Let's Define "Emergency"

[turtle md]

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I did a rotation in New Zealand and they had a widespread advertisement campaign to educate the public about when to go and, more importantly, when not to go to the Emergency Department.

I thought we could perhaps start with a definition of what an "emergency" is by defining what it is NOT.

For example,

If it has been going on for months, it is, by definition, not an emergency.

 

[igcgnerd]

What is frustrating is there is a difference between someone that needs to go to the ER vs. someone that needs to go there by ambulance. Nausea + vomiting x 2 days, probably doesn't need an ambulance
things that don't need an ambulance:
broken fingers or toes
non acute abdominal pain
headache
EMERGENCY= iminantly life threatening emergency or significant disability aka life or limb
the only problem is that the term is relative what any person with medical training might be considered minor, people panic and think it is threatening like people who think superficial lacerations are worth screaming over.

 

[doctawife]

Unless you're neutropenic, fever alone is not an emergency.

If your child is eating Cheetos, dollars to donuts your child does NOT have an emergency. (aka the + Cheetos sign as a negative predictor of disease)

An ear infection is not a reason to visit the ER... or call an ambulance.

In a similar fashion, ADHD is not an emergency. F*(king inconvenient and annoying to the ER staff, but not an emergency.

 

[EctopicFetus]

Ahh doctawife we have a name for the cheetos..

We call it "peri-oral Cheetosis" this is a sign kiddo can go home.. Even if he was vomiting 400 times in the last hour prior to arriving but hasnt puked since.

 

[EctopicFetus]

Emergency is not CC of "Bilateral knee pain for 6 months" yep.. I saw him!

 

[Dr. Dukes]

You only need an ambulance if you can't drive yourself to the hospital, or if waiting the extra 30 min for treatment will cause risk to life, limb, or sight. (If you're on a Boat you can "only" call mayday if you're at risk for life, limb, sight, or boat, and I think that should be the same for 911).

 

[doctawife]

Ahh doctawife we have a name for the cheetos..

We call it "peri-oral Cheetosis" this is a sign kiddo can go home.. Even if he was vomiting 400 times in the last hour prior to arriving but hasnt puked since.

I love you Ectopic.

On another note, getting bit by an unknown pit bull is an emergency and we'll be happy to see you that night. Instead of waiting several days and presenting with a raging cellulitis and the always interesting rabies question... Grr. 😡

 

[EctopicFetus]

You only need an ambulance if you can't drive yourself to the hospital, or if waiting the extra 30 min for treatment will cause risk to life, limb, or sight. (If you're on a Boat you can "only" call mayday if you're at risk for life, limb, sight, or boat, and I think that should be the same for 911).

It is broader than this.. How about if you have excruciating CP, dizziness (real dizzyness) or any other condition where driving isnt safe!

 

[Dr. Dukes]

It is broader than this.. How about if you have excruciating CP, dizziness (real dizzyness) or any other condition where driving isnt safe!

Fine...don't call 911 unless you're going to die at home or on the way to the hospital because you're condition (whatever it is) makes it impossible for you to drive safely.

 

[The Tolf]

It is a tough call to define an emergency. Just a week ago I responded to an 85yo female who thought she had the flu all day, but finally a friend called 911 when she fell to the floor from exhaustion. Come to find out, the lady had a pulse of 22 and was in complete AV block.
So, does the "flu" constitute calling an ambulance??? I think in some situations it does, and probably saved this ladies life!!!
Some situations that us medical people may think and find to be "non emergent" may in reality be very emergent to our patients, so we have to consider where they are coming, and educate them for the future.

 

[EctopicFetus]

I agree with the overall sentiment. some of this stuff is super silly. As I said before we had a guy do 6 months in jail for abusing the EMS system here. He was using them like a cab company.

 

[USAF MD '05]

If it has been going on for months, it is, by definition, not an emergency.

