Yet Another Pitting of...Emergency Room Care

The BBQ Pit
1

IANAD, but I have some training in emergency medicine.

Last night, a friend was doing some gymnastics in the kitchen (totally sober, I swear). Imagine using the countertop and the island as parallel bars. During one technique, he pushed himself up, flipping his legs over his head. His arms, however, were not happy about this, and he fell ass-over-teacups onto his shoulder and head.

He didn’t lose conciousness, but it was clear that something was wrong with his shoulder and he had a pretty nasty bump on the head. He declined an examination from me, so I threw a sling and swathe on his arm and drove him to the ER.

It was 8:30pm on a Friday night. There were two or three patients in the ER, and no one in the waiting room. His care included:

-acting as if they’d never seen an improvised sling, they told him they’d need to cut it off to examine him. He simply untied the obvious knot.

-They took some x-rays of his shoulder.

-Their investigation of his spine involved about two seconds of palpating his C-spine, and not even all of it. This despite a pretty distracting shoulder injury. They didn’t even check CSM’s in his feet.

-They didn’t do any kind of head-to-toe examination, and so missed a significant injury on his leg (which we discovered when we got home).

-They gave him contradictory instruction on what to do in the following days (ROM exercises vs. no movement).

-This took 4 hours, during which time they interacted with him for approximately ten minutes.

Why? Why is the standard of care so low? It wasn’t busy. These people are well-trained. He has good health insurance. WTF? A semi-literate monkey with access to Google could have given him better care–and it would have been faster and cheaper. I don’t get it.

2

So what were the extent of your friends injuries? Concussion? Separated shoulder? Fused spine? Paralysis? Bumps and bruises?

3

IANAD either,but, geez. I don’t even know where to start.

Richard, the emergency room is for…“emergencies”. It’s not for thorough physical workups. The job of ER staff is to stabilize people who are screaming in agony, bleeding heavily, unconscious, or giving birth–and then to send them further up the chain for more treatment.

And when people present at the ER who are not screaming in agony, bleeding heavily, unconscious, or giving birth, the ER staff’s job is to make sure they’re stable–and then send them home.

Yes, they’re “trained”–they’re trained to stabilize people, and then send them on. They’re NOT trained to perform thorough, detailed head-to-toe examinations in order to find out what ELSE might possibly be wrong with a patient, especially with somebody who presents at the ER with, “I bumped my shoulder and my head.”

If he doesn’t say, “…and my leg hurts, too”, it’s not their job to examine every square inch of him like Marcus Welby, “Does this hurt? How about this? And this?..”

So. During his ER visit, they successfully established that he hadn’t fractured his skull, he didn’t have a concussion, he didn’t have a dislocated shoulder, he hadn’t fractured his spine, he hadn’t broken an arm bone or a collar bone–IOW they managed to discover that basically he was okay.

And yeah, this only takes a total of about 10 minutes total patient interaction time. That’s because their job is NOT to take a total medical history and discuss it thoroughly with each patient; their job is…wait for it…to stabilize him, decide whether he needs further medical attention, and send him onwards.

So, you got exactly what the typical ER visit entails, and it sounds to me like they didn’t miss any bets. They did their jobs.

But–my God! They didn’t even check CSMs in his feet!! :eek: And they didn’t do a head-to-toe examination! :eek: They totally MISSED another really nasty bump on his leg! And, one person told him to take it easy when he got home! But another person told him to do some stretching exercises! The unfeeling, lazy louts! He could have died, with such poor medical care! They should all be fired and made to go work as CNAs!!!

Strewth. :rolleyes:

They aren’t allowed to fumble around with improvised slings, because if they’re dealing with a serious injury, that can make it much worse. They much prefer that if the patient, or the people who brought him in, are capable of removing it themselves, that they do so.

And apparently your friend was not so badly injured that he couldn’t do it himself, which right there is a pretty good diagnostic for, “He’s okay, X-ray his shoulder and send him home.”

Oh, and BTW: I have yet to encounter the ER staff dealing with seriously injured people that let their caregiving be affected by whether the patient has “good insurance” or not. That’s because their job is to stabilize seriously injured people and send them on; whether the patient can pay for the treatment has nothing to do with the treatment they get.

People who are not obviously seriously injured, yeah, they get a lot less concerned rushing around with IVs and things–because they don’t need it. Not because they have inferior insurance.

