17 January 2008

Advice from CNN

In response to the Glenn Beck incident, CNN posted an article today on "What not to do in the ER." (h/t gobiidae) After some context about long waiting times, the bullet points are below (with my responses):

1. Don't forget to call your doctor on the way to the ER. When ER doctors hear from a fellow physician, they listen.

Better advice might be to call your doctor *before* you decide to go in. If you are not so sick that you need 911, then you probably have time to call your doctor. You may not need to go to the ER at all. Maybe they can advise/reassure you over the phone, call in a prescription, make arrangements for an office visit, a specialty referral, or even a direct admission. However, don't expect that a "call-in" is going to have much of an impact on your ED visit. We won't have a bed waiting for you, you won't be seen any sooner than your complaint would otherwise require, the doctor who took the call may not even be on duty any more, and unless your doctor has important background/technical information about you, the call is just wasted time for both of us.

2. Don't use an ambulance unless you really need it.

Amen. What more can I say?

3. Don't be quiet. If the triage nurse -- that's who makes the decisions about who needs care first -- isn't helping you, don't stop there . . . Speak up. Say, 'I need to see the person in charge.'

Great advice. Wonderful. All we need is for every patient in the waiting room aggressively advocating to be bumped to the front of the line. Disruptive behavior by patients and families is a huge time suck and slows the process down for everybody else. The truth is that if you are in the waiting room, it is for one (or more) of these four reasons: your condition is such that you can safely wait; there are sicker patients who need to be seen first; the ER does not have the resources to care for you now; or the triage nurse has made an error in his/her evaluation of your condition. Complaining to the charge nurse or administrator on call will not change the first three, far more common, situations. If you really think that the triage nurse didn't understand the situation, or if something changes while you are waiting, then, yes, do speak up. But otherwise, frustrating as it is, accept that your spot in the queue is what it is and deal with it. I've been there. It sucks. But until the ER crisis abates, wait times will be a fact of life for most, and complaining won't change that.

4. Don't get angry, and don't lie.

Oh god yes. Disruptive, complaining patients are hard enough to manage. Once emotions are unleashed, things grind to a halt. The staffer(s) who have to de-escalate the angry person get nothing else done till things settle down, and then those staff (be it a doctor, nurse, tech, or administrator) are always themselves upset -- it's a natural reaction -- and need to take a break of their own to reset their attitudes before they get back to work. So getting angry just pulls people off their real jobs and slows everything else down. And lying -- don't go there. If you get busted, and you probably will, you will almost certainly get labeled as a malingerer and whatever real reason you came for will be lost. And you may get subjected to unnecessary medical procedures and risks -- "chest pain" becomes a CT scan with lots of radiation, or "worst headache" becomes a spinal tap, etc. Don't ever lie to your doctor.

5. Don't forget the phone. If things get really bad, and no one is helping you, look for a house phone, dial zero, and ask for the hospital administrator on call.

See #3 above. Also remember that ER staff are people, and when you precipitate confrontations such as this, there is a natural reaction that damages the therapeutic alliance we want to have with patients. The staff won't like you. They will label you as a complainer. They may passively-aggressively sabotage your care in small but unpleasant ways. I don't condone it, and I try to be professional as do we all. But it occurs. Furthermore, excessive complaining and escalation of complaints is a common manipulative behavior, and will raise a legitimate suspicion that the complainer has "an agenda." Most commonly, it's narcotics. Sadly, we also see a lot of folks with various mental health and personality disorders, and these people are more likely to generate complaints. I realize this is advice with a "chilling effect." But it's truth: there are down sides to being too much of an advocate in health care settings. Know this, and make sure that if you do decide to complain, the potential benefit exceeds the likely cost.

