16 December 2006

Expectations

KevinMD linked to an unfortunate guy named Dave who is fighting a tough disease and had a really tough day at the ER. It struck a nerve with me, since I see the same thing every single day of my working life, though not so much from the patient's perspective. I flatter myself that I am better at handling it than the ER doc Dave had to deal with, but I have enough insight to know that I have good days and bad days.
Dave was understandably upset about a whole bunch of things: he wasn't seen in a timely manner, his pain was untreated for a long time, the staff seemed to lack compassion, the ER doc listened poorly, the doctor's office was unresponsive and poorly communicative, etc. Pretty frustrating. Part of the frustration was, I think, due to unrealistic expectations of what happens in the ER. Some of the problems may be avoided and/or mitigated in the future with different strategies. Here were my thoughts for Dave and others like him.

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I have a close family member with IBD, so I have some sympathy for your situation, but as an ER doc, sadly, I have to say that your experience is typical, and future expectations should be tempered by the reality of our "wonderful" health system.

Several reasons:
1. ERs are terribly overcrowded. in 1992 there were 6000 ERs nationally seeing 80 million patients. In 2004 there were 4000 ERs seeing 110 million patients. Our ER has not been significantly expanded in over a decade and we see nearly double the volume we used to. So private rooms are a thing of the past, and hallway beds and long wait times are all too common. A three-hour wait is actually on the short end of the spectrum in many ERs, if you have a non-life-threatening complaint. Sadly, a crohn's exacerbation is not dangerous, so you will be at the bottom of the priority list, but requires a lot of resources (bed, IV, labs, X-ray), which will keep you out of the Fast Track.
2. Private MDs rarely ever see "their" patients in the ER. It has become the standard for the ER docs to primarily see every patient and only consult the specialists as needed.
3. "Chronic condition with painful exacerbation" is, sadly, not best treated in the ER. The docs don't know you, may not trust you (due to the high prevalence of drug seekers), and pain perception is so variable that pain of 10/10 is not a priority for the ER staff. It's a grim joke for us that every patient rates their pain as a "ten." Makes it hard to sort the wheat from the chaff.
4. The fact that you were acting as if you were in pain doesn't mean much to us either, since we see so many hysterical people and fakers that all overt demonstrations of pain are taken with a grain of salt. In fact, the general rule in the ER might be that the more vocal a patient is about their pain, the less likely it is than an objective diagnosis will be determined. We are human and have our biases, and tend to respect stoicism. This ironically means that the less you complain, the more sympathetic and responsive the staff tends to be.
5. A better strategy for you is to have a plan with your GI doc of what to do at home when the pain spikes. Have a limited supply of some really strong pain meds which is to be used in case of emergency, and use it only very rarely. And honestly, IV pain medicine is no stronger than oral. So as long as you are not vomiting, oral medicines are preferred. Also, IV pain medicine can be more addictive and seems to decrease the pain threshold for the next episode, and are best avoided for that reason.
6. When home management fails, if it's during working hours, it's better to coordinate with the clinic than brave the ER. Get a same-day appointment if possible, or walk in. Coordinate a direct admission to the hospital, if it's probably going to be necessary. To be sure, some private practices are resistant to this, but the ER (as you learned) is generally not the best place for treatment of non-emergency conditions and should be the option of last resort.
7. Complaining, criticizing, demanding, and threatening the staff (i.e. asking for an administrator) will not endear you to the staff at either the ER or your doctor's office. The staff are human, and their reaction to perceived manipulative behavior will be to get defensive or passive-aggressive. The squeaky wheel does not get the grease. You will get labeled as a drug seeker or fired from the practice or undertreated or treated last. You *are* dependent on the good will of the staff (at both sites), and alienating them is not in your best interests. I do not defend bad behavior on the part of the medical folks, but you have to live in the real world.

Sorry you had a crappy day, and sorry the ER doc was a dud. Good luck to you in the future.

Shadowfax

7 comments:

  1. Great post! Very educational: thank you.

    I once saw a patient who'd lost a finger (via amputation by sword by enraged S.O.) threaten to murder the ER staff when they said the finger couldn't be reattached. Everyone felt really sorry for this patient, but threatening homicide wasn't going to change the medical situation, much less create a good relationship with caregivers.

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  2. Anytime a patient mentions they have a high pain tolerance, I know that a splinter in their finger would send them over the edge.

    I hate to say this, but one tends to become extremely cynical in this business because so many of us have been manipulated by patients when we were once young, wide-eyed, gullible and naive.

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  3. I understand your comment that the ER is not the best place to go during office hours for break-through pain that is just untolerable, but...

    I have migraine headaches and asked my doctor just last month during a visit what should I do if I have another like the one I had just gotten over. I mean I was hurting so bad I just knew I was about to die ande welcomed it. I was throwing up with barely any time to come up for air in between.

