This document provides information about surviving a visit to the emergency room from the perspective of an emergency physician. It was written to help patients and their families understand how the emergency room works. The book explains where patients should go, what they can ask for, and what to expect during a visit. Understanding the emergency room process better allows patients to be more realistic and actively engaged in their emergency medical care.

1. Surviving the Emergency
Room: Expecting the
Unexpected
Ron Clark, M.D.
Emergency Physician
The Hospital of Central Connecticut

2. Surviving the Emergency
Room

3. Surviving the Emergency
Room
• Book was written for patients and family members
to explain how the Emergency Room works so
they can use it better
• It tells patients where to go, what to ask for, and
what to expect
• It allows readers (patients) to be realistic and to
actively participate in their emergency medical
care

4. About the Author

5. About the Author
• Board Certified Attending Emergency Physician at
the Hospital of Central Connecticut (HCC)
• Director of Emergency Department Risk
Management for HCC
• Clinical Instructor, University of Connecticut
School of Medicine
• Guest Lecturer, Central Connecticut State
University

6. About the Author
• Instructor and medical advisor for the Connecticut
Alliance to Benefit Law Enforcement (CABLE)
• Connecticut State Police Surgeon
• Board of Directors, Connecticut College of Emergency
Physicians
• Fellow of the American College of Emergency
Physicians
• Medical-Legal Consultant, Clark Medical Consulting

7. The One Thing That I Am An
Expert On

8. HCC ER

9. The Hospital of Central
Connecticut

10. Typical ER Room

11. Objectives
• Background of why Surviving the Emergency
Room was written
• What you can do to be prepared (as preparation
leads to better outcomes)
• National Emergency Department Issues
• Emergency Room Planning

12. TV shows often inaccurately
portray EM services

13. Patients often have
misconceptions of the ER

14. Common Questions
• Why did that person get triaged to a room before
me?
• Why was there no specialist available to see me?
• Why did I wait so long for a room after I was
admitted?
• When is the best time to go to the ER?
• What should I do before I go to the ER?

15. Who is that person in the
scrubs?

16. Emergency Medicine
• All people have the the potential to be an ER
patient (even me)
• By educating patients and family members about
how the Emergency Room works, they can better
prepare themselves
• Emergency Room images (some graphic) mixed
with some humor to keep you all interested
• Images are all taken from public domain

17. What’s An Emergency?
• A medical emergency is any potentially life or limb
threatening symptom
• Medical emergencies happen randomly and often
without warning (Box of Chocolates- Anyone,
Anywhere, At any time, For any reason)
• The experience is often frightening and most
patients feel unprepared

18. Emergency Medicine is about
information management

19. Emergency Medicine
• Chief Complaint
• History of Present Illness (HPI)
• Past Medical/Surgical History
• Medications and Allergies
• Social and Family History

20. Emergency Medicine
• Physical Exam
• Emergency Physician recognizes symptom
patterns combined with physical exam findings
• Generates a Differential Diagnosis (possible
causes for patient’s medical problem)
• Emergency Physician orders tests to “rule in” or
“rule out” various Diagnoses

21. Emergency Medicine
• Final Diagnosis
• Emergency Medical Treatment
• Disposition: discharge, admit, transfer, die

22. My experience on the
Trauma service
• Live
• Die
• Admit
• Discharge

23. Life Star

24. It’s important to focus
emergency medical
complaints

25. Some patients are easy to
diagnose

26. Symptom: Ankle Pain

27. X-Ray: Ankle Dislocation

28. Symptom: Arm Pain

29. X-Ray: Radius and Ulnar
Fractures

30. Some Symptoms are not as
easy (nonspecific)
• Dizziness
• Weakness
• Nausea
• Bodyaches
• “I don’t feel well”
• “Something is wrong”

31. Differential Diagnosis

32. Lets Get Back to Focused
Patient Complaints

33. Chest Pain (MI)
• Common Complaint
• High Risk
• Large DDx
• Must Risk Stratify

34. You can get sick for any
reason

35. Knife in Chest

36. Chest Pain

37. Shortness of Breath

38. Dental Pain

39. Face Pain

40. Back Pain

41. Another stab in the back

42. Neck Pain
• Suicidal patient (now paralyzed)

43. Eye Pain

44. Difficulty Speaking

45. Runny Nose
• Upper Respiratory Tract Infection/ Otitis Media

46. Endless Potential ER
Cases

47. Each person’s emergency
will be different
• Emergency is a deeply personal issue
• Most people do not like being sick
• Most people have a story about the Emergency
Room (some good and some bad)
• Most patients remember their ER visit vividly
(Emergency Physicians only usually remember
the worst cases)

