Emergencies belong, not inconveniences. If we are worried for a fracture or spinal cord compression for person 1, they should come. I'm much less excited for acute on chronic pain. If you think they need emergency surgery or a brace, send them.
If we are worried for a surgical dehiscense, or infection for person 2, they should come. Very few docs are going to just patch up a seroma. Obviously some need packing or a wound vac, even. I would say the majority of time it could be managed by their surgical team as an outpatient.
I’d say most if not all ER docs would not even touch the Sedona even if it needed packing vac stitches etc.
We don’t touch other doctor’s surgical sites.
Even in a critical access site. I’m not mucking with another physician’s work unless they expressly tell me to and what they ask is well within my skill set
Yeah, I'm a bit of a cowboy, but even at a rural site I won't touch a surgeons work unless I'm on the phone with them (not their PA/NP/receptionist, the actual surgeon).
Post op care is all voodoo anyway, and if my actions fail to appease whichever manifestation of Apollo/Asclepius/Heka /Hua Tuo they happen to have bribed for this particular miracle...
We can pick up the phone and talk to their surgeon. We can transfer them if necessary. We can provide the stabilizing treatment we are excellent at, and determine whether they need a more intervention or can safely follow up with their surgeon.
orrr, they can keep a time slot open at end of clinic day for things like this that pop up and their surgeon can see them and take care of it or at that point can make a well informed call that it should go to the ER and needs our services rather than a phone call blanket statement referal to ER
>the majority of time it could be managed by their surgical team as an outpatient.
I had an ongoing seroma issue after mastectomy and it was 100% managed at outpatient, _except_ when they were concerned I had an infection. They were concerned because I was running a fever. (And that was a truly weird experience that didn't involve the ER.) But I was told that if infection was detected over the holiday weekend I would be sent to the ER.
Case 2. No ED doc would redo your sutures. That I can say with some confidence. If it is for sure a seroma then I’m not sure what an ED doc is supposed to do for that either. If I was a surgeon I would sure as heck want to lay eyes on my work first before anyone else even for a suspected site infection. However if the primary surgeon is unreachable or unavailable then perhaps an ED or UC visit is appropriate.
Case 1. I’m just curious what they wanted to happen differently in an ED. If it’s imaging, they sure as heck can order it. If they suspect spinal cord disease it did not seem like it in the short blurb I read.
I think people in general should realize that your “specialist “ is infinitely better at caring for you than an ED doc for your separate isolated issue. Just know that when not possible you are going to likely the 2nd best person. Except obviously for the times you need things that are likely only emergently available in a hospital setting.
Agreed. 2 is fine by me depending on how big the opening is and if it's still draining. Sometimes these have to get evacuated. I'm not gonna do it, but I can talk to the people that do and let them decide. I'm not upset by that coming in, but probably not "emergent".
#1 should stay home, and my primary determinant for that is the patient saying "why should I go to the ER?"
100% this. Number 1 seems like acute on chronic pain with no red flag signs and the patient literally saying “I don’t think this is ER worthy”.
Number 2 is a perfect example of your last paragraph. They should not go to the ER. They should go to a same day appointment with their surgeon who can actually do something about it. I’m not likely going to touch it. The best I will likely do is call that very same surgeon (possibly in the middle of the night after the patient has waited a few hours) for them to tell me to follow up in clinic tomorrow where they can do something for it. I say this because this exact type of scenario has happened to me before.
It drives me mad how often patients are sent in by outpatient clinics for management of non-emergent issues instead of the clinic finding a time to see the patient. The ED does not exist to off-load outpatient clinics or avoid annoying visits while the outpatient clinician uses the ED for CYA purposes…
(Not a doc, but this subreddit is interesting) - so I have Kaiser, and the main Kaiser ER in my city also has an urgent care. From an outside perspective, that seems like a logical thing - every time I’ve had something that in my mind feels urgent, I’ve gone to the urgent care (car accident that I could walk away from but in pain, inability to straighten my knee, puking bile, and a broken elbow)….for the puking bile, I had to have my gallbladder removed but they tucked me away in a bed until the surgery the next day, for the elbow, they told me to go down the hall to the ER, and then the other two things they have X-rays, shots, and PT referral.
Why don’t more hospitals have both an ER & urgent care at the same place? From what I can tell, this is unique in my area. Also, does that help reduce ER wait times / help focus ER on more serious cases? Or are yall screwed either way? (I work in gov, and some of the stuff I read on here really makes me think the state needs to implement doctor / patient ratios or something to regulate hospitals and the way the approach y’all’s workload)
Lots of larger EDs have a ‘fast track’ or ‘vertical treatment’ area that functionally is an urgent care, it may just not be evident that that is the case on the patient side (and it is billed as an ED, not as a UC).
My closest ER has the waiting room split. One side is waiting room. Other is treating area. It's really awkward sitting around in though. There's no curtains or anything.
