Surviving The Emergency Room

How to get the most out of your trip to the ER with the least amount of pain and suffering – for all involved

At one time or another just about everyone will have an ‘Emergency Room Experience’. Maybe you will be the patient, or, just as likely, you will be there with a friend or family member in need of emergency medical care. Either way it will not be a planned event and it will not be convenient. If you are the patient there will be pain and possibly some bleeding involved, you will most likely not know the doctor or nurses taking care of you, their qualifications to do so, or track record. At best it will be an unpleasant interruption of a normal day. At worst—well… But there are some things you should know and some things you can do to minimize the chances of that worst-case scenario.

This user’s guide is intended primarily for those patients who enter the Emergency Room through the front door, having arrived via some sort of private transportation. Those coming through the back door on a gurney being pushed by several firemen and EMT’s are generally given a bit more leeway—though the situations in which they are not will be discussed a little later.


Emergency Medicine is an actual medical specialty. To become an emergency medicine specialist there are certain things a doctor must do. First is the completion of a four-year residency program after graduation from medical school. Then there is the Board Exam. This consists of a written exam, which, if passed, is followed several months later by an oral exam. Only upon successful completion of these tasks can a doctor become a Board Certified Emergency Medicine Specialist. But is doesn’t end there. In order to maintain board certification a recertification exam has to be taken every ten years.

Not all hospitals require the doctors working in their ER’s to be board certified, though most do, and in large urban areas it is the rule. Why, you might ask, does this matter? Because when you have an emergency medical problem you have enough on your mind without having to wonder whether or not the doctor taking care of you knows what he’s doing. Chances are he does.

In an emergency you are going to go, or be taken, to the ER closest to where the problem occurred. Since your home is the likeliest spot it might be wise to do a little research before the need to visit the place arises. Find out which is the hospital nearest you, go to its web site, or call the hospital administrator, and get the information you need. Are the ER doctor’s board certified? Is the hospital a paramedic receiving facility? A trauma center? Is it a department with special expertise in pediatrics?

The workplace is another popular spot for accidents, injuries, and exacerbations of chronic problems to occur. So, you probably want to do the same bit of research into the hospital nearest your place of employment. Of course none of this does you any good if you are on vacation or out driving around somewhere far from your normal haunts and get into an accident. In those situations you will have to find whatever comfort there is in knowing it is difficult, at best, to prepare for the unpredictable.

That said, let’s discuss some things you are likely to encounter once you enter the system.


I think it’s fair to say we all know that not everyone who shows up in the ER has a true medical emergency. The cough you’ve had for two weeks, the ankle you sprained three days ago, the rash you’ve been scratching for a month, the ingrown toenail that just won’t get better. And we know you don’t have a regular doctor, or you have one but can’t get in to see him for another two weeks, or you have an appointment to see her in two days but it’s going to interfere with your tee time. Or maybe there’s an insurance issue. Your HMO wants you to go to their clinic but it’s too far away, or you don’t have insurance, or you think you have insurance but what you really have is Medicaid and only three doctors in your area code accept it. Whatever the case, it just seems the ER is the best place for you to be seen.

We know these things and we are fine with them. We also agree that your problem deserves expert medical attention. But does it need that attention at 6:15 PM on a Saturday? Probably not. This is important because Emergency Rooms have a rhythm, an ebb and flow. This is true of all ER’s. Let me explain.

The ER staff, the nurses, techs, clerks, and doctors, work shifts. Depending on how large the department is and how many patients are seen each day, there will be more or fewer shifts per day, of shorter or longer duration. What is almost universal, though, is that the day shift begins somewhere around 7 AM.

At 7 AM, thereabouts, the ER staff is fresh, fully caffeinated, and ready for a new day. Coincidentally, there are usually very few patients in the department at 7 AM. That’s just the way it is and it’s why you should show up with your not-really-an-emergency problem at that time. You can get in and out before the place becomes a zoo. Your window is narrow, a couple of hours, max. If you miss this window you might want to pack a lunch.

Again, this applies only to those patients with less than emergent problems. If you have run your thumb through the skill saw, fallen off your roof and now have a peculiar angulation of your forearm, or spilled a cup of hot tea in your lap, please come immediately.