Advice they should have given, but did not:

6. Pick the right time to go to the ER

Some may say that if you can choose when to go in, it's not an emergency and you shouldn't go at all. Realistically, there are times/conditions when there is no viable alternative. Holidays and after hours. Those with no doctor or insurance. Certain things many primary care docs just don't do, like setting a fracture, draining an abscess, IV fluids, etc. So, if you can wait and pick your time to go in, you will be much better off. Early mornings -- 6 to 10AM are reliably quiet and you may well be seen promptly. Early evenings 5 to 9PM are by far the worst. After midnight can be good, but between 3-6AM staffers are tired and more prone to making mistakes.

7. Pain is your priority, not ours.

That sounds bad, doesn't it? But my job is first and foremost to make sure you are not going to die or suffer a serious complication, and to make sure the other 40 patients in the ER are not going to die or suffer a complication. For us, it's all about risk, and despite the propaganda, pain is not a vital sign. Severe pain might bump you up a triage category, but it's not going to put you ahead of someone with heart symptoms, difficulty breathing, a serious infection, or stroke symptoms. Yes, we will do our very best to get your pain managed to an acceptable degree, and it is part of our mission to do so. But patients need to understand that if pain management is your main problem, there will be a disconnect between your sense of urgency and ours. If your pain is very acute -- a kidney stone, a long bone fracture, urinary retention, it will garner faster attention than long-standing pain. When things are going well and nobody has to wait (see #6), then we can and do make pain control the priority. But when demand exceeds capacity, the life threats come first.

8. Pay no attention to the man behind the curtain.

Chances are, you will hear the ER staff chatting about non-work related things. It may sound like they are slacking off, or not paying attention to work that needs to be done. Remember, that this is a job for us, and the same social/personal milieu that exists in any other workplace also exists here. I know patients don't like to be an audience for these interactions, and I tell our staff to try to keep the chatter down and out of sight because of the negative perception it generates. But the concept of "acoustic privacy" is new in ER design and in most ERs the patients can hear the conversations from the nursing stations. The fact that we are having conversations does not mean we are not working hard -- often we talk as we chart, review labs, and perform other patient care activities, and in most cases there are rate-limiting steps in patient care that leave us with non-productive time to interact with our co-workers. Maybe I'm waiting for the specialist to return my page. Or the nurse is waiting for the pharmacy to tube down your meds. Or there is no bed to take you back to. So please don't take offense at the fact that not every second of our time is consumed by direct patient care. However, if you do overhear someone say something inappropriate or derogatory, don't be afraid to call them on it. A reminder that patients can hear and are listening is often helpful.

9. Be realistic, and be understanding

We are on the same team, we share the same goals, and we really are working hard for you. Our job is not easy, there are obstacles to care, and outcomes are not always perfect. Everything takes longer than we (and you) would like. The average ER stay in the US is something like three hours. Work with us, be pleasant, express gratitude when it is earned, and be forgiving of our failures. If you can make a positive personal connection with your caregivers, chances are we will work even harder for you. If you are hostile or express a sense of undue entitlement, it will make it harder for us to empathize with you and your care will be adversely affected.

10. Ask a lot of questions.

We are often in a hurry and talk quickly using medical jargon. If you don't understand your diagnosis, the treatment, the alternatives, or the follow-up plan, PLEASE ASK for clarification. If you go home and do badly because we failed to explain things such that you could understand, that is our fault and our liability. So you do us a favor, as well as yourself, when you take a moment to make sure you really understand the plan. Most health care professionals enjoy educating patients, so it's not burdensome to ask. Sometimes your questions are revealing and very helpful.


  1. About number 2: My husband had neighbors take him to the E.R. two different times. He had a heart problem, but it wasn't diagnosed until two years later. We "decided" it was panic attacks.

    After open heart surgery, his cardiologist told him to ALWAYS call an ambulance for chest pains, dizziness, or anything that might be heart-related, because he might need to be resuscitated. That would keep him alive on the way to the hospital.

    Sometimes it's hard to know whether you need an ambulance or not.

    Just my two cents.

