Hallway Four

In my hospital, Hallway Four is where the crazy people go. This is a glimpse of their lives and mine.

It’s all about Perspective

Posted by Amy on June 4, 2007

An ED patient Timeline:   A stroll  in their shoes and mine…


Ms W’s perspective: 

0800-1200:  I’m sitting in the waiting room with abdominal pain – I thought this was an “emergency” room.

1200-1240:  Finally, I get a room.  Where is the doctor?

1240-1247:  The doctor talked to me and checked me out for about 5 minutes.  She pushed on my stomach and asked me a few questions.  She said something about my gallbladder and told me they needed to run some tests and that she’d be back later.  Now, she’s already gone.

1330:  What’s taking so long?

1420:  My ultrasound is done.  Where is the doctor?

1600-1605:  The doctor said my gallbladder is filled with stones and infected and will need to be removed by ANOTHER doctor.   This is absurd – that ER doctor didn’t even do anything for me!

Amount of time the doctor spent with me:  12 minutes.

My Perspective:

1200:  5 new patients in the rack:  68 yo chest pain, 55 yo chest pain, 6 wk old fever, 30-yo upper abdominal pain (Ms. W), 87 yo weak and dizzy.  We can save the abdominal pain for last.

1240-1247:  I examined Ms. W and she’s stable with right upper quadrant tenderness and mildly positive Murphy’s sign.  Probably has gallstones vs gallbladder infection.  Will start labs and ultrasound and make sure she’s not pregnant.  Will keep her comfortable.  Have discussed with her that she’ll be here a few hours getting tests. 

1248-1251:  I look Ms. W up in the computer and find that she’s never been here before for gallstones, but has had her appendix taken out and has been pregnant 3 times.  No other medical problems noted in the system.

1257-1259:  I write orders for Ms. W and ask the nurse to please start and IV, get blood, keep her NPO (no eating or drinking) and give her some pain medicine.  The nurse is busy and says she’ll get to it when she can. 

1330-1332:  I go to check labs and the computer doesn’t show Ms. W’s liver panel.  Tech, please call the lab and see where the liver panel is.

1350-1354:  I check the computer again – still no liver panel for Ms. W.  I call the lab myself (after sitting on hold for 2 minutes) and they assure me “it’s on the machine right now”. 

1410-1412:  I notice that we’re also STILL missing the urine on Ms. W.  I ask the nurse and the tech to please get urine from the patient. 

1430-1435:  The urine is back, but the lab forgot to run the pregnancy test.  I call the lab again and they tell me that the pregnancy test wasn’t ordered right in the computer.  I ask the tech to please re-order the pregnancy test and make sure the lab is actually doing it. 

1450-1451:  I check in on Ms. W and she’s sleeping so I don’t disturb her.  I note that her vitals signs are still fine and she’s gotten her 2nd liter of normal saline.

1500-1502:  I know that Ms. W has had the ultrasound, but I haven’t heard back from radiology.  I call radiology and ask them to please call me when the results are back.

1528-1531:  Radiology calls back to say that Ms. W has acute cholecystitis (infected gallbladder).  I recheck her liver panel and find that her alk phos (liver test)  is elevated and lipase is okay. 

1535-1536:  I ask the front desk tech to please call the surgeon on call.

1537-1538:  I ask the nurse if Ms. W is still doing okay pain-wise and she assures me she is.

1555-1556:  After never hearing back from the surgeon on call, I ask them to please call the surgeon again at which time his nurse calls back and says he’s in the OR and will call back in an hour. 

1600-1605:  I talk to Ms. W and explain that she will need surgery for her gallbladder and that the surgeon will be in to see her as soon as he is available.  I check her abdomen again and it is mildly tender only. She seems comfortable and I explain that we’ll get her admitted soon. 

1630-1633:  Dr. Surgeon calls back and I give him the story on Ms. W.  He agrees to admit her and asks me to do some transition orders, which I do.  I then call the charge nurse to make sure we have a bed.

1635-1638:  I dictate Ms. W’s chart.

Amount of time I spent on this patient:  45 minutes.

27 Responses to “It’s all about Perspective”

  1. […] It’s all about Perspective « Hallway Four Indeed it is. […]

  2. Greg P said

    It’s interesting that your doctor perspective doesn’t consider the 4 hrs the patient waited to see you, and this was someone who ended up needing admission — something wrong with triage?

    Aside from that, as those of us outside the ED have to deal with, for the various E&M codes, all the time spent on the phone talking to lab, looking at images, talking to nurses, doesn’t count — it’s the time spent face-to-face with the patient.

  3. scalpel said

    Bedside ultrasound saves a lot of time with cases like that, but interdepartment politics sometimes restrict its use in certain emergency departments. It shouldn’t, however. We can bill for a limited study, and the radiologists can still bill for a confirmatory comprehensive study. Of course, after we print out pictures of the gallstones and admit the patient to the surgery service, sometimes the surgeons don’t bother getting a confirmatory study. And the radiologists can’t order studies themselves.

