The Clinton Herald, Clinton, Iowa

March 20, 2014

The 10 types of ER patients

By Leana Wen
Slate

— You're sitting in the waiting room, icing your sore ankle. The teen-ager to your right is moaning and clutching his belly. The woman to your left is coughing into her mask. A stretcher rolls by with a man yelling at the top of his lungs. An ambulance arrives. You see paramedics performing CPR.

You wonder, with all this chaos around you, how can you make sure that your emergency room doctor will address your concerns?

Along with primary care physicians, we emergency providers are the frontlines of medical care. We see people with every imaginable issue. Some ER patients are critically ill - from trauma, heart attack, or severe infection. These patients will get seen immediately and have the full focus of ER staff. Other patients are not critically ill but still have needs that must be tended to.

As an emergency physician and patient advocate, I've met many patients who are frustrated by their medical care. I wish I could have given them advice before they came to the ER.

 I see some of the same missed opportunities and miscommunications again and again. Categorizing the clusters of difficulties can help to identify and fix the problems. Here are my suggestions for 10 types of ER patients. I don't intend to stereotype or imply that every patient falls into one of these categories. If you recognize yourself in one of these categories, you may benefit from some guidance to help us best help you.



1. The Repeat Customer. Often, ER docs will see a patient who's had headaches for 10 years or foot pain for even longer. If you have a chronic, ongoing issue, explain why today is the day you came to the ER. Help us understand why you're here. Maybe your symptoms have changed. Perhaps your sister just got diagnosed with cancer and you're worried. Please tell us the truth. If there is truly nothing new and you have a primary care physician, please consider making an appointment with her. We can take care of acute pain, but you will need someone to follow you for ongoing medical problems.



2. The Second-Opinion Seeker. You've had months of troublesome symptoms. Nobody - not your primary care physician, not the five specialists you've seen - has given you a satisfactory answer. We understand that you're concerned, but it's unlikely that in the ER, with limited time and resources, we can give you the in-depth investigation you deserve. Ask your regular doctor for referrals and further testing. Keep in mind that we have finite resources; if you're in our emergency MRI for your chronic knee pain, that means the patient with the possible stroke needs to wait.



3. The Googler. The Internet can be a powerful tool for empowering patients, but please use it responsibly. Looking up your symptoms yourself might turn up that you have a brain tumor when you have food poisoning or that you are pregnant when you have belly pain (and you're a man). Use the Internet to help you understand your diagnosis and treatment and to come up with questions - not to diagnose yourself.



4. The "Pain All Over" Patient. We call it the "positive review of systems" when you say yes to everything we ask. Headache? Chest pain? Shortness of breath? Fatigue? Muscle aches? Yes, yes, of course, yes. Some illnesses really affect many parts of the your body, but more often than not, patients will say yes to convince us they are ill. We know you aren't well, so tell us the truth. (If you don't, you run the risk of undergoing unnecessary testing.) If everything hurts, try to tell us your story. When did you last feel normal and well? What happened then? And please don't exaggerate. If you say that your pain is 15 out of 10, but you're eating lunch and texting on your iPhone, it's hard for us to calibrate your symptoms.



5. The "Totally Healthy" Person. I can't tell you how often a patient will tell me he is healthy with no medical problems, then mention to his nurse that he gets insulin shots and takes "some white and blue pills." Please give us the full information about your health. Few visits to the ER are truly such an emergency that you don't have time to prepare in advance. Carry a card with you of all your medical conditions, past surgeries, allergies and current medications and dosages. Don't forget vitamins and herbal supplements. Let your doctor know you're coming; she can call in and let us know, or she might say you can see her that day instead of going to the ER.



6. The Forgetter. Often, I'll ask patients what brought them to the ER, and they'll look at me blankly. "I don't know," they'll say. Going to the ER is stressful, especially if you're ill and already not feeling well. While you're waiting for the doctor, write down your symptoms and key concerns. Bring a family member or friend with you who can help you speak up. There is limited time to see the doctor, so you have to make use of that time and tell us why you are here. If you brought a loved one to be seen, stay with the person - this isn't the time to go shopping and leave granny alone in the waiting room.



7. The Narcotic Seeker. This is the patient who says he has chronic pain and is out of his narcotic medications; for some reason, he cannot contact his primary care physician, and his pills have all been "stolen." The United States has an epidemic of prescription drug abuse, and we in the ER inadvertently become detectives. We want to be careful to identify patients who have real pain and real need, but we also don't want to feed addiction and even criminal behavior of those who abuse the system. If you have a real need, explain what happened and why you cannot see your regular doctor. If it's a different pain than usual, tell us clearly - perhaps there is an underlying new problem that we have to investigate.



8. The Small Talker. We want to talk to you; we really do. Actually, the greatest pleasure of my work is getting to know people, and I would love to sit and chat. Unfortunately, there are 20 other patients waiting to see me, and my job is to help you and them. So please tell me about your health, and ask me as much as you want about that. I don't want to be rude, and I appreciate your interest in me, but please help me help you by focusing on your health.



9. The Yeller. You've been waiting for hours. You're in a tiny room; the TV doesn't work. We are sorry about this; we truly are. Our ER may have 50 - 100 - patients in it, and we have to take care of everyone in order of severity. Screaming and shouting doesn't help, nor does threatening to call your lawyer, the hospital CEO, or the local news station. Please be assured that we are working very hard and are trying to take care of you as quickly and as well as possible. If something has changed and you are feeling worse, please let us know. If you want to help the ER improve, there are often opportunities to do so by joining patient advisory committees.



10.  The Apologizer. "I'm so sorry to come in for this. You have a lot of other patients who look worse than me." It's possible that other patients may be sicker, but you came because you weren't feeling well. Help us understand what prompted you to come in today. We know it's hard to know when it's necessary to come to the ER and when it's not. And there's no need to feel sorry for us. We chose this job because we want to treat all patients, regardless of who they are and what conditions ail them. We are proud to have the privilege of caring for you.