When you arrive in the ER you will be greeted by someone sitting behind a window made of something transparent and bulletproof. That person will be either an admitting clerk, or, possibly, a triage nurse. You will be asked to give your name and the reason you’ve come. This latter bit of information will determine what happens next.

‘Triage’ (FR. trier , to sort) is a word for the process of sorting through battlefield casualties to identify those who will benefit from immediate treatment, those who can wait, those who can do without treatment, and those for whom there is no treatment and who are ‘goners’, (ENG slang, one who is doomed). Once you’ve given your name and stated your problem you will be triaged.

This function is usually performed by a nurse with sufficient training and experience to be able to tell the difference between someone with a minor problem, who can wait if necessary, and someone at risk of dropping dead if not taken to the treatment area immediately. The triage nurse’s opinion regarding the severity of your ailment could well be at odds with your own. In the vast majority of cases the nurse is correct.

Your vital signs, (heart rate, respiratory rate, blood pressure, and, more recently, your degree of pain), will be measured and recorded. You will be asked to provide details about your problem. How long have you had it? Have you had it before? And, if your answers are ‘for a while’ and ‘yes’, you might be asked ‘why now’? No one is trying to be snide here. Why you’ve chosen this moment to seek attention for a problem you’ve had ‘for a while’ is useful information.

If the triage nurse has by this time determined you are not at risk of dropping dead any time soon she, (it could easily be ‘he’ but for our purposes we will use ‘she’ when referring to the nurse), will ask additional questions about your past medical history, what medicines you are taking, (more about this later), and whether or not you have any allergies. Based on this information you will be assigned a ‘severity scale’ and placed in the queue waiting to see the doctor—the higher the degree of severity, the closer to the front of the line.

Certain complaints will allow you to bypass the queue altogether. Chest pain, difficulty breathing, and massive bleeding will get you into the ER immediately. Grossly abnormal vital signs will also do the trick. If your ‘severity score’ is low but the department isn’t busy, (see Pick Your Spots), you will be taken right back. If, however, the place is a madhouse and you’re there with a sore back after a minor traffic accident you can count on spending some time in the waiting room.

The waiting room of an urban ER can be a fascinating place, anthropologically speaking. People of all ages, walks of life, and cultural backgrounds, anxious, and in various forms of misery, in one room, with a TV turned to the one station the fewest people there have any interest in watching with no remote anywhere to be found, surrounded by old magazines and ‘helpful’ pamphlets describing what they or their loved ones are about to undergo. And a vending machine. For hours.

Fortunately, many hospital administrators and ER medical directors have learned that keeping patients diverted and the process moving is good for ‘patient satisfaction’ and good for business. Patients who leave without being seen are lost revenue and bad press. They will tell everyone they know how inefficient the ER is, how uncaring the staff. That their wait may have been affected by the steady stream of seriously ill people coming through the back door courtesy of the paramedics makes no difference.

So the triage nurse has also become the waiting room ringmaster. She lets the doctor know who’s there and what their problems are. Evaluations can then be started while the patient waits. Blood is drawn, urine samples collected, x-rays and ultrasound exams ordered. Patients are ferried back and forth from lab to radiology and the wait seems less. Then, when they finally do get back into the ER, everything the doctor needs, theoretically, is done.


You’ve made it to the inner sanctum. You have been walked or wheeled into the actual ER and have been assigned a bed. Depending on the department, this could be a private room, a semi-private room, or a gurney separated from other gurneys by a privacy curtain. You are asked to undress and put on a patient gown, open in the back, please. You ask ‘Why?’ since it is your ankle that’s bothering you. You may or may not get an answer but the reason is this: there are many ways to injure an ankle, and several of them carry the risk of injuring the knee or some other body part distant from the point of maximum discomfort. Simply pulling up your pant leg does not provide adequate exposure. Things could be missed. Liability, (about which we will speak at length a bit later), could be incurred. So take off your damned clothes. We’ve seen it before and unless you are in some way physically astonishing we are not that interested.

Your nurse will do an assessment. She will ask you all the questions you were asked in triage. She already has most of that information but she wants to hear it for herself. She will then say, ‘The doctor will be right with you’. Maybe or maybe not. It depends on what the doctor is doing at the moment. If he, (another sexist convenience, sorry), is in the middle of suturing a complex laceration on the chin of a terrified four-year-old it might be a while. There are a number of things that could be monopolizing the doctor’s time, and the level of chaos in the department should give you some idea you might be waiting a while to see him.