You think your “good insurance” entitled you to better treatment by ER staff? You got another think coming. The extent of your injury is what entitles you to better treatment–if your friend really had broken something, you’d have had lots and lots of personal attention.

But I’m assuming that the ER staff established within the first 10 seconds that this “pretty distracting” shoulder injury wasn’t anything serious, and that he didn’t have a head injury, and so yeah, they didn’t rush around concernedly with IVs and things; they basically gave your friend a brisk once-over and sent him home.

That’s their job.

P.S. Why on earth would you have expected them to check his feet for circulation, sensation, and motion? He was presenting with a shoulder injury and possible head injury.

4

This is pretty normal operation. They cut it and possibly the shirt underneath to minimize movement of the arm and shoulder as a precautionary measure.

5

Too bad you didn’t get the stunt on tape. I understand there are TV shows where such activities can win you $10,000.

6

Given the mechanism, it seems plausible that he suffered some sort of spinal injury, and at least asking about numbness, tingling, sensation, etc. combined with a brief physical exam would have been useful and without added cost.

I’m going to side with the OP here and say that his friend seems to have some valid complaints.

7

2nd degree Separated AC Joint, concussion, and some sort of musculo-skeletal problem with the leg that has yet to be professionally diagnosed.

Meh. Each are deserving of their own pitting.

OK, but stable includes “does not have spinal issues.” Do you think you can fully evaluate the spine in a few moments of palpation on the neck?

The rest of the stuff was just poor patient care–the equivalent of failing to empty a bed pan when it should be–but still worthy of pitting.

Good patient care, for example, means not cutting off articles of clothing when it is entirely unecessary.

Good patient care means (IMHO–and especially when there’s no one else to attend to), making sure there isn’t anything else that is obviously, acutely wrong with the patient.

Well, he may really have broken something–we won’t know until later since they didn’t check. Am I’m not convinced that everyone gets the exact same ER care regardless of insurance, but that’s another matter. You’re right that in this case that clearly wasn’t the issue. I was just tossing that in, in case anyone was wondering.

Brisk=4 hours? That’s the thing. If, as you say, all the ER had to do was rule out a serious head or shoulder issue, and they could do this in a ten minute exam, why did it take 4 hours?

I am under the impression that SOP for a possible spinal injury (i.e. falling onto your head from 3 ft. up), is to palpate the spine and check CSMs for all four limbs. No?

I fully understand the notion of cutting off stuff when necessary. But to look at a very simple sling with an obvious shoe-lace style not on the other shoulder and tell him they needed to cut it off indicates, to me, a lack of concern for the patient or an utter lack of flexibility with protocol.

8

If the leg injury was so bloody obvious and acute, then why didn’t you or your friend discover it until you were back home?

9

Because he hit his head pretty hard and his shoulder hurt a lot. Then, shortly after arriving, they gave him Vicodin in the ER. He didn’t expose it until he took his pants off and noticed the bruising and deformity.

10

Ah. So he presents complaining of head and shoulder pain, receives near-immediate appropriate treatment for the pain, and the ER staff is supposed to know that his leg, which is so severely injured that he doesn’t even notice it, is also injured. Because they know his body better that he himself does.

Got it.

11

I’d say the deformity was not on his leg.

12

Triage.

Someone who’s obviously going to live through the night regardless of what is or isn’t done is going to be ***last ** * on the list. I’m not a medical person, but even I know that.

My family and I have had more than our share of trips to the ER, and we know that if it’s just something that hurts, you’re going to wait a loooooonng time. I was in a car accident years ago and turned out to have a cracked bone in my neck and soft tissue injuries to my knee. The accident happened in the morning when I was on my way to work, somewhere in the vicinity of 8 a.m. I did not get home until about 6 p.m. I’m sure I was last on the list, behind everyone who was bleeding severely, having chest pains, was in labor, and a whole lot more.

13

Apparently going to the emergency room requires a head to toe physical, just IN CASE there’s something else wrong. It’s not like they don’t have the time, they’re open all night, and how many emergencies can there be? :rolleyes:

Richard Parker, if you’re so fantastic, then why didn’t you check CSM’s on all four limbs? Why didn’t you do a head-to-toe examination?

FFS, it’s an EMERGENCY room, not a “my friend fell can you please check every part of his body” room.

14

Read this again…

DDG summed up most of it nicely.

