ED MANAGMENT All patients have a door-to-provider time…

When you see the image above perhaps you think of an angle of mercy…and if you do you are on the right track!  For we are all servants (Angels of Mercy) to our patients!  So to them we are like angels and often they are hoping for a miracle since we are held to a higher standard by God and they (and their families) know this or simply feel it to be true.  You must never forget this and that you have two key functions above all the rest:

THE FISRT DICTUM: THAT YOU ARE TO DO NO HARM TO ANY PATIENT

THE SECOND: ALWAYS RELIEVE SUFFERING.

All emergency patients have a door-to-provider time…and it tells if you care or not.  It tells the patients and their beloved families whether you are a servant of God (an Angel) or just another “ER DOC” whose name they will likely forget if you provide care that causes them to improve or one whose name they despise for a variety of factors-notably your bedside manner and early or late attentiveness to their true medical/surgical condition.  They are patient and ABEM scores you on bedside manner when you sit for your oral examinaiion-your inal test to achieve board certification.

Whether you or anyone else who works at your hospital realizes these to key points they remain for thousands of years the two most important functions of a healthcare provider (I mean physicians not nurses nor any other “person or persons.” in medicine.

Initially these concepts were limited to the leaders of medicine–i.e., only to the most educated and capable….physicians.  Sadly, physicians have given up their leadership of medicine, something they need to get back through hard work to prove they are the most skilled and most knowledgable about how to accomplish these two seemingly obvious tasks which are also OUR MOST IMPORTANT GOALS for all patients!

Yet these tasks are different for each patient and they vary based on a multitude of factors.  How to relieve suffering (prinicipally pain) is not always an easy path for each physician and their patient.  Some conditions are so advanced and some patient’s so “immune” to their pain medication from physiological tolerance as seen with cancer and chronic severe pain which causes both physiological effects and chemical effects in the brain that we must communicate out limitations to the patient after we have done our best to relief the pain.  Not before.  The medications themselves alter brain chemistry (,and when chronic, these changes are permanent), so that we are not in the ‘drivers seat’ as much as we were decades ago in how we were able to control pain).

Some basics are to always talk to the patient, as and soon as possible after they arrive in the ED.  Sit down whenever possible and make both physical and eye contact.  Patients do have a vision in their mind of how a physician or nurse behaves so they look to see what are often idealized images of such behaviors from whatever they were exposed to through movies, television, and their own personal experiences that gave them an idealized vision of a physician.  They need to know that we care.  They need to know we are going to say that we will do everything we can to help diminish there pain.

They know we have questions.

The patient cannot perform their own problem solving nor their mgmt or they would not need an ED.

In some patients our goal is to totally abolish all pain as with acute myocardial infarction.  I always tell the nurse as long and the vital signs are hemodynamics normal we will continue to aggressively treat all chest pain believed of cardiac origin until it is a zero and to continue to treat it if it returns while we are waiting on a rapid disposition to the cath lab.   We would like to do this for all cases but this is a case where it is done because it is better healthcare (it does, help the heart).  Patients do not know what is the true definition of better healthcare.  It is often difficult to get them to admit they have any residual pain when we even make it clear they need to tell us if their pain persists after a specific time limit.

I CAN ASSURE YOU THERE IS SIMPLE, ABEM TESTS FOR TIME ISSUES…WHEN THEY SAY, “A NURSE IS CALLING YOU INTO A PATIENT’S ROOM, THEY WANT TO SEE YOUR BEHAVIOR AS YOU EXPRESS IT VERBALLY, (“OK I IMMEDIATELY WALK INTO THE ROOM OF THAT NURSE AND WHAT DO I NOTICE ABOUT THIS PATIENT?”)…THAT IS SCORED UNDERE BOTH PATIENT  MANAGEMENT. PROBLEM SOLVING, and the HEALTH E OUTCOME SCORES (at minimum* see my discussion on how the American Board of Emergency Medicine Scores you on oral test simulations-the final board certification sep in their process).

GETTING INTO THE ROOM QUICKLY CAN SAVE A LIFE.  THAT IS A PRIMARY OBJECTIVE (IT MEANS THE SAME THING AS DO NO HARM).  IN LATIN: “PRIMUM NON NOCERE (FIRST CAUSE NO PAIN IS ALSO AN IMPLICATION TO FIRST DUE NO HARM; THE WORLD NOCERE IS THE DERIVATIVE WORD FROM WHICH WE ALSO GET THE WORD NOXIOUS-IS A WORD THAT MEANS IRRITATING OR PAINFUL).  I THINK YOU GET THE IDEA.

