Distress vs. Disaster
There are two thresholds when it comes to medical complaints in the ER: distress and disaster.
The distress threshold is the point at which patients decide to come to the ER. Whatever is bothering them, they feel it needs medical attention right away.
The disaster threshold is the point at which a patient requires an immediate procedure, specific treatment, medicine, hospital admission, surgery, or specialist intervention.
We in the ER live in the middle.
Here are a few examples (assuming normal vitals and well-appearing patients):
An 80-year-old woman with vaginal bleeding, soaking a few pads every day for the past month. Her hemoglobin is normal and has been stable over multiple checks. She has a gynecology follow-up scheduled, but not for a few weeks.
An 85-year-old man with a 2 × 2 cm malignant skin lesion on his arm that is oozing small amounts of blood continuously. He is on blood thinners. Oncology has already seen him and decided not to excise the lesion. His wife is concerned because it’s soaking the equivalent of a 2 × 2 gauze daily (less than a tablespoon of blood).
A 70-year-old woman with a prolapsed uterus for over a month who finally decided to seek care. I reduced it and placed a consult to Gynecology. The family wanted it “fixed” the same day, even though the problem had been present for a month and the patient had been functioning at home without other complaints.
These issues are clearly distressing to the patients, but what is a specialist or consultant going to say when I call—especially at night or on the weekend?
“I’ll see them in clinic.”
No one is coming in to do a procedure or admit these patients.
Having done this long enough, I’m well aware of what the system is capable of—and, more importantly, what it is not capable of. Specialists are always on call at larger hospitals. Depending on the size of the medical system, you may have every possible specialist available, while at smaller facilities you only have some. Surgeons can (and do) rush to the OR at 2 a.m. on a Friday night to stop traumatic bleeding. Cardiologists can place a stent in a coronary artery at 4 a.m. on a Tuesday for a heart attack.
But short of those true emergencies—and a few others—no one is coming in. Problems that are distressing to patients, especially those that have been going on for weeks or months, usually do not meet the threshold that would make specialists get out of bed. The problem is simply not a disaster.
There is a real cost to keeping specialists on call. They are paid for being available, and the more nights they’re on call, the more they earn. There is also a personal cost to the specialist: it’s hard to operate all night and then perform scheduled surgeries or see a full day of patients in clinic the next morning. (As an ER doctor who only works nights, I have some sympathy for disrupting someone else’s sleep—but not too much.) I wouldn’t want the surgeon repairing my rotator cuff at 9 a.m. to have been up most of the night fixing a femur fracture from a motor vehicle collision at 3 a.m. Neither would you.
There is a cost to the system as well. A trauma surgeon doesn’t operate alone; an entire OR team of techs and nurses is required. The same is true for the cath lab team supporting a cardiologist or the staff involved in an interventional radiology procedure. All of those people must be compensated for call, and they can’t be on call every night, so the schedule rotates. Being up all night again limits their performance the next day, and the system pays for that too.
I have this conversation with patients regularly. I live in the space between distress and disaster. My job is to deliver both the good news and the bad news:
Good news: This is not a true emergency.
Bad news: No one is coming to fix it tonight.