*This is evidently not an exhaustive list, and I am not a medical professional. Please use your own discretion, particularly if you live outside Australia. Your country’s medical system could differ in significant ways, and thus will impact your treatment options.
I recently had a friend proudly inform me that, after being mildly irritated by foot pain, decided to present to the Emergency Room.
This news frustrated me immediately for three reasons;
- Context. This friend of mine had ensured that a medically-trained friend took a look at their foot already. The qualified doctor-friend insisted that it was fine, to care for the foot, and to moisturize more while wearing enclosed shoes instead of flip-flops. A simple fix. The doctor-friend performed a basic intervention for pain relief and their social interaction continued as normal.
- CONTEXT. This friend of mine – the one with the foot pain – had listened to me discuss the foundation of my PhD thesis for well over a year now. Talks over beer and coffee were often on the topic of clinicians being overworked, what I was doing about it, and the systemic issues that require fixing. This friend had engaged in that conversation, adding their opinions, and I had thought that a level of understanding had been reached.
- Context. This friend lives in a country where a General Practitioner (GP) can be called to the house for free between the hours of 5pm and 6am. Such a professional has a full kit of things such as syringes, bandages, ointments, medications for general prescription, blood pressure testers – the lot. It’s literally a GP that travels to you. This GP – being free and well-advertised – will refer unwell patients to specialists and hospitals if the needs of the patient extends beyond their capacity.
So with these three context-frustrations in mind I tried – gently, expending serious levels of emotional labour in order to remain polite to a person who had directly contributed to the issue I was undertaking my PhD to resolve – to explain why their behaviour was harmful.
I was told that they have no regrets, and will do it again because they were ‘seen very quickly’.
Indeed, patients who present to the ER are generally seen quickly due to the fact that the ER is designed to intervene during life-threatening events where time is of the essence. A screening nurse cannot ascertain that a stranger wandering through the doors is about to drop dead without first talking to them, and so they must. Within an hour my friend was admitted, screened, and ‘treated’ with the same advice the doctor-friend provided for free only hours earlier. Except this ‘free’ service my friend received in the ER cost the Australian public approximately $620 for a foot pain.
(Where did I get $620 from? Consider that my friend presented on a public holiday, so many rostered staff would have been on penalty rates. The nurse who saw my friend, at a low-level pay grade, would have been working for approximately $60 per hour that day. To facilitate a nurse’s presence, there usually needs to be at least one registrar (approx. $100 per hour), and an on-call consultant clinician (approx. $200 per hour in attendance, $50 per hour when not on-site). Adding the fact that there is usually more than one medical professional present in the emergency room to cater for multiple, actual emergencies – the cost of a team working in the ER to allow my friend to be ‘seen quickly’ by a nurse would be in the ballpark of $620 dollars…most likely more. I’m conservative here, but remember that Nurse Practitioners, Nurse Managers and medical interns would also be in attendance and their wages are based on penalty rates during public holidays as well).
What is the alternative? His free, licensed-to-practice friend. Or the cheaper-for-the-taxpayer alternative of the After-Hours GP, which would have visited his home at any point in the day for a tidy out-of-pocket sum of $0. Why was an after-hours GP more appropriate than an ER? Because the foot pain was due to hardened skin caused by a lack of care.
A pumice stone, moisturizing, or a good soak with epsom salts would have done the trick.
However I am aware of the fact that the general public may not be aware of the purpose – or use – of an Emergency Room. So what’s it for, and when should you go?
In short, the Emergency room is to intervene in the event of a life-or-death situation, and for treatment by specialist clinicians for issues where time is of the essence.
What is the Emergency Room useful for?
- Treating Anaphylaxis (allergic reaction causing the airway to be blocked by swelling)
- Dislodging foreign objects from airways, ears and eyes without further injuring someone (bug in the ear, glitter in the cornea, inhaled popcorn – you get the idea)
- Intervening during a heart attack
- Resuscitation if a person has lost consciousness
- Setting broken bones
- Screening for harmful side-effects after receiving a concussion
- Treating acute dehydration (usually marked by delirium and inability to recall basic facts about themselves, sometimes a side effect of gastroenteritis)
- Reducing the effects of alcohol poisoning
- Treating large and/or deep burns
- Sewing up lacerations (also known as ‘stitches’)
- Replacing blood after a traumatic injury (sometimes in tandem with receiving stitches if the laceration was bad enough)
- Suddenly going into labour, particularly if the baby is pre-term or the pregnancy is unexpected (The ER will usually admit the patient before sending them to the specialist maternity ward)
- Treating drug overdosing
- Safely monitoring a person whose mental health has significantly deteriorated to the point of becoming a danger to themselves or others,
- Diagnosing and treating symptoms associated with serious illnesses, such as Meningitis, Measles, Tetanus, Rubella, Mumps, Gangrene, Sepsis, Deep-Vein Thrombosis, etc
- Relieving and treating an Asthma Attack
- Treating blood clots
- Fast-track to specialist services within the hospital for serious suspected illnesses, such as brain trauma, a malfunctioning organ, a burst appendix, heart arrhythmia, atrophying muscles or a potential cancer diagnosis (if presenting to the ED with acute symptoms of such issues)
- Health issues impacting small children that would otherwise be harmless in adults, such as an infant catching a Flu virus or a child who hasn’t eaten for days
- Injuries requiring the use of anesthetic and/or careful extraction so as to not further injure the patient, such as stepping on a nail, losing an appendage, an injury involving a foreign object close to a vital organ (stabbing injuries come to mind).
