The other day Dr. Cranky was speaking with Mrs. Cranky (who is not at all cranky herself) and asked her the following question: What is the one thing the general populace should know about Emergency Medicine? Her answer was immediate. “That’s easy,” she responded, “you should write a guide telling people how to come to the Department. Think of how much aggravation you could avoid if people knew what they should do ahead of time.” Your intrepid chronicler stared straight ahead for a moment, mouth agape, with that fish-out-of-water look he possesses when he finds himself in the presence of absolute brilliance. But of course! This was preventative medicine at his finest. It is moments like this which remind Dr. Cranky of how lucky he is to have chosen such a truly insightful spouse. This is in direct contrast to those times when Mrs. Cranky (who is not at all cranky herself) gives him insight into the personal habits she believes he should abandon for the sake of the neighborhood, but that is another story altogether. And so, dear reader, it gives your humble servant great pleasure to introduce the first in a series of articles detailing what you should do if you ever find yourself visiting Dr. Cranky or any of his collegues at their place of alternate reality, also known as your local Emergency Department.
How to Go to the Emergency Department – Part One: Should You Go to the Emergency Department in the First Place?
The Short Answer: It is never wrong to come to the Emergency Department. Dr. Cranky would rather his patients come to the ED and have it be a false alarm than have them stay at home and have something terrible happen. He realizes that the lay public has a limited understanding of disease and what constitutes a true emergency. What may seem obviously benign to an experienced emergency physician is not so obvious to a 23 year-old college student with chest pain from a pulled muscle. The only thing the college student knows is that just before she died, his dear Aunt Bessie complained of chest pain as well.
The Long Answer: Although the above is a quick and simple guideline, there is one caveat which bears mentioning. We who work in this nation’s Emergency Departments don’t mind if you come to the ED with a sincere concern about your immediate health and well-being. That is what we are here for. What frosts our shorts are people who consciously try to use the system for their own benefit or convenience. We are the Emergency Department, not the Convenience Department; by definition our job is to handle emergencies. Also, we are not suckers to be scammed. If you come to us with either of these intents please be aware that, although you will be seen and appropriately treated, your visit may not be as pleasant or time effective as it could have been.
So then, what does Dr. Cranky mean when he speaks of those who consciously try to use the system for their own benefit or convenience? He’s glad you asked. Allow him to elucidate by listing some specific examples which cause a rise in his, as well as his colleague’s, cortisol level. Extra debits accrue if EMS is called for transport or presentation occurs during the wee hours of the morning. Dr. Cranky has personally seen all of these scenarios on a regular or semi-regular basis and at all hours of the day or night. This list is not all-inclusive but hits a good many of the highlights:
- Routine Health Care Visits: Dr. Cranky and his colleagues understand that sometimes people find themselves without a health care provider because they just moved to a new area, their primary care physican has just retired, and so on. This is not a problem. Our blood pressures skyrocket, however, with those patients who return to the Emergency Department over and over again for their primary health care. Especially abhored are the dreaded “three-fers, four-fers,” etcetera whereupon multiple members of a family are brought in, usually for some trivial complaint and the parents can’t bother to make an appointment with their family doctor because, you know, like, they have other things they have to do.
- Pregnancy Tests: It is amazing the things people do whilst entrapped in the thoes of blind passion. We understand how you might later regret your lack of adequate contraceptive planning. However, the Emergency Department is not the place to determine if your night of libidinous abandon has resulted in an unanticipated side-effect. Especially egregious are those who come to us under the false pretense of abdominal pain, and Dr. Cranky has never ceased to be amazed at the therapeutic effect a negative pregnancy test can have regarding this particular symptom. Please be advised that the Health Department performs this evaluation for free and is a more appropriate venue. The same applies for requests to have an HIV test.
- Work Notes: Dr. Cranky is sorry you have found yourself in the employ of Simon Legree. His heart aches at the very thought of your involuntary servitude to this truculent taskmaster. Nonetheless, your protestations of disability on Sunday evening at 9:00 PM, especially following a weekend of wild abandon (and despite the onset of your symptoms the previous Thursday), will not engender sympathy from yours truly.