  2. Old EMT saying -- Air goes in and out, blood goes round and round, any variation on this is a bad thing.

    Blood all over the floor; might be a heart attack; some reason that breathing isn't going well... these are fair, just, and reasonable causes to call an ambulance.

    There are many others, but the heart and lungs are high-priority organs.

    Stubbed toes, hang-nails; these are NOT.

    OH, and so y'all don't get upset or grumpy... I HAVE SEEN PEOPLE DO THIS. My husband (a paramedic) got called at 3:30 in the morning to a man who wanted a band-aid.

  3. However, if you do overhear someone say something inappropriate or derogatory, don't be afraid to call them on it. A reminder that patients can hear and are listening is often helpful.

    Can you say more? I can't think of a way to do this that doesn't shame the speaker publicly or otherwise make them resentful.

  4. House Whisperer1/17/2008 6:48 PM

    The CNN article was written by an imbecile who did no research. The majority of those recommendations are entirely self-defeating.

  5. 3. Don't be quiet. If the triage nurse -- that's who makes the decisions about who needs care first -- isn't helping you, don't stop there . . . Speak up. Say, 'I need to see the person in charge.'

    Great advice. Wonderful. All we need is for every patient in the waiting room aggressively advocating to be bumped to the front of the line. Disruptive behavior by patients and families is a huge time suck and slows the process down for everybody else.

    Sorry, but the advice given on this one wasn't bad. There may be a fine line between advocating for yourself or dependent and just being selfish in terms of trying to get ahead in the line. But, as someone that has spent hours upon hours navigating hospitals and clinics, I know that often doctors/nurses/administrators/receptionists/etc do what they do for no other reason than it is what is easiest for them. Or because it is just how they usually do something. Sometimes you have to "advocate" for yourself or someone else. And sometimes "advocate" means be angry and express your anger.

    Now, specifically in the context of hurrying up an ER visit, you are probably spot on. Even knowing you very well though, I can't help but bristle at the tone of your response on this one. It is probably my emotional baggage and anger, but I hate it when doctors or others put on their condescending tone over length of wait or other comfort issues that sometimes can be accommodated and make a huge difference in the emotional well-being of the patient.

  6. Luke,

    I see we are on the same page here, but it's worth clarifying that I intended this advice/commentary to be applicable in the context of the ER waiting room, and the concept of triage in particular. Certainly I would not extrapolate this to more general medical settings, or to decision-making in terms of detailed decisions of what care will be provided and how it will be provided. That's a whole nother ball of wax (and a good time to address the idea of the therapeutic alliance).

    And again, triage nurses do make mistakes. I remember when I brought my post-partum wife into an ER with a kidney infection and a temp of 105. We sat patiently in the waiting room until she began to faint, and then I got up and told the triage nurse that we needed a bed immediately. So I'm not opposed to advocacy, but in the right measure and the right time...

  7. Great post!

    When I'm the triage nurse and a patient complains about being not brought back quickly enough, and the usual speech about "we see heart attacks and strokes and things first" doesn't work, and sending the patient to the patient relations person doesn't work, I have NO problem calling the nursing supervisor. Most of them reiterate exactly what I've told them and are able to see if there are any other alternatives, leaving me free to do my job.

  8. A trick I learned years ago when patients started complaining about the wait..I always redid their vitals without complaint.
    This seemed on the whole to settle them.
    Sometimes we forget as people who live in hospitals that other people view hospitals as the place people die in. This makes them scared as they do not want to be one of the dead people. Rechecking their vitals and telling them they are hanging in there settles their fear.
    I also compliment patients for waiting and I let them know what is going on. If we have real emergencies I tell the waiting room and let them know it's all hands on deck in the back for a bit until we get things settled down.

    If you ignore people, don't let them know what is going on and refuse to see their fear ? Well, then you get waiting rooms that are out of control.

    If after all that people are still harassing? I call in the management and let it be their problem.

  9. Last time I was in the emergency room, one of the workers there advised me to leave, and call an ambulance. He said that you should never come in on your own because the ambulance patients always get priority.