- Treating someone who is suspected to have inhaled water (didn’t drown, but was underwater for longer than they could hold their breath)
- Treating snake bites, spider bites and accidental poisonings
- Conducting scans after a road accident or an accident around the house (electrocution, falling off a ladder, being crushed by a bookcase, etc)
- Investigating serious pain with no clear explanations (particularly if the onset is sudden)
The above list is far from exhaustive, but are the most common presentations I’ve heard of from my clinically-competent friends and acquaintances. If time is of the essence, it’s a good idea to present to the ER – but if you’re certain it can wait 12 to 24 hours it doesn’t hurt to book a GP instead.
In some countries around the world, access to emergency healthcare is a costly and risky endeavor. However, in other countries a General Practitioner is not appropriate or available to patients and thus a different process of screening for health issue severity is needed.
Why is it so important to only present to the ER if you really need it?
In Australia, and many other countries, there is an issue of burnout in medical staff. Burnout is directly caused by overwork, negative working cultures, and a lack of a healthy work-life balance. Trouble is, it’s difficult to prevent overwork, a negative working culture, and an unhealthy work-life balance if the workload at the hospital is unreasonable for doctors to handle.
One of the reasons that doctors in hospitals are overworked is a lack of staff adequate to the needs of the patients, but also inappropriate patient referrals and presentations.
In a recent report by the Australian Government, non-urgent ER presentations was almost equal to actually ‘urgent’ presentations. For every patient arriving with serious medical issues, there was another wandering in with a sore finger*. Regardless of the severity of the issue, both patients need to be seen by a medical practitioner – creating roughly 50% more work than required.
This, essentially, is why we have GPs. To judge whether someone is seriously unwell enough to require a specialist or immediate intervention, and to treat the condition if able. GPs are not as routinely overworked as their hospital counterparts, often working fewer hours and seeing less patients per week. While the General Practice sector of healthcare has its own issues, the intensity of the work isn’t as heavily compounded as the experiences of those working in our emergency rooms. Part of the difference is the fact that GPs usually operate on a booking-basis, whereas any person who walks into an ER can expect to be seen. As fewer Australians express health literacy regarding how to prevent preventable illnesses, and when a visit to a doctor is appropriate, the strain on acute-care services such as hospitals grow at a rate proportional to the rate of declining primary care attendance. (primary care = seeing a local nurse or GP for low-intensity issues such as hayfever, medications for pain, low-level asthma treatment and general aches).
How Does This Happen?
Some of the lack of health literacy is due to poor Science Communication (referred to as SciComm on Twitter) provided for the general public. Another source of health-illiterate adults is a lack of knowledge of services available. While a reasonably educated person may be aware that hayfever isn’t a reason to present to the hospital, they might not be aware of the fact that a registered Pharmacologist (Pharmacy technician) can help, in addition to the fact that many pharmacies across Australia retain a Nurse Practitioner for issues that are serious enough to require a prescription, but aren’t common enough to warrant a doctor’s appointment.
So What Can We Do?
It seems that I have my work cut out for me – but the general population also has a responsibility to care for those who provide our essential services. Many firemen and rescue personnel receive a pat on the back for their work, yet the same people who move out of the way for an ambulance’s rush to the hospital will clog up the ER with inappropriate issues. Educating yourself on when an issue requires emergency intervention, and when a GP will suffice, is important for every adult who is capable of doing so. Identifying after-hours services and advice hotlines is also useful for those ‘I’m not sure’ and ‘better safe than sorry’ moments.
Personally it feels like I need to design pamphlets and info-graphics for the average Joe in my area. I would start first with this friend of mine, but as of today my patience has worn thin enough to start a fight rather than a respectful conversation about the use of emergency services. As for now, I’ve expressed my displeasure and will work on my own SciComm in the morning.
To all emergency services personnel working while I sleep – God Bless, and may you have a quiet night.