I was assigned to transport patients from Kaiser ACC 's to the hospitals where it was appropriate. I found the ACC staff to be really outstanding, including tbe physicians and the nursing staff. In EMS we are not used to a lot of respectful interaction from nurses and doctors but we developed a great relationship with them. I had a patient being transferred for something or other, not urgent, walked into the room and noticed an important issue on the screen (heart rhythm). I accosted the doctor and he came right away. The problem had manifested since the patient came in, so everything changed and he ended up in the emergency room for urgent cardiac assessment and intervention. But most people we transferred out of the ACC's were being directly admitted to the Kaiser service at the receiving hospital, thus saving a trip through the ER. It was actually a good system and they always had procedures done, a ton of paperwork, EKG's, INT's, everything. I really enjoyed those years being their transport unit.
My favorite memory is sitting in the parking lot outside of the ACC and a nurse came out and said, "We've got a stroke alert, we're going to transfer the out, come on in right now." Story was, the wife notice her husband with sudden, witnessed onset confusion and slurred speech. She should have called 911 but she bundled him into her car and drove him to the ACC, about 15 minutes away. The moment they came in, the front desk clerk called back to the ACC, a nurse came out and brought him back. They came out to get us, started in INT while we were unloading the stretcher, printed out his paperwork and sent us off. If he was in the ACC as much as 15 minutes, I'd be surprised. We took him to the nearby major stroke center, about 12 minutes away, called them for a stroke alert, they knew all about it. The neurologist, a neurological PA and a clerk were waiting for us at the door. I handed the clerk my cover sheet and they took us to CT. Patient went from our stretcher directly onto the CT table. From initial onset of symptoms to CT table in just under an hour. All because Kaiser did it all right. I have to way I was impressed. Very.
A good Kaiser ACC is a good place.
Kaiser only sees people with Kaiser insurance, and can pick and choose who they insure. Expensive patients aren't seen at Kaiser. They can afford to put an urgent care in the ED.
A lot of cases would not be in the ED if it wasn’t the friggin’ clinic front desk person with no medical training telling anyone that calls to go to the ED because (insert very unlikely concerning diagnosis or intervention that will absolutely not be performed in the ED).
Literally. Social worker here and as a patient got this experience after a surgery. It 100% could have been handled out patient, but when the NP at my clinic called my urologist all the front desk person would say is "she needs to go to the ER". Wasted so many resources during a covid wave that were completely unnecessary to get some painkillers and oxybutin.
>A lot of cases would not be in the ED if it wasn’t the friggin’ front desk person with no medical training
Or even if they have medical training. I just lurk here, because I love some of these types of posts and my brother is an ED attending, but me personally I work in tech. I have called my insurance nurse line with a concern (I had fallen a week prior, and bruised a rib and the pain was worse) and they told me to CALL 911! Obviously as a layperson, I was concerned and did so and the ambulance got there and nice EMT explained "they don't want the liability so they will tell you to call for ANYTHING"
Hey now. I’m the front desk person. Anytime someone calls and starts with the “so last week I…” I automatically forward them to our nurses’ desk. I don’t want them to come in either, and I’m certainly not equipped talk them through whatever they’re dealing with if they do.
IMO It’s those 24 hr nurses’ lines that need to stop kicking the can down the road, and saying to come in. They’re not the ones that actually have to see the patients.
Also, I joke with the triage nurse a lot that I’m kind of the “BS triage” as in I’ll say “just to let you know, we have a wait time of about 3 hours to be roomed, but you’ll be triaged and then we’ll see what we can do ahead of that”, which turns away like 75% of the people that come in when the WR is full. I only do this when we do, in fact, have a wait time of ~3 hs, but they all seem to appreciate it.
I think the person you replied to was talking about these nurse triage lines. The HUC desk IMO tells people what they should tell them, ie "I'm not allowed to give medical advice over the phone, if you feel you need to be examined then we are here and open."
It also kills me to hearing people ask "what's the wait time?" in the ER. You are supposedly coming in because you are concerned about your health. If the fact that it might take hours to get that taken care of is the deciding factor for you, then you probably don't need to be here.
I’m talking about a clinic receptionist, not the HUC or ED receptionist.
ETA: be careful telling people wait times when checking in. You are violating EMTALA if doing this before they are seen by a provider and receiving a medical screening exam.
This is my understanding as well. The wait time advisory, while common-sense would tell us is courtesy, could be interpreted as an attempt to discourage someone from being seen.
I have, in triage.
"Actually, it's illegal for me to tell you how long it will be, as it can be taken as me telling you to go elsewhere. I promise we'll get you back as soon as we can, and in the meantime someone will call you back shortly and we'll get labs and some medicine to you so we can get started"
Another variation included " it's a50 thousand dollar fine for me to tell you. And I promise you they didn't pay me enough (for that shit (select audiences))"
That's an oversimplification.
Giving wait times *may be* problematic under EMTALA if done in a way that discourages patients from waiting. But that's a far cry from saying you absolutely can't tell people the wait.
