What is an ER For?
Evaluating patients for the presence of emergency conditions.
Stabilizing and treating patients if necessary, and making an appropriate disposition.
Reassuring patients if they do not have an emergency medical condition.
Educating them about warning signs that might indicate their condition is becoming an emergency.
Arrogantly dismissing their complaints as trivial wastes of our time.
Stabilizing and treating patients if necessary, and making an appropriate disposition.
Reassuring patients if they do not have an emergency medical condition.
Educating them about warning signs that might indicate their condition is becoming an emergency.
posted by scalpel at 9:44 PM
49 Comments:
I think I love you!
On my thread you listed off a bunch of stuff like "that 'cold' might be pneumonia". If you are someone who says that with EVERY minor problem, you should be eval'd for hypochondria or histrionic personality disorder. The constant need to be seen in ERs for silly stuff is a personality disorder symptom.
It's not arrogant to point out that every little minor ache and pain and sniffle or stuffy head during pollen season doesn't need to be evaluated in the ER of all places JUST IN CASE it's something awful. This coming from the doc who says "I don't do U/S because CT is more lucrative." Obviously you want everyone with histrionic personality disorder, entitlement issues or hypochondria and good insurance to go to your ER. Everyone else in the world likes patients to see primary doctors for primary care of a minor issue.
There's a huge difference between someone who really does think they have an emergency but a trained person would not find it as such and someone who, like the fella in my thread, makes an appointment to be seen in the ER because he doesn't want to wait for his regular doctor. Not that he can't wait, he doesn't WANT to wait, so he's going to raise the cost of the insurance for everyone else in his company.
I shocked your ass to bring you back from the dead, and this is what you give me? "You're arrogant" for wanting people to use the health care system appropriately? This is not Earth-shattering stuff here, Scalpel.
What you don't seem to want to acknowledge is that there is a spectrum of emergencies. Not only are you apparently only interested in evaluating those in the triage level 1-2 category, but you are rudely dismissive of anyone with a lesser emergency.
If you only want to work the shock/trauma rooms, then go for it. But the majority of cases seen in typical ERs are of the urgent or nonurgent variety, and those patients are our responsibility as well.
Telling someone that they shouldn't have come to the ER because they should have known they didn't have an emergency is something I have never done and something that I will never do, no matter if I'm working in a non-profit or a for-profit facility. And I have never ordered a test or performed a procedure for my own benefit rather than for the benefit of the patient. If I choose to buy a CT scanner for my freestanding facility rather than risk the solvency of the entire enterprise by paying for a seldom-used Ultrasound machine and tech, it's not because of greed, it's because CT is more useful.
If a patient thinks they need to be evaluated, I'm happy to evaluate and treat them to the best of my ability, and I will NEVER try to make them feel bad about their decision to seek care in the ER. They may not like what I tell them or agree with my recommendations, but I will always treat them with respect.
Yeah, because I sound just like Nurse K in real life.
I love educating patients about stuff. "Warning signs" are something I give every patient as part of a standard discharge speech. Since doctors spent 3.5 minutes with the patient, I answer their questions, what a negative d-dimer means, why we checked for that (BCPs and smoking--not good!), blah blah.
Sometimes I do bust out a little tough love and let them know that their problem can be better managed by one doctor in one clinic, that we don't provide comprehensive care for XYZ. I'll even ask why they don't see a regular doctor. I have all sorts of resources for patients that have little money; I have the WallyWorld $4 scripts memorized. The vast majority of unsophisticated but legit patients are grateful. I encourage patients who can't get in to their regular doctor for same-day appointments routinely to go to a larger clinic with more providers and an urgent care if they have insurance.
If you're just showing up because it was "your day off and you wanted to get such and such" checked out, I'm going to be a little irritated in my head and really emphasize the PMD at the end of the encounter.
So if you really think they shouldn't have come to the ER but you don't tell them because in real life you're nothing like the blunt and cranky Nurse K, then I would say it is you who have sold out. Your principles, that is (so you can keep your job).
