Ask Dr. M: What to expect in the emergency room and how to prepare

Emergency Rooms don’t often receive 5-star reviews or glowing customer testimonials. But, to be fair, they aren’t exactly set up for success:

  • People show up only when they’re feeling their worst and have exhausted all other options;
  • Once they hit the door, patients have to wait for several hours, which when you’re feeling your worst, can seem like an eternity;
  • There is little transparency as to what is going on behind the scenes.

Hopefully I can help manage your expectations for your next ER visit and impart some wisdom on how to make the process more seamless.

Expect to wait.

This is the most obvious — and most important — statement. People generally know that they’ll have to wait once they arrive to the ER, but it’s important to know why.

The hospital is a complex system, and the ER is the front door. Given how complex patients are nowadays, many admitted patients end up needing to stay longer than anticipated to sort out their affairs prior to discharge. This backlog of admitted patients trickles down to the ER, and many of the beds usually used to see new patients are occupied by admitted patients who don’t have a room upstairs. This essentially transforms an ER that might have 40 beds to one that has 20. Despite the staff working as fast as they can to provide safe, effective care, the shortage of beds — on top of lab and imaging test turnaround — is a significant obstacle to seeing more people.

While you wait, consider doing things like pulling up old records and getting your medications organized to make the visit more efficient. Also, take a look at your calendar and see if you have any upcoming family doctor or specialist appointments — this can help the doctor create a discharge plan for you.

Expect to be on the move.

Once you are triaged into the ER, there are often many smaller waiting rooms and exam areas past the front doors. Depending on the assessment needed and the investigation or treatment ordered, you might be moved around multiple times. Furthermore, to combat long wait times, ER staff often get creative to see more people faster. Unfortunately, this might mean that you are assessed in a hallway or a chair, which is not optimal for your comfort or privacy. The intent of care providers is noble, and if you decide that you feel comfortable talking about an issue or getting a physical exam in one of these settings, it may speed up your stay. Having said that, you should never feel coerced to divulge sensitive information in this setting, and it is your right to request a private place for your assessment and treatment.

While you get shuffled between areas, make sure to keep your belongings with you as you may not return to that area. Regarding hallway or chair assessments, it can be helpful to share parts of your story with the nurse and/or doctor so they can get the workup started, while retaining potentially more sensitive information once a private room becomes available.

“The hospital is a complex system, and the ER is the front door.”

Expect to be bumped down the queue.

Unlike a bakery, the ER is not designed to see people in chronological order. Although the default is a ‘first come, first serve’ policy, this process is immediately disrupted once a very sick patient arrives. This can be upsetting for people who have been waiting many hours, as someone who arrives much later than you may be seen more quickly. This process is in place to optimize patient safety, and to make sure that everyone’s issues are addressed in a timely fashion. Unfortunately for you, this may mean that you get bumped down the queue unexpectedly and have to wait for longer than anticipated. The flip side is also true — if you become more severely ill, the ER staff will do their best to get to you sooner.

If anything changes while you’re waiting, let the nurse or doctor know. Even if you can’t receive a detailed assessment, issues like pain or nausea can be quickly addressed.

Expect to meet lots of people and repeat your story.

When you come to the ER, you’ll first meet a triage nurse who will take your vital signs and ask you a few screening questions to understand the acuity of your problem and where to send you. After that, you’ll see a bedside nurse who will sometimes repeat your vitals, and ask you more detailed questions, some redundant, about your issue. After that, depending on the ER, you may see a medical trainee, like a medical student or resident physician, prior to seeing the staff physician ultimately responsible for your care. There are many other permutations to this process, which can include seeing a consulting service and their respective trainee(s) and staff. This can be frustrating for you as the patient, because it feels like you are responding to several repeat questions, and can leave you wondering if the staff are actually talking to each other.

It might be helpful to understand that a lot of diagnostic power in an ER setting comes from hearing your story. Despite a trainee taking a very detailed history, the staff physician may ask many questions over again to hear your specific answer. Moreover, they may repeat certain physical exam maneuvers to determine which set of investigations is appropriate. If you feel that an exam may be particularly sensitive or uncomfortable, consider requesting it to be performed only once with all of the medical staff present.

“A lot of diagnostic power in an ER setting comes from hearing your story.”

Expect to have a short amount of face time with the doctor.

For all of the reasons mentioned above, the doctor may only spend a few minutes with you to explain your issue and outline the management plan. This is done because they are under enormous pressure to see the several patients out in the waiting room, get the room turned over for the next patient, document the assessment and put in the appropriate referrals, and many other tasks. Hopefully you, as the patient, don’t equate your quality of care or the gravity of your problem with the amount of face time with the doctor. Many processes are occurring in parallel in the ER, and the doctor is constantly keeping tabs on them. So even if it seems like they only spent 5 minutes talking to you, they have spent several more checking your labs and imaging, or talking to colleagues about you.

While you are waiting to speak with the doctor, it is helpful to create a list of questions so you can use your time more effectively once you are in front of the doctor.

The Bottom Line

The ER isn’t perfect, and I’ve tried to outline some of the pressures the staff face while treating you. Nevertheless, as bad a day the ER staff are having, yours is worse — you came to us seeking help for an acute problem causing you some sort of significant physical or emotional suffering. If you keep in mind some of the above issues and take steps to mitigate them, it might just help make your visit a more bearable experience.

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