I saw a guy tonight who had had pain for 4 days, no better no worse. Why come in today? Well, he was on a cruise ship when he injected his penis with caverject (PGE1) and got the boner. 4 DAYS later his wang is still rock hard, painful and swollen. The cruise ship doc said, don't worry, ice, it'll wait till we get back to the states. Straight from plane to my ED. Sudafed, terb fail. Uro comes in, can't drain it for the amount of sludging, off to the OR for dorsal incisions in the glans and amputation internally of the bilat cavernosa/sponsiosa. That is a chronic pain that TRULY was an emergency. OUCH!!😱 BTW: pH of blood in penis 6.8. My first VBG on pee-pee blood. Love this job.
Steve

 

[doctawife]

If your child is having an 'asthma attack' but can recite the entire alphabet in one breath, it is not an emergency.

Having insurance and being white does not change what constitutes an "emergency" - even if, I too, am white and have insurance. If your child is not dying, then your child is not as important to me as the child that actually IS trying to die.

 

[AmoryBlaine]

To shift the discussion slightly...

As much as the "vomiting x 1 day" or "6 months of knee pain" complaints drive us crazy, does anyone want an ED shift that is mostly emergent presentations?

I don't know the answer so I'm soliciting opinions from the higher ups. Has anyone ever had a dream/nightmare shift where everyone they saw was either sick or needed to be ruled-out? How was it?

 

[Apollyon]

Has anyone ever had a dream/nightmare shift where everyone they saw was either sick or needed to be ruled-out? How was it?

Yes. It's exhilarating - sometimes it's procedure after procedure, going back and forth from room to room, and other times it's intellectual challenge, but always being confident in the way you manage the cases. It's something when you can actually feel the catecholamine surge in your body. Also, it's more satisfying than a lot of the trivial/vague cases that don't have a definite endpoint or climax to the story.

 

[turtle md]

Has anyone ever had a dream/nightmare shift where everyone they saw was either sick or needed to be ruled-out? How was it?

As second years, were have a good majority of our shifts in "the core" where all we see are the critical or near critical. I love those shifts. You show up, see several truly sick people, blink a few times, and the shift is over. Makes me realize the fun of my job.

 

[NinerNiner999]

Maybe we can educate EMS providers to counsel patients before they accept to trasfer them to the ED. Something like "Mam, I realize that you have had toe pain since you dropped that book four weeks ago, but we need the ambulance for sicker patients."

I'm also a big fan of the Outback model. Once you sign into the waiting room, you should be given an estimated waiting time based on your complaint. Something like - "Mam, your bed will ready in six to eight hours. Please have a seat." We could also put a big clock in triage like they do for the rides in Disney World, saying "Wait is 7 hours from this point."

Maybe this will help people reconsider their "emergency."

 

[EctopicFetus]

Maybe we can educate EMS providers to counsel patients before they accept to trasfer them to the ED. Something like "Mam, I realize that you have had toe pain since you dropped that book four weeks ago, but we need the ambulance for sicker patients."

I'm also a big fan of the Outback model. Once you sign into the waiting room, you should be given an estimated waiting time based on your complaint. Something like - "Mam, your bed will ready in six to eight hours. Please have a seat." We could also put a big clock in triage like they do for the rides in Disney World, saying "Wait is 7 hours from this point."

Maybe this will help people reconsider their "emergency."

The problem is this then places liability on the EMS people and I doubt they want that. I know what your saying. I wish they would tell the people up front with these stupid complaints something like you wait will be at least 12 hours or something like this. Of course this only leads to lying. The ED pros know how to get into the ED by just saying the right things to the triage folks.

 

[paramed2premed]

This is a funny discussion. I know that people just need to blow off steam and such, but there seems to be a consensus that ED crowding and long wait times are directly related to hospital crowding and delays to inpatient admission, not to the low-acuity patient. Furthermore, almost every study that looks at defining the "inappropriate" ED visit/patient ends up finding a significant percentage of serious illness in patients that a protocol would have deemed an inappropriate visit.

The comment about EMTs and paramedics "accepting patients for transfer" is a perfect example. I never did mind the low-acuity patient. There was practically no work involved, and the rig was ready for service in no time. Heck, I didn't have the patient get on the stretcher, just have 'em walk out and put on a seatbelt. "Counseling" would entail MORE time in discussion and documentation than just scooting to the ED and dropping them off!

