Episode 4: How Being a Patient in the ER Works, Part 3

The final part of our 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 the final part of our series about how being a patient in the emergency department works. Please make sure to listen to our previous episodes, including episode 1, the introduction to the podcast…Please? C’mon…

Ok so last episode we discussed the process of being seen by a provider as a walk-in patient. In this case the patient had their workup completed in the front, or Fast Track, area of the ER, found to be OK, and discharged. This last episode will focus on arriving via ambulance, being a main side patient, and admission to the hospital.

Before we get into it…I wanna let you in on a little secret. Are you ready? No? Well…too bad, here goes…calling 911 and coming in by ambulance does not guarantee you are seen by a provider any faster! This will not ensure you get a main bed either! If you are not in distress and have normal vitals, then you’ll likely get sent to the waiting room and get triaged as if you walked in. As I said last episode, main beds need to be reserved for patients that must have them. This will especially be true if the ER is busy. When the ER is busy, that means there are already people waiting for a main bed long before you arrived.

Now, of course, if you arrive via ambulance in distress then you’ll have a lower emergency severity index or ESI number (remember that from last episode?) and you’ll be seen right away. This could be due to a patient having dangerous vital signs, unconsciousness, severe injury, difficulty breathing (such as the case we’ll use soon), obvious heart attack on EKG, obvious stroke symptoms, acute psychiatric emergency, you name it. 

I am not saying any of this to dissuade anyone from calling an ambulance. If you’re having a medical emergency, then do not hesitate to call 911. EMS personnel such as paramedics and EMTs (emergency medical technicians), are trained medical professionals. They can recognize emergencies and render initial treatment. If you call 911 for chest pain, EMS can perform an EKG, recognize a heart attack, give you aspirin, and let us know you’re coming. If you call for hives or itching. EMS can spot your allergic reaction and give you immediate medication.

As an aside here, never say “ambulance driver,” this is an incorrect, outdated term and disrespectful to our EMS.

Another thing to point out is that if you arrive via ambulance and get assigned a main bed, that still does NOT mean you will require admission to the hospital. We’ll use a hypothetical case of a patient with shortness of breath to see how paths could diverge. For this example, you have a history of asthma and you develop shortness of breath at home. You believe this is due to your asthma flaring up, or an exacerbation. Despite using your home medications, perhaps an albuterol inhaler (which dilates the lower airways), you’re not improving so you call 911 for help. 

EMS arrives and recognizes you appear short of breath and are wheezing, suggesting it is likely an asthma exacerbation. They take your vital signs and render immediate treatment, such as nebulized medication, a mist you inhale, and transport you to the ER. Weaving through traffic and speeding to the ER as fast as possible is not without risk. The severity of your illness, often measured in Priority codes where 1 is the highest, will determine if the ambulance goes all “lights and sirens” or if they drive in a normal manner.

When you arrive, you’re registered and triaged in the same manner as if you walked in, except you’re sitting on an EMS stretcher or wheelchair. For our case, the triage-er determines that you’re better suited to be treated in a main bed…assuming one is available. A main bed room has a stretcher, a vital sign monitor, oxygen and suction ports on the wall, a sink, a supply cupboard, and, hopefully for you, a TV. It’ll often not have a door, just a curtain. If an ER is especially overcrowded there may be beds that aren’t even in rooms but in the hallway. That is the current state of the American medical system.

Thankfully the benefits of the main bed are not the décor, but that you’re in a monitored setting, have a nurse assigned to you, and seen by a provider faster. Remember, your nurse and provider are taking care of multiple patients at once, some of which may be critically ill, so please be patient (haha).

For our shortness of breath case, your nurse places you on the vital sign monitor so that we can have a real-time display of your oxygen saturation, heart rate, blood pressure, and respiratory rate. Your provider performs your history and physical and agrees you are likely having an asthma exacerbation. They order testing similar to that of the chest pain case: EKG, blood work, and chest x-ray, and maybe add on a COVID/flu swab. This would be done to make sure nothing else is going on, which I’ll touch on later. While this is all happening, your provider orders and asks your nurse to give more nebulizing treatments and medications, including a steroid like dexamethasone, to decrease the inflammation. 

As you’re sitting in your bed, having testing or treatments done, you may notice something that I also mentioned about the waiting room in the previous episode. The ER can be a loud and chaotic place, filled with people from all walks of life and in various states of health. While you won’t see much from your main bed, you will hear…a lot. Staff running to critical patients, patients vomiting or coughing, security being called to help restrain violent patients. 

Just remember, you won’t know the context of what you’re hearing. That patient yelling for help? Maybe they’re not in pain but have dementia and their nurse has already been in their room multiple times trying to redirect and calm them, all while other patients need attention too. You heard staff yell at a patient? Maybe you didn’t hear the racial slur or threat of violence the patient used a minute earlier. We can’t kick patients out because they’re inappropriate or even threaten us, we have to make sure they’re ok.

Anyway, as with being taken care of in the front, your provider will need to interpret the results of your testing as they become available. Now hopefully, you feel much improved with the asthma flare medications. Your repeat vital signs are normal and your testing shows no dangerous abnormalities. Your provider reevaluates you and you discuss being discharged. Perhaps your nurse will have you walk to see if your oxygen drops or you become too short of breath. If everything looks OK, then you are discharged in the same manner as laid out earlier. In this case, you are prescribed a steroid course and refill of your inhaler. Your return precautions stress that if your breathing again worsens, to not delay returning to the ER.

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…being prepared to be admitted! Are you heading to the ER or calling 911? Do you have a moment to spare? Then prepare yourself to get admitted! Call your family, gather your medications, bring an extra layer, bring a book, bring a phone charger, you name it! Don’t have the time? Then don’t sweat it but if you do then give it a shot. “But wait,” you say, “I won’t get admitted.” Maybe not but if you feel ill enough to come then there may be something wrong, right? So go ahead and mentally prepare yourself for admission as well. If you end up needing it, you’ll be happy you came ready!

