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June 13, 2014 5:45 AM   Subscribe

hit by a car, an emergency doctor experiences firsthand the shortcomings in ER care
posted by and they trembled before her fury (133 comments total) 29 users marked this as a favorite

 
Yeah, his experience is very much like every ER experience I've ever had. The staff isn't at all callous or trying to do an incomplete job, but the ER is so over-full and busy that they do whatever they can to get you back out and generally it's a miracle if an actual physician manages to see you. I think nurses and PAs and techs are extremely talented, devoted people, but they don't tend to do overall examinations and the doctors seem to be there to determine how quickly you can be sent back out and if you need prescriptions.
posted by xingcat at 6:07 AM on June 13 [7 favorites]


I've seen a couple of articles like this where a doctor was shocked, shocked! to discover that the patient experience is uncomfortably close to, say, the livestock experience. Has the medical field never heard of dogfooding? It is neither a complicated nor a newfangled idea.
posted by Western Infidels at 6:07 AM on June 13 [21 favorites]


Has the medical field never heard of dogfooding?

"They make psychiatrists get psychoanalyzed before they can get certified, but they don't make a surgeon get cut on. That seem right to you?"
posted by mhoye at 6:13 AM on June 13 [38 favorites]


Definitely echoes experiences I've had, albeit indirectly, as a helpless care-giver in a few ER situations.
posted by tehjoel at 6:18 AM on June 13 [1 favorite]


I had a dose of food poisoning years ago, and I was lying there, groaning ostentatiously in the ER waiting area. Someone came over and asked "Do you await to see a doctor?" Um, yes, that was the idea.

I recommend creating a perception that you are about to spew all over the waiting area: this will help motivate them to get you back into the treatment area.
posted by thelonius at 6:22 AM on June 13 [2 favorites]


I've definitely found emergency rooms to be very test-centric. They do all the tests they can think of, and if there's a positive result, then they can act in their prescribed ways. But if it's just a general pain complaint, good luck.
posted by smackfu at 6:29 AM on June 13


medical executives

It's all about the hospital administrators...
posted by hal_c_on at 6:32 AM on June 13


This is a joke, right? You might as well blame the cashier for the shortcomings of McDonalds
posted by phaedon at 6:39 AM on June 13 [7 favorites]


As with all professions, your mileage may vary. I once spent 8 hours in an ER for dehydration because the staff failed to actually activate the saline drip. Twice.
posted by grumpybear69 at 6:41 AM on June 13 [4 favorites]


It's all about the hospital administrators...

It's all about the corporation the hospital is owned by. And what insurance will pay for.
posted by Thorzdad at 6:44 AM on June 13 [14 favorites]


Yeah, his experience is very much like every ER experience I've ever had.

Her experience. Charlotte Yeh.

It seems to that the problem is that there is not good second step care once possible emergencies are resolved (though maybe the spinal problems could have been reduced if diagnosed sooner?). Emergency rooms should really be just about keeping people from dying. The rest of the hospital should be about helping them live well.
posted by srboisvert at 6:48 AM on June 13 [9 favorites]


I recommend creating a perception that you are about to spew all over the waiting area: this will help motivate them to get you back into the treatment area.
posted by thelonius at 8:22 AM on June 13


I actually did throw up in an ER once, and I have never been seen so quickly.
posted by joannemerriam at 6:51 AM on June 13 [6 favorites]


Health Insurers are the devil.

This entire healthcare ecosystem is driven further and further into the muck and mud by the fact that Insurance companies wield far too much power, and they exist not to serve the potential patients. They answer to their shareholders.

Hospital administrations also answer to their shareholders, and they get their money from insurance companies.
posted by DigDoug at 6:52 AM on June 13 [15 favorites]


As somebody that works in pharma marketing (mostly for the "good" drugs, the ones that treat cancer and heart failure, etc.) I feel I can say with some authority that the Holy Grail for a drug is to make it into recognized practice guidelines for the specialty college in your nation of choice. In the USA, for instance, you want more than anything for your chemotherapy-induced-nausea drug to be part of the ASCO (American Society of Clinical Oncologists) guidelines.

Because once you're in the guidelines, you're part of The Algorithm.

I've become very algorithm-sensitive over the past few years; it's such a crucial part of messaging to doctors that it trumps efficacy and tolerability if your drug is well-known enough that there's no news in those categories. The Algorithm for whatever you're dealing with is easy to understand, easy to follow, and absolves the treating physician of all blame. They followed The Algorithm.

Reading the article, with no particular experience in U.S. emergency care, I can still see The Algorithm shining through. The author's progress from admission to discharge was very clearly predetermined, to the point that when she started professing bafflement that nobody had examined her knee even though she said it was painful, I actually said "oh, come on" out loud. Why would they check her knee? Who is responsible for this? I'm guessing that there's an algorithm that includes scanning for vertebral and internal injuries, etc., and her knee and butt complaints fell off the algorithm, and as her file got bounced from person to person, shift to shift, anything that wasn't on the Algorithm got ignored.

Being a Canadian, and having a number of emergency-room visits under my belt, I've felt The Algorithm in action. I've had a number of great medical experiences here, but other than my family doctor, who actually takes 15-20 minutes during my annual check-up to sit down, chat with me, and ask me how things are going and what's bothering me and so on, being treated in Emerg (or even by specialists) is astonishingly like calling a computer tech support line. There's a flowchart. If A, then B. If B, either C or D. I've had doctors blankly deny symptoms because they're not on The Algorithm. Specialists, too.

Doctors engage in no small amount of hand-wringing about Doctor Google and patients self-diagnosing and coming in with their own ideas of what they have, but I have great sympathy for people who self-diagnose, because at least we listen to ourselves. Once you feel like you're just being treated via scripted responses, and that anything anomalous about your particular case is being ignored in favour of hammering you into a box in The Algorithm, you start to want to do your own homework.

I'm not particularly upset about it, either. We also have animal-health clients, and I've attended my share of focus groups with vets, and one of the big-nod-around-the-table moments was when a vet said "every one of my clients feels like I like their pet the best, better than all the other ones I treat." I was a nodder. I've fallen prey to the fallacy that the vet has a secret special fondess for my cat that is not felt towards all those other cats the vet treats. It's a harmless little ego trip that is obviously ridiculous when you think about it for a few minutes.

But I think we tend to carry the idea that we're the hero of Our Story into environments like banks and the ER and the DMV, and find it hard to grasp that to the doctor who also has a kid home with the flu and is behind on their car payment and a nagging headache that won't go away, we are not a Very Special Person with Very Particular Needs, but rather Patient 56 out of 78 that needs to be seen before their shift ends.

To us, we've been hit by a car and we're hurt and scared and things hurt and this is all new and terrifying.

To the doctor, we're a dot on The Algorithm.
posted by Shepherd at 6:52 AM on June 13 [152 favorites]


Good article, and the noise about "dogfooding" is kind of hard to understand. Besides the general crappy ER experience, there's also the problem that the medical system doesn't "do" soft tissue injuries like those suffered in an automobile accident very well at all. If you can't see it in a CAT scan, you can't diagnose.

It's a big problem for people who have been in auto collisions.

Interesting article. I don't think the fact the writer is a physician (part of the 1%, amirite?) should be held against *her* (not him, and if you RTFA it is very obvious it is a *her*).
posted by KokuRyu at 6:54 AM on June 13 [5 favorites]


A little appalled that this woman works in an ER but her patients' experience was a revelation to her. She's spent her career threading her way past occupied gurneys stacked up in the hall, eyes averted, and never realized she was doing this? She had to be hit by a car to understand how she has been caring for patients?

Strategically, maybe not the best move to tell the world that the best way to get doctors to improve care is to run them down in the street.
posted by stupidsexyFlanders at 6:59 AM on June 13 [29 favorites]


I've seldom been to Emergency, but have received very good care. At least 1 local hospital has wifi, and I was able to read and do a little work online while I got re-hydrated and monitored. I've mostly been there when it's not crazy busy. One ER visit with my son was marred because the resident, in a surplus of caring, had us wait 45 mins. to get tylenol, when we were exhausted and wanted to get home. This doctor's experience points out the lack of anyone owning responsibility for her care.
posted by theora55 at 6:59 AM on June 13


~ the more you know ~
posted by St. Peepsburg at 7:00 AM on June 13


It's almost like she was sent to an 17th century craft village, bounced from one independent craftsperson to another - none of whom actually talk to each other. In my work, I get a lot of crap about how manufacturing/supply-chain principles won't work in heath care because they're "people not widgets, dammit". A Toyota Corolla going down the line in Georgetown gets a hell of a lot of systematic attention and better care than any human ever sent to a US hospital.
posted by klarck at 7:05 AM on June 13 [32 favorites]


I've seen a couple of articles like this where a doctor was shocked, shocked! to discover that the patient experience is uncomfortably close to, say, the livestock experience.

As someone who looks after my grandmother, the livestock experience would be a serious step up from how an elderly and disabled person is treated in such cases. I get the shakes if we have to go to Emergency and want to ask the staff, "Do you realize this is a human being and someone who wants to live?"

Worse, many hospitals do not have x-rays or equipment that can be used for people with mobility issues. If you can't walk, you are up the creek there.

For comparison, I took my mother to Emergency several years ago when she visibly broke her hand. The doctor x-rayed it and said it wasn't broken. Pointing out her floppy hand convinced him that maybe he checked out the wrong spot.

When I had to go after taking a serious tumble down the stairs, I got the most and best attention with me and ER doctor discussing rescuing feral cats.

I find in my experience, if you are young and not sick, it is a passable experience. If you are old, sick, and really need the service, good luck with that...
posted by Alexandra Kitty at 7:10 AM on June 13 [3 favorites]


A little appalled that this woman works in an ER but her patients' experience was a revelation to her. She's spent her career threading her way past occupied gurneys stacked up in the hall, eyes averted, and never realized she was doing this? She had to be hit by a car to understand how she has been caring for patients?

It's very possible the hospital she works in operates a bit better than the one she was treated in. Like her, I live in Boston and work in a hospital (though I don't usually go near the patients) and I have been treated in various departments here, including the ER. Short of a few total dick doctors, my experiences have been mostly positive.

I've also been treated at the ER in the suburbs where I live, and my experiences haven't been as good, though nothing like what she reported.

Incidentally, if you want to get treated right away, be a 40-something man with chest or arm pains. They take that shit pretty seriously.

One of the things I learned as I got to know a lot of doctors is that a lot of the time they have no frigging clue what's wrong with you and they're mostly just guessing.
posted by bondcliff at 7:10 AM on June 13 [1 favorite]


Hit by a car 2-3 years ago, still walks with a cane: just love that the ads are for rock climbing equipment!

But in her narrative I don't see that the ER staff missed anything that would have significantly improved her recovery. Perhaps they could have been 'nicer' and let her know more detail and looked over non-life-threatening injuries but it seems like she was in a busy but good ER.

Did I miss something? Was there an immediate treatment that would have helped her long term recovery?
posted by sammyo at 7:11 AM on June 13 [8 favorites]


A little appalled that this woman works in an ER but her patients' experience was a revelation to her.

I'm not surprised, though. The ER is a crazy, busy machine, trying to respond to anything that comes in the door, along with whatever gory messes the ambulances bring, which almost always disrupt the treatment of those who walked-in on their own. To survive working in the ER, you almost have to slip into a routine of checking boxes, and running-through set steps. It's a lot like any public service job, really. You become blind to the individuals and just get focused on the routine.

That's why stories like these come wrapped in so much schadenfreude, and are met with a collective "No shit." from us commoners.
posted by Thorzdad at 7:11 AM on June 13 [2 favorites]


I've definitely found emergency rooms to be very test-centric. They do all the tests they can think of, and if there's a positive result, then they can act in their prescribed ways. But if it's just a general pain complaint, good luck.

Ditto to this. Have spoken before about this - I had a pretty rare flukey medical complaint about 20 years ago now, about which the only symptom was "abdominal pain like a total muthafukka". The ER I went to elected not to give me any painkillers until they had ascertained the cause - and then proceeded to run their usual battery of tests in order to do that.