My principles are not for sale, and they are as reliable as the sunrise.
All the shit I've "stood up for" could fill a hard drive in a second. I just don't cuss patients out to their face. Docs who are blatant assholes to me, yes. Patients, no. I like food in my stomach at least tid, thanks. Sorry if eating and paying for my internet offends.
You'd be able to figure out who I was if you were dropped in my ER, don't worry.
Wow - you guys need some boxing gloves and a ring.
I can see Scalpel's point about people not knowing if they have a true emergency - because honestly, most people have very poor or bizarre understanding of their physiology and medicine in general. The problem is that while 99/100 people with bullshit have bullshit, 1/100 has something bad. The law was created to catch that 1/100. (by the way Scalpel, your argument is sounding a little lefty....). It is the same as welfare and disability, there will always be some bad apples/abusers but you can't deny these to people who are honestly in need because of the abuse potential.
Now, that said, I TOTALLY think that scheduling ER appointments will encourage the bullshit to come in. If your free standing ER schedules people for thier trivial things, yes you may catch the once in a blue moon emergency, but most of the cases will be bullshit. You will make money on them because they will pay or have insurance but we go back to my argument from weeks ago. This is NOT emergency medicine.
I don't hit girls either, but I admittedly enjoy irritating them.
I'd pull you into the XR room and you'd think you were going to get lucky, but, no, it's just Nurse K calling you an asshole to your face again.
LOL, too funny Nurse K. That is how I met my wife.
Wonder how you would feel, K, if you were paid per patient and you, Scalp, if you were hourly.
I like how this argument has extended over 3 threads. It's like you two were arguing in the ER...then down the hall...and now still out in the parking lot...
Funny, Ten, but I don't think it should matter. You're there to look for and treat emergencies whether you are an hourly nurse or paid-per-pt doc. If all of a sudden you turn and start seeking out non-emergency patients (not just treating them, but deliberately encouraging them to show up by offering appts and strip mall ERs with nice couches and flat screen TVs) just to make a quick buck, you have sold out. I'm not there to spit in the face of years of training and experience to rush non-emergency patients back ahead of emergency patients just because they have $25 and an Internet connection, I'm there to look for and treat emergencies.
You have to kiss a little ass for the purposes of capitalism, but the ass-kissing should stop short of blatant encouragement of inappropriate use of health care services.
So your ER must be a WWII era crusty old fortress with no fast track and no advertising then, because you are not a hypocrite.
10, you should have seen her e-mail.
I disagree with any system that allows non-emergent patients to be taken back before emergent ones. That's not synonymous with an ER that schedules appointments though. You could easily have a couple of appointment-only fast track beds where patients bypass triage and are taken straight back where they are triaged at the bedside by the fast track nurse, etc, while the actual triage nurse is unaffected and keeps assigning priorities to the patients that walk through the door unannounced.
The pure view of what we do is to look for and treat emergencies. The most enjoyable shift I've had in recent memory was last Thanksgiving when all the bs stayed home and I only had a handful of patients that all had true emergencies.
But the reality is that ER docs are high acuity specialists who make a living by treating low acuity patients. Not catering to these folks is flat out bad business, and internet appointments are just an extension of the fast track spectrum.
But my actual point is this: how you view all this depends on how you are paid. I've been on both sides. When I was a salaried resident, I hated the 3am low back painer. Whether that patient showed up or not had no affect on my paycheck. Now, while I am at my core lazy and still get annoyed by the 3am lbp, I do recognize that they are necessary to sustain the overall health of my company and my annoyance is tempered by being directly compensated for my services.
We are all predictable actors. When low acuity patients don't influence your bottom line, you tend to take a "pure" stance. When they do, you "sell out."
Put another way, what if your hospital decided to put in the internet appt thingys and asked you to set it up. For your trouble they're offering $10,000. If you don't do it someone else will. Would you turn it down?