48. Worst Case

49. X-Ray

50. Good Outcome
• The “golden hour” was not wasted

51. The Golden Hour

52. The Golden Hour
• The first hour of definitive emergency medical
care can seal the patients fate and ultimate
medical outcome
• Most important for trauma, heart attack and stroke
• Don’t minimize medical symptoms and seek
emergency medical care immediately if you or a
loved one have concerning symptoms (chest pain,
sob, abdominal pain, difficulty speaking,
headache, visual changes)

53. Emergency Department
• Emergency Room is more correctly referred to as
Emergency Department (don’t tell Amazon)
• Many Rooms (trauma room, ENT room, OB/GYN,
monitored rooms, orthopedic rooms, isolation
rooms, Fast Track ER)
• Many different staff (MD, PA, RN, Tech, Students,
security, housekeeping)

54. Who is the “Face”
• Ask ED Staff members who they are and what
they do
• House

55. Emergency Physicians

56. Emergency Physician
• Provides direct patient care
• Physically examines patient and determines
emergency medical care plan
• Performs emergency medical procedures
• Consults with specialists
• Ultimately responsible for patient’s disposition

57. Emergency Physician
Assistant
• Well trained for urgent and non-urgent medical
problems
• Most staff Fast Track ER
• Assist with patient management
• Often work side by side with MD’s
• Valuable resource (patient flow)
• Very Experienced (sutures, fractures)

58. Emergency Nurses

59. Emergency Nurse
• Many men chose to work in the ER

60. Emergency Nurse
• Provides direct patient care
• Places IV’s
• Administers medications
• Often first to assess a patient (The Look)
• Makes suggestions /works in conjunction with MD
• Major determinate of patient satisfaction (spends
a lot of time with patient)

61. Emergency Tech
• Performs ekg
• Draws blood
• Assists during procedures
• Transports STAT labs
• Transports patients
• Blankets, food, bathroom

62. Students
• You provide a service to them (ER is the best
place to learn clinical skills as the patients are
often very sick and need emergent interventions)
• Someone did this for your MD/RN
• Learning often done at bedside
• One chance - IV, suture (supervised)
• See one, Do one, Teach one

63. Security
• Keeps patients and staff safe
• Screens patients (Dr. Safe)
• Called for violent patients (4-point restraint)
• Always present in ER

64. Experience Counts
• It is important to always confirm the experience
level of the staff member that is taking care of you
• If you are unsure, ASK.

65. Emergency Room
• Open 24 hours a day/ 7 days of the week
• Over 100 million ER visits per year -large and
renewing potential readers for Surviving the
Emergency Room (Amazon loves this)

66. Allows for management of
ER expectations

67. What have you done?
• Most patients want quality and efficient EM care
• Most patients and family members do little to
prepare for their ER visit
• Patients call 911 or drive to the ER and just show
up and expect good medical care
• Patients often do little to assist in their emergency
medical care (despite the fact that they have the
most invested in their health- it’s their body)

68. Prepare for your emergency
because it is going to happen
• Hopefully all these patients prepared

69. What you can do to prepare
• Learn roles of various ER staff (we just did this)
• Become Familiar with how the ER functions
(Triage, Admission, Discharge and Transfer)
• Research and understand local hospital
resources
• Patients should know and have all their basic
medical information written down
• Go to the hospital where your MD has privileges
and where records kept (EKG, OR reports, X-
Rays)

70. Triage
• Triage RN and Charge RN determine how fast
you get to a room
• “The Look” can give you a visceral response (sick
child, patient about to have a seizure, patient with
SVT (fast heart beat), patient who is going to be
violent)

71. Admission

72. Hospitalist Physician
• Good- Physically in hospital, good relationships
with staff, can get studies quickly, and available to
perform procedures
• Bad- Not patient’s regular doctor, impersonal,
have to start with basics that PCP would already
know, often lack of trust, short interactions
• Ugly- Patients often withhold info (STD, alcohol or
drug use – can lead to complications), Some
PCP’s dump patients, PCP’s often don’t call back

73. Blocked Admission
• Sometimes admission can be “blocked” if patient
is on the medical fence (Chest pain, dizziness that
does not look right, diabetic cellulitis with no
doctor)

74. “Bounce Backs”
• Patient who returns to ER after recently being
seen
• Emergency Physicians generally don’t like to hear
about them (implies patient was dissatisfied with
care or that something may have been missed)
• Often a blessing in disguise (as second chance to
make diagnosis and provide medical care)
• Sometimes clinical signs and symptoms may have
changed or condition may have worsened