The thing was, they were testing me for more standard complaints - appendicitis, etopic pregnancy, kidney stones - so they didn't actually figure out what was wrong for nine solid hours. And I was pretty much at a nine or ten on the standard pain scale that whole time, and thus was having to endure things like pelvic exams and rectal probes while under that level of severe pain. By the time they finally sent me up to get a sonogram in a last-ditch effort to figure out what was the what, I was so out of my mind with pain that I cursed out the sonogram tech as soon as I got wheeled into the room insisting that someone get me some motherfucking morphine. They still didn't - but things moved a hell of a lot more quickly after that and within an hour I finally had a diagnosis and was being admitted into surgery.

I understand the need for a thorough exam to ascertain the cause of one's symptoms, but for the love of God if you haven't found anything in the last rectal exam you gave, and your patient is in that much pain, why on earth do you give her a second one?
posted by EmpressCallipygos at 7:15 AM on June 13 [5 favorites]


I actually did throw up in an ER once, and I have never been seen so quickly.

The first time I had a panic attack I thought it was a heart attack. When I got to the ER I read the little sign in the waiting room and it said to tell the attendant if you were having chest pains, difficulty breathing and tingles in your arms, so I dutifully did so.

Thirty seconds later I was in a tiny room with a BP cuff on.
posted by winna at 7:21 AM on June 13 [7 favorites]


Empress, I suspect you actually know the answer: It's because people faking pain in the ER to get issued "the good stuff" is a very real and serious problem. You likely triggered someone's suspicions when you first arrived and got marked as a possible faker. It's a terrible outcome but they're not denying pain meds out of cruelty or callousness.
posted by BigLankyBastard at 7:22 AM on June 13 [5 favorites]


Every two years I have to get a MRI to scan my (shrinking, stable thankfully) brain tumor and everything you've heard about MRI machines is true. They're loud, claustrophobic, and just about 45 of the most miserable minutes you'll spend at a hospital.

Every time I get out of one, the tech tries to say something to lighten the mood, and every time I ask how often they've taken an MRI themselves. Everyone that designs and operates a MRI should have to endure one trip in it once a year. I think it might make for more innovation when they realize places they could improve the experience.

Most often I hear they only did it once in med school, not at all, or just once one time for an injury to a leg or knee.
posted by mathowie at 7:22 AM on June 13 [11 favorites]


You likely triggered someone's suspicions when you first arrived and got marked as a possible faker. It's a terrible outcome but they're not denying pain meds out of cruelty or callousness.

Oh, I'm not questioning the withholding of pain meds. They pitched it to me as "if we do give you pain meds and it gets worse we wouldn't know about it and that may be bad," which - even if it was a bullshit excuse - I still think makes sense.

I'm more questioning the line of thinking that goes, "let's give her a rectal exam....huh, that came back normal. Weird. Hell, give her another rectal exam...."
posted by EmpressCallipygos at 7:27 AM on June 13 [1 favorite]


To make it through a trip to the ER, the patient has to be able to stand up for themselves, and even push into "being rude" territory.

Of course, when you're sick or in terrible pain, or just old and confused, that's pretty unlikely to happen.

Most people WANT to trust doctors and nurses to do the right thing, but the right thing is not the ER's first priority. The ER's priority is triage.

So, yeah: the only viable first step toward a solution is a thorough ghost shopper experience in the ER with a full, actionable report. Ideally, in a dream world, improvements would be tied to measurable stakeholder reviews. But. Well. A dream.
posted by gsh at 7:28 AM on June 13 [1 favorite]


There are absolutely things an ER takes very seriously and moves extremely fast to diagnose. Chest and tingly arm pain is right up there.

Unfortunately, joint damage, even a broken limb, is at the bottom of the list, as the doctor found out. Her experience mirrors my bike-hits-car experience in university. Immediate wound care, then observation and a summary "do't let the door hit your ass on the way out" in the morning. It's a brutal machine, but one that mostly cares if you are living or dying. ER doesn't, for the most part, care if you're in pain or (quietly) wigging out. They just don't have the time spare.

The best thing you can do is have a helper and an advocate for you, a spouse, a friend, a child. One of the kindest things we can do for each other is sit in a waiting room with someone in pain and non-life-threatening distress.
posted by bonehead at 7:33 AM on June 13 [11 favorites]


Almost all the ER visits I've made, either for myself or escorting someone else, have been for vomiting or bleeding, and we typically get seen within half an hour, if not immediately (that would be the time I sliced my finger open). The one time it wasn't for either of those things? I was in the waiting room for four hours.
posted by Holy Zarquon's Singing Fish at 7:34 AM on June 13


Every two years I have to get a MRI to scan my (shrinking, stable thankfully) brain tumor and everything you've heard about MRI machines is true. They're loud, claustrophobic, and just about 45 of the most miserable minutes you'll spend at a hospital.

Heh. I used to work at a neuroimaging center. Me and the techs would get recruited every couple of weeks to have an MRI done so the doctors could refine some scan or get new timings or try out something they read in the literature.

I always really enjoyed it. Except when I had to pee in the middle of the scan. Ever try to hold really still when you really have to pee ?
posted by Pogo_Fuzzybutt at 7:35 AM on June 13 [1 favorite]



Incidentally, if you want to get treated right away, be a 40-something man with chest or arm pains. They take that shit pretty seriously.

I pulled a chest muscle on my left side and it was excruciating. For some reason, our doc couldn't see us the next morning so we went to the ER. When I, fat 40-something guy, walked into the ER clutching and rubbing my pecs and said that my chest was realling hurting since the previous night, the receptionist (or whatever) got eyes like dinner plates and said, "Just come back here now!"
posted by codswallop at 7:35 AM on June 13 [2 favorites]


I'm on my way to work to fight the good fight, but I could write volumes about this.

I take care of a lot of substance abusing homeless folks, who guess what, end up in emergency rooms a lot. Every day, almost every hour, I piece together the fucking obvious diagnosis on a patient that the ER spent thousands of dollars in scans and blood tests, because I like, talked to the patient. There's nothing like the inability to ignore people and check boxes on a computer order entry screen to hone your clinical skills. But that takes time and insurance companies pay for technology with far less questioning than they pay doctors to talk to homeless dudes. Which is why I'm cutting my answer short, I got a busy day ahead of me and I have a bus to catch, my dingy little clinic doesn't have paid parking for my Maserati.
posted by Slarty Bartfast at 7:41 AM on June 13 [43 favorites]


I used to work at a neuroimaging center. Me and the techs would get recruited every couple of weeks to have an MRI done so the doctors could refine some scan or get new timings or try out something they read in the literature.

I always really enjoyed it. Except when I had to pee in the middle of the scan. Ever try to hold really still when you really have to pee ?


One of the tests I regularly have to have involves injecting some dye that makes it feel like you have peed yourself. It's so disturbing, even if you know it's coming, because you can't move to check your gown down below and you know you haven't urinated, but it feels exactly like that.
posted by xingcat at 7:45 AM on June 13 [4 favorites]


As a medical transcriptionist for the last 10 years, every day I have typed about someone who went to the ER and was sent home untreated for their problem. Yesterday it was a 91-year-old lady who fell and broke a bone. They did x-rays at the ER and told her "nothing is broken, you can go home." She went to her regular physician the next day, who ordered an MRI, and presto, fractured humerus.

This happens EVERY SINGLE DAY! It's maddening.

What is really amazing to me is that this physician was unable to stand up for herself and be more assertive. She must have really been in shock (or maybe it was the morphine). Doctors are not usually that passive as patients. Constant references to being a "good patient" are worrisome to me. I hope people reading it are inspired to be bad, noisy, fussy patients who get what they need rather than worry about upsetting or offending someone.
posted by AllieTessKipp at 8:09 AM on June 13 [11 favorites]


Also, people who go to their primary care first get a lecture about going to the ER first if they are standing there bleeding - but if you go to the primary first, they assess you before sending you along to the ER. They will talk in doctorspeak to other doctors and health care professionals, and create paperwork, and you are far more likely to get the right care at the ER than if you walked into the ER yourself. I type this just about every week. These, I figure, are the smart patients. They have already been to the ER on their own and know how things go wrong there. Having an escort of Official Paperwork is very helpful.
posted by AllieTessKipp at 8:13 AM on June 13 [14 favorites]


There is enormous variability in ERs. I took my wife to the suburban Burlington, MA Lahey emergency room when she was bleeding internally, We sat in the waiting room for hours while I called upstairs to her doctor's office trying to get his staff to exert some pressure for somebody to look at her. She wasn't puking or externally bleeding or screaming or clutching her chest, so it couldn't be that bad, right? Eventually, I must have annoyed the people upstairs enough, and they let us into a stall in the ER. An intern examined her, but couldn't find anything to fit his models, so he was going to send her home. At that point, one of the nurses left the room. Five minutes later, the head of the GI department appeared to announce they were going to check my wife into a room. Her doctor hadn't told her she should be concerned if the prescribed meds drove her blood pressure too low. The GI doc said she could have died.

OTH, I've had to go to the ER in urban Lowell General, 15 miles away a few times, and have found them responsive and professional. It's really like night & day.
posted by Kirth Gerson at 8:13 AM on June 13 [3 favorites]


I was surprised that not being able to walk led to her being admitted. I mean, it's pretty good chance that having a leg injury is going to lead to mobility issues, and that sucks, but a hospital stay doesn't really help with that.
posted by smackfu at 8:31 AM on June 13


My grandfather went into the ER for something neurological, then stuck around there until we could find him a long-term place. Fine. He was on the old people who forget things floor, but he was still, officially, an ER patient. Which meant that the doctor in charge of his case changed every week. Without fail. So a doctor (an ER doctor, not a neurologist) would see him, see my grandmother, make a plan, and then before anything got anywhere, new doctor, new plan. I think they hit about 20 doctors (no repeats) before he was transferred to long-term care.
posted by jeather at 8:36 AM on June 13


Couple of experiences/observation:

--Hit the ER in an ambulance and you are seen immediately. Go to the admitting area and you will do paperwork with an admin and often wait for hours (sometimes, many many hours).

--Avoid "teaching" hospitals if at all possible. I've seen a new intern, with an attending watching from a distance, attempting to insert a chest tube with no medication as the patient screamed in pain. A nurse finally noticed and started holding up a syringe of Fentanyl with eyebrows raised....

--In the story, she states that she received morphine *before* the physician did an exam. Ain't gonna happen. There's also a big paranoia about RXing any kind of pain killers in ERs. I've been sent home with two (yes two) Vicodin to wait 3 days for broken bone surgery. I know many others with the same experience. "Take some Tylenol and go see your physician" is a common exit statement....
posted by CrowGoat at 8:52 AM on June 13 [1 favorite]


Six hours in the hallway in a bed with extreme kidney pain with several hundred other patients while nurses inexpertly poked me full of holes that bled an alarming amount just to insert an IV drip that I did not need and after ONE test was told that nothing was wrong, that I was to leave, and then charged upwards of $1K (turned out I needed antibiotics for an ongoing case of pyelonephritis, which I TOLD them I had had on and off for three years). Oh, but if we instituted free healthcare we'd have to WAIT IN LINE to get care, right?
posted by Mooseli at 8:53 AM on June 13 [8 favorites]


I personally go to urgent care for anything emergent that is even remotely urgent-care appropriate, because the standard of care is so much better -- I mean, obviously something that would require an ER isn't appropriate for urgent care, so I wouldn't go there for difficulty breathing or something, but for bad lacerations requiring suturing, potential strep over a weekend, etc. the urgent care center is a far, far better experience. (Cheaper, too. Although at least once the person driving me to urgent care has threatened to overrule me and bring me to the ER instead!)

re: Lahey vs. Lowell General: That is SO WEIRD, because I'm familiar with both hospitals (not personally but on the basis of visiting people there, etc.) and I would have predicted the exact opposite. In fact I've had people tell me to try Lahey's emergency room (assuming I needed one) because they were mostly empty and available. (I don't doubt your story at all, though!)
posted by pie ninja at 8:55 AM on June 13 [1 favorite]


Every time I get out of one, the tech tries to say something to lighten the mood, and every time I ask how often they've taken an MRI themselves.

