The obviousness of long waiting times in the emergency department

The obviousness of long waiting times in the emergency department

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because “we are overbooked today.” And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients’ outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

“Whoa,” I said, walking up to him, standing between him and the secretary, “what seems to be the problem, sir?”

“We’ve been waiting two hours to be seen by a doctor!” he exclaimed. “What the hell is going on around here?”

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

“Sir,” I asked, “what brought you to our ER today?”
“My daughter’s left ear is hurting her.”
“For how long?” I asked.
“Two hours,” he replied.

Two hours of ear pain? I get it–maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. “We’re all trying our best, sir,” I added, “but you’re going to need to be a little more patient.”

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. “Well, then,” he spoke, sarcasm dripping from his pathetic words, “try harder.” It didn’t end there, though. He continued. “This is bullshit waiting two hours to be seen.”

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. “And,” the nurse added, “I had already explained to him why they were waiting to be seen.”

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was “I just want to take a nap and was too far from my apartment.” Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes–I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. “Go right to the ER,” she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. “What can I do to help you tonight? What brought you to our emergency room?”

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

“Well,” she said shyly, “I’ve had some burning when I pee for about a week. And,” she added, not done “I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke).” Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. “What made you come to the ER at 2am when these symptoms have been going on for over a week?” I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn’t. Her answer to my question–”Why not?” I didn’t even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I’m not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don’t get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic “nuisance,” so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.

“StorytellERdoc” is an emergency physician who blogs at his self-titled site, StorytellERdoc.

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  • mimieliza

    Here is my take on the causes of the ER problems:
     1. The ER treats anyone.  It’s the safety net for the uninsured.  Which is necessary, but leads to lots of people coming in who would be much more appropriately (and less expensively) treated in other settings.  2. In my state, at least, Medicaid patients CANNOT be charged co-pays.  Which is understandable (if you’re poor enough for Medicaid, you can’t afford co-pays) but I think they should have an ER co-pay as a mild deterrent to unnecessary ER visits.  I have private insurance, and our ER co-pay is $100, compared to $35 for an office visit.  And my experience accessing urgent and emergent care:   The hospital where I work started an Immediate Care clinic to take all the urgent-not-emergent patients during the hours of 7 am to 7 pm.  It is empty.  Really, really empty.  I have gone there myself for minor ailments (sinus infection, etc.) when I can’t get into my doctor’s office in a reasonable amount of time.  It’s a great option, I don’t know why people aren’t using it.  They continue to show up at the ER in the middle of the night with ailments that could wait until Immediate Care opens at 7:00 AM.  I have taken my children to the ER twice – a four-year-old with a broken clavicle, and a one-year-old with an acute asthma attack.  We got care fairly quickly – immediately for my asthmatic baby – because the problems we presented with were actual emergencies that could not wait.  We also had the good fortune to not turn up at  the same time as a multi-victim MVA.  

  •!/CloseCall_MD Close Call

    A colleague just told me about a Medicaid patient he’d seen today who was in the ED because of vertigo… caused by the cruise she had just been on.

    Classic stuff.  

    • Payne Hertz

      As always, we don’t have the whole story. The whole story might be that this woman was on Medicaid due to an illness or disability, and has now returned to work but is still eligible for Medicaid under the return to work program Social Security has. Thus she can afford a trip but still has her Medicaid benefits. Another possibility is that a friend, family member or employed boyfriend gave her the money for the trip, which is not against Medicaid rules.

      The fact you can only jump to but one of many possible conclusions and would begrudge a poor woman any pleasures at all tell us more about you than about her.

  • Payne Hertz

    What’s “obvious” to you isn’t obvious to everyone. Most of us don’t work in the ER, and don’t know the rules by which you define what constitutes an “emergency” versus the rules by which common sense defines it.

    When the “check engine” light comes on in your car, do you know immediately whether it represents a meaningless anomoly or if it is evidence of something serious? Do you avoid taking your car to the shop for weeks because your mechanic clearly has more pressing problems to deal with?

    It is unrealistic to expect lay people to somehow triage themselves, and know what is a “legitimate” vs “Illegitimate” reason to go to the ER.  The fact that lay people forced to do so are guaranteed to guess wrong resulting in thousands of unnecessary deaths should be enough to persuade you that the times they guess wrong in the ER is a small price to pay to avoid them guessing wrong outside it. I’d rather a man with GERD panicking over his “heart attack” go to the ER than a man with a heart attack die because he thinks it’s GERD.

    Is it reasonable to expect a man to ignore his little daughter’s severe ear pain on the grounds that he will be inconveniencing you if he doesn’t? Of course not.  He doesn’t live his life by your rules, nor should he.

