Surviving the Emergency Room: Expecting the

Unexpected

Ron Clark, M.D.Emergency Physician

The Hospital of Central Connecticut

Surviving the Emergency Room

Surviving the Emergency Room

• Book was written for patients and family members to explain how the Emergency Room works so they can use it better

• It tells patients where to go, what to ask for, and what to expect

• It allows readers (patients) to be realistic and to actively participate in their emergency medical care

About the Author

About the Author

• Board Certified Attending Emergency Physician at the Hospital of Central Connecticut (HCC)

• Director of Emergency Department Risk Management for HCC

• Clinical Instructor, University of Connecticut School of Medicine

• Guest Lecturer, Central Connecticut State University

About the Author

• Instructor and medical advisor for the Connecticut Alliance to Benefit Law Enforcement (CABLE)

• Connecticut State Police Surgeon

• Board of Directors, Connecticut College of Emergency Physicians

• Fellow of the American College of Emergency Physicians

• Medical-Legal Consultant, Clark Medical Consulting

The One Thing That I Am An Expert On

HCC ER

The Hospital of Central Connecticut

Typical ER Room

Objectives

• Background of why Surviving the Emergency Room was written

• What you can do to be prepared (as preparation leads to better outcomes)

• National Emergency Department Issues

• Emergency Room Planning

TV shows often inaccurately portray EM services

Patients often have misconceptions of the ER

Common Questions

• Why did that person get triaged to a room before me?

• Why was there no specialist available to see me?

• Why did I wait so long for a room after I was admitted?

• When is the best time to go to the ER?

• What should I do before I go to the ER?

Who is that person in the scrubs?

Emergency Medicine

• All people have the the potential to be an ER patient (even me)

• By educating patients and family members about how the Emergency Room works, they can better prepare themselves

• Emergency Room images (some graphic) mixed with some humor to keep you all interested

• Images are all taken from public domain

What’s An Emergency?

• A medical emergency is any potentially life or limb threatening symptom

• Medical emergencies happen randomly and often without warning (Box of Chocolates- Anyone, Anywhere, At any time, For any reason)

• The experience is often frightening and most patients feel unprepared

Emergency Medicine is about information management

Emergency Medicine

• Chief Complaint

• History of Present Illness (HPI)

• Past Medical/Surgical History

• Medications and Allergies

• Social and Family History

Emergency Medicine

• Physical Exam

• Emergency Physician recognizes symptom patterns combined with physical exam findings

• Generates a Differential Diagnosis (possible causes for patient’s medical problem)

• Emergency Physician orders tests to “rule in” or “rule out” various Diagnoses

Emergency Medicine

• Final Diagnosis

• Emergency Medical Treatment

• Disposition: discharge, admit, transfer, die

My experience on the Trauma service

• Live

• Die

• Admit

• Discharge

Life Star

It’s important to focus emergency medical complaints

Some patients are easy to diagnose

Symptom: Ankle Pain

X-Ray: Ankle Dislocation

Symptom: Arm Pain

X-Ray: Radius and Ulnar Fractures

Some Symptoms are not as easy (nonspecific)

• Dizziness

• Weakness

• Nausea

• Bodyaches

• “I don’t feel well”

• “Something is wrong”

Differential Diagnosis

Lets Get Back to Focused Patient Complaints

Chest Pain (MI)

• Common Complaint

• High Risk

• Large DDx

• Must Risk Stratify

You can get sick for any reason

Knife in Chest

Chest Pain

Shortness of Breath

Dental Pain

Face Pain

Back Pain

Another stab in the back

Neck Pain

• Suicidal patient (now paralyzed)

Eye Pain

Difficulty Speaking

Runny Nose

• Upper Respiratory Tract Infection/ Otitis Media

Endless Potential ER Cases

Each person’s emergency will be different

• Emergency is a deeply personal issue

• Most people do not like being sick

• Most people have a story about the Emergency Room (some good and some bad)

• Most patients remember their ER visit vividly (Emergency Physicians only usually remember the worst cases)

Worst Case

X-Ray

Good Outcome

• The “golden hour” was not wasted

The Golden Hour

The Golden Hour

• The first hour of definitive emergency medical care can seal the patients fate and ultimate medical outcome

