The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Sunday, June 03, 2007

What To Expect From Your ER Doc

People bitch about doctors a lot. Not necessarily to me, but in my presence. I don't mind, most of the time. Many times these people have legitimate beefs. But more often than not, I think that the problem lies in poor communication. Doctors often assume a level of medical knowledge in the general public that simply isn't there. And patients, for one reason or another, don't ask questions. When this is the situation, the patient will leave the encounter upset, and the doctor will have no idea that the patient wasn't satisfied with the result.

A patient's expectations should be different depending on the physician and the circumstances. This view may reflect the fact that I am currently awkwardly straddling my roles as family physician and emergency physician, have have yet to become truly comfortable with either one. But I find that whereas a certain degree of bedside matter and handholding should be expected of a family physician, to expect the same from an emergency room physician is misguided. Not to say that ER docs have free reign to be assholes, but their role is different.

So here's a quick primer on what you should expect from your friendly emergency room physician:

1. To be appropriately triaged.

The first thing that happens to you in the emergency room is that your complaint is ranked on a scale of how likely it is to be life-threatening. This system may not seem fair, but it usually works very well. So if you're grumbling because the young girl in the corner with seemingly minor stomach pain is seen before you in spite of the fact that you're puking from your horrendous migraine, remember that you don't know the whole story. If there is a chance she's pregnant, the possibility that her pain is resulting from an ectopic pregnancy definitely outranks your migraine (which, although obviously unpleasant, isn't likely to kill you). See how this works?

2. To have life-threatening conditions ruled out.

Let's say you're the one with the belly pain. If you're not pregnant, not bleeding, have no signs of an acute (aka surgical) abdomen and aren't dehydrated, you'll likely be discharged. I can understand that people want answers, but sometimes we're not going to be able to give them. It might be gastro. It might be food poisoning. It might be muscular. It might be very early appendicitis that just hasn't 'declared' itself yet. If it's the latter, that will become clear soon enough. It it's any of the former, it won't kill you. So we're sorry that we can't tell you exactly why you woke up with belly pain and had some diarrhea, but we don't have all the answers.

3. To do what is medically indicated for your condition.

Not everyone walking into the ER warrants extensive investigation. The job of the EMERGENCY room is to rule out EMERGENCIES. See how this works? So once it has been established that your presenting complaint is unlikely to cause you significant morbidity or mortality any time soon, you may find yourself punted in the general direction of your primary care provider for further care.

4. To see the doctor (although the length of time you waited is not reflected in the amount of actual time you spend with him/her).

This may come as a shock to those of you who have waited 3-4 hours in the ER only to get less than 30 seconds of face time with the physician who breezes by to tell you that your wrist is not broken (and, if you're lucky, perhaps a script for some Tylenol #3's). But if you're looking for a longer discussion about how long you can expect to be in pain, what kind of limitations you should put on your activity, how you should ice it, what kind of exercises you can start doing and when to regain strength... well, you're best to see your family doc.

This may seem unnecessarily harsh, but it's reality. Not only is the ER doc usually the ONLY doctor in the emergency room (and therefore balancing the multiple needs of many patients, most of whom are far sicker than you) but it's often hard to muster up convincing sympathy for someones infected ingrown toenail when you've got people actively trying to die in 3 different resuscitation rooms. This is not usually the place for handholding and sympathy.

5. To be waiting longer if you abuse the nurses.

Wandering back and forth to the nurses station to complain about the wait and threaten the nursing staff will prove to the nurses (and, by proxy, the doctor) that you are well enough to ambulate and complain and therefore not sick enough to warrant immediate attention. So stay where you've been put and wait your turn. Besides, wandering around the emergency department compromises patient confidentiality-- would you want people wandering around overhearing the doctor ask you personal questions? I think not.

6. To be treated respectfully.

Although you might not get stickers and hugs, you should expect to be treated as a human being. That means that your dignity will be preserved as much as possible in an environment like the ED, you will be treated fairly, and you won't feel as though you are being judged for your problem (particularly if it involves mental illness, substance abuse, physical/sexual abuse or sexually transmitted infections). If this is NOT true of your emergency room visit, this warrants an official complaint.

No doubt I'll be adding to this list as time goes on. But for now, please excuse the disjointed blogging... there has been a lot going on in my real life, which hasn't left much time for blog updates. More to come soon.


Anonymous tlc said...

Great post!!

I wish I could make copies of today's blog entry and hand them out in the waiting room.