  4. hannah said

    Great post. :)

    I’m sitting in the waiting room with abdominal pain – “I thought this was an “emergency” room.”

    Ugh. I get this a lot in my position. At least your lady had a legit complaint. Most seem to come to the ED because they think it’ll be faster than seeing a PC or going to the clinic. I can’t count how many people I’ve had storm out in disgust with, “It would have been faster to go to the clinic!” Yeah, dipshit, it probably would have.

    Also from the patient’s perspective — that any delay in treatment is chalked up to “nobody cares.”
    “I’m sick and nobody here cares.”
    “I could have sat out here and died and nobody would care!”
    “My doc told me to come here right away and now I have to wait and nobody cares!”

  5. […] How it works in the ER, because it’s all shotgun medicine. Talk with patient, ask questions, feel belly. Most of the time the patient is waiting is either because there are sicker patients, you’re doing a procedure, or you’re playing phone tag or following-up on labs that are pending or didn’t get sent. Great writeup. […]

  6. […] the flip side of that complaint, with a h/t to medical instapundit Kevin, […]

  7. In response to Greg P, it sometimes seems that there IS something wrong with our triage, but the problem isn’t that the nurses don’t want to bring the moderately sick patients back, it’s that sometimes there are too many sicker patients and not enough beds.

    I worked overnight last night with one other doctor. The waiting room had 40 patients in it the entire night and the ER was full of admitted patients. Only the sickest of the sick got back and quite a few of the rest left.

    When there’s nowhere to put them, even the best triage systems don’t work well.

  8. Scalpel,

    Bedside ultrasound would have been very helpful, but unfortunately, we don’t have a very good ED ultrasound machine. We do have one, but it’s old and small and I only use it to place lines, quickly rule out big AAA’s and look at fetal heart tones. Oh, and I’ll do an occasional FAST exam, but honestly the picture quality is so poor that I wouldn’t trust a negative study as being all that negative!

  9. scalpel said

    Like many tests in the ER (the urine pregnancy test being a notable exception), I usually don’t consider negative results to be very reassuring. Positive tests are more useful, and as soon as you see a gallstone most surgeons will take the patient at that point. Saves an hour or two sometimes.

  10. Judy said

    When I had RUQ pain, vomiting, diarrhea, no fever at 0200, I waited until 8am when the office opened and saw my primary care doc by about 10. No infection, just stones, so I put off surgery until my grandmother talked some sense into me. If I’d had an infection, I probably would have been admitted in less time than Ms. W. OTOH, that was over 20 years ago and things have changed a little. I still won’t go to the ER if I think it can wait until morning, though.

  11. SeaSpray said

    So true hallway four! Too bad patients couldn’t see something like your post posted somewhere so that maybe they could feel a little better about the time factors.

    When I was first hired to ED registration – they told me to remember that every patient coming to the ER thinks that THEIR emergency IS an emergency.

    The patients don’t understand why they have to wait. The little old people are usually the most polite. They will go quietly sit down when they have chest pain because they don’t want to bother you!

    You ED docs do work hard. :)

    P.S. Interesting posts – hope you don’t mind that I am blogrolling you. :)

  12. Jrobatc said

    Greg P: While people may spend hours in Triage, EMS will bring in other patients, patients with higher acuity problems will sign in, and those already back are in the midst of a work up or awaiting admission. As an ER MD, I barely have time to take a piss managing a 22 bed ER at night when we drop to single coverage and every bed is full along with a busy waiting room. I’d love to clear out the ER and triage so I can snooze but this is not reality. When people go to a busy restaurant on Friday they expect a wait. Why is it people don’t think there should be a wait when a multitude descends upon the ER. As this example shows, most serious complaints take time to work up and that bed will remain occupied for that time. I, and all my partners are busting our tails to speed up the process but will not do so if it means compromising patient care.

  13. SeaSpray,

    You’re absolutely right about the polite old people – many of them can have a bone popping out and they’ll still maintain their manners and poise.

    Oh, and I love being blogrolled! Thanks for reading.

  14. Great post.

    Years ago when I was an ER nurse at my county’s trauma center, I thought that the Emergency Nurses Assn. shot themselves in the proverbial foot when they declared that “an emergency is whatever the patient perceives it to be”. I, however, have always felt that lack of planning on the patient’s part does not constitute an emergency on my part. A prime example of this is med refills. A patient’s failure to plan for refills doesn’t move them to the head of the line, and frankly, I can’t believe the nerve some of them have to even think it does.