I tried to lighten the mood just before an MRI once. As the bored tech was looking down at his clipboard and escorting me to the machine, he said, "I just want to confirm: you have no metal plates or pins, right?"

I said, "No, but I think I swallowed a nickel last week. That won't be a problem, will it?" Suffice it to say, his level of attention went up dramatically and I had to reassure him several times it was a jest.
posted by ricochet biscuit at 8:55 AM on June 13 [6 favorites]


I recommend creating a perception that you are about to spew all over the waiting area: this will help motivate them to get you back into the treatment area.
posted by thelonius at 8:22 AM on June 13

I actually did throw up in an ER once, and I have never been seen so quickly.
posted by joannemerriam at 6:51 AM on June 13


I had a completely different experience.

I went to the ER in the middle of the night one weekend with excruciatingly painful stomach cramps that had lasted for hours. After sitting in emergency for a few hours, I told the staff there I felt like I had to throw up again. (I was only able to leave the house and go to the hospital in the first place because my vomiting had temporarily subsided.) No response. I gave them another warning. Again nothing. Not even directions to the washroom. So of course the inevitable happened.

The only response I got was a scolding because I made mess on their floors. I swear they kept me waiting longer to see a doctor as punishment for my terrible transgression.
posted by sardonyx at 8:56 AM on June 13


I'm a med student who might end up specializing in ER -- just wanted to say it's really interesting reading this thread and getting a sense of people's experiences. Hopefully one day I can make some of them a little less stressful. :)
posted by saturday_morning at 9:04 AM on June 13 [14 favorites]


I was just in the ER on Wednesday night. I thought I had inhaled a small piece of chicken while at home alone, and I felt light headed and almost passed out. I am not sure if I really inhaled it, or if I thought I inhaled it and then freaked out and had a panic attack.

They gave me x-rays and an EKG, but the entire time, they insisted that I was probably fine, because if I had inhaled anything I wouldn't be able to talk or breathe. They eventually said all my tests came back negative, though it was of course possible that a small piece of meat wouldn't show up on x-ray, and released me (I called the ambulance at 9:30pm and left the hospital at 4:30am.)

It wasn't until the next day, when I, yes, looked it up online, that I learned it's totally possible to inhale something into your lungs and continue breathing, and that it can cause pneumonia.

So, I'm going to be monitoring myself for pneumonia symptoms for the next little bit. I'm not exactly worried- they PROBABLY did everything right, I am PROBABLY just fine- but I can't shake this disturbed feeling, because absolutely no one mentioned that it's possible to inhale stuff into your lungs and keep breathing, and that this can cause pneumonia. It seemed like the assumption was "she's not choking, so she's fine."
posted by showbiz_liz at 9:11 AM on June 13


My mother is an ER doctor and was hit by a car a few years ago in the parking lot of the ER on her way to work. The car was going pretty slowly, and she got up and yelled at the driver and kept walking, but a colleague saw what happened and ran over to her and insisted she go in as a patient instead of a doctor - definitely a weird experience for her. The car hurt her knee pretty badly, but I think it was more a factor of her being in her late 60s than the impact of the accident, though the whole thing was scary and upsetting anyway. It's obviously a different experience because she was in her own hospital, but I've also seen her get more detailed information from doctors when my dad has had emergencies just by dropping the fact that she's a doctor into the conversation. Hell, *I've* got more detailed information from doctors when i tell them my mother is a doctor. I even got a radiologist to see me sooner. It's kind of a crazy special club.

From my mom's description of her own work and those of her colleagues, yes they get frustrated with drug seekers and complainy patients who self diagnose weird things, and dealing with the public is wearying especially for ER docs, but they really do care and don't see people as a number or whatever people are reporting in this thread.

I feel like people really blame doctors for things that are the fault of our horrible healthcare system and bureaucratic/for profit craziness that ties doctors' hands a lot of the time.
posted by sweetkid at 9:13 AM on June 13 [10 favorites]


everything you've heard about MRI machines is true. They're loud, claustrophobic, and just about 45 of the most miserable minutes you'll spend at a hospital.

I rather like the MRI machine. I find them cozy (have fallen asleep in them), and the noises are not annoying kinds of loud. (I've had them for "do me a favour and be part of this study about neuro-whatever" reasons and for "it seems like there is something wrong with your brain" reasons. The latter turned out to be nothing.)
posted by jeather at 9:15 AM on June 13 [3 favorites]


It wasn't until the next day, when I, yes, looked it up online, that I learned it's totally possible to inhale something into your lungs and continue breathing, and that it can cause pneumonia.

The internet is about "possible", while the ER docs are all about "probable".
posted by smackfu at 9:19 AM on June 13 [15 favorites]


The algorithm serves a purpose. It's true that this patient would have been better served if someone had used their judgment, but a system primarily relying on judgment calls would be more likely to make critical mistakes.

First check that air goes in and out while blood goes round and round, not the reverse. Missing a knee due to algorithm slavery is bad, but overlooking an abdominal bleed would be far worse.
posted by justsomebodythatyouusedtoknow at 9:23 AM on June 13 [4 favorites]


I spent several demoralizing hours in an ER once and eventually ended up leaving untreated because I had to catch a plane the following morning. The guy sitting next to me had a visibly broken femur and had been waiting five hours (although it turned out that he had wheelchaired himself to the washroom after four hours and in that two minutes of absence his name had been called -- with no response he was struck from the list and when he inquired later, he went back to the end of the line).

This was also in the heavily bilingual city of Ottawa and the nurses calling out the surnames to summon patients were Calgary-level unilingual. I heard numerous francophone names mangled to the point of unrecognizability or just Ellis-Islanded into an English equivalent. It was only because I was sitting relatively close to the admissions desk and I heard waiting patients inquiring only to be told their name had "already been called" that I was able to connect their stated names with the unrelated names I had heard called out. The nurses seemed to have transposed many to an anglo name that had a few characters in common with the French one. Someone sharing a surname with Jean-Luc Picard, for example might not recognize his summoning when the name "Packard" was called out, let alone "Patrick" or "Richards".
posted by ricochet biscuit at 9:23 AM on June 13 [2 favorites]


I rather like the MRI machine. I find them cozy (have fallen asleep in them)

Same here. The whoomp-whoomp of the cryogenic pump is quite soothing.
posted by Johnny Wallflower at 9:27 AM on June 13


It seemed like the assumption was "she's not choking, so she's fine." not going to die in our ER, or within ten feet of the exit door, and is therefore Not Our Problem.

That aspect of ERs -- if it's not going to actually kill you, right there, they're probably going to tell you to go home and call your doctor (under the laughably quaint assumption that most people have "a doctor" they can just ring up the next morning who will be dee-lighted to hear from them and will totally get them right in) -- is unfortunately something that I do not see changing even with the most optimistic view of near-future changes to US healthcare. There are just too many people and too few doctors / emergency-care workers to provide anything resembling whole-person care in that environment.

Of course, part of the reason why there are so few doctors and care workers is that you'd have to be insane, in my opinion, to want to work in an ER. A physician assistant might get 5 minutes or less per patient; an attending, on average, probably even less (since there are many patients they won't see at all). That's not enough time to actually practice medicine as many practitioners define it.

It's a bit absurd, but if you call 911 for some (random but sub-acute) illness, the single person you will probably spend the most time with between picking up the phone and discharge is probably the EMT or paramedic in the back of the ambulance. Everyone else will probably have less time for you, in total, than the time it takes on average to drive to the hospital. Pure craziness.
posted by Kadin2048 at 9:28 AM on June 13 [1 favorite]


Once I went to the ER after having suffered a blow to the head-- it wasn't a huge thing but I had read that these can turn out really serious and need to be addressed relatively quickly if so. I waited for 6 hours without really even being acknowledged and then...just gave up and went home. At some point I can't just live in an ER waiting room on the tiny chance I have a subdural hematoma or something, but boy am I glad it turned out to be nothing.
posted by threeants at 9:32 AM on June 13 [1 favorite]


The last time we went to the ER it was as a whole family with a screaming, bleeding 2-year-old who'd gashed his hand open and his 4-year-old brother. They got us right back to the room and told us to make sure to immobilize his hand and they'd be in right away to examine him and (offhandedly commented) they'd make sure he wasn't going to lose mobility in the hand.

THEN WE SAT THERE FOR TWO HOURS while my 2-year-old screamed and bled attempting to keep him still and semi-calm, my 4-year-old systematically disassembled the (not child safe, obviously) room, and my husband and I took turns to go out to the desk and ask WHEN THE HELL IS SOMEONE GOING TO HELP US?

You know who was responsible for examining my child or calling a doctor to do so? Nobody. Not one person. "Oh, that's not my job, but I'll mention it to the doctor if I see him." You know who was responsible for going through a CPS checklist to ensure I hadn't abused my child to bring him to the ER? EVERY. SINGLE. PERSON. WE. INTERACTED. WITH.

Before anyone looked at his fucking hand, we had been interviewed SIX TIMES about whether the BLEEDING HAND NOBODY WOULD EXAMINE was caused by abuse. (It was caused by him grabbing a chicken wire fence.)

When the doctor finally came and looked at him and gave him three stitches, he told me very sternly that I really shouldn't have let my child cry for two hours before getting him care, because now he was almost impossible to get calm enough to stitch the hand. He asked if I usually allowed him to scream for so long before giving him care, because that wasn't really good for him, and then he asked a bunch more CPS questions to ascertain whether I routinely neglected my child by allowing him to cry for long periods of time before attending to him (I've done the same training, I'm a mandatory reporter, so I knew the script). I'm not sure I've ever been so close to punching someone in the face.

We've received great and quick care at the same ER in the past, which is what makes this doubly infuriating ... I can go to a different ER, but how do I know which ER will give me good care this time? Since there's no consistency to the quality. I'm just still ENRAGED at how little anyone cared that my toddler was bleeding and scared and in pain.
posted by Eyebrows McGee at 9:32 AM on June 13 [42 favorites]


Holy shit, that's awful. I've had some long waits for doctors once we got out of the waiting room, but never that bad - the worst was about an hour for pain medicine, at which point my wife was literally screaming from abdominal pain and I very nearly punched a doctor myself. Two hours with an open wound? I'd probably have ended up in jail.
posted by Holy Zarquon's Singing Fish at 9:37 AM on June 13


I felt very guilty, because since I arrived via ambulance, I was sitting in a bed having already been looked at by a couple of people the moment I arrived, yet I heard a man yelling at reception that he had been in the waiting room for ten hours and was in pain. His symptoms were undoubtedly worse than mine, but since I came in an ambulance I got to jump the line.
posted by showbiz_liz at 9:41 AM on June 13


I'm just still ENRAGED at how little anyone cared that my toddler was bleeding and scared and in pain.

Advice now, in Ontario, is to go immediately to a walk-in clinic rather than emerg, for most injuries, up to and including possible broken limbs. Care is better and faster in a local clinic than Emerg, which is always overbooked and will triage you down to the bottom, or your doctor who is booked for months, if you even have access to one. Walk-ins, most based in a group medical office, for better or worse, are turning into the primary way many people use the Health system here. Like pharmacies, there are some required to be 24-hour or late opening in every area.
posted by bonehead at 9:48 AM on June 13


phaedon: This is a joke, right? You might as well blame the cashier for the shortcomings of McDonalds

1. If the cashierist has a shitty attitude, yeah, I certainly will blame them. And, in my experience, they'll soon be working somewhere else - because McDonalds trains and polices employees on making the customer experience pleasant.

2. If your argument is that RNs and MDs have no more clout in this world (and especially in the US) than a minimum-wage worker who might not even have a GED... your comment is a joke, right?
posted by IAmBroom at 9:53 AM on June 13 [2 favorites]


I have a neighbor who suffers from migraines. I'm talking about incapacitating, daily pain that has lead to a real threat of suicide several times. The treatment has been progressing from injecting botox directly into her brain with a 6" needle to now talking about brain surgery to try to reduce them to a level that will allow her to work again. At one point, when she was uninsured and not getting any treatment, she had about reached the breaking point, so her husband took her to the public hospital ER, the one that all the poor and uninsured get routed to.