Maybe we can educate EMS providers to counsel patients before they accept to trasfer them to the ED. Something like "Mam, I realize that you have had toe pain since you dropped that book four weeks ago, but we need the ambulance for sicker patients."

I'm also a big fan of the Outback model. Once you sign into the waiting room, you should be given an estimated waiting time based on your complaint. Something like - "Mam, your bed will ready in six to eight hours. Please have a seat." We could also put a big clock in triage like they do for the rides in Disney World, saying "Wait is 7 hours from this point."

Maybe this will help people reconsider their "emergency."

 

[igcgnerd]

if the patient has more than 5 complaints= more than likely its not an emergency

 

[emtp6811]

In my EMS service, we do counsel the GOMER patients as suggested above. We do tell them that they would be better off going to an urgent care center or doc in the box or their PCP. In fact, if they still insist on going by ambulance, I call in report as usual but let the ED know that I will be dropping this patient off at the waiting room for sign in, not directly in an ED room. This seems to work well.

There are rare cases of a unit being allowed to take a patient to their PCP's office. I have not done this myself, as I would have to get special permission from my duty supervisor and I feel that this truely would be the definition of Taxi Service, but it has been done.

 

[deleted77919]

As EMS if someone called 911 and we showed up and then didn't want to be transported we had to semi-badger them and make them sign a little waiver saying they understand they might die.

It's all about liability and personally I think it's BS.

 

[Apollyon]

if the patient has more than 5 complaints= more than likely its not an emergency

A (now old) study (from the 90s) - I think from the UK - showed that, if a patient had 3 major complaints - nothing was wrong. This is NOT the positive review of systems complaint: it is the "well, there is this and this and this" thing.

 

[USAF MD '05]

To shift the discussion slightly...

Has anyone ever had a dream/nightmare shift where everyone they saw was either sick or needed to be ruled-out? How was it?

Oh yeah- In my program, those nights are few and far between. Had one the other night with 3 critical trauma patients and a hypothermic arrest all in an hour. 3 of the 4 needed multiple lifesaving procedures. All the crap had to wait. Left with a huge smile on my face and remembered why I love this gig so much.
Steve

 

[NinerNiner999]

Furthermore, almost every study that looks at defining the "inappropriate" ED visit/patient ends up finding a significant percentage of serious illness in patients that a protocol would have deemed an inappropriate visit.

I never suggested these patients not go to the ER, I'm merely suggesting that they don't need to go by ambo. Nor am I suggesting that any of this is even plausible. It would be nice to go back to the good old days when an ambulance en-route to the ED actually carried an emergency. I think wolf has been cried far too many times for that become a reality again 🙁

 

[AmoryBlaine]

Maybe we can educate EMS providers to counsel patients before they accept to trasfer them to the ED. Something like "Mam, I realize that you have had toe pain since you dropped that book four weeks ago, but we need the ambulance for sicker patients."

I'm also a big fan of the Outback model. Once you sign into the waiting room, you should be given an estimated waiting time based on your complaint. Something like - "Mam, your bed will ready in six to eight hours. Please have a seat." We could also put a big clock in triage like they do for the rides in Disney World, saying "Wait is 7 hours from this point."

Maybe this will help people reconsider their "emergency."

What I would be curious to know is if pt's are able to assess with any degree of precision their own triage level... I think that alot of people are stupid enough that they would not be able to understand fully how their 1 episode of clear vomit was less serious than septic shock.

Another curious thing to me (and this ties in with the recent threads about universal coverage) is the use of emergency care in the VA setting. Back when I was at the VA the vets still came to the ED for toe pain, 1 episode of vomiting, or knee pain x 6 months. Considering that most of them had free and relatively quick access to PCPs I was suprised at how many came to the ED for urgent care.

Thanks for all the replies about "dream shifts," it sounds freaking awesome.

 

[bulgethetwine]

To shift the discussion slightly...

