Author’s note: This is the sixth diary in a series that I will post monthly, on medical topics related to emergency care. If you want to check out the first diary in the series, you can find it here, on the topic of insider tips to improve your ER visit, and the second one here, on the topic of heart attacks. Some of these diaries will focus on the medical system or process, and some will be disease-specific. My goal, as your friendly neighborhood ER doc to the Daily Kos community, is to provide useful information for this community to stay healthy and get the best results from our medical system. I hope you find it helpful!
You are outside, enjoying a summer afternoon in the backyard, and suddenly you experience crushing chest pain. In a panic, you dial 911 and an ambulance brings you to an emergency room. You made a good decision to make that telephone call.
Another summer afternoon, you slip and fall, twisting your ankle. It hurts, and you can’t seem to walk very well. You know that the fundamental question is simple — did you break something, or is this a sprain that will take a week to feel better? Do you go to an emergency room? What about this relatively new thing called an urgent care? What about another strange place called a “free standing” emergency room? You really don’t want a long wait to be seen, but you want good care. It’s a weekend, so your primary care doctor’s office is closed. What to do?
The modern US health “system”, in the opinion of many people including myself, is a mess. One aspect of this byzantine and inefficient system is the growing array of confusing options for unscheduled care. An important context for this discussion: emergency medicine is a relatively young concept. The modern notion of an “emergency department” (many ER docs prefer this term over the more pedestrian “emergency room”) was born about 50 years ago, when it was recognized that many conditions couldn’t be easily handled in the office setting. Hospitals built emergency departments into their buildings, and a new paradigm of the emergency medicine physician was born. The first training program for this new field began in 1970 at the University of Cincinnati (for those who enjoy medical history, I recommend a book by Dr. Brian Zink on the history of emergency medicine; Amazon link to the book is here).
As emergency departments became fixtures of our healthcare system, the demand for their services grew steadily. More and more physicians, busy in their office practices, developed the (mostly reasonable) habit of re-directing acute complaints to the local ER. And patients, who couldn’t manage to get an appointment with their doctors, would seek immediate attention on their own. And now, so many patients lack insurance and don’t have primary care doctors: their main path to healthcare is through the doors of the ER. Additionally, the need for trauma care (mostly from car accidents and gun violence) have increased as well. For these and other reasons, ER waiting rooms have swelled, the waiting times have grown, and the whole system has strained to the breaking point. In my busy urban ER, we will often have upwards of 30 patients in the waiting room, and delays to be seen commonly reach 6-8 hours. Can you imagine waiting all day long in a noisy and unpleasant ER waiting room for a sprained ankle? Many of you can — because you have done just that. And it is unfortunate for so many reasons.
So….. the demand for unscheduled care has created new options. These include:
- urgent care centers — sometimes free-standing, sometimes build into pharmacies or retail chains such as CVS. Some are linked to local healthcare systems, some to private urgent care for-profit franchises, such as RediClinic or NextCare.
- free standing ERs — not linked to hospitals; these have grown rapidly in Texas and Ohio, for a variety of reasons. They often have relationships with nearby hospitals so that patients who require hospitalization can be transferred. For an interesting take on these entities, check out this editorial from the San Antonio Express-News.
- telemedical urgent care — medical care using on-demand live video via the internet, usually fee for service although some will bill through insurance. A number of companies have sprung up in the last few years to offer this “Uber” model of healthcare, including Teladoc or doctorondemand.
These new options bring more choices for patients, which in theory can be a good thing — but they have many pitfalls as well. It is important to understand what these services can offer, and what they cannot. We will not turn our attention to these options and I will try to offer some tips on how to get the most out of them while staying safe.
First and most importantly: there are some symptoms for which you really don’t want to ever consider these new modes of care. If you experience sudden slurred speech or arm weakness that is new for you, or significant difficulty breathing, or chest pain that stops you in your tracks, there is really only one best safe option: call 911. This is why we have the emergency medical services (EMS) infrastructure in almost all communities — let the prehospital professionals (emergency medicine technicians and paramedics) take you to the hospital in an ambulance. There are a number of reasons for this: (1) sometimes these symptoms are signs of rapidly evolving conditions, and if you deteriorate quickly, you don’t want to do this in a waiting room, or in a car as a friend or spouse drives you to the ER; (2) EMS providers can often administer treatments right away that may be life-saving, and (3) prehospital providers can route you to the right ER for specific medical emergencies since they are trained to know the local hospital system.
Next pro tip: if you have a symptom that is likely related to a chronic medical condition (for example, worsened shortness of breath in a patient with chronic emphysema, or headache in a patient with known migraines, or abdominal pain and diarrhea in a patient with ulcerative colitis, or worsened pain with advanced cancer) — it is often best to be seen by the specialist who cares for that condition before going to the ER. Going to an ER is certainly reasonable, but remember that the good folks in the ER aren’t familiar with you and the context of your complaint, so they are likely to order many more tests than might be needed. And they might admit you to the hospital unnecessarily out of an abundance of caution. If you have a doctor who knows you and your specific condition well, and they can see you the same day or the next day, that may be the best call. At the very least, call their office and discuss the situation.
Related to this, a very important principle to follow if you seek care in the ER: go to the ER that is most closely linked to the doctors who regularly care for you. Many people are surprised to learn that medical records are not available to ER staff in one ER from the nearby hospital or clinic that is part of a different healthcare system. The lack of universal, shared medical records is a major problem in the US, and a cause of greatly increased costs from unnecessary repeat testing and hospitalizations. This is especially important for patients with complex surgical histories or ongoing cancer treatment — if your cancer care or recent surgery was performed at hospital A, do your best to go to the ER at hospital A, not hospital B. It can truly save you from enormous hassle, and you will get better care. I see this principle violated on literally every shift I work in the ER — well-meaning and frightened patients show up in the ER, with multiple surgeries recently performed at the hospital across town that is part of a different, competing healthcare system. Sometimes this happens because patients called an ambulance, and many EMS providers are trained to take patients to the nearest hospital, which often isn’t the right hospital. So if you call an ambulance, be sure to tell them “if possible, please take me to hospital X; most of my care takes place at that hospital”. Often they can honor this request, if made firmly but politely.