So you lie there, on the gurney, partially obscured by the privacy curtain that offers no such thing, watching and listening to the commotion swirling around you. Patients walking by, gowns open in the back, plus or minus underwear. Someone moaning, someone else shouting for the nurse, a child wailing, phones ringing, cardiac monitors beeping, your anxiety level rising as the minutes pass.

Finally the doctor arrives. Introductions are made and you are asked the same questions you’ve already been asked in triage and by your nurse. Don’t get frustrated. Answer the questions as clearly and succinctly as possible. It is an axiom of emergency medicine that no patient will tell the triage nurse, the treating nurse, and the doctor the same things. It is the sum of what’s revealed to each that gives the best picture of what’s going on.

In the case of your ankle it is fairly straightforward. You tripped, or you were involved in some sporting event, whatever, and you twisted it. If, however, your complaint is abdominal pain, things become exponentially more complicated. If you happen to be a woman with abdominal pain, double that. Listen carefully to the questions asked and be as specific as possible. “A while ago”, is not the appropriate response to “When did the pain start?” “Everywhere” is not a helpful reply to “Where does it hurt most?” unless it really does hurt the most everywhere.

If you are taking medications you should know what they are and how much you’re taking. Keep a list handy. “You have my records” or “my doctor knows” or “ask my husband/wife/son/daughter” is no substitute for the actual list. We might not have your records or be able to access them, your doctor could be in Hawaii or on the golf course which is why you’re in the ER to begin with, and your relatives likely have no idea what medicines you take.

You will be examined. The extent to which you will be physically violated depends on your complaint. For the ankle, an evaluation of the lower leg may be all that’s indicated. For the abdominal pain, don’t be surprised if a rectal and pelvic exam are involved.

Once that humiliation is complete tests will be ordered. If it’s the ankle, and you were in the waiting room for a while, the x-rays might already have been done. Lucky for you. You are almost finished. The films will be read, a diagnosis made, some sort of stabilizing device will be applied, perhaps you will be given crutches, and you’re good to go. If it hasn’t been done you will be sent to radiology and then all of the above will ensue.

If your problem is abdominal pain, or some other unobvious, non-orthopedic complaint, more testing will be needed. Blood tests, urine tests, ultrasound exams, CT scans. They are all a possibility. You will be in the ER for at least an hour and a half, and most likely longer, while we sort your problem out. Meanwhile, you will continue to lie on the gurney free to enjoy the show.

If you are in significant pain feel free to ask for pain medicine. Failure to address a patient’s pain is frowned upon by the Feds, so we are usually happy to oblige. Try not to sound like a junky, though. Things like “I’m allergic to everything but Dilaudid”, “I need x number of milligrams or it won’t work”, and “I have a high tolerance for narcotics” tend to raise our suspicions that your visit to the ER is more about acquiring drugs than it is about receiving medical care. Some of us even have access to your prescribing records, kept on file by the State. If we look you up and see you’ve been prescribed two hundred Vicodin in the past month by a variety of doctors we are unlikely to give you more.


Once you have had your Medical Screening Exam it is OK for us to ask about your insurance status. We need to do this for a number of reasons, and getting paid is only one of them. The healthcare system is complex and the type of insurance you have will determine which consultants we can call, who your attending physician will be if you get admitted to the hospital, and which hospital we can admit you to. For these reasons it’s important that you have your insurance card with you when you arrive.

If you have no card, and we have no prior information about you in our files, there could be problems. If your condition is such that you need to be hospitalized, and your regular doctor isn’t on staff at our hospital, you will be taken care of by the on-call physician. If the next day your card materializes and indicates you have an HMO that contracts with a specific medical group working at a certain hospital a ruckus will ensue. If the HMO determines that at the time of hospitalization you were stable to be transferred to their contract facility they will refuse to pay the on-call, non-contracted doctor and the hospital. This potentially leaves you on the hook for a very large bill.

The on-call doctor and the hospital CEO will blame the ER for the mix-up. Blaming the ER is convenient and whenever something goes wrong it’s the first thing the affected parties will do. We’re used to it, but it doesn’t mean we enjoy it. When the dust finally settles it is likely the doctor and hospital will get paid something for their trouble, you will get transferred to the contracting hospital, and no one will try shaking you down for the balance. Nevertheless it will have been unpleasant and unnecessary, so keep your insurance card next to your medication list.