So, yes, patients have expectations.  BUT IT IS NOT HOW THE BUSINESS WORLD ATTEMPTS TO DEFINE IT.  When you listen to the business world of medicine and how it defines these words “patient expectations” which is another subject, but one that has much to do with this discussion because the business of medicine is only about the bill. THIS IS THE COST OF THE BUSINESS OF MEDICINE AND SOME USE THIS TO distort our behaviors and even controls them which may minimize cost at risk to the patient(s).  The business of medicine has nothing to do with patient care.

Patients are not customers.  A customer is someone who goes to a place of business to make a purchase.  Patients are not in hospitals for that purpose.  It is a twisted minds of “‘business people” who have no role in the clinical directives of medicine.  Yet they currently tell you how to practice medicine in as much of your clinical practice that they can burrow into.  That causes you to act in a way that will do nothing but eventually bring harm (morbidity) and even mortality to real patients.  The ones you complain sue you.  They would not be suing you if you just listened to me.  To an educator of medicine;  stop being foolish and listening to anyone about clinical care unless they have years of experience, have published and written about their medical field of expertise, and they must never include the cost of patient care into their “care” of emergency patients or you are listening to someone in disguise.  Someone who says they are a medical doctor but is really a business person.

Ask them if you are using a current EHR or one that may take 18 clicks just to see the the patient’s chief complaint.  Such programs still exist and so many are so confusing and time-consuming throughout their entire use, that they cause tremendous delays in patient care.  Why?  They are not designed to follow the two key tenets of medicine.   They are designed for billing purposes.

Physicians are so poorly trained in medicine throughout their education they they will often go to the EHR/EMR before they go directly to the patient.  THIS IS AN ABSOLUTE ERROR 100% OF THE TIME.  They will mark the time as seen much earlier for fear of being punished but they are stuck on a computer much too long and it can fail–It can freeze.  It may need to be rebooted even.  It can do anything that can impede the one thing the patient is “screaming” for.  Pain relief and or the relief of some form of suffering (condition), causing their pain.  An EHR is not designed for the proper management of that.  It has damaged a who generation of physicians and continues to make the problem worse.

So in the first moments of arrival a physician has failed the patient often because they did not simply just go in the room and see the patient.  A physician should be trained in every speciality that they do not need anything but their mind and their stethoscope, to enter any room to see any patient.  They don’t need the patient’s record!  Physicians need to learn that computers are not here to help you better manage your two most sacred oaths.  You must do this on your own.

Go in the room.  Introduce yourself.  With a few concise moments of observation and listening first, you should know they type of pain, it’s severity, time of onset, (its pattern..which can help tell you the etiology), and the patient’s statement of what they believe is causing their pain.

A single dose of a narcotic wil never cause narcotic addiction and likewise narcotic DO NOT relive specific kinds of pain.  One of the most classic pairs is pain of origin somewhere in the OB-GYN system, and genitourinary pain such as ureteral pain due to stone disease.  These two forms of pain respond much better to an NSAID, most specifically ketorolac administered parenterally.  This pain is not relieved by opiates because it is caused by smooth muscle spasm/contractions either due to obstruction or inflammation (infection).

It is not always how quickly you see the patient because I see physicians manipulate this “door to time patient seen” value often manipulated.  Physicians do this out of fear of their employers and thus they become liars.  They will say they “saw the patient” and thus met some stupid criterion that might be expected to lessen the time of how long the patient remained in the ED suffering in severe, unrelenting pain, but this is just a number for the “bean counters” in administration.  So what are they doing?  Some modified approach to the basic care they are NOT DOING.  These are the doctors who are trying to function like they can somehow defeat a system of abuse so if they perceive any ED abuse they will first see the old record and not see the patient.  This is very, very risky because the cause of the patients pain could even be rapidly lethal and they will not manage the problem causing the pain and this can lead even to the death of the patient.  So such things should not bemused as your guide to your approach to any patient.  You approach should be the same and it gets at the core of your function.  To get at the true cause TODAY of the patient’s suffering, and to get at the true cause TODAY of the potential harm(s) you may cause by not addressing the primary problem that is presenting as pain or some other primary symptom.  I use pain as the primary chief complaint because it is so common and physicians allow themselves to become biased.

If you ever learned a third critical dictum in medicine is that you should enter the room as a professional with no bias of any kind lest you will cause the patient harm by making assumptions that are absolutely false.