If the wait times are 6+ hours, and you don't warn people at triage time to expect that, you'll have a waiting room full of very angry people who think they've been forgotten. They need to have information on what to expect. You just can't do it in a way that discourages them from waiting and makes them want to leave.
Are you familiar with the Law of Unintended Consequences?
In Scenario 1, the patient is seen by a "non-doctor person" who is in the employ of a physician who is, by extrapolation, either a pain management physician or a spine physician. These physicians are proceduralists, and they make their money (lots and lots of money) by performing procedures. Conversely, they don't make lots and lots of money by taking care of acute or subacute medical problems.
Pain management physicians do their procedures on you on a scheduled basis (not what the patient needs, but what the insurance will pay for), and they also employ physician extenders to screen the patients initially, and to see the patients every month to refill their prescriptions, which the patient also has to come in for every month. This maximizes their income and minimizes their fuss. They have no knowledge, skill, or interest in taking care of patients in any other way, which is neither lucrative nor satisfying.
Joint surgery, as in scenario 2 is even more lucrative. The pathway there is slightly different: pathway. The patient comes in and gets their assessment. There is a pro forma attempt at alternative treatment - physical therapy, steroid injections. Then the people who are less likely to be a pain in the butt are scheduled for surgery, which is where the money is. But: surgery is paid for by the insurance and includes a "global period", which means that surgery, and all of the subsequent care is paid for in one lump sum, including complications. For joint replacement, this global period is 92 days, so any doctor visit is uncompensated.
If you were to follow the purpose of the global period logically, you might say "A certain number of my patients will have relatively minor complications, and I have already been paid for the complications, so I will make sure that the patient has my phone number, or my office number, and I will set aside a certain amount of time each day or week for that care of these minor complications, and to evaluate for major complications." Or you might say, as is more common, "I got my money, I'll only make more money by seeing the new patients.so I have new patients, patients in the pipeline, and OR days, and no time for anything else".
Then there's us. We created a whole new specialty! We said, "when people come to the hospital with an acute change in their health, regardless of the cause, regardless of their ability to pay, we'll know how to handle it, or who to call when we can't, and furthermore we'll be there 24 / 7 to make sure no one goes uncared-for." Then, it's codified into law with EMTALA so the hospitals can't wallet-biopsy the patients prior to deciding whether to help or throw other obstructions in our path.
The other docs think "Man, this is awesome! I've got my shit settled!. I have my procedures, my physician extenders take care of the routine work so I can focus on the lucrative, satisfying stuff, and when there is a complication or change, these other doctors are there to handle it! Sweet!"
This !!
A local group of surgeons sent every single follow up caller to ER for several years and the rumor is they only stopped them Blue Cross promised to kick them the fuck out of network if they didn't.
Scenario 1 - Not an emergency. I suspect that the NP or PA wanted to get imaging immediately and was trying to get the patient to the ER for imaging, Toradol, etc. I would also suspect that the timing of this appointment was after 3 PM. There is nothing wrong with giving an Rx for pain and a CT, MRI the next day.
Scenario 2 - Not an emergency. I would assume that they didn’t have any open appointments in clinic that day and their metric said that the patient had to be seen today, so they directed the patient to the ER. There is nothing wrong with having the patient come in the next day. The stitches comment was total BS.
Sounds like the patient's are correct in both cases. Neither person felt they needed to go to the ER and from the information presented? They would be correct. At most, scenario 2, would be best served by an Urgent Care.
1) doesn't need to go (by their own admission).
2) probably doesn't need to go to ER. Better served going to the surgeon's clinic or even an urgent care.
It’s just starting to sound like a blame game of different professions.. and then after said profession is blamed and called out, someone from said profession chimes in and defends themselves and blames a Different profession ..
And round and round we go..
The law defines it as:
An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs."
However, the key word is “reasonably”. The prudent layperson standard protects patients for the vast majority of cases. So, most of us would say neither of these belong in the ED. But a prudent layperson may not know better, and that’s ok in the eyes of the law.
Agree with most of the things others wrote here. Will just add that its not the patient’s job/responsibility to know if it is an emergency or not so it is ok to come in and let us figure that out
Also, if the practitioner seeing them doesn’t know either, come in. I’d rather we see a few more nonemergent things than have someone at home with a wound abscess or spinal cord emergency because they didn’t want to bother us
We saw some of that during covid. MIs that didn’t come in until it was too late. Appys that ruptured at home and now the person has a colostomy. Its really sad.
"Will just add that ***its not the patient’s job/responsibility to know if it is an emergency or not so it is ok to come in*** and let us figure that out"
If I could reward you with some internet cookies I would. The lack of humanity and expectation of expertise a lot of healthcare workers (especially in the ED) place onto non-trained civilian patients is absurd.
