Questions in the ER

The ER is, not surprisingly, a hectic place. When I'm evaluating a patient, it's often hard to have a conversation what with all the traffic and talking and monitors beeping, pagers going off, and phones ringing. It's also an undignified place-most people lying on the gurneys didn't plan to be there, so they didn't have the luxury of wearing something comfortable, bringing things they would need for the 8 or 9 hours they might be waiting, or calling someone who loves them to keep them company.

Most people who visit the ER are on the patient end of things. Here's how it is from the other side: our team, on call for the day, gets paged that we have a new admit. Most of the time, we're either sitting around in the team room waiting for this call, or we're in the middle of taking care of the last call. When we're free, we look the patient up in the computer to see if he/she's ever been to this hospital before. We build up our clinical suspicion based on previous record: if she was in for liver disease last time, we're going to bring drugs and alcohol up. If she's an asthmatic, we're going to ask about compliance with controller meds. If we have no prior history to go on, we look at the ER questionnaire to form a picture in our heads.

Once we've gleaned all we can, we go down to visit our new charge. We pepper them with rapid fire questions. Are you experiencing any chest pain, sir? Palpitations? Shortness of breath? How about nausea, vomiting, diarrhea, or constipation? Does it hurt when you pee? And how about when you poop? What did your mom die of? Your dad? Cancer in the family? Oh, I'm sorry. What kind? Where do you live? Where do you work? In the event that you were incapacitated and could not make decisions for yourself, who would you like to make medical decisions for you? Would you like to have chest compressions or a tube put down your throat to help you breathe if you suddenly stopped doing so on your own?

All this, and we met five minutes ago.

Then we move on to the physical exam: Can I unbutton your shirt? Roll up your pants? Take off your shoes and socks? Does this hurt? Can you feel that?

It is a whirlwind 20 minute conversation, after which we leave the patient as promptly as we arrived, go back to our computers to write the official admission note and put in our orders, and wait for the patient to get a bed on the floor. In the meantime, we think of questions we forgot to ask that will help us figure things out.

What all too often forgets to be asked:

How are you holding up? Do you understand the plan? What questions can I answer for you? Not do you have any questions, but what questions do you have. Did anyone tell you the results of your blood test/X-ray/MRI? You'd be surprised. And what do those results mean to you? From a 5-year-old kid in need of a tonsillectomy: you're going to cut my head off and take out my tonsils and then sew it back on. From a patient with pneumonia found to have a pleural effusion, or fluid in the lungs, on chest X-ray: this happened because i drank too much water.

At the end of the day, sure, it could be more elegant. But nothing about this process is elegant. When you are sick enough to show up to the ER, you are stripped to your very core. When you are on call for 18-30 hours, sometimes into the wee hours of the night, you are also stripped to your core. And for the most part, decorum aside, patients are simply glad to answer any question they think will help you solve what's happening to them.

We just need to remember to return the favor.