This argument hurts my head. Interestingly enough, it is also precisely the reason I quit the ER. Funny, my headache is much better now.
The ER as we knew and loved it is dead, K. Long live the clinic with a few surprise emergently ill patients thrown in just to keep you on your toes.
Ten, you could do just that but in essence you are opening an urgicare place staffed by ER docs. Its staffing would have to be scheduled separately so as not to pull them out of real emergent cases.
I agree about our motivations though, you ALWAYS are somewhat happier to see a patient when you are paid per patient vs per hour. I like a hybrid pay system - per hour base plus an incentive per patient (collective patients I mean, not that a particular patient with insurance would pay you your bonus - but the group's bonus would be from all the extra money collected and those that saw more RVU's and more patients per hour would make a higher bonus).
10, you should have seen her e-mail.
It was rough....I called him an internist.
So your ER must be a WWII era crusty old fortress with no fast track and no advertising then, because you are not a hypocrite.
Our ER lobby has no TV (and no TVs in the rooms either), a daily newspaper for everyone to share, 45K yearly visitors, and it's about 50% undersized. We have a Fast Track, but that's Medicaid and uninsured central. Sure, you get the occasional simple fracture w/insurance, but most is Medicaid or less. If we started encouraging MORE people to show up, we'd all kill ourselves. I've never seen an advertisement for our ER anywhere.
Re: Appts for Fast Track: I decide who goes where, not the patient him or herself. How would you expect a patient to know they're appropriate for FT if they didn't even know that vag discharge x 2 weeks isn't an emergency? Every hospital (and each provider) has different FT criteria anyway.
"I practice emergency medicine because I enjoy being able to evaluate anyone of any age for any problem they are concerned about, to treat their problem myself or to make the appropriate disposition."
Damn scapel are you sure you didnt mean to go into family practice instead. Think about it. If you did family practice you could take as many appointments as you liked and you could send the rest to the ED.
"But the majority of cases seen in typical ERs are of the urgent or nonurgent variety, and those patients are our responsibility as well."
If that is true then why is it that under EMTALA we can screen the "nonurgent" PTs out?
You CANT make appointments on ER period, you dont know when a real emergency is showing up.
I consider troublesome to dismiss the complaint of patients, even if they are trivial things, there are abusers indeed, but im more worried about those lay persons that get uremic and dont go to ER, first onset of cetoacidosis and dont go to ER, they end going nearly dead, with a code labeled on their heads.
Personally i dont have problems treating non emergency conditions as long as i dont have other critical patients.
For patients their emergency is just pain, of any kind, and is reasonable. from a medical point of view an emergency is = PE, MI, CHF, VT arruthymias, Pneumotorax, HSA, Stroke etc etc etc.
but known recurrent medical conditions such as seasonal alergies can be seen by a PCP. still i have seen alergies on my ER what would i do? they wouldnt understand even if they undertand they are already in there. some patients know and they still go cause they are gonna get treated, they even know that if they go at night they will get treated faster, is evil but its like that. the most hilarous example was that mon with his 12 year old boy with ACNE at 2:00 am, i treat him (nobody was there) but it told her mon ACNE wasnt an emergency, maybe scapel treat those patient too as an appoitment ER.
Scapel you are a PCP from the bottom of your heart.
Scapel for PCP!!!! Scapel for PCP!!!
Scapel for PCP!!!! Scapel for PCP!!!
hip hip hooray!!! hip hip hooray!!!!
SEASONAL ALLERGIES FTW
Where do you live?, I'll send you my relatives for a consultation on the middle of the night.
If they want to pay me $500 for a Flonase prescription instead of paying $5 at Walgreens for some Claritin, then please send them in. I'll be happy to see them.
I say this should be printed in BIG letters and posted in all ERs across the world...both doctors and patients need to know this...in my country, especially patients!!
"some patients know and they still go cause they are gonna get treated, they even know that if they go at night they will get treated faster, is evil but its like that."
lol! this is so true!!
