Thursday, July 10, 2014

Defining Emergency

I originally wrote this piece in December, 2010. Recently, I learned that it has been "reborn" in the social media world with over 120k shares from just one resource (thank you, KevinMD). Please feel free to share your thoughts and experiences...

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because "we are overbooked today." And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients' outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

"Whoa," I said, walking up to him, standing between him and the secretary, "what seems to be the problem, sir?"

"We've been waiting two hours to be seen by a doctor!" he exclaimed. "What the hell is going on around here?"

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

"Sir," I asked, "what brought you to our ER today?"
"My daughter's left ear is hurting her."
"For how long?" I asked.
"Two hours," he replied.

Two hours of ear pain? I get it--maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. "We're all trying our best, sir," I added, "but you're going to need to be a little more patient."

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. "Well, then," he spoke, sarcasm dripping from his pathetic words, "try harder." It didn't end there, though. He continued. "This is bullshit waiting two hours to be seen."

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. "And," the nurse added, "I had already explained to him why they were waiting to be seen."

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was "I just want to take a nap and was too far from my apartment." Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes--I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. "Go right to the ER," she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. "What can I do to help you tonight? What brought you to our emergency room?"

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

"Well," she said shyly, "I've had some burning when I pee for about a week. And," she added, not done "I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke)." Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. "What made you come to the ER at 2am when these symptoms have been going on for over a week?" I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn't. Her answer to my question--"Why not?" I didn't even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I'm not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don't get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic "nuisance," so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.

As always, big thanks for reading. Please feel free to share any ideas or opinions you may have had in dealing with your local emergency best, Jim.


Anonymous said...

Thanks for re-posting! As a former ER RN I've seen this many times so I guess that some things never change. Although, in some ways I think the hospital I worked for asked for some of the non-emergency type patients by changing their label to Urgent Care/Emergency Care. Also, here in Wisconsin, the state care system makes the pt pay less for ER care than for a primary care visit. That doesn't help matters! But! Thank you for what you do! And for your positive attitude!

Anonymous said...

So true. I left ER management, after 25 yrs. some of this over utilisation is due to our society "fast food" mentality, and some is lack of access. Either way, the less sick are more troublesome oft times, than the critically ill.
After a physical assault , I was ready to leave the rat race.
Too bad. I loved making a difference to people.

TheTracker said...

Time and time again I tell myself this is just the world we live in, and people who need care are people who need care . . . time and time again I end up frustrated.

Part of the problem is that the medical liability system makes it difficult for us to accept even the most minimal risk of a miss. Probably 90% of the chronic back pain, dental pain and maybe 50% of stable chronic abdominal pain could go home from triage, no labs, after a MSE. Follow up free clinic in the morning.

But the miss rate for that is going to be non-zero -- 0.1% maybe? When one lawsuit can plague your existence for years, few docs will take that risk -- but that's what the system needs.

Lisa said...

I have been the sickest person in a medical situation. I didn't wait on anything. I would have rather been in the waiting room.

Anonymous said...

I would have kicked that little whore right out of the er. If the bitch had to pay even a little, this would not be a problem. Lets bring on obamacare and take care of these degenerates. Unfortunately obamacare is violating the survival of the fittest. Those that are fit and smart and have insurance will live. Those who drink and abuse their bodies and contribute nothing to society will continue to take us all down. Sad. Dr Jim, I honestly do not know how you do it. I am in the medical field as well…I think we know each other. I do not know how you do what you do. I get so sick and tired of these people abusing the system.

Cartoon Characters said...

As sad as this story is, statistics show that it's not the needless non emergent cases that are blocking up the ER, but the old people with chronic problems that need placement in facilities other than acute care hospitals. They clog up the beds so there is nowhere to put the people already seen in ER (or ED, whatever) and the ER lineups lengthen. There are also not enough nurses and MDs to go around either. At least, that's the way it is where I live. Thanks for reposting! It's a good reminder to people that an Emergency Department is actually for emergencies....

Anonymous said...

A few weeks ago I called the pediatrician because one of my children was found doing something bizarre, and could offer no explanation about why, when, or how this bizarre behavior should have happened. This was atop a huge drop in school grades and violence towards a sibling. Pedi said "Can't help. Call a counselor." Called a counselor who fit us in within a day. Saw counselor, who was GRAVELY concerned by child's flat affect and complete unwavering insistence about inability to explain bizarre behavior. Counselor called pedi and discussed it. Two agreed child should go straight to the Children's Hospital ER *NOW*! Do not pass go, do not go home to collect coins for vending machine. Pedi called ER to say we were coming.

I have to say that when we were waiting in our little cubby room, we turned on the TV to try to drown out ER sounds - babies wailing, incessant beeps of myriad tones. (You probably Zen out these sounds but I was Migraine Fodder within minutes.) We were giggling to the antics of classic Brady Bunch episodes on TVLand every time a medical person entered the room.

Child got an IV lock, scores of blood & urine tests, and a brain MRI as soon as a machine was available (1 AM). All revealed nothing: no obvious brain tumor, trauma, or lesion; no drugs or alcohol; no thyroid or ammonia or hypoglycemia issues.