Sometimes I think it's such a shame that it's primarily health professionals who follow your blog because I think the general public would benefit from a glimpse into "our world".

If only patients knew the "method to our madness" when we prioritize someone else's needs about theirs.

Trina RN

5:53 PM

Anonymous Anonymous said...

Well said!

I'm a paramedic and on more than one occasion I've had patients walk out of the ER and call 911 because they assume that if they show up on my stretcher they'll been seen faster...needless to say we put them in a wheelchair and they end up back in the waiting room back at the beginning.

It's frusterating to see that's for sure!

8:07 PM

Blogger doctor T said...

I've been in the ER a number of times (but never for a life-threatening condition) and I'm always surprised by how many people are rude, impatient and just plain nasty while they wait. The most recent time I was in the ER was for a cat bite, and while I thought it was petty and expected to wait a while, I also knew I had to go to the ER (advised by Nurse line and it was Saturday at 2 am, so not much choice) -- so I brought a book, an ice pack for my hand and hunkered down for a long wait. One girl bitched and moaned because she had thrown up twice and was pissed when a young guy who who was hit by a car while walking was seen first. Um, perspective much? Yeesh.

Also, a good triage nurse is worth her weight in gold. Seriously.

8:42 PM

Blogger Xavier Emmanuelle said...

Great post! I can never understand people who blatantly misuse ER services. I'm sorry, but a cold you've had for 2 weeks is really not an emergency.

About assuming that patients have a greater medical knowledge though: perhaps in the ER this is true, but when talking to fam docs and specialists I've always been spoken to as if I'm 5 (and it's rather hard to convince them that they don't need to explain what anemia (or the femur, or rubella, etc.) is without sounding rude). How do you do that anyways? (So far the only thing that worked was slipping the surgery I had scrubbed in on that morning into the first 30 seconds of the conversation, but I really want to avoid having to do that).

10:20 PM

Blogger scalpel said...

I disagree that patients should not expect their ER doc to explain their condition, recommended restrictions, recommended homecare, and what they can maybe expect to happen.

Breezing in and saying "your wrist is not broken" is not sufficient in my book.

10:25 AM

Anonymous MLO said...

Um... Since I suffer from on e of the most underdiagnosed life-threatening illness in the ER, I have very little faith in ER Docs as a whole.

What disease? Anaphylaxis. But of course, I don't swell or get a rash so it can't be anaphylaxis. No, I just have my blood pressure drop and pass out, and have even been known to "forget to breathe." Now, mind you, blood pressure continually dropping, no veins to be found (itty bitty veins to begin with), and skin going from white to ruddy, throwing up, etc. MIL who is a nurse (but a relative) said I looked like I was in diabetic shock. But, according to the ER doc that is not an allergic reaction.

I had 3 other doctors review the records - only one was an allergist - and they agreed that the ER doc was wrong.

I did a literature review soon thereafter and found that in every country there is a similar problem of people actually dying because proper treatment was withheld out of fear of side effects from epinephrine or not recognizing the reaction for what it was.

Also, when you are wearing a medic alert necklace that the people read and then choose to ignore, well, it makes your faith in triage competency rather shaky. Now, mind you, I was a bit out of it, but I could swear I was babbling to give me epinephrine (I wasn't really conscious for most of this) or to call my allergist. It was during regular business hours - or just into the dinner hour. I know he answers calls because he has yelled at ER docs in the past for patients. (Almost every allergist has, btw.)

Oh, if I don't know what a something means, I'll ask.

I realize that triage is hard. But, I find it inexcusable that someone presents wearing a med alert with a known history and treatment is withheld when the patient can't help herself. (Relying on family, even medical professionals, is never a good idea. Judgment gets clouded.)

Ok, sorry to rant, but the statement about the "cold" also irked me. Without knowing if the person has asthma and has suddenly had a turn for the worse and is trying to prevent a life-threatening incident, I cannot judge.

The full story of this REAL incident is on my blog somewhere.



12:24 PM

Anonymous Simbo said...

Maybe a little patient teaching? Is it possible to have big poster with "Red: Likely to die soon. Yellow: Will die soon, but not as soon as Red. Green: Not going to die, but have a bit of pain. White: Shut-up and go home" gussied up in administration speak?

3:13 PM

Blogger Joy said...

Would it be too much to ask for someone to explain the wait time? I HATE going to the ED. I go to the ED with my kids when the family doc says to go -- it's a last resort and I'm always prepared to wait. (I also have learned that if I pack an overnight bag on the assumption that we'll get admitted, we usually get to go home -- it's my little insurance policy!).