If your medical condition is such that you are deemed unstable for transfer none of the above matters. In cases of true emergency admissions your insurance company, whichever it happens to be, will pay the bills until you are stable.

If you have no insurance you will not be denied care. We are legally and morally obligated to take care of you, and we will. If you need to be hospitalized you will be, if you need surgery you’ll get it. You will, though, be responsible for the bills and the bills will be ridiculously high. Understand that no one expects you to pay full price. Not even close. You will be able to negotiate for the lowest amount the hospital accepts from its worst payer—usually Medicaid. You will be given a payment plan. If you are truly indigent you’ll probably be allowed to walk on the whole amount. Despite what you read in the news, none of us wants to send you to the poor house.


Almost no one comes to the emergency room alone. I don’t blame you. Something unpleasant and possibly dangerous has just happened, you are not feeling well, and you have to go to a place that requires you to cede control of what’s about to happen to you to a bunch of people you’ve never before met in your life. Of course you want someone there for moral support, and, hopefully, a ride home when the nightmare is over.

It is also reasonable that you would want that person, or those persons, by your side during the entire ordeal. We understand. Unfortunately, that is not always possible. When you are first brought back to the department there are things that might need to be done during which the presence of one or more extra people would be a distraction or impediment. Drawing blood, for example, can provoke an untoward reaction from a ‘non-pro’. Having to pick your visitor up off the floor after a fainting episode and have him registered as a new patient is just adding more unnecessary work to an already busy day.

Also, there are privacy issues. If you are an adult, no one has the right to your medical information but you and the people treating you. There may be questions asked that you would prefer to answer without your friend being present. It is also possible that you might not be as forthcoming with certain bits of pertinent information if someone else is there to hear them. Whether or not you are sexually active and with whom come readily to mind.

So, don’t be surprised or indignant if the doctor wants a moment with you alone. As soon as the coast is clear, so to speak, your visitor or visitors will be allowed back. One at a time. Most ER’s have space limitations and having more than one visitor with each patient creates crowding problems, further loss of what little privacy you do have, and inefficiency. Work it out among yourselves. It’s like tag team wrestling. One visitor in, the previous visitor out. The more willing you are to comply with this system the more happy the staff will be to accommodate your requests, even to the point of letting more than one person at the bedside if the place isn’t too busy.

There are exceptions to this rule. If the patient speaks no English but the person with him does, that person will likely be allowed back immediately. The more exotic the language spoken, the more likely this will be. Many of us can speak enough Spanish to make ourselves understood, and given the large number of Philippino nurses, Tagalog is usually not a problem. If the patient speaks Hmong we will be looking for all the help we can get.

The Feds have recently issued a diktat banning the use of non-professional translators in the ER. I’m not sure why, since in practice this has held us in good stead for many, many years. In theory, which is the world in which the Feds live, it is possible that things could be misunderstood, errors could be made, patient safety jeopardized. OK. Fine. We will use the special phone line to speak to the professional Hmong translator. One receiver for us, one for the patient, and a crackly connection in between. But we will also avail ourselves of the family member at the bedside. No one is more concerned for the patient’s safety and well being than we are, regardless of what the Feds might think.

Young children are another exception to the rule. If the child is accompanied by both parents, both will be allowed to stay from the outset. If, though, there are multiple young children we would prefer one parent to stay with the patient and the other to ride herd on the siblings somewhere other than in the emergency room. It’s difficult enough for the staff to wrangle one child, let alone two or three.

A young child with a laceration requiring sutures is best left in the hands of the ER staff when the time comes for the suturing to be done. This is counterintuitive to most parents who understandably assume that the child needs them most when things are looking their worst. In fact, the opposite is usually the case.

In order to do the job properly the child will need to be restrained. This could involve being wrapped in a sheet, creating what is known as the ‘baby burrito’, or strapped to a papoose, a short board with velcro straps over the chest and legs, or, more likely, both. If the laceration is on the scalp or face, there will also be someone holding the child’s head still. The child will object. Loudly. The wound will be anesthetized and from that point on there will be little if any actual discomfort. But the child will continue to object to the indignity of being held down and physically assaulted by his caregivers.

