Why Emergency Treatment Can Be a Guessing Game

Emergency department physicians often are accused of ordering too many tests and admitting too many patients to the hospital. But even if medical overuse is a problem, sometimes the circumstances in the ER don’t leave a doctor much choice.

One ER doc, Leana Wen, recently blogged on NPR.org about just such a situation, and her account is a cautionary tale for family and friends of people who are vulnerable to overtreatment because no one knows, or cares, about their situation.

Wen is director of patient-centered care research in the Department of Emergency Medicine at George Washington University and the author of “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care.” She’s also founder of Who’s My Doctor, a project to encourage transparency in medicine.

She tells the story of an elderly man delivered on a stretcher to the ER in the middle of the night by ambulance paramedics. He’s bleeding around his neck brace and smells of urine.

“We found him by his bed,” the paramedic tells Wen. The patient told the paramedics he slipped, had back pain and cuts and bruises.

The paramedics could find no medical history or medications he might be taking. All they know is his name and address, and no one else was at his home.

The ER team works quickly to rid him of his soiled clothes, take his blood pressure, start an IV line, shave his chest and attach electrodes to check his heart.

The patient is crotchety, and physical. He claims that none of the care is necessary, that he only slipped in the shower. But the paramedics found him in the bedroom.

The patient gives his full name, and claims that it is 1843. “It’s 2014,” Wen tells him. A medical student searches for his records on a computer. There are none from this hospital.

The patient offers two phone numbers for his son. Neither works. The patient says his doctor lives in Kansas.

He has a 1-inch laceration over his eyebrow, a bruise over his right wrist and scrapes on both knees. He winces when his back is touched. His arms and legs are strong.

Wen sends him for X-rays and a CT scan of his head and spine. There’s no bleeding inside his brain and nothing is broken. His laboratory tests come back and show that he has anemia and kidney problems.

He pleads to go home. His home phone and the son’s numbers are called again. No answer anywhere. Another doctor calls two other local hospitals to see if he’s known to them. He’s not.

The patient now says it’s 1914. “Everyone sighs,” writes Wen. “We have to admit him. It’s the last hospital bed we’ve got, and the patients who come after him will have to wait through the night in the ER.”

The next day, the patient’s son and daughter-in-law telephone Wen. They’re irate. The patient has dementia and frequently falls. That’s why, they say, the family arranged for live-in help 18 hours a day.

He’s had anemia and kidney problems for years, and his longtime doctor, who is local, closely monitors his health. The hospital internist taking care of him now says he never should have been hospitalized.

So, of course, Wen is defensive. “Where was his family last night?” she wonders. “What would the man’s usual doctor have done in my position?”

“When caring for patients we don’t know and who could have life-threatening illnesses,” she says, “emergency physicians have to do what is safest and best with the information at hand, sparse as it may be.”

Her decision, working with minimal information, was to admit the patient. He was confused. He had abnormal test results. His safety at home couldn’t be assured.

Still, Wen understands his family’s distress. They’re unhappy that he was stripped, poked and kept against his wishes. They’re frustrated at our system of care: “Why don’t we have unified electronic medical records?” she asks. “Why aren’t there better interventions for coordinating care and keeping people out of hospitals?”

Wen apologized to the family.

“Knowing what I know now,” she writes, “I would have made a different decision. I gently suggest that it would be helpful to make sure he carries a document in his wallet with updated phone numbers, medical conditions and wishes for his care.”

That’s not only reasonable, we’d call it the bare minimum. A doctor’s job is hard enough without having to guess about something that is simply common sense.

Wen concludes her essay: “I’m back in the ER. It’s another busy shift, and I see him again. Well, not the same 73-year-old, but another elderly gentleman who also fell. Again, he’s confused, and we can’t reach his family. He doesn’t want to stay, but again we hospitalize him. This time, too, I’m filled with doubt and a desire for a better system to care for my patients.”

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