    Sorry, but writing in pain on the floor IS an emergency, and no one should have to wait hours to get pain relief. What's the danger of pain relief anyway?

    What's your feeling about being made to lie on the floor when there are available beds? I'm thinking of lodging a complaint with the hospital, but an unsure if I'm being unreasonable.

    I wasn't seen for about five hours, and I was on the floor in my own vomit for all of it. BTW: my diagnoses ended up being an ovarian tortion - not pleasant. Is that not enough of an emergency to at least warrant a bed?

  10. Pain is not an emergency. Pain can be a signal for an emergency, but pain, by itself, will not kill you. The jobs of everyone in the ER are to do these things, in this order.

    1) Make sure nobody dies
    2) Make sure nobody has some sort of serious complication that will result in death in the near future
    3) Make sure nobody gets some sort of permanent damage
    4) Make sure nobody gets temporary damage
    5) Make sure nobody has intolerable pain.

  11. Very good post. I do agree with most of what you say here. When people are sick, or hurting, etc. they tend to forget that the ER staff are humans too, and as such they cannot perform miracles. Test results take time, the beds are all full, the staff have as many patients as they can safely care for currently, etc.

    I have been in the unfortunate situation as to require the ER services at my local major metropolitan area on multiple occasions, and as a result have learned many lessons. I am a multiple organ recipient (liver, kidney, pancreas, and small intestine). My doctors and I have had to resort to using the ER on occasion to admit me to the hospital after hours (hospital requirement), and it is usually not a pleasant experience for either the staff or myself. At least most of the time now, when I go in, they have been warned ahead of time that I am on my way, so I get right back to a bed, and we usually always agree that I'm as afraid of them as they are of me.

    So some of the lessons I've learned is that yes, for people with major chronic medical issues, absolutely DO call your personal physician. The ER staff needs to know that someone is coming in with problems not normally encountered on a daily basis. And no, I will never call an ambulance unless I am passed out because, well, they scare me too, and they have absolutely no idea how to help me as opposed to my immediate family who very likely does.

    But there are also things that the staff needs to know. First off, I have lived for 17 years with a chronic medical condition, the last 7 1/2 with my "after market parts", so I know ALOT about my condition and what is needed to get me through whatever crises that has brought me in, so listen to what I have to say, it could save both of us time and trouble. Second, don't treat me like I'm a junky on a bad trip needing a fix when all I'm asking for is saline with bicarbonate because I've been excreting body fluids out both ends of my new intestine so quickly that I am acidic, I know when my CO2 has dropped to just barely above a 10, and waiting 30 minutes for the blood test can be bad. I'm just trying to stay alive and avert a crises. Thirdly, if someone comes in with a known medical condition that you have no experience with, or have no clue how to treat, PLEASE get someone who does. I learned the hard way on more than one occasion that I should ALWAYS question the treatment of a physician I don't know before the treatment is started, and that I can and will refuse treatment if I feel that I need to until my own physician either lets me know that he agrees with said treatment, or he writes the order himself. So even if you think you know the best treatment because you have seen something similar, please do me a favor and make sure you're right first (and be prepared to defend your decision, many of us have educated ourselves on our conditions and have no problem with questioning your judgment). I have run across many hospital staff and physicians that think they know how to treat transplant patients, but have never seen (and in some cases never even heard of) someone with an intestinal transplant. And unfortunately an intestinal transplant is an altogether
    different beast. For me, there is no such thing as a "simple" belly ache because I have adhesions and narrowings that get blocked, and mild dehydration can cause rejection that doesn't show up until the intestine is in full rejection and cannot be saved.

    So please forgive those of us with real chronic medical issues, we have learned many things the hard way, and experienced too much unnecessary hardship because of physicians and staff at other times. And don't get upset with us if we question decisions and orders. Because for me, personally, I'm just trying to stay alive.

    Thank you for allowing me to express my opinion as a patient:)


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