Episode 3: How Being a Patient in the ER Works, Part 2

Part 2 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. This is Part 2 of our three-part series on how being a patient in the emergency department works. Please make sure to listen to our introductory episode and Part 1 of this series first. You know you wanna!

This episode we’ll dive into being seen by a provider, finishing your testing and treatment, and, assuming you’re ok, being discharged. Last episode we ended on you hearing your name sound through the waiting room!

Try not to look too smug to the rest of the patients waiting when you are finally called for that Fast Track room, because you may not be in that room for very long. The Fast Track rooms are meant to be turned over quickly, so that we can see as many patients as possible. This is where you will formally be seen by a provider, which may be a PA, NP, or physician, and this is the most time you’ll have with them so remember to use it wisely. If you have a different preferred language, please make this known and the provider can call an interpreter. The provider should introduce themselves, clarify who you are, and undertake the H and P, or history and physical, by interviewing you and performing a physical exam. I’m going to present these as two separate entities but they’ll often happen at the same time.

The history is comprised of the HPI, or history of present illness, where you’re asked to first explain your reason for visiting the ER. When I was in medical school, we were trained to allow the patient to speak first and tell their story, and avoid interrupting. This is your time to speak your piece, so remember to focus in on your symptoms, circumstances, and your concerns. Please stay on topic, do not veer off and confuse your narrative. If you have an embarrassing complaint or circumstance, just tell us, we need to know! Besides, we’ve probably heard worse.

Try not to cut to the chase with, “What do my tests show?” Focusing on the tests already performed without getting the full story may cause your provider to anchor and not entertain alternative diagnoses that need to be ruled out. 

If the provider interrupts you when you’re speaking, please don’t take offense, and try to pick up where you left off. Usually I interrupt if there is an important point you just said that I have to clarify in that moment. Oh also, it’s normal to be frustrated if you’ve been waiting hours to be seen, but that’s not the provider’s fault. They are with you now so do not take it out on them, that’s not doing you any favors.

As part of the HPI, the provider may then ask you for more detail about your symptoms, such as location, quality, severity, duration, timing, context, modifying factors, and associated signs. So put together this would be: “I have pain located in the middle of my chest, it is sharp in quality, it is a 3/10 severity, it has been there for a few hours, the pain was worse in the morning and has lessened, it started after breakfast, nothing makes it better or worse, and I’ve felt the urge to belch since it started. I have no other symptoms, such as I have no shortness of breath, fever, cough, abdominal pain, etc.” Try to be as descriptive as you can when asked for this information. The clearer you are, the better picture we will have of what could be wrong. Please try to avoid terms like “I felt bad” or “I felt sick,” sick how?,  or “awhile,” is that days? Years? “Dizzy” is a tough one too, do you mean lightheaded like you’re going to faint or a room spinning sensation like vertigo? 

This will then flow into the ROS or review of systems, which is a series of questions focused toward different body systems (cardiovascular, respiratory, gastrointestinal, etc). This may be very brief or nonexistent if your visit is straight forward, or could be extensive if you’re a complicated case. If someone comes in for a trip and fall, I may simply ask them what they injured or struck, clarify how they fell (just a trip? or Did you faint and fall?), and then confirm they didn’t feel ill otherwise. Most patients I see at a bare minimum I’m asking about chest pain, shortness of breath, and abdominal pain, just in case.

I remember one patient told me she just tripped and fell onto her hip. She denied any other symptoms on her review of systems except fatigue, and was clear that her was fall was mechanical, as in just a trip. But I had a suspicion something else was going on, got blood work and later found out she was dangerously anemic from a gastrointestinal bleed she was unaware of, hence her fatigue.

The next section is your past history, which includes your medical and surgical history, as in what medical conditions have you been diagnosed and dealt with in the past, and what surgeries have you had. If you present with abdominal pain, it’s important to know you have a history of appendicitis with a prior appendectomy. Then you may be asked about your social and family history: your living situation, profession, any toxic habits (smoking, drugs, heavy drinking), and any conditions that run in your family. Maybe your headache is benign, but if you have a family history of brain aneurysm, or live in a building with a carbon monoxide leak, then that could matter. This entire section could be very brief if you have a simple, straightforward issue.

