Episode 2: How Being a Patient in the ER Works, Part 1

Part 1 of our 3 part series going over how being a patient in the ER actually works.

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Transcript

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician. If you haven’t yet, please listen to our first episode which is a short introduction to the podcast. No…seriously…go listen. It’s ok, I’ll wait…

All right so today’s episode will be the first of a three-parter going over how being a patient in the emergency department works. This first episode will delve into general ER topics and then touch on triage and getting one’s testing started. Even if you are already familiar with this, maybe you or a relative have gone through it, I still suggest listening because…I would like that…but also because there’s a lot to learn from an insider’s perspective. 

I will be covering the American ER system as that’s what I know. If you’re listening from outside the US, your emergency department or ER may be called something different such as accident and emergency department (A&E) or emergency ward (EW) but from what I’ve read, the experience can be similar. While it is indeed an emergency department, not just a room, I like to say ER because ED can mean…something...else. 

Anyway, the ER is a department, usually open 24/7 and located within a larger hospital, where anyone can seek care. In the United States, there is a law called EMTALA, or Emergency Medical Treatment and Active Labor Act, passed in 1986, that applies to every hospital that accepts Medicare, which is essentially all of them. It dictates that anyone presenting to the ER must receive a medical screening exam to determine whether an emergency medical condition exists and render the appropriate treatment. This is regardless of citizenship, insurance status or ability to pay. EMTALA was partly created to prevent patient dumping, as in hospitals turning away ill or uninsured people due to how much un-reimbursed care they would need. If you’ve ever seen a TV show where an ER straight up refuses to see a patient, nowadays that would be very stupid cause that ER could be fined into oblivion.

I’m going to go into some definitions here from EMTALA and the Center for Medicare Services, or CMS. They define the ER as “a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions." Now what constitutes an emergency medical condition? "A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." You still awake? Good. So, the medical screening exam the patient requires varies depending on what emergency medical condition could exist. You may simply need an x-ray to rule out a fracture, or you may need blood work, imaging, and admission for surgery because you have appendicitis.

Now, if you present to the ER for any reason asking to be seen, you will be seen, whether you have an emergent medical condition or not. Clearly, that is not a good use of resources in some cases, but as it is our job is to help, and we don’t want to miss something or violate EMTALA, we will see you. However, please reconsider coming to the ER if you don’t have an actual medical need. EMTALA mandates we screen and treat emergent medical conditions, we do not do checkups or routine blood work or complete any kind of insurance or work forms for you. This is not what the ER is for. Please go to a primary doctor.

As an aside, don’t forget about your local urgent care. Let’s say you have a non-emergent medical need, for instance you have a runny nose and you want a COVID test, or you nicked your finger making avocado toast and you want to see if you need stitches. That is the perfect time to go an urgent care. Urgent care providers are not busy with critically ill patients (like we are in the ER) and so they may be able to treat you faster. Now, of course, they have much more limited resources and can’t handle complicated cases. So if you have respiratory distress or you have chest pain and you’re at high risk for a heart attack, they may not be comfortable seeing you and recommend you come to the ER.

We’re first going to start with patients checking into the front, sometimes called the walk-ins. Later I’ll talk about what it’s like if one comes in via ambulance. So, for this example let’s say you’re having chest pain but it’s not severe and you can function and you decide to walk into the ER. Because you listened to this episode first, you made sure to bring a list of your medications, an extra layer because the ER is kept cold, and maybe a book or phone charger. By the way forgive me as I describe a person walking in but even if you have mobility issues and you use a wheelchair or assistive device, as long as you are not presenting in severe distress then the situation will be similar.

So, right away the triage staff see you coming in and note that you are not in obvious severe distress, as in you’re awake, mobile, speaking coherently, and not screaming. Generally, there is a window or alcove where you are first registered. Here is where they take your demographic information such as your name, date of birth, gender, insurance information, and also your chief complaint, which is a few-word reason for your visit, such as chest pain. Often they will ask for a form of ID such as a driver’s license. 

After registration, you are triaged where a nurse or provider asks you for a brief reason for your visit, along with some pertinent medical history and your medication allergies.

