Emergency Room - Expectations

Hi everyone I wanted to impart some information regarding your eventual visit to your local emergency department (ED).

There is a fundamental difference when you visit an ED and when you go to your clinic, internist, pediatrician, family doc etc. The way ED docs think and their priorities are not necessarily that of your regular doctor. In the world of emergency medicine, we do NOT necessarily need to figure out what's going on with you... interesting right? The job of the emergency physician is to identify and manage immediate and near-term life or limb threats. I tell my juniors and students. I don't have to be right, I just can't be wrong.

Let me explain further. If you come in with chest pain it's my job to rule our a life threating cause based on history, physical, diagnostics and gestalt. After I've ruled out the heart attack, dissection, pneumothorax, pneumonia etc and there are no other concerning features that require an acute intervention (cardiac catheterization, stress test, etc) I'm going to send you home.

But Mike, what about my chest pain? I'm sorry I MAY not be able to figure that out for you in our short visit but I've made sure its not a life threat and you don't need additional inpatient evaluation. You may be in pain and I'll give you something for that but this is when you need to follow up with your doctor who knows you, your history and can follow you and the interventions that are prescribed.

When you go to the ED you may get a different doc every time. There is no (rarely) continuity of care.

So when you come to the ED understand the doc who is seeing you is 1. trying to make the actual diagnosis 2. If they can't they are ruling out the life threats 3. May admit you for further workup/management or send you home without a definitive answer.

The specialty of emergency medicine I feel can be characterized as "Jack of all trades and master of resuscitation" We do a lot of everything and are best at interventing on acute life threats. Those are our priority. Which leads me to how you get seen.

Triage: This is the process of sorting all comers to the ed based on vitals, history, and short nurse physical (sometimes a triage doc) into how acutely ill they are and how quickly they need to be seen. In general, the process works pretty well, but there can certainly be a backlog due to volume in the waiting room or the ED due to the acuity of active patients or those boarding in the ED waiting for a bed upstairs.

It does not matter if you come by ambulance. If you are not that sick you will go to triage in the waiting room.

What I mean by this is if you come into the waiting room with chest pain the nurse will see you and an EKG will likely be done. This will be brought back to the doc who can read it in a few seconds. If it's concerning along with the report of your symptoms, brief history you'll be brought to the dept sooner. If its normal or unchanged we have some time and you are back in the que for regular triage.

This is why you may see people in the waiting room who got there after you get brought back to be seen first. This is based on your acuity level. If you are not having a life threat you will wait until all those of higher acuity get seen before you.

I know. This leads to long waiting times, but good news you likely aren't THAT sick. At least when it comes to having an immediately intervenable life threat.

EDs are overcrowded because we are open 24/7 and have patients who really do not need our services clogging up the system. We are working on throughput and seeing you as quickly and safely as possible.

This is why your ED doc is moving so fast. It may seem like we aren't listening to you but we are. We ask pointed questions because it helps us determine your workup and disposition. I have 11- 18 beds with hallway beds active all at once all who expect immediate "emergency" care. We have to go fast, sorry if it seems we aren't listening but we are. We just can;t let you talk for 10 minutes without getting to the meat of the problem.

The ED experience.

1. Chief complaint or concern - tell me what's concerning you. They may be the same thing but often they are not and sometimes what you are worried about, I'm not. On the flip side some things you are not worried about I am.

2. How long has this been bothering you, getting better or worse, what were you doing when it started, what does it feel like (characterize it, "pain" does not help me {sharp, dull, achy, burny, stabby, electric}), is it going anywhere, what makes it better, what makes it worse, what have you tried for it, have you been seen for this before, and what's different about it today that landed you in the EMERGENCY ROOM. I'm going to ask you all these questions if it's pain you came to see me for.

The ED doc will ask you something called a review of systems. Rapid fire yes/no signs that MAY be associated with your chief complaint.

Example: Back pain.... its sharp, midline and happened after a fall. I ask you if you have any numbness in your groin or urinary difficulties and you tell me yes... well those go together and I'm going to work you up differently than if it seems more musculoskeletal

1. Change into the gown. I know its cold. We will get you a blanket. I cannot do a good physical when you've got your jeans jacket and everything else on. Change into the gown so I can properly examine you.

2. One major and one minor. We are here to rule out life threats. We will note all of your complaints because they may be interconnected but I cannot workup every complaint you have in your ed visit. In general most of us have the one major complaint and one minor complaint we will attempt to address for you. Your burning feet from diabetic neuropathy you've had for 5 years... No. Your chest pain with shortness of breath - YES. Please tell us about your complaints so we can document them and determine if they are related to your main complaint but do not expect us to deal with every ache and pain when you've got something else that's more concerning going on.

3. Be patient with us and our staff. We are going as fast as we can to get you out of the department after addressing your complaints. If we decide to order labs or imaging they can take HOURS to come back. Blood tests take an hour in general. An ultrasound 2 hours to get done, a CT scan with oral prep... 3 hours. You may be spending time with us for a while. If you expect rapid in and out care that requires advanced imaging or blood work... you will wait... and wait and wait. The ED is not the place to come if you have an appointment in the next hour or two. You came to be seen for an "EMERGENCY" and it's my job to rule out life threats because society says I'm not allowed to miss.

4. You may not have a private room and you may be seen in the hallway. Congrats you get to see real medicine. You do not need a private room for your ankle sprain. It's nice to have one but when the waiting room has 20 people in it you will get seen in the hallway. It's not as private we know, but we can do a pretty good evaluation for a lot of simpler complaints without taking up a whole room. (Think dental pain, sprained ankle, clavicle injury, most back pains, certain abscesses, painful urine symptoms)

5. Don't get upset with us after we see you for 5 minutes and we discharge you. We are sorry you waited 4 hours to be seen by an EMERGENCY doc/PA. We've determined your complaint to be manageable from the outpatient primary care perspective please follow up with them. There is no immediate life or limb threat, please see YOUR doctor. If you do not have one here is a list of the clinics in the immediate area.

6. We DO NOT refill chronic pain/anxiety meds. If its schedule 2, we will not refill them. Please see your primary or specialist doc for chronic pain or anxiety meds. But..but..but can I just have a few to hold me over.... in general, no. I'll treat you with a Percocet in the ED... rarely, but I will not send you home with chronic pain meds. The main reason is that these meds are regulated and should be prescribed by one provider. They are the one managing this condition and they need to know if things aren't working out for you. Too many cooks spoil the broth and the same is with pain meds.

7. If you have to pee ask for a urine cup. I don't know if I need it before talking to you but if you need to pee just ask for one and give us a sample. I'd rather have it and not need it than have to wait an hour and slow down your workup.

In general, if you are a woman of childbearing age I'll likely need it for a pregnancy test.

Whew... I guess thats a good start with a lot of information.

Take home message. Please be patient with us. We will do our best to address your concerns. You will be seen, but it may take a while.

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