Podcast 7 – The Emergency Room

The Emergency Room


Dr. Chad Edwards: This is Dr. Chad Edwards and you are listening to Podcast #7 of Against the Grain.

Announcer: Welcome to Against the Grain Podcast with Dr. Chad Edwards, where he challenges the status quo when it comes to medicine. We get into hot topics in the medical field with real stories from real patients, to help you on your way to a healthy lifestyle. Get ready because we’re about to go “Against the Grain.”

Brian Wilkes: This is Brian Wilkes here with the Dr. Chad Edwards. Dr. Edwards, how are you doing today?

Dr. Edwards: If I were any better I’d be twins. I’m just so excited to be here.

Brian: Oh, man. That is good news. That is good news. I love your dry humor. It’s great.

Dr. Edwards: Is there another kind?

Brian: Speaking of humor, we’ve got a great kind of teaser episode – short episode today on the emergency room. How to get in, what to do when you get there, all that good stuff. It’s going to be great.

Dr. Edwards: It’s awesome. We’ll just get right into it. We’ve got a couple of sponsors we got to talk about.

Brian: Yes, we’ll talk about a couple of sponsors today. We got to get through them briefly, but Revolution Health and Wellness Center. Chad.

Dr. Edwards: If you got muscular skeletal pain, athletic injuries, knees, backs, necks, any kind of pain come see us. Prolotherapy, PRP stem cell, we’re going to fix that stuff right up for you. Also, functional medicine stuff. Come see us, 918-935-3636 or www.revolutionhealth.org.

Brian: Cervical Health Centers is a chiropractic place here in town in the city of Tulsa, Oklahoma. Tulsa Prolotherapy

Dr. Edwards: T-Town.

Brian: T-Town. Chad has a lot of good friend of Chad and highly recommends these guys. Their patients have seen overall improvement over 75% of their health, so I would say that’s a pretty good stat. Their number is 918-742-2300, or you can visit www.uppercervicaltulsa.com/newyou.

Chad, with that let’s jump right to the ER. And I imagine you have some awesome ER stories.

Dr. Edwards: Yes, hot topic.

Brian: Oh, yes the hot topic. Oh, yes.

Dr. Edwards: I am Board Certified in Family Medicine, but I’ve spent innumerous hours in the emergency room. I use to moonlight in the emergency room. I’ve been in some little bitty ones, been in some rather big ones, and it was definitely a growing experience, to say the least. Tulsa Prolotherapy

Brian: When I come to the ER, what can I expect, the average ER?

Dr. Edwards: Okay, the first thing I would say is that emergencies are relative. And when you get the average patient that has an ouie, I don’t know how else to define ouie but fill in the blanks, that’s not going to result in your death, then that is probably not a true emergency.

Brian: How many people come to the ER? What percentage would you say come with non-life threatening ailments? Tulsa Prolotherapy

Dr. Edwards: Oh, 80% or 90%.

Brian: Right, so they shouldn’t be there.

Dr. Edwards: Understand, they need help. They need something.

Brian: Okay.

Dr. Edwards: If you’ve got a broken bone and your bone is sticking through, is that going to result in your death, no? Does that need to be managed? Absolutely. The only reason that I bring that up is because I remember specifically a patient that came in that was complaining of knee pain. Now she wanted to be referred to an orthopedic surgeon for knee evaluation. That was the reason for her coming into the emergency room. Tulsa Prolotherapy

She’s had knee pain for years. She comes into the emergency room. This was a relatively small emergency room, and this particular night we were busy. We literally had a six hour wait in the waiting room.

Brian: Wow!

Dr. Edwards: And this lady was complaining because she was waiting because of her chronic knee pain. Now, it wasn’t that we didn’t care and didn’t want to see her. But when you have patients come in without a pulse, or that aren’t breathing, or unconscious, those patients take precedent. Tulsa Prolotherapy

Brian: How do hospitals manage ER clinics? In the sense of if you have, let’s say 2:00 o’clock in the morning you’re on a rotational shift, and there’s a car accident involving 10 people. They all come to your ER clinic and there’s 10 people waiting that have fairly urgent matters. How does the hospital scale up and down accordingly? How does it work?

