Thursday, December 16, 2010

Patient's Guide to the Emergency Department

During my last month of working in the Emergency Department, I've come to realize that patients have a lot of misconceptions about the ED. I became inspired to write a sort of "Patient's Guide" to the ED, to air some of them out.

1) Their goal is not, ultimately, to figure out what's wrong with you. Don't get me wrong; a lot of times they will. At the same time, that's not their ultimate goal. There's a lot of patients they need to see, so what they need to do is get you out of the ED as soon as possible. That either means admitting you to the hospital, or ruling out life-threatening conditions and having you "follow up with your primary care physician".

2) Not everything we do is medically "indicated". A lot of times, ED docs (ok...ALL docs) order tests and workups that they don't think are actually necessary. Often, this is either because the hospital requires them, or because the ED physician (EP) is afraid of missing something and getting sued. I see this ALL the time. ALL the time. Patient comes in with symptom X and the doc says to me, "Well, I'm pretty sure this guy has condition Y, but we'd better get such-and-such test to rule out condition Z, just to cover our butts."

3) You're at the mercy of our convenience once you come to the hospital. Sorry. There's a lot of waiting around at the hospital. If you come to the ED on a Friday night with chest pain that sounds heart-related, but isn't exactly a heart attack right now, we'll admit you to the hospital and keep you sitting there over the weekend until someone is around on Monday to do a stress test on your heart. We can't afford to take the risk of sending you home and having something bad happen to you over the weekend. That's how we get sued.

4) Kind of the sum of 2+3...You can say no. You can say, I don't want X test. I don't want to be admitted today. If you want to leave, we'll make you sign an "AMA" form...Against Medical Advice. That's not always a terrible thing...we just need it to cover our butts in case something happens to you. Be VERY, VERY careful about saying no, though. I've heard that if you DO end up having a poor outcome because you did something AMA, insurance companies won't cover it. And, of course, there IS that risk of something happening to you. That's why we want to do XYZ to you...because we're not quite comfortable saying your OK. The best thing to do is talk with your ED doc and try to get his honest opinion. A lot of them will be straight up with you...they'll say, I'm not really worried about X, but just to be careful, I want to keep you overnight. Then take it from there.

5) The ED doc doesn't know you. Anything about you: your medical conditions, how "tough" you are about pain, your family history, your social history, etc...Your PCP does. That makes a world of difference. Think about it.

All of this to say: Don't go to the Emergency Department unless you have to. It's not the place to workup chronic conditions. They can't and won't do need to see a primary care physician about it, unfortunately. Things happen more slowly in the "outpatient" setting...but they're also cheaper and you get to go home in between. If you're not sure about whether or not to go to the ED, consider calling your primary physician. They can often help you over the phone. They (should), after all, know you a LOT better than they do in the ER.

Of course, when in doubt...go to the ED!

Wednesday, December 8, 2010

Helicopter Ambulance

How cool is my job--yesterday, I got to fly around with the local helicopter ambulance team. Unfortunately (for me, at least), weather kept us grounded for most of my shift. I got a lot of much-needed studying done, though!

5 minutes (literally) before I was about to leave for the night, we got a call. It was a perfect run for me, because we were basically transferring the patient from one "community" hospital in town to a higher-acuity it would be a lot of up-and-down, but we wouldn't be sitting around for very long, and since it was all in-town, it wouldn't take long.

The helicopter was in our hanger on a flat-bed trailer. We ran out and pulled it out to the landing field and the pilot fired up the engines. Within a few minutes, we were airborne! I had been hoping that I'd be able to fly during the day, but the view of the city and all the Christmas lights at night was a beautiful sight from the air. Literally a few minutes later, we were coming in for a landing at the community hospital.

We landed and the medic and flight nurse slipped the gurney out of the chopper's rear doors. We hustled inside and discovered that an elderly woman had actually been in the emergency room visiting her sick husband, when she had what appeared to be a stroke, and became unresponsive. We heard the rest of her story and bundled the frail, thin woman up as warmly as we could and headed back out in the the sub-freezing weather. We got her strapped in and the chopper headed back up into the sky.

Moments later, we came in for a landing at the larger hospital. As we neared the ground, I spied a little girl and her mother standing in the parking lot near the landing pad. The little girl was pointing excitedly at our helicopter, clearly fascinated. When you do stuff like this every day, I can see how it can be easy for the glamor to wear off. But looking at it all through the eyes of this little girl, it was pretty neat to think about how much of a privilege it is to get to do what I do.

We dropped the lady off and headed back off into the night. I don't know what happened to her, but I hope it turned out alright. My wife says that older couples often pass away within hours, days or months of each other. Perhaps this was the time for this couple...if so, I hope they passed with dignity, and I feel privileged to have been able to help with her care.

In sum, yesterday was exciting on so many different levels. It was such a thrill to ride in the helicopter. It was such a privilege to be able to participate in the care of this elderly woman. And it was really cool to see the fascination in a little girl's eyes as she watched us land.