Why is it taking so long?

Aren't emergencies...emergencies?!?!

This is by far the most frequent complaint in the Emergency Department. Why does everything take so damn long? It even SAYS Emergency in the name, so shouldn’t everything happen just lickety split? How come I’ve been waiting here an hour and that person was whisked back to a room right away? Why haven’t I gone for my CT yet? The doctor said they would come back and discuss my test results and I haven’t seen them once? Why can’t I have food if I have to wait this long?

Because the ER is not only for emergencies. It’s also turned into a place where people without primary care providers or insurance come for minor complaints. Or when the primary care providers can’t get you in. Or when Dr. Google tells you that strained muscle in your ribcage might be lung cancer. We don’t turn people away. We’re happy to see you no matter if you stubbed your toe, or having a stroke. But when there are more patients than rooms, we operate on one rule. The worst come first.

This isn’t the DMV. It’s not taking a number and being called in turn. It’s treatment by priority. When patients arrive, they are triaged and given ESI level to indicate priority. ESI stands for emergency severity index. The ESI system was designed in the late 90s, and has been in widespread use since.

A quick and dirty breakdown of ESI. The scale goes from 1-5. A level 1 shows up on the tracker boards in blue. Can you guess why? Heard of a code blue? That’s right! Blue is BAD. Examples of this level are your cardiac arrests, and anything that requires IMMEDIATE, life saving interventions.

Level 2’s are red. Because red is also BAD. Red means there is a HIGH RISK of rapid deterioration, or time critical problems. Like strokes. In ischemic or “clot” strokes, there’s a pretty bad ass drug called TPA. It can reverse the effects of a CVA by dissolving the clot causing the problem, but it MUST be given within a certain timeframe and is really most effective when administered within three hours.

3’s are yellow. Meaning they are stable, but whatever their chief complaint is (probably abdominal pain or similar) does need to be investigated.

4’s are green. They’re your lacerations, minor fractures, back pains that are neurovascularly intact.

I don’t even know what color 5’s are. I think I have maybe one 5 a year. That’s a med refill or a wellness check. Easy, breezy, quick disposition.

Here’s a hypothetical situation that occurs a lot. Let’s say you’ve come to the ER for abdominal pain. You register, and a triage tech or nurse takes your vitals and gets your height and weight. They ask you what brought you in. Quick tip to speed the process along—be brief. We’re looking for “nausea and vomiting” or “back pain”, not “I ate eggs a month ago and since then I have nausea in the mornings and sometimes, I have a rash.” That’s “Nausea and rash.” You’re going to have repeat this all again in the back and we are looking for the CHIEF complaint. Sure, that information might be important, but unless you just ate a peanut and have a history of anaphylactic shock with exposure to nuts, we don’t need it now. There’s a time for that.

Then you’re sent back out the waiting room, to wait for an open bed, with a urine cup in case you’re able to give a sample. It is a trend to urinate right before coming to the ER, which is understandable—I pee myself before ever leaving the house even if I’m just going to the post office. You’re out there for twenty minutes. Then a guy comes in, walks to the desk, and says “I have chest pain.” POOF he’s gone. Why did he get to go back?

Because chest pain can be really bad. Especially at a certain age. He might be coming back, but right now he’s getting an EKG to rule out a STEMI—ST Elevation Myocardial Infarction. If it’s happening, that guy’s getting 324 of Aspirin, two large bore IV’s, and an immediate trip to the cath lab because there’s a blockage in one of his coronary arteries that is killing is heart tissue. TIME IS TISSUE. Same with strokes. TIME IS BRAIN. Hearts, brains, lungs all take priority, cause you know, you sort of need them to live.

Also, if you keep hearing ambulance sirens pulling in, or overhead pages like “LEVEL ONE TRAUMA ALERT”, you might want to get comfortable. Because shit is getting WILD in the back. People are trying to die. It’s an influx of critical patients, like a stampede, and the nurses and doctors are all trying to herd everyone back to their bodies.