But while we're waiting, it really helps to know that they just got a trauma in, or that CT is backed up, or the lab just had a machine break down, or whatever. Then we know we weren't forgotten. When you DO use the ED legitimately, you don't want to think someone forgot about you!

6:26 PM

Blogger Midwife with a Knife said...

I would agree with most of this. However, some sort of reasonable attempt to take a history and do a physical exam should be undertaken. You know, just in case the condition ends up being something that would be exacerbated by the treatment.

For example.... arthritis is a fairly common extraintestinal manifestation of inflammatory bowel disease. I went to the ED a few weeks ago because I thought there was something really wrong with my foot (swollen, hot, mtp). I got an x-ray and a "your foot isn't broken" speech. No history, no physical exam. It didn't occur to me that it was connected to my health problems, but had the ED doc simply asked if I had been feeling ill in any other way, I would have commented on the 3 weeks of bloody diarrhea, weight loss, fevers, and abdominal pain (which I'd been ascribing to a food borne infection). The thing is, the treatment for gout (which the ED doc diagnosed me with), NSAIDS, actually tends to worsen ulcerative colitis (which is what I actually had).

I don't necesarily expect a diagnosis in the ED, but as a physician, I don't think it's too much to expect some sort of history and physical that at least has the potential of leading to a differential. Instead of, "You have gout, get out of my ED".

8:05 PM

Anonymous Anonymous said...

mlo - your comments are very offensive. obviously, you have a rare condition that many MDs would not even be aware of, unless told by a specialist. you also have a very negative view of the ER. you have no idea of what our jobs are like there. not all ER docs are stupid, as you seem to imply. most of us are just trying to help people the best we can and we are only human like the rest of you. no one wants to wilfully withhold treatment from a patient or bring harm to that patient. unless you are a psychopath.

i think the comments about the wait time and being informed of when traumas, heart attacks, etc. come in, are absolutely ridiculous. i'm sorry, but if i am dealing with a real trauma or some other emergency, neither i, nor the nurses, have any time to run out and let the walking wounded know that we might be a while. no, we are starting life saving treatment - IVs, intubations, chest tubes, administering medications... just think if that was your family member (child, parent, husband, wife) in that resuscitation bay. would you want your ER doc and nurses to be outside in the waiting room, holding everyone's hand and telling them it might be a while??? or would you prefer to have a life saved? seriously.

1:20 PM

Anonymous Anonymous said...

I think if you are going to the ER then you need to adjust your expectations. I have a chronic medical condition that causes severe dehydration and low potassium levels that always seems to happen on a weekend, holiday or in the middle of the night which means that the ER is the place I am heading. I expect to wait. I expect it to take 6-10 hours depending on what's going on and I know that I will see drunks on stretchers and lots of people in the waiting room complaining about the wait.

Since I go to a large teaching hospital I always have to give a history to about 3 people before I see the attending. Most times I will ask if my primary is in service and if he is I will ask that they call him.

I don't expect the nurses to tell me what's going on, how long I will have to wait or hold my hand. I bring my husband for that and I bring a book, my mp3 player and cards to pass the time.

If I am sick enough to be there then I am sick enough to wait.


7:15 PM

Anonymous MLO said...

To Anonymous: The truth is offensive? I'm stating a fact that is borne out in the medical literature, not just my own anecdote. That was used as an example. AAAI is actively involved in trying to educate ER physicians. So are several international groups.

The single most disturbing fact of the incident was that I was wearing a Medical Alert which told them I was subject to anaphylaxis. BTW: Sudden loss of blood pressure is the 3rd symptom listed in the Physician's Desk Reference - so, not really all that rare for the disease - and was still told by the attending that passing out was not a sign of allergy (BP 50/70, duh - barely conscious). And, anaphylaxis or anaphylactoid reactions do occur on a regular basis in most hospitals according to a few radiologists and allergists I've met.

In my mind, it is inexcusable to ignore a Medic Alert all the way down the line. Let me make this very clear - I was not truly conscious through most of this, but I know that they actively ignored the Medic Alert through my MIL (a nurse). It wasn't until she intervened that I got proper treatment. I also know that this is all too common. My knowledge comes from both anecdotal evidence and doing medical literature surveys.

