How Emergency Rooms Work

Millions of Americans visit an emergency room each year. Millions more have seen the
hit TV show "ER." This has sparked an almost insatiable interest in the fascinating, 24-
hour-a-day, non-stop world of emergency medicine.A visit to the emergency room can be
a stressful, scary event. Why is it so scary? First of all, there is the fear of not knowing
what is wrong with you. There is the fear of having to visit an unfamiliar place filled with
people you have never met. Also, you may have to undergo tests that you do not
understand at a pace that discourages questions and comprehension.

Emergency Room Patients

One of the most amazing aspects of emergency medicine is the huge range of conditions
that arrive on a daily basis. No other speciality in medicine sees the variety of conditions
that an emergency room physician sees in a typical week. Some of the conditions that
bring people to the emergency room include:

• Car accidents
• Sports injuries
• Broken bones and cuts from accidents and falls
• Burns
• Uncontrolled bleeding
• Heart attacks, chest pain
• Difficulty breathing, asthma attacks, pneumonia
• Strokes, loss of function and/or numbness in arms or legs
• Loss of vision, hearing
• Unconsciousness
• Confusion, altered level of consciousness, fainting
• Suicidal or homicidal thoughts
• Overdoses
• Severe abdominal pain, persistent vomiting
• Food poisoning
• Blood when vomiting, coughing, urinating, or in bowel movements
• Severe allergic reactions from insect bites, foods or medications
• Complications from diseases, high fevers
Understanding the ER Maze

The classic emergency room scene involves an ambulance screeching to a halt, a gurney
hurtling through the hallway and five people frantically working to save a person's life
with only seconds to spare. This does happen and is not uncommon, but the majority of
cases seen in a typical emergency department aren't quite this dramatic. Let's look at a
typical case to see how the normal flow of an emergency room works.

Imagine that it's 2 a.m., and you're dreaming about whatever it is that you dream about.
Suddenly you wake up because your abdomen hurts -- a lot. This seems like something
out of the ordinary, so you call your regular doctor. He tells you to go to your local
hospital's emergency department: He is concerned about appendicitis because your pain
is located in the right, lower abdomen.

Triage
When you arrive at the Emergency Department, your first stop is triage. This is the place
where each patient's condition is prioritized, typically by a nurse, into three general
categories. The categories are:

• Immediately life threatening

• Urgent, but not immediately life threatening
• Less urgent

This categorization is necessary so that someone with a life-threatening condition is not

kept waiting because they arrive a few minutes later than someone with a more routine
problem. The triage nurse records your vital signs (temperature, pulse, respiratory rate
and blood pressure). She also gets a brief history of your current medical complaints, past
medical problems, medications and allergies so that she can determine the appropriate
triage category. Here you find out that your temperature is 101 degrees F.
Registration

After triage, the next stop is registration - not very exciting and rarely seen on TV. Here
they obtain your vital statistics. You may also provide them with your insurance
information, Medicare, Medicaid or HMO card. This step is necessary to develop a
medical record so that your medical history, lab tests, X-rays, etc., will all be located on
one chart that can be referenced at any time. The bill will also be generated from this
information.

If the patient's condition is life-threatening or if the patient arrives by ambulance, this

step may be completed later at the bedside.

Examination Room
Now you are brought to the exam room. You promptly throw up in the bathroom, which
may be more evidence of appendicitis. You are seen by an emergency-department nurse
who obtains more detailed information about you. The nurse gets you settled into a
patient gown so that you can be examined properly and perhaps obtains a urine specimen
at this time.

Some emergency departments have been subdivided into separate areas to better serve
their patients. These separate areas can include a pediatric ER, a chest-pain ER, a fast
track (for minor injuries and illnesses), trauma center (usually for severely injured
patients) and an observation unit (for patients who do not require hospital admission but
do require prolonged treatment or many diagnostic tests).

Once the nurse has finished her tasks, the next visitor is an emergency-medicine
physician. He gets a more detailed medical history about your present illness, past
medical problems, family history, social history, and a complete review of all your body
systems. He then formulates a list of possible causes of your symptoms. This list is called
a differential diagnosis. The most likely diagnosis is then determined by the patient's
symptoms and physical examination. If this is inadequate to determine the diagnosis, then
diagnostic tests are required.

Diagnosis and Treatment

When the emergency physician has all the information he can obtain, he makes a
determination of the most likely diagnosis from his differential diagnosis.

Alternately, he may decide that he does not have enough information to make a decision
and may require more tests. At this point, he speaks to a general surgeon -- the
appropriate consultant in this case. The surgeon comes to see you and performs a
thorough history, physical exam, and review of your lab data. She examines your
symptoms: pain and tenderness in the right, lower abdomen, vomiting, low-grade fever
and elevated WBC count. These symptoms all point to appendicitis. The treatment of
appendicitis is removal of the appendix, or an appendectomy. The surgeon explains the
procedure, including the risks and benefits. You then sign a consent form to document
this and permit her to operate on you.
Who's On First

The vast array of people caring for patients in an emergency department can be quite
confusing to the average health care consumer -- as confusing as if you were watching
your first baseball game ever and no one was around to explain all those players.

Additionally, most people are uncertain of the training and background necessary to
become a member of the emergency-department team. Well, here's the scorecard.

Emergency Physician
The emergency physician comes to the team after spending four years in college studying
hard to get as high a GPA (grade point average) as possible in order to get accepted into
medical school.

Medical school is a four-year course of study covering all the essentials of becoming a
physician. It generally includes two years of classroom time, followed by two years
rotating through all the different specialties of medicine.

Toward the end of medical school, each medical student must select a particular specialty
(emergency medicine, family practice, internal medicine, surgery, pediatrics, etc.). The
medical student then completes an internship (one year) and residency (two to three
additional years) in order to be a specialist in emergency medicine.

Physicians must pass an all-day written exam and an all-day oral exam to become board
certified in emergency medicine. As of 2001, there were approximately 32,000
emergency physicians practicing in the United States, of which 17,000 were certified by
the American Board of Emergency Medicine.

Emergency Nurse
The emergency nurse comes to the team in a number of ways. One way is completing a
four-year degree in college to obtain a BSN. (bachelor of science in nursing). Alternately,
a nurse may complete a three-year diploma program (usually at a hospital) or a two-year
associates degree program (usually at a community college). After completing any of
these academic endeavors, the nursing graduate is eligible to take a licensing exam. After
passing this exam, the nursing graduate becomes an RN (registered nurse) and can
practice nursing. Many emergency nurses take an additional exam to become a CEN
(Certified Emergency Nurse).