75. The Blessing in Disguise
• If you feel something was missed, it is appropriate
to return to the same ER or seek medical care at
another ER

76. Discharge
• Ask your Emergency Physician about your
diagnosis
• What is your prognosis? (when should you feel
better?)
• What should you do if you feel worse?
• Who should you follow up with and when?
• What are your discharge medications?
• If you do not understand, ASK

77. Hospital Transfer
• Patient can turn into a hot potato

78. Transfer
• Time consuming for both the transferring
physician and the accepting physician
• Need to get an accepting physician’s name
• Antidumping laws (EMTALA) and have to have
capacity
• Often leaves patient and doctor frustrated, as
could not treat patient at current facility
• Can cost patient their “golden hour”

79. Call Ahead
• Patients and family members are encouraged to
call ahead if they have an anatomically specific
complaint (hand injury, eye injury, genital injury)
• Confirm that specialist is on call and available

80. Research Local Hospital
Resources
• Know what is available in your area
• Each ER has strengths and weaknesses
(specialists, radiology equipment, pediatrics,
psychiatric services, trauma services)

81. Know What Can Kill You
• Patients should have all basic medical information
written down (past medical hx, past surgical hx,
medications, allergies, social history and family
history)
• Name of doctor
• Name of pharmacy (bring prescription bottles)
• Avoid telling Emergency Physician “You know the
white pills”

82. Many medications have side
effects and drug interactions

83. Avoid Surprises
• Go to the hospital where your doctor has
privileges
• Where surgery was performed and OR reports are
located
• Where old EKG’s are stored (my favorite, I
compare about 10 EKGs every shift)
• Where old radiology studies are stored (can often
use computer to look at previous studies and
compare to present films)

84. Be Careful What You Wish
For
• Confirm experience level of medical providers
• How many times have you done this?

85. Avoid being the Squeaky
Wheel
• Write questions down so that you can be prepared
to ask them when MD or RN is in your room
• Do not excessively call MD or RN into your room
(they usually have many other patients)
• Thank your provider if they answered your
question or provided good medical care
• MD or RN will consciously or subconsciously
avoid your room if you become the squeaky wheel
(can be dangerous)

86. National Issues

87. ER is the Safety Net
• Safety net for mental illness, uninsured patients,
homeless, substance abuse, medical care when
primary care doctor unavailable, trauma)

88. Equal Playing Field
• All patients have access to the Emergency Room
• All patients use the same services (EMS,
hospitals)

89. Emergency Room
Overcrowding
• Increased volume of ER patients each year
• Limited number of inpatient beds so many ER
patients become “boarders”
• Some Emergency Rooms will go on diversion

90. Shortage of Specialists
• On Call: a CT study 90% of medical directors in
CT stated that specialty coverage was deficient or
unreliable
• Specialty medical coverage only matters when
you are that special patient
• Major challenge for hospital systems to get
specialists to take call (often called at night,
compensation issues, interferes with family time)

91. Doctor can feel like an Army
of One
• Literally, when the specialist is unavailable, the
Emergency Physician still has to see the patient

92. Emergency Room
Planning
• When is the best time to go to the ER?
• Dangerous Times
• ER wait times

93. Timing is Everything
• Mornings are generally the slowest time
• ER volume increases from morning and peaks in early
evening (approximately 7 PM)
• Avoid “Manic Mondays”- busiest day of the week with
each successive day being a little slower (HCC has
quadruple coverage plus 2 PA’s on Monday-Thursday)
• Be aware of “Frustrating Fridays”- non-emergent tests
and procedures may not get done until Monday (some
specialists and equipment are not available on the
weekend)

94. Wait times
• Emergency Rooms post wait times on the
Internet, billboards, text messages and smart
phone applications
• “CentralCT ER” iPhone application for HCC

95. Wait Times

96. Danger Zone

97. Danger Zone
• Emergency Physician “sign out” time can be
dangerous (ask for both doctors to sign out at your
bedside)
• Ask your medical provider when his/her shift ends
and ask for a “good-bye”

98. On The Night Train
• Volume is lower during the night, but there is less
staff
• Some equipment will be unavailable (ultrasound,
MRI)
• Some staff will be unavailable (crisis intervention,
social worker)
• One very sick patient can impact the entire
Emergency Department (cardiac arrest)

99. My Advice
• Educate yourself on Emergency Medical Services
• Be realistic
• Be proactive and prepare for your emergency
• Actively participate in your emergency medical
care

100. Surviving the Emergency
Room

101. Questions?