Prelude: The Daily Kos community has meant a great deal to me over the past decade — and I have wanted to give back to this group of humans that I adore. This led me to one of my New Years resolutions for 2019: to finally start a monthly blog on emergency care topics. My reasoning: (1) I’m a long-time ER doc and medical school professor, and common advice to writers is “write what you know about”; and (2) all of us, sooner or later, have an emergency medical condition — so I hope some sharing of knowledge might be helpful to many of you. I meant to start this monthly blog a while back; if you want to see my first such piece (on cardiac arrest), you can find it HERE. In future, I will aim to cover specific medical conditions, but this month I will provide some orientation and pro tips to the ER experience.
The scenario: it’s 2 AM, and you feel awful
You suddenly have chest pain, or worsened difficulty breathing, or severe vomiting — and you just can’t avoid the frightening truth that you need to go to the local ER. Maybe you’ve never been to the ER before, or have only been there a few times and have found it to be a slow and unpleasant place. But here you are, it’s 2 AM, and you are scared that something serious is happening, something that needs medical care…. NOW. You hastily grab your wallet, keys and phone and head for the car, or you call 911 for an ambulance — but either way, you grimace and head to the hospital.
What an ER does well, and what is does not do well
The first and most important thing to understand is that ERs are designed to care for potentially life-threatening or serious acute conditions. Heart attacks, bowel obstructions, kidney stones, allergic reactions and the like — these conditions are what ER staff are trained for, what they generally diagnose and manage quite well. So if you have a relatively new, or a newly worsened symptom such as chest discomfort, difficulty breathing, vomiting, severe abdominal pain, or a new itchy rash all over your body, the ER is the right place for you. What ERs tend to do a lousy job with are conditions that are more chronic in nature — one month of abdominal pain, several weeks of back pain for which you have seen a specialist already, or intermittent headaches for 6 months. We just don’t have the resources, time, or ability to do a great job with such conditions, and your visit to an ER is likely to be frustrating, and result in an expensive co-pay without many answers. Sometimes you just don’t have a choice (maybe you don’t have health insurance or don’t have a regular primary care provider) — but your ER visit often won’t get you the care that you need.
The discussion above may sound obvious to you — but you’d perhaps be surprised to know that easily half of the patients that I see in my ER have conditions that are chronic or mild in nature, and would have been more efficient and more pleasant for the patients to manage in a clinic setting.
Orientation to the ER: who are these medical people and what crazy language are they using?
There are a bewildering array of staff who work in the ER setting. Knowing who they are, and the roles they play, can be a useful bit of knowledge when you visit the place. The ER also has a whole set of bizarro jargon terms, often used by staff to patients without remembering that “civilians” don’t use these words — thus adding to confusion and miscommunication.
The ER is generally led by a supervising physician (known as the “attending physician” or simply the “attending”, a word I dislike because no one outside an ER actually knows what this means. I always introduce myself as the “supervising physician” to patients and families, everyone gets the meaning of that). The supervising physician makes the final decisions about “disposition”, meaning whether you stay in the hospital or go home, and what treatments you will receive. At many hospital ERs, there is a junior group of physicians who may care for you, physicians-in-training known as “residents” (much more familiar term, thanks to all the medical TV shows out there). If you are in the ER, and a physician walks in and says “Hi, I’m Dr. Jenkins” , it’s important to know if they are resident or supervising doc. It’s totally fair to pleasantly ask them, “Hi Dr. Jenkins, nice to meet you, are you the resident or attending physician?” That way, you will know if they are really calling the shots. It is absolutely your right to speak to the attending; if the resident physician says “you’re going home, everything checked out just fine” but you haven’t actually spoken to the attending (believe it or not, this happens not infrequently, but is not OK) — ask to speak to them. Ditto if the resident is telling you things that are totally confusing, it’s always fair to nicely ask “I appreciate what you are trying to say, doctor, but I’d like to ask some questions of the attending when they get a moment”.