Now we move to the question of an urgent care center and when to use them. As many of you know, these places are best used for minor complaints — concerns about a nagging dry cough, a sore throat, or a swollen finger are perfect for urgent care. If you have a rash that you think is poison ivy or pain from a bee sting, urgent care is a good option. Here’s an important pro-tip: some urgent care centers have x-ray capabilities and some do not. If you are seeking care for a twisted ankle or other limb pain from an acute injury, call ahead to ask if they have the ability to perform x-rays, or ask at the registration desk before you sign in. Don’t waste your money and time, only to be told “you need an x-ray and we don’t do those. You need to go to the ER.”
Another key thing about urgent care centers: they have a very wide range of providers — some have physicians, but many do not. To keep costs down, urgent care centers are usually staffed by physician assistants or nurse practitioners, who have different skill sets and levels of training. So just because the person seeing you is wearing a white coat, don’t assume they are the final word on your condition. I have sadly seen an enormous amount of misdiagnosis via urgent care centers; to be fair, we often misdiagnose folks in the ER as well, so I don’t want to imply we are blameless. That said, I have seen cases of missed appendicitis where urgent care centers told patients they just had a stomach flu; cases of kidney stones where patients were told they just had a urine infection; and worst yet, cases of heart attack where patients were told they had stomach ulcers. My advice? Don’t go to urgent care for chest pain, shortness of breath, abdominal pain, or pregnancy-related problems. The risks are too great, the chance of getting the wrong answer too high. Indeed, most urgent care centers would agree with me, and indeed have policies to turn such patients away. But some are less scrupulous, and would be glad to take your money only to tell you to go to an ER after they evaluate you. Another bit of advice — find out if your primary healthcare provider’s hospital system has an affiliated urgent care center, and go there instead of a for-profit unaffiliated one. Care will be better, and more efficient, if they are linked via medical records and hospital providers.
How about free-standing ERs, and what’s the deal with those? These are strange entities. Think of them as urgent care clinics on steroids — they can handle a wider range of significant problems, which I suppose is a good thing, but they aren’t part of any hospital. Meaning if you need to be admitted, or need a surgery, they will transfer you to a hospital at which they have contractual relationships. Personally, I think it’s bizarre and I am skeptical of these places. At least urgent care centers feel more transparent to me — most of them don’t claim to offer full emergency care services. But these free standing ERs do — and they tend to make a healthy profit, since they don’t have the overhead costs associated with an entire hospital. My advice? Stay away from free-standing ERs, unless you really don’t have a choice. For example, if you have sudden chest pain while driving, and you see a sign for a free-standing ER that is a few blocks away, sure — go there. If your community is located a long drive from the closest hospital, but a free-standing ER is nearby (I’m directing that comment to readers in many rural Texas locations) — I suppose it’s your best option. If you feel ill enough, or are worried enough, to need an ER, go to a full-service one that is linked directly to a hospital. That way, if you may need a surgery, there are surgeons on staff who can see you during your ER visit. If you might have a stroke, there are neurologists upstairs in the hospital who can be activated. If you find yourself at an unfamiliar ER and it’s not obviously in a hospital-building, ask them “is this a free-standing ER or a hospital ER?” — and if your complaint isn’t dire, you might want to redirect yourself. I would be very curious to hear from readers about their experiences at such places; please offer your comments and we’ll have some discussion.
Telemedicine offers another option for unscheduled care. This is an exciting, rapidly growing area of healthcare that is poorly understood and poorly studied, so it’s hard to know if it’s a good thing or not. But the convenience is certainly there — pick up the phone and video chat with a doctor on-demand within minutes. Much like Uber or Lyft or Amazon, this concept caters to the desire for instant service right from your computer or smart phone. I suspect the best use of these telemedicine services might be like urgent care — they are best reserved for minor complaints that don’t require physical examination. Another potentially useful role for telemedicine services — to help answer the key question: do I need to go to ER or can this wait? This is such a common problem that I see all the time. For example, true story from a large collection of similar ones: it’s a Sunday night and my neighbor’s 8-year-old kid develops lower abdominal pain. The kid looks more or less OK, but my neighbor knows that appendicitis is on the potential list of concerns. She and her husband both have work in the morning, and they know that a Sunday night visit to the ER will gobble up at least six hours of their life, and may not be necessary. So, they ask me to check the kid out. I drop by, examine the kid, and reassure them that they can wait 24 hours to see what develops. The next day? The kid has had a massive poop and feels much better. No ER visit, no bill, no CT scan! 10 minutes from me saved them tons of time and aggravation. I suspect most telemedicine physicians or nurse practitioners could offer similar services — not definitive care, but triage assistance to help you decide if something is a real emergency or can wait until the next day’s visit to the doctor’s office. Pro tip: some hospital systems have developed their own telemedicine programs, so before you call a random telemedicine for-profit company, find out if your primary provider, or their hospital, offers a linked system. Again, it will often lead to better, and more efficient, care.
In summary, the modern infrastructure for unscheduled care in the US is complex and evolving. There are many options, but it’s crucial to understand what each option can offer. Hopefully the discussion above is helpful to you; I welcome additional questions and comments. The ER Doc is “in” — let’s discuss!