As much as the "vomiting x 1 day" or "6 months of knee pain" complaints drive us crazy, does anyone want an ED shift that is mostly emergent presentations?

I don't know the answer so I'm soliciting opinions from the higher ups. Has anyone ever had a dream/nightmare shift where everyone they saw was either sick or needed to be ruled-out? How was it?

Can I get a HELL YES!!!!

I don't even mind staying late to do notes if it is because we had a slamming, high acuity night.

If I didn't want sick folk, I'd seek to work in urgent care more often.

And another thing -- those studies that conclude that lower acuity care doesn't hold up an emergency department. This is true, but it sure makes for low job satisfaction. I actually LIKE when our waiting room is full because it means the trivial stays out in the waiting room and/or leaves. Sure, I accept that there is certain risk in this philosophy that some will leave despite possibly having something emergent, but I don't think the liability should be on the medical center or the ED doctor (who might not have even seen the patient if they left after triage but before being shown to a room).

guess what? It turns out life is risky, and no lawyer should be permitted to argue that you deserve compensation every single time in life that one of your "risks" (avoiding PCP appointments, shooting drugs, poor dietary habits) results in an adverse outcome.

 

[zinjanthropus]

if it wasn't for "overuse" of the ER for non emergency conditions, we wouldn't have new residency programs springing up all over the country, we wouldn't have slots for all of us and we wouldn't have nearly as much job security - there just ain't enough true emergencies. the only thing that worries me about some form of universal health care is the potential long term decline in ER visits in substitution of primary care

 

[deleted109597]

Latest Annals shows that it isn't really the non-emergency cases that increases LOS. It is the fact that idiot hospitals won't fix problems with boarding.

 

[bulgethetwine]

if it wasn't for "overuse" of the ER for non emergency conditions, we wouldn't have new residency programs springing up all over the country, we wouldn't have slots for all of us and we wouldn't have nearly as much job security - there just ain't enough true emergencies. the only thing that worries me about some form of universal health care is the potential long term decline in ER visits in substitution of primary care

You can stop worrying. Canada, and to some degree, Britain, all have near universal health care. And their EDs are crowded and understaffed, too.

 

[AmoryBlaine]

if it wasn't for "overuse" of the ER for non emergency conditions, we wouldn't have new residency programs springing up all over the country, we wouldn't have slots for all of us and we wouldn't have nearly as much job security - there just ain't enough true emergencies. the only thing that worries me about some form of universal health care is the potential long term decline in ER visits in substitution of primary care

I would refer you to my annecdotal evidence about VA healthcare.

 

[deleted109597]

You can stop worrying. Canada, and to some degree, Britain, all have near universal health care. And their EDs are crowded and understaffed, too.

As well as NY EDs are crowded with Canadian "refugees" as well.

 

[Febrifuge]

What I would be curious to know is if pt's are able to assess with any degree of precision their own triage level...

Hmmm. I smell study!

Thanks for all the replies about "dream shifts," it sounds freaking awesome.

Yeah, when I'm a provider I'll probably feel that way, too. Speaking as a tech, it blows. I look around the nurses' station, and one RN has been called to a trauma, one is on break, and one is nowhere to be seen -- probably in the med room, praying to the trauma gods to make it stop. The pit boss is in the trauma, the staff is wherever staff go and usually it's fine because the pit boss is there, and the med student is... probably at the trauma. Sometimes, it's literally just me. And god help the patient who comes in by ambulance at that moment.

It's like when Reagan was shot, and Al Haig stared down the camera in the press room and said "I am in charge here."

 

[deleted6669]

Yes. It's exhilarating - sometimes it's procedure after procedure, going back and forth from room to room, and other times it's intellectual challenge, but always being confident in the way you manage the cases. It's something when you can actually feel the catecholamine surge in your body. Also, it's more satisfying than a lot of the trivial/vague cases that don't have a definite endpoint or climax to the story.

agree. much better to have reasonable volume and appropriate cases than hrs of vague bs or the pt I saw who arrived via ems for no bm this am. no pain. no n/v/d. no fever. just no bm. she had a bm every day by 9 am so at 1030 she called 911. stable vs, benign exam. d/c home within 5 min of hitting the door. no rx. d/c instructions say" do not call 911 for constipation ever again."