• Most important for trauma, heart attack and stroke

• Don’t minimize medical symptoms and seek emergency medical care immediately if you or a loved one have concerning symptoms (chest pain, sob, abdominal pain, difficulty speaking, headache, visual changes)

Emergency Department

• Emergency Room is more correctly referred to as Emergency Department (don’t tell Amazon)

• Many Rooms (trauma room, ENT room, OB/GYN, monitored rooms, orthopedic rooms, isolation rooms, Fast Track ER)

• Many different staff (MD, PA, RN, Tech, Students, security, housekeeping)

Who is the “Face”

• Ask ED Staff members who they are and what they do

• House

Emergency Physicians

Emergency Physician

• Provides direct patient care

• Physically examines patient and determines emergency medical care plan

• Performs emergency medical procedures

• Consults with specialists

• Ultimately responsible for patient’s disposition

Emergency Physician Assistant

• Well trained for urgent and non-urgent medical problems

• Most staff Fast Track ER

• Assist with patient management

• Often work side by side with MD’s

• Valuable resource (patient flow)

• Very Experienced (sutures, fractures)

Emergency Nurses

Emergency Nurse

• Many men chose to work in the ER

Emergency Nurse

• Provides direct patient care

• Places IV’s

• Administers medications

• Often first to assess a patient (The Look)

• Makes suggestions /works in conjunction with MD

• Major determinate of patient satisfaction (spends a lot of time with patient)

Emergency Tech

• Performs ekg

• Draws blood

• Assists during procedures

• Transports STAT labs

• Transports patients

• Blankets, food, bathroom

Students

• You provide a service to them (ER is the best place to learn clinical skills as the patients are often very sick and need emergent interventions)

• Someone did this for your MD/RN

• Learning often done at bedside

• One chance - IV, suture (supervised)

• See one, Do one, Teach one

Security

• Keeps patients and staff safe

• Screens patients (Dr. Safe)

• Called for violent patients (4-point restraint)

• Always present in ER

Experience Counts

• It is important to always confirm the experience level of the staff member that is taking care of you

• If you are unsure, ASK.

Emergency Room

• Open 24 hours a day/ 7 days of the week

• Over 100 million ER visits per year -large and renewing potential readers for Surviving the Emergency Room (Amazon loves this)

Allows for management of ER expectations

What have you done?

• Most patients want quality and efficient EM care

• Most patients and family members do little to prepare for their ER visit

• Patients call 911 or drive to the ER and just show up and expect good medical care

• Patients often do little to assist in their emergency medical care (despite the fact that they have the most invested in their health- it’s their body)

Prepare for your emergency because it is going to happen

• Hopefully all these patients prepared

What you can do to prepare

• Learn roles of various ER staff (we just did this)

• Become Familiar with how the ER functions (Triage, Admission, Discharge and Transfer)

• Research and understand local hospital resources

• Patients should know and have all their basic medical information written down

• Go to the hospital where your MD has privileges and where records kept (EKG, OR reports, X-Rays)

Triage

• Triage RN and Charge RN determine how fast you get to a room

• “The Look” can give you a visceral response (sick child, patient about to have a seizure, patient with SVT (fast heart beat), patient who is going to be violent)

Admission

Hospitalist Physician

• Good- Physically in hospital, good relationships with staff, can get studies quickly, and available to perform procedures

• Bad- Not patient’s regular doctor, impersonal, have to start with basics that PCP would already know, often lack of trust, short interactions

• Ugly- Patients often withhold info (STD, alcohol or drug use – can lead to complications), Some PCP’s dump patients, PCP’s often don’t call back

Blocked Admission

• Sometimes admission can be “blocked” if patient is on the medical fence (Chest pain, dizziness that does not look right, diabetic cellulitis with no doctor)

“Bounce Backs”

• Patient who returns to ER after recently being seen

• Emergency Physicians generally don’t like to hear about them (implies patient was dissatisfied with care or that something may have been missed)

• Often a blessing in disguise (as second chance to make diagnosis and provide medical care)

• Sometimes clinical signs and symptoms may have changed or condition may have worsened

The Blessing in Disguise

• If you feel something was missed, it is appropriate to return to the same ER or seek medical care at another ER

Discharge

• Ask your Emergency Physician about your diagnosis

• What is your prognosis? (when should you feel better?)