We were discharged at 2 AM without any answers. Child was offered a chance to have a psych consult or an overnight stay if that would have made child feel safer.

My point in telling this story is that sometimes a doctor DOES send someone straight to the ER even if the ER docs might think the patient's situation is not critical. I was genuinely frightened, especially when it dawned on me that the hospital had posted a sentinel outside our cubby. At least I gathered that was the role of the person who just sat by our door watching us & doing NOTHING else (no paprrwork, no blood drawing, no temp taking, nothing. Just watching us.)

Maybe the Attending went home and said "Can you BELIEVE who came in tonight? A mom and a kid were sent in by pedi for an urgent MRI of the brain. Kid seemed totally fine & coherent & logical & present. What was pedi thinking? Sheesh."

All that expensive fancy testing revealed nothing. I would hope no one is rolling eyeballs at our situation but instead saying "Thank Heaven we found no brain tumor or trauma in that young child."

Cartoon Characters said...

Anonymous who was sent to ER by the peds: That is so true. Sometimes ER staff is very judgmental due to first appearances rather than finding out the whole story. This very thing is what made me stop reading a lot of medical/nursing blogs. So disheartening. (and I am an RN)

Anonymous said...

I distinctly remember two ER visits I had as a 19 yr old for my first ever bladder infection (I had next to no idea what was going on). On the first visit, I had gross hematuria (very much so). The doctor I obviously woke up treated my like a piece of trash (when I asked what caused the UTI and what I could do to prevent it from recurring, he snapped at me, "Stop wiping from back to front!" He didn't even give me pyridium. When I went back a few nights later because I wasn't getting better, I woke a different doctor, who was as kind as the other was nasty. He treated me with respect, educated me on UTIs, gave me pyridium and my first dose of a different antibiotic, and smiled when I left. 40+ years later, I still feel gratitude for him.

I am still an ER doc. The stuff you describe simply comes with the territory, and it's getting worse, no doubt about it. But it's never appropriate to expect lay persons to be medically sophisticated, to know what can or not wait. Nor should a PCP who hasn't seen a non-compliant patient for 3 years make a tight schedule worse by seeing a chronic hypertensive. A lot of the stuff you're complaining about surprises me. You are a primary care provider who is also trained for emergencies. Act like one; think like one.

In all my years as an ER doc, I only ever became angry with one patient. It was the middle of the night shift (alone back then), my telemetry beds were full (and two more in the halls) with MIs, I hadn't been to the bathroom since before I'd arrived, and I went to see a patient who presented with a raspberry seed stuck between his molars. I told him I wasn't a dentist, to go home, try flossing, call his dentist in the morning and leave now, thank you, no charge for this visit.

You have what I consider an ungracious attitude towards the people you are generously paid to serve. Almost all kids make liars out of their parents in the ER. People no better equipped than I was to tell an emergency from a non-emergency come in all the time. It's part of the package, one that package contains fruits and nuts. I hope you find more satisfaction in your work.

Anonymous said...

I think access is becoming a bigger and bigger problem. I've given up on primary care. They never have an opening. Specialists need 4-6 months advance notice. So I go to Urgent Care for things that can't wait. Sometimes I have to go to the ER because I can't see specialists and I'm sicker than what urgent care can do. It's a mess. The whole system. The ignorant/lazy patients aren't the majority anymore imo. It's the ones who can't get an appointment!

Kendra said...

Anonymous @5:05pm: Please read any other post on this blog before you call Dr Jim ungracious. While I do not know him in real life, his writing depicts him as a sensitive, thoughtful, and highly compassionate human being. I hope you reserve your judgement on his character. (I feel weird defending someone I only know through their online writing, but I was too offended for Dr Jim not to say anything!).

PYM said...

Even though we don't come anywhere close to providing your type of emergency care, I fully empathise with the situations you describe. Think about getting called out at night for a case of conjunctivitis.....

Living the Life Right On Main Street said...

I read your whole blog in the past 24 hours. It is so entertaining and really makes you shake your head some times!

You have posted in a few months. I hope all is OK. Please write more!

BluenotesBb said...

As a patient, who is compliant with all her care plans but still ends up in the ER due to mast cell issues and constant anaphylactic type reactions to anything that may trigger me that day...I will tell you that ALL of my docs tell me to go into the ER no matter what time I call them. This has always been true for years....

Unknown said...

I think that's interesting that they both were giggling. With how much they both were laughing, I would have thought the same thing you did. I know that if I were in a real emergency, I would be in a panic instead of laughing. I honestly would have responded the same way you did!

Anonymous said...

I give you kudos. You were far more diplomatic with ear ache girl's father than I would have been.

Creativeyogi315 said...

These patients who encounter you in the E.R. Are so blessed beyond belief to be treated by a loving caring and compassionate professional knowledgeable E.R. Doc like you Dr feel good- god placed you in this position to help those in need regardless if they are abusing the system. The main focus is your knowledge of bringing them back to good health. Your care is a way of paying forward and you will be blessed beyond your wildest dreams for all of your hard work and dedication. We need to celebrate and honor those that are helping others the way that you tirelessly and selflessly commit to those in need. Thank you for all of your service. God bless you ❤️