After 18 hours in the waiting room they finally said that it would be at least another 24 before she would be seen, possibly more and if she left the room for any reason, she went back to the end of the list. They gave up and went home. She finally got treatment that evening from the psych hospital, after her husband called 911 when she was threatening suicide, because she couldn't stand the pain any more. (She has a doctorate in chemistry, it's nearly impossible to keep her away from anything she can figure out how to kill herself with.)

This was all years before Obamacare, of course, when we had "the best medical system in the world"!
posted by pbrim at 9:55 AM on June 13 [7 favorites]


Advice now, in Ontario, is to go immediately to a walk-in clinic rather than emerg, for most injuries, up to and including possible broken limbs. Care is better and faster in a local clinic than Emerg, which is always overbooked and will triage you down to the bottom, or your doctor who is booked for months, if you even have access to one.

And that's in Canada, which is a veritable health-access paradise compared to the USA.

Actually, that brings up another point about my ER visit - I very nearly had my then-new insurance company refuse the bill for my surgery because I had failed to secure a referral from my doctor. It took a rather heated phone call during which I said "it's kinda hard to get hold of your doctor while you are lying on an operating table at 6 am on a Saturday" for them to agree to pay my OR charges.
posted by EmpressCallipygos at 9:58 AM on June 13


I vomited four times in a row in the ER once, and still didn't get seen for hours.

My (former) doctor had taken me off an SNRI cold turkey, and assured me that everything would be fine as long as we increased the dosage on another medication. Things did not work out as planned.
posted by johnofjack at 9:59 AM on June 13


When I go to the grocery store after work there's always a huge crowd of shoppers. In response the store staffs every register and you can still do your shop and get out reasonably quickly. What they don't do is make people with small purchases wait for hours to check out because there's only one cashier and, well, what can you do?

If only there was some way to increase the bandwidth of emergency medical centers but I guess that's a scientific impossibility.
posted by LastOfHisKind at 9:59 AM on June 13 [4 favorites]


2. If your argument is that RNs and MDs have no more clout in this world (and especially in the US) than a minimum-wage worker who might not even have a GED... your comment is a joke, right?

That's not quite my point and the situation is relative. If you think you doctors, as representatives of the downtrodden, or as "people whose jobs is it to take care of people," "have clout" in health care, you've been asleep for the last 20 years. Many doctors are struggling to break even.

As for RN's. Do you think that just because someone has a degree, they determine the course of their career? At most hospitals, well-trained, experienced RN's either simply don't exist or are phased out in favor of less-experienced, cheaper, specialized labor. You can thank hospital administration for that.

The situation is way more complicated than "shitty attitude."
posted by phaedon at 10:03 AM on June 13 [3 favorites]


My cousin died last month, much too young. Two days before, she'd gone to the ER with a migraine. She had a long history of migraines but this one was different, it had gone on for days and her eye was bloodshot and she and her husband thought something was very wrong. She was given what her husband called a cursory vitals examination, and a morphine drip, and sent home. And then she died of an aneurysm that, maybe, someone could have caught if they'd listened to her and her husband telling them this was not just a migraine, and run an actual test instead of giving her morphine and shoving her out the door.

I don't know what would fix our medical system, but I wish we'd figure it out before anyone else goes through what her family is going through.
posted by Stacey at 10:05 AM on June 13 [41 favorites]


That is so scary and messed-up, Stacey. I'm sorry for your loss.
posted by threeants at 10:06 AM on June 13 [8 favorites]


I learned it's totally possible to inhale something into your lungs and continue breathing, and that it can cause pneumonia.

For what it's worth, my friend is an ER doc (in Europe) and told me that it's not uncommon -- people inhale food, and the big bits can be vacuumed out but mushy stuff like bread can't be, and it's fairly likely to cause pneumonia.

I have been super careful about this ever since she started telling me these stories.
posted by jeather at 10:12 AM on June 13 [2 favorites]


If only there was some way to increase the bandwidth of emergency medical centers but I guess that's a scientific impossibility.

This is the whole point of increasing the number of urgent care centers, whether free-standing or in a place like CVS. It's a big enough thing right now that real estate developers are planning for these in retail shopping centers and new office or medical office developments. Some are stand-alones, some are chains, some are associated with local hospital systems or practices. The idea is that you divert the less serious cases from the ER and free up bandwith for the true emergencies (or potential emergencies). (For example.)

The unfortunate thing is that some states are seeing this turn into "free-standing ER" complexes instead of true urgent care (urgent care is generally an office visit co-pay, while "free-standing ER" is an ER copay, but the second often doesn't have much more capacity than a decent urgent care center -- so the free-standing ER is making a lot more money for providing the same service).
posted by pie ninja at 10:15 AM on June 13


It's a terrible outcome but they're not denying pain meds out of cruelty or callousness.

I'm not sure I understand this line of thinking. So someone comes into the ER claiming symptoms that would require pain meds. Either they're faking it, in which case they're someone suffering from addiction and withholding the meds prolongs their psychological suffering, or they're not faking it, in which case withholding the meds prolongs their physical suffering. I suppose they could be non-addicts looking to get pain meds to resell, but it's not my sense that this is the problem we're trying to solve; it feels like it's more that we're trying to keep the fakers away.

It just seems to me that if I were a doctor, I'd be more concerned about keeping a patient in needless pain than with being tricked into providing a junkie with a fix. I hope I would be, anyway.
posted by hades at 10:27 AM on June 13 [16 favorites]


I've had people tell me to try Lahey's emergency room (assuming I needed one) because they were mostly empty and available.

I work less than 2 miles from Lahey. I've had several conversations with coworkers who had complaints about that ER. It's not just me. If you get referred in or are admitted, their care is first-rate. The ER, though ...is not.
posted by Kirth Gerson at 10:30 AM on June 13 [1 favorite]


If you don't take steps to keep from giving pain meds to junkies, the FBI comes after you.
posted by Holy Zarquon's Singing Fish at 10:31 AM on June 13 [6 favorites]


CrowGoat: In the story, she states that she received morphine *before* the physician did an exam. Ain't gonna happen.
The last time I went to an ER, I was in a lot of pain. They asked me if I was in pain, I said yes, and I got a drip in the arm immediately, within moments of walking in the door, long before a doctor showed up. The ER was very idle. And the stuff they gave me wasn't morphine, it was some synthetic opiate, though.

I've been told that this protocol is a relatively recent development, the result of some sort of rule change about pain management.

I've also had less comforting ER experiences.
KokuRyu: ...the noise about "dogfooding" is kind of hard to understand.
All I meant was: How can it be that any of this surprised her? Was this her first trip to an emergency room? What do medical people usually do when they need medical care, emergency or otherwise? I guess they mostly self-treat, or work connections to get VIP treatment?

It suggests that doctors generally avoid submitting to the systems they built when they can; what does that say? How would you feel about a waiter who refused to eat the food he served?

I think the medical system might work better if the people running it also experienced their creation from time to time.
posted by Western Infidels at 10:43 AM on June 13


As a first responder for the past seven years, I'd like to dispel the myth that arriving by ambulance will have you seen more quickly than walking in. It's a crapshoot either way. If you aren't having a MI, stroke, GSW, or major internal injuries, you will be laying on a stretcher until they can find a bed for you. Which may be several hours. Many first responders do not appreciate when people who do have a valid complaint but it is NOT life-threatening take a ride in the whambulance. That's what urgent care centers or catching a ride to the hospital are for. Most of the time, even when I have a valid issue (like the concussion I got a few years ago, or in January when I thought I had shattered my patella), I roll up to the urgent care. They have drugs and x-ray machines and I am seen much more quickly and with greater doctor-patient interaction than if I had gone to the ER.

As far as withholding pain meds, yeah, the staff generally needs to find out what is going on before they are dispensed. We don't really give pain meds in the field unless it is a MI or obvious traumatic injury. You'd be surprised the number of people who show up in ambulances and in ERs trying to get a fix. And we know.
posted by sara is disenchanted at 10:49 AM on June 13 [6 favorites]


I'm 'lucky' enough that the almost every time I've had to go to the ER in the last decade or so, it's been for symptoms serious enough that I'm seen pretty quickly. Atypical migraine masquerading as stroke symptoms = call Telehealth to find out WTF was going on, ambulance at my door five minutes later, literally thirty seconds in the door of the hospital I was already hooked up to monitors and being filled with anti-clotting drugs. They even woke up the ultra-MRI tech in the middle of the night and made him come in to scan my brain.

Another time, I went in with left arm tingling and left chest radiating pain, and a history of heart problems in my family. Turned out to be a sort of form of arthritis in the cartilage of my ribcage--but even though I walked in under my own power I was in a bed with meds and monitors in under five minutes, and a cardiologist consult within half an hour.

Went in once with a broken arm (most ERs, in Toronto at least, have a sort of 'rapid treatment' line that bypasses other patients if your complaint is simple and easily dealt with) , because it was the only way I could get it X-rayed and (I had hoped) get right back to work. I was seen, X-rayed, and had a cast on my arm and a scrip for PRN painkillers in under an hour.

I was in the ER last Friday night, actually, for possible anaphylaxis (on the recommendation of the after-hours consulting doctor for my GP's practice, which is connected to the hospital I went to). It was pretty empty, especially for 3:30AM on a Friday night, but still: the triage nurse said "Wait there, not in the waiting room, where I can keep an eye on you until I can get you a doctor. Do you have your epi-pen with you? Good, if your breathing becomes a problem stab yourself and yell for me." I was in a bed within five minutes, hooked up to a heart/respiration monitor. When the sensor slipped off my finger as I drifted off due to the MASSIVE load of Benadryl they injected as a first-line treatment/rule out anaphylaxis, the machine started beeping and wailing and literally within five seconds there were three nurses and a doctor sweeping the curtains aside, thinking I was going into biphasic anaphylactic shock. And, again, I'd walked in under my own power--benefit of having a hospital about 7 minutes' walk from my apartment.

A little further back (March), I was whisked to the ER in an ambulance for an (intentional; suicide attempt) overdose. Again, from what they told me later (I was already comatose) I was being treated in the ambulance with care passing directly to waiting doctors as soon as I was in the door.

I think the longest I've waited in an ER without treatment was about six hours when I had appendicitis, because they needed the ultrasound tech to show up and confirm the dx and that I wasn't a drug-seeker before they shot me full of enough morphine to kill the pain.

While I do understand that Canada's healthcare system isn't perfect, especially regarding wait times for specialists and in the ER, that is what single-payer socialized healthcare looks like. (And, yes, I am reeking with privilege inasmuch as all but one of those experiences were in Toronto's best hospitals; Toronto General, West General, St Mike's. The long wait with appendicitis was St Joseph's. Do not ever go there. Just don't. Worst hospital I have ever been to in Canada.) If you have more serious symptoms than someone else, yeah, they are going to wait a bit longer (which has also happened to me, but was entirely correct; my symptoms were minor, I didn't have a GP at the time, walk-in clinics were closed, and there were people literally bleeding in the waiting area).

So these ER horror stories (and yes, again, I know they happen here too) are just utterly foreign to me; I cannot conceive of any of the scenarios I've been involved with--or friends have been involved with--ending with "Go home and take some aspirin" without actually, you know, investigating the complaint and ruling out truly serious shit. I mean hell, an ER trip got a friend of mine PEP for a possible HIV exposure and got him to quit drinking, because the doctor we saw, and the nurses, actually gave a damn about the sick person in front of them. Yes, we had to wait a while (3? hours if memory serves), but once he started going into alcohol withdrawal he was in a bed right quick.

One has to wonder how much of this is tied to the profit motive in the States. In Canada, it makes sense for doctors to treat as fast as possible--costs less in the long run. In the USA (and I know there are other considerations at play) keeping someone in the ER for 24 hours just means the accounts department gets to send out a bigger bill.

It just seems to me that if I were a doctor, I'd be more concerned about keeping a patient in needless pain than with being tricked into providing a junkie with a fix. I hope I would be, anyway.