"If they want to pay me $500 for a Flonase prescription instead of paying $5 at Walgreens for some Claritin, then please send them in. I'll be happy to see them."
Scalpel I see what you mean, some patients just beg for it...but I just wouldn't want my family member having to pay extra money just for being annoying...I wouldn't do it myself..maybe I'm just naive being a new and unemployed doc myself :P but my conscience wouldn't allow me to do such a thing...
So nurse k (who isn't even thirty and has done this wor for only three years full time) talks/acts like a burned out 30 year ER veteran.
A word of advice: You are either going to have to find some coping mechanisms in this field or you simply are not going to last. That's the truth.
These people are not paying "extra" money and we don't charge them more for being annoying. Any ER visit where a medication is prescribed is a level 3 evaluation and management physician fee, which is about $225 plus a level 2 facility fee of somewhere around $250. This covers most problems that don't require X-rays or blood tests.
These charges are about the same for any ER in the country, and neither hospitals nor physicians set the rates (Medicare and insurance companies do), so why should we feel guilty about it?
And yes you will do it, Rita, because you don't get to decide unless you opt out of the system altogether.
So nurse k (who isn't even thirty and has done this work for only three years full time) talks/acts like a burned out 30 year ER veteran.
You are the SAME GUY who has posted, several treards, in everyplace where Nurse K post something, comment just to bash her, you hide in anonymous messages, but your way or expressing is very characteristic, i guess you got an anonymous stalker Nurse K.
I get paid 400$ on my ER per month, as a standard.
Scapel you are paid 500$ per patient on the ER? would you treat someone without insurance with seasonal allergies for free on the ER? i just wonder.
well here, where I live, is a bit different although i've only been to public hospitals (where they don't charge patients a dime at the ER) during my internship...patients who were not an emergency were told to come the next day and get an appointment for internal medicine or any other specialty depending on the case...
Scalpel treats many uninsured pts just like every ER doc does (at least until he opens his strip-mall ER where he can turn uninsured pts away). A $225 seasonal allergy pt is a windfall for him, like finding a wad of cash on the street. No one is arguing that this type of pt isn't personally profitable to Scalpel. Encouraging this type of abuse of an emergency department with pandering and appointments though is where we differ.
I've never found more than $20 on the street, but I see a handful of $225 "sinus infection" patients every day. Of course most of them don't pay. So no, it isn't a windfall or like finding money on the street. It's just another day.
Personally, I think nurse K would be like every doctors and every patients worst nightmare. She is, and has been, on some kind of ego trip for way to long. You would honest to God think she is the only and the best nurse in the entire world. I actually know some very very good nurses who do not act like a damn top sergeant in the military. They are kind and considerate. for nurse K it seems to mean that if you are a good nurse you must also be a complete asshole. She really wants to be in charge in every way, including her belief that she is smarter and knows more than every doctor she works with.
Scalpel,
You will be pleased to know that your blogs do have a far reaching effect. I am in Omaha and had to go to the ER yesterday because one of my twins needed stitches. I followed all of your advice about how to behave in the ED. We were cooperative, did not ramble on about symptoms, patiently waited our turn, and thanked the nurses and doctors. Just wanted you to know that your advice is valuable. I am going to compose a letter of gratitude for the fine service of the staff of the ED.
Helen
Alexy:
Two points
1: This blog is in English, learn the language.
2: Please do tell how the following thread is nothing but a bash?:
"So nurse k (who isn't even thirty and has done this work for only three years full time) talks/acts like a burned out 30 year ER veteran.
A word of advice: You are either going to have to find some coping mechanisms in this field or you simply are not going to last. That's the truth."
Very simply those of us who have spent DECADES (you are 23 right?)in the ER have found a way to cope. Coping is not flaming everyone in the ER on your blog (whether it be patient's, other RN's, axillary doc's, or the docs). Nurse K is really kidding herself if she thinks her blog is truly anonymous to all that have seen it (I am not including myself here I couldn't care were she lives). Yeah I have called them as I see them. I guess that makes me a "stalker" in your eyes. If you really think that, then you don't know what is a true stalker.