    It is “BS” to have to wait for 6 hours in an ER when you’re in pain. You prefer to blame patients who you feel don’t belong in the ER for long waits, but the reality is the cause of long waits is that your hospital is too cheap to hire adequate staff. For less than the bill for an ER visit per day for ear ache, your hospital can hire another doctor. If there is that much of a problem and therefore that much of a market with what you perceive as non-emergent cases in the ER, they can establish an urgent care center. Most hospitals won’t take this obvious step though, as they prefer to bill patients at ER rates rather than at urgent care rates.

    So once again we see patients being blamed for the callousness and greed of this system.

    Then there’s this old chestnut:

    “…Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV.”

    This is a standard ER trope, that anybody who can watch TV, use a cellphone, eat the proverbial Cheetohs or laugh can’t possibly be in pain. This widespread belief is so patently absurd it wouldn’t pass muster in a fourth grade logic class. Why wouldn’t a girl with severe ear pain be able to watch TV, and how does the nurse know that she was “comfortable?” Is she telepathic?

    Why are you and so many ER doctors so entrenched in your prejudices you can’t ask yourself these simple and obvious questions, and adjust your behavior and expectations based on their obvious answers?

    • Desideratum

       While I agree that lay people cannot be expected to completely understand what constitutes an emergency and what does not, I think it should be expected that they use a little common sense. You’re giving a great benefit of the doubt to the patients, but not to the doctors. Part of the reason of having long waiting lines at emergency is because people with non-emergency problems help go clog up the waiting list. Why is it that ER doctors, after coming out of hours of surgery operating on people who need immediate, life-saving procedures, must deal with people (and their ire) who aren’t in need of “urgent need for assistance or relief”?  ER doctors should not have to treat chronic illness patients.

      “You prefer to blame patients who you feel don’t belong in the ER for
      long waits, but the reality is the cause of long waits is that your
      hospital is too cheap to hire adequate staff.” This is an unfair assumption that not only expects the ER doctors to perform a job that is NOT his but expects them to basically cater to patients. What ratio of doctors to patients do you want? 1:2? You said the cost of an ER treatment for one day can afford the hiring of another a doctor – but for how long, considering cost of medical equipment and other overheads? Maybe you’re right, the hospital would prefer not to
      have an urgent care room so as to bill the patients at higher prices. With non-emergent cases, the patients should be directed
      to urgent care asap, rather than making them wait for an ER doctor.  However, that is not the focus here.

      The main problem is that these non-emergency patients waste the time, energy, and resources of the ER room by not being responsible. They belong at the office of PCPs or specialists. It may be understandable that patients want immediate relief for their pain – it’s a natural instinct, after all- but that does not excuse them from showing up at the ER to do so. And while neither the nurse nor the doctors are telepathic, and yes pain can be somewhat appeased or distracted from, I would also question the extent of it if they are not bleeding somewhere or whimpering in pain, given that is a growing trend for people (at least for those who can afford it) to have very very low pain tolerance. Patients should be held accountable for their actions and decisions. Understanding why they took an action or made a decision, does not justify either.

    • maribelchavez

      Your idea of who should go to the ER would work in a perfect world with unlimited resources and plenty of physicians to go around.  The author of this post doesn’t at all sound apathetic – it’s not hard to understand that after seeing some of the stuff he sees it may be a little frustrating to have to treat someone with a diagnosed yeast infection in the ER.  It’s not that these people don’t need treatment but not in the ER. (and he didn’t include chest pain as something that could wait- that is different.)

       To put things in perspective – tag along on a surgical mission trip to a developing country and see what those poor people have to deal with and for how long.  You’ll never hear complaining, only expressions of gratitude.

  • Sapphire Storm

    I can totally understand this doctor’s frustrations I think I would feel the same ones. The question is, why can’t we expect laypeople to understand their bodies more? And why can’t there be an alternative to the emergency department for things like ear pain? Then the question becomes: how can we make these things happen? I think it’s important to hear the problems coming from an end point such as the ED as well as from the beginning: when the patient decided to go there. This would take some investigation via a Public Health professional. I would not be happy to see a young woman laughing with her mom after coming to the ED via ambulance with a yeast infection. It’s not that she was laughing with her mom; it was the whole story. I wish the doctor DID ask her why she came via ambulance.
    It’s a very tricky thing; personal responsibility vs medical responsibility and who pays for what.
    I think this a very ripe area for expanding wellness and education. Why would we teach in school things like ancient history but not things like: health care system, what it costs, and who pays. Sure, that’s not the total answer, but it takes time and this is definitely an area that needs massive change.
    If my child had two hours of ear pain I would treat as the doctor said, (except probably not use tylenol) and use home treatments like a warm compress. I’d check for a fever. I’d call the doctor if things got out of control, if not, I’d go to the doctor the next day.

  • petromccrum

    Other doctors can be held responsible for this ER mess as well. My critically ill husband was continually sent to the ER by his doctor.  When I requested an office visit or a direct hospital admittance the response was always:” That is NOT our policy; you have to go to the ER”.  So what is the patient to do??

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