Providing a junkie with a fix is a problem in two ways. First, you are using up expensive and/or scarce resources on a medical problem that the drugs are contraindicated for, and second, you are prolonging their disease, meaning more psychological suffering. I wonder if--and maybe you could explain why/why not, sara is disenchanted--giving everyone with pain complaints a dose of methadone would quickly and easily sort the seekers from those truly in pain? Would there be negative side effects in a non-opiate-addicted person?

As a protip for other Ontario residents, if you call Telehealth and they recommend that you go to the ER, you can also give them permission to send all the information you've given them to the hospital, which streamlines things quite a lot with triage. They will also call an ambulance for you if it seems indicated, and stay on the phone with you until it arrives.
posted by feckless fecal fear mongering at 11:09 AM on June 13 [2 favorites]


I think a lot of times, especially in a big ER, the object is to stabilize folks, not diagnose and cure them. They are more interested in confirming that you're not going to die, right now this second, and then they're off to the next thing.

So the ER will confirm that as of this minute, you are 'good to go.'

We all have an anecdote. I picked up my sister from the ER at General Hospital in the Mission. She had been in a car that was broadsided by a drunk on St. Patricks day. Her ankle was injured and swollen. The doc said, "it's just sprained, stay off it and she should be fine." I asked for the films (that shocked him a bit) took her home, bought her breakfast and said, "You'll need to follow up, with your doctor." She went to her ortho who confirmed that she needed surgery to fix the snapped tendon.

This was in the eighties, where MRI wasn't really a thing yet. But the point is, they do the bare minimum to get you up and out. When I worked in an ER, in 70% of everything we saw, most of it was ruling out the terrible stuff with, "Follow up with your regular doctor tomorrow."

The other 30% was clearly serious enough to need admission, and the attention of a specialist.
posted by Ruthless Bunny at 11:25 AM on June 13 [1 favorite]


I went to the ER recently for a severe allergic reaction. I'll spare the anecdote but I wasn't very happy with how I was treated, and seeing the bills process through my insurance is making me grumpy. I understand their job was to stabilize me and send me home so I could see my doctor--which I did--but I feel like I got charged an arm and a leg for not particularly good service and it's only because I'm fairly conservative about when to go to the ER that I didn't have to go back: technically facial swelling is straight to the ER again, but I'd already been seen and medicated and they weren't going to do anything more for me unless my throat started to close, which it didn't.

Also, coming in as a person with a strong sense of her own medical history and what treatments are appropriate/not appropriate because of chronic illness, plus having a strong advocate with me (my husband, who knows my history and is tough with medical staff when he needs to be), I still had to fight to get things I need. No, don't give me drugs I'm allergic to, and yes, give me a damn anxiety shot to keep me from freaking out about the IV. I haven't hit a medical provider since I had the therapy but I'd rather not break that record.
posted by immlass at 11:33 AM on June 13 [2 favorites]


Honestly, having entered the ED by both foot and helicopter, my perspective is that I'm happy to wait. You don't want to be the person who can't wait.

Re: Lahey Burlington, our experience was that a GP in regular practice at Lahey missed a completely obvious, stereotypical presentation of Lyme (diagnosis: summer flu, just a headache, and the rash was a reaction to deodorant. Wtf?). Later that same day in the Lahey urgent care/ED, the diagnosis and appropriate care were very expedient. And the attending marched a whole bunch of trainees, aides and nurses in for them to see and remember the rash, which was an impressive thing.
posted by Dashy at 11:34 AM on June 13 [2 favorites]


I had quite a few trips to various ERs last year on account of abdominal pain. The wait times are awful (around 4 - 6 hours), even in the middle of the night, but overall I can't complain too much. I did find it frustrating that the first few times I left without a real diagnosis ("Could be kidney stones, but our ultrasound department is closed for the night", "Try some Advil", "Could be indigestion"), but everyone was generally pleasant and sympathetic, especially the nurses. I'm definitely aware that I'm just a file to be closed by the end of someone's shift, but I don't mind it -- how else could it all work?

The last trip was to a larger downtown hospital where I got the best care of all -- I was seen within 30 mins or so and almost immediately put on escalating types of pain killers all the way up to morphine, followed by an ultrasound, another fuller ultrasound, xrays, and finally a diagnosis of gallstones. They gave me a prescription for morphine to take home and a few weeks later I saw a surgeon and got that busted up gall bladder out.

This is in Toronto, so I recognize how lucky we are to have free health care. I just see the wait times as being the price of not having to go bankrupt every time I get sick.
posted by The Hyacinth Girl at 12:01 PM on June 13


I've been a flown-in, driven-in and walk-in client, and a first responder (search & rescue) in ERs. Obviously different ERs at different times and locations are going to have different resources and different workloads. Big city hospitals tend to be... bigger. Privately-held hospitals tend to be fancier.

In terms of who gets seen how quickly and how effectively, HOWEVER, in the US two of the biggest factors are going to be the color/age/gender/SES of the client and whether the ER is part of the publicly-funded hospital-of-last-resort for the uninsured. If you're a POC, teenager/elder, female, or perceived as poor, it's going to be a long wait. Even an ambulance ride won't hasten your visit if you're not making a blood puddle on the floor. If you're at the county/city hospital, you'll wait your turn or not be seen at all, *even if you have insurance* because it will be assumed by the staff that you're not able to pay. If your coverage is Medicaid/Medicare and you don't look middle-class, be prepared for a long wait.

You know why chest pain/radiating arm pain heart-attack symptoms are treated immediately? Because that is how infarctions present in middle-aged MEN. Guess what - the symptoms for most women and elderly folks are more like GI disturbance. Present in an ER with severe upper-abdominal pain or what appears to be constipation (the vagal nerve reports both cardiac and gut impulses) and you're likely to have the MI right there misdiagnosed as non-urgent GI issues, or go home and have that 2nd MI that kills you.

The US medical system is as much part of the class/race/sexism/ableism complex as any other part of the culture.
posted by Dreidl at 12:11 PM on June 13 [22 favorites]


CDC 2009 Emergency Department Survey

- 136 million visits (46 per 100 persons)
- Immediacy with which patients need to be seen:
1. 3% immediate
2. 8% emergent
3. 35% urgent

In 2009 there were 1800 EDs in the US. I understand people would like them to do better but seeing the numbers above it's a miracle there are actually reports of satisfactory results.
posted by 7life at 12:23 PM on June 13 [3 favorites]


I did want to say that the ER is the WORST place to go for diagnosis of a chronic issue. If you're having constant stomach pain, you want to get into your GP first then referred to a specialist.

ER docs are amazing, but they're generalists. If you have a hard to diagnose issue, they won't have the expertise or experience in that particular thing to be of much use to you. Again, they'll do their best to insure that you're not going to drop dead, and if you're in pain, they may prescribe something to help, but if you're there after hours, or on a weekend, that's probably the best they can do, ESPECIALLY if you're in a suburban hospital that's mostly about stapling boo-boos and dealing with cardiac stuff.

I always tell people, if you're having a problem, and it's during the work day, during the week, go NOW to your actual doc, beg for an emergency appointment, to be seen. Even if you do end up in the ER, at least in the day, there are specialists in the hospital who can be called in on a consult, right there, rather than having to call Dr. Peters in from home on Saturday evening.

Unless you have a gun shot wound, or significant trauma, a Class 1 Trauma Center is the LAST place you want to be on a Saturday night with non-specific stomach pain.
posted by Ruthless Bunny at 12:35 PM on June 13 [3 favorites]


I rather like the MRI machine. I find them cozy (have fallen asleep in them)

Same here. The whoomp-whoomp of the cryogenic pump is quite soothing.


i have a question

are you a robot?
posted by Aizkolari at 12:49 PM on June 13 [1 favorite]


Is this to be an empathy test? Capillary dilation of the so-called blush response? Fluctuation of the pupil. Involuntary dilation of the iris...?
posted by Johnny Wallflower at 12:55 PM on June 13 [3 favorites]


A family friend is an ER doc. I try to get him to talk about the interesting cases, just because LOL people. He talks a lot about addicts who come in for a pain Rx and how they manage that. The more entertaining ones are the events that come with "the last thing I remember was saying, 'hold my beer'" or "I slipped in the bathroom and fell on it [and it went up my ass]."

Our local is generally pretty good. I do recall a point where I'd sliced up my thumb and needed some stitches and when I showed up the ER was empty and dead quiet. Hooray! I'll be in and out in no time. Then I heard a nurse in the hall say, "a high school kid just came in - caught her arm in a printing press" and knew it was game over for that. Thumb vs arm loses in the Triage game. Did get some sweet-looking stitches, so of course I decorated.

I think the biggest scare we've had to date was a bout of croup wherein the usual home remedies didn't work and my daughter started showing cyanosis (lips and fingers turning blue). I bolted to the ER, called 911 (hte only time I've ever called) on the way to make sure that had a respiratory team waiting at the door, which they did. Hooray!

The croup experience (mental note, that will be the name of my next band) has always been bad. The formula is the same: try the home remedies (steam, cold air, etc.) and if they work, set up a humidifier and hope for the best. If it doesn't subside, off to the ER where they hook her up to a nebulizer and then we go see our GP who gives up an Rx for Orapred. After the 3rd go round in one winter, our GP gave us a standing script for Orapred, thus cutting out the middleman (and we'd gotten good enough at being able to tell well ahead of time when croup was going to be on the horizon).
posted by plinth at 12:56 PM on June 13 [1 favorite]


are you a robot?

Specifically, Daft Punk?
posted by Holy Zarquon's Singing Fish at 12:58 PM on June 13


Holy Zarquon's Singing Fish: "Holy shit, that's awful. I've had some long waits for doctors once we got out of the waiting room, but never that bad"

Yeah at one point I was literally standing in the hallway shouting specifically to make a scene and get some attention, and scenes are something I absolutely abhor. After the first hour I was making a gigantic stink to anyone I could find -- the admitting clerk, the insurance clerk, the security guard, the orderlies and nurses, the doctors, every single person who walked past our room ... nobody gave half a shit. And every time I demanded care someone started in giving me the CPS child abuse survey, which, I have to admit, started to make me feel like I was being threatened to go sit down and shut up or they were going to call a social worker before a doctor.

(There were two follow-up appointments, both of which ALSO involved two child abuse questionnaires each AND multiple lectures about not letting my child grab sharp objects and I was like OH MY GOD, REALLY? REALLY?)

I called the hospital ombudsman afterwards and complained and the answer was basically a shrug and "sometimes that happens."

bonehead: "go immediately to a walk-in clinic rather than emerg, for most injuries, up to and including possible broken limbs."

Urgent care was not open and in many cases they send small children to the ER anyway. (Also pregnant women.)

What's so frustrating is that I just have no idea if this time I'm going to receive excellent, expeditious, caring care at the ER or if it's going to be a two-hour hell-hole where you can stand screaming in the hallway and be ignored. It's been both and there's no rhyme or reason to it. Or at the other ER in town. If I knew it was going to be awful, that almost seems easier to deal with, psychologically, than the crap shoot of whether it's going to be good or bad.

On the plus side, if you ever want to BLOW A TODDLER'S MIND, have some local anesthetic injected into the palm of his hand. Watching him try to figure this out was hilarious. "It's a hand, but I can't like FEEL my hand, man ..."
posted by Eyebrows McGee at 1:02 PM on June 13 [2 favorites]


Oh and two other points:

1. Had it been me (IANAD): I would have been self-diagnosing and I don't know how it is for women, but I sure as hell can tell when the catheter comes out if not from the relief of not having something the diameter of a McDonald's straw inserted in from, but at least from the empirical evidence of having to pee and not seeing an increase of pee in the bag over time1.

2. If I drank coffee, I would expect the ER to have a personalized coffee mug for me at this point.

1One time I've had a catheter installed, I noted the the manufacturer was C. R. Bard, a company that had a substantial presence in my home town. On this particular time, the catheter was being put in around 4:00AM EST. Why is this important? The dad of one of my closest friends through grade school and high school worked in at Bard. I still had their phone number memorized. I was sorely tempted to call up and have this conversation, "Hi Mr. S! This is plinth. You know, John's friend from school. Yeah, it is early, isn't it? Oh, well you see I was just having one of your catheters put in and I wanted you to know that I was thinking of you."
posted by plinth at 1:05 PM on June 13 [4 favorites]


This was all years before Obamacare, of course, when we had "the best medical system in the world"!

