surviving the emergency room
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TRANSCRIPT
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Surviving the Emergency Room: Expecting the
Unexpected
Ron Clark, M.D.Emergency Physician
The Hospital of Central Connecticut
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Surviving the Emergency Room
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Surviving the Emergency Room
• Book was written for patients and family members to explain how the Emergency Room works so they can use it better
• It tells patients where to go, what to ask for, and what to expect
• It allows readers (patients) to be realistic and to actively participate in their emergency medical care
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About the Author
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About the Author
• Board Certified Attending Emergency Physician at the Hospital of Central Connecticut (HCC)
• Director of Emergency Department Risk Management for HCC
• Clinical Instructor, University of Connecticut School of Medicine
• Guest Lecturer, Central Connecticut State University
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About the Author
• Instructor and medical advisor for the Connecticut Alliance to Benefit Law Enforcement (CABLE)
• Connecticut State Police Surgeon
• Board of Directors, Connecticut College of Emergency Physicians
• Fellow of the American College of Emergency Physicians
• Medical-Legal Consultant, Clark Medical Consulting
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The One Thing That I Am An Expert On
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HCC ER
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The Hospital of Central Connecticut
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Typical ER Room
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Objectives
• Background of why Surviving the Emergency Room was written
• What you can do to be prepared (as preparation leads to better outcomes)
• National Emergency Department Issues
• Emergency Room Planning
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TV shows often inaccurately portray EM services
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Patients often have misconceptions of the ER
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Common Questions
• Why did that person get triaged to a room before me?
• Why was there no specialist available to see me?
• Why did I wait so long for a room after I was admitted?
• When is the best time to go to the ER?
• What should I do before I go to the ER?
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Who is that person in the scrubs?
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Emergency Medicine
• All people have the the potential to be an ER patient (even me)
• By educating patients and family members about how the Emergency Room works, they can better prepare themselves
• Emergency Room images (some graphic) mixed with some humor to keep you all interested
• Images are all taken from public domain
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What’s An Emergency?
• A medical emergency is any potentially life or limb threatening symptom
• Medical emergencies happen randomly and often without warning (Box of Chocolates- Anyone, Anywhere, At any time, For any reason)
• The experience is often frightening and most patients feel unprepared
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Emergency Medicine is about information management
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Emergency Medicine
• Chief Complaint
• History of Present Illness (HPI)
• Past Medical/Surgical History
• Medications and Allergies
• Social and Family History
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Emergency Medicine
• Physical Exam
• Emergency Physician recognizes symptom patterns combined with physical exam findings
• Generates a Differential Diagnosis (possible causes for patient’s medical problem)
• Emergency Physician orders tests to “rule in” or “rule out” various Diagnoses
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Emergency Medicine
• Final Diagnosis
• Emergency Medical Treatment
• Disposition: discharge, admit, transfer, die
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My experience on the Trauma service
• Live
• Die
• Admit
• Discharge
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Life Star
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It’s important to focus emergency medical complaints
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Some patients are easy to diagnose
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Symptom: Ankle Pain
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X-Ray: Ankle Dislocation
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Symptom: Arm Pain
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X-Ray: Radius and Ulnar Fractures
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Some Symptoms are not as easy (nonspecific)
• Dizziness
• Weakness
• Nausea
• Bodyaches
• “I don’t feel well”
• “Something is wrong”
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Differential Diagnosis
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Lets Get Back to Focused Patient Complaints
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Chest Pain (MI)
• Common Complaint
• High Risk
• Large DDx
• Must Risk Stratify
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You can get sick for any reason
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Knife in Chest
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Chest Pain
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Shortness of Breath
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Dental Pain
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Face Pain
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Back Pain
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Another stab in the back
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Neck Pain
• Suicidal patient (now paralyzed)
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Eye Pain
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Difficulty Speaking
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Runny Nose
• Upper Respiratory Tract Infection/ Otitis Media
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Endless Potential ER Cases
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Each person’s emergency will be different
• Emergency is a deeply personal issue
• Most people do not like being sick
• Most people have a story about the Emergency Room (some good and some bad)
