An ER over capacity, but still usually bored?

After tonight, I will be half way done with my Emergency Department rotation.  So far it has been a lot less exciting than I thought it would be.  That's not to say they haven't been busy, it just hasn't been with people who have any pharmacy-related needs.  I'll explain more in a bit, but here's a little bit about what I have done so far.  The only thing the ED pharmacist really does every day is following up on lab results for people who came and left, but results took a day or two to complete.  We'll evaluate the appropriateness of what drugs they did receive and, if necessary, consult one of the doctors for a decision that either they are okay untreated or they need a prescription.  We then have to call the patient and discuss the results, and sometimes call prescriptions in to their pharmacy.  Other than that, the day is spent answering the many (usually simple) questions that come up from nurses or doctors and participating in some of the more complicated procedures.  So if it's a slow day, there's not much to do.  But if there are a lot of sick patients, it can be a lot more interesting and fast-paced (which has been 2 of the 9 days so far).  

New things I've seen or helped with on this rotation (and they're fewer and farther between than for most students, since I had such a fantastic rotation last month) are chest tube placement with conscious sedation, an ankle reduction (using multiple people's brute force to pull a broken ankle into a splint-able position), and a little more experience with sedation/paralysis for intubation and post-cardiac-arrest management.  Also, since it has been slow most of the time, I have gotten to sit in on a few basic things not directly related to pharmacy but good general knowledge items if I am to work in that environment someday.  I helped transport a couple patients to CT and watched the scan, watched a couple central line placements, watched a PA drain an abscess, and observed the triage process for a couple hours.  Overall, though, it has been a pretty slow 2 weeks in terms of the percentage of my total time spent being something interesting.  Besides all that, I have gotten pretty good at interpreting and treating urine cultures, STD results, and common women's health complaints because of the daily labs I review (sometimes up to 50 or so).  I've also gotten to dose a few things, mix some IV drips, administer some medications, and set up infusions with smart pumps.  Not too glamorous or complicated, but I'm glad I'm getting the repetition and experience so I can confidently do those things when I'm out on my own, wherever that ends up being.

The biggest reason that my opportunity for experience has been slow in light of a sometimes overcrowded ED is because most of the people that come in don’t have any sort of emergency at all.  I knew that this was the case, but I had no idea how huge the difference was between the number of people that belong there and the number of people who could be more appropriately served at another, less emergent facility.  I realize that my personal threshold for thinking about seeking emergency care is higher than the average American, since I was raised in a healthcare-heavy family and also know a fair bit about first aid and diagnosis of simple conditions from scouts and school. But I still can't see how some people view certain things as grounds for going to the ED. 

A lot of people come in for something that has been bothering them for a week, two weeks, sometimes even a few months.  If it's been an issue for so long, why is it all of a sudden an emergency that needs to be evaluated right away?  Another common issue is people coming in if they need a test or imaging but their doctor can't schedule them for a week or two.  Sure, you may not want to wait 2 weeks for an STD test or an ultrasound to confirm a viable pregnancy, but those things are not emergent.  If your doctor isn't helpful, there are a number of walk-in clinics that do those things regularly.  There are also a lot of people that come in who don't need anything that couldn't be picked up at their local pharmacy.  And there are also a lot of people who were advised to do something (medications, follow-up, etc.) and didn't, so they just come back to the ED.

"My knee has been hurting for 6 months and I just played basketball and it hurts more."  Hmm… I wonder if you should have seen a doctor 4-5 months ago?

"I 'went out' with a woman and later she called me and said I should 'get myself checked out.'"  Ok, so go to a clinic, STD center, or even urgent care.  It's not an emergency room issue.

"I've been constipated for 2 days." 

Go to the store and get some Miralax.  If it's been a week and you're in pain, sure, come in, but 2 days is not a big deal. 

"I was just moving a bunch of furniture and my side hurts now." 

Ya think you could have pulled a muscle?  Heard of ice or heat packs? Tylenol? Ibuprofen?   

"I was here yesterday and diagnosed with the flu and I'm not better."  You were told to rest, take Tylenol for your fever, and drink plenty of fluids.  Do you really expect that just because you were in the ED yesterday, your flu will just *poof* go away overnight?

"I came in last month for this condition and was told to follow up with my doctor but I didn't and now it's worse."  Why should we treat you again if you're just going to ignore us anyway? It's your own fault for not following up!

Those are all real patient complaints I've heard over the last couple weeks.  Of course, you can't say those things to people.  Doctors will, and sometimes do, explain to patients that they really don't need to come to the ED for these non-emergent concerns and social workers will follow up with the frequent repeat customers discussing the concept of "primary care physicians," partially because Medicare and Medicaid are not paying for ED visits in certain cases (such as a man who came in 12 times in 15 months for the same non-emergent complaint).  It's hard to say what the reason is for people not making better decisions about the acuity of care they require (I think I'll write more about that in a separate post), but the outcome is often that people who really do need emergency care are left in the waiting room or in ambulances diverted to other hospitals because all the beds and nursing assignments are occupied by people who really shouldn't be in that setting.  There are urgent care clinics they can go to, and primary care doctors associated with public health or Medicaid for those who may not be able to afford private insurance.  It may be an insurance coverage issue, but also may be a lack of health knowledge in the population that creates this issue.

It's easy to get sarcastic and complain about the scads of people who don't have any business coming to the Emergency Department, but I don't want to gloss over the people that really do need that level of care and I'm glad there are so many great health care systems in the area that can provide that care.  Though my days are boring a lot of the time, when they are busier it is because there are patients that do have conditions that are either life-threatening or need care more urgently than making a doctor's appointment could guarantee.  At those times, I learn a lot and it is rewarding to see the pharmacists' and my knowledge put to use.  So I'll keep trudging through the boring parts and hope that the next interesting things comes up again soon, not wishing for people to be really sick, of course, but so I can learn more and get more exposure and comfort with the things pharmacists are asked about and the things we have to do.