The other crucial person on your ER team is the “primary nurse” — that means the nurse assigned to you during your stay. ER nurses are some of my favorite people in the world — generally strong-willed, sometimes blunt but deeply caring under that gruff exterior, smart and dedicated to their vocation. They can be your best ally during the ER stay — so make sure you are as courteous to them as your condition allows. Like flight attendants, they have a really tough customer service job, with most people complaining or being rude. A few kind words of appreciation towards a primary ER nurse can make a huge difference in their day, and often in the attention paid to you in the ER. You may also meet an “ER tech”, often a paramedic. These techs do a range of activities to support your care, including placing intravenous lines, preparing splints for sprains and fractures, and sometimes serving as a transporter to get you to x-rays or CT scans. Another member of the cast of characters is the “registration clerk” who will collect your information (insurance, drivers license) during your stay. “Consultants” are other physicians you may meet during your stay, called upon for specific expertise, such as surgeons or dermatologists or neurologists. They will help the ER team make decisions, but often are not ultimately responsible for your care.
ER physicians and nurses tend to work fast, and they often forget to drop their ER-speak. Here’s some common terms you may hear: “dispo” means disposition, or whether you are going to be admitted to hospital or sent home — if you hear a nurse say “let me find Dr. Jones and find out your dispo” that’s what they mean. Often abbreviations are used with patients (inappropriately) to explain test results. If a resident says “good news, your CBC was normal” — they mean your “complete
blood count”, a lab test that measures the number of white blood cells, red blood cells and platelets in a given volume of blood. If they say “we’re going to draw a BMP” — sometimes called a “Chem-7”, that means they are going to measure blood electrolytes (such as sodium and potassium). Another common ER blood testing term is “belly labs” — this means blood tests for the liver, gallbladder and pancreas. Another term that is often thrown out there to patients: “acute abdomen” — if a resident says “Mr. Adams, we are worried you have an acute abdomen”, that means they are worried you may have a sudden process in the abdomen often requiring surgery (conditions such as appendicitis or bowel obstruction are often considered “acute abdomens”). If a nurse says “I need to stick you again, Ms. Ramirez”, that means he or she needs to draw blood for another test. They may grab a “butterfly” to “stick you”; a butterfly is a form of needle to draw blood. If you are a family member, and someone tells you that your confused loved one (the patient) is “only A and O x 2” that means alert and oriented to only two criteria (the three criteria often used are person, (“tell me your name”), place (“where are we right now?”) and time (“what is the date today? what day of the week?”). Unfortunately, there are many more jargon terms, enough to fill a book, but hopefully this list of common ones may be useful as you interact with the ER team.
PRO TIP #1: when possible, go to the ER linked to your prior care
There is no universal electronic medical record in the US, unlike many other countries (a sad consequence of not having single-payer healthcare, although I suppose the two don’t have to go hand-in-hand). That means your ER team may not know about your prior heart attack, or your high blood pressure, or your usual asthma medications. Sometimes, such information is critical to your care. If you go to an ER at an unlinked health system, the staff may have no access to your medical records, and may end up duplicating many expensive (and possibly unnecessary) tests. So, if your primary care doctor is affiliated with a specific hospital, or you have recently hospitalized at a specific hospital, it is ideal to go to the ER at that hospital.
No matter where you end up going for emergency care, it’s best to assume that some records may not be in the computer system, and you can help yourself by bringing a few items along. A specific example where you can be a rock-star patient: if you ever get a routine ECG (electrocardiogram, electrical recording of your heart, often called a “12-lead ECG” or simply a “12-lead”), take a photo of your ECG with your phone and put it in your “favorites” — or if you’re old-fashioned like me, just make photocopies and bring one along to the ER). When you go to the ER with chest pain or difficulty breathing, showing the team your old ECG is a hugely helpful thing. Another example — if possible, keep handy any recent blood testing you may have had and similarly put your recent blood tests in your phone or on a folded sheet of paper in your purse or wallet. It could save loads of testing time in the ER, and possibly save you a hospitalization, if the abnormalities they find are actually your usual state. Always be ready to answer the question “are you allergic to any medications?” — putting your allergies on a card in your wallet can be lifesaving.