For instance, with the chest pain example, they may ask you when it started, if you have any other symptoms such as shortness of breath, and what chronic medical conditions you have. That last part is important because a 25-year-old with no prior medical problems presenting with chest pain is a different case than if they had history of blood clots. While you won’t have a lot of time speaking to triage, please make sure to advocate for yourself and tell them briefly what you are worried about. 

If you don’t share a crucial fact, such as “my chest pain started after I got hit by a car,” then you are only doing yourself a disservice. Also, while the ER is a not a one-stop-shop for all of your medical needs, if you have another time sensitive complaint, please let triage know. It’s frustrating for everyone when I see a patient who’s been waiting for hours and they tell me about another issue that hasn’t been addressed, meaning now they’re going to wait even longer for a different test. This would be like, “Doctor, I only mentioned chest pain at triage but also I’m having horrible pain in my scrotum so I need an ultrasound to rule out testicular torsion.” Yeah, we love when this happens.

Anyway, whoever is triaging documents your complaints and, nowadays, orders some tests. It used to be more common that only nurses would triage but they would not be allowed to order any diagnostics, forcing the patient to wait with nothing being done until a provider could see them. Thankfully, now many ERs allow the triage nurse to use a premade order set or there is a provider at triage (usually a physician assistant, PA, or nurse practitioner, NP). 

These tests comprise your workup, as in what needs to get done to complete your medical screening exam. These could include an electrocardiogram, or EKG, blood work, urinalysis, swabs like a COVID test, and imaging like an Xray. Rarely the triage-er may perform a brief physical exam, but triage has to be fast so there is no time to take your full history or perform a complete physical. For your case of atraumatic chest pain, they order an EKG (which happens first), blood work which includes a heart test, and a chest x-ray. 

They also at this time assign you an emergency severity index, or ESI, level. The term triage is derived from an old French word meaning to choose or sort, and that’s triage’s function. To sort patients into levels of urgency so we know who has to be seen first. ESI level 1 is the most urgent and it goes all the way down to level 5, the least urgent. An ESI level 1 patient requires immediate attention because that patient is at imminent risk of decompensating or even dying. This may be a patient in cardiac arrest, as in their heart is not beating. 

Meanwhile an ESI level 5 patient can wait to be seen as there will be no deterioration in their condition. This is something simple like a medication refill. Most patients are somewhere in between, and will be taken care of in the front of the ER, which may be called the Fast Track, Minor Care, Vertical Care, or RME (rapid medical evaluation). I’m going to call it Fast Track from now on for simplicity as that’s a common term.

The ESI level also indicates to providers how many resources the patient will need. A patient with severe abdominal pain may require blood work, IV placement for fluid and medication, and a CAT scan. That’s a lot more work than someone who only needs a COVID swab. Outside of small, rural ERs, you’ll encounter a lot of staff helping you get these tasks done, such as nurses, technicians, phlebotomists…the list goes on.

Obtaining vital signs are a crucial part of your triage and can adjust your ESI level, and hence decide how quickly you are formally seen by a provider and if you will be whisked away to the “back” or a “main bed.” Vital signs consist of your temperature, pulse rate, blood pressure, oxygen saturation, and respiratory rate. If you have dangerous vital signs, this may deem you unstable, lower your ESI number, and require you are seen quickly. The same to be said if your EKG shows an active heart attack or arrhythmia, abnormal heart beat. Remember, patients in the ER are seen according to acuity and need, not on a strict first come first served basis. There are simply too many patients, so seeing them all quickly is just not possible, hence the urgency of a patient’s condition has to be taken into account.

You do not want to be the first patient brought back because that means you are in trouble.

But let’s say for this example, you’ve presented with chest pain, your tests are ordered, your vital signs are normal, and your EKG is reassuring. You’re made an ESI 3 and treated in the front and not a main bed. But first you are sent to the waiting room, also called waiting area or results pending area. And there…you…wait. If you’re lucky, perhaps it’s a very slow day or you live in a rural area, then the wait to be seen by a provider may be brief. But for many people in the US, this wait can be loooooong. Remember, ERs are the most crowded on Mondays and after a holiday, you can guess why.