Since I have had the experience of training thousands of physicians both at the bedside and in the classroom in simulations I can tell you that if the scenario is something like this, it is often a total disaster for the patient:  “It is Sunday at noon and a 28 year-old white female is presenting with a chief complaint of dental pain.  She has a BP of 110/90mmHG, pulse of 96 bpm, saturation of 99%, temperature of 97.6 °F and states she has taken acetaminophen for the problem with no relief.  The patient in the core review of systems has ALSO STRESSED SHE HAS HAD NAUSEA and or has had nausea with vomiting days ago that seems to have improved but continues and her dental pain persists and is worse.

I have seen this exact scenario (with minor variations) play out the same over and over and the delay in the patient’s care for her stage III APAP overdose is completely missed and she is sent after vomiting in the ED restroom with a prescription for tylenol #3, 12 tabs (or a similar product), and even anti nausea medication and instructions to see a dentist.

I saw a doctor who was the director of the department of emergency medicine manage this case and I will try to state it with the actual words that were used since I was there for a potential assignment for his company which had been sued many times and he wanted help to solve this issue.  HE IS PART OF THE PROBLEM.

We enter the room.  He fails to notice because (he is not really looking at the patient as a clinician and misses the fact that she is extremely pale and even diaphoretic).  He fails to ask to see her pill bottle which I obtained for him which showed she had taken over 30G of APAP in three days or less.  Her initial nausea that cleared up is (classic for stage one APAP poisoning that has entered stage II).  This is a pathophysiology question  I taught him several times over many occasions when he attended my program.

ALWAYS CONSIDER APAP POISONING IN ALL ADULTS WITH UNEXPLAINED NAUSEA AND/OR VOMITING.  THIS PATIENT’S SYMPTOMS WERE NOT EXPLAINED BY ANYTHING BECAUSE HE DID NOT PURSUE ANY OF THAT INFORMATION.  HE DID NOT EVEN PERFORM A PREGNANCY TEST AT THAT POINT.

The blood pressure is not normal but he considers it normal.  It is not and shows evidence of adrenergic surge and/or dehydration or both.  He percussed her tooth with a wooden stick as if that is important (if it was and he truly though she had a dental abscess, he would have also prescribed an antibiotic).

He states to her,” Dear (a derogatory term for 99.99% of all women) that she has a dental infection (yet she has no gingivitis or purulence) and what can she expect him to do for a prolonged dental infection of a Sunday at noon?”  He then made it clear, “I am not a dentist.”  He also noted the tooth looked normal but he believed it was an infection because it hurt when he percussed her tooth.  (His interpersonal skills border on I have decided you are not a liar so I will give you some more pain pills [which happen to contain APAP]).

I remained in the room to get the accidental OD data, her vomiting, pallor and poor po intake history and also showed she was severely dehydrated clinically.  He did nothing for this.

He was angry when I told him to tear up his prescription for tylenol #3 and showed him the pill bottle and had him look at the patient to perform her exam again and also asked him to order a battery of tests such as the APAP level, the liver enzymes, and to call poison control.

Her APAP level came back in the range of definitely hepatotoxic.  This was a short acting form of APAP and we were well beyond the 4 hour limit and she was in stage III based on her liver enzymes and she stated her consumption of the APAP began three days ago which is textbook classic timing for stage III APAP poisoning.  He LFTs which were in the range of 15,000.  No she was not jaundiced but she was not comfortable with RUQ palpation and jaundice is not seen in stage III APAP poisoning.

Yes we called the Poison Control Center (which he refused to call himself again because he was angry), stated to still give her NAC and IV NAC was begun per the protocol and she was admitted.

“The department must focus on having processes focussing on meeting patient expectations.”  

Dwight Collman Comments:

This is irrelevant because patients cannot, and do not, in most cases know what is best for their problem(s).  The patient did not care about whether we took 2 minutes or five to see her…we were there this time to save her life and she had no idea she was at risk of death.  She was the only patient in the ED and this angered the ED director.  I saw it; I know him well.    

Dwight Collman comments:  Emergency departments do not go through each potential presentation that will show up in any ED.  None of them have this as a policy book.  I have never seen one.  This means it is up to the physician to know what is best for the patient and that depends, in this situation mostly on the horrific attitude displayed by the director of the department.  He condemned this patient by coming to his ED and by actually stating his unprofessional attitude.  No course is teaching this but me.  I teach it over and over and show how doctors get themselves into trouble by making assumptions.  My father had many friends who died when they were designing rocket motors for ICBMs:  He taught me: when you make an assumption you make an ass out of yourself and possibly me.  Me is the patient…in this case…killing the patient.

