Sunday, March 05, 2006

Waiting in the ER

One day last year I spent 7 hours waiting with my son in the emergency room of the premier children’s hospital. It wait was medically irresponsible and administratively unnecessary. It was emblematic of the lack of respect shown by doctors to patients.

My son had badly fractured his humerus 10 days earlier. He had had surgery and was left with two K wires protruding from his arm. The previous day he had spiked a fever and was seen to have pus leaking from the K wire tracts. He should have been admitted then (that is a story for another post), but was sent home on oral antibiotics.

I brought him back to the hospital with a fever of 102.5 and shaking chills. I knew precisely what was wrong (he was septic from his infected arm) and precisely what was needed (admission and IV antibiotics). I spoke to the admitting orthopedic resident and told him we were coming and what we needed.

What should have happened? We should have been taken to an examining room when we arrived and the orthopedic resident should have been paged. After a brief exam by the orthopedic resident, he should have been started on IV antibiotics. Either the resident or the attending on call should have pulled the K wires and he should have been sent to the floor. In all, this should have, and could have, taken an hour at most.

What actually happened? When we arrived, my son was given Tylenol by the triage nurse and told that he would be seen shortly since the ER was not busy, but:

We waited 2 hours in the lobby before being taken into a room.
We were seen by the medical intern in the ER who agreed with diagnosis and treatment.
We waited an hour to be seen by the medical attending in the ER who also agreed.
We waited an hour to be seen by the ortho resident who agreed with diagnosis and treatment, then disappeared.
After 5 hours, my son had received no treatment, not even additional Tylenol.

Then I got angry and demanded to see the ortho resident immediately:

I demanded that the ortho resident start IV antibiotics immediately before doing anything else. She complied and called the ortho attending on call.
The ortho attending appeared and was appalled at the state of my son’s arm. He pulled the K wires.
We waited an additional hour to be transferred to the floor.

Ironically, various members of the ER staff repeatedly apologized to us for the wait. Amazingly, they did not seem to understand that we were waiting because of them. I was repeatedly struck by the fact that the staff viewed the wait as one might view bad weather: unfortunate, but not under their control. It was taken for granted that if you come to the ER, you must expect to give up your entire day to be seen and treated at the pleasure of the hospital staff.

Where did this attitude come from? Why do we believe that people who come to the ER can’t expect to be seen in a timely fashion? Why do we expect that sick and injured people should be expected to sit until we are good and ready to see them, are not entitled to know how long they will wait, or who they are waiting for? None of this would ever countenance this behavior from any other professional and the fact is that when we, as physicians, seek medical care, we don’t expect this behavior from other physicians.

A respectful approach to patient care in the emergency room would require:

Notifying the patient of the anticipated wait.
Updating the waiting time if it changes.
Explaining how many patients must be seen ahead of time.
Notifying the patient which doctor he is waiting for and the education level of the doctor.

None of this requires any additional time or money. Failing to do this does not satisfy any medical or administrative reason. All of this is simply a matter of treating patients with respect. Why don’t we do it?

1 Comments:

Blogger Kim said...

Based on the fact that you are a physician, your observations should have accepted by the patient's surgeon and he should have been directely admitted to the hospital.

If possible he should have been seen in the surgeon's office. The ER never should have been involved.

It sounds like the ER you used is a teaching hospital, what with all the different residents and attendings getting involved here. Too many cooks in the broth.

And the staff (nurses)really don't have any say in these places. I worked a teaching hospital, the nurses are at the mercy of the different residents/specialists. I don't work there any more.

A septic teenager with pus coming from a surgery site would have been roomed, medicated, cultured, antibiotics administered and admitted with holding orders from our ER doc.

But then, I work in a very nice medium sized ER with MDs who give a damn about their patients. If it took seven hours to get to the room (rare,rare in my facility), your son would have been comfortable in the ER because we would have made sure of it.

9:55 PM  

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