Dr. Edwards: Well, so that gets into what we call triage. And in the military we did a lot of this, because you are in a position where your resources are overwhelmed. You then have to prioritize and you put patients into categories. And in the military we would use expectants, urgent, delayed, immediate, these kinds of categories.

Brian: Squeaky wheel gets the grease.

Dr. Edwards: That’s exactly right. When you have something that you can fix and will save their life immediately, you do that and then you go onto the next patient. It’s this cycle. Now it’s uncommon in America that you’ll be overwhelmed with 10 patients all at once, all life threatening.

Brian: Because of the resources.

Dr. Edwards: Well, outside of when you look at things like Columbine, you look at things like the Boston bombing. What was the one in Connecticut?

Brian: Major events.

Dr. Edwards: Yes. Where you have multiple severe casualties. The most recent one in France with the terrorist attacks, and they implemented their white plan. And you’re talking hundreds of casualties that all have to be evaluated, and there is a process for doing that. And most hospitals have, all of them should have an emergency plan.  And you activate based on what you have going on. We don’t have to do that every day. Now you may get busy and relatively overwhelmed, but the patient with the knee pain is going to wait until you can get them in. Now, some hospitals will go on divert, so they’re no longer accepting ambulances because they don’t have the resources to do it.

Brian: So they literally divert it to another hospital where they have predefined relationships with?

Dr. Edwards: Correct. In Tulsa you’ve got St. Francis, for example. If all of your ICU beds are full, or all of your trauma type ICU related services are full, you may go on divert for trauma. You may go on divert for neurologic because you don’t have the neuro ICU. You can’t put them anywhere. It’s better for them to drive an extra few minutes to go someplace else where they do have the available resources.

Now you may only go on to divert for only a few hours. Usually, that’s the case, a day or two. And if the whole town, if the whole city got overwhelmed, then of course you would take them as you can. But in trying to manage, so that takes it to an echelon higher than the hospital itself. You’re now going to the city resources and go to another hospital.

That’s one mechanism by which the system could work. But going back to that, emergency is relative. I think one of the things that we want to discuss in this podcast, is how can we help our patients understand how to utilize the emergency room? How to utilize an urgent care? Those kinds of things.

And really the question is, can this wait or not? And when it comes to things like chest pain, things that would be concerning for a potentially life threatening issue.

Brian: Better to be overcautious.

Dr. Edwards: Absolutely.

Brian: Forty-five-year-old overweight male with chest pain, probably come on down.

Dr. Edwards: Yes, you need to go. And that is going to take precedent over knee pain. It might take precedent over a broken bone. We may do a couple of things and then you may sit and wait for a long time.

Brian: Yes. Give you a good pain killer and you are good to go.

Dr. Edwards: Exactly. Because we’re screening these things. We might get some vital signs, and we might get an EKG, and then you may be sitting and waiting. Or we might get bloodwork. And all of this stuff is cooking. And then if the labs come back and the EKG looks normal, and a doctor may not have even seen the patient yet.

Brian: You’ve gotten pass those most serious checkmarks.

Dr. Edwards: You’ve gotten information that helps you prioritize. And if you get an EKG and there’s big, what we call ST segment elevation, that guy immediately goes to the top of the line because that’s a potentially fatal condition.

Brian: Right there on the spot.

Dr. Edwards: Exactly. There’s a lot going on behind the scenes that patients don’t necessarily see. And when you’ve got one ER— I remember when I was in a 16 bed ER and at 2:00 o’clock in the morning I was the only doc. I had 16 beds.

Brian: Oh my gosh.

Dr. Edwards: Sixteen patients that I’m supposed to take care of, plus whatever’s in the waiting room. And I’ve got to prioritize those. Plus, you still have ambulances that could still come in.

