The previous five parts of our Surviving the Emergency Room series have brought us to this: basic etiquette and standards of behavior. Or, put another way, The 7 Things That Drive ER Doctors Crazy.
1. Abusing the System
First, don’t abuse the system. While it’s true that patients brought to the ER by paramedics get seen faster than those coming through the front door, especially when the department is busy, it’s because they are usually sicker. Please don’t dial 911 because you want to avoid the wait, don’t have a ride, or don’t want to pay for a cab. Save it for the day you have crushing chest pain, can’t move your right leg, or can’t stop vomiting. The day you wrap your car around a telephone pole while talking on the phone, someone will do the calling for you.
If you come by ambulance and we suspect you’ve done so for convenience only we will not be amused. If the ER is busy you will be rolled through the back door, through the ER, and out to the waiting room. You will be triaged and placed in the queue. Probably not near the front. Then, a couple of weeks later, you will get a bill from the County for something in the vicinity of twelve hundred dollars—the price of the ambulance ride. It is unlikely your insurance will cover it.
2. Cell Phones
Cell phones are ubiquitous but you are in the ER because you have an emergency medical problem, or a not-so-much-of-an-emergency that you want dealt with quickly. When the doctor gets to your bedside, get off the phone. Immediately. We don’t care whom you are speaking with or who initiated the call. Hang up. Thank you.
The ER isn’t the space shuttle or a commercial airliner poised for takeoff. Using your cell phone to make calls or play games is not going to cause the cardiac monitors to malfunction or the department to burst into flames. Still, making us wait for you to finish your telephone business before allowing an interview is considered to be a sign of disrespect and dubious breeding.
It is perfectly fine to use the phone in whatever way you wish when we are not there with you. It’s a good way to pass the time waiting for your various test results. The only function you are to avoid is the camera. No pictures. Of yourself and certainly not of anyone else in the department. There are laws about this. If somehow you haven’t gotten the message yet, patient privacy is a big deal with the Feds. Sharing someone’s medical information inappropriately could land you in prison. Taking a photo of the guy in the next gurney being treated for an overdose and sending it to everyone in your address book is never a good idea. It doesn’t matter how hilarious it seems to you at that moment. Don’t do it.
4. Eating Food at Inappropriate Times
Eating is a popular diversion for patients and family members spending time in the ER. I’m not sure why, given the unappetizing nature of the environment, but it is. In general, patients should not eat or drink anything without first asking the doctor if it is OK to do so. Your condition could be made worse, eating could interfere with tests we need to perform, and, if you need surgery, it will be delayed for as much as eight hours if you have recently stuffed yourself.
If you must eat there are a few options available. If you are the patient, and if for whatever reason you will be staying in the ER for an extended period, the nurse can order a meal for you from the hospital cafeteria. It will not be either the worst or best thing you’ve ever eaten but it won’t kill you and it will comply with whatever dietary restrictions the doctor has imposed upon you.
Friends and family members can get food from the cafeteria if the cafeteria happens to be open at that moment. The nurse will not provide specially prepared-to-order meals for members of your entourage. If the cafeteria is closed, there will be vending machines available to them. There is also the fast-food take out option. No one is going to stop them from bringing food into the department. But is it really necessary? If you are only going to be there for an hour or so wouldn’t it be better for them to wait until you are discharged to have that Happy Meal?
And we understand that feeding your child helps keep him calm while waiting to see the doctor, but trying to examine the throat of a child with a mouthful of crackers is unnecessarily difficult. Same thing for candy that changes the color of his mouth. What is the significance of a red throat in a child who has spent the last hour sucking on a lollypop?
5. Foul Language and Threats
There is also some language to avoid. We will take care of you regardless of whether or not we like you, but isn’t it better to be liked? If you think so then it’s best to refrain from swearing at us, calling us vulgar names, and threatening us. Threats can be verbal or physical. Neither is appreciated. Depending on the nature of the threat we will ignore you, call security, or call the police. We have a special relationship with local law enforcement. We do the alcohol screening tests for suspected drunk drivers in custody, we do the “OK to Book” evaluations for prisoners on their way to jail, and, most importantly, we are there 24/7 should an officer get injured on the job. They get a little special consideration from us. We try not to waste their time. If you pose a real physical threat to us we will call them and they will be in the ER with guns drawn within minutes. Your day will have gone from bad to much, much worse.
You should also avoid telling us about your lawyer. We don’t like your lawyer. We don’t like lawyers much in general. We in the ER are particularly vulnerable to medico-legal actions, popularly known as medical malpractice lawsuits. It is not because we make a lot of mistakes. Despite the complexity of our job and the environment in which we do it we make surprisingly few mistakes.
But, malpractice cases are not usually about mistakes. They are about outcomes. A patient who does something stupid or irresponsible, or who has something bad happen for no good reason, and has a poor outcome, is going to be angry. He might be angry with himself for doing the dumb or irresponsible thing, but he understands that being angry with us is likely to be more productive. He will find a lawyer who will convince him that it would be wise to sue.
You don’t know us, (it’s not like we’re your family doctor with whom you have a twenty-year relationship), you assume we work for the hospital, (we don’t, we work for ourselves), and that the hospital will pay for our defense and whatever judgment is ordered, (it won’t, we have our own, very expensive, malpractice insurance), and it’s no big deal. It is. Even if we prevail, which we usually do.
Our insurance company doesn’t really care if we win or lose. They only care about how much the process is going to cost them. If they can settle for ten grand or go to trial for a not-guilty verdict that will cost them a hundred grand, they will opt for the settlement every time.
We want to be not guilty. We want to fight back. The insurance company has to do what we want, though they will make every effort to get us to see things the right way, meaning their way. So we go to trial. We endure the demeaning depositions, the attacks on our character and ability, the insinuations that we are somehow monsters. It goes on for a year or so. Then, finally, we are vindicated. A jury finds us not guilty. We win!
Six months later, when it’s time to renew our malpractice policy, we are informed that the premium has been adjusted upward by twenty percent due to our “loss record.” What “loss record?” We won. Didn’t we? Well, technically, yes, but our victory was Pyrrhic. It cost the insurance company a small fortune it now needs to recoup. So don’t tell us about your lawyer. In fact, if you happen to be a lawyer you might want to keep it to yourself.
Trust me, this deserves to be listed twice.
In the end, the best behavior in an emergency room is the same as the best behavior anywhere: be respectful, considerate, and if you can, nice. We’ll do our best to return the favor.
Next time, disposition, discharge, the aftermath, and wrapping things up.
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.