I often reach the end of an ER visit without a definitive diagnosis, which is not uncommon for complaints like dizziness, chest pain, or abdominal pain. I explain to the patient all the emergency and serious conditions we’ve ruled out and clarify that I don’t have an exact answer. Patients are often incredulous that I don’t have all the answers.
On one hand, I could feel proud that they think I know so much. They are extremely confident in my abilities and assume I represent the best of medicine. While this seems like a compliment, it doesn’t make me feel better because I know it’s not true. If the ER had definitive answers for every condition patients present with, there would be no need for other specialties. No one would ever need to see a specialist in a clinic if the ER had all the answers.
I had a patient who presented to the ER with an episode of chest pain 24 hours prior. She also experienced an episode of severe nausea and sweating, which is consistent with a vasovagal response. Sweating and feeling warm in this context do not indicate a fever.
While we were discussing her many symptoms, the patient’s daughter mentioned that her mother had pain in her foot and that her toes were reportedly black. I examined her toes and noted some discolored nails, but there was clearly no new issue with her feet. Both feet were the same color and temperature; there was no evidence of infection, trauma, or other abnormality. However, the daughter seemed perturbed by my dismissal of the toe concern.
Patients come to the ER for work notes, and I wish they would just be honest upfront about it rather than concoct complaints and then slip in a comment about a work note. It’s frustrating to do all the song and dance about some potential problem they have that they often have difficulty describing. Their answers to my line of questioning about symptoms sometimes don’t make sense, and I’m left scratching my head, sometimes worried there is really something sinister going on. In reality, they are only halfway paying attention because the goal is the work note, nothing more.
She was 85 years old with a bad heart and many chronic medical problems. Tonight, she had severe abdominal pain, and the CT scan showed a perforated bowel. Her future would include antibiotics and surgery. I was at a smaller hospital and spoke with my local surgeon. He was concerned that the patient was too sick to go to the operating room locally and she would need to be transferred to a bigger hospital. She would likely need ICU care afterward. Having abdominal surgery for a perforated bowel is a big deal, and with her baseline cardiopulmonary medical problems, it would likely be a rough road to recovery.
Once you have a break in your skin, you will have a scar. There’s not really any way around that. People come to the ER expecting that we will be able to keep them from having a scar, but that’s not the case. Even the most controlled scars, like those from a surgical procedure, will leave you with a scar. Why would getting hit with a baseball bat in the head, causing a big, complex, star-shaped laceration with smashed edges and macerated tissue not result in a scar? It just doesn’t make sense.
It’s a good idea to be upfront about the specific condition you’re most concerned about when you come to the ER. I’ve had many conversations with patients who undergo an extensive workup in the ER for a condition I’m concerned about based on their symptoms. At the end of the visit, the patient or their family may ask a question that seems out of left field to me. I recall evaluating a patient with neurologic symptoms that suggested a possible stroke or other neurologic condition. At the end of the visit, the patient’s wife asked if I had checked the patient’s heart. I hadn’t done any cardiac evaluation because the symptoms they described didn’t raise any concerns about a heart condition. If we had discussed this at the beginning of the visit, we could have tailored the discussion and workup, and I could have addressed their concerns much sooner.
When you arrive at the ER, it’s standard practice to prohibit eating or drinking until a doctor has evaluated you. This rule likely exists because sedation for a procedure or surgery is considered higher risk if you have a full stomach. However, this policy is not always practical, as the vast majority of ER patients do not require acute surgery, procedures, or sedation. It’s reasonable to ask the nurse checking you in if you can have something to eat or drink. Their answer will likely be no, but it’s also reasonable to politely ask if they can consult the doctor rather than provide a blanket response. Depending on whom you’re speaking with, this request may meet resistance. There may be reluctance to allow eating or drinking because, at the start of your visit, the only information available is your vitals and a triage note from the nurse.
I see lots of patients who deal with anxiety because of their medical conditions. Last night, I had a woman who gets palpitations frequently. She calls 911 and comes to the ER. She has been seen by Cardiology and does not have any underlying cardiac rhythms that would be considered concerning. She has PVCs and PACs, which can be distressing but are not typically thought to be dangerous. They don’t require interventions or medications, but she has also at times had atrial fibrillation, which is a more concerning cardiac rhythm. She has been evaluated by Cardiology, has worn extended cardiac monitors to try to capture the rhythm, which has been unsuccessful. She is clearly distressed when these palpitations happen because she thinks it’s something dangerous. I can’t fault her for that; it actually could be something dangerous, but most of the time it is not.
On the night shift in the ER, there are two types of patients: predators and prey. (There are many more types but this combo is a common theme.)
For example, last night I had a female who was the victim of domestic violence. Her husband had choked, punched, and kicked her. She ended up with a fracture of her cheekbone, a ruptured eardrum, and lacerations on her fingers from bite marks. She is prey. She doesn’t leave the ER in the middle of the night unless she is safe. This includes offers for domestic assault nurse evaluation, making a police report, and social work if available to arrange a safe disposition (DV/womens shelter, etc). She has the option to pick and choose what resources are offered, but we do our best to make sure she is offered those things more than once, by myself and nursing. I can’t actually make her choose/do anything.