Brian: Wow!

Dr. Edwards: What are you going to do? You do the best you can. And you’ll start collecting data, because you want as much of that data so that when you go see the patient you can immediately determine this patient needs to come in the hospital, they can go home. They’re going to die. They’re not going to die. Here’s our appropriate follow. That’s what we’re trying to do.

In the emergency room you’re trying to answer a couple of very basic questions. Is the patient going to die or not? Do they have a life threatening condition that we can intervene on? Do they need to be admitted or do they go home? Those are really the questions that you want to ask. And I’ve had patients that would come in to the ER, and they’re coming in for a relatively chronic thing. It might be abdominal pain, which that can be problematic.

And you’ll do a workup looking for certain things. Does this patient need to be admitted? Do they need surgery? Can they go home? Those basic questions you’re going to ask every time. And the ER has a process through which we work through those things. We’re not looking for the final answer. We’re not looking for why do you have abdominal pain. In the emergency room you don’t care. The only thing you care about is do they need to be admitted? Are they going to die? Do they need a surgeon? Can they go home? Those really basic questions.

So, we do want to try and help that patient, but they have pain, they have the same pain a month later and it hadn’t gotten any better and they come back to the ER, you’re going to get the exact same work up essentially. For the most part, because you’re trying to ask the same questions. So, patients would be very frustrated like, “I’ve done this five times and they keep doing the same thing,” and it’s frustrating to them. And I understand that, but you’re asking the wrong question. You’re asking an emergency room question. You got to quit asking the emergency room question, and go find a primary care doc, go find a gastroenterologist, go find somebody else that can actually work this up. And in the ER you just can’t do that.

Brian: Yes. I think that a lot of people go to the ER because they feel like their primary care physician is not going see them for a week. And so, if the pain is too much or too irritating or whatever the problem is, right?

Dr. Edwards: Right. And certainly that’s one of the things that we do different at Revolution. If they’ve got an issue and they need to be seen, we’re going to get them in. Almost without exception. We’re going to get them in as quickly as we can. I don’t want them to spend their money in the urgent care or the ER.

Brian: This is going to get on a whole another level of service with you.

Dr. Edwards: The most cost effective way to deliver health care is with a one-on-one relationship with the primary care provider. It’s one of the most cost effective ways to do it. That doctor knows the patient, they know what’s going on, they know their meds and supplements, and those kind of things. When you get any other provider you have to start from scratch. The minute you cross the threshold in the ER you are automatically, your costs go up. Hundreds of dollars just to have a doctor come in and wave his hands over you. It’s just incredibly expensive.

Brian: So talk to me about when I go to the ER. I come in with a chronic problem that has worsen, right? How much can you, as a family care physician or primary care physician to that person, how much communication can and will happen in those hours at the ER clinic?

Dr. Edwards: Well I’d say it depends on the system. When I worked at one of the large clinics here in town, I heard nothing overnight. Let’s say you’re my patient, you go to the ER at night. I’m not going to hear anything about it until tomorrow morning at the earliest, and usually since it’s within the same system I’ll get a message on my computer that I’ll be able to pull up and see the ER notes and labs and those kinds of things. My current clinic is not in that system so I don’t have access to those records, but I’ll often get a relatively brief facts report. I might get some of the labs, but I often don’t get the full “hey, here’s exactly what’s going on.” I’ll have to request those records, and that’s only if the patient tells them: “I want them sent” over there.

Brian: In other words not a lot of good communication. Either way, let’s say you have your primary care physician, and let’s say you have diabetes and you’re having some sort of diabetic episode, right? Does the ER doctor generally have a channel to pull up your medical records, prior to that visit? Any kind of connectivity in there?

Dr. Edwards: In my current system, no. When I was in the clinic associate with the hospital, yes, they had access to everything they could pull it up. But you got to understand that doctor has 16 patients and he’s only got a few minutes.