FINALLY, they call your name. You’ve waited maybe an hour, or on a really bad day, a few hours. You did produce your specimen, and you hand it to the person walking you back. They ask for more information, then leave with the urine sample after another vitals check. You wait again, maybe for a few minutes, maybe longer, before the doctor comes in. They ask you to repeat EVERYTHING you told the other people. Then they tell you they will get some blood work, along with the urine sample, and probably a CT.  They leave too. They probably forgot to tell you that you’re NPO, nothing by mouth, until the CT results are back. Because if you’ve got appendicitis, the anesthesia team will not take you to surgery on a full stomach. Helpful hint.

A nurse comes in, starts your IVs, asks more questions. The bloodwork will take about an hour and a half, she tells you, and the doctor has ordered fluids and a nausea medication. Maybe pain medication if your pain is severe. She leaves. Someone brings you the fluid and meds, and you settle in, and wait.

And wait. And wait. Why aren’t you getting your CT? Because they ordered IV contrast, which can’t be performed until the creatinine level is resulted, which gives an idea of your kidney function and whether the contrast dye could harm them. Actually, your level came back just now and you’re next up, but ten minutes ago two cars smashed into each other head on and multiple critical patients are inbound by ambulance, and guess what! That whole THE WORST COME FIRST thing is back in play. Their unstable vital signs, altered level of consciousness, and high-risk mechanism of injury is gonna bump your trip. Sorry, the tech who answers your call light says, there’s been a critical situation, but you’ll go very soon.

And you do! Twenty minutes later you roll to the scanner, and back to your room. The tech says your results will be back in an hour or so. The light at the end of the tunnel is there!

By this time, you’ve had a whole liter of IV fluids in. You’ve got to pee, but you figure you’ll go in a while, when they come with the results. Didn’t they say you could eat when you were done with the CT? Maybe you can ask for something to eat and pee at the same time. You put on your call light.

A couple minutes tick by. No one comes. By now, the urge to pee is a necessity. You push it again. It’s answered, but when the door opens you can hear someone SCREAMING. There’s a lot of bells and whistles ringing, and a naked person runs by, chased by someone in scrubs and a guy in a security uniform. What the hell kind of place is this anyway?

The person unhooks you and walks you to the bathroom. Unbeknownst to you, the ER doctor has come to give you results at the same time. They leave, called to the naked person emergency, and then a stroke comes in, and you’ve been back in your room for almost an hour before they return.

By this time, you’ve been in the ER for FIVE to SIX hours. You’re hungry, your pain has subsided, and you want to go home. There’s no diagnosis. Your labs are normal. Your CT is normal. Might be something you ate, or a mild intestinal virus. What a waste of time, you think, waiting for your discharge paperwork from the nurse. Later, you’ll tell people about the wait, how everything took so long, how people were taken ahead of you. Because you don’t know that the nurse who took twenty minutes getting your discharge instructions was face timing an elderly confused patient’s daughter to help calm her down and reorient her to decrease her fear and anxiety. The tech who took you to the bathroom and went to check to see if you could eat got called into a room to perform chest compressions. The doctor who didn’t come straight back to your room again was calling a surgeon to see if they’d be able to remove the large collection of blood in someone’s head.

That’s why sometimes, the wait in the ER feels so long. If people aren’t running to your room, if you’re awake and alert, and can walk on your own, you might be an ESI level 3. The ER is for emergencies first, and urgent matters second. Absolutely anyone who needs medical attention SHOULD go to the ER. But take with you the knowledge the average ER visit is 4-6 hours long, across the United States, unless you just need stitches. And we’re sorry it’s so loud, and so wild, and that sometimes naked people are being chased or someone is screaming nonstop but also, we’re super happy you’re not running the halls naked or screaming nonstop. We appreciate your patience and we WILL get you seen and your workup performed and you to where you need to be, whether that’s home with follow up care information, admitted to the hospital, or even off to surgery to have that damn gallbladder removed!

— The Midwestern One