If the ER is going to ignore the Medic Alert what are they for? Perhaps I am wrong in thinking they are to alert emergency medical personnel of existing conditions that will influence proper diagnosis and treatment?

I do not dismiss that doctors are not perfect - of course, they are human! It was the active dismissal and arrogance that made me the most angry. Active refusal of proper treatment by the attending personnel is never acceptable. We are not talking about trying to get painkillers or other substances of that type. I, of all people, know doctors make mistakes. Anyone with food and drug allergies learns that very, very fast.

Even if I offended you, perhaps your having this knowledge now might save someone else. And, to me, that is much, much more important than whether a true story is offensive. If you doubt my veracity, please check out the international literature regarding the danger to allergic and asthmatic individuals in this type of situation.

Yep, I'm passionate about this because severe allergy seems to be on the rise in the modern world - and you won't always see visible swelling. I'm just as passionate about heart disease being dismissed as heartburn in women who go to the ER - as happened to my grandmother. But it has a better PR program than this does.

Take offense if you like, but, please, educate yourself as well as this condition is becoming more and more prevalent.



1:24 PM

Anonymous Anonymous said...

My complaint is similar to MLO- if a patient says they are allergic to something, believe them. I'm allergic to lidocaine, clearly indicated on the printed list of medication & allergy sheet I provided and discussed with the doctor. I had a new onset severe headache and needed to have a spinal tap. Was assured again both before and during by the doctor the numbing medication was not lidocaine and was perfectly safe for me. You want to know what it was? Lidocaine with benedryl added- my friend happened to be walking back from the restroom and overheard the doctor instructing the nurse to draw it up that way; unfortunately my friend wasn't aware it was for me & I was allergic to lidocaine (she had been in the restroom when I had discussed it with the doctor). This was confirmed later when the chart was reviewed.

I made it through the spinal tap without flinching a bit, but the lidocaine caused its normal localized swelling and pain. I left the ER with both the headache I came in with and the feeling someone was shoving an hot stove poker into my lower spine & twisting it for over 10 days, which in the end resulted in my being hospitalized a few days later. The ironic thing is the doctor had debated sending to radiology for the spinal tap and I was only a few steps away from radiology, where they are very use to dealing with my lidocaine allergy on a regular basis when they replace my PEG/J feeding tube.

I can understand MLO not feeling she can trust ER doctors, I know with all my allergies, I avoid ERs if at all possible after that experience.

6:43 PM

Anonymous Anonymous said...

My comment never posted, but I do want to point out that by the time you (the doctor) see the patient many times we are frustrated from lack of response or understanding from the nurses. Especially if our "condition" is unusual.

I've also found that ER doctors are not open to taking the time to listen. If my doctor says I need to be in the ER, of course I'll be frustrated and angry when the nurses repeatedly tell me I'm wasting your time. I know your time is valuable, as is mine. I know that you are busy dealing with life and death situations and I'm willing to wait. But I'm not willing to be ignored, or to listen to the nurse behind the plastiglass tell her companions that I'm a pain because of my or my childs health needs. And I'm not willing to be patiently dismissed when I know you haven't listened to me. As MLO pointed out, sometimes patients have a unique situation, where we need your medical expertise for an unusual condition. You may actually need to learn something, from a patient. You can't do that when you generalize everyone.

12:06 PM

Blogger rookie bebe said...

To joy and mlo. I'm an emt. I believe it was said in this blog or comment section that not everyone who comes in by ambulance gets seen faster.

We can't help the unexpected car accident or man who just decided to go into cardiac arrest when you think you need to go to the ER "when your cold of two weeks" starts to bother you.

We see our fill of trash. The drunk that the police can't take in and we have to. The frequent flyers that call every single day, sometimes twice a day (no joke), they're wasting everyone's time and making you wait longer.

Do you want to say to the girl who wrecked and possibly have to have surgery on her pelvis that she'll have to wait so the doc can see you first and give you nothing more than ibuprofen for your pain that you could have just taken some aspirin for in the first place?

10:49 AM

Blogger rookie bebe said...

to midwife with a knife. Did you think to tell them your history???

Guess what? Nurses, Doctors, everyone working in the ER, medics, CANNOT read minds.

I know. It comes as a great big shock to you, but we are not mind readers. We don't have super powers. We can only treat what we see and take tests on. But those tests aren't going to tell your doctor your medical history.

You will have to telll them yourself.

