The Stress of Hospitals
Emergency departments can be a stressful place, both for patient’s and healthcare providers. Patient’s are often scared, in pain or other distress, and anxious about what is happening to them, and what is about to happen to them. As Providers, we are often caring for multiple sick and/or injured patients who all want one-on-one attention, constant interruption by nurses and other staff, plus keeping things like patient satisfaction and turn-around times in the back of our minds so that we can satisfy administration’s expectation of us. This mixture can easily lead to dissatisfaction by both patients and Providers, which is completely counter to the reasons many of us went into the practice of Emergency Medicine in the first place. It doesn’t have to be like this, and I can show you some ways to help improve everyone’s experience in the ER.
The Patient Experience
First, let’s talk about patient experiences. For a moment, pretend you are a patient who is experiencing chest pain, and you have absolutely none of the education and training you now possess. Maybe you also feel a little short of breath. This is a new experience for you, and the only thing that goes through your head is what you’ve seen on TV medical dramas, so you are convinced that you are dying from a massive heart attack. You call 911, and the Paramedics bring you to the ER. They haven’t told you much, other than the EKG doesn’t look like a STEMI, whatever that means. They give you some medicines to chew up, and place an IV in your arm and some oxygen in your nose. Once you arrive at the ER, there are people everywhere. Doctors, nurses, patients, it appears like the chaotic scene from TV. Now you are convinced you are dying!
Now, in walks a person with a lab coat and a stethoscope around their neck. Finally, “the doctor” is here and they will make it better. He/She introduces themselves, but you don’t know what they said because you just want to tell them about what’s going on with you. They ask you a few quick questions while typing something into the computer, barely taking the time to look up at you. They mention that the EKG “looks ok”, state that they are going to order some tests to the nurse, and off they go. It seems like they were only in the room 30 seconds! You barely got to explain what was happening! This isn’t what happens on TV! The nurse draws some blood, they do another EKG, give you some more medicine under your tongue, and then everyone leaves. Now what? A couple of hours later, your “doctor” comes in and says everything looks ok, but they want to admit you overnight for observation and more testing, and then they are gone again. But you still don’t know what is going on! Why did you have this episode? What was it? Do I need surgery? When can I go home? Why aren’t there any answers? I’m sure we can all agree that this must be a frightening and frustrating experience for those patients who have no medical background.
The Providers Experience
So now we can look at this scenario from the Provider perspective. You are working in the main ED of a busy hospital on a Saturday afternoon. You overhear an EMS radio call about another patient with chest pain, shortness of breath, and a normal EKG. Great. You have two lacerations yet to close, an abscess to I&D, two patients who need to be admitted but have CTs pending, a Psych patient who is screaming and needs to be sedated, and a patient with chronic back pain who wants more pain medications. And you haven’t charted on anybody. Your attending is intubating a critical GI bleed and placing central lines and the next shift doesn’t start for 2 hours, so any new patient is automatically going to be yours. So, on top of all of this is some person who is having chest pain and thinks they are having a heart attack but is probably just anxious or out of some medication.
When the patient arrives, you see a middle-aged person laying in bed who has mild hypertension, appears slightly anxious, but has an unremarkable EKG by EMS. You get ready to see the patient when the charge nurse informs you that EMS has just activated a Stroke Alert in the field and they are 5 minutes out. Looks like you are going to have to make this a quick visit. In an attempt at efficiency, you try to chart and interview the patient, so you introduce yourself as the APP on duty and immediately sign in to the computer in the room when you walk in. You review the EKG obtained in the ER, and it looks unchanged. While you are documenting the EKG, you ask the patient some questions about what happened prior to arrival, tell them that the EKG looks ok, instruct the nurse to collect some blood and give the patient some nitroglycerin, and dash off to see the stroke patient who is about to arrive. Your plan is to come back in a few minutes and do a proper history and physical, but you know that may not actually happen.
An hour later, all of the testing has returned and is unremarkable, and the patient’s nurse informs you that “the chest pain patient in Room 5” is better after two nitroglycerin, so you decide to admit them for further cardiac work up. The nurse states that the patient wants to know what is happening, so you go to inform them of the results and your recommendation for admission. Between your desk and the patient’s room you are stopped 3 different times by three different people who want 6 different things, so you are thoroughly frazzled by the time you make it to the room. You tell “the chest pain patient in Room 5” that all of the tests look ok so far, but they need further cardiac evaluation and should be admitted overnight for additional testing and a cardiology consult. As you are finishing this statement, you are paged overhead to come to the phone to speak to the admitting physician for one of your other patients, so you quickly run out of the room so that the other physician doesn’t hang up.
I’m sure we can all agree that this scenario is fairly accurate, and I am also sure that we can all find the places where we have failed our patient as well as ourselves.