 

[deleted6669]

Maybe we can educate EMS providers to counsel patients before they accept to trasfer them to the ED. Something like "Mam, I realize that you have had toe pain since you dropped that book four weeks ago, but we need the ambulance for sicker patients."

I'm also a big fan of the Outback model. Once you sign into the waiting room, you should be given an estimated waiting time based on your complaint. Something like - "Mam, your bed will ready in six to eight hours. Please have a seat." We could also put a big clock in triage like they do for the rides in Disney World, saying "Wait is 7 hours from this point."

Maybe this will help people reconsider their "emergency."

stay in the e.d waiting room should be proportional to duration of complaint.any benign complaint > 1 yr = 24 hr wait( so not increasing c.p. x 1 yr obviously). if you go out to smoke your time starts at zero again.
for each month of complaint you get at least a 2 hr wait...even if the e.d. is empty.....

 

[docB]

We all make $ off the worried well but on those shifts where I'm seeing 3+/hr I really wish the non-emergent crap would stay home. I don't buy the bit about the non-emergent stuff not clogging up the EDs. You have to remember that a lot of the non-emergent stuff winds up looking like emergent stuff because of the defensive medicine rule out paradigm we use in the ED. Most "ankle pain for a year" winds up getting an US and goes in the books as a "RO DVT" which seems like an emergent visit. And raise your hand if you've ever admitted a "chest pain" that you just knew was bronchitis/pleurisy but weren't willing to bet your house on it. It is true that we sometimes find sick people lurking in the level 4 and 5 triages (it's not as much like looking for a needle in a haystack as it is like looking for a turd in a pile of dirt) but we also over call and CYA enough of the BS to continue the problem. That's what we do in the ED, think of the worst first.

 

[EctopicFetus]

CC of the day in the ED.. Abscess for 2 yrs underarmpit. Here for 2nd opinion.

in the ED for a 2nd opinion after 2 surgeons cut on it twice.

 

[Midwest Medic]

As both an ex-paramedic and a ED resident, I am against the mis-use of the EMS system. But on the same hand, do not think that we can let EMS personnel triage calls and turn them away. For example, 76y/o with vomiting X 1 day, we get report from the medics that this is a nothing and we all think that initailly too. Turns out it was a large posterior CVA. Also, what may be a life threatening emergency to one person may not be to another. A professional piano player may think that a dislocated finger or fall onto hand is a emergency, we usually do not. Does this need EMS, no, but they may think it does.
A few other scenarios that all sound like absolutely nothing when we were medics or when we get the radio call. Vomiting and diarrhea for one day. Sounds like a whiny person, I have thought that, we all have. How do we know that this is not a person who has vomited every 15 minutes for the whole day, and is now so dehydrated and hyopkalemic that they can't walk, can't drive, and have no family or a supportive family/friends to help them out.
All this aside, I to hate it when people misuse the system. We really need to educate the public more on proper use of the system. At my hospital we usually do point out that there may have been a more appropriate way for this patient to come to the hospital, that EMS is for life threatening emergencies and that their misuse may have cost someone thier life. People usually respond well to that, unless they are of the mindset that the wolrd owes them what ever they want.
Sorry for the ramble, just wanted to voice my 2cents...

 

[DropkickMurphy]

Hmmm. I smell study!

I'm game. You in Feb?

 

[ERMudPhud]

It is true that we sometimes find sick people lurking in the level 4 and 5 triages (it's not as much like looking for a needle in a haystack as it is like looking for a turd in a pile of dirt)

Another great quote from DocB

 

[AmoryBlaine]

I'm game. You in Feb?

Hey guys, I get first author!