PRO TIP #2: make sure you have an exit strategy
ER visits tend to be long — expect to stay for hours. This means that sometimes a friend drives you there at 8 PM, but suddenly it’s 2 AM and you’re being sent home. Be sure to plan for a way home. Uber and Lyft have really changed the game for many patients going home from the ER; but if you don’t have the funds or the app, be sure to have a plan. A dear friend who would be sure to answer the phone at all hours and pick you up? A clear knowledge of bus or light rail routes? An emergency $20 for getting a taxi? Whatever your plan, realize you need one — ERs generally don’t provide services to get you home (in the ideal world, they should, in my opinion), so you need to be ready. In a real pinch (no funds, no ride, and it’s freezing cold outside), many ERs will take pity and allow you to stay in the waiting room until daytime or a ride can be found — ask them nicely, explain your predicament, and this might be a last-resort option for you.
PRO TIP #3: bring food or money for vending machines
Because ER visits are long, you will get hungry and thirsty. If the ER staff thinks it’s safe for you to eat (corollary pro tip — always ask your ER team if you can eat before you chow down, there may be some snacks available for free in the ER itself (often apple juice, crackers, and sometimes lousy turkey sandwiches are available as ER fare) — but if you can, bring a preferred snack in your purse or backpack, or bring a bunch of quarters for the frequently overpriced vending machines endemic in ER waiting rooms (many don’t take bills, so bring coins). If you’re like me, a 2 AM snickers bar goes a long way towards keeping my despair levels down and my mental alertness up.
PRO TIP #4: bring something to pass the time
Not only will the long ER visit (sometimes 6-8 hours in the ER is common!) make you hungry, it will drive you bananas with boredom. So bring a book, or iPad, or stack of work, or a newspaper — bring something so that you’re not hostage to the crappy TV in the patient room which only picks up Three’s Company re-runs or informercials.
PRO TIP #5: most ERs have phone chargers
If you have an iPhone or common Galaxy model smart phone, and it’s dying in the ER with 2% charge, don’t despair. Most ERs have chargers for staff, and if you ask nicely, your primary nurse can either bring your phone to a charger and bring it back later, or bring a charger to you. This is often a well-kept secret for obvious reasons, but in a pinch, and again if you ask super nicely, they are likely to help you with this. Nothing worse with a dead phone at 2 AM when trying to get a ride home!
PRO TIP #6: get your test results before you go home
Similar to TIP#1, you need to make sure you have your records handy for follow-up visits. It is absolutely your right to the results from any lab or imaging tests. Before you are “dispo’d home” (discharged from the ER), be sure to ask for a print out of all of your lab tests, x-ray reports, etc. Don’t assume this will get to your other health care providers. When you see that specialist in follow-up, bringing the CT report or lab tests will be hugely helpful to expedite your care.
PRO TIP #7: it’s your right to be transferred to your hospital, when possible
Let’s say the ER diagnoses you with a minor stroke, and you’ve had strokes before with all of your care at another hospital that is in the same city as the ER in which you are receiving care. Or you have a bowel obstruction, and you had prior abdominal surgery at another hospital. Let’s also say they want to admit you to the hospital for this condition. You can always ask to be transferred to Hospital X (the place where you have received most of your care). This is common, and often leads to better medical care, but many patients or families don’t realize this is an option. The ER can arrange for an ambulance to take you to the other hospital where you can be admitted. The process is somewhat slow and paperwork-heavy, but it absolutely can be done.
The ER is a challenging place to receive medical care. There are many more pro tips I could share, but I should stop since this is quite a long diary already — I want to avoid “TL;DR” comments as much as possible. Please let me know if you found this helpful, or what you would like to hear about in future posts, or how I can improve my communication for next time. I’m thinking of doing the next blog on blood clots (pulmonary embolism and deep venous thrombosis). My goal is to serve as the “friendly neighborhood” ER doc to this wonderful community, and keep all of us as safe and healthy as possible so that we can work together to make a better and more progressive world.