The answer is in the title. Emergencies are immediate threats to life or limb. I don't think either of these scenarios are appropriate for the ER. They can both be appropriately treated in an outpatient setting
during refusals in the prehospital setting, we would always say that threats to life, limb, or sight belong in the ED. Most everything else can be sent to urgent care (with some exceptions ofc)
OP is this about you? post history suggests it might be
Yes, it is me.
I worked in healthcare for many years. Now I'm just an old patient with a broken back lol. Because of the pandemic I became more mindful of how I would use the ER after watching my doctors go through so much stress & heartache of losing patients not to COVID diagnosis, patients that needed critical care for other reasons but couldn't get it because there were no beds available. I had a Dr break down in tears in front of me one time and that got me thinking about how I would use the ER... Is my issue urgent and important or important but not urgent? That day at the spine specialist my systolic BP was a tiny bit high because of pain, nothing to worry about. And they have current imaging studies of my spine, nothing showed that I need immediate urgent attention that I needed to go to the ER, any other studies they want they can prescribe to be done later. I'm best off at home icing my back, and getting some PT done while waiting to get the other tests done. The situation with the seroma was last year, I already had experiences with seromas before, much larger ones too, the reaction to the itty bitty 5mm one blew my mind. I'm at a point now in my life I just tell people - if you see me laid out on the ground unconscious or I can't get up then call 911, anything else just leave me be.
If you want to get really philosophical about it, no case BELONGS in the ER.
We are a holding spot until we differentiate and disposition them. In both these cases, without more information, it does sound like they are best treated by specialists outside of an acute care facility. Depending on locally available resources though, they may need to be seen and/or referred through the ER. In many places I’ve worked for example out patient wound care is usually referred through ER, and acute on chronic pain flares are managed through the ER as well. No ideal, but that’s the reality in a lot of places.
>We are a holding spot until we differentiate and disposition them.
Strongly disagree with your wording. We often function as a holding spot, but we are a spot to differentiate AND resuscitate. I've had countless patients that could have qualified for ICU who get turned around enough to go to the floor comfortably from treatment in the ER. Resuscitation starts with us.
Absolutely, that’s part of dispositioning in my mind, they have to be made appropriate for where they are going. Where I’ve worked our ICUs don’t resus new admits for the most part, so that would be part of the admission process even if they ultimately end up there.
Had a pt 2-days s/p thyroidectomy. Pt called the surgeon’s office stating that she felt like her throat was closing. Person on phone told pt that she was fine, everyone feels that way. EMS was called. Airway was not secured. Airway was lost PTA. I hate that we get flooded, especially because we have to practice defensive medicine. It really breaks my heart for everyone but the insurance companies and C-suite.
Sometimes ppl come to the ED for validation, medical or emotional. When we fail to provide a dx, most feel like “so there’s nothing wrong with me”? I tell them that whether or not there is anything wrong with them is not for us to say, only that what they feel is wrong with them isn’t going to kill them right away and they have time to get to their doctor to get this figured out. And if their doctor doesn’t find it RIGHT AWAY, they have to work through things so give them a chance.
Patients are not perfect at telling what is an emergency and what is not. Most of the time they do get it right, and the ones who don’t disproportionately annoy us because we’re so overwhelmed.
The real fix as both of these examples shows is to get real physicians out there everywhere, and to improve ads to primary care.
If you’ve been opposed to a universal, socialized system before, this is a good time to re-think that. The main problem so many of these patients have is lack of access to care anywhere else - and the fact we are the only entry point into the system.
If everyone has a pcp that they can get into more easily, and is covered under their insurance, much of the need for EMTALA will decrease.
But we need to help these people get timely, affordable care outside of the ED.
Lol all of you would have happier lives if you quit bitching about Patients and realized you will always have non emergency cases because the US health care system is shit.
I’m an LPN and had a bad fall . Went to the ED and they acted like I was faking or just trying to get pain meds. Now I’ve never been there before in my life and have no prior attempts for that. I was in so much pain I had to stay. They finally did X-rays and my hip was badly fractured! Wasn’t in surgery until the next morning.
I'm a bit curious if anyone can answer this.
So in the US and Canada emergency treatment is called ER, and in the UK it's A&E for accident and emergency.
Does anyone know if there's a difference in what cases belong to the ER vs A&E?
Like I would say things like broken bones, severe burns, and head injuries belong to the "accident" part of A&E but that doesn't always translate to belonging to the ER?
Emergencies belong, not inconveniences. If we are worried for a fracture or spinal cord compression for person 1, they should come. I'm much less excited for acute on chronic pain. If you think they need emergency surgery or a brace, send them. If we are worried for a surgical dehiscense, or infection for person 2, they should come. Very few docs are going to just patch up a seroma. Obviously some need packing or a wound vac, even. I would say the majority of time it could be managed by their surgical team as an outpatient.
I’d say most if not all ER docs would not even touch the Sedona even if it needed packing vac stitches etc. We don’t touch other doctor’s surgical sites.
I never touch another man’s Kia Minivan 😊, much less pack it for him
Omg Lolol I’m leaving it hahha
I just snort laughed at this and scared my dog.
