Problems With The ED
Some of these are inherent to going to an Emergency Department; others are just the difficulties of clinical medicine.
- Your doctor will assume the worst. This is something patient’s really don’t get, and only recently have I started to get myself. Emergency medicine trains a person to rule out the really deadly, nasty stuff. We treat, we diagnose when we can, but above all, we make sure you’re not having a heart attack or any other potentially deadly disease. Let’s remember, of course, that you the patient, have generally gotten yourself to an emergency department for some reason–and we’d like to figure out if it really is an emergency. For this reason, my lists of possible diagnoses have changed.
I saw 5 kids a day with nausea and vomitting on my Peds rotation, and we primarily made the diagnosis of acute gastroenteritis and sent them on their way with fluids and education. But in the ED, it’s not just the stomach flu. It’s an appendicitis, or an incarcerated hernia. (I realize I should have been considering this more often in the outpatient clinics, but my awareness is definitely more heightened.)
The correlate of this emergency paranoia is that you, the patient, will get poked and prodded much more than you would if you just went to your outpatient doctor. Your stomach ache isn’t just a stomach ache in the ED; it could be a heart attack, an aortic dissection, pancreatitis, a kidney stone, or an early appendicitis. (And this isn’t just exaggeration on the part of the ED–there’s many people who have heart attacks who don’t have the classic “crushing chest pain.”) It’s almost like once you’ve got a bed in the ED, you’re stuck there until we’re done with you. I know this sounds terrible. It probably is. But think of the physician’s responsibility for his or her patients: you’ve gone to an Emergency Department and want his or her help. Is it worth drawing blood and urine on patients who might have a heart attack (but might not) if you catch more heart attacks, or other deadly conditions? I’m inclined to say yes. I’ve been in the ED two weeks and I’ve already had at least one patient with a heart attack that I never would have suspected. She had no chest pain, but had a very significant history of heart problems. (Note: this does not mean go to the ER for a heart attack every time you have a stomach ache! Do not tell them I sent you!) - On to number 2: You will wait. And wait, and wait, and wait. We don’t see people in the order they came in, like they do in your doctor’s office. We see them by seriousness of illness, and then by when they came in. If you’re next up to get a bed, and then a guy comes in with left-sided weakness, and another comes in with a broken arm, and then the clerk announces that a 3-person trauma from Life Flight is on its way, you’ve just been bumped. Again, emergencies go first.
And even if you’ve got a bed, if someone more sick comes in and requires your doctor’s attention, that patient’s care goes first. Your labs may be done and your CT scans and drugs may be finished, but your doctor’s busy managing someone that’s not breathing. You wait. Is this suboptimal? Yes, but if you were the patient that wasn’t breathing, you’d want it that way, too. Have your partner or spouse or friend bring a book or magazine for you. - If you don’t speak English, you’ll likely wait longer on average. I can’t imagine what it’s like in an area of the country that’s pretty homogenous. Even in central California, which has an enormous immigrant population, translation is a problem. Even at one of the many hospitals we rotate through, which has 24-hour, live and breathing translators, they still have to be paged, or they’re currently seeing another patient. I had several non-English speaking patients, both in pain, but without knowing what their problems were, we had a difficult time treating their pain adequately. I’m heading to Guatemala next year to get my Spanish up to fluency standards, but still most doctors only speak two languages: English and medicalese. (There are many problems with using kids as translators as well–if they speak one language at home and English at school, they may have never learned medical words like pancreas or palsy or gall bladder, for example.)
- You don’t get much privacy. Your neighbor can probably hear you when you tell the doctor you’ve had STDs in the past, or abortions, or use drugs, or whatever else you’re supposed to be ashamed of. They can probably hear your diagnosis, your intimate, private details. And it’s probably safe to say that the ED isn’t the best for grieving, or talking about death, or anything solemn and serious. There’s no peace, nor quiet, in the ED.
For next time: the great things about the ED, of which there are many.
Quite insightful. The three times I’ve been to the ER for myself or a friend after a bike wreck, I always wonder if the people at the front desk realize the extent of our injuries. It just seems weird to be sitting in a waiting room bleeding all over the floor as other waiters go “ewwwwww…”
However, it’s a great point… we’re walking (ok, limping), talking, and breathing. It could be a lot worse, and if it was, I’d really not want to be waiting because someone with a body slammed into the pavement but feeling okay was taking up the time of a doctor who should be seeing my life-threatening issues.
“…if they speak one language at home and English at school, they may have never learned medical words”
So. very. true. Trying to translate between the doctor and my grandmother, I was at a complete loss to explain what was going on. There are just too many words I don’t know.
Thankfully the translator showed up 10 minutes later and grandma was comforted by the fact that the doctor could hear everything she has to say. (Yes, she talks a lot.)
Number 1 leads to an even more horrendous outcome, that is the education of the population that minor illnesses REQUIRE EMERGENCY LEVEL OF CARE. Think about the effect this education has on a society.
best,
Flea
Quite insightful indeed.
I remember my first experience with #2 on your list, the fun waiting. I was around 8, with a fish hook hanging from my cheek (one of those really colourful ones, with feathers and stuff). So there I was, waiting for the doc to come back from lunch, with both my parents making fun of how I looked to make themselves feel less guilty about the whole thing.
I don’t think I’ve been to the ED since then. I plan to avoid it in the future too if at all possible, not because it was a bad experience (they had great comic books, and comfy chairs), I don’t know, I think I’m just a “wait till the family doc has time” kind of person.
That’s an excellent point, Flea. Changes people’s expectations about what level of workup they “should” be getting. Maybe I’ll try pointing this out to people that end up having minor illnesses.
Where I trained, we eventually had to take it upon ourselves regularly to check the people on the stacked-up gurneys, to be sure they were ok; the triage system was often overwhelmed. If you stayed in the acute care area and just picked up the next chart in the pile, you could easily fail to notice what was going on in the hallway, crowded as it was with people waiting to be seen for a sore throat, and others patiently bleeding internally.
Eeep, then I read the title there, I just assumed “ED” meant “Erectile Dysfunction.” When it said in bold “your doctor will assume the worst,” I had touble imagining what that might be (???).
I guess I’m just used to calling it the “ER.”
Anyway, an insighful post, and some things you mentioned are really important for patients to know in order to get the right type of attention from the system.
Just another FYI- Most everyday orthopaedic injuries (bone/joint/muscle)can wait for a day or so to be treated by your local orthopedic surgeon. What often happens is that you roll you ankle and can’t walk on it…(or you shut your finger in a car door, or fall and hurt your wrist, or jump of a moving vehicle and feel a tearing sensation in your knee… you get the idea) and you go to the ER (I’m with you Jessica…ER not ED). With an injury like that, you are WAY down on the list (while all those people rude enough to come in AFTER you with leaking intracranial anyeursms get treated BEFORE you).
After many hours of waiting, you get an Xray that shows maybe a small fracture, but we can’t really tell so go see an orthopedist (or you have a definite fracture, go see and orthopedist; or nothing is broken, but you may have torn something, go see an orthopedist; or looks OK, here is some ibuprofen and if it doesn’t get better go see an… you get the idea). Now if bone is sticking though the skin; or you were in a car accident with multiple injuries; or you and your body part arrive in separate vehicles, by all means, go to the ER.
But bottom line, you can save a lot of time (not to mention money) by going first to where you will be sent next anyway.
Just my 2 cents…