Whenever someone says this, I honestly wish I could take away their health insurance and force then to experience some kind of incredibly expensive medical emergency, then see how awesome they think it is.
posted by Steely-eyed Missile Man at 1:09 PM on June 13 [3 favorites]


I've had my own long waits in the ER for various non-life threatening issues, but I'm ok with that and I'm glad they're there in the ER. Especially for whoever the doctor on duty was in the middle of the night when my cousin was brought in after having fallen out of bed. Because she had bacterial menengitis and this doctor did everything right and probably saved my cousin's life.

The people at the hospital, on the other hand, really need to work on their communication. Stop asking the family if she's had pain meds, because that isn't our job and I'm her cousin and have no medical decision making power. And get a better computer system, because that software is just plain bad if you can't tell from a look at the screen. It took a week for a nurse to actually bravely make the decision to give her some Tylenol and do it.
posted by monopas at 1:39 PM on June 13


This particular story must have to do with the money in US healthcare. Here in Socialist Europe, I can't imagine something that grotesque happening. But, I can imagine a lot of other really frustrating stuff happening. Long waiting hours - check. Doctors and nurses stereotyping patients and ignoring patients' own experience - check. Faulty or inefficient treatments - check.
The thing is, you should never, ever go to a hospital alone. If you are at a conference out-of -town, ask the organizers to help. If you are new in town, ask your neighbor, your colleague, the local bodega-owner to help. Hey, you'll make a friend; people love helping people. And you may save your own life or at the very least secure your future quality of life.

Apart from that, you should be well-versed in the capabilities of your local and regional hospitals. One day, I came to pick up my 86-year-old gran for a car ride. She showed me a bothersome rash on the back of her leg - it was totally obviously the beginning of a Lyme infection. Her car ride became a bit longer than planned because I took her to the ER near her summer cottage - 5 hours away. Here she was admitted right away, was treated correctly, and then she had a nice time with a lot of yogurt dishes at the cottage while recovering.
I did this because I called the local ER at her city home to ask for the waiting time, and they told me they would prefer she waited till her GP opened the following weekday (this was a Saturday) - otherwise there would be a four-hour wait. When I suggested Lyme Disease could be dangerous for a 86-yo, they were bold enough to ask me how long I expected her to live.

The same hospital that wouldn't treat my Gran's Lyme disease is actually my preferred place to go with children after accidents. They prioritize the children and are very caring and careful with them. This is in an area with lots of addicts and other "problem"- people, and the ER staff tend to categorize +40 people's problems as consequences of "bad" lives: even Lyme disease. One of my children spent far too much time there for several years in a row, and she always came in first and was treated by the top staff.
Once my other child had a really bad accident, and couldn't find me, she called my relative. The relative barged into the main emergency unit in the state, which is reserved for *really terrible accidents* and *famous people* - the one where people are brought in by helicopter and TV reporters are waiting. It turns out they have very little to do on most days and really enjoyed making sure my child was treated like the queen of Sheba and healed completely. If my relative had just called the GP, or even gone to the local ER, my child would have been scarred for life.

Since these problems seem to be almost universal, I have come to believe that "dealing with health-care" is basic skill, just like "preparing for an interview", "boiling an egg" or "attending class". I actively work to change this, because I find it unfair on the most fundamental level of society. But as an individual and parent and caregiver, I have sought to educate myself and make sure I am always informed and ready.
posted by mumimor at 1:53 PM on June 13 [8 favorites]


After my 30MPH meets pavement accident I was sent home with crutches and a leg brace. I had to go wash out and bandage my own black eye and road rash at home. Was told maybe I needed surgery on my knee but *shrug*? (I DEFINITELY needed surgery) Oh and by the way, hop around on these two sticks, which no one will show you on how to use or how to get up the stairs to your apartment. Bye!
posted by fontophilic at 2:08 PM on June 13 [1 favorite]


When I suggested Lyme Disease could be dangerous for a 86-yo, they were bold enough to ask me how long I expected her to live.

BEST IN THE WORLD
posted by Steely-eyed Missile Man at 2:19 PM on June 13 [1 favorite]


I have come to believe that "dealing with health-care" is basic skill

It is a skill, called "health literacy." It is currently in vogue to have providers take training on health literacy to help them understand (1) that a lot of people really have no idea what is going on in health care, and (b) how to evaluate that and better communicate.

This works more or less well depending on the quality of the training, the emphasis management places on it, the individual provider's inclination, etc.
posted by jeoc at 2:22 PM on June 13 [2 favorites]


I have had mostly positive experiences with our local ER, but it was sad and frustrating how different people acted towards my husband the time they (my deduction) decided he was a med-seeker. All compassion flew out the window.
posted by bq at 2:33 PM on June 13


Not all ER experiences are like the one in the OP. Just yesterday I had to take the spouse to the ER for reasons. In addition to all of the various techs and nurses and residents that stopped in to ask questions and perform tasks, there was a supervisory physician on staff who just sat down and talked with my wife and I for at least fifteen minutes.

She talked about our specific reason for coming to the ER--her specialist wanted to admit her but there wasn't a room available immediately). She talked about whether the staff was addressing the reason or if there was some other complaint that needed to be explored. She asked about how we function with my wife's health issues at home. She even traded a few pet anecdotes with my wife which definitely helped calm her.

Her job is to put a human face on the ER experience and make sure that the things that need to be addressed are, in fact, being addressed. Absolutely brilliant! All of this being the reason why we will make the drive to this hospital if at all possible instead of visiting the one just down the hill from our home. The level of care at this facility is incredible all things considered.
posted by Fezboy! at 2:48 PM on June 13 [1 favorite]


I've got to address all the consternation about widely varying wait times and quality of care in the same facility. It depends on what other patients are there, and how the ER is staffed at that moment. Seriously. Nurses and doctors are scheduled according to the usual trends in how many patients come to the ER at various times of day, but they don't just have 20 people sitting around twiddling their thumbs in case a bunch of extra patients show up. Hospitals have to do their best to staff for expected patient volumes; when the system gets overloaded, people who aren't actively dying are going to have to wait a while longer.

Having sat alone in an ER room for 6 hours with no tv/magazines/entertainment, no companion, no medication, nothing to relieve or distract me from the itchy rash that made me want to TEAR MY OWN SKIN OFF, was pretty awful. I paced the room talking to the walls and opening and closing my fists compulsively trying to keep from scratching. But I was not at risk of death or permanent loss of function, and I know the staff were busy caring for people who actually were that sick. On a different day I might have waited less time, or much longer. It all depends on the mix of patients and how many staff are available to care for them.

Another problem for ERs is bed availability in the hospital, for people who need to be admitted. Have you or anyone you know ever sat around in your hospital room, ready to go home except "my ride can't be here for 3 more hours?" The nurse in the ER who is caring for a patient who is stabilized and ready to be admitted, can't transfer her patient to your room because you haven't left yet. The ER nurse can only watch over so many patients at a time, which means that same nurse can't take on the care of someone else who is still waiting in the ER waiting room. Nobody would ever say it to your face if you're discharging, but yeah, you wanting to finish watching this movie before you go home really does affect people who are sitting in pain the the ER waiting room.

Lastly, I am all for people being strong advocates for themselves and their family members, because patients need that, especially in the ER. But as much as it might sometimes feel like it, the doctors and nurses did not forget you. They have triaged and prioritized and if they are not in your room right now doing things for you, it is because they are needed more urgently somewhere else. Going out to the desk and/or repeatedly pressing your call button just to ask when someone is going to do something just makes everything happen slower for every patient, because all those staff people who could be providing care, are instead spending their time telling you and every other person up and down the hall that they just have to wait, trying to calm you down, trying to be polite and empathetic but also realistic.

So my advice is, when you check in at the ER, and again when you get roomed at the ER (i.e. pulled from the waiting room and assigned a nurse), ask that person, "What kind of change in my condition would I need to call you for right away?" And then do your best to be patient unless one of those changes occurs. Write down your questions as they occur to you and then ask them when someone comes in to check on you, rather than calling staff in every 20 minutes to ask another question. Those staff know that you are probably having the worst day you can remember in the last decade, but if you're conscious enough to be frustrated, there are other patients having a much worse day who need the staff members more.


unrelated to address this previous question from the thread: I wonder if--and maybe you could explain why/why not, sara is disenchanted--giving everyone with pain complaints a dose of methadone would quickly and easily sort the seekers from those truly in pain? Would there be negative side effects in a non-opiate-addicted person?

Doing this wouldn't actually accomplish anything. Methadone is an extremely slow-acting pain medication, taking days to build up in the system enough to provide any relief for people who are actually in pain. I don't think you would see any difference in response between addicts and non-addicts, either, so it wouldn't help you figure out which category a person was in. Hope that helps.
posted by vytae at 3:05 PM on June 13 [9 favorites]


I rather like the MRI machine. I find them cozy (have fallen asleep in them)

Same here. The whoomp-whoomp of the cryogenic pump is quite soothing.


During my only MRI to date, I played Rad Racer in my head.
posted by Coatlicue at 3:07 PM on June 13


Whenever someone says this, I honestly wish I could take away their health insurance...

I took pbrim's comment to be sarcasm. I don't think sarcasm is reason enough to revoke their health insurance & all.
posted by Kirth Gerson at 3:16 PM on June 13 [1 favorite]


Late coming back to the thread. As noted above, methadone is for folks who have issues with dependence on painkillers - this isn't going to help anyone who is A) in a significant amount of pain B) seeking a high. So we just wasted time and medication on a situation that should be handled differently.

Also, folks have a lot of different reactions to pain meds, but most of them are going to make you pretty sick, so an anti-emetic is usually given as well. Many emergency painkillers have a pretty short effective time period (a morphine drip notwithstanding), and may not produce the effects the ill or injured person was expecting. We have frequent flyers, and we have people who are unaware that they are obviously seeking pain medication, but there are "tells."

Again, we don't want to mask where the pain is originating from nor the quality of the pain until the source of the pain is determined. The qualities and descriptors of pain tell medical personnel where and how to start forming a diagnosis, and as also noted above, referred pain IS a thing. But someone experienced in emergency medicine can hear a description of abdominal pain and begin determining if it's appendicitis, a GI issue, cardiac, etc. Pain exists for a reason; it's the body attempting to tell the mind and whomever will listen "hey! Something is WRONG! Start looking HERE!"

TL;DR - methadone is not an emergency drug; other emergency painkillers are extremely strong and require some background information to avoid contraindications and facilitate development of a diagnosis in a non-life-threatening situation.
posted by sara is disenchanted at 3:31 PM on June 13 [1 favorite]


And yeah, after having mostly been to ERs in relatively affluent, white-ish areas, which are bad efuckingnough as is, it was really eye-opening for me to wait for a friend in the middle of the night in the ER of Grady, Atlanta's public hospital which serves a heavily low-income black population. At least some other ERs I've been to are vaguely cheery in an antiseptic way-- this waiting room was dim, poorly maintained, physically uncomfortable. Scores of people were strewn around the room, many groaning or weeping out loud from pain; no indication that any of them had even been triaged in any meaningful way. The bathroom was as nasty as you'd expect from a high-use public building like a library or a DMV-- I'm not normally remotely prissy about this sort of thing, but shouldn't care be taken to keep a bathroom in a hospital sanitary for patients? Sure, when I finally got into the clinical room to see my friend, everything was clean and appeared to be medically advanced, but damn, you could feel a palpable sense of "the system does not care about you" from the waiting room. I'm sure the employees of the hospital mostly do the very best that they can, but wow; can't we auction off a drone or two to raise some money for giving low-income communities and communities of color hospitals that are up to par?
posted by threeants at 3:37 PM on June 13 [3 favorites]


And something I can't fathom is this: we are frequently told that, due to a constellation of factors not least of which including our fucked-up healthcare system, there is a systemic problem with people using the ER as, or like, primary care. Ok...so why is the medical establishment not responding to this problem? Why aren't hospitals operating urgent-care analogues that you can be triaged to from the ER? Where's the harm-reduction reaction to patient misuse of Emergency infrastructure?
posted by threeants at 3:42 PM on June 13 [1 favorite]


Late coming back to the thread. As noted above, methadone is for folks who have issues with dependence on painkillers - this isn't going to help anyone who is A) in a significant amount of pain B) seeking a high. So we just wasted time and medication on a situation that should be handled differently.