“The providers must individually strive to meet patient expectations and department goals.” This nonsensical sentence should be replaced with words that define how to get at the chief complaint and how to manage it properly.  It is focussed then on the patient’s actual problem.

Both of these absurd statements come from the Emergency Medicine Boot Camp Manual page 8 illustration 5.  My point is these so-called academicians are failing because they don’t know how to teach medicine.  Spending time on Door to provider time on multiple more screens emphasizes my point.  They say they are the best.  Sorry.  It is bunk.

they go on to say that some EDs “shoot for 30 minutes for door-to-provider-time and that this is probably the single most important time in the ED.   THE MOST SINGLE MOST IMPORTANT TIME IN THE ED IS THE TIME DURING WHICH EACH PROCEDURE OR STEP FOR THAT STEP WHICH IS ALREADY KNOWN, IS THE MOST IMPORTANT TIME AND THERE ARE HUNDREDS OF THESE.  THIS STATEMENT IS JUST A JUNK BASKET STATEMENT ABOUT GETTING IN THE ROOM.  IT WILL NOT HELP IN ANY CIRCUMSTANCE HOW LONG IT TAKES YOU TO GET IN THE ROOM IF YOU DONT KNOW HOW TO RECOGNIZE SOMETHING AS COMMON AS APAP POISONING THAT IS ADVANCED.  

THE REAL PROBLEM IS WITH THE FAILURE OF THE RESIDENCY SYSTEMS IN THE US.   Then they take physicians like me and push me to work in clinics.  I wil never agree to this as long as our system is so messed up.  My job as I see it is to make all of you accountable.  I do it by teaching you what is right.  I know why this physician is a total failure.  He is a drunk.  He should have had his license revoked years ago.  I read over 100 of his charts charged him 5000.00 and told him every single chart is full of charting errors of omission that require he reeducate his physicians and or simply hire physicians who know how to document.  When you read the same physical exam on every patient, and you see his doctor A is using a boiler plate method and does nothing to be specific to a particular patient it is so glaring and he paid me for that.  How absurd.

So forget about this time is….and just go see the patient’s.

Stop talking and just go see the patients.

Stop complaining and just go see the patients

If you have a fast track for non life-threats, great, otherwise, just go see the patient!

Provider in Triage only works well if you have enough providers that you are not taking away from the providers who perform the actual patient care.  I am yet to see an ED that does this.  I am yet to see an ED that manages triage with an ED physician 24/7.  It just wont happen.  It can work in small EDs with one ED physician if he does his/her own triage.  It is more accurate and always obtain a better outcome….but where can we find the magical doctors who are willing to be it all?  NONE ARE.  Our speciality is full of apathy.  Many of those of yo who complain about the X-ray that was not needed but ordered at triage would do better if you just were also the triage doctor for at least part of the shift.  Perfhaps in an ED with two ED physicians much of the triage could be shared by them…The bottom line is no one is will ing to pay for a triage ED physician.

However, when you look at times, at money wasted, at costs to patients that are unnecessary…much of this would be solved with a physcian at tradge.

WHAT HAPPENS IF THE TRUE DIAGNOSIS IS MISSED AND THE OUTCOME IS “BAD”

THE TIME OF “DOOR-TO-PATIENT SEEN” IS IRRELEVANT once this has happened in our APAP cases because what has happened is a complete miss of the true diagnosis.  I have seen as large as 30G accidental APAP overdoses being prepared for discharge when I have stopped the process and it is usually the ED director who has mad this blunder.

I have read algorithms and attended worthless programs that state:

MEETING THE PATIENTS’ EXCPECTATIONS

Meeting the patient’s expectations requires two elements

-The department must have processes focusing on meeting expectations….my comment: what a worthless rhetorical piece of “HS”.  What does this mean?  It has nothing to do with why the patient I describe above was failed and nearly murdered by a drunk of an ED director in the Midwest who owns the group and is now retired.  I will show you how bad it gets, but remember, this is one example of the same case I have seen blundered by the emergency physician  because of failure to keep their oath.  FIRST DO NO HARM…and this also means BE A PROFESSIONAL AND GO INTO THE ROOM WITH NO UNPROFESSIONAL BIASES IN YOUR MIND.  You must clear your mind each time you see a patient.  Anger is common in emergency physician and much of it is our own fault.  We gave up control of our work to hospitals and nurses.  They now control our processes so we are so angry we don’t do “our processing” normally anymore.