Brian: Yeah, so it’s not even good information anyways.

Dr. Edwards: Well, he’s got access to everything. But how much time do you have?

Brian: But my point is when I go to the ER clinic, does the doctor get any kind of medical background other than what I tell him?

Dr. Edwards: That depends on the system.

Brian: So why don’t we have a unified system?

Dr. Edwards: Well, that’s what they’re working on. They’re working on that through the electronic medical records and through what’s called “meaningful use”. Where they’re trying to kind of standardize some things and create these documents that will transfer from one to the next, and those kinds of things.

Brian: But it’s important to know, when you walk in that ER clinic, chances are that doctor has no access to your other medical records or any information about you as an individual prior to that visit.

Dr. Edwards: Right. And I think it’s important that in the electronic medical record, I use an electronic medical record, there’s a portal and patients can log on to the portal and they can pull up their results. They can pull up their EKG. That’s actually saved a couple of my patients from having multiple issues, because the patient was able to pull up on their iPhone their EKG. We’re changing systems, but my current system won’t let me do it, previous system did, and the new system will be able to. So EKG, they were able to pull up.

Brian: EKG, labs, everything.

Dr. Edwards: ER doc was able to look at that and say, “Oh, okay. This finding that I see here was there two years ago,” they’ve got something to compare it to.

Brian: That’s a big deal.

Dr. Edwards: It is. It’s a really big deal. When I have it in the EKG for comparison it could save an admission. Or it could say there’s definitely something wrong here that we need to intervene on, that I may not have caught had I not have that.

Brian: Yes, that’s a great takeaway from this teaser episode that you need to have your medical records on file somewhere. And your clinic makes it available for people that have that through that portal, which is great. Which anybody can log into, you can have a doctor log into it if they have the permission. If you travel overseas, wherever. It’s kind of like the old school medical tags that you used to have. My father still wears one. They can scan or look at the number and pull up the medical record. That’s important for ER care.

Dr. Edwards: And things that you can do: have a current list of your medications and supplements, have a current list of your allergies, medical conditions, surgeries.

Brian: And your kids too.

Dr. Edwards: Absolutely. Have that list available when they go in and say, “Do you have this, this this?” you can just hand them the list. That is so helpful. And if that’s current, that is incredibly helpful. Have an appropriate expectation, understand if you go to the ER at two o’clock in the morning on Christmas Eve, you may be there a while. And I’m not going to tell you not to go, because I can’t. But if you have a concern, then by all means go, but just understand that it costs more to go to the ER than it does urgent care, depending on the condition you may need that. Just have appropriate expectations, understand that it might take a long time.

Brian: Should you call before and say, “how long is it going to be?”

Dr. Edwards: I would say no. Because if it’s an issue that you need to be seen for, then why are you wasting your time with a phone call?

Brian: Yeah, it’s not an emergency.

Dr. Edwards: Exactly.

Brian: So if you’re having to call five places?

Dr. Edwards: I say, go. Something like – Johnny’s got an ear infection and can’t sleep? That’s not an emergency room condition. That’s an urgent care condition.

Brian: It’s a good thing I have your cellphone number. And you owe me. So why do I need to go to the emergency room? So the point of this broadcast is just get friends with the doctor, right? So, that’s it. That’s our teaser, hopefully this is helpful to people. I think it is, I think the big takeaway here is to understand what happens in an emergency room from a doctor’s perspective and the prioritization that you put on each patient, be respectful of that because other people that are probably going through life threatening things. If you have a broken bone or etcetera get some good pain medicine. And the other takeaway is make sure you have clear medical records, I think that’s very helpful. Especially if you have a chronic disease, right?

Dr. Edwards: Yes, absolutely.

Brian: Thank you, Dr. Chad. We’ll see you on the next episode.

Dr. Edwards: See you soon.

Announcer: Thanks for listening to this week’s podcast with doctor Chad Edwards. Tune in next week where we’ll be going Against The Grain.