I thought the whole point of methadone is that it does deal with people seeking a high. And, okay, anecdata but my pharmacy doubles as a methadone dispensary and I've seen people come in with the shakes and be fine about five minutes after they get their dose.

My point is actually that it wouldn't help anyone in group A; but I thought it would help to very quickly weed out those in group B, by providing relief without adding to the addiction?
posted by feckless fecal fear mongering at 3:59 PM on June 13


there is a systemic problem with people using the ER as, or like, primary care. Ok...so why is the medical establishment not responding to this problem?

Who's going to pay for this? The majority of people using the ER as primary care are not people with insurance or large piles of cash, AFAIK.

Yet again, the profit motive needs to be removed from healthcare if people are actually going to be healthy.
posted by feckless fecal fear mongering at 4:01 PM on June 13


Why aren't hospitals operating urgent-care analogues that you can be triaged to from the ER?

My HMO has this! (Group Health in Washington) I had to go to the 24-hour urgent care just last week because of cellulitis in my foot -- it was not an Emergency, in the sense that the air was going in and out and the blood was going round and round and everything was likely to stay that way, but it had progressed rapidly over the previous 4 hours and the health line told me to go in. The urgent care is colocated with the ER, there are just different doors into the facility, and the staffing for the UC acts as overflow for the ER. They told me when I checked in that I would be waiting a while because the other side was slammed, and I told them "that's OK, I am a low-acuity situation, it's fine that I wait."* I probably waited about an hour for a doctor to come in, look at my foot for 4 seconds, poke it to watch it blanch and watch the color return, and go get her scrip pad to write me a prescription for a (staggering) course of antibiotics. She handed me the discharge instructions and grunted "It's good that you came in, that looks terrible." I was very skeptical about switching over to this HMO from the PPO we'd been at for 19 years, but so far they have been great.

But a situation like Eyebrows McGee's -- I understand, like I said above, that low acuity situations need to wait. But a 2-year-old with an actively bleeding laceration is a situation that at the very least needs to have expectations managed appropriately, you can't just park that family in a room and forget about them. Unless there's a tornado bearing down on the facility, one would hope that you could at least send an MA to tell them "we haven't forgotten about you, there are a lot of critical situations elsewhere in the hospital, lemme take a look and that and make sure we don't need to bump you up the list, I'm so sorry, here kid have a popsicle." That situation isn't a failure of the medical staff at the hospital, but it IS a failure of the administrative staff.

*When I filled out my press-ganey survey I made sure to say that, too.
posted by KathrynT at 4:08 PM on June 13 [1 favorite]


I thought the whole point of methadone is that it does deal with people seeking a high. And, okay, anecdata but my pharmacy doubles as a methadone dispensary and I've seen people come in with the shakes and be fine about five minutes after they get their dose.

My point is actually that it wouldn't help anyone in group A; but I thought it would help to very quickly weed out those in group B, by providing relief without adding to the addiction?


What do you mean "deal with people seeking a high?" Methadone does not provide a high, but it does prevent opioid withdrawal. That's why it's used for maintenance for people who would otherwise be addicted to frequent doses of heroin. It prevents the shakes and other symptoms of dope sickness/withdrawal, but it doesn't provide quick pain relief.
posted by vytae at 4:18 PM on June 13 [1 favorite]


Re MRIs, the sound it makes is going to depend a lot on what scan it's doing. So some of you might have had noisier/grating-er experiences than others. (Plus, the model of machine matters. There are frankly crazy energies being flung around inside that bland white torus; the fact that it's actually relatively quiet is kind of amazing.)

Ok...so why is the medical establishment not responding to this problem? Why aren't hospitals operating urgent-care analogues that you can be triaged to from the ER?

I've wondered that also. It seems to me that in a sane world, the urgent care would be down the hall from the ER; if the ER intake determines that whatever's going on isn't likely to actually kill or cripple you in the next 24-48 hours, you go to UC, or make an urgent appointment with your doctor, or whatever.

But in my limited experience UCs seem to be operated by entirely different organizations, and are outside the normal triage process. This is weird, and leads to situations like in this article— the writer was no longer in need of emergency care after the first few hours, so there was no reason for her to stay in the ER; but she did still need some medical care. The ER did exactly what it's there for, but there was no good process to get her from the "about to die? [y/n]" track to the "you should definitely see a doctor within the next day or two, but you can sleep at home instead of on a gurney" track.

(On preview: from what KathrynT said, Group Health has exactly this setup. My friends who've been there say pretty good things about that hospital, actually. So perhaps it's just some places that are screwed up.)

I wonder if it's just that hospital process design dates to a time when it was optimistically assumed that the ER system would have enough throughput to handle "urgent care" situations normally.
posted by hattifattener at 4:19 PM on June 13


but it doesn't provide quick pain relief.

Once again, I KNOW THAT. I am saying that if someone is so drug-seeking that they are turning to ERs to get their fix (I can't imagine that's easier than finding a dealer), they're probably in or close to withdrawal.

Methadone will fix that. It will not fix the person in actual pain, meaning you can separate the two groups pretty easily without keeping the person who actually needs the meds in pain. Like me, writhing on a gurney in the ER for HOURS with acute-about-to-rupture appendicitis before they would give me the morphine I actually needed.
posted by feckless fecal fear mongering at 4:24 PM on June 13


But in my limited experience UCs seem to be operated by entirely different organizations, and are outside the normal triage process. This is weird, and leads to situations like in this article— the writer was no longer in need of emergency care after the first few hours, so there was no reason for her to stay in the ER; but she did still need some medical care.

This has happened to me in the past (the first time I went into the ER as an adult, in fact; I was told "allergic reaction + facial swelling = ER" and by the time they saw me on football night, the swelling was down) and I agree it would be a lot better if you could get urgent care at the hospital. I would also be perfectly happy if the medical clinic system my GP and rheumatologist belong to had an urgent care clinic so my allergic reactions could go straight into their electronic system. But I've also gone to the nearby urgent care clinic, which is separate from both, in the last couple of years, and it has all the downsides of the ER plus they don't have the equipment to deal with a lot of crisis situations. I never even considered it as an option for this last allergic reaction.
posted by immlass at 4:33 PM on June 13


I'm with you immlass. If I'm having an allergic reaction that the helpful documentation from my allergist says is concerning, I'm not going anywhere but the ER. Especially if I have to inject myself with epi at some point.
posted by feckless fecal fear mongering at 4:38 PM on June 13


I am saying that if someone is so drug-seeking that they are turning to ERs to get their fix (I can't imagine that's easier than finding a dealer), they're probably in or close to withdrawal.

Ah, I see what you're getting at. The thing is they're often hoping for a prescription, not just a one-time dose. They're hoping to hear, "Oh, you strained your back? Here's 30 vicodin and see your primary care doc if it's not feeling better in 10 days."
posted by vytae at 4:40 PM on June 13 [1 favorite]


Yeah, that makes sense. There are signs in my local hospital's ER waiting room that say they simply will not provide narcotic prescriptions period unless your GP actually shows up and confirms you should have such a scrip. (They will feed you narcotics as necessary when in-hospital, though.)

This was actually something of a problem when I started with my GP (who works in the family practice unit at the hospital), because he was kind of iffy about prescribing me clonazepam. I was like, "You have my records from CAMH. You know I need them, and you know that the doctors there have been prescribing them for me for two months. Your policy is bunk" (paraphrased). He caved, but was all "I could get in huge trouble for this."

I DGAF. But it does point to blanket policies as being bad, yet again.
posted by feckless fecal fear mongering at 4:46 PM on June 13


Also, it's frowned upon to give people unnecessary medications, like giving methadone to someone who probably doesn't need it.

Also also, addicts don't come to the ER complaining of withdrawal symptoms, they come complaining of pain, same as somebody with appendicitis. Neither group comes to the ER with severe pain, gets a shot of morphine (or methadone, in your proposal), and then says, "Whew, much better. I can go now, thanks." It's not like the drug seekers would suddenly admit to feeling better after the methadone and decide to leave. So it still wouldn't really help anyone separate out the two groups.
posted by vytae at 4:46 PM on June 13 [1 favorite]


But surely a trained medical professional would be able to tell "Oh hey, all the visible signs of their symptoms stopped dead after we gave them something specifically designed to help with opiate addiction"?

Then again there's placebo effect so I guess it's a wash.
posted by feckless fecal fear mongering at 4:49 PM on June 13


Buddy in a hospital ER could not get a nurse to come to the room; called 911. Got moved, did not have to pay for stay, and got well. In a different hospital.

Do any of these people ever get ... fired ?
posted by buzzman at 4:58 PM on June 13 [2 favorites]


I nearly left the hospital (with, as it turned out, an actually ruptured appendix) when the idiot orderly came back to ask "Oh are you still in pain?" after I was begging for a doctor or nurse to show up.

Not even joking. Turned to my then-boyfriend and said "Call a cab, we're leaving and going to a real hospital." Luckily my surgeon showed up a couple minutes later but I was actually trying to get out of bed and put on clothes.

Torontonians: never go to St Joe's ever.
posted by feckless fecal fear mongering at 5:01 PM on June 13 [2 favorites]


Who's going to pay for this? The majority of people using the ER as primary care are not people with insurance or large piles of cash, AFAIK.

Yet again, the profit motive needs to be removed from healthcare if people are actually going to be healthy.


Yes, absolutely.
posted by threeants at 5:33 PM on June 13


ER resident physician here. ERs are terrible and I almost regret going into the field. If you are very sick, you probably get good care. If you are middling sick, you may or may not get recognized as such. If you are not sick, or if you have a complaint that doesn't fit snugly into an algorithm, or if you have a chronic problem, you are probably going to have a very frustrating experience.

It is unsatisfying work because patients are always unhappy (with wait times, with being put into an algorithm that doesn't fit, with the fundamental superficiality of an ER work-up) and because I am constantly running around, juggling too many small problems and a few big ones, interrupted on all sides at all times, so much so that I don't often have TIME to really think about a patient, or be in the room as long as I would like to. I like people and I want to be a good doctor. In the ER, I feel like I am not doing a great job medically and I am not making anyone happy.

There are a lot of reasons ERs are such a disaster. Some of it comes down to medical-legal considerations (which make ER physicians extremely risk-averse and compulsive over-testers) and also by folks who do not use the ER appropriately and end up taking time (and, as importantly, staff energy and morale and goodwill) away from other patients who are there with problems that need prompt medical attention.
posted by half life at 5:38 PM on June 13 [9 favorites]


The last time I went to the ER, I think I got pretty good care — I was apparently just cursing at everything and anyone, especially when they banged my broken arm on the MRI. But I got checked for soft tissue and concussions, and people seemed pretty engaged (my girlfriend did give them the wrong birth year so we went round and round with that for a bit).

But the previous time was after I'd had my tonsils out and my stitches burst and I was choking on globs of semi-coagulated blood, and they gave me a paper cup and had me wait, and only jumped to see me once I overflowed it with blood onto the floor.

Oh, and for folks wondering about ER versus UC, one of the things Obamacare is nominally working on is making it easier for people to get UC treatment so they don't clog ERs (and even better if they can get regular GP access, so they don't clog the UC).
posted by klangklangston at 6:03 PM on June 13 [1 favorite]


fffm: But surely a trained medical professional would be able to tell "Oh hey, all the visible signs of their symptoms stopped dead after we gave them something specifically designed to help with opiate addiction"?

The person seeking drugs doesn't usually come in with visible symptoms of withdrawal. They come in with false complaints of pain, which we can't measure objectively -- we can only ask them to describe and rate it. Since the original symptom report was fake, their report of whether their symptom (pain) has gotten better or not isn't really a reliable way to figure out how they're responding to a drug. (If anything, it'd be the opposite of "symptoms stopped dead" -- they'd still be rating their pain 10/10 while playing cellphone games after getting a big dose of narcotics. Because if they said it was better, we would stop giving them more drugs.)