• Most patients remember their ER visit vividly (Emergency Physicians only usually remember the worst cases)
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Worst Case
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X-Ray
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Good Outcome
• The “golden hour” was not wasted
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The Golden Hour
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The Golden Hour
• The first hour of definitive emergency medical care can seal the patients fate and ultimate medical outcome
• Most important for trauma, heart attack and stroke
• Don’t minimize medical symptoms and seek emergency medical care immediately if you or a loved one have concerning symptoms (chest pain, sob, abdominal pain, difficulty speaking, headache, visual changes)
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Emergency Department
• Emergency Room is more correctly referred to as Emergency Department (don’t tell Amazon)
• Many Rooms (trauma room, ENT room, OB/GYN, monitored rooms, orthopedic rooms, isolation rooms, Fast Track ER)
• Many different staff (MD, PA, RN, Tech, Students, security, housekeeping)
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Who is the “Face”
• Ask ED Staff members who they are and what they do
• House
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Emergency Physicians
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Emergency Physician
• Provides direct patient care
• Physically examines patient and determines emergency medical care plan
• Performs emergency medical procedures
• Consults with specialists
• Ultimately responsible for patient’s disposition
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Emergency Physician Assistant
• Well trained for urgent and non-urgent medical problems
• Most staff Fast Track ER
• Assist with patient management
• Often work side by side with MD’s
• Valuable resource (patient flow)
• Very Experienced (sutures, fractures)
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Emergency Nurses
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Emergency Nurse
• Many men chose to work in the ER
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Emergency Nurse
• Provides direct patient care
• Places IV’s
• Administers medications
• Often first to assess a patient (The Look)
• Makes suggestions /works in conjunction with MD
• Major determinate of patient satisfaction (spends a lot of time with patient)
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Emergency Tech
• Performs ekg
• Draws blood
• Assists during procedures
• Transports STAT labs
• Transports patients
• Blankets, food, bathroom
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Students
• You provide a service to them (ER is the best place to learn clinical skills as the patients are often very sick and need emergent interventions)
• Someone did this for your MD/RN
• Learning often done at bedside
• One chance - IV, suture (supervised)
• See one, Do one, Teach one
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Security
• Keeps patients and staff safe
• Screens patients (Dr. Safe)
• Called for violent patients (4-point restraint)
• Always present in ER
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Experience Counts
• It is important to always confirm the experience level of the staff member that is taking care of you
• If you are unsure, ASK.
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Emergency Room
• Open 24 hours a day/ 7 days of the week
• Over 100 million ER visits per year -large and renewing potential readers for Surviving the Emergency Room (Amazon loves this)
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Allows for management of ER expectations
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What have you done?
• Most patients want quality and efficient EM care
• Most patients and family members do little to prepare for their ER visit
• Patients call 911 or drive to the ER and just show up and expect good medical care
• Patients often do little to assist in their emergency medical care (despite the fact that they have the most invested in their health- it’s their body)
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Prepare for your emergency because it is going to happen
• Hopefully all these patients prepared
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What you can do to prepare
• Learn roles of various ER staff (we just did this)
• Become Familiar with how the ER functions (Triage, Admission, Discharge and Transfer)
• Research and understand local hospital resources
• Patients should know and have all their basic medical information written down
• Go to the hospital where your MD has privileges and where records kept (EKG, OR reports, X-Rays)
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Triage
• Triage RN and Charge RN determine how fast you get to a room
• “The Look” can give you a visceral response (sick child, patient about to have a seizure, patient with SVT (fast heart beat), patient who is going to be violent)
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Admission
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Hospitalist Physician
• Good- Physically in hospital, good relationships with staff, can get studies quickly, and available to perform procedures
• Bad- Not patient’s regular doctor, impersonal, have to start with basics that PCP would already know, often lack of trust, short interactions
• Ugly- Patients often withhold info (STD, alcohol or drug use – can lead to complications), Some PCP’s dump patients, PCP’s often don’t call back
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Blocked Admission
• Sometimes admission can be “blocked” if patient is on the medical fence (Chest pain, dizziness that does not look right, diabetic cellulitis with no doctor)
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“Bounce Backs”
• Patient who returns to ER after recently being seen
• Emergency Physicians generally don’t like to hear about them (implies patient was dissatisfied with care or that something may have been missed)
• Often a blessing in disguise (as second chance to make diagnosis and provide medical care)
• Sometimes clinical signs and symptoms may have changed or condition may have worsened
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The Blessing in Disguise
• If you feel something was missed, it is appropriate to return to the same ER or seek medical care at another ER
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Discharge
• Ask your Emergency Physician about your diagnosis
• What is your prognosis? (when should you feel better?)
