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An Emergency Room Visit: A Game of Chance

January 31, 2015

Unfortunately, your first encounter with a hospital is very often in the emergency department or, as it is more familiarly known, the emergency room. You may have a broken arm or a bad cut, you may have burned yourself cooking pasta at the stove or worse, your young child may have swallowed some potentially harmful cleaning fluids or prescription medications. However, it is also possible that you may be having a heart attack or have been badly injured in an automobile accident and are unconscious or near death. No matter what the situation is or how grave your condition may be, this initial encounter with a doctor, who is likely a total stranger, is critical, and one does not have to be watching reruns of ER to know that if a mistake is made here it could be extremely serious.

In the past, before you chose a physician, hopefully you did some research and made an effort to find a compassionate and respected doctor. (I lay out a simple prescription in my book What Your Doctor Won’t (and Can’t) Tell You on how to do this.) But now, perhaps when you are the most ill and require medical care that may mean the difference between getting cured or sicker or even between life of death, you have no choice as to who will be making care decisions for you.

Maybe it’s the first time in your life that you needed to call an ambulance and be rushed to a hospital and now, every choice that you previously had about your healthcare is gone: The ambulance will take you to a hospital of their choosing; the triage nurse will decide how acute your illness is, and how quickly you should be seen, and even in what part of the Emergency Department. And finally, you’ll be seen by the first physician, or even a mid-level provider (nurse practitioner or physician assistant), that is available. There’s no time to choose the best physician or even an actual doctor; it’s all a game of chance with your life on the line.

Since healthcare is the largest business in our nation, and the pursuit of profit competes with the pursuit of quality of services, every hospital that I know of is using mid-level providers, especially in their emergency rooms, to care for patients. In general it’s a heck of a lot cheaper to hire a PA than a board-certified emergency room physician.

With the economics of medicine being what they are and the current shortage of emergency room physicians, mid-level providers have become a very necessary part of every emergency medicine team. In theory, that works in a “supervised” environment. But in reality, faced with economic limitations of the hospital environment, physicians can end up being overwhelmed by the number of patients and — the rules for supervising mid-level providers can sometimes be unclear: Does supervising a physician assistant mean that the physician has to review all the findings with the provider and the patient or just sign off on the record?

In a recent case that I was allowed to review, a physician sent her patient, who had a dangerously elevated blood pressure, to the emergency room for further care. That patient, who would later die at home, was never examined by a physician and apparently, according to the records, only saw a mid-level provider. No doctor ever touched the patient, questioned the patient or, evidently, made any decisions about how to treat the patient. No one could prove that there was any negligence, but for me, the idea that the only doctor the patient saw that day was the doctor who sent her to the ER for more advanced care, is quite telling.

My advice to everyone is this: if you are travelling, carry a brief history of your medical problems as well as a list of the medications you take and any that you are allergic to. This is particularly important when you are traveling and unlikely to go to a hospital that has access to your electronic medical records. A physician in a strange city far from your home and your personal physician will more often make the correct treatment decision if he or she has access to your records. A single dose of a medication you are allergic to can lead to shock, possible kidney failure, life-threatening electrolyte abnormalities, or even death.

In addition to carrying essential medical information, on your arrival at the ER, I would urge you or a family mem­ber (if you are lucky enough to have one there) to insist that a staff member contact your regular doctor immediately and that the staff make decisions only after they have consulted him or her. If you are able, do not accept any excuse and insist.

I would estimate that I am not called by ER doctors, when one of my patients is admitted to a hospital I am not affiliated with, more than 90 percent of the time. In other words, I almost never get called! What’s more, in my experience there is an even more troubling correlation: The lower the quality of the hospital, the lower the likelihood that I will be called.

You would be deeply troubled, even incredulous, at the overconfidence possessed by some of the physicians out there. It seems that some feel that a simple call to the patient’s regular doc­tor (in my case, the patient’s cardiologist) is unnecessary or will be of no real value to the patient. This flies in the face of logic, of course, so if you do end up dealing with an uncooperative ER, consider calling your doctor yourself if you are able or… threaten to fire the physician and transfer to another hospital. This may not be practical in all situations, but remember, you are not only the patient, but also the paying customer.

Consider this patient’s bad luck. Let’s call him Mr. Black. When Mr. Black entered an emergency room with heart failure, the ER physicians there, instead of taking a few moments to call me, noticed that Mr. Black’s foolish cardiologist had failed to prescribe a drug known as angiotensin converting enzyme inhibitor, or ACEI, for him. What they weren’t aware of is that Mr. Black had developed acute angioedema from that drug in the past, a life-threatening response that results in asphyxia. A few hours after Mr. Black received the drug at this ER he was intubated and sent to an ICU for several days as a result of recurrent angioedema.

So what’s the takeaway here? Always carry with you a list containing all your pertinent medical data when away from home. This is even more critical if you are allergic to any drugs. Here’s what you should include:

  • your name, phone number, Social Security number, and health insurance carrier ID number;
  • your doctors’ telephone numbers/beeper numbers;
  • your illnesses, if any;
  • the medications you are taking;
  • any allergies you might have;
  • your next of kin or who to call in case of emergency, with telephone numbers;
  • and, if you have a heart condition, a copy of your EKG.

Finally, whenever possible make sure the emergency room discusses your care with the physician who knows you and, if a mid-level provider sees you, that you also see the physician before a plan of care is finalized.

For non-emergency conditions, when your physician’s office is closed, I would consider seeking care at an urgent care facility that your physician knows of and recommends.


About the author: Evan S. Levine, MD FACC, is Director of the Cardiovascular Center at Saint Joseph’s Hospital and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You”. He lives in Connecticut with his wife and children.



4 Responses to An Emergency Room Visit: A Game of Chance

  1. globalcitizen on March 6, 2015 at 3:08 pm

    How about some sort of unified healthcare system? W/O insurance companies and where patient care comes before profits. A system like, well… most European states have. I’ve seen small hospitals in the southern states of the US that were dreadfully inadequate by European as well as, I would assume, US standards. I’m wondering who audits (or heaven forbid, regulates) hospitals and insures that care is not substandard?

  2. heartdude on February 4, 2015 at 9:34 am

    The Emergency Rooms are a cash cow for most hospitals. They bill thousands for simplest visit that if seen at another facility would cost a fraction of that charge. And the ERs are packed with everything from catastrophic illness to patient with anxiety to an undocumented person in need of a simple antibiotic.

  3. liberalvoice on February 3, 2015 at 6:14 pm

    When will we enter the 21st Century? Can we not modernize our healthcare system in step with other Western democracies? Out infrastructure is wasting away. And although our best medical centers are top notch, rural, poorer urban areas, and poorer states, suffer some very bad hospitals with very substandard facilities and care.

  4. jamese on February 2, 2015 at 12:17 pm

    What’s taking so long with the national health database? No doubt security issues are slowing things. We’re trying to retrofit good design on top of a bad design (or really, minimally designed system). If our healthcare system wasn’t such a hodgepodge and was more unified a la France, Denmark, Norway, etc., it would be simpler. In France, 99% of the people are covered. Patient satisfaction is the highest (or one of them) in the world. Best medical outcomes.

    France recognized long ago that “the lack of co-ordination between health care providers generates both quality problems (e.g. physicians ignoring the prescriptions of each other, lack of follow up after hospitalisation, insufficient guidance for patients with chronic diseases) and that it is a cause of inefficiency (e.g. duplication of procedures, patients shopping around for doctors…).”

    So why is it so hard for America to fix its healthcare system problems? Two words: “Free market.”

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