At the end of the interview, this may seem like a lot of questions, and it is. That’s the point. Please be patient and answer as best you can. Some patients are annoyed at repeating their story (to triage, maybe to a nurse, and now the provider) or don’t understand why they’re being asked so many questions. The provider needs a lot of information to get a full clinical picture. “I had chest pain after eating a burrito” is very different from “I’ve had chest pain and shortness of breath ever since my leg swelled up.” One is acid reflux, and the other is blood clot. We need to have a complete picture not only to help you but also, frankly, for charting and billing purposes. Sometimes I’ll say, “And for the chart I need to ask you…”

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

Today’s sponsor of Inside the ER is…PEE. Yes, that’s right, pee, urine, or as I call it, liquid gold. Are you in the ER? PEE IN A CUP. No, I don’t care why you’re there, give me your pee! “But I’m here for an injury” you might say. Yes, I would say, I know, but I need to know if you’re pregnant, or if you have blood in urine, so give me your pee! Do you know how many times I see a patient for painful urination, and they’ve been in the ER for two hours, and they STILL haven’t given us their pee!? So please, DO NOT PEE before you come to the ER but as soon as you get here, ask for a urine cup. “But wait,” you might say, “I really don’t have any issues with my pee.” Trust me, GIVE ME YOUR PEE. Patients with urinary tract infections can present with atypical symptoms such as fever, fatigue, body aches, vomiting, or vague abdominal pain. Remember, the sooner you pee, the sooner you’ll get to leave!

Now, back to the show:

The next portion, the P, in H and P is of course the physical exam. This may vary wildly depending on your complaints. It actually starts before any words are exchanged, as soon as the provider walks into the room, it’s visual. We “lay eyes” before we “lay hands.” Are you awake and alert? Do you appear comfortable or in pain? Are you able to sit still? Are you anxious or calm? Are you pale for your natural skin tone? Are you sweaty? Are you breathing quickly or working to breath? Are you clutching a part of your body? Do you have any obvious injuries? Do you have any rashes, marks, cuts, or discoloration? Are your face, neck, or limbs swollen? Do you have a tremor? Are you well-kempt or disheveled? When I’m in public, I find myself looking at people and making the same determinations, force of habit I suppose.

This continues during the interview. Is your speech clear or slurred? Do you appear confused or lucid? Can you formulate coherent sentences? Are laughing inappropriately or speaking to yourself? When it’s time to physically examine you, this will depend on your complaints and past medical history. A truly complete physical exam is a long, invasive process that requires inspecting and palpating every inch of you, listening with the stethoscope, and demanding you complete neurological tasks. Rarely is the whole thing needed. 

As I keep offering as an example, if you have a simple trip and fall, then you may just need to be assessed for any injuries you sustained. The affected area will be palpated, you will be asked to range any involved joints, all to ensure that you already had satisfactory imaging, or for the provider to assess if an occult fracture (a fracture not seen on x-ray but still very much there) is likely. 

For instance, I recently saw a patient after a fall onto an outstretched hand, or FOOSH. Their wrist x-ray was negative, as in did not show a fracture or dislocation, but they had significant tenderness in their anatomical snuffbox, ya know that notch next to the base of your thumb that people used to sniff snuff out of. Hence, I was concerned about an occult fracture of one of their wrist bones, the scaphoid, and placed them in a splint as a precaution.

With our chest pain example, your provider palpates your chest (looking for point tenderness or swelling), and listens to your heart (listening for a murmur) and lungs (making sure your breath sounds are normal). They also palpate your pulses (to ensure they are symmetric), your legs (checking for signs of fluid overload or a blood clot) and perhaps your abdomen (assessing for distention or tenderness). We may also inspect your chest if there’s a worrying skin lesion. There’s the tale of a patient being transferred from a rural ER to a big city hospital for a heart attack workup all for the doctors to realize the guy just had a painful shingles rash on his chest. 

Examining you properly may necessitate you adjust or remove some of your clothing or even change into a gown. As a side note, keep this in mind if you have time to choose your attire before coming in. Got a wound on your knee? Leave the skinny jeans at home and wear something looser instead that you can pull up. One time in medical school, my roommate fell and broke his ankle. We went to our ER and when it was time to splint him, we realized his jeans would be impossible to take off once the splint was on. It was the winter, so he didn’t want to leave in only a gown, nor did he want to cut his jeans off when we got home. But what was I wearing? Sweat pants. So what did we do? Switched pants. Worked like a charm.

If a sensitive exam is required, perhaps a pelvic or rectal, then we will have another staff member come in as a chaperone. This is for your comfort and the provider’s safety. If you have an objection to a provider of the opposite sex examining you, you may request someone else, and we will do our best to accommodate. On the flip side of that I once had a man come in asking to be examined only by a woman. When he got to the exam room he proceeded to behave very…inappropriately. Needless to say, we did not fulfill his request.