I'm extrapolating ER experiences based on what I've seen of drug-seeking patients in the inpatient setting, so I'm somewhat outside my real realm of experience here. But if you want to keep discussing, maybe shoot me a MeMail? I'm happy to explain more, but I feel like this is starting to derail.
posted by vytae at 6:21 PM on June 13 [1 favorite]


Yeah I didn't mean to derail, I was more thinking aloud about the problems that drug seekers inflict on those who truly need the medication, and how to rapidly sort one group from the other.
posted by feckless fecal fear mongering at 6:25 PM on June 13 [1 favorite]


My worst hospital experience, even after this past Cancer Year, is still - just like Dr Yeh - being discharged from the ER to the hallway to wait for a room after being hit by a car. If my husband hadn't been there to flag down and argue with nurses ("She's discharged, we can't treat her." "But she's still here, in the hallway!") no one would have medicated me for the pain of my broken, unsplinted arm for the 8 hours we waited. And even though I was supposedly being kept for close observation post head injury, no one observed me while I was in the hallway, and neither the ER nor the floor did any imaging of my head, probably because - like Dr Yeh - I was admitted to a non-ortho floor and it wasn't part of The Algorithm. Unlike Dr Yeh I got lucky and don't have significant sequelae.

mathowie: "Every two years I have to get a MRI to scan my (shrinking, stable thankfully) brain tumor and everything you've heard about MRI machines is true. They're loud, claustrophobic, and just about 45 of the most miserable minutes you'll spend at a hospital.
Every time I get out of one, the tech tries to say something to lighten the mood, and every time I ask how often they've taken an MRI themselves. Everyone that designs and operates a MRI should have to endure one trip in it once a year. I think it might make for more innovation when they realize places they could improve the experience.
Most often I hear they only did it once in med school, not at all, or just once one time for an injury to a leg or knee.
"

Ohhh, MRIs arent even the most miserable time you can spend in the Imaging Department. Ultrasound-guided biopsies, where they dig around inside you with a needle or scalpel while they shove an ultrasound probe next to it, are worse.

It's not a coincidence that my favorite Nuclear Medicine tech is a woman about my age who had had an early-onset colon cancer that was treated super-aggressively. She understood the whole patient experience. She was and is very good about sympathetically explaining what the likely patient-side experience is going to be - I know the test xingcat is talking about (a well-known iodine contrast effect) and it's totally disconcerting and uncomfortable, but she warned me about it so at least I wasn't startled.
posted by gingerest at 6:47 PM on June 13


Regarding Urgent Care, I think there's just a major lack of awareness of what they do, how they work, and even where they are. Everybody knows where hospitals are-- they tend to be major local landmarks and are open 24 hours. I have literally no idea where my nearest Urgent Care clinic is. I don't know how much they cost, whether they take insurance, whether they take my insurance, if I'll be seen by a qualified medical professional, when they're open, what they do and don't treat, whether they have access to my medical records...obviously all of these things can be found out, but I'm talking about the baseline knowledge people use to self-triage. And even despite the medical system's myriad injustices, I think people have some level of implicit trust for a nonprofit hospital whereas an Urgent Care place feels sort of like mystery meat in terms of whether its mission is to operate for the public good. (Are these places nonprofits; companies; branches of hospitals? I have literally no clue and I suspect most others in the general public don't either.)
posted by threeants at 7:27 PM on June 13 [3 favorites]


Pre-ACA, I used a local private urgent care clinic for everything, because they'd tell me right up front (on the phone, even) how much things would cost me without insurance, and they were convenient and pleasant to deal with. They weren't a great choice for ongoing care without insurance to cover it, but could handle most minor emergencies, like suturing, road rash cleanup, or strep tests, for a moderate, unobfuscated price. I think they have an x-ray machine and could probably do minor uncomplicated fractures, or at least let you know whether you need to go to the ER (which beats going to the ER and finding out it was unnecessary.)

In the post-ACA world, I've got awesome reasonably-priced health insurance operated by a large public hospital system that has services for everything I'm ever likely to need, and it's great. I never need to worry about schlepping records around or whether visits are covered, and everything's in the same place. Primary downside is I have to use their pharmacy for everything, and waiting to get prescriptions filled is extra boring when I can't do my household shopping at the same time.
posted by asperity at 8:47 PM on June 13 [2 favorites]


I tell you what, the best way to get instant care in the ER it to be a baby. A baby with a very high fever, a baby with a rash, anything that could be construed as meningococcal or meningitis, or a baby with a dislocated elbow (I've had all of those). Aside from the elbow which was fixed straightaway and sent home, we were seen instantly, then very frequently as they monitored us over many hours, jumped whatever queue existed and had very thorough attention. Thankfully it was nothing serious.

When I said that I was surprised we were seen so promptly, I was told that the ER doesn't mess around when it comes to sick babies because they're so small that things like fevers can get very bad, very quickly. What's more, they actually encouraged me to come back later if need be and then did a follow up call the next day, so I was very impressed.

Luckily I haven't had the need to get ER attention myself in Australia but I'm told as an adult, it can be quite a different story. So yes, apparently you need to be a baby.
posted by Jubey at 9:49 PM on June 13


Every two years I have to get a MRI to scan my (shrinking, stable thankfully) brain tumor and everything you've heard about MRI machines is true. They're loud, claustrophobic, and just about 45 of the most miserable minutes you'll spend at a hospital.

Yeah, I got mine in '89-90, not long after my town opened its first MRI clinic, so good timing on my getting cancer. From what I gather the mechanics of MRI scanning hasn't changed drastically since then, only the interfaces and imaging, so the experience is pretty similar to decades ago, you just get the images right away instead of waiting for a lab - all second hand through friends' experiences, so maybe I'm not correct in how it's done now. It was annoying and tedious, but miles better than a CT scan and not anywhere near as risky. The radioactive iodine contrast dye they shot into me for the first diagnostic CT scan I had at Mayo caused an allergic reaction, which had never happened with regular iodine in salt and seafood or whatever. My throat fully closed up and couldn't breathe until they shot me with something else to counteract it. So, no more radioactive iodine for me. It's a weird experience going through the whole battery of testing involved with cancer diagnosis at the Mayo Clinic, and hearing doctors commenting about how they've never seen that particular reaction to radioactive iodine before, which is what they were also saying about the type of cancer I had and my age, and how it was spreading. So, uncharted territory, right? It was relatively easy to treat, but I did several rounds in the rattling tube as treatments progressed.

I'm glad it's caught up to where it's easier to do MRIs across the US now, and there's not as much reliance on CT scanners which effectively scan 3D cross sections through numerous parallel XRay scans. Not as bad as radiation treatments as far as damage and risk, but kinda squicked me out knowing it pushed me right to the top edge as far as max recommended annual radiation exposure. I can kinda zone out in the MRI tube, though I did squirm a bit.

ERs are designed around triage, because resources are spread thin and gotta move people through somewhat impersonally and mechanically. It feels like you're being forgotten sometimes, but I also don't have any real horror stories from my own ER experiences. I've been pretty lucky in that regard, despite some broken bones and accidents that landed me there a few times. It's been quite a few years since the last one, so my guess is things have gotten worse with increased patient volume and financial pressures of modern hospitals.
posted by krinklyfig at 2:07 PM on June 14


What is really amazing to me is that this physician was unable to stand up for herself and be more assertive. She must have really been in shock (or maybe it was the morphine). Doctors are not usually that passive as patients.

I was surprised that even after she identified herself as an emergency physician she still couldn't get attention for her knee from her fellow Acolytes of the Algorithm. I guess the Algorithm rules all.
posted by homunculus at 1:05 AM on June 15


naked capitalism: Buying Health Insurance: A Pig In A Poke
posted by the man of twists and turns at 4:15 PM on June 15


man of twists, he's right that it's impossible to know what you're getting when you buy insurance. I find it ironic, however that he's an MD and feels has the right to make this complaint. Does he disclose to his patients all of the costs of his treatment, including tests he orders? Example: I had a sonogram done. Later, I got a bill from the sonographer. I paid it. Then I got a bill from a doctor in another state who interpreted the images.I paid that. Much later (10 months), I got a bill from the facility where it was done. This adds up to hundreds of dollars now. Even had I asked the doctor who ordered the scan, I would not have learned how much I would be charged, because he doesn't know, either. Neither does the sonographer or anyone else I spoke with.

We really need single payer.
posted by Kirth Gerson at 6:15 AM on June 16


Sarah Kliff: Five ways the American health care system is literally the worst
The United States comes in dead last in a new, international ranking of health care systems from a top health-care non-profit.

This doesn't mean that we're the worst in the world; there are plenty of less-developed countries that have worse systems than America's. But when the United States is compared against peer countries like France and Canada it does not come out well. It comes out the very worst.

A new Commonwealth Fund report looks at how the United States stacks up against other countries on things like access to doctors and quality of care. It pulls from three separate surveys conducted over the past three years: a 2011 survey of sicker patients, a 2012 survey of doctors and a 2013 survey of adults over 18. It also uses health outcome data from the OECD and World Health Organization. This means it captures the experience of the medical system from the people who use it a lot, those who use it a little and the doctors treating them.
posted by zombieflanders at 8:29 AM on June 16 [2 favorites]


vytae: " But as much as it might sometimes feel like it, the doctors and nurses did not forget you. They have triaged and prioritized and if they are not in your room right now doing things for you, it is because they are needed more urgently somewhere else."

The one and (thankfully) only time I've needed to go to an ED, towards the end of the visit I had a radiation tech tell me "You are a lovely and patient person. But the next time you've been sitting for 45 minutes waiting for somebody to come run a scan on you? Please make a fuss. Really." So sometimes they — or other departments doing things for their patients — do forget.

When I was at the ED they seemed busy but not slammed, and everybody I dealt with was perfectly reasonable. The one person I still feel mildly annoyed towards is the security guard who tried to tell my taxi driver not to pull up in front of the door. There was nobody else around, we could see a block either way and could tell there were no ambulances within 30 seconds, and I was being half-carried by somebody because I couldn't freaking walk. Yes, we stopped by the door. (The other guard, who looked me and said "You coming in here?" then disappeared and promptly reappeared with a wheelchair, I wanted to hug.)
posted by Lexica at 6:39 PM on June 24 [1 favorite]


It feels like you're being forgotten sometimes, but I also don't have any real horror stories from my own ER experiences.

One time I went to the ER and for some reason they kept forgetting about me. I was in intense pain with a kidney infection while passing a kidney stone (though I didn't know that at the time). For whatever reason I'd kept assuring myself that cranberry juice would cure whatever was wrong with me, which it obviously didn't, and when I started throwing up multiple times in a row and getting to be in too much pain to sit, I decided to go to the ER.

As soon as I started puking in the ER's waiting room, they hustled me to the area of the emergency department where you have a bed surrounded by a curtain, and they stuck me for the IV (which three different people had to attempt before anyone got it, because for some reason when I say that my veins are difficult to stick, nurses tend to take that as a challenge rather than a warning). But then for a few hours I was lying in that curtained-off bed without getting help. At first I just lay on my side and tried to zone out to the weather channel and listen to the nurses and doctors talk to a homeless guy across from me who obviously came into the ER a lot. But then I started throwing up this putrid neon-yellow bile, and still nobody was helping, and it just hurt too much.

So I pulled back the curtain around the bed I was lying in and ran to this sink on the back wall, which was right in full view of the nurses' station, and started vomiting in it and then all over it and the floor. It wasn't all that long after that when they gave me the morphine and things became a blur, thankfully. Best drug I've ever had. Someone asked if I was still in pain a few minutes after they gave it to me, and were wheeling me in to get some kind of scan, and I said that, yes, I was still in pain, but I didn't care anymore.

So yeah, never going to try heroin. But also, I hate the emergency room. Every time I've been, everyone has been competent, I guess, but callous as hell. I don't really blame them, because they see a whole lot and I guess that's the attitude they need. But it's difficult to deal with, as a patient.
posted by rue72 at 9:48 PM on June 24


Related: Treating the Disease Instead of the Person.
posted by gingerest at 11:32 PM on June 25


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