    I asked him if I come to his office would he give me something or just what should I do. He TOLD me to to go the ER. He said he did not keep anything strong in his office so it would do me no good to go there.

    I have never went to the ER with the headaches...not because there were not a couple of times I wished I would just hurry up and die, but because I was afraid of being suspected of being a druggy and wind up sitting there and not being treated anyway.

    My doctor has seen me for years. He knows I am not an addict. This is just how he runs his practice and I'm willing to bet he is not far from average.

    Not pretending to know the answer, because I cn see where some of you may have been burned in the past, but if I were going to err, I believe I would rather err on the side of possibly easing someone real pain.

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  4. the stoicism thing is interesting.

    after a car knocked me off my bike and under its back tire, the apologetic driver drove me to the hospital, and i limped into an e.r.

    because one foot had gone under a tire at an unplanned angle, the bleeding knee was on my "good" leg. the other leg looked fine, but the foot was in fact proceeding to swell up and turn purple. i hobbled up to the the admission counter and said i'd been hit by a car and was having trouble walking. i only started crying when i saw the blank look on the e.r. admitter's face. never having been to an e.r. before, i was at a loss. did it mean that:
    1. he didn't give a damn about the whole not-being-able-to-walk thing?
    2. he didn't believe me?
    3. he didn't know what to do about it?

    i'd started out stoic. the pain in my squashed foot was an eight -- nothing compared to finger loss or migraines that make you vomit. but that blank look broke me right down. if e.r. admitters don't know what to do when you can't walk any more, jeez, who does?

    i think it was the blubbered words "i'm bleeding" and limping around the counter to point at my concrete-filled kneecap that finally got me a wheelchair -- exactly what i needed and didn't know to ask for.

    i don't think i got briefly uncaring treatment because i was weak. i suspect it was quite the opposite: i got it because on the surface, i was a healthy, strapping young lass with a scraped knee, and i didn't have any experience to help me communicate whatever it was e.r. admitter guy needed to hear. i repeatedly forgot, throughout the evening, to tell people that my foot had been squashed, so i suppose multiple people may have seen me that day as a drama queen with a scraped knee.

    the expectation that when you go into the e.r., competent and intense people are shouting your relevant information to several doctors waiting with multiple beeping machines is an unfortunate result of your profession being so darned telegenic.

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  5. I personally think the ER is useless for treating pain. Most of the chronic pain patients I know who’ve gone to the ER have done so when their pain is absolutely unbearable, and they can’t take it anymore. Many of your patients are reporting level 10 pain because they are, in fact, in level 10 pain. Most people with chronic pain have an unbelievable tolerance for pain, as I ‘ve witnessed seeing some of the ladies in my group go through the ordeal of breast cancer surgery and another guy who was impailed by a forklift but refused meds. They don’t go to the ER for nothing. When someone with chronic pain says they are hurting, they are most definitely hurting bad.

    But when these people show up in the ER, most receive little or no treatment and are more often than not dismissed with the “drug seeker” label if they dare to ask for meds, discuss which meds work for them and which don’t, show up in sweatpants...you get the picture: the usual evidence-based, infallible criteria used by the medical profession for the identification and elimination of drug seekers.

    If you have chronic pain and need help, try to get to a legitimate pain specialist. If there is a chronic pain support group in your area, go there and ask which doctors are willing to treat pain appropriately and which ones you should avoid like the plague. Unless you are feeling suicidal and absolutely can’t bear the pain, don’t waste your time with the ER. If you do go, try not to ask for pain medication if you can avoid it but ask for an emergency referral to a pain specialist instead. Try to verbalize to the doctors the exact nature of the pain and how the pain is effecting you, as you may be dismissed as a faker if you groan and grimace but also if you are too stoic and don’t grimace at all.

    Most importantly, do not let them abuse you. You have a right to be treated with dignity and respect. Insist on it. Get a copy of your records afterwards and if they have labeled you a drug seeker, demand that the comment be removed from your records or you’ll sue them for libel. Most hospitals won’t take the threat seriously, but will choose the path of least resistance anyway. Don’t allow crap like that to fester in your records as it will come back to haunt you.

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  6. Redhawk:
    Most of your comments are right on. Treating patients (even the worst of them) with dignity and respect is an absolute. The ED is not ideal for treating chronic pain. Pain specialists are definitely superior, when available. "Labeling" a patient a drug seeker in the records is dangerous and unprofessional. Thanks for contributing.

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  7. Just came across your blog and love it! I also read the guy"s blog on his trip to the ER. Now if you are having 10/10 pain to me you are not able to get dressed and walk out of the ER. Also, if you need to get to a doctors appt, take a cab if you have too. If you are ill enough to need the appt, find anyway you can to get there! duh Oh yeah, I am an RN with a chronic, terminal disease so maybe I am just a bit jaded by pt's like this guy!

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