Surviving the Emergency Room, Part 3: The Inner Sanctum

In Part 1 and Part 2 of our “Survival Guide to the Emergency Room,” you were registered, triaged, assigned a severity code, and had a chance to enjoy the amenities offered in the waiting room. And then your name is called. It’s time—you’re going in! You’re about to find out what goes on in the ER, behind those locked double doors with the frosted glass windows. Now we’re talking.

the inner sanctum

The inner sanctum. c Some rights reserved. Flickr user: Stuckincustoms

Congratulations, you’ve made it to the inner sanctum. You have been walked or wheeled into the actual ER and have been assigned a bed. Depending on the department, this could be a private room, a semi-private room, or a gurney separated from other gurneys by a privacy curtain. You are asked to undress and put on a patient gown, open in the back, please. You ask “Why?” since it is your ankle that’s bothering you. You may or may not get an answer but the reason is this: there are many ways to injure an ankle, and several of them carry the risk of injuring the knee or some other body part distant from the point of maximum discomfort. Simply pulling up your pant leg does not provide adequate exposure. Things could be missed. Liability (about which we will speak at length in a later installment) could be incurred. So take off your damned clothes. We’ve seen it before and unless you are in some way physically astonishing we are not that interested.

Your nurse will do an assessment. She will ask you all the questions you were asked in triage. She already has most of that information but she wants to hear it for herself. She will then say, “The doctor will be right with you.” Maybe or maybe not. It depends on what the doctor is doing at the moment. If he (another sexist convenience, sorry) is in the middle of suturing a complex laceration on the chin of a terrified four-year-old it might be a while. There are a number of things that could be monopolizing the doctor’s time, and the level of chaos in the department should give you some idea of whether or not you might be waiting a while to see him.

So you lie there, on the gurney, partially obscured by the privacy curtain that offers no such thing, watching and listening to the commotion swirling around you. Patients walking by, gowns open in the back, plus or minus underwear. Someone moaning, someone else shouting for the nurse, a child wailing, phones ringing, cardiac monitors beeping, your anxiety level rising as the minutes pass.

Finally, the doctor arrives. Introductions are made and you are asked the same questions you’ve already been asked in triage and by your nurse. Don’t get frustrated. Answer the questions as clearly and succinctly as possible. It is an axiom of emergency medicine that no patient will tell the triage nurse, the treating nurse, and the doctor the same things. It is the sum of what’s revealed to each that gives the best picture of what’s going on.

In the case of your ankle it is fairly straightforward. You tripped, or you were involved in some sporting event, whatever, and you twisted it. If, however, your complaint is abdominal pain, things become exponentially more complicated. If you happen to be a woman with abdominal pain, double that. Listen carefully to the questions asked and be as specific as possible. “A while ago,” is not the appropriate response to “When did the pain start?” “Everywhere” is not a helpful reply to “Where does it hurt most?” unless it really does hurt the most everywhere.

If you are taking medications you should know what they are and how much you’re taking. Keep a list handy. “You have my records” or “my doctor knows” or “ask my husband/wife/son/daughter” is no substitute for the actual list. We might not have your records or be able to access them, your doctor could be in Hawaii or on the golf course (which is why you’re in the ER to begin with), and your relatives likely have no idea what medicines you take.

You will be examined. The extent to which you will be physically violated depends on your complaint. For the ankle, an evaluation of the lower leg may be all that’s indicated. For the abdominal pain, don’t be surprised if a rectal and pelvic exam are involved.

Once that humiliation is complete tests will be ordered. If it’s the ankle, and you were in the waiting room for a while, the x-rays might already have been done. Lucky for you. You are almost finished. The films will be read, a diagnosis made, some sort of stabilizing device will be applied, perhaps you will be given crutches, and you’re good to go. If it hasn’t been done you will be sent to radiology and then all of the above will ensue.

If your problem is abdominal pain, or some other unobvious, non-orthopedic complaint, more testing will be needed. Blood tests, urine tests, ultrasound exams, CT scans—they are all a possibility. You will be in the ER for at least an hour and a half, and most likely longer, while we sort your problem out. Meanwhile, you will continue to lie on the gurney free to enjoy the show.

If you are in significant pain feel free to ask for pain medicine. Failure to address a patient’s pain is frowned upon by the Feds, so we are usually happy to oblige. Try not to sound like a junky, though. Things like “I’m allergic to everything but Dilaudid,” “I need x number of milligrams or it won’t work,” and “I have a high tolerance for narcotics” tend to raise our suspicions that your visit to the ER is more about acquiring drugs than it is about receiving medical care. Some of us even have access to your prescribing records, kept on file by the State. If we look you up and see you’ve been prescribed two hundred Vicodin in the past month by a variety of doctors we are unlikely to give you more.

Next Time

Next time, everyone’s favorite subject: the bills, and dealing with insurance.

Dr. Jim Pagano, MD, FACEP, is the chief medical officer of Precision Scribes and has over thirty years of emergency medicine experience. He’s seen everything an emergency physician can see, and more than a few things they should not.