Who goes to the ER?

I see many patients with myriad complaints who come in and out of the ER. I know I'm only a second-year resident, but I think all patients who come to the ER can be grouped into five major categories:

1) Those that are sick.

2) Those that are not sick.

3) Those that are sick but appear/pretend not to be sick.

4) Those that are not sick but appear/pretend to be sick.

5) Those that are dead.

Keep in mind that I work in a famous Manhattan county hospital. People from all walks of life come in throught the gateway that is the ER: foreign dignitaries, tourists, bums, drunks, everything. Since it is a public county hospital, we also provide medical clearance and care to NYPD prisoners, a source of many stories. It's overcrowded, understaffed, and understocked with necessary medications. People wander in off the street, are picked up by 911, are brought in by the police yelling and screaming, and some are even hurled at the front entrance in a drive-by dumping by drugged-out "friends" who don't want to get caught. So my classification system is, I think, pretty okay considering I have an N of over 1000 in this study so far.

The aforementioned categories:

1) Those that are sick

These people still scare me. They arrive with the grim reaper as their escort; they're minutes or hours away from death. They're infected, bleeding out, end-stage cancer, or maybe running in the front entrance holding their severed hand.

Being as this is a famous hospital (they're actually filming a movie in it right now, starring Jessica Alba), people from all over the world will seek care here. Case in point of a very sick man: he arrived from a remote region of Pakistan to JFK airport, then took a cab straight to the hospital. He spoke no English. He carried with him only one piece of paper that someone else had written in broken English: "My father with cancer. Please to help in New York America." That's it.

"Well," I thought, "at least we have a diagnosis." I have no idea who wrote the note (I guess his son did), what kind of cancer he had, or was it even cancer?, how far along was he in his illness? What I did know was that his heart rate was very fast, his temperature was high, and his blood pressure was low. At that point, few words need to be exchanged, so it was no big deal that we couldn't speak to each other. I hooked him up to a monitor, drew some blood, ran some tests, got an EKG, ordered a CT scan for him, did a lumbar puncture, started broad-spectrum antibiotics (in short, he got the ER special; one of many ER rules: "If you don't know what you're dealing with, do everything.")

Here's the part that mattered: white blood cell count of 88,000 (typical is 8-12K), hematocrit of 12 (normal in an adult male is about 45), 21,000 platelets (normal is between 150K to 450K). Of those white cellls, a large percentage of them morphologically were myeloblasts -- this man had acute myelogenous leukemia.


2) Those that are not sick

Many, MANY people come to the ER because they have no primary care doctor. They also don't have insurance. So they might say, "hmmmm....that back pain I've had for the last five years? I'm in the neighborhood, I might as well get it checked out now." So they pop into the ER like they were buying a soda, except they have no intention of paying for anything. These are the same patients that will thusly wait for hours (since the sicker ones need to be seen first) and then loudly complain about their wait time. This category includes those with nausea, those with one episode of diarrhea, drug-seekers, fakers, those who need attention, those with a seasonal cold. Before I got into medicine, I probably fit into one or more of those categories anyway, so I'm never really mad at these patients; they usually just need a little attention and assuaging and telling them they'll be fine.


3) Those that are sick but appear/pretend not to be

Probably the smallest of the categories, these people have a regular doctor, don't like going to the ER (too noisy, wait too long, they get discombobulated) and have no interest in seeing a physician. They're usually there at the insistence of their families. To wit:

"Doc," one concerned daughter of a patient said to me. "My father said he was having severe chest pain after he climbed upstairs to our apartment."

"How long ago was this?" I asked.

"Two days. He didn't want to come here, I had to drag him here."

I re-directed. "Sir," I said, "how are you feeling right now? Are you having any chest pain?" His arms were folded tightly and he had little beads of sweat on his forehead.

"NO," he grunted. "I'd really just like to go home and get some rest."

These are the patients you really need to keep a keen eye on -- don't rely only on what they say. Look at how they act, listen to their families, ask very probing questions, run more tests than you think is necessary, and even pay attention to their ethnic background. Not to racially profile, but I will (in a good way): certain cultures and ethnic groups tend to be very stoic and see illness as weakness; thus, they deny they are sick.

In this instance, after speaking more with the daughter, the nurse handed me his EKG. How about that -- an acute heart attack in evolution. Call the catheterization lab stat!


4) Those that are not sick but appear/pretend to be sick.

By far and away this is the largest proportion of patients in the ER. These are the ones you want to strangle -- they whine and moan (but only when you're watching) in inverse proportion to their underlying pathology; they demand things, they threaten you legally, they need -- no, desperately crave -- attention, they pull your mental and physical resources away from other patients who need your care. I believe their thinking is that if they act very dramatic, you'll take them more seriously. These patients also tend to feel very entitled; they act as VIPs or visiting royalty who need incessant one-on-one care. Their most-asked question is, however, "when are you bringing me food?"