• What should you do if you feel worse?

• Who should you follow up with and when?

• What are your discharge medications?

• If you do not understand, ASK

Hospital Transfer

• Patient can turn into a hot potato

Transfer

• Time consuming for both the transferring physician and the accepting physician

• Need to get an accepting physician’s name

• Antidumping laws (EMTALA) and have to have capacity

• Often leaves patient and doctor frustrated, as could not treat patient at current facility

• Can cost patient their “golden hour”

Call Ahead

• Patients and family members are encouraged to call ahead if they have an anatomically specific complaint (hand injury, eye injury, genital injury)

• Confirm that specialist is on call and available

Research Local Hospital Resources

• Know what is available in your area

• Each ER has strengths and weaknesses (specialists, radiology equipment, pediatrics, psychiatric services, trauma services)

Know What Can Kill You

• Patients should have all basic medical information written down (past medical hx, past surgical hx, medications, allergies, social history and family history)

• Name of doctor

• Name of pharmacy (bring prescription bottles)

• Avoid telling Emergency Physician “You know the white pills”

Many medications have side effects and drug interactions

Avoid Surprises

• Go to the hospital where your doctor has privileges

• Where surgery was performed and OR reports are located

• Where old EKG’s are stored (my favorite, I compare about 10 EKGs every shift)

• Where old radiology studies are stored (can often use computer to look at previous studies and compare to present films)

Be Careful What You Wish For

• Confirm experience level of medical providers

• How many times have you done this?

Avoid being the Squeaky Wheel

• Write questions down so that you can be prepared to ask them when MD or RN is in your room

• Do not excessively call MD or RN into your room (they usually have many other patients)

• Thank your provider if they answered your question or provided good medical care

• MD or RN will consciously or subconsciously avoid your room if you become the squeaky wheel (can be dangerous)

National Issues

ER is the Safety Net

• Safety net for mental illness, uninsured patients, homeless, substance abuse, medical care when primary care doctor unavailable, trauma)

Equal Playing Field

• All patients have access to the Emergency Room

• All patients use the same services (EMS, hospitals)

Emergency Room Overcrowding

• Increased volume of ER patients each year

• Limited number of inpatient beds so many ER patients become “boarders”

• Some Emergency Rooms will go on diversion

Shortage of Specialists

• On Call: a CT study 90% of medical directors in CT stated that specialty coverage was deficient or unreliable

• Specialty medical coverage only matters when you are that special patient

• Major challenge for hospital systems to get specialists to take call (often called at night, compensation issues, interferes with family time)

Doctor can feel like an Army of One

• Literally, when the specialist is unavailable, the Emergency Physician still has to see the patient

Emergency Room Planning

• When is the best time to go to the ER?

• Dangerous Times

• ER wait times

Timing is Everything

• Mornings are generally the slowest time

• ER volume increases from morning and peaks in early evening (approximately 7 PM)

• Avoid “Manic Mondays”- busiest day of the week with each successive day being a little slower (HCC has quadruple coverage plus 2 PA’s on Monday-Thursday)

• Be aware of “Frustrating Fridays”- non-emergent tests and procedures may not get done until Monday (some specialists and equipment are not available on the weekend)

Wait times

• Emergency Rooms post wait times on the Internet, billboards, text messages and smart phone applications

• “CentralCT ER” iPhone application for HCC

Wait Times

Danger Zone

Danger Zone

• Emergency Physician “sign out” time can be dangerous (ask for both doctors to sign out at your bedside)

• Ask your medical provider when his/her shift ends and ask for a “good-bye”

On The Night Train

• Volume is lower during the night, but there is less staff

• Some equipment will be unavailable (ultrasound, MRI)

• Some staff will be unavailable (crisis intervention, social worker)

• One very sick patient can impact the entire Emergency Department (cardiac arrest)

My Advice

• Educate yourself on Emergency Medical Services

• Be realistic

• Be proactive and prepare for your emergency

• Actively participate in your emergency medical care

Surviving the Emergency Room

Questions?