When I was little, I tried to cheat my grandma at a card game. I don’t remember the specific game; I only recall that it featured Donald Duck and Friends characters on the cards. While her back was turned as she worked in the kitchen, I stacked the deck so that when we drew cards, I got all the good ones. She quickly figured out that I had cheated. She said, “Shame on you,” and refused to play cards with me anymore. I offered to make it right by stacking the cards in her favor, not understanding that that didn’t solve the problem.
My job is to reassure people that their symptoms are not too far outside the norm, or the “bell curve.” Most patients don’t understand what the bell curve means, but when their illness or injury doesn’t progress as expected, I reassure them that their condition is within one to two standard deviations from the mean.
For example, an 80-year-old woman had been dealing with upper respiratory infection (URI) symptoms for over ten days. She visited the clinic and was started on antibiotics for a possible sinus infection and prednisone for wheezing (i.e., reactive airway disease). The prednisone improved her symptoms, but she reported that her previously prescribed albuterol didn’t seem to help. This piece of history is sometimes revealing because, although the patient may not always remember, someone prescribed that medication in the past, suggesting she likely had similar symptoms before. As a provider, it’s reassuring to know the patient has experienced this condition previously.
Besides employers placing ER doctors in the middle of decisions about a patient’s return to work, we also get caught between divorced parents and between parents and their children. This includes parents with minor children as well as parents of adult children. I can tell you that no ER doctor wants to be in the middle of these situations.
In high-conflict situations, it’s tempting to want someone else to solve the problem for you. In high-conflict divorce cases, this often involves one parent bringing the child to the ER for a very minor complaint. The story typically begins with, “Well, they just came back from their dad’s…” or “Mom had them for the weekend…” When I hear that, I know where this is going. The child usually has a minor issue, such as a cough, a stomach bug, a bug bite, mild upper respiratory infection (URI) symptoms, or vague pain. Almost never does the child have a significant medical complaint that warrants an ER visit.
There are only 2 MRIs that typically need to happen in the ER. Brains and spinal cords. There are virtually no extremity MRIs that have to happen emergently. I see patients regularly that have things that could be diagnosed on an MRI… rotator cuff tears, meniscus injuries, torn ACLs. But none of those things need emergency surgeries so they don’t need emergent MRIs. Patients often come to the ER within minutes of a knee injury and they may very well have a torn ACL. But I don’t have to find it immediately. No Ortho surgeon is rushing to the ER to fix it. You would not want them to in most cases. For things like rotator cuff tears and minor tendon or ligament tears, the first line of treatment is physical therapy and pain medicine. This is referred to as “conservative therapy”. Most of the time, this resolves the problem. Surgery is something to consider when conservative therapy fails. It is not the thing that has to happen immediately upon finding an injury.
A 30-something-year-old male presented to the ER via EMS. He has a history of methamphetamine use. On this particular day, he had not made any threats of violence, was not suicidal, and was not homicidal. He had not committed any crimes. However, his pre-hospital behavior resulted in him being brought to the ER.
When talking with him, he was visibly paranoid and regretful of the decisions he had made in his life. He was worried about people talking about him and spreading lies. He stated multiple times that he just wanted good for everyone and couldn’t understand why people were speaking poorly of him or blaming him for things. He expressed repeatedly that he did not want to hurt himself or anyone else.
A 21-year-old male presented to the ER with a couple of days of progressively worsening abdominal pain, now located over his right lower quadrant. As he was telling me his story, his opening statement was, “I use marijuana every day, so I have a high pain tolerance.”
I ignored the ignorance of his comment at the time because correcting it would not have helped our interaction. He had appendicitis, and that was the bigger concern.
At times in my career, my job has been less about actually practicing medicine, especially at a small, rural hospital. Instead of seeing patients, I am the quarterback of the transfer game. This is not unique to my hospital or system. Across the country, providers are doing this same thing literally every shift. Even at medium-sized hospitals that still don’t have all the specialties, there is still a lot of transferring going on. This is how the game is played.
I took care of a 650 pound woman once. She had renal failure and needed dialysis when I met her. We admitted her to the hospital but probably for the last time. Due to her size, she was immobile. She basically had to have six firefighters lift her every time she went anywhere. When it comes to dialysis, that’s usually a three days per week event. Patients that have transportation issues can usually be set up with services to accommodate their schedule. However, that’s usually one driver of a handicap accessible van. That’s not six firefighters lifting her onto an ambulance gurney that is almost maxed out for weight and then picking her up to take her home.
There are lots of metrics by which ER physicians are measured. This has to do with how fast they see patients, how many patients they see per hour, how many patients leave the ER without actually being seen after they check in, how fast patients get their tests done and get discharged or admitted… and there are many more.
I think there are only three metrics that matter:
If nurses see your name on the schedule and they pick up shifts when you’re working or try to work in your area of the ER, if they come to you with personal questions about medical things, and if they bother you when they are worried about a patient.
If you bring your teenager or young adult child to the ER and that person helps “sell” your symptoms to me, I feel sorry for both of you.
Today, I saw a 42-year-old with chest pain and shortness of breath. Her daughter described how Mom “couldn’t breathe” when she woke up, and Mom reported her breathing got worse all day. You probably picture someone struggling to breathe based on that description—i.e., could not breathe in the morning, and now at 3 p.m., it’s worse.