PS: Why don't you get back to us after say your first 10-15 years in the ER . Then you will have some EXPERIENCE in the ER.
1: This blog is in English, learn the language.
Never been on states, I have been living all my life in Venezuela, and I talk 3 languages (not perfectly), it has some merit don’t you think? You can demote my grammar even my spelling, but not my ideas. Even tough if you are going to demote please be educational, I’m open to corrections. But I feel most of people understand me and I understand too, so that’s the real purpose of communication
Please do tell how the following thread is nothing but a bash?
Why don’t you put an ID, instead of being anonymous, you’ll get more respect on your comments, you look like a coward to me; I just can’t take it too seriously, more when is negative stuff.
PS: Why don't you get back to us after say your first 10-15 years in the ER? Then you will have some EXPERIENCE in the ER.
If you think, my opinion is less important, for being younger than you or anyone else in here then, you are moron, It doesn’t matter my age, do you feel my comments are out of the line?, if that’s so feel free to make an observation, we can learn form everybody, but being older doesn’t make you necessarily right, you can be 50 and lack of common sense and being unprepared, so age is not the only determining factor, I went to medical school too, as I assume you did, I’ve been working for 2 years alone, with very accurate diagnoses and many working limitations, in a very difficult population. Better don’t judge a book for its cover.
PD: you know that some of the best discoveries were made by young people; theory of relativity by Albert Einstein at the age of 24
Interestingly Tyler, the founder of INQuickER, is also 23 years old.
So Scalpel, I've been lurking for a while. I worry you are a bit existential -- this will be your undoing. I am a corporate girl going into nursing. Hoping you are not wanting this to work so badly that you are going to make grave mistakes. MD's don't usually make good players. I have to say I am already drooling as I eye you, a gazelle, at my water hole on the Serengeti plain...
-SCNS
The more important point scalpel is how many 23 yo attending ER MD's have you met?
Alexy to be clear, I don't care if you think I am a coward or a moron. My opinion of you is that you are simply naive. You readily admit you have never been to the states. Do you really think your 2 years in a venezuelan ER makes you competent as to the activities here? If you think that then you are making my point.
Alexy, clearly you work in a difficult situation and if I were to end up in your ER I am sure I could learn a thing or two about tropical ER medicine frome you. Because of your EXPERIENCE. But frankly, I can't remember the last time I learned anything from an attending 23 yo doc here in the US. In fact in the States that is an oxymoron. I understand non US/Canadian system's have a 6 year as opposed to an 8 year system but are you really telling me you started med school at 15? Let alone the lack of a residency or internship. If that is true, then it is frankly scary.
PS: To finish the thread, you have not pointed out how I am bashing "old" nurse K for simply pointing out she won't last without a serious attitude adjustment. See the next thread someone else feels the same way. Then again, maybe it's me can your spidey sense tell the difference?:>
Anon 2:12, Wondering have you any international experience? I have. Thing is, some countries still utilize a tradesman/apprenticeship-like approach to learning. This is how it was done most everywhere for years. You get to a certain age then the extraneous stuff we waste our time with in highschool/college is replaced by concentration on a specific field. All coursework is directly related to field of study. Alexy can tell us if this is his experience or not, but sometimes I feel we waste our time and money in the US by not allowing this concentration earlier. Excepting the constraints that his country puts on him, I feel Alexy most likely goes pretty far in his efforts to expand his education as he can on his own. Sure some of his medical topic posts seem "book-derived", but quickly translating some things to make sense can be difficult. Either way he is learning. At 23, he has written some amazingly insightful posts on other blogs that show a intellectual/emotional maturity that not too many 23 year olds have here in the states. The web is an international place. I suggest you try to embrace that. Who knows what you really do for a living. And if medicine, nobody here knows if you are well respected by your peers. My point being, any "experience" you/I have is imaginary really. Go with the flow.