If the parents are in the room, the child will expect them to intervene. When they do not, and start singing nursery rhymes in a well intentioned but futile effort to calm him, he will become more frustrated and angry. This anger and resentment could well carry over to the post-treatment period. There are enough good reasons for children and their parents to have issues with one another. Hanging around impotently while he gets his laceration fixed should not be one of them.

Let us be the bad guys. We’re used to it. (See the section on Insurance Cards above.) Once we’re done you can come rushing back into the room to ‘save’ your child from the evil ER personnel. It works. But we recognize that not all of you are going to believe it and will insist on being present. It’s your choice. We only ask that if you do decide to stay, you stay far enough away from the body part being worked on to allow us to get it over with as quickly as possible. If you feel you must sing, fine.

Adolescents. Enough said. They are not adults and therefore have no expectation of privacy but are old enough to have grown up problems. You as the parent have the right to be with them throughout their ER visit. They as the adolescent are almost certainly involved in behaviors they think you don’t know about and don’t want you to learn about. The best solution is for you ask the doctor if it would be OK if you stepped out of the room for a few minutes. The second best solution is for you to comply if the doctor asks you to leave.

If you do leave the room we should have a nurse present as a chaperone. If you see that we do not, request that a nurse be there. It is for our mutual protection. Once you are gone we will have the best chance of finding out what your child has been up to and whether or not it has any bearing on his or her current problem. Of course, some of you have remarkably open and honest relationships with your children and there are no secrets. Great. Now take a hike for a little while.


Don’t abuse the system. While it’s true that patients brought to the ER by paramedics get seen faster than those coming through the front door, especially when the department is busy, it’s because they are usually sicker. Please don’t dial 911 because you want to avoid the wait, don’t have a ride, or don’t want to pay for a cab. Save it for the day you have crushing chest pain, can’t move your right leg, or can’t stop vomiting. The day you wrap your car around a telephone pole while talking on the phone, someone will do the calling for you.

If you come by ambulance and we suspect you’ve done so for convenience only we will not be amused. If the ER is busy you will be rolled through the back door, through the ER, and out to the waiting room. You will be triaged and placed in the queue. Probably not near the front. Then, a couple of weeks later, you will get a bill from the County for something in the vicinity of twelve hundred dollars—the price of the ambulance ride. It is unlikely your insurance will cover it.

Cell phones are ubiquitous but you are in the ER because you have an emergency medical problem, or a not-so-much-of-an-emergency that you want dealt with quickly. When the doctor gets to your bedside, get off the phone. Immediately. We don’t care whom you are speaking with or who initiated the call. Hang up. Thank you.

The ER isn’t the space shuttle or a commercial airliner poised for takeoff. Using your cell phone to make calls or play games is not going to cause the cardiac monitors to malfunction or the department to burst into flames. Still, making us wait for you to finish your telephone business before allowing an interview is considered to be a sign of disrespect and dubious breeding.

It is perfectly fine to use the phone in whatever way you wish when we are not there with you. It’s a good way to pass the time waiting for your various test results. The only function you are to avoid is the camera. No pictures. Of yourself and certainly not of anyone else in the department. There are laws about this. If somehow you haven’t gotten the message yet, patient privacy is a big deal with the Feds. Sharing someone’s medical information inappropriately could land you in prison. Taking a photo of the guy in the next gurney being treated for an overdose and sending it to everyone in your address book is never a good idea. It doesn’t matter how hilarious it seems to you at that moment. Don’t do it.

Eating is a popular diversion for patients and family members spending time in the ER. I’m not sure why, given the unappetizing nature of the environment, but it is. In general, patients should not eat or drink anything without first asking the doctor if it is OK to do so. Your condition could be made worse, eating could interfere with tests we need to perform, and, if you need surgery, it will be delayed for as much as eight hours if you have recently stuffed yourself.

If you must eat there are a few options available. If you are the patient, and if for whatever reason you will be staying in the ER for an extended period, the nurse can order a meal for you from the hospital cafeteria. It will not be either the worst or best thing you’ve ever eaten but it won’t kill you and it will comply with whatever dietary restrictions the doctor has imposed upon you.