My 2 cents worth

He has a patent airway

He is breathing spontaneously

has a pulse and appropriate blood pressure

No obviously broken bones

no serious bleeding ( as in at least a thin steady stream)

You are pretty much wasting your time in any big city ER.

If you were not seriously considering dialing 911, he probably can wait and see his MD in morning or hit the first walk in clinic type place you can find, they will be alot more likely to make you a priority.

Hell, if he does not meet the above criteria he might wait till morning anyway. Just because there is nobody in the waiting room doesn’t mean they are not running 4 victims of a high speed rollover car accident, prepping a gunshot for surgery, and monitoring several other high acuity patients that could die any minute without interventions as needed.

I have seen plenty of slow nights in ED’s in my EMT days, some of them end up fighting over patient care duties to avoid other less amusing tasks like narcotic inventories.

And as to the insurance comment…on behalf of every EMS person I have ever talked to , GO FUCK YOURSELF. 99.9% of the time they have zero clue what your insurance status is, nor do they care. If they wanted to find out your chart prolly has it in there somewhere. EMS crews will ask for insurance info if time and circumstances permit its part of the paperwork, but no ER nurse or EMT/paramedic has any financial stake in the ability of a patient to pay. They get paid by the hospital/ambulance company/ fire department to provide appropriate care to their patients.

15

Diagnosis…shaken not stirred

What level of spinal damage has he suffered if he walked in under his own power… many assumptions can be made based on the fact that he walked in on his own, appropriately answered questions when triaged, had no complaints other than bump on head and hurt shoulder.

Cutting an improvised sling is hardly an issue. Its not like they cut a womans shirt and bra off in the waiting room for all to see while addressing that pesky splinter in her toe. Rather than ever mess with the knot, just cut it, its also alot easier and less damaging pretty much across the board to cut away coverings of injured areas rather than trying to manipulate the injured area to remove them.

Although there is some breathtaking finesse displayed in many ER’s at times, its still the quick and dirty version of medicine in many respects. Your post in ways sounds to me like someone walking into Dennys and expecting fine cuisine and world class service.

A floor nurse would do the type of survey you are expecting of the ER staff even if it did not seem relevant to the injury. Full nursing assessments take a while and IIRC are not SOP for ER staff.

16

Stat! Charge…clear!

17

Plenty of patients with spinal injuries are fully concious and walking about complaining of pain on the head and other distracting injuries.

It would have taken an additional 30 seconds to fully rule out a spine problem.

Did he have an MOI for spinal injury? Yes.
Should they have ruled out spinal injury? Yes.
Can they do this with a few seconds of palpation on the neck and by making assumptions? No.

If this were a triage situation, I agree: he should have been at the bottom of the list. But I was in the ER, I saw who they were treating, and everyone (all three of 'em) looked pretty stable. Even if he was at the bottom of the list, they still should have ruled out spine.

I will be happy to withdraw this complaint if an MD comes in here and says otherwise.

As for the rest: c’mon. I’m not saying they almost let him die, or that they ought to be sued for malpractice–or even that this was way out of line for the ER. I’m just saying that it would have been very, very easy to have a higher standard of patient care. Is cutting off the sling a big deal? No, it’s just stupid–hypothetical situations notwithstanding, in this case the nurse just wasn’t paying attention. Is giving contradictory treatment advice the end of the world? No, but it’s still bad care.

You don’t have to take every pitting as a personal attack on your line of work. I’m just (rather mildly) complaining about the bare minimum level of care given to my friend.

18

Have you ever been to an emergency room with a similar injury before? I’ve taken my son more than once for injuries that included bumps to the head, and never was a head to toe check done. Maybe it would have been easy in this particular case to have a higher standard of care- or maybe it wouldn’t have. The one time we spent a really long time in the ER with him ( he turned out to have appendicitis) there were a whole lot of ER patients who weren’t actually in the ER for long periods of time - they were off getting X-rays and CAT scans etc. They also have no idea what’s going to be coming in soon. As far as I know the same protocols are followed whether the ER is jammed or empty, and I don’t see how that could change as a practical matter. How could you do that- If there are fewer than 5 people in the waiting room do A,B,C, D and E, if there are 5-10 leave out E, between 10-20 leave out D& E, more than 20 just do A& B?
Although I’d really like to know what kind of spinal damamge allows a person to walk in under their own steam but still needs emergency treatment.

19

:rolleyes:

20

The ER tends to be for obvious injury, not the “might have”.

They are always operating in the “Next” mode.