10:53 AM

Anonymous MLO said...

rookie bebe,

Um... I think the thing you are missing was that I was barely conscious and had come in via ambulance where the EMTs, doctors, etc. all ignored the Medic Alert. Again, I had passed out and was barely conscious. I could not help myself and the Medic Alert was ignored.

According to my allergist, the likely reason I am alive is because I had antihistamine in my system. I was in danger of dying. This is not an exagerration. This is what concerns me. Ignoring a barely conscious patient with falling blood pressure with a known history of anaphylaxis wearing a Medic Alert.

People die due to delayed or wrong treatment of anaphylaxis.



10:01 PM

Anonymous Anonymous said...

I can definitely relate to MLO in the fact that I too have been in the ER with severe dystonic/allergic reaction to meds (two weeks ago was 5th time!). Before I became paralyzed, couldn't speak for hours, and was convulsing, I handed them my medical file with ALL info on how to treat me, what I was allergic to, all of my medical problems, etc. and they stood there arguing about how to treat me!! My husband kept asking to transport me somewhere else with no response!! He finally got the doc on the phone who put the ER straight (ER continuously refuses to call my PCP because "they know what they are doing, they are afterall doctors"). I can only speak for myself - I have had horrible results with 2 specific hospitals in my area on too many occasions. They DON'T care what you have to say about your own care.

Furthermore, they kept me in the ER for 2 days for heart observation, gave me meds I was ALLERGIC to again and I pushed the call button for 2 hours w/ no response. Had to call my husband to bring me my meds from home to stop the allergic reaction!!!!! Please people, listen to your patients. I know some are hypochondriacs, crazy, pain in the you know what, but most of us know our own bodies and just want to be taken care of with the utmost respect and professionalism.

I KNOW working with the public is very difficult, but we are talking life and death. Look at the woman who died in LA ER just recently while staff just watched saying she would get her turn.

4:28 AM

Blogger Violets said...

I don't think anyone is saying that there's trouble with prioritizing. But there is a trouble, with ERs in general, with *listening* to patients. Not just the doctors...something in the whole system is failing those who have unique needs.

Maybe since we're statistically insignificant, we don't count. But it doesn't make us need the ER any less when it really does matter. It only makes us that much more hesitant to utilize your services in a timely manner when the on-call nurse says "You need to go to the Emergency Room." I hope if you can take a minute to step back and read some of the posts with a clean slate, you'll see that some patients are as frustrated as the ER staff seems to be, and for just as good a reason.

1:51 PM

Anonymous Anonymous said...

Fascinating! Reading the comments above, I have to say that Couz's point is proven all over again:

"I think that the problem lies in poor communication"


9:00 AM

Blogger Alison said...

Thanks, Scalpel. That's a point I would have wanted to make, but I'm only a patient, and I try to be good, and to accept bad treatment submissively.

7:37 PM

Anonymous Anonymous said...

I was hit from behind at a stop sign the guy who hit me ask me if I was alright I said no. I was confused and told to get back on the car before someone else hits me. He tells me here's my phone call me when you get home. I never experience a accident being hit. Any how I get home having problems with my leg and back. My friend calls me I tell her she takes me to the Emergency room. I was scene by a Male nurse he ask me questions about my neck and i told it was my back and legs. I get to see a female Dr. I told what happen and she ask me if I had any medical history of back issues. I said no but can you give me and mri or x-ray I having pain and pins and needles down my leg. She tells me it's because of the hit gives me a needle some sort of cocktail for the muscle spams she tells me. She says if it continues come back in 10 days.I go home Still getting those pains and numbness I go see another Dr. Mri/ spine and joint needless to say I had major surgery I had bone on top of bone. Now in her recording she puts history of back issues bugling disk, L5 which I never said. Why would she give me and mri or xray to that matter if I had said that. Which I didn't. My case is against a the guy who hit me. Not her Why would her irresponsibleness effect my case. I had a person in the room me who is my wittiness. I understands Dr.s get busy but the defendant is saying this is what written. My lawyer say not to go to the hospital to get the report. Why can't I. I am not lying. First of all I did see a nurse before her and the same questions were ask. I don't understand how we prioritize something that is not correct???

12:34 PM

Anonymous Anonymous said...

I just though of something The male nurse I seen first ask me the same questions the doctor did. would both recording be on record? And there was very much a misunderstanding with communication gap with me and the Dr. I know it's not easy for for Nurses and Dr.s but her writing that doesn't make sense. When I didn't say I ever had prior back issues and there is no record any where I ever had or ever been treated for back related issues.

12:52 PM


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