- Prescription Refills: Just last night Dr. Cranky tended to a gentleman who had not taken his blood pressure medications for the prior three months because he had let them run out. He had no symptoms; no chest pain, headache, or malaise. The patient checked his own blood pressure at home and it was 145/92, which is not dangerously elevated. For reasons known only to him, it was urgent he be seen right away and have new prescriptions written. When asked why he did not call his primary care physician and ask her to phone in refills, his response was, “I don’t want her to be mad at me.”
- Chronic Problems: Dear patient, if you have had a pain in your heel, an itch or bothersome rash for the past six months which and has not changed character since its inception, the Emegency Department is not the place for you. Especially at 3:00 AM.
- Second Opinions: No one revels at the thought of elective surgery or outpatient testing. Dr. Cranky and his colleagues applaud your foresight and diligence by having a prior evaluation performed by your personal physician. However, when your doctor recommends a particular course of action or provides you with the name of a specialist for follow-up, the ED is not the place to inquire if these recommendations are sound advice or if the specialist in question is competent and/or of sterling character.
- Already Here: This is a variation of that anathema known as the “three-fer” (see above). Usually, these patients desire an evaluation for some chronic problem because another member of the family is already being seen and believe it’s a good idea to check in because “I’m already here.”
- Have Appointment but Don’t Want to Wait: In this scenario, the patient or caregiver has already made an appointment to see a physician for some specific problem but doesn’t want to wait. Dr. Cranky has seen more than one child brought in by the mother at 8:00 AM because of a fever which began the night before. The mother has already made an appointment with the pediatrician, which is scheduled for 10:00 AM. The child is afebrile while in the Department and is literally running around, tearng up the examination room. Regrettably, the mother finds the appointment time inconvenient and figures the Emergency Department is just the place to “pop in and out.”
- Want it Now: These patients usually have had some problem for a long time, sometimes years. Their primary care physican has evaluated them and is quickly running out of diagnostic options. As a result, some all-inclusive test such as a CT scan, MRI, or ultrasound has been ordered in the hopes something will show up. The test has already been scheduled but cannot be performed for another day or two. Despite the chronic nature of the problem, the patient doesn’t want to wait.
- Desire the Result of Previously Peformed Test: This is a variation of the “Want it Now” situation described above. In this instance, the patient has already had their CT, MRI or U/S performed and just can’t bear the thought of waiting another day or two to see their doctor for the results.
- Drug Screens: Alas, the bundle of joy you birthed 16 years ago has now matured into that sullen hooligan known as The American Teenager. He no longer looks to you with the awe and reverence he once did and dares to challenge you when asked if his homework is done. You are not entirely happy with his choice of friends, either. You are concerned he might be hanging out with the wrong crowd. You have no evidence of illicit drug use but just want to be sure. Please be advised we don’t provide this service, and the look your teenager gives you will be nothing compared to the glare from the triage nurse.
- End-Run Around the Primary Care Physician: These patients have seen a television advertisment for that wonderful new drug called Placebo. The announcer has described their malady in exacting detail and this miracle drug seems to be the very panacea they have been searching for lo these many years. The suffering wretches in the ad all seem so happy now that their pesky tooth itch has resolved, thanks to Placebo. Even the family dog wags its tail with extra energy! Relief awaits these hopeful patients except for one thing: their nasty old doctor won’t prescribe it! How horrible!!! Eternal bliss is only a pill away but their salvation has been thwarted!!! Obviously, it’s time to come to the Emergency Department and see if that doctor will give them the solace promised by modern advertising.
- “Have it Your Way”: We live in a society based on instant gratification. We want what we want, and we want it NOW! Doctors? We don’t need no stinking doctors! We know our bodies and we know what’s best for us. We’re intelligent adults. We’ve been on the internet. We’ve seen the experts on Oprah! Some of us even have college degrees! We just know we need a CT/MRI/Ultrasound/PET scan and serum porcelain level. We have a date tonight and we want our Viagra, Cialis or Levitra! Just give us what we want and we’ll go away quietly. As a resident, Dr. Cranky witnessed what he regards as the best response to this type of patient. It was said by his Chief Resident, F***ing Frank Flannigan, to an especially obnoxious patient who did not get the narcotic prescription she wanted and was having a dying-duck-fit right in the middle of a patient care area. Without pause, and in front of the entire Department, Frank looked this patient square in the eye and calmly uttered the immortal words “Lady, this ain’t f***ing Burger King. You can’t have it your way.”
