Visiting The Emergency Room
What to know when visiting the emergency room
Illness doesn’t often present itself at convenient times. Most of the ailments we deal with in ERs are not really emergencies, but rather more semi-urgent. Heart attacks, strokes, traumas, and real life-threatening situations are really not that common. Unfortunately, since illness often presents after the primary care clinics close, or making a same day appointment with a primary care provider is often impossible, ERs have become somewhat of a “default” convenient primary care clinic.
Knowing this, I believe that most people can be better prepared when visiting the ER. Since most “emergencies” are not really so, there is generally time to gather relevant medical information, find a sitter for your newborn baby, and prepare to wait. Today I will answer a few questions that are commonly asked of me about the emergency department.
Why do I have to wait so long?
If you are having a truly life-threatening emergency, we strive to get you back immediately. And our triage process is actually time-tested to be effective if done properly. A chief complaint is recorded, vital signs are measured, and a ‘severity score’ is assigned. You are measured against everyone else in the waiting room, on their way via paramedics, and with our current patient load in the ER beds (in the back). How long you’ve been waiting is a secondary marker. Someone with a sore throat that has been waiting 6 hours will be seen before someone with a sore throat that has been waiting 2 hours (all other things equal). But every chest pain will be seen before every sore throat, no matter how long the sore throat has been waiting.
So, if your complaint is non- LIFE threatening, you will probably have to wait. There are so many people in the ER waiting room because it’s convenient, open all the time, people don’t have to pay for services to receive them, or they have no primary care physician to provide basic medical care to them. Since we currently take all comers, the wait is long.
How can some ERs advertise short wait times to see a provider?
Time to provider simply means, how long it takes for a doctor or mid-level to initially see you. So if you go to an ER that promises “quick time to provider” one of two things are happening. Either, the ER is not a busy place to begin with, so they are trying to attract insured (paying) patients to make money…and they set up ‘fast track-like’ systems to see these patient’s quickly so they’ll keep coming back for care. OR, they lure you in with promises of being seen quick…and you are. But you are then promptly ignored for hours as the ER staff does *real* ER work…and your time from presentation to ER discharge is the same 4-6 hours that the average patient experience regardless of where they go.
I guess there is one more option. Some ER groups will put a midlevel in triage, and that provider will see “quick” patients that don’t require medications, IVs, or any work-up at all. They will do the paperwork (which is actually the most time-consuming part), and discharge the patient from triage without that person ever having to wait for an empty ER bed, or going to the back.
Are there certain ERs that are better than others?
There are definitely certain ERs that are more specialized and better equipped to handle specific emergencies. So much so that many cities have EMS (emergency medical services) protocols that dictate which hospital a certain ‘type’ of patient should go to. Stroke patients go to hospitals with stroke center destination. Heart attack patients do better when they go to hospitals with an open/active cardiac cath lab. Trauma patients go to trauma centers. Children’s hospitals are better for children. Honestly, most community ERs would prefer to NOT ever see children. Children require special equipment, calculated medication doses, and are loud. Most ERs do not see enough children to keep the staff (including the physician) in the mindset to care for kids. So they are uncomfortable, and eager to transfer them somewhere else, especially if the child is really sick. If the child is not really sick, honestly, we don’t understand why you waited until midnight to come to the ER when you could have went to a pediatric urgent care at 10pm.
What information should I bring with me when I go to the ER?
You should absolutely know your medications, the dose you take, and the frequency in which you take them. You should know your medical history. Do you have HIV, diabetes, high blood pressure? We need to know this. You should know what sort of surgeries you’ve had. It is frustrating when a person has abdominal pain, a large midline abdominal scar, and when questioned about the scar the response is “I think that’s when they took my gall bladder out.” Although possible, a scar like that is usually due to something more serious.
Do they treat patients with insurance better than those without insurance?
No. The ER staff is not even aware of a patient’s insurance (or citizenship) status when they are seen. I, as the physician, rarely have a need to look at the patient’s insurance status. So I do not know who’s insured and who’s not. That means I order tests and studies based on the medical issue, and admit or discharge patients based on the results of my evaluation.
Why can’t I just go to the ER for my primary care?
Primary care physicians (family practice, internal medicine, pediatrics, and Ob/gyn) have specialized training and knowledge to care for patients long-term. They know how to adjust medications, they are familiar with the latest guidelines for medical screening exams, and they are up-to-date on the latest research and information on caring for their patients. In the ER, we are NOT experts in long-term management of patients. We cannot follow your progress over the long haul, and make adjustments in medications to maximize your health. Coming to us, in lieu of primary care provides, really does your health a disservice. Cancers will be missed, cholesterol unchecked, education not done, and signs and symptoms of disease unrecognized if you have no primary care doctor.
Why doesn’t the ER ever tell me what’s wrong with me?
We are experts in *exclusion*. What we do is, when a patient has a medical issue, we think of the worst things this can represent. Not the most common, but rather the most deadly (especially if missed). Then we target our evaluation to rule-out (or make sure you don’t have) these deadly things. There are only a few really immediately deadly things common enough for us to look for with any given complaint. After we rule out life-threatening emergencies…we are satisfied. We are done. If we find nothing, that is probably a good thing for you. This means that we didn’t find anything that is immediately threatening your life right now.
Sure, you may have *something wrong*…but we don’t really care as much about that. We want to make sure your “something” isn’t going to kill you today, or tomorrow. If your something can be seen by your regular doctor, and dealt with on an outpatient basis, you are discharged and instructed to see your doctor in 1-2 days.
Why don’t you let patients just stay the night if they don’t feel well?
The hospital would become a very expensive hotel if everyone who felt a little bit sick were allowed to “just spend the night.” There would be no beds available for those in the community who *really* are sick. And the hospital would lose lots of money. Many hospitals have utilization review staff who are really there to tell the doctor what an “appropriate” admission is (and isn’t), and insurance carriers will likewise refuse to pay for hospital services that aren’t deemed “necessary” by whomever they have retrospectively going through the medical record. So, getting admitted to the hospital isn’t just a decision that the ER physician can make without regard for the real financial impact on the hospital if they want to keep their job.
Do you have other questions about the ER? Email me at