Prep Yourself for the ER

Expectations - Reality = Happiness

When you go to the ER, having the right expectations can make your visit better. It no doubt won’t be perfect regardless, but expecting too much or expecting the wrong things can certainly make it feel worse.

Some key points to consider:

Taking an ambulance won’t necessarily get you seen faster. Triage exists for a reason to prioritize who needs to actually be evaluated first. EMS doesn’t necessarily jump the line. Common sense would dictate that an ankle sprain arriving by an ambulance doesn’t need to be seen before a patient coming to triage with severe chest pain and a history of heart attacks.

Understand that you will probably have a long wait. On my last shift when I arrived at 11pm, there were 20 patients in triage with no rooms available in the ER, with the longest wait times around 6 hours. It’s interesting to note that if you’ve been waiting in triage for that long, it’s a pretty safe bet you don’t have an emergency. The first 2 patients I saw both needed to be admitted, but needing admission and having a truly life-threatening emergency are not the same thing. Most hospitals admit 20-30% of the patients coming to the ER. Truly critical patients are usually <10% of all arrivals. That means there’s about a 70-80% chance you’ll go home and less than 1 in 10 that you actually have a life-threatening emergency.

You will likely get some/most/all of your work-up done in triage if wait times are long. EKGs happen within 10 minutes of arrival for things that could potentially be cardiac in nature. You may get pulled back to a room so blood work or a urine sample can be collected. Radiology may come to get you to have an XR or CT done. Depending on bed availability, you might go right back out to triage to wait even longer.

ER doctors often see roughly 2 patients per hour, give or take. My average on a busy 8-hour shift is probably 16-18. Do the math. You typically won’t get a lot of time with a doctor. You will see someone for an initial conversation to discuss what diagnostic and therapeutics interventions will be done. There should be a discussion about any test results and a reassessment of your symptoms and if things are getting better, staying the same, or getting worse. After that, which can typically be a couple hours by the time tests are ordered, processed, and resulted, there should be a discussion about disposition. Disposition means where are you going. Are you being admitted to the hospital or going home? Average length of stay (LOS) in the ER is generally 3-4 hours for patients that discharge and 5-6 hours for patients that get admitted. (That doesn’t include boarding time, which is another discussion altogether.)

Sharing your concerns from the beginning is important. I’ve had patients or family ask at the end of a visit if I checked their cholesterol because they were seen for a cardiac issue. The answer is always no. I’ve never ordered a cholesterol panel in the ER. Feel free to ask what the doctor is actually ordering and what might be going on. Sometimes it’s quite obvious to us. Kidney stones, for example, often have a very characteristic presentation. Chest pain and abdominal pain have a wide variety of causes and since < ⅓ of patients need admission to the hospital, odds are we won’t find an answer for those things that would require admission.

Expect uncertainty. The younger and healthier you are, the less chance we find a disaster. We are good at saying what something is not, i.e., not a disaster. We don’t have answers for every problem. There’s a good chance you will go home with a non-specific diagnosis like “chest pain” or “abdominal pain”. We will know it’s not a heart attack, pneumothorax, bowel obstruction, kidney stone, appendicitis, etc. But we often don’t know exactly what it is.

Don’t expect solutions to chronic problems. If you always have back pain that is now worse, we are unlikely to make you better or diagnose something new. Perhaps we can prescribe a medication that helps you feel better, but that’s not a long-term solution.

Googling your symptoms is rarely helpful. Most websites will tell you the absolute worst thing possible but probably won’t tell you that that thing is super rare. If you’re going to use AI, you need to have an intelligent conversation and provide more detail rather than one symptom. Provide more details.

For example, if I were to ask Google about chest pain, e.g. “49 yo M with chest pain”. It’s going to give me the worst case scenario. But if I add some details like, “49 yo M without any medical problems with chest pain, no difficulty breathing, normal pulse, no radiation of pain, came on 1 day after lifting weights, worse with movement of arms and shoulders and twisting my torso. Somewhat better with ibuprofen, etc.” That’s going to get me a much better answer. Context matters. That is much different from “49 yo M with a history of untreated hypertension with severe chest pain that radiates to the back and feels like tearing.” AI quickly and appropriately gets you to aortic dissection as a top possibility.

Be able to provide a somewhat concise story about your symptoms. Expect some line of questioning related to OPQRST, which is what we learn in medical school.

Onset- when did it start, how did it start, gradual or sudden?
Provocation/Palliation- what makes it worse or better?
Quality- how would you describe it?
Radiation/Region- where is it and does it seem to move or go anywhere else?
Severity- how bad has it been and how bad is it now?
Timing- constant or intermittent, frequency if intermittent?

Avoid relating details of every medical thing you have experienced. If you present with abdominal pain and get asked about “prior surgeries”, getting your tonsils out in elementary school is not relevant. Having an appendectomy 1 week ago is.

Try something before you come to the ER. Acetaminophen and ibuprofen, cough and cold medicine, acid reflux and diarrhea medicine are all available over the counter for a reason. I have never seen a true emergency be masked because a patient tried to feel better at home. If you have not tried any of these things, that’s what we will start with in the ER.

If you come to the ER with addiction or mental health-related problems, you will leave with those same problems. The same thing is true of homelessness. If there were easy solutions to those things, those problems would not exist. To expect a complex problem to be solved in 1 ER visit, you are naive and will absolutely be disappointed.

The healthcare system is broken. Within it you will find good people that are also flawed and human. Expect frustration related to all those things as well.