One very busy day, I picked up the next chart in the rack. Low back pain. I sighed.

Look, I know lower back pain hurts, I've had it before, it SUCKS, it takes a long time to go away, regular strength over-the-counter drugs barely help, and you hobble around. But unless the proximate cause was a true traumatic event and you're having worsening neurological function due to, say, a fractured vertebrae with sequelae like fecal incontinence, then it's not a TRUE emergency in the strictest interpretation of the word. Yes, they need to be seen by a doctor, they need prescription-strength analgesia, and they need reassurance and instruction in proper exercise and lifting.

"I might as well make this quick," I thought. Yeah, right.

I pulled back the curtain and saw the same middle-age obese woman I had just seen in the cafeteria walking around, buying a doughnut. Make that three doughnuts. Somehow, I knew it was going to be her that I would be treating. I hadn't heard a peep coming from that curtain until I opened it. Then it was caterwauling.

"DOCTOR," she cried, "it's my back, it REALLY hurts, I can't walk or do nothing at all!"

I always try the calm, sympathetic approach first. "Hi ma'am, I understand you're feeling a lot of back pain.

"Ju don't even know, o-KAY?" Her hand is up in Jerry-Springer-like fashion with one finger pointing up, neck cocked.

Uh-uh bitch! I'm trying to help!

"How did it happen, ma'am?"

"I was lifting a box, and -- " ring ring, her cell phone is crying for attention. (Actually it was a Beyoncee ringtone: "Baby boy, make me lose my breaf.")

"Ma'am, please don't answer that right now, and besides, you can't have it on in here, it can interfere with the equip--"

"Hey gurl, nah, I'm at the doctor now, they said I might have to be admitted for pain control. I think I might have a spine tumor or something. Call you later!"

Who said anything about admitting?

"Anyways," she continued, "I lifted a box and it was heavy and then I was having pain. But I've been having this back pain for years now. I can't even walk or anything."

"Actually I saw you walk into the ER and to your bed."

Whoops! Wrong thing to say. But it was a reflex reaction on my part! Even as that sentence was escaping my lips, I still couldn't -- wouldn't -- take it back. It's provocation just hung in the air.

"What??" she yelled, "Ju don't believe me??? Are ju calling me a liar?"

"No ma'am." Play defense just a bit. "I just meant to say that if it's a longstanding thing and it's not crippling, we can get you some great pain control and put you on bedrest for a little while."

"I dunno doc," she starts. "I think I need to be admitted, or least get an MRI right now."

"You can't get an MRI from the ER in this hospital."

"Well you can for me. I'm having BACK PAIN."

Healthcare in this country is going bankrupt, but we'd head there exponentially time-wise if we got an MRI for everyone who came to the ER with low-grade back pain.

"No we cannot. And I don't think you need it, you're not having symptoms consistent with spinal cord injury."

"Like what?" she was fishing for something she could use. I wasn't about to give it to her.

"Anal incontinence. I'll have to do a complete rectal exam on you to determine your rectal tone." Ace in the hole (so to speak), heh heh.

"No, I can shit just fine." (I didn't doubt it, she seemed to be full of it.) "You need to admit me to the hospital then."

I was certain her tenement apartment was getting fumigated and she needed a place to stay. "No ma'am, you also do not need to be admitted. Now what you DO need is a prescription for --"

"You'll just have to speak to my lawyer then."

I hear that a lot. The personal injury lawyers have a stranglehold on many people's minds and make them believe it's a type of lottery. You sue, they settle, you get money, there's no messy trial. But believe it or not, most of the cases that actually go to trial are won by the defendant/hospital. To my knowledge, in this particular instance, I had done everything according to the standard of care, and she refused a rectal exam anyway. And for every 100 people who say they have a lawyer, maybe only one of them actually does. So I called her bluff.

"Put him on the phone." Our eyes locked, my pupils became pinpoint, and she attempted a face-saving maneuver.

"I don't have his number with me. But give me my pain prescription so I can leave."

Do you see what kind of mental and time resources a patient like that drains out of the ER? I'm really a nice guy, but I can be a bitch on command, and it never makes me feel good or better to do that. But I also believe in treating others how you wish to be treated. And I also believe that even if you are ill (really ill), it does not give you license to be rude to anyone, especially your treating physician. I understand when patients are short-tempered or loud because they are in pain, and it's my job to alleviate that discomfort. But there is a difference in being rude and being appropriately demanding of a certain level of warranted care. Not everyone in category 4 is as egregious as this woman, but it certainly highlights the type.


Finally, there is category 5: those that are dead.

Believe it or not, there is a fair number of people who are dead on arrival to the ER. Whether they are brought in by ambulance or family, a certain percentage are unsalvageable: massive heart attack with no pulse in the last hour; someone whose brains were squished into a colloidal mess by a subway train; someone who jumped 10 stories; and even those who died peacefully in their sleep after a brave struggle with a long, protracted illness.

The next time you're headed to the ER, think about which category you fit into.