  15. Run With Scissors,

    I absolutely agree. I’m more than happy to treat anybody who is sick (or believes they are actually sick) but it gets old dealing with “emergency” medication refills (especially pain medicine refills!) as well as other non-emergencies like women who complain of vomiting in the mornings when really all they want is a pregnancy test.

  16. 911doc said

    sounds like my last job. currently our waiting room will sometimes get twenty or thirty down but that’s about it. rather than spending most of my time trying to admit patients to our place i spend at least half my time trying to find a hospital with beds that has the specialty capabilities to care for my patient.

  17. RevMedic said

    Thanks for that perspective. I’ve only been in the ED once as a patient, and once as a parent, but I do bring them in and stack them like hotcakes. I’m usually not around long enough to see the entire ED cicus run its course. This is valuable – now if we could print it out & leave it in each exam room for the inhabitants to read (prolly would need stick figures for most of them to figure out, though).

  18. Lisa said

    I broke my sterum one time… so I’m sitting out in the waiting room, having a coronary for all I know (at the time) lol. Some lady is out there belly-aching about the wait and had some very, very minor problem involving her toe. I suggested, “Have you considered calling your GP or, maybe, and Urgent Care clinic? I have to be here, my doctor insisted.” It was like a little lightbulb over her head appeared. Gawd, she was making my ears hurt.

  19. Lisa,

    Ouch – a broken sternum! That’s pretty hard to do and (I imagine) extremely painful. Hopefully they didn’t make you wait too long!

  20. Lisa said

    They thought I had a pulmonary embolism at first, but remembering a strong hug my husband gave me while my arms were crossed a few days beforehand finally brought light to the situation. One heck of a hug, it would seem. Or just the precise alignments. I had Cushing’s Disease at that time, I’ve recently had surgery to remove the pit tumor, so my bones have some weaknesses maybe… I’m not your usual customer, lol.

  21. Rich said

    About 15 years ago, while living in NYC, I cut off half of the first joint of my right forefinger in a carpentry accident.

    I decided this was worth an ambulance because I was REALLY freaked out. The ambulance took about 20 minutes to arrive. During the trip to the hospital, I had to ask the EMT to close the porthole to the driver’s compartment as the driver’s smoking was making me sick. In retrospect, it was pretty funny, but for some reason I didn’t see the humor at the time.

    At the ER, the EMT sat me down in the waiting room (blood-soaked wrapped hand elevated) and spoke to the triage nurse.

    An hour or so later, the same EMT came back through, and I heard him tell the triage nurse something to the effect of “you know you’ve got that partial amputation in your waiting area?” Her
    response was “yeah.” That was about it.

    I was seen about 1/2 hour later.

    After taking x-rays, the ER doc called in a hand specialist, who worked on my finger for about 45 minutes.

    The finger is a little short, but it healed quickly and cleanly, and that’s all I could really ask for. In the end I’ve go no complaints, but it was a very sureal experience.

  22. Great post

    and Hannath
    I can’t count how many people I’ve had storm out in disgust with, “It would have been faster to go to the clinic!”

    so familiar:)

  23. Heidi said

    Being a medical brat who grew up in med offices and hospitals, I’m often a little too calm and collected for my own good.

    A few years ago I managed to stab myself in the hand with a sharp knife (prying apart frozen burger patties, you’d think I’d know better). I immediately grabbed a handful of paper towels, clenched my hand tightly and elevated it. Got dressed one-handed, woke my sweetie to tell him I was going to go get my hand stitched up, and walked a mile or so to the nearest E.D. Told the admitting nurse my problem and sat down, reading a paperback book.

    Eventually the triage nurse called me back. I should point out that the paper towel wasn’t even visibly bloody, so she wasn’t expecting much of anything. She was pretty surprised to find a deep laceration at the base of my finger. It hadn’t been bleeding all over until then, so she got a nice look at it before the blood started welling up, as did I (I hadn’t realized quite how deep it was either).

    The doctor sutured it up for me, we chatted about this and that (my father has privileges there) and then I apparently blew their minds all over again when I asked if I could have a single Tylenol 3 just to get me through the heavy throbbing stage.

    I’d like to think I helped balance out the day’s load of frequent flyers, but I probably should have been a little less nonchalant about the injury – I was in the waiting room until she’d gotten through *all* the non-emergencies like runny noses.

  24. […] Trauma Center ER for about a year and a half. This is about the best explanation of a typical ER. It’s all about Perspective Hallway Four Socialized medicine is about the worst thing we could do for healthcare in this country. Even with […]

  25. drwings said

    I had a patient stop me in the hall and ask if my trauma/code was dead yet because he wanted to be treated NOW for his cold and didn’t want to wait any longer.

  26. DRwings,

    Wow, that’s really a new level of low. I hope you put tha patient in his rightful place (like, kicked to the curb?).

  27. […] This is one of my all-time favorite posts.  If you’ve never been to her site before you should go, it’s worth your time.  […]

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