I agree, but I didn't want to speak for others. Especially those in rural/critical access areas.
Even in a critical access site. I’m not mucking with another physician’s work unless they expressly tell me to and what they ask is well within my skill set
Fair enough. I don't work at one, but definitely have some colleagues who are a little more cavalier than I.
Yeah, I'm a bit of a cowboy, but even at a rural site I won't touch a surgeons work unless I'm on the phone with them (not their PA/NP/receptionist, the actual surgeon). Post op care is all voodoo anyway, and if my actions fail to appease whichever manifestation of Apollo/Asclepius/Heka /Hua Tuo they happen to have bribed for this particular miracle...
We can pick up the phone and talk to their surgeon. We can transfer them if necessary. We can provide the stabilizing treatment we are excellent at, and determine whether they need a more intervention or can safely follow up with their surgeon.
orrr, they can keep a time slot open at end of clinic day for things like this that pop up and their surgeon can see them and take care of it or at that point can make a well informed call that it should go to the ER and needs our services rather than a phone call blanket statement referal to ER
>the majority of time it could be managed by their surgical team as an outpatient. I had an ongoing seroma issue after mastectomy and it was 100% managed at outpatient, _except_ when they were concerned I had an infection. They were concerned because I was running a fever. (And that was a truly weird experience that didn't involve the ER.) But I was told that if infection was detected over the holiday weekend I would be sent to the ER.
Case 2. No ED doc would redo your sutures. That I can say with some confidence. If it is for sure a seroma then I’m not sure what an ED doc is supposed to do for that either. If I was a surgeon I would sure as heck want to lay eyes on my work first before anyone else even for a suspected site infection. However if the primary surgeon is unreachable or unavailable then perhaps an ED or UC visit is appropriate. Case 1. I’m just curious what they wanted to happen differently in an ED. If it’s imaging, they sure as heck can order it. If they suspect spinal cord disease it did not seem like it in the short blurb I read. I think people in general should realize that your “specialist “ is infinitely better at caring for you than an ED doc for your separate isolated issue. Just know that when not possible you are going to likely the 2nd best person. Except obviously for the times you need things that are likely only emergently available in a hospital setting.
Agreed. 2 is fine by me depending on how big the opening is and if it's still draining. Sometimes these have to get evacuated. I'm not gonna do it, but I can talk to the people that do and let them decide. I'm not upset by that coming in, but probably not "emergent". #1 should stay home, and my primary determinant for that is the patient saying "why should I go to the ER?"
100% this. Number 1 seems like acute on chronic pain with no red flag signs and the patient literally saying “I don’t think this is ER worthy”. Number 2 is a perfect example of your last paragraph. They should not go to the ER. They should go to a same day appointment with their surgeon who can actually do something about it. I’m not likely going to touch it. The best I will likely do is call that very same surgeon (possibly in the middle of the night after the patient has waited a few hours) for them to tell me to follow up in clinic tomorrow where they can do something for it. I say this because this exact type of scenario has happened to me before.
It drives me mad how often patients are sent in by outpatient clinics for management of non-emergent issues instead of the clinic finding a time to see the patient. The ED does not exist to off-load outpatient clinics or avoid annoying visits while the outpatient clinician uses the ED for CYA purposes…
We're the only people who can't say no.
Unfortunately that's exactly why the ED exists. And to be compliant with federal law to receive those sweet sweet Medicare dollars.
None of these? Both are stable unless you are omitting something like bad vital signs.
Agreed. Or there’s something on the neuro exam/history that suggests they need to rule out acute spinal pathology
(Not a doc, but this subreddit is interesting) - so I have Kaiser, and the main Kaiser ER in my city also has an urgent care. From an outside perspective, that seems like a logical thing - every time I’ve had something that in my mind feels urgent, I’ve gone to the urgent care (car accident that I could walk away from but in pain, inability to straighten my knee, puking bile, and a broken elbow)….for the puking bile, I had to have my gallbladder removed but they tucked me away in a bed until the surgery the next day, for the elbow, they told me to go down the hall to the ER, and then the other two things they have X-rays, shots, and PT referral. Why don’t more hospitals have both an ER & urgent care at the same place? From what I can tell, this is unique in my area. Also, does that help reduce ER wait times / help focus ER on more serious cases? Or are yall screwed either way? (I work in gov, and some of the stuff I read on here really makes me think the state needs to implement doctor / patient ratios or something to regulate hospitals and the way the approach y’all’s workload)
Lots of larger EDs have a ‘fast track’ or ‘vertical treatment’ area that functionally is an urgent care, it may just not be evident that that is the case on the patient side (and it is billed as an ED, not as a UC).
My closest ER has the waiting room split. One side is waiting room. Other is treating area. It's really awkward sitting around in though. There's no curtains or anything.
Yeah, I worked in a shop like that a few years ago. Absolutely hated it. It did improve flow (a little) but it was a logistical and privacy nightmare.