Attempts to Scam the System
- Drug seekers: These poor souls have personally discovered the horrors of drug addiction. Be it alcohol, opiates, cocaine, or any other compound you care to mention, rest assured that Dr. Cranky has seen more than one person entrapped by this heinous evil. Once again, your host would like to reiterate he has no problem with those who comes to the ED expressing a sincere desire to rid themselves of this demon. He will move heaven and earth to secure them a bed at the detox center. The line is drawn, however, when it comes to those who take Dr. Cranky for a sucker and think he is someone who will provide them with the means to further indulge in their habit. When denied, such patients tend to voice their dissatisfaction in an especially ugly and public fashion. For the record, your correspondent wishes for all of his future drug-seeking patients to be aware of the following:
- Dr. Cranky has no interest in your promise of sexual favors as he is quite happy in his relationship with Mrs. Cranky (who is not at all cranky herself). In fact, Dr. Cranky adores his spouse of twenty-four years and cannot imagine life without her love and companionship.
- Dr. Cranky will not respond to threats directed toward his physical well-being. He has previously worked in ghastly, crime-ridden urban areas of major cities and has been threatened by the likes of people far more fearsome than you could ever hope to be. He does not care if you know where he lives, because he is somewhat of a firearms afficionado and will be happy to have you “say hello to his little friend” should you care to pay him a visit at Stately Cranky Manor. As a side note, you should also be aware that Mrs. Cranky (who is not at all cranky herself) is quite a proficient shot in her own right.
- Dr. Cranky could not care less if you are personal friends with the hospital administrator, mayor, chief of police or the fact that you are active in the Junior League. Despite your predecessors’ many prior attempts, it should be painfully obvious that he still works in this town. He also doesn’t give a rodent’s posterior about your plan to contact the State Board of Medicine or your threat to get in touch with the Action News Team at Channel 23.
- Attention Seekers: We men and women of Emergency Medicine grieve at the thought your life has not turned out the way you planned. We are forever sorry your boyfriend/girlfriend/husband/wife has chosen to not provide you with the rapt attention you so richly deserve. We feel your pain. Really, we do. However, your attack of the vapors as a feeble attempt to manipulate those around you will fall deafly upon our ears. Dr. Cranky will have more to say on this topic in the next installment of his thrilling adventures, which he has tentatively entitled “The Princess and the Macho Man.” Stay tuned.
- Don’t Want to go to Jail: In a perverse way, Dr. Cranky sympathizes with people who suddenly develop chest pain, shortness of breath, or an inability to feel/move their legs following their apprehension by the police after engaging in some nefarious criminal enterprise. He would not like to face incarceration or be confronted with the prospect of “dancing with Bubba” either. Unfortunately, Dr. Cranky is also a strong believer in the venerable words of Barettawhen he said, “Don’t do the crime if you can’t do the time.”
- My Lawyer Sent Me: Yes, Dr. Cranky has actually had more than one patient come to the ED and divulge, up front, their plan to sue someone. They have already consulted with a lawyer, who advised them to go to their local Emergency Department to document whatever accident they were in. Dr. Cranky, in the interests of his blood pressure, will decline further comment.
There is one special circumstance which bears mentioning. The situation does occur, from time to time, when a patient is instructed to go to the Emergency Department simply for the convenience of their primary care physician. These people know they don’t belong in the ED, are apologetic for their presence, but don’t know what else to so. After all, their own doctor told them to come see us. Dr. Cranky personally knows of several physicians in his area who routinely tell their patients, whenever they call the office, to “go to the ER right away.” The reasons for this are unclear, but for these patients Dr. Cranky would like to offer this one piece of advice – perhaps it’s time you found a different personal physician.
Your insightful host feels better now. His spleen has been vented and he feels the bile receeding from his throat. All is right with the world, once again.
Dr. Cranky shall return soon. In the meantime, take care and stay well. Oh, and you mother was right. Always wear clean underwear. Please!