What’s your emergency?
By Laurence Degelsmith, MD
November 30, 2007
It’s 5 p.m. and you’ve arrived at the emergency department with severe back pain, or perhaps a splitting headache, and you want to see the doctor right away.
After all, your severe pain is an emergency, so shouldn’t you get seen right away? I rarely encounter an emergency department “virgin” these days. Most patients have been here, or another emergency department, before, so they know what to expect. Hopefully they will be pleasantly surprised when they come to Northern Westchester’s ED, since we try to get them into the department from the waiting room within a few minutes, if not immediately, if there’s a bed to put them in.
The system has gotten remarkably better as of late. It wasn’t too long ago that you would be seen by the triage nurse, then registered and then asked to wait in our “beautiful” waiting room until we were able to see you. This fairly static and rigid system was used by most emergency departments around the country. It contributed to long waiting times and many people got frustrated and decided to leave before being treated.. Occasionally people died at home after leaving an emergency department waiting room. We at Northern Westchester, as well as many other hospitals, have heard those cries and complaints and have adjusted the triage system to make it a more active, flowing process than the previous system.
What to expect when you arrive
You will initially be seen by the triage nurse who assesses your condition and decides how “emergent” it is from the emergency department’s point of view. Keep in mind that what you consider an emergency may be not considered an emergency by us. That doesn’t mean that you shouldn’t be seen as quickly as possible. The triage nurse has to decide who needs to be seen first based on life threatening conditions versus non-life threatening conditions. Depending on how busy it is, the triage process should take only a few minutes, after which you will probably be brought right into the department, either into a room or to a hallway bed to await a physician or registration clerk.
Unfortunately, our little department was built over 20 years ago and is far too small for the population we serve, so we often don’t have enough beds or rooms for everyone all the time. We are, however, building a brand new state of the art facility which should open in 2009. Nevertheless, our ability to see patients quickly has improved dramatically with the new system. I am often seeing patients within minutes of their arrival into the department, usually before they have even registered as a patient. The average “door to doc” time has dropped significantly as of late since being urged by hospital administration to see patients within fifteen minutes of their arrival if at all possible. I believe that we are meeting this goal most of the time except when we are significantly overcrowded However, there are many instances when we are so busy that fifteen minutes may become an hour and fifteen minutes. The afternoon and evening are especially busy times. Doctors will send many seriously ill patients from their offices to the ED then who need to be seen right away.
Ambulances and heart attacks
The emergency department is a living, breathing machine. The throughput of patients flows well at times but becomes stagnant at others. You might be told by the triage nurse that the wait to see a doctor should be only a few minutes, but then three ambulances pull up along with two private cars bringing people with chest pain and suddenly your few minutes turns into a lot more. On the other hand, I’ve found that it’s not uncommon to wait more than an hour to see a doctor in his or her office, when all patients are by appointment and there are no ambulances.
Obviously, we have to see sicker patients first. It often doesn’t seem fair when you’re sick and have been waiting for half an hour and you see someone who arrived after you get seen first, but that’s the nature of the emergency department. “Life threatening,” as defined by our standards, gets seen before “non-life threatening.” Most people can appreciate the way things work, but every so often we get a patient who doesn’t get it and is very upset. I’ve had patients complain that they haven’t been seen yet when the entire department staff was on the other side of the curtain treating a cardiac arrest.
Time constraints
Medicine is not like fast food. You can’t come in complaining of abdominal pain and expect to be diagnosed and treated in thirty minutes. I had a patient last week who had stomach pains for two weeks and was upset when I told her she would be here for a few hours. She needed to be somewhere and couldn’t stay very long. While what used to take days in the past to assess, diagnose and treat, now often takes hours, but it still can’t be done in mere minutes. Blood tests take about an hour before we get the results. CT scans take up to ninety minutes to prep for and then another hour to be read.
Consultants aren’t always available immediately.
We want to get patients in and out of the ED as quickly as possible to make room for new patients, but this is not always possible. The average visit for complaints such as abdominal pain can take three to four hours, sometimes longer if more tests are needed. I had a 69-year-old male patient a few months ago who spent ten hours undergoing various tests in the emergency department. Blood tests and ultrasound took two hours. A CT scan had to be done twice because the contrast hadn’t yet passed into the large intestine, which took an additional three to four hours. More blood tests were ordered and another consult was called. These work ups are necessary so as not to miss any serious disease. Contrary to what you may see on T.V., they take time.
How much time you spent in the ED also depends on how busy we are. We have excellent nurses and doctors, the best I’ve seen in any ED, but even the best nurses can only start so many intravenous lines and give so many medications safely in a given period of time. Paperwork is also a major issue. Doctors and nurses probably spend fifteen minutes doing paperwork for every one minute of time spent with a patient. This documentation is meant to prevent medical errors and make your time in the ED safer, but it always slows down the process. I definitely spend more time on the computer or with documentation than I do with most patients. This is a necessary delay, but one you don’t see while waiting and wondering where the doctor is.
Medical care in the ‘burbs
One of the benefits of living in the suburbs is our medical care. I spent seven years working in the Bronx and can state for a fact that the average waiting time to see a doctor often approached four to six hours. Patients accepted this begrudgingly and expected to spend the day or night when coming to the ED. I remember times at a very prestigious hospital in the Bronx when I would show up for work at 7 p.m. and see patients who had been waiting since noon. The medical care they eventually received was excellent but it took more than a while to get to them. Patients often waited one or two days in the ED, once they had been admitted, for a bed upstairs to be available. Some never even got a bed and were eventually discharged from the ED before a bed opened up. Unfortunately, this is an all too common sight in most city emergency departments. We really have it good once you put it in perspective.
Lastly, keep in mind that we are trying to provide the best care possible to every patient we see. We can’t diagnose every ailment. In fact, statistically speaking up to fifty percent of patients with abdominal pain will not get an exact diagnosis, despite our best efforts. We often have to rely on return visits or referrals to specialists. Medicine is a science, but also an art, and individual physicians may work up patients with the same complaint in different ways. You might feel cheated or upset that we didn’t provide you with the answer you were looking for when you came into the ED. You might feel like your care was inadequate, since you left with the same pain you came in with. Remember, the emergency department is there to diagnose and treat life threatening and painful crises, fix broken bones, suture cut fingers and deal with similar problems. We are often able to provide comfort and assistance for less urgent conditions as well, but often your care may be initiated in our department and continued in your doctor’s office over the next few days, or months or years.
You may love Northern Westchester’s emergency department or another hospital’s ED but be disappointed on a particular visit because the wait was longer than usual or you didn’t get the doctor you like. Even the best sometimes falter. I’ve had patients over the years in different EDs tell me that they won’t go anywhere else and others tell me that they won’t ever come back. It’s very common to have a great visit one week and a not-so-great visit the next week in the same department. I hear this from many patients and sometimes I tell them that doctors and nurses have good days as well as bad ones too. Some days I feel great after a shift because I’ve saved a life or cured an illness that had been “incurable” for years. Other days I can’t wait to leave the hospital because every patient that shift was complicated and I don’t think I helped anyone. Even with the bad days, I still love my job and I wouldn’t practice any other field of medicine.
Author’s note: This article encompasses general guidelines taken from several published sources as well as my ten years of personal experience as an emergency physician. There will often be exceptions to the above guidelines because the risk vs. benefit ratio of using any medication will be different for each patient.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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