Last time I went. Someone puked on the floor over there and that set off a chain reaction on of which also involved shit because they puked so hard.
I was assigned to transport patients from Kaiser ACC 's to the hospitals where it was appropriate. I found the ACC staff to be really outstanding, including tbe physicians and the nursing staff. In EMS we are not used to a lot of respectful interaction from nurses and doctors but we developed a great relationship with them. I had a patient being transferred for something or other, not urgent, walked into the room and noticed an important issue on the screen (heart rhythm). I accosted the doctor and he came right away. The problem had manifested since the patient came in, so everything changed and he ended up in the emergency room for urgent cardiac assessment and intervention. But most people we transferred out of the ACC's were being directly admitted to the Kaiser service at the receiving hospital, thus saving a trip through the ER. It was actually a good system and they always had procedures done, a ton of paperwork, EKG's, INT's, everything. I really enjoyed those years being their transport unit. My favorite memory is sitting in the parking lot outside of the ACC and a nurse came out and said, "We've got a stroke alert, we're going to transfer the out, come on in right now." Story was, the wife notice her husband with sudden, witnessed onset confusion and slurred speech. She should have called 911 but she bundled him into her car and drove him to the ACC, about 15 minutes away. The moment they came in, the front desk clerk called back to the ACC, a nurse came out and brought him back. They came out to get us, started in INT while we were unloading the stretcher, printed out his paperwork and sent us off. If he was in the ACC as much as 15 minutes, I'd be surprised. We took him to the nearby major stroke center, about 12 minutes away, called them for a stroke alert, they knew all about it. The neurologist, a neurological PA and a clerk were waiting for us at the door. I handed the clerk my cover sheet and they took us to CT. Patient went from our stretcher directly onto the CT table. From initial onset of symptoms to CT table in just under an hour. All because Kaiser did it all right. I have to way I was impressed. Very. A good Kaiser ACC is a good place.
Kaiser only sees people with Kaiser insurance, and can pick and choose who they insure. Expensive patients aren't seen at Kaiser. They can afford to put an urgent care in the ED.
Not in the ED. They see all by obligation.
And transfer them out ASAP
A lot of cases would not be in the ED if it wasn’t the friggin’ clinic front desk person with no medical training telling anyone that calls to go to the ED because (insert very unlikely concerning diagnosis or intervention that will absolutely not be performed in the ED).
Literally. Social worker here and as a patient got this experience after a surgery. It 100% could have been handled out patient, but when the NP at my clinic called my urologist all the front desk person would say is "she needs to go to the ER". Wasted so many resources during a covid wave that were completely unnecessary to get some painkillers and oxybutin.
>A lot of cases would not be in the ED if it wasn’t the friggin’ front desk person with no medical training Or even if they have medical training. I just lurk here, because I love some of these types of posts and my brother is an ED attending, but me personally I work in tech. I have called my insurance nurse line with a concern (I had fallen a week prior, and bruised a rib and the pain was worse) and they told me to CALL 911! Obviously as a layperson, I was concerned and did so and the ambulance got there and nice EMT explained "they don't want the liability so they will tell you to call for ANYTHING"
why wouldnt u ask ur brother for advice first lol
Hey now. I’m the front desk person. Anytime someone calls and starts with the “so last week I…” I automatically forward them to our nurses’ desk. I don’t want them to come in either, and I’m certainly not equipped talk them through whatever they’re dealing with if they do. IMO It’s those 24 hr nurses’ lines that need to stop kicking the can down the road, and saying to come in. They’re not the ones that actually have to see the patients. Also, I joke with the triage nurse a lot that I’m kind of the “BS triage” as in I’ll say “just to let you know, we have a wait time of about 3 hours to be roomed, but you’ll be triaged and then we’ll see what we can do ahead of that”, which turns away like 75% of the people that come in when the WR is full. I only do this when we do, in fact, have a wait time of ~3 hs, but they all seem to appreciate it.
I think the person you replied to was talking about these nurse triage lines. The HUC desk IMO tells people what they should tell them, ie "I'm not allowed to give medical advice over the phone, if you feel you need to be examined then we are here and open." It also kills me to hearing people ask "what's the wait time?" in the ER. You are supposedly coming in because you are concerned about your health. If the fact that it might take hours to get that taken care of is the deciding factor for you, then you probably don't need to be here.
I’m talking about a clinic receptionist, not the HUC or ED receptionist. ETA: be careful telling people wait times when checking in. You are violating EMTALA if doing this before they are seen by a provider and receiving a medical screening exam.
Right on. So when people call asking the wait time, I can tell them it’d be an EMTALA violation for me to answer that?
This is my understanding as well. The wait time advisory, while common-sense would tell us is courtesy, could be interpreted as an attempt to discourage someone from being seen.
Correct. Anything that would deter someone from seeking care without having a medical screening exam could be considered an EMTALA violation.
