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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
let start by not automatically taking the good Dr at his word that we floor nurses are part of the problem. It is NOT a fact. It is his opinion that we are slowing the process up willfully.
I’ll second Son of Spengler here- I don’t think any of the civilians on this thread read Kozak’s piece as an indictment of nurses. In fact, I was busy typing up my list of medications (scotch, water,) when I learned there is a whole Sharks Jets drama going on behind the scenes.
One reason for the delays in getting patients to the floors is a classic example of economics. The floors have no incentive to take the patient. It’s more work, and human nature being what it is, without some reward for that, there’s no motivation to do it. I’m not calling nurses lazy, I’m pointing out they are human. The exact same dynamic works with doctors. We make terrible employees. The guys working for themselves are more driven to see patients because it means they make more.
Now the one solution I have seen actually work in this situation was at a Kaiser Hospital in Sacramento. We were having long delays getting the patients to the floor, exacerbating our department overcrowding. So, the experiment was once the admission decision was made, to charge all costs to the unit that was getting the patient. Nursing time, meds, supplies, everything that patient needed was charged to the receiving unit. When the unit managers realized their funds were going to go to pay the ER, they made damn sure procedures were in place to get the patients to the floor as quickly as possible. In a few cases we had ICU nurses swoop down and take patients to the unit to avoid their getting their TPA in the ER. Suddenly having patients in the unit hallways was not problem. ” Don’t hang that antibiotic, bring the patient up and we will start it”. Our ability to get patients moved improved dramatically.
At other hospitals, when we would bang our heads over the exact same problem, with endless committees or even worse,the dreaded task force, all kinds of technical solutions were discussed. I would mention this experience and how well it worked and I would get looked at, as if I had grown a second head. Use money as an incentive to try and solve the problem? How absurd.
What if I cut off my own arm with a bowie knife on a dare?
(I’m just establishing parameters).
Tom, if you ever want to visit Utah, come hiking with Rudert, me, and Mr R. I guarantee you we’ll go somewhere where it’s easy to have an accident…
I was a floor nurse before I moved to the ED, so I’ve seen both sides. The biggest cause of delays in giving report is not “The nurse is on break”–I’ve never been told that. Busy with another patient is a lot more common, but that’s not the nurse’s fault. The Charge Nurse and House Supervisor should not assign patients to nurses who are already overloaded, but sometimes that cannot be avoided. More likely is “The nurse for that room is being called in but is not here yet.”
Kozak: If the hospital is making you give report to the floor nurses, I have a suggestion that would make that process a little more efficient.
JamesAtkins: In eight years as an RN, I’ve never had a doctor ask me to bring them coffee. I have had several doctors buy coffee for me (tea, actually; I can’t drink coffee) .
Oh, I’m already good on hiking accidents.
But I’ve not spent nearly enough time in Utah, and I think we should very much fix that.
I don’t call report. But I sit right next to the nurses who do so I can hear their side of the conversation, and we also discuss why the patients haven’t gone to the floor.
I spent 4 years as an ER orderly “paying my dues”. A large part of my job was transporting the patients to the floor. I know exactly what goes on.
Jason, pull in the long knives, son. I have been a hospital nurse for 27 years. I’ve worked nearly everywhere (started out in a 2 floor hospital. You did it all.) Kozak isn’t far off. Back in the day I worked 3-11 shifts, it was a given that if I followed a certain nurse, I’d have at least 2-3 discharges at the start of my shift. The patients had discharge orders from that morning, but if the nurse sent them home before her shift ended guess what that meant—–she’d have more admissions! Now that’s not good for the patient that is ready to go home, the patient in the ED waiting for a bed, or in my case (I worked on a post-surgical unit) not good for the recovery patient. This behavior also backs up the OR because if the recovery is full, there is nowhere for the fresh post-op patient to go. I have beat my head against a wall for years about this, but to no avail. I’m not saying this is the only reason for backups, but don’t act like it doesn’t happen. I didnt read Kozak’s comment as a that negative. I just saw it as fact. If administration would get out of their offices and stupid meetings and actually walk the floor for more than 5 minutes, they might actually see where the problem is.
Re ER wait times:
What came in just ahead of you: Many years ago (I was 8 years old) I had a bicycle accident that nearly put my eye out (at the time we feared I had put it out), but had to wait because the ER staff was trying to hold together two youths who had been hit by a train. Reasonable triage, though I wasn’t particularly understanding at the time.
At the other end of the spectrum: I have never seen a staff responding as quickly as one did when a prominent heart surgeon personally wheeled my father into the ER from the surgeon’s office across the parking lot. My father had gone to the surgeon to to check on an odd feeling my father had in his post-surgery incision area, which turned out to be an infection of type A streptococcus with necrotizing fasciitis (the “flesh eating” infection). The ER staff apparently decided that if the the heart surgeon determined that if my father was in enough need for the surgeon to personally wheel him into the ER, my father really did need immediate attention.
Necrotizing Fasciitis is a real emergency. There’s a high mortality rate and requires immediate antibiotics, frequently hyperbaric oxygen, and almost always surgery. I’ve only seen a few cases in my career and it’s terrifying in it’s aggressiveness, and unfortunately can be tough to diagnose early. That’s definitely an express pass into the ER.
As long as no one drops a junior mint into you during surgery……
Great article – I am passing on to friends.
Speaking to the above and all, this was just on news:
http://www.usatoday.com/story/news/nation/2015/06/25/beach-water-bacteria/29270185/
Thank you for sharing this story, Claire. It is quite fascinating (particularly in combination with your City Journal piece). Have you read James Bartholomew’s latest book “The Welfare of Nations” (pun obviously intended)? It is an excellent follow-up to his earlier “The Welfare State we’re in”, which had a jolly good notice from Milton Friedman. The chapter on health care is written as a travelogue – as he goes from country to country seeking the best health care in the world. His conclusion is that there is no one-best system, though he passes through the French, Swiss and Singaporean ones in his search.
[There’s a whole post to be written and discussion to be had on how Obamacare tried to emulate the excellent Swiss model, and why that failed]