• What should you do if you feel worse?
• Who should you follow up with and when?
• What are your discharge medications?
• If you do not understand, ASK
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Hospital Transfer
• Patient can turn into a hot potato
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Transfer
• Time consuming for both the transferring physician and the accepting physician
• Need to get an accepting physician’s name
• Antidumping laws (EMTALA) and have to have capacity
• Often leaves patient and doctor frustrated, as could not treat patient at current facility
• Can cost patient their “golden hour”
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Call Ahead
• Patients and family members are encouraged to call ahead if they have an anatomically specific complaint (hand injury, eye injury, genital injury)
• Confirm that specialist is on call and available
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Research Local Hospital Resources
• Know what is available in your area
• Each ER has strengths and weaknesses (specialists, radiology equipment, pediatrics, psychiatric services, trauma services)
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Know What Can Kill You
• Patients should have all basic medical information written down (past medical hx, past surgical hx, medications, allergies, social history and family history)
• Name of doctor
• Name of pharmacy (bring prescription bottles)
• Avoid telling Emergency Physician “You know the white pills”
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Many medications have side effects and drug interactions
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Avoid Surprises
• Go to the hospital where your doctor has privileges
• Where surgery was performed and OR reports are located
• Where old EKG’s are stored (my favorite, I compare about 10 EKGs every shift)
• Where old radiology studies are stored (can often use computer to look at previous studies and compare to present films)
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Be Careful What You Wish For
• Confirm experience level of medical providers
• How many times have you done this?
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Avoid being the Squeaky Wheel
• Write questions down so that you can be prepared to ask them when MD or RN is in your room
• Do not excessively call MD or RN into your room (they usually have many other patients)
• Thank your provider if they answered your question or provided good medical care
• MD or RN will consciously or subconsciously avoid your room if you become the squeaky wheel (can be dangerous)
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National Issues
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ER is the Safety Net
• Safety net for mental illness, uninsured patients, homeless, substance abuse, medical care when primary care doctor unavailable, trauma)
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Equal Playing Field
• All patients have access to the Emergency Room
• All patients use the same services (EMS, hospitals)
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Emergency Room Overcrowding
• Increased volume of ER patients each year
• Limited number of inpatient beds so many ER patients become “boarders”
• Some Emergency Rooms will go on diversion
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Shortage of Specialists
• On Call: a CT study 90% of medical directors in CT stated that specialty coverage was deficient or unreliable
• Specialty medical coverage only matters when you are that special patient
• Major challenge for hospital systems to get specialists to take call (often called at night, compensation issues, interferes with family time)
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Doctor can feel like an Army of One
• Literally, when the specialist is unavailable, the Emergency Physician still has to see the patient
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Emergency Room Planning
• When is the best time to go to the ER?
• Dangerous Times
• ER wait times
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Timing is Everything
• Mornings are generally the slowest time
• ER volume increases from morning and peaks in early evening (approximately 7 PM)
• Avoid “Manic Mondays”- busiest day of the week with each successive day being a little slower (HCC has quadruple coverage plus 2 PA’s on Monday-Thursday)
• Be aware of “Frustrating Fridays”- non-emergent tests and procedures may not get done until Monday (some specialists and equipment are not available on the weekend)
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Wait times
• Emergency Rooms post wait times on the Internet, billboards, text messages and smart phone applications
• “CentralCT ER” iPhone application for HCC
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Wait Times
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Danger Zone
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Danger Zone
• Emergency Physician “sign out” time can be dangerous (ask for both doctors to sign out at your bedside)
• Ask your medical provider when his/her shift ends and ask for a “good-bye”
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On The Night Train
• Volume is lower during the night, but there is less staff
• Some equipment will be unavailable (ultrasound, MRI)
• Some staff will be unavailable (crisis intervention, social worker)
• One very sick patient can impact the entire Emergency Department (cardiac arrest)
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My Advice
• Educate yourself on Emergency Medical Services
• Be realistic
• Be proactive and prepare for your emergency
• Actively participate in your emergency medical care
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Surviving the Emergency Room
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Questions?