Friends and family members can get food from the cafeteria if the cafeteria happens to be open at that moment. The nurse will not provide specially-prepared-to-order meals for members of your entourage. If the cafeteria is closed, there will be vending machines available to them. There is also the fast-food take out option. No one is going to stop them from bringing food into the department. But is it really necessary? If you are only going to be there for an hour or so wouldn’t it be better for them to wait until you are discharged to have that Happy Meal?

And we understand that feeding your child helps keep him calm while waiting to see the doctor, but trying to examine the throat of a child with a mouthful of crackers is unnecessarily difficult. Same thing for candy that changes the color of his mouth. What is the significance of a red throat in a child who has spent the last hour sucking on a lollypop?

There is also some language to avoid. We will take care of you regardless of whether or not we like you, but isn’t it better to be liked? If you think so you should refrain from swearing at us, calling us vulgar names, and threatening us. Threats can be verbal or physical. Neither is appreciated. Depending on the nature of the threat we will ignore you, call security, or call the police. We have a special relationship with local law enforcement. We do the alcohol screening tests for suspected drunk drivers in custody, we do the ‘OK to Book’ evaluations for prisoners on their way to jail, and, most importantly, we are there 24/7 should an officer get injured on the job. They get a little special consideration from us. We try not to waste their time. If you pose a real physical threat to us we will call them and they will be in the ER with guns drawn within minutes. Your day will have gone from bad to much, much worse.

You should also avoid telling us about your lawyer. We don’t like your lawyer. We don’t like lawyers much in general. We in the ER are particularly vulnerable to medico-legal actions, popularly known as medical malpractice lawsuits. It is not because we make a lot of mistakes. Despite the complexity of our job and the environment in which we do it we make surprisingly few mistakes.

But, malpractice cases are not usually about mistakes. They are about outcomes. A patient who does something stupid or irresponsible, or who has something bad happen for no good reason, and has a poor outcome, is going to be angry. He might be angry with himself for doing the dumb or irresponsible thing, but he understands that being angry with us is likely to be more productive. He will find a lawyer who will convince him that it would be wise to sue.

You don’t know us, (it’s not like we’re your family doctor with whom you have a twenty-year relationship), you assume we work for the hospital, (we don’t, we work for ourselves), and that the hospital will pay for our defense and whatever judgment is ordered, (it won’t, we have our own, very expensive, malpractice insurance), and it’s no big deal. It is. Even if we prevail, which we usually do.

Our insurance company doesn’t really care if we win or lose. They only care about how much the process is going to cost them. If they can settle for ten grand or go to trial for a not-guilty verdict that will cost them a hundred grand, they will opt for the settlement every time.

We want to be not guilty. We want to fight back. The insurance company has to do what we want, though they will make every effort to get us to see things the right way, meaning their way. So we go to trial. We endure the demeaning depositions, the attacks on our character and ability, the insinuations that we are somehow monsters. It goes on for a year or so. Then, finally, we are vindicated. A jury finds us not guilty. We win!

Six months later, when it’s time to renew our malpractice policy, we are informed that the premium has been adjusted upward by twenty percent due to our ‘loss record’. What ‘loss record’? We won. Didn’t we? Well, technically, yes, but our victory was Pyrrhic. It cost the insurance company a small fortune it now needs to recoup. So don’t tell us about your lawyer. In fact, if you happen to be a lawyer you might want to keep it to yourself.


Your disposition, that is, what we are going to do with you when we’re done with our evaluation, is something we’ve been thinking about since you walked in the door. Getting patients out of the ER and into the appropriate aftercare environment is as important as treating their medical problems in many cases. Roughly eighty per cent of you will be going home. The sprained ankle has been splinted, the laceration repaired, the abdominal pain found to be a bladder infection for which antibiotics have been prescribed. The remaining twenty per cent, though, will need in-patient care.



It is also possible you will need to be transferred to a different hospital. Usually this will be for a ‘higher level of care’, meaning the services you need are not available at our facility. Examples of this are the psychiatric patient needing admission to a psych hospital and the patient with an obvious heart attack needing to go to the place with a catheterization lab and cardiac bypass capability. Or maybe you cut some tendons in your hand and we don’t have a hand surgeon on call. Whatever.










If there is no insurance company involved please refer to the section on The Insurance Card above. Contact the various entities and make a deal.




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