It’s time for a break, we’ll be right back after a word from our sponsor.

Are you currently a patient Inside the ER? Are waiting to be called back for testing or a room? Then I have a revolutionary new concept to share with you, because today’s twin sponsors of Inside the ER are…LISTENING FOR YOUR NAME and STAYING INSIDE THE ER. Yes, yes, I know, this is groundbreaking stuff, but the ER staff will look for you in the waiting room and if they can’t find you then your workup isn’t happening! “But I want to watch YouTube so loud that I hear nothing else and my ear buds shatter my ear drums,” you might say! And that’s fine, I’d say, but do it on your own time! Well, actually, no that’s not fine, you should turn down the volume, but you get the point! “But hold on,” you might say, “I want to wait outside, or in my car, or in the gas station across the street!” That’s not waiting to be seen, that’s forfeiting your place, so park your keister! 

Now, back to the show:

There is a tendency nowadays for people to put in their ear buds and tune out the world, which I totally understand, but please keep the volume down or one ear bud out. I can’t tell you the number of times a patient has been summoned for testing or to come back to a room, but they don’t respond all because they didn’t hear. And if you leave the ER then the game is over. We’re not going through the parking lot tapping on car windows looking for patients.

While you wait, you are called to the phlebotomy area to have your blood drawn, a crucial step in evaluating chest pain, and then later to radiology for your chest x-ray. These tests are ran or interpreted in the background in the hopes that when they finally call your name to be seen by a provider, your results will be back. If your testing shows something concerning, perhaps your heart test is abnormal, then you may be called sooner into a main bed.

This period of your ER visit, the waiting, can be very frustrating. You came because you have a frank medical concern and we stick you in this giant room with florescent lighting? Yes, as I said earlier, unfortunately, if you are not critically ill, waiting in the ER is inevitable. There are nowhere near enough staff and resources for every patient to be seen and tested quickly. And there are certainly not enough beds, so please do not ask for one. Beds in the back or main are limited and often reserved for those who need them. If it’s a busy time in the ER, then not only will there be delays in being seen but also in all of testing. Waiting for a CAT scan for instance? The ER probably only has one or two of those, and as always, critically ill patients take priority. 

I sometimes remind people who complain about the wait that the process of making an appointment with a primary doctor, being seen, having testing done, and then being seen again for interpretation of results could take weeks or even months, so accomplishing it in a manner of hours in the ER is actually a big deal.

While you are waiting, you may notice that the ER waiting room is full of people from all walks of life and in all sorts of situations. Blue collar, white collar, people struggling with homelessness or substance abuse, people who are vomiting or in pain, people who are injured or in emotional distress, you name it. The ER waiting room is truly a melting pot. Just remember that you may not know someone’s full situation. Also, you may wonder why someone is in pain, not knowing we have already given them a ton of medication, or why an elderly person is sitting in an uncomfortable chair, not knowing that the main has no beds. With this many people moving in and out of a space, it is difficult to keep the area clean so please forgive us if the bathroom is dirty. If you spot a dangerous situation, do not hesitate to alert the front desk or security.

During your wait time, you should go over your story. As in, remembering your medical problems and medications, what symptoms you are having, and if you have any specific worries. So you could think to yourself, “I have a history of high blood pressure but I don’t take any medications. My chest pain started this morning after eating breakfast. Nothing seems to make it better or worse. I’m nervous about my untreated high blood pressure and I want to make sure I’m not having a heart attack.” When it’s time to see the provider, you don’t want to leave out crucial information or forget to voice your concerns. Whenever I take my kid to the pediatrician, I prepare a list of questions I want to ask ahead of time.

Wait…what’s that? They’re calling your name, it’s time, it’s finally time to be seen by a provider! …And that’s where we’ll pick back up next episode! 

That’s it for Part 1 of this topic! Don’t worry, don’t worry! The riveting Part 2 is already waiting for you! Next episode I’ll talk about the actual process of being interviewed and examined by a provider, completing your workup, and being discharged.

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Thanks for listening and all the best!