Any pertinent positives on your physical exam could steer your visit into a different direction, or simply reinforce what the provider already suspected. A patient presenting with vertigo for 2 days with an abnormal neurological exam, perhaps a facial droop or arm weakness, makes me concerned for a stroke. A patient complaining of chest pain with a swollen calf makes me concerned for a blood clot. But if you presented with chest pain and had abnormal lung sounds with bilateral, or both side, leg swelling that compresses or pits with my fingertip, then perhaps heart failure is the cause.

At some point, perhaps at this time, the provider can go over any results that came back, such as your EKG, blood work, or imaging. With our chest pain example, your hope is that your EKG is unremarkable, showing no irregularity, your blood work is normal, showing no signs of a heart attack or other abnormality, and your chest x-ray is “clear”, with no evidence of pneumonia or heart failure. 

If, however, your workup is not done, or your testing shows an abnormality, then the provider will discuss the next steps, or THE PLAN. This could be any number of things depending on your complaints that visit: performing a procedure such as splinting your broken bone, bringing you back to a main bed, admitting you to the hospital, calling a consultant such as a cardiologist, ordering further testing such as a blood clot test, or ordering you pain medication or perhaps acid reflux medicine if I believe your chest pain may be caused by that. 

If you arrived in obvious distress, then you may have been administered pain medication earlier. A nurse will sideline a provider concerned that a triaging patient is in a lot of pain and so, once the allergies are confirmed, we may order something before formally assessing the patient. Usually this is the case with a kidney stone or a bad fracture. The ER is a team, and we rely upon each other to help take care of everyone.

Remember before your time with your provider is over to SPEAK YOUR PIECE, and ask any questions or voice any worries. When discussing the results and the plan, I may ask my patients, “Does that make sense?” or “Do you have any questions or concerns?” to make sure they have one last opportunity to speak. Your provider may be stressed or feeling rushed, so be pro-active and be heard.

Let’s close out this episode by finishing our chest pain case. In this scenario, you are lucky: your testing is normal, you’re feeling better, and the provider has determined that you do not have an emergency. So, the PLAN is that it is time to go home -> you are being discharged. Besides addressing your results and any worries you have, the provider or nurse will summarize your discharge instructions. Often the provider will let you know you are being discharged, go over all of this verbally, but then a nurse may actually hand you the paperwork and formally discharge you. 

Discharge instructions have multiple parts to them, first could be to take a medication being prescribed for your ailment. An antibiotic for a UTI or acid reflux medicine for the chest pain that’s likely heartburn. If you are prescribed medication, nowadays many ERs can transmit the prescription to your pharmacy, but I always give the patient a physical slip as well. Sometimes the transmission doesn’t go through so you have the paper copy as a backup. 

Next, the instructions may tell you to follow up as an outpatient with a primary doctor or specialist. If you do not have a primary doctor, please let your provider know and they can recommend someone. With chest pain cases, I may ask the patient to follow up with a cardiologist. We do not make these appointments for you, this is on you to be a self-starter: call some offices, and start making appointments.

Perhaps the most important portion of your discharge instructions are your return precautions. These are reasons for you to return to the ER. These will be included in premade information about your diagnosis and your provider can also write specific ones for you. As a standard I always tell patients to return if they have a worsening of their condition, specific pains, difficulty breathing, fainting, stroke-like symptoms, etc. Specific return precautions could also be leg swelling for the chest pain patient, signs of infection for a patient who presented with a cut, or vaginal bleeding for a pregnant patient. Return precautions are very important because new or worsening symptoms could mean something serious is developing and we need to re-evaluate you.

Your discharge instructions will also have a lot of general information about billing, medical records, and descriptions of your diagnosis. Speaking of your diagnosis, it may not be a definitive answer. Many patients who present with “chest pain” are given a discharge diagnosis of well…“chest pain.” I may have a strong suspicion of what is causing your chest pain, again, acid reflux, but I can’t prove it and so the formal diagnosis on the chart will just be chest pain. In the ER, it is often more important to confirm you do not have an emergent condition than it is determine the exact cause.

That’s it for Part 2 of this topic but don’t worry, Part 3 is already out, ready for you to listen! Next episode I’ll talk about arriving by ambulance, being a main side patient, and admission.

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