 

[bulgethetwine]

We all make $ off the worried well but on those shifts where I'm seeing 3+/hr I really wish the non-emergent crap would stay home. I don't buy the bit about the non-emergent stuff not clogging up the EDs. You have to remember that a lot of the non-emergent stuff winds up looking like emergent stuff because of the defensive medicine rule out paradigm we use in the ED. Most "ankle pain for a year" winds up getting an US and goes in the books as a "RO DVT" which seems like an emergent visit. And raise your hand if you've ever admitted a "chest pain" that you just knew was bronchitis/pleurisy but weren't willing to bet your house on it. It is true that we sometimes find sick people lurking in the level 4 and 5 triages (it's not as much like looking for a needle in a haystack as it is like looking for a turd in a pile of dirt) but we also over call and CYA enough of the BS to continue the problem. That's what we do in the ED, think of the worst first.

This is a very well articulated assessment of the data regarding low acuity visits clogging up an ER. It has become impossible to voice this in the greater domain because it is so fashionable to chant "but the data SAYS...". These studies (including the one cited above that is in Annals this month) are good examples that have too much bias to be readily applicable. Of course, positive or negative, how is the study data applicable to an ED, I mean REALLY?? Even if we had data to PROVE that low acuity visits clogged an ED, what's going to change? Until we get better liability conditions, I'm raising my hand with DocB on the "admitted because I wouldn't bet my house on it".

The top 3 problems, in order, as I see them in modern EDs as regards overcrowding:

1. Litigious society whereby patients do not bear any burden of the risk
2. Slow moving bed clearing "upstairs"
3. Low acuity, non-emergent traffic


Ok, let the flames go. Game on

 

[doctawife]

No flamage here. I'm a pediatric generalist (read - board eligible pediatrician) employed by a Department of Pediatrics, Section of Emergency Medicine in a major medical center. My employment depends entirely on the non-emergent patients. All I see - all day, every day - are the folks who really could've waited to see their pediatrician. But they came to the ER. Why? Who knows... Generally, they don't need an ER. I just move the meat to try to keep the other sections of the ER clear for kids who are actually sick.

And trust me fellas, I see plenty of patients. My paycheck won't ever be in danger.

Do I want to see crap all day long? Hell no. I get really happy when someone is mis-triaged back to me. And it's the reason I'm applying for pedi EM fellowship. 'Cause the crap is killing me.

 

[Febrifuge]

I'm game. You in Feb?

Oh, heck yeah. My PA program will be wanting me to do a Master's Thesis anyhow.

 

[DropkickMurphy]

Hey guys, I get first author!

Of course.....are you willing to have me help?

 

[DropkickMurphy]

This is a very well articulated assessment of the data regarding low acuity visits clogging up an ER. It has become impossible to voice this in the greater domain because it is so fashionable to chant "but the data SAYS...". These studies (including the one cited above that is in Annals this month) are good examples that have too much bias to be readily applicable. Of course, positive or negative, how is the study data applicable to an ED, I mean REALLY?? Even if we had data to PROVE that low acuity visits clogged an ED, what's going to change? Until we get better liability conditions, I'm raising my hand with DocB on the "admitted because I wouldn't bet my house on it".

The top 3 problems, in order, as I see them in modern EDs as regards overcrowding:

1. Litigious society whereby patients do not bear any burden of the risk
2. Slow moving bed clearing "upstairs"
3. Low acuity, non-emergent traffic


Ok, let the flames go. Game on

You hit the nail (or rather, nails) squarely on the head. 👍

 

[deleted109597]

Remember, it was in my signature before.

An emergency on you part does not necessarily constitute one on mine.

 

[wrested]

Latest Annals shows that it isn't really the non-emergency cases that increases LOS. It is the fact that idiot hospitals won't fix problems with boarding.

Did you notice where this study was performed?

Ontario, Canada!

"Low-, medium-, and high-complexity patients represented 50.9%, 37.1% and 12% of all patients, respectively."

I wonder how much of the issue is access to one's PCP, given that PCPs being so overwhelmed; vs. not having a PCP in the U.S. d/t lack of insurance... Or, how many of those people think going to the ED might get them their MRI in a few hours/days instead of 8 months like the other outpatients.

Oh, and I'd like to see the patient-provider triage discrepancy study as well...