-SCNS
"Who knows what you really do for a living."
Board certified EM thank you. Four years of undergrad (yeah could have shaved off a year or two), four years of med school (couldn't shave off a minute, but then again I treated the fourth year like an AI), and four years of residency (couldn't shave off a second and this was back when the residency was four years). The point is you don't know what you don't know. I've worked with docs all over the world. The human body is the human body. Whether it be a German, American or Venezuelan Alexy isn't talking about a residency or apprenticeship. He's the doc. If you really think you can be a ER doc in a couple of years, well go for it. Just don't touch my loved ones.
But here lies my point. You cannot control anybody but you. This is just a blog on the Internet. Never to be taken too seriously. Maybe I am too "street" IDK... I might pick up a tip or trick on blogs but that's few and far between. This is 99.9% entertainment :-D!!
-SCNS
Are you really telling me you started med school at 15? Let alone the lack of a residency or internship. If that is true, then it is frankly scary.
Yes, I started at 15.
it would be frankly scaring if I cant recognize to TSV with aberrancy between and TV, frankly scaring if I didn’t know how to recognize and treat a pnuemotorax, frankly scaring if i didn’t know how to do CPR, frankly scaring if i didn’t know when/ how intubate, or diagnose and treat MI with subtle ST changes, CHF, Immobilize a politraumatized patient, treat uterine atony after a delivery or treat a diabetic cetoacidosis.
the first time I entered on ER I have read and interpretated already at least 500 abnormal EKG, at that time I entered with BLS ACLS done, I practiced like 40 times on many mannequins, before intubating a real patient, and took a basic radiology course, you have to recognize that at least I have a level instructor on BLS/ACLS/ATLS/FCCS/PALS/neonatal by your American standards. I did have to sacrifice my vacations in order to studying electrophysiology by my own for like 3 months, because I knew I was getting into.
I did not chose going to an ER on my own, I was obligated by the system, yet I took the countermeasures to have an acceptable performance during those 2 years, anyway I’m about to start my residency at last.
The last time I went to an ER, it was because my doctor couldn't get me in and he TOLD me to go to ER specifically because he didn't think I had an emergency. Pain severe enough to make me pass out felt pretty urgent, so I sucked up my hate of ERs and went in. Lo and behold, my PCP was misdiagnosing my problem, the ER doc agreed with my amateur diagnosis (which turned out correct) and even referred me to a doc qualified to diagnose. It was the best waste of time and money I ever experienced. Totally changed my life. Sorry if that was a waste of ER resources, but I did pay my bill in full.
I saw my first ER for an after-hours facial dog bite. Had the "pleasure" of sitting amongst bleeders and screamers and oozers for many hours before being seen, and it turned me off to ERs forever.
But if I want to go to an ER for sniffles, I don't think it's the nurse's place to decide that I shouldn't be there. Maybe I have a crucial job interview the next day, maybe I'm terrified because a family member died after a similar symptom, or maybe my religion teaches me that I will die of AIDS because of pre-marital sex. Geez, I'd think y'all would be HAPPY to see us solvent insureds.
the bottom line is this, in a freestanding ER your not going to be intubating, your not going to be putting in chest tubes or central lines or reducing fracture/dislocations. your just not an emergency room
You are wrong on all counts, "er doc."
how am I wrong? I'd like to know how many intubations, chest tubes and cvl's you've done at a freestanding ER. emergency procedures to me are a big part of emergency medicine, and what distinguishes us from other specialties
I've done all of the above in freestanding ERs. It's not the volume of procedures that makes a facility an ER, it's the ability to do them when necessary, and we have that ability just like any other ER.
Since we aren't getting ambulance dropoffs, we will always have fewer patients requiring intubations and chest tubes than a hospital-based ER. We probably reduce just as many fractures and dislocations though.
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