational now. JamesAtkins, maybe there is a hidden accusation behind Kozak’s words, but they really are just a statement of fact. You are uniquely positioned to explain why he encounters that answer (clearly it is not just because floor nurses can’t be bothered), and what would have to happen to fix it.
The fact that Dr Kozar feels perfectly justified in punishing the patient in para 4 for lying by admitting that he sent a document to the Ca. DMV without any correct diagnosis of syncope is horrible. What his patient did was wrong, she should not have lied to get to the front of the line in the ER. It is clear to me that Dr Kozar is letting all of us know that he thinks, that we should all get a good laugh at how he got back at her for all those good folks waiting to be seen in the ER. I can tell you all as a nurse if I behaved like this, I would rightly be fired, and I would probably lose my license, but hey according to the good Dr Kozar, she deserved it because she lied to him…disgraceful
JA, I’m married to a nurse, so I may have a bias here (for or against, someone else will have to say ;-). I understand your personal pride but I don’t interpret Kozac’s statements as negative toward nurses. People need breaks, and report is essential. What I understand him to be saying is that, for whatever systematic and organizational reasons, there are many times when a shortage of nursing resources is the bottleneck that causes people to wait for a bed. That doesn’t make nurses lazy or nursing leadership dysfunctional. It means there’s a reality that patients need to understand. My interpretation of the situation is that the nursing shortage we’ve been hearing about for a decade is moving from a chronic problem to an acute crisis.