Now, back to the show:

We’re now going to rewind and see how this case could go differently and instead you require admission. Let’s say the initial presentation is the same, you arrive via EMS with shortness of breath and are placed in a main bed. Your provider again believes this is due to an asthma exacerbation but note that your oxygen level is low, and puts you on continuous oxygen via a nasal cannula (two little plastic prongs in your nose). After your initial round of treatment, your breathing has not improved and you are still wheezing significantly. 

While this is going on, your workup finishes and your provider informs you that this isn’t just an asthma exacerbation, but you have something else too, perhaps pneumonia or COVID. You are going to require further treatment and monitoring and while you aren’t critically ill, you certainly aren’t well enough to go home. You are simply at too high risk for decompensating to be discharged. You’re getting admitted. 

Admission to the hospital means that a patient will be staying at least one night and be moved to an inpatient bed, or “upstairs” as we say, to be taken care of by an inpatient team of providers and nurses. During admission you will have more testing, medications, maybe procedures, and just plain ole observation to ensure your condition improves. Some patients are discharged within a day or two, and others much longer. In our case here, your provider contacts an admitting physician to give “sign out,” as in presents your case and why you require admission, and the admitting physician accepts you onto their service, agreeing to take over your care. 

The admitting provider is generally a hospitalist or medical resident trained in the field of Internal Medicine. If we had a completely different case and we were admitting a child then the inpatient physician would be trained in Pediatrics, or…Surgery if we were admitting an appendicitis case for instance. Some patients require consultations, or for your provider to call a specialist to weigh-in on or assist in your care. This can be something simple, such as a cardiologist confirming your EKG does not show an active heart attack, or something more involved, such as a nephrologist arranging for hemodialysis while you’re admitted. This consultant may not be admitting you to their service, but they will be pivotal in your care.

I’m probably going to devote an entire episode to this, but I’ll touch briefly on boarding here. Boarding is when a patient is technically admitted to the hospital as the hospitalist has accepted the admission but there is no inpatient bed available. This can be due to overcrowding and understaffing. There may be beds that are physically empty in the hospital, but with no nurse to staff them, no patient can be placed there. With no inpatient bed to be sent to, inpatient boarders simply have to wait in the ER. The inpatient provider taking care of them will put in orders for further treatment and testing, but it is up to the severely overtaxed ER nurses and other staff to carry them out. Unfortunately, this means there will be delays.

When the hospital is especially overcrowded and understaffed, sometimes admitted patients sit in the waiting room! Not even an ER main bed is available for them. This is particularly stressful for everyone and we as caregivers hate it as much as the patients. Days like that, when the ER reaches a breaking point, there is no space and everyone is upset, may make the ER staff even question their jobs, but they’re still coming back for their next shift. Please remember that if you find yourself in this situation. 

To close out this episode, I’d like to touch on some miscellaneous topics. I’ll likely address these again in future episodes as well.

If your gender identity or preferred name is different from that listed on your ID or insurance card, please let us know. At my hospital, our medical record is not capable of representing a transgender person, and so we generally list the patient’s biological sex and legal name and then make a notation as to their preferred pronouns and name. This may be distressing for some patients but it is important for us to know your biological sex. For instance, if you are a transgender man, I may need to know if you are physiologically capable of becoming pregnant but also I want to address you properly.

Moving on, I want everyone to understand that the ER is about finding and treating emergencies. We have limited time and resources and can’t do everything. I often tell medical students to think about not what does the patient have, as in what is their definitive diagnosis, but what does the patient NEED, as in what testing do they need to rule out an emergency. If a clinician anchors on a diagnosis they think you have, they may omit a crucial step needed to rule out something more serious. 

Frequently, we discharge patients with a diagnosis of just, “pain”, such as chest pain or abdominal pain. We may tell the patient our best idea as to what exactly is causing their pain, but we are not making a formal diagnosis. We are ensuring that they are safe to be discharged, perhaps with some medications, so they can follow up with their primary doctor to get more answers down the line. This can be frustrating for patients but that is how it works. We have our clinician judgement and our diagnostics, we can’t wave a wand to tell us what’s wrong.Nor can we wave a wand to treat you. For many of you this goes without saying, but if you’re coming to the ER, expect to be offered medication. Medications are the primary way that we can improve your symptoms and treat your condition. If you’re the type that doesn’t want to take any medications and you come to the ER, then prepare to be triggered. If you refuse to let us help you, then that’s that. But it’s also important to remember these medications are not magic, they do not work instantly nor will they make your pain disappear completely. That will take time.

Many ERs are limited in the sense that MRI or other testing is often not available and certain specialist doctors are not in house. With limited time, resources, and staff, we can’t check for everything. If you’re able to, it’s important to understand what ERs are available to you, and determine which is right for you. Is all of your specialty care at one hospital or did you just have surgery? BY THE FATES please go to the same hospital. I cannot tell you the number of times I see a patient who just had surgery and they tell me, “The surgeon told me to go to any ER.” NO, go where your surgeon actually works!

In the same vein, if you have options, go to an ER that has the specialty you need on call. Do you have a complicated history of eye problems, figure out which ER has ophthalmology on call and go there! You can always call ERs before you visit to ask them this simple question: “do you have this specialty in house?” If you go somewhere that doesn’t have access to who you need, you may waste hours and hours as your provider struggles to get a consultant from another hospital on the phone and then try to transfer you. I literally just had this happen.

Well, that’s it for the final episode of this series. Try to hold on and we’ll back with an all new episode in two weeks!

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Thanks for listening and all the best!