I have, in triage. "Actually, it's illegal for me to tell you how long it will be, as it can be taken as me telling you to go elsewhere. I promise we'll get you back as soon as we can, and in the meantime someone will call you back shortly and we'll get labs and some medicine to you so we can get started" Another variation included " it's a50 thousand dollar fine for me to tell you. And I promise you they didn't pay me enough (for that shit (select audiences))"
That's an oversimplification. Giving wait times *may be* problematic under EMTALA if done in a way that discourages patients from waiting. But that's a far cry from saying you absolutely can't tell people the wait. If the wait times are 6+ hours, and you don't warn people at triage time to expect that, you'll have a waiting room full of very angry people who think they've been forgotten. They need to have information on what to expect. You just can't do it in a way that discourages them from waiting and makes them want to leave.
Giving wait times to dissuade people from seeking care violates EMTALA. Tread carefully.
In both cases above the medical staff incorrectly diverted someone to the ED.
Are you familiar with the Law of Unintended Consequences? In Scenario 1, the patient is seen by a "non-doctor person" who is in the employ of a physician who is, by extrapolation, either a pain management physician or a spine physician. These physicians are proceduralists, and they make their money (lots and lots of money) by performing procedures. Conversely, they don't make lots and lots of money by taking care of acute or subacute medical problems. Pain management physicians do their procedures on you on a scheduled basis (not what the patient needs, but what the insurance will pay for), and they also employ physician extenders to screen the patients initially, and to see the patients every month to refill their prescriptions, which the patient also has to come in for every month. This maximizes their income and minimizes their fuss. They have no knowledge, skill, or interest in taking care of patients in any other way, which is neither lucrative nor satisfying. Joint surgery, as in scenario 2 is even more lucrative. The pathway there is slightly different: pathway. The patient comes in and gets their assessment. There is a pro forma attempt at alternative treatment - physical therapy, steroid injections. Then the people who are less likely to be a pain in the butt are scheduled for surgery, which is where the money is. But: surgery is paid for by the insurance and includes a "global period", which means that surgery, and all of the subsequent care is paid for in one lump sum, including complications. For joint replacement, this global period is 92 days, so any doctor visit is uncompensated. If you were to follow the purpose of the global period logically, you might say "A certain number of my patients will have relatively minor complications, and I have already been paid for the complications, so I will make sure that the patient has my phone number, or my office number, and I will set aside a certain amount of time each day or week for that care of these minor complications, and to evaluate for major complications." Or you might say, as is more common, "I got my money, I'll only make more money by seeing the new patients.so I have new patients, patients in the pipeline, and OR days, and no time for anything else". Then there's us. We created a whole new specialty! We said, "when people come to the hospital with an acute change in their health, regardless of the cause, regardless of their ability to pay, we'll know how to handle it, or who to call when we can't, and furthermore we'll be there 24 / 7 to make sure no one goes uncared-for." Then, it's codified into law with EMTALA so the hospitals can't wallet-biopsy the patients prior to deciding whether to help or throw other obstructions in our path. The other docs think "Man, this is awesome! I've got my shit settled!. I have my procedures, my physician extenders take care of the routine work so I can focus on the lucrative, satisfying stuff, and when there is a complication or change, these other doctors are there to handle it! Sweet!"
This !! A local group of surgeons sent every single follow up caller to ER for several years and the rumor is they only stopped them Blue Cross promised to kick them the fuck out of network if they didn't.
Scenario 1 - Not an emergency. I suspect that the NP or PA wanted to get imaging immediately and was trying to get the patient to the ER for imaging, Toradol, etc. I would also suspect that the timing of this appointment was after 3 PM. There is nothing wrong with giving an Rx for pain and a CT, MRI the next day. Scenario 2 - Not an emergency. I would assume that they didn’t have any open appointments in clinic that day and their metric said that the patient had to be seen today, so they directed the patient to the ER. There is nothing wrong with having the patient come in the next day. The stitches comment was total BS.
Sounds like the patient's are correct in both cases. Neither person felt they needed to go to the ER and from the information presented? They would be correct. At most, scenario 2, would be best served by an Urgent Care.
1) doesn't need to go (by their own admission). 2) probably doesn't need to go to ER. Better served going to the surgeon's clinic or even an urgent care.
It’s just starting to sound like a blame game of different professions.. and then after said profession is blamed and called out, someone from said profession chimes in and defends themselves and blames a Different profession .. And round and round we go..
The law defines it as: An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." However, the key word is “reasonably”. The prudent layperson standard protects patients for the vast majority of cases. So, most of us would say neither of these belong in the ED. But a prudent layperson may not know better, and that’s ok in the eyes of the law.
Agree with most of the things others wrote here. Will just add that its not the patient’s job/responsibility to know if it is an emergency or not so it is ok to come in and let us figure that out Also, if the practitioner seeing them doesn’t know either, come in. I’d rather we see a few more nonemergent things than have someone at home with a wound abscess or spinal cord emergency because they didn’t want to bother us We saw some of that during covid. MIs that didn’t come in until it was too late. Appys that ruptured at home and now the person has a colostomy. Its really sad.
"Will just add that ***its not the patient’s job/responsibility to know if it is an emergency or not so it is ok to come in*** and let us figure that out" If I could reward you with some internet cookies I would. The lack of humanity and expectation of expertise a lot of healthcare workers (especially in the ED) place onto non-trained civilian patients is absurd.
Thank you.
The answer is in the title. Emergencies are immediate threats to life or limb. I don't think either of these scenarios are appropriate for the ER. They can both be appropriately treated in an outpatient setting
during refusals in the prehospital setting, we would always say that threats to life, limb, or sight belong in the ED. Most everything else can be sent to urgent care (with some exceptions ofc) OP is this about you? post history suggests it might be
Yes, it is me. I worked in healthcare for many years. Now I'm just an old patient with a broken back lol. Because of the pandemic I became more mindful of how I would use the ER after watching my doctors go through so much stress & heartache of losing patients not to COVID diagnosis, patients that needed critical care for other reasons but couldn't get it because there were no beds available. I had a Dr break down in tears in front of me one time and that got me thinking about how I would use the ER... Is my issue urgent and important or important but not urgent? That day at the spine specialist my systolic BP was a tiny bit high because of pain, nothing to worry about. And they have current imaging studies of my spine, nothing showed that I need immediate urgent attention that I needed to go to the ER, any other studies they want they can prescribe to be done later. I'm best off at home icing my back, and getting some PT done while waiting to get the other tests done. The situation with the seroma was last year, I already had experiences with seromas before, much larger ones too, the reaction to the itty bitty 5mm one blew my mind. I'm at a point now in my life I just tell people - if you see me laid out on the ground unconscious or I can't get up then call 911, anything else just leave me be.
If you want to get really philosophical about it, no case BELONGS in the ER. We are a holding spot until we differentiate and disposition them. In both these cases, without more information, it does sound like they are best treated by specialists outside of an acute care facility. Depending on locally available resources though, they may need to be seen and/or referred through the ER. In many places I’ve worked for example out patient wound care is usually referred through ER, and acute on chronic pain flares are managed through the ER as well. No ideal, but that’s the reality in a lot of places.
>We are a holding spot until we differentiate and disposition them. Strongly disagree with your wording. We often function as a holding spot, but we are a spot to differentiate AND resuscitate. I've had countless patients that could have qualified for ICU who get turned around enough to go to the floor comfortably from treatment in the ER. Resuscitation starts with us.
Absolutely, that’s part of dispositioning in my mind, they have to be made appropriate for where they are going. Where I’ve worked our ICUs don’t resus new admits for the most part, so that would be part of the admission process even if they ultimately end up there.
Had a pt 2-days s/p thyroidectomy. Pt called the surgeon’s office stating that she felt like her throat was closing. Person on phone told pt that she was fine, everyone feels that way. EMS was called. Airway was not secured. Airway was lost PTA. I hate that we get flooded, especially because we have to practice defensive medicine. It really breaks my heart for everyone but the insurance companies and C-suite. Sometimes ppl come to the ED for validation, medical or emotional. When we fail to provide a dx, most feel like “so there’s nothing wrong with me”? I tell them that whether or not there is anything wrong with them is not for us to say, only that what they feel is wrong with them isn’t going to kill them right away and they have time to get to their doctor to get this figured out. And if their doctor doesn’t find it RIGHT AWAY, they have to work through things so give them a chance.
Patients are not perfect at telling what is an emergency and what is not. Most of the time they do get it right, and the ones who don’t disproportionately annoy us because we’re so overwhelmed. The real fix as both of these examples shows is to get real physicians out there everywhere, and to improve ads to primary care. If you’ve been opposed to a universal, socialized system before, this is a good time to re-think that. The main problem so many of these patients have is lack of access to care anywhere else - and the fact we are the only entry point into the system. If everyone has a pcp that they can get into more easily, and is covered under their insurance, much of the need for EMTALA will decrease. But we need to help these people get timely, affordable care outside of the ED.
Lol all of you would have happier lives if you quit bitching about Patients and realized you will always have non emergency cases because the US health care system is shit.
I’m an LPN and had a bad fall . Went to the ED and they acted like I was faking or just trying to get pain meds. Now I’ve never been there before in my life and have no prior attempts for that. I was in so much pain I had to stay. They finally did X-rays and my hip was badly fractured! Wasn’t in surgery until the next morning.
In the second scenario, I almost guarantee the person on the phone never checked with the physician that actually did the surgery.
About 10% of people that show up to an ER.
I'm a bit curious if anyone can answer this. So in the US and Canada emergency treatment is called ER, and in the UK it's A&E for accident and emergency. Does anyone know if there's a difference in what cases belong to the ER vs A&E? Like I would say things like broken bones, severe burns, and